.UC  SOUTHERN  REGIONAL  LIBRARY 


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OPINIONS  OF   THE   PRESS 

ON 

WATSON'S  PEACTICE   OF  PHYSIC. 


The  Publishers  have  great  pleasure  in  submitting  the  following  letter  from 
Professor  Cliapman,  as  well  as  a  few  of  the  notices  of  the  medical  press,  with 
which  this  work  has  been  honoured. 

Philadelphia,  September  27th,  1844. 
Watson's  Practice  of  Physic,  in  my  opinion,  is  among  the  most  comprehen- 
sive works  on  the  subject  extant,  replete  with  curious  and  important  matter,  and 
written  with  great  perspicuity  and  felicity  of  manner.  As  calculated  to  do  much 
good,  I  cordially  recommend  it  to  that  portion  of  the  profession  in  this  country 
who  may  be  influenced  by  my  judgment. 

N.  CHAPMAN,  M.D. 

Professor  of  the  Practice  and  Theory  of  3Icdicine 
In  the  University  of  Pennsylvania, 


"  We  know  of  no  work  better  calculated  for  being  placed  in  the  hands  of  the  student,  and 
for  a  text  book,  and  as  such  we  are  sure  it  will  be  very  extensively  adopted.  On  every  import- 
ant point  the  author  seems  to  have  posted  up  his  knowledge  to  the  day." — America?i  Medical 
Journal. 

"  In  the  Lectures  of  Dr.  Watson,  now  republished  here  in  a  large  and  closely  printed  volume, 
we  have  a  body  of  doctrine  and  practice  of  medicine  well  calculated,  by  its  intrinsic  soundness 
and  correctness  of  style,  to  instruct  the  student  and  younger  practitioner,  and  improve  members 
of  the  profession  of  every  age." — Bulletin  of  Medical  Science. 

"  We  regard  these  lectures  as  the  best  exposition  of  their  subjects  of  any  we  remernber  to 
have  read.  The  author  is  assuredly  master  of  his  art.  His  has  been  a  life  of  observation  and 
study,  and  in  this  work  he  has  given  us  the  matured  results  of  these  mental  efforts." — New  Or- 
leans Medical  Journal. 

"We  know  not,  indeed,  of  any  work  of  the  same  size  that  contains  a  greater  amount  of  inte- 
resting and  useful  matter.  The  author  is  evidently  well  acquainted  with  everything  appertaining 
to  the  principles  and  practice  of  medicine,  and  has  incorporated  the  stores  of  his  well-stocked 
mind,  in  the  work  before  us,  so  ably  and  agreeably,  that  it  is  impossible  for  the  interest  of  the 
reader  to  flag  for  a  moment.  That  they  are  well  adapted  foi  such  a  purpose,  all  must  admit; 
but  their  sphere  of  usefulness  may  extend  much  beyond  this.     We  are  satisfied,  indeed,  that  no 

fihysician,  well  read  and  observant  as  he  may  be,  can  rise  from  their  perusal  without  having  added 
argely  to  his  stock  of  valuable  information." — Medical  Examiner. 

"In  this  volume  of  the  '  Principles  and  Practice  of  Medicine,'  we  have  before  us  a  mass  of 
information  which  is  rarely  to  be  found  within  the  boards  of  a  single  volume.  This  is  the  age  ol 
condensation.  Here  is  bi-ought  together  mature  views  of  the  present  state  of  the  science,  by  a 
lecturer,  acknowledged  by  all  to  be  of  the  first  order,  and  that  which  was  spread  over  1700  pages 
of  the  London  edition,  we  have  in  about  1100,  (of  course  large  pages,)  and  so  cheap  that  no  me- 
dical reader  will  hesitate  a  moment  to  transfer  it  from  the  bookseller's  counter  to  his  own  table 
where  it  should  lie  constantly  before  him." — U.  S.  Gazette. 

"  We  know  of  no  systematic  work  on  the  Practice  of  Medicine  equal  to  this.  To  extensive 
erudition  and  natural  cleverness,  the  discrimination  and  tact  of  a  practical  man,  personally  fami- 
liar with  all  he  treats  of,  is  added.  Besides  showing  himself  a  sound  pathologist  in  these  pages, 
he  proves  that  he  is  an  admirable  therapeutist.  A  vein  of  practical  good  sense  distinguishes 
every  page.  The  time  and  patience  of  the  reader  are  not  consumed  by  idle  disquisitions  on 
mooted  points  of  no  real  utility.  The  style  is  agreeable,  and  we  may  even  say  fascinating.  To 
the  medical  student  we  consider  the  work  as  invaluable,  and  there  are  few  practitioners,  old  or 
voung,  who,  on  reading  it,  will  not  be  willing  to  acknowledge  their  obligations  to  it." — Saturday 
'Post. 

"  The  medical  literature  of  this  country  has  been  enriched  by  a  work  of  standard  excellence, 
which  we  can  proudly  hold  up  to  our  brethren  of  other  countries  as  a  representative  of  the  natu 
ral  state  of  British  medicine,  as  professed  and  practised  by  our  most  enlightened  physicians. 
And,  for  our  own  parts,  we  are  not  only  willing  that  our  characters  as  scientific  physicians  and 
■kiiful  practitioners  may  be  deduced  from  the  doctrines  contained  in  this  book,  but  we  hesitate 


2  NOTICES  OF  Watson's  practice. 

not  to  declare  our  belief,  that  for  sound,  trustworthy  principles,  and  substantial  good  practice,  it 
cannot  be  paralleled  by  any  similar  production  in  any  other  country.  *  *  *  *  \ye  would 
advise  no  one  to  set  himself  down  in  practice,  unprovided  with  a  copy." — British  and  Foreign 
Medical  Ixeview. 

"  We  cannot  refrain  from  calling  the  attention  of  our  younger  brethren,  as  soon  as  possible,  to 
Dr.  Watson's  Lectures,  if  they  want  a  safe  and  comprehensive  guide  to  the  study  of  practical 
medicine. 

"In  fact,  to  any  of  our  more  advanced  brethren,  who  wish  to  possess  a  commodious  book  of 
reference  on  any  of  the  topics  usually  treated  of  in  a  course  of  lectures  on  the  practice  of  physic, 
or  who  wish  to  have  a  simple  enunciation  of  any  facts  or  doctrines,  which,  from  their  novelty  or 
their  difficulty,  the  busy  practitioner  may  not  have  made  himself  master  of  amidst  the  all-absorb- 
ing toils  of  his  professional  career,  we  can  recommend  these  lectures  most  cordially.  Here  we 
meet  with  none  of  those  brilliant  theories  which  are  so  seductive  to  young  men,  because  they 
are  made  to  explain  every  phenomenon,  and  save  all  the  trouble  of  observation  and  reflection ; 
here  are  no  exclusive  doctrines  ;  none  of  those 

'Bubbles  that  glitter  as  they  rise  and  break, 
On  vain  Philosophy's  all  babbling  spring.' 

But  we  have  the  sterling  production  of  a  liberal,  well-stored,  and  truly  honest  mind,  possessed 
of  all  that  is  currently  known  and  established  of  professional  knowledge,  and  capable  of  pro- 
nouncing a  trustworthy  and  impartial  judgment  on  those  numerous  points  in  which  Truth  is  yet 
obscured  with  false  facts,  or  false  hypotheses." — Provincial  Medical  Journal. 

"  We  find  that,  from  the  great  length  we  have  gone  in  our  analysis  of  this  work,  we  must 
close  our  notice  of  it  here  for  the  present,  not,  however,  without  expressing  our  unqualified 
.  approbation  of  the  manner  in  which  the  author  has  performed  his  task.  But  it  is  as  a  book  of  ele- 
mentary instruction  that  we  admire  Dr.  Watson's  work." — Medico- Chirurgical  Review. 

"  One  of  the  most  practically  useful  books  that  ever  was  presented  to  the  student — indeed  a 
more  admirable  summary  of  general  and  special  pathology,  and  of  the  application  of  therapeutics 
to  diseases,  we  are  free  to  say,  has  not  appeared  for  very  many  years.  The  lecturer  proceeds 
through  the  whole  classification  of  human  ills,  a  capite  ad  calcem,  showing  at  every  step  an  ex- 
tensive knowledge  of  his  subject,  with  the  ability  of  communicating  his  precise  ideas,  in  a  style 
remarkable  for  its  clearness  and  simplicity." — N.  Y.  Journal  of  Medicine,  cj-c. 

"  The  style  is  correct  and  pleasing,  and  the  matter  worth  the  attention  of  all  practitioners, 
young  and  old." — Western  Lancet. 

"  Wc  are  free  to  state  that  a  careful  examination  of  this  volume  has  satisfied  us  that  it  merits 
all  the  commendation  bestowed  on  it  in  this  country  and  at  home.  It  is  a  work  adapted  to  the 
wants  of  young  practitioners,  combining,  as  it  does,  sound  principles  and  substantial  practice. 
It  is  not  too  much  to  say,  that  it  is  a  representative  of  the  actual  state  of  medicine  as  taught  and 
practised  by  the  most  eminent  physicians  of  the  present  day,  and  as  such  we  would  advise  every 
one  about  embarking  in  the  practice  of  physic  to  provide  himself  with  a  copy  of  it." — Western 
Journal  of  Medicine  and  Surgery. 

"  It  is  an  admirable  digest  of  general  pathology  and  therapeutics.  As  a  text  book  for  medical 
Bchools,  it  cannot  be  surpassed,  and  in  no  other  treatise  can  practitioners  find  so  concise,  and  at 
the  same  time  so  complete  a  summary  of  the  present  state  of  the  science  of  medicine." — Balti- 
more Patriot. 

"It  is  the  production  of  a  physician  of  undoubted  talent  and  great  learning,  and  whose  indus- 
try in  performing  the  most  laborious  duties  of  this  profession  has  been  well  known  for  a  long 
series  of  years.  *  *  *  Let  us  not  forget  to  add  that  the  style  and  general  character  of  the 
work  are  peculiarly  practical ;  and  the  cases  which  Dr.  Watson  has  from  time  to  time  introduced 
to  illustrate  his  views,  are  highly  appropriate  and  interesting,  and  add  much  to  the  value  of  the 
work ;  and  this  certainly  must  be  admitted  to  be  one  of  the  great  advantages  of  casting  this 
work  in  the  shape  of  lectures,  in  which  these  cases  assuredly  appear  more  fitly,  and  in  which 
they  are  introduced  more  easily  and  naturally  than  they  could  have  been  had  the  form  of  the 
work  been  ditferent. 

"  Lastly,  we  are  well  pleased  to  observe  that  a  strong  vein  of  common  sense,  as  well  as  good 
tuste,  runs  through  the  whole  treatise,  and  sustains  both  the  interest  and  the  confidence  of  the 
reader  throughout." — Edinburgh  Medical  and  Surgical  Journal. 

"  In  calling  the  attention  of  the  profession  to  the  elegant  volume  recently  published  by  Lea  & 
Blanchard — the  lectures  delivered  at  King's  College,  London,  by  Dr.  Watson — we  do  not  suppose 
any  one  at  all  conversant  with  the  medical  literature  of  the  day  to  be  unacquainted  with  its  gene- 
ral character.  Dr.  W.  delivered  these  now  celebrated  lectures  during  the  medical  session  ot 
lt<3(J-7.  I'hey  have  been  revised  by  the  author,  and  those  who  now  study  these  erudite  pro- 
ductions will  have  them  divested  of  any  objectionable  matter  that  might  have  formerly  crept  in 
through  inadvertence.  There  are  ninety  lectures,  fully  written,  embracing  the  whole  domam  of 
human  maladies,  with  their  treatment,  besides  an  appendix  particularly  remarkable  for  its  rich- 
ness in  important  practical  information.  We  could  not  give  even  a  tolerable  synopsis  of  the  sub- 
jects discussed  in  this  great  undertaking  without  materially  entrenching  on  the  limits  assigned  to 
other  matter.  *  *  *  Open  this  huge  well-finished  volume  wherever  we  may,  the  eye  imme- 
diately rests  on  something  that  carries  value  on  its  front.  We  are  impressedT  at  once  with  the 
strength  and  depth  of  the  lecturer's  views  ;  he  gains  on  our  admiration  in  proportion  to  the  extent 
of  our  acquaintance  with  his  profound  researches.  Whoever  owns  this  book  will  have  an  acknow- 
ledged treasure  if  the  combined  wisdom  of  the  highest  authorities  is  appreciated." — Boston 
Medical  and  Surgical  Jourfial. 


LECTURES 


PRINCIPLES   AND    PRACTICE 


OF 


PHYSIC; 


DELIVERED  AT  KING'S  COLLEGE,  LONDON, 


BY 


THOMAS  WATSON,  M.D., 


fELLOW  OF   THE  ROYAL  COLLEGE  OF  PHYSICIANS;    LATE   PHYSICIAN  TO  THE  MIDDLESEX    HOSPITAtJ 
AWD  FORMERLY  FELLOW  OF  ST.  JOHn's  COLLEGE,  CAMBRIDGE. 


THIRD  AMERICAN,    FROM   THE   LAST  LONDON    EDITION. 


REVISED.    WITH    ADDITIONS 


BY 

D.  FKANCIS  CONDIE,  M.D., 

8ECKETARY   OF   THE   COLLEGE   OF   PHYSICIANS  ;    AUTHOR   OF   A   TREATISE  ON   DISEASES 
OF   CHILDREN,    ETC.    ETC. 


PHILADELPHIA: 
BLANCHARD    AND    LEA, 

185G. 


Entered,  according  to  the  Act  of  Congress,  in  the  year  1845,  by 

LEA  AND   BLANCHARD, 

in  the  clerk's  oflBce  of  the  District  Court  for  the  Eastern  District  of  Pennsylvania. 


'  »       •  « 


T^^ 
\^X 


100 


PREFACE  BY  THE  EDITOR. 


» 


The  very  full  and  accurate  exposition  presented  by  Dr.  Watson  of  the 
present  state  of  pathology  and  therapeutics,  in  reference  to  nearly  all  of 
the  diseases  embraced  in  these  Lectures,  has  rendered  it  unnecessary  to 
augment  materially  the  size  of  the  work  by  the  addition  of  frequent  and 
extended  notes.     In  regard,  however,  to  a  few  of  the  forms  of  disease 
more  particularly  interesting   to   the  American  physician,  the  account 
S      given  by  the  Author  will  be  found  somewhat  defective,  while  he  has  omitted 
^o      to  notice  one  or  two  affections  endemic  in  the  United  States,  his  lectures 
being  chiefly  confined  to  a  consideration  of  the  diseases  most  prevalent  in 
^      Great  Britain.     It  is  to  remedy  these  deficiencies  that  the  Editor,  in  pre- 
paring the  present  edition,  has  mainly  directed  his  attention.     In  the  notes 
•^      he  has  added  to  Dr.  Watson's  lectures  on  diarrhoea  and  dysentery,'  he  has 
1^   endeavoured  to  fill  up  the  very  brief  sketch  presented  in  the  text,  of  the 
'N.      chronic  forms  of  those  diseases  ;  he  has  attempted,  also,  to  supply,  in  part, 
r^  the  omissions  of  the  Author,  by  his  notes  on  the  history,  pathology  and 
*     treatment  of  typhoid  pneumonia,  remittent  fever,  &c. 
!         The  intrinsic  merits  of  Dr.  Watson's  Lectures  are  sufficient  to  ensure 
"^     for  them  a  favourable  reception.     If,  by  the  few  notes  he  has  been  induced 
to  append  to  the  present  edition,  the  Editor  has  succeeded  in  adding  in 
some  slight  decree  to  their  value,  he  will  be  amply  repaid  for  his  labour. 


CO 


o 


I 
Philadelphia,  September,  1845. 


In  passing  through  the  press  a  new  edition  of  Dr.  Watson's  Lectures,  the 
Editor  has  only  to  remark  that  he  has  corrected  some  few  errors  which 
escaped  attention  in  the  last,  while  he  has  added  some  additional  notes 
where  the  subject  appeared  to  require  them. 

Philadelphia,  August,  1847. 

a2  (H) 


r"^>/i 


ADVERTISEMENT 

TO 

THE    FIRST    EDITION. 


The  following  Lectures  were  put  together,  with  unavoidable  haste,  dur- 
ing the  Medical  Session  of  1836 — 37,  in  which  they  were  first  delivered. 
They  were  repeated,  with  slight  variations,  for  four  successive  years ;  the 
Author  always  meditating,  but  never  finding  time  to  accomplish,  their 
thorough  reconstruction  and  revision.  They  were  afterwards  printed,  to 
fulfil  a  rash  promise,  in  the  pages  of  the  Medical  Gazette :  and  they  are 
now  published,  in  a  collected  form,  at  the  request,  formally  conveyed  to 
him  in  writing,  of  many  who  had  heard  or  read  them,  including  several 
of  his  colleagues  at  King's  College. 

Writing  for  mere  beginners,  and  without  any  thought  of  future  publica- 
tion,  the  Author  took  no  pains  to  note  autnorities  as  he  went  along.  He 
may  often,  therefore,  have  used,  without  acknowledgment,  not  only  the 
facts  and  reasonings,  but  sometimes,  perhaps,  the  very  words  of  others 
This  omission  he  regrets,  but  is  now  unable  to  supply.  Neither  has  he 
leisure  to  correct,  if  that  were  desirable,  the  colloquial  and  famihar  style 
in  which  the  Lectures  were  originally  composed. 

Should  they  attract  the  notice  of  any  who  are  no  longer  in  statu  pupil- 
lari,  he  would  request  such  readers  to  bear  in  mind  for  whom  these  les- 
sons were  intended.  They  do  not  profess  to  present  a  formal  and  complete 
treatise  on  the  Practice  of  Physic,  much  less  to  exhaust  the  various  subjects 
upon  which  they  touch.  His  chief  hope  is  that  they  may  prove  useful  as 
a  text-book  for  students. 

As  they  are  passing  through  the  press,  such  additions  and  alterations 
have  been  introduced  as  the  Author  would  have  made  had  he  continued  to 
deliver  the  Lectures  orally. 

Henrietta  Street,  Cavendish  Square, 
September,  1843. 

(7) 


AUTHOR'S    ADVERTISEMENT 

TO 

THE    SECOND    EDITION. 


The  dnexpected  exhaustion  of  the  former  edition  of  these  Lectures 
within  the  space  of  a  twelvemonth,  has  left  but  little  opportunity  to  the 
Author,  whose  leisure  is  small,  for  such  revision  as  might  render  them 
more  worthy  of  the  encouragement  they  have  received.  Some  errors 
liave  been  corrected,  but  in  substance,  as  well  as  in  form,  the  Lectures 
are  nearly  the  same  as  before. 


CONTENTS. 


LECTURE  I. 

InTROSUCTOBT ...^.^  .....^ FAQS       17 

LECTURE  IL 

Pathology — meaning  of  the  term.  Pathology,  general  and  special.  Morbid  alterations  of 
the  solid  parts  of  the  body.  Alterations  in  bulk.  Hypertrophy — law  of  its  production — 
its  effects.  Atrophy — its  causes  and  consequences.  Changes  in  form.  Alterations  in 
consistence.     Induration — its  various  kinds 25 

LECTURE  III. 

Softening;  its  causes  and  varieties.  Transformations  of  Tissue;  Changes  of  situation — in 
the  Chest,  of  the  Lung,  of  the  Heart — in  the  Abdomen  and  Pelvis,  Hernia,  Intussuscep- 
tion, Prolapsus 33 

LECTURE  IV. 

Morbid  alterations  of  the  Fluids,  especially  of  the  Blood.  Changes  in  its  quantity  and  distri- 
bution. General  and  Local  Plethora.  Poverty  of  Blood.  Active  Congestion — its  Phe- 
nomena— state  of  the  Vessels,  as  seen  by  the  Microscope.  Mechanical  Congestion.  Pas- 
sive Congestion.  Relations  of  these  forms  of  Congestion  to  Inflammations — to  Hemorrhages 
— to  Dropsies SB 

LECTURE  V. 

Different  modes  of  Dying.  Pathology  of  Sudden  Death.  Death  by  Anaemia ;  its  Course, 
Phenomena,  and  Anatomical  Characters.  Death  by  Asthenia;  its  Course,  Phenomena, 
and  Anatomical  Characters.  Syncope.  Death  by  Inanition.  Death  by  Apnoea:  Death 
by  Coma :  their  Course  and  Phenomena,  and  the  Anatomical  Characters  common  to  both. 
Application  of  the  Principles  obtained  from  the  investigation  of  the  Phenomena  of  Sudden 
death,  in  elucidating  the  Symptoms  and  Tendencies  of  Disease 48 

LECTURE  VL 

Causes  of  Disease:  distinction  between  predisposing  and  exciting  causes.  Enumeration  of 
causes,  as  connected  with  the  Atmosphere — Food  and  Drink — Poisons — Exercise — Sleep 
— Mental  and  Moral  Conditions — Hereditary  Tendencies — Malformations.  Temperature. 
Effects  of  Heat  and  of  Cold 57 

LECTURE  Vn. 

Causes  of  Disease,  continued.  Laws  by  which  the  operation  of  Cold  upon  the  Bodily  Health 
is  regulated.  Circumstances  that  favour  its  injurious  Effects,  and  respect,  first,  the  Body 
itself;  secondly,  the  manner  in  which  the  Cold  is  apphed.  Modifying  influence  of  certain 
states  of  the  Mind — of  Sleep— of  Habit.  Means  of  protection.  Influence  of  the  different 
Seasons.  Impurity  of  the  Air.  Its  influence  in  the  production  of  Disease  [no/el.  Heredi- 
tary tendencies  to  Disease 68 

LECTURE  VIIL 

Symptoms.  Their  Uses  in  relation  to  the  Diagnosis,  the  Prognosis  and  the  Treatment  of 
Diseases.  Signs,  as  distinguished  from  Symptoms.  Pathognomonic,  Commemorative, 
Direct  and  Indirect  Symptoms.  Examples  of  Symptoms  as  they  consist  of  uneasy  Sensa- 
tions, disordered  Functions,  or  changes  of  Sensible  Qualities 79 

LECTURE  IX. 

Inflammation.  Its  Morbid  and  its  Salutary  Effects.  Sketch  of  the  Local  and  Constitutional 
Phenomena  of  Inflammation  as  it  occurs  in  External  Parts.  Examination  of  the  Symp^ 
toms  of  Inflammation  ;  Pain  ;  Heat ;  Redness  ;  Swelling.     State  of  the  Capillary  Blood- 

Tessels  and  of  the  Blood  [note]  in  a  part  inflamed - 93 

(9) 


10  CONTENTS. 

LECTURE  X. 

Inflammation,  continued.  Buffy  Coat  of  the  Blood.  Terminations  or  Events  of  Inflamma- 
tion. Resolution — Delitescence — Metastasis.  Effusion  of  Serum.  EtTusion  of  Coagulable 
Lymph,  or  Fibrin.     Organization  of  this  Lymph.     Suppuration.     Ulceration 103 

LECTURE  XI. 

Mortification,  as  an  event  of  Inflammation.  Inflammatory  Fever.  Hectic  Fever.  Typhoid 
Fcer  Modification  of  Inflammation  by  differences  of  Tissue  ;  Areolar  Tissue  ;  substance 
of  Glands  and  Solid  Viscera ;  Serous  Membranes ;  Synovial  Membranes  ;  Tegumentary 
Membranes — Skin — Mucous  Membranes;  Muscular  Tissue  ;  Arteries;  Veins;  substance 
of  the  Brain 118 

LECTURE  XIL 

Varieties  of  Inflammation:  Acute  and  Chronic;  Latent  ^  Specific.  Scrofulous  Inflammation. 
Tubercles.  Forms  of  Tubercles  [no^e].  Relative  frequency  of  Scrofulous  Disease  in 
different  Organs.    Signs  of  the  Strumous  Diathesis ^ - 124 

LECTURE  XIIL 

Cancer;  its  Species  or  Varieties.     Scirrhus;  Encephaloid  Cancer;   Colloid  Cancer.     Its 

mode  of  Growth  and  dissemination.     Habitudes  of  the  several  Varieties. 
Treatment  of  Inflammation.     Antiphlogistic  Regimen.     Blood-letting 136 

LECTURE  XIV. 

Treatment  of  Inflammation,  continued.     Recapitulation.    Bleeding.     Purgatives.     Mercury. 

Antimony.     Digitalis.     Colchicum.     Opium. 
Local  Remedies.     External  Cold.     External  Warmth.     Counter-Irritation 149 

LECTURE  XV. 

Hemorrhage  : — most  commonly  by  Exhalation.  Habitual  Hemorrhages.  Vicarious  Hemor- 
rhages. Idiopathic  Hemorrhages.  Active  and  Passive.  Symptomatic  Hemorrhages. 
Usual  Situations  of  Hemorrhage.     Symptoms  and  Diagnosis.     Principles  of  Treatment.  .    159 

LECTURE  XVI. 

Dropsy :  its  General  Pathology.  Passive  Dropsy ;  Cardiac  and  Renal.  Active,  Acute,  or 
Febrile  Dropsy.     Prognosis;  and  General  Principles  of  Treatment  in  Dropsies 168 

LECTURE  XVIL 
Diseases  of  the  Eye.     Catarrhal  Ophthalmia.     Purulent  Ophthalmia  of  Adults 180 

LECTURE  XVIH. 

Purulent  Ophthalmia,  continued.  Gonorrhoeal  Ophthalmia.  Purulent  Ophthalmia  of  Infants. 
Strumous  Ophthalmia - 190 

LECTURE  XIX. 

Strumous  Ophthalmia,  continued.  Recapitulation.  Treatment  of  Strumous  Ophthalmia. 
General  Remarks  on  Conjunctival  Inflammations.  Iritis:  its  Symptoms  and  Treatment 
Causes  of  Iritis 199 

LECTURE  XX. 
ntis  concluded.     Rheumatic  Ophthalmia.     Amaurosis 209 

LECTURE  XXL 

Diseases  of  the  Brain  and  Nervous  System.  Difficulties  of  the  subject.  Short  Revievr  of 
some  points  in  the  Physiology  of  the  Brain  and  Nerves.  Peculiarity  of  the  Cerebral  Cir- 
sulation.     Pressure 220 

LECTURE  XXII. 
Symptoms  of  Cereoral  Diseases.     Inflammation  of  the  Dura  Mater  and  Arachnoid,  from 


CONTENTS.  li 

external  injury ;  from  Disease  of  the  Bones  of  the  Ear,  and  of  the  Nose.     Inflammation 

of  the  Pia  Mater 229 

LECTURE  XXIII. 

Acute  and  general  Inflammation  of  the  Encephalon.  Period  of  Excitement.  Modes  in 
which  the  disease  may  commence.     Period  of  Collapse.     Treatment.    Delirium  tremens.   249 

LECTURE  XXIV. 

Delirium  Tremens,  concluded;  treatment  [note'].  Chronic  Inflammation  of  the  Brain. 
Softening,  Suppuration,  Abscess,  Induration,  Tumours  in  the  Brain. .  .^ .^ ^  . .  247 

LECTURE  XXV. 

Hypertrophy  of  the  Brain  [note] ;  Atrophy.  Acute  Hydrocephalus  ;  Premonitory  Signs ; 
DiSerent  Modes  of  Attack ;  Stages  of   the  Disease ;  Anatomical  Characters ;  Causes...  259 

LECTURE  XXVI. 

Acute  Hydrocephalus,  continued.  Prognosis  and  Mortality  of  the  Disease.  Treatment ; 
Blood-letting ;  Purgatives  ;  Cold  ;  Mercury  ;  Blisters.  Prophylaxis.  Spurious  Hydroce- 
phalus. Chronic  Hydrocephalus,  or  Dropsy  of  the  Brain.  Shape  of  the  Head  and  Face. 
Anatomical  Conditions.     Symptoms 271 

LECTURE  XXVIL 

Treatment  of  Chronic  Hydrocephalus  ;  Internal  Remedies :  Mechanical  Expedients ;  Band- 
ages.  Tapping.  Meningitis  Encephalica  [note].  Symptoms  of  Spinal  Disease.  Inflam- 
matory conditions  of  the  Spinal  Marrow.     Cerebro-Spinal  Meningitis  [note] 28^ 

LECTURE  XXVIIL 

Inflammatory  and  Structural  Diseases  of  the  Spinal  Cord,  continued.     Treatment. 
Apoplexy.     Its  General  Symptoms  and  Diagnosis.     Different  forms  of  the  attacks.     Predis- 
position to  Apoplexy — Natural,  and  accidental.     Precursory  Symptoms 298 

LECTURE  XXIX. 

Apoplexy  continued.  Symptoms  characterizing  the  Apoplectic  State.  Pressure  the  ordinary 
Physical  cause.  Hemiplegia.  Affection  of  Involuntary  Muscles.  Anatomical  Characters. 
Situation  of  the  Clot  of  Blood.     Disease  of  the  Cerebral  Blood-Vessels 307 

LECTURE  XXX. 

Apoplexy  continued.  Relations  between  the  Symptoms  and  the  Appearances  found  in  the 
brain  after  death.     Exciting  Causes.     Prognosis.     Treatment 321 

LECTURE  XXXL 

Spinal  Hemorrhage.  Paraplegia.  Facial  Palsy  and  Facial  Anaesthesia ;  their  Symptoms, 
Prognosis,  and  Treatment.     Other  Forms  of  Local  Paralysis,  and  Local  Anaesthesia  ....  332 

LECTURE  XXXII. 

Tetanus.  Its  Symptoms  and  Varieties.  Causes.  Diagnosis.  Pathology.  Treatment : 
Opium  ;  Blood-letting ;  the  Warm  Bath ;  the  Cold  Bath  ....^ ^ 345 

LECTURE  XXXIIL 

Treatment  of  Tetanus  continued.  Wine ;  Mercury  ;  Purgatives ;  Digitalis  ;  Tobacco ;  Musk ; 
Prussic  Acid  ;  Belladonna ;  Carbonate  of  Iron  ;  Oil  of  Turpentine ;  Strychnia ;  Surgical 
Expedients ;  General  Rules.    Hydrophobia 355 

LECTURE  XXXIV. 

Hydrophobia  concluded.  Various  Questions  considered  respecting  the  Disease  as  it  appears 
in  the  Human  Subject,  and  respecting  Rabies  in  the  Dog.  Pathology  of  tbi*  Disiwrder. 
Treatment.    Preven,ive  Measures .--.«_  , . . .  «  ... ,.,.*  —^...^   .  ,  86A 


12  CONTENTS. 

LECTURE  XXXV. 

Epilepsy.  Its  Symptoms  and  varieties  ;  duration  and  recurrence  of  the  paroxysms  ;  periods 
of  life  at  which  they  commence  ;  warnings.  Efiects  of  the  paroxysms,  immediate  and 
ultimate.     Pathology.     Anatomical  characters 379 

LECTURE  XXXVL 

Epilepsy  continued.  Recapitulation.  Exciting  causes.  Simulated  epilepsy.  Diagnosis. 
Prognosis.     Treatment :  during  the  fit ;  during  the  Intervals  ;  during  the  Warnings  ....   388 

LECTURE  XXXVn. 

Chorea.  Symptoms  ;  Pathology  ;  Complications  ;  Causes  ;  Treatment.  Chronic  Chorea. 
Other  Nervous  Disorders  to  which  the  same  name  has  been  applied 399 

LECTURE  XXXVIIL 

Paralysis  Agitans.  Mercurial  Tremor.  Hysteria ;  Two  Forms  of  Hysteric  Paroxysm  ; 
Diagnosis  from  Epilepsy;  Class  of  persons  most  liable  to  Hysteria ;  Diseases  apt  to  be 
simulated  by  Hysteria  ;  Treatment ;  Prevention.     Salaam  Convulsions  [note] 410 

LECTURE  XXXIX. 
Catalepsy.     Ecstasy.     Neuralgia;  Tic  Douloureux ;  Sciatica;  Hemicrania 424 

LECTURE  XL. 

Intermittent  Fever.  Phenomena  of  an  Ague  Fit.  Species  and  varieties  of  Intermittents. 
Predisposing  causes.  Exciting  cause.  Malaria :  known  only  by  its  effects  ;  places  which 
it  chiefly  infests  ;  conditions  of  its  production  ;  its  efiects  upon  the  human  body  ;  influence 
of  soils  in  evolving  it 1 435 

LECTURE  XLL 

Ague,  continued.  Speculations  respecting  its  periodicity.  Habits  and  properties  of  the 
malaria  ;  most  noxious  at  night ;  lies  near  the  ground  ;  is  carried  along  by  winds;  cannot 
pass  across  water  ;  attaches  itself  to  trees  ;  is  diminished  by  the  increase  of  cultivation  and 
of  population.  Ultimate  effects  of  the  poison  on  the  body.  Ague  formerly  thought  salu- 
tary.    Prognosis.     Propriety  of  stopping  the  disease -  • .  447 

LECTURE  XLII. 

Treatment  of  Intermittent  Fever  ;  during  the  paroxysm  ;  during  the  intermissions.  Prophy- 
laxis   457 

LECTURE  XLIIL 

Epistaxis.  Bronchocele  ;  Cretinism  ;  their  Phendmena  and  probable  Causes.  Medical  antf 
Surgical  Treatment  of  Bronchocele 467 

LECTURE  XLIV. 

Cynanche  Parotidffia.  Spontaneous  Salivation.  Aphthae;  pathology  of  [rjo/e].  Cynanche 
Tonsillaris 479 

LECTURE  XLV. 

Acute  Laryngitis.  Symptoms.  Treatment ;  Blood-letting.  Tracheotomy,  Mercury,  Antu 
mony.  Anatomical  Characters  of  the  Disease.  Causes.  Secondary  Laryngitis.  QEdema 
cf  the  Glottis.     Chronic  affections  of  the  Larynx 491 

LECTURE  XLVL 

Cynancne  Trachealis  :  Symptoms  ;  Pathology ;  Prognosis  ;  Treatment.  Tracheotomy  [note]. 
Child-crowing,  or  Spurious  Croup.  Spasmodic  Laryngitis  [no/e].  Nocturnal  periodic 
Cough  [note]  . .  ..^ ^ - - - ^ - 50S 

LECTURE  XLVn. 

Diseases  of  the  Thorax.  General  observations.  Dyspnoea.  Cough.  Methods  of  exploring 
the  physical  conditions  of  the  Chest,  by  the  senses  of  sight,  touch  and  hearing 517 


CONTENTS.  13 

LECTURE  XL VIII. 

Catarrh ;  its  varieties.  Acute  Bronchitis.  Dry  sounds  attending  the  Respiration  ;  Rhonchus 
and  Sibilus  ;  Moist  sounds  ;  Large  and  Small  Crepitation :  how  these  are  produced,  and 
what  they  denote.  Treatment  of  Acute  Bronchitis.  Peripneumonia  Notha.  Sudden 
Infraction  of  a  large  Bronchus 528 

LECTURE  XLIX. 

Influenza.  Symptoms  and  progress.  Conjecture  as  to  its  Cause.  Treatment.  Hay  Asthma. 
Chronic  Bronchitis.     Its  varieties.     Morbid  Anatomy  of  these  affections 539 

LECTURE  L. 

Hooping-cough  :  symptoms ;  duration  ;  complications  ;  pathology;  treatment.  Pneumonia  ; 
its  stages  and  morbid  anatomy;  auscultatory  signs 552 

LECTURE  LL 

Pneumonia,  continued  ;  its  general  symptoms  ;  pain,  dyspnoea,  cough,  expectoration.  Course 
of  the  disease.     Prognosis.    Treatment.     Pneumonia  in  Children  [note]  .  .^ 564 

LECTURE  LIL 

Pleurisy.  Its  anatomical  characters  ;  false  membranes ;  liquid  effusion  ;  effects  of  these  upon 
the  shape  and  contents  of  the  Chest,  and  upon  its  healthy  sounds.    Symptoms  of  Pleurisy  579 

,  LECTURE  LIIL 

Pleurisy,  continued.  Recapitulation  of  symptoms  ;  of  diagnostic  signs.  Causes  of  Pleurisy. 
Pneumothorax  ;  its  condition,  and  signs.  Treatment  of  Pleurisy.  Empyema.  Paracen- 
tesis Thoracis.     Typhoid  Pneumonia  [note'j ^ 590 

LECTURE  LIV. 

Pulmonary  Hemorrhage ;  its  varieties  ;  its  connection  with  pulmonary  consumption,  and 
with  disease  of  the  heart.  Pulmonary  Apoplexy.  Prognosis  in  Haemoptysis.  Symptoms 
Treatment 608 

LECTURE  LV. 

Pafmonary  Emphysema ;  vesicular  and  interlobular.  Anatomical  characters  of  vesicular 
Emphysema  ;  physical  signs  ;  general  symptoms  ;  causes  ;  treatment.  Interlobular  Em- 
physema ;  its  anatomical  characters,  symptoms,  cause,  and  cure.  CDdema  of  the  Lungs. 
Phthisis  Pulmonahs 618 

LECTURE  LVL 

Phthisis,  continued.  Vomicae ;  adhesions  of  the  pleurae  ;  ulceration  of  the  larynx  and  trachea 
— of  the  intestines ;  fatty  liver ;  auscultatory  signs  of  a  vomica  ;  gurgling ;  cavernous 
respiration,  pectoriloquy.  General  Symptoms  of  Phthisis  :  cough,  expectoration,  dyspnoea, 
pain,  hectic  fever,  diarrhoea,  wasting,  oedema,  aphthae 62tt 

LECTURE  LVIL 

Phthisis,  continued.  Diagnosis.  Forms  and  varieties  of  Phthisis.  Ordinary  duration.  Age 
at  which  it  is  most  frequently  fatal.  Influence  of  sex,  and  of  occupation.  Question  of 
contagion.     Treatment,    Curability  of  [no/e]    641 

LECTURE  LVIIL 

Melanosis  of  the  Lung ;  true,  and  spurious.  Accidental  intrusion  ot  solid  substances  into 
the  air-passages (J52 

B 


J4  ■  CONTENTS. 

LECTURE  LIX. 

Diseases  of  the  Heart ;  usually  partial.  Changes  in  its  muscular  texture.  Mechanism  of 
those  changes.  Natural  dimensions  of  the  Heart.  Natural  sounds.  Modifications  of 
these  by  disease.  Review  of  the  physical  and  general  signs  that  accompany  Cardiac 
Disease 660 

LECTURE  LX 

Diseases  affecting  the  muscular  texture  of  the  Heart,  and  their  treatment.  Changes  to  which 
the  valves  of  the  Heart  are  subject.  Effects  and  diagnosis  of  those  changes.  Angina 
Pectoris - 671 

LECTURE  LXL 

Pericarditis ;  its  frequent  connection  with  Acute  Articular  Rheumatism.  Rheumatic  Car- 
ditis.  Anatomical  characters  of  acute  inflammation  of  the  pericardium  ;  of  the  Endocar- 
dium.  General  symptoms.  Auscultatory  signs.  Relations  of  Carditis  with  Rheumatic 
Fever ^ 682 

LECTURE  LXn. 

Treatment  of  Acute  Pericarditis  and  Endocarditis  :  blood-letting;  mercury;  blisters.  Chro- 
nic and  partial  inflammation  of  the  pericardium.  Disease  of  the  Aorta.  Thoracic  Aneu- 
risms ;  their  various  situations  and  symptoms  ;  plan  of  treatment 697 

LECTURE  LXHL 

Diseases  of  the  Veins.  Phlebitis  ;  adhesive  and  suppurative  ;  consecutive  scattered  Abscesses. 
Treatment  of  Inflammation  of  Veins.  Effects  of  the  gradual  obstruction  of  large  Venous 
Trunks 707 

LECTURE  LXIV. 

Asthma  :  its  nature ;  complications ;  exciting  causes ;  and  treatment.  Diseases  of  the 
CEsophagus ;  Inflammation  of  Infants  [no/e]  ;  Stricture;  Spasm:  Dilatation 716 

LECTURE  LXV. 

Diseases  of  the  Abdomen  ;  sometimes  diflacult  to  identify.  Method  i>f  investigating  these 
diseases  ;  by  the  eye,  the  hand,  the  ear.  Inflammation  of  the  Peritoneum  :  its  symptoms  ; 
and  causes.     Puerperal  Peritonitis.     Peritonitis  from  Perforation -^ 727 

LECTURE  LXVL 

Treatment  of  Acute  Peritonitis  ;  Bleeding,  Mercury,  Opium.  Chronic  Peritonitis  ;  Granular 
Peritoneum.  Ascites;  Ovarian  Dropsy;  Diagnosis  of  these  diseases.  Other  forms  of 
Abdominal  Dropsy 736 

LECTURE  LXVIL 

Pathology  of  Chronic  Ascites  ;  of  Ovarian  Dropsy.  Treatment  of  these  two  disorders.  In- 
ternal remedies  ;  Extirpation  of  the  ovarian  sac  ;  Paracentesis  Abdominis 744 

LECTURE  LXVm. 

Acute  Gastritis  ;  symptoms  ;  anatomical  characters  ;  treatment.  Acute  Gastritis  of  Infants 
[note].  Chronic  Iriflanmiation  of  the  Stomach;  thickening  of  the  Mucous  Membrane ; 
Ulceration  :  symptoms  and  treatment  of  the  disorder.     Cancer  of  the  Stomach 763 

LECTURE  LXIX. 

Hemorrhage  from  the  Stomach  :  sometimes  from  a  large  vessel,  usually  by  exhalation. 
Idiopathic  Hsematemesis.  Vicarious  HjEmatemesis.  Hsmatemesis  from  gastric  disease 
for  injury:  Irorn  disease  in  other  organs.  Melsena.  Haematemesis  from  a  morbid  state 
of  the  blood.     General  phenomena  of  Hsmatemesis.     Diagnosis.     Treatment 76i 


CONTENTS.  15 


LECTURE  LXX. 

Dyspepsia.  Physiology  of  Digestion.  Symptoms  of  Dyspepsia.  Treatment  and  Prevention, 
Dietetic  and  Medicinal 774 

LECTURE  LXXI. 

Enteritis  :  its  symptoms  ;  causes  ;  treatment.  Mechanical  occlusion  of  the  Intestinal  Tube. 
Colic.     Colica   Pictonum  ;  its  symptoms,  complications,  treatment,  and  prevention 784 

LECTURE  LXXIL 

Diarrhoea.  Chronic  Diarrhoea  [notej.  Sporadic  Cholera.  Epidemic  Cholera.  Cholera 
Infantum  [note]  798 

LECTURE  LXXIIL 

Dysentery:  Morbid  Anatomy  [note] ;  Chronic  [notty  Diarrhoea  Adiposa.  Intestinal  Con- 
cretions.    Worms 814 

LECTURE  LXXIV. 

Entozoa,  continued.  Hydatids.  Trichina  Spiralis.  The  Guinea  Worm.  Strongulus  Gigas. 
Origin  of  Entozoa.  Question  of  Spontaneous  Generation.  General  Symptoms  of  the 
presence  of  Intestinal  Worms,  Particular  symptoms,  and  remedies,  of  the  common  Round 
Worm,  of  Thread  Worms,  of  Tape  Worms 829 

LECTURE  LXXV. 

Diseases  of  the  Liver.  Acute  Inflammation.  Abscess  of  the  Liver.  Causes  and  Treatment 
of  Acute  Hepatitis.  Chronic  Hepatitis.  Jaundice.  Its  symptoms,  causes,  species,  and 
pathology  [note'] 841 

LECTURE  LXXVL 

Treatment  of  the  various  species  of  Jaundice.  Diseases  of  the  Gall-bladder  ;  of  the  Spleen  ; 
of  the  Pancreas.  Diseases  of  the  Kidneys.  Nephritis  and  Nephralgia.  Phenomena 
constituting  a  "fit  of  the  Gravel."  Dillerent  kinds  of  Gravel.  Diseased  states  of  the 
UTine.     Description  and  Remedies  of  the  Lithic,  Pliosphatic,  and  Oxalic  Diathesis 854 

LECTURE  LXXVIL 

Suppression  of  Urine.  Diabetes  :  Qualities  of  the  Urine ;  symptoms  ;  anatomical  appear- 
ances ;  general  pathology  of  the  disease  ;  treatment.     Diuresis 866 

LECTURE  LXXVIII. 

Albuminous  Urine.  Means  of  detecting  the  Albumen.  What  it  imports.  Anatomical 
characters  of  Bright's  Kidney.  Symptoms  to  which  this  renal  disease  gives  rise.  Nature 
of  the  Affection ^77 

LECTURE  LXXIX. 

Anasarca  ;  its  consideration  resumed.  Distinction  of  Chronic  General  Dropsy  into  Cardiac 
and  Renal.     Characters  and  signs  of  each  of  these  varieties.     Treatment 88T 

LECTURE  LXXX. 

Chylous  Urine.  Haematuria  ;  its  diagnosis,  general  and  particular ;  Local  Disorders  of  the 
Urinary  Organs  on  which  it  depends  ;  treatment.     Abdominal  Tumours 897 

LECTURE  LXXXL 

Acute  Rheumatism  ;  symptoms  ;  varieties  ;  treatment.    Chronic  Rheumatism  ;  phenomena  , 

plan  of  cure. 
Gout :  description  of  a  paroxysm  ;  progress  of  the  disease ;  general  state  of  the  health  in 

gouty  persons  ;  causes  of  the  disease  ;  diagnosis  between  Gout  and  Rheumatism 906 


16  CONTENTS. 

LECTURE  LXXXII. 

Pathology  of  Gout.  Prognosis.  Prejudices  respecting  the  disease.  Treatment :  during  the 
paroxysms  ;  during  the  intervals.     Cutaneous  diseases 91'1 

LECTURE  LXXXin. 

Exanthemata.  They  are  contagious  ;  sometimes  epidemic.  Period  of  the  eruption  ;  period 
of  incubation.     Theory  of  contagious  Febrile  Diseases.     Continued  Fever 925 

LECTURE  LXXXIV. 

Continued  Fever,  continued.  Phenomena  of  the  second  week ;  Delirium,  an  Eruption, 
DiarrhcEa  :  of  the  third  week  ;  Recovery,  or  death  in  the  way  of  Coma,  of  Apnoea,  of 
Asthenia.  Symptoms  that  usher  in  those  modes  of  death  ;  morbid  changes  found  after 
them °3' 

LECTURE  LXXXV. 

Varieties  of  Continued  Fever.     Its  causes,  exciting  and  predisposing.     Prophylaxis 946 

LECTURE  LXXXVL 

Continued  Fever,  concluded.  Treatment.  Bilious  Remittent  Fever  [note].  Small-pox. 
Its  essential  symptoms.  Distinction  into  discrete  and  confluent.  Periods  and  modes  in 
which  it  proves  fatal o .      957 

LECTURE  LXXXVn. 

Small-pox,  continued.  Inoculation.  Vaccination.  Their  comparative  advantages.  Treat- 
ment of  Small-pox   .-^ 978 

LECTURE  LXXXVIIL 
Chicken-pox.    Measles.    Scarlet  Fever 991 

LECTURE  LXXXIX. 

The  Plague.  Erysipelas.  Erysipelas  in  Infants  [no/e].  Erythema  Nodosum.  Urticaria. 
Prurigo.     Scabies 1004 

LECTURE  XC. 

Herpes  ;  Eczema  ;  Pompholix  ;  Lepra  ;  Psoriasis  ;  Impetigo ;  Boils  ;  Carbuncle  ;  Purpura ; 

Scurvy.     Conclusion  of  the  Course 1017 

Vkv^x ^ 1031 


LECTURES 


PEINCIPLES  AND  PRACTICE  OF  PHYSIC. 


INTRODUCTORY   LECTURE. 

Gentlemen  : — In  approaching  any  new  course  of  systematic  inquiry,  there  are 
certain  points  concerning  which  the  inquirer  should  always  be  careful  to  satisfy 
himself.  He  should  comprehend,  distinctly,  what  it  is  that  he  proposes  to  learn  ; 
its  subject-matter,  and  its  objects  :  he  should  consider  whether  he  is  about  to  adopt 
the  most  easy,  direct,  and  effectual  means  for  obtaining  his  purpose ;  and  whether 
he  is  qualified,  by  the  possession  of  the  requisite  preliminary  information,  for  pursu- 
ing his  inquiries  with  intelligence  and  profit.  To  these  points,  and  to  some  others, 
as  they  are  connected  with  the  duties  with  which  I  have  been  entrusted  in  this  col- 
lege, I  wish  briefly  to  direct  your  attention  on  the  present  occasion.  It  will  be  my 
endeavour  to  furnish  you,  at  the  outset,  with  clear  notions  of  the  nature  and  the  ends 
of  that  branch  of  study  upon  which  you  are  now  about  to  enter;  to  explain  why  it 
is  taught,  and  how  far  it  may  be  taught,  by  oral  discourses  ;  to  point  out  to  you  what 
may  reasonably  be  expected  from  me,  and  what,  to  render  my  attempts  prosperous, 
will  be  required  on  your  parts.  Something  also  it  is  expedient  you  should  know 
beforehand  respecting  the  general  order  and  arrangement  of  the  course  ;  and  a  short 
explanatory  comment  upon  some  of  the  terms  that  we  shall  constantly  be  employing, 
will  clear  the  way  for  the  succeeding  lectures,  which  forming,  more  strictly  than  the 
present,  a  part  of  the  series,  will  also  be  more  strictly  didactic  in  their  character. 

The  subject  of  our  study  is  that  wonderful  thing,  the  animal  body — and  more  par- 
ticularly the  human  body;  its  construction  and  qualities;  its  actions  and  its  suffer- 
ings ;  its  derangements  ;  its  decay. 

In  this  study,  which  affects  the  mind  with  a  strong  feeling  of  curiosity,  not  un- 
mixed with  awe,  you  have  already  advanced  a  certain  way :  for  you  have  observed 
the  outward  form  and  configuration  of  the  body ;  examined  its  internal  composition 
and  structure ;  and  learned  what  is  known  of  its  various  endowments,  the  working 
and  the  uses  of  its  several  parts. 

This  amount  of  knowledge  was  indispensable  to  j'our  further  progress.  But  it 
forms  a  portion  only  of  what  you  assemble  here  to  learn  :  or  rather  it  is  the  neces- 
sary preparation  for  that  ulterior  knowledge  which  it  is  your  main  purpose  to  acquire. 
The  sublimer  speculations  springing  naturally  from  the  researches  in  which  you 
have  as  yet  been  engaged,  have  not,  I  trust,  been  unregarded.  You  cannot  have 
looked  into  the  mechanism  of  that  intricate  but  perfect  work, — you  cannot  have  con- 
templated its  fullness  of  exquisite  contrivance,  its  endless  examples  of  means  adjusted 
to  ends;  its  prospective  expedients  against  future  needs,  its  compensations  for  inevi- 
table disadvantages,  its  direct  provisions  for  happiness  and  enjoyment, — without 
receiving  the  profoundest  conviction  of  the  being  and  the  attributes  of  its  Maker.  Il 
is  upon  human  anatomy  that  Paley,  in  his  unrivalled  argument  for  Natural  Theology, 
"  takes  his  stand ;"  and  sixteen  centuries  before  him,  Galen  !.ad  felt  that,  in  writing 
3  b2  (17) 


18  INTRODUCTORY    LECTURE. 

his  aniUomical  treatises,  he  was  composing  a  hymn  to  the  Deity ;  that  a  declaration 
so  plain  of  the  wisdom,  the  power,  and  the  goodness  of  God,  was  an  act  of  piety 
and  praise.  But  beyond,  though  not  above,  these  higher  objects  of  a  diligent  inves- 
tigation of  man's  bodily  fabric,  we  have  another  and  still  a  nobler  end;  and  it  is  my 
business  to  take  you  one  step  nearer  to  that  end.  Hit}  erto  you  have  been  told  of 
structure  and  of  function.  Henceforward  our  theme  must  be  of  health  and  of  dis- 
ease. Of  health,  that  we  ma)"^  understand  disease;  of  disease,  that  we  may,  under 
Providence,  restore  health.  Our  objects  are  to  preserve  the  one ;  to  prevent,  remove, 
or  mitigate  the  other. 

What  then  do  these  contrasted  terms  denote? 

Health  we  regard  as  a  standard  condition  of  the  living  body.  But  it  is  not  easy 
to  express  that  condition  in  a  few  words,  nor  is  it  necessary.  My  wish  is  to  be 
intelligible  rather  than  scholastic;  and  I  should  probably  puzzle  myself  as  well  as 
you,  were  I  to  attempt  to  lay  down  a  strict  and  scientific  definition  of  the  term  health. 
It  is  sufficient  for  our  purpose  to  say,  that  it  imphes  freedom  from  pain  and  sick- 
ness ;  freedom  also  from  all  those  changes  in  the  structure  of  the  body  that  endanger 
life,  or  impede  the  easy  and  effective  exercise  of  the  vital  functions. 

It  is  plain  that  health  does  not  signifj^  any  fixed  and  immutable  condition  of  the 
body.  The  standard  of  health  varies,  in  different  persons,  according  to  age,  sex, 
and  original  constitution  ;  and  in  the  same  person  even,  from  week  to  week,  or  from 
day  to  da}',  within  certain  limits  it  may  shift  and  oscillate. 

Neither  does  health  necessarily  imply  the  integrity  of  all  the  bodily  organs  :  it  is 
not  incompatible  with  great  and  permanent  alterations,  nor  even  with  the  loss,  of 
parts  that  are  not  vital ;  as  of  an  arm,  a  leg,  or  an  eye. 

If  we  can  form  and  fix  in  our  minds  a  clear  conception  of  the  state  of  health,  we 
shall  have  no  difficulty  in  comprehending  what  is  meant  by  disease,  which  consists 
in  some  deviation  from  that  state  :  some  uneasy  or  unnatural  sensation  of  which  the 
patient  is  aware ;  some  embarrassment  of  function  perceptible  by  himself,  or  by 
others;  or  some  unsafe,  though  hidden  condition,  of  which  he  may  be  quite  uncon- 
scious :  some  mode,  in  short,  of  being,  or  of  action,  or  of  feeling,  different  from  those 
which  are  proper  to  health. 

I  use  the  word  disease  generically.  Various  terms  in  our  language  bear  nearly 
the  same  meaning,  and  endeavours  have  been  made  to  appropriate  some  of  these 
more  distinctively.  Thus  the  word  disorder  has  sometimes  been  apphed  to  simple 
derangements  of  function,  where  no  alteration  of  structure  is  seen,  or  can  reasonably 
be  inferred  to  exist ;  while  the  term  disease  has  been  restricted  to  maladies,  which 
are  attended  with  appreciable  change  of  texture,  or  which  run  a  short  and  definite 
course.  I  see  no  great  utility,  but,  on  the  contrary,  some  risk  of  confusion,  in  tying 
ourselves  rigidly  down  to  such  distinctions:  indeed,  we  cannot  always  make  them. 
During  life  it  is  often  no  easy  thing  to  determine  .i|jhether  the  parts,  of  which  the 
functions  are  disturbed,  preserve  their  integrity  of  structure  or  not :  and  even  when 
the  peccant  organ  is  placed  before  our  eyes  after  deam,  and  the  most  careful  scrutiny 
fails  to  discover  in  it  any  fauhiness  of  texture,  there  may  still  be  ground  for  suspect- 
ing that  some  material  change,  too  subtle  for  detection  by  our  senses,  may  have  been 
wrought  in  its  finer  and  more  delicate  orsfanization.  I  shall  take  care  to  point  out 
to  you,  as  we  go  along,  the  cases  in  which  we  can  trace  organic  change,  and  the 
cases  in  which  we  cannot ;  but,  for  the  sake  of  simplicity,  I  shall  call  all  deviations 
irom  the  healthy  standard,  whether  of  function  or  of  structure,  by  the  generic  term 
disease ;  and  to  avoid  the  perpetual  and  tiresome  recurrence  of  the  same  word,  I 
shall  not  scruple  to  employ  the  several  terms  disorder,  complaint,  malady,  distemper, 
illness,  as  its  synonyms. 

The  number  of  these  deviations  from  the  standard  of  health,  (in  other  words,  the 
whole  number  o(  diseases,)  if  we  include  all  their  differences  in  Idnd  and  in  degree, 
is  scarcely  calculable ;  and  the  first  thing  requisite  towards  investigating  the  laws 
that  govern  their  phenomena,  is,  that  we  should  break  them  into  groups,  and  dispose 
them  according  to  some  principle  of  order. 

Now,  there  are  various  methods  in  which  this  first  broad  classification  of  diseases 
miffht  be  framed. 


INTRODUCTORY   LECTURE.       '  19 

The  most  cursory  examination  of  the  animal  economy  suffices  to  show  that  it  is 
made  up,  not  merely  of  separate  parts,  but  of  several  distinct  systems.  There  is 
one  set  of  organs  foi  the  mechanical  circulation  of  the  blood  ;  there  is  an  apparatus 
expressly  designed  for  the  repeated  exposure  of  the  blood  to  the  air ;  a  system  for 
regulating  the  movements  and  the  feehngs  of  the  body;  another  for  receiving,  pre- 
paring, and  appropriating  its  nourishment ;  another  for  the  elaboration  of  matters 
that  are  useful  or  essential  to  its  functions  ;  another  for  carrying  off  its  impuritiqs, 
and  for  removing  its  superfluous  or  effete  materials  ;  and  another  for  the  continuance 
of  the  species. 

Now  each  of  these  systems  is  liable  to  changes  of  structure  and  interruptions  of 
function,  peculiar  to  itself;  and  these  peculiarities  must  be  taken  into  account,  what- 
ever may  be  the  order  adopted  in  treating  of  diseases  in  detail.  But  I  shall  not 
divide  the  subject,  as  some  have  done,  into  diseases  of  the  circulating  system — dis- 
eases of  the  respiratory  system — diseases  of  the  nervous  system — and  so  on ;  for 
this,  among  other  reasons,  that  there  are  many  forms  of  disorder  that  effect  all  these 
systems  in  common,  or  simultaneously,  and  comparatively  few  that  are  strictly  con- 
fined to  any  one  of  them. 

Neither,  in  the  lectures  which  I  am  about  to  commence,  shall  I  classify  diseases 
according  to  the  several  tissues  of  which  the  animal  frame  is  composed.  In  speak- 
ing of  diseases  in  general,  it  will,  indeed,  be  both  proper  and  necessary  to  explain  in 
what  manner  the  same  morbid  process  may  be  modified  by  the  nature  of  the  special 
tissue  affected.  But  as  the  entire  body  is  more  or  less  penetrated  and  pervaded  by 
the  intermixture  of  several  of  these  tissues,  so  no  useful  nor  lucid  arrangement  of 
diseases  could  be  founded  on  this  basis. 

Nor  shall  I  attempt  to  construct  a  nosological  system  by  grouping  together  certain 
sets  of  symptoms,  and  calling  each  set,  in  its  collective  form,  a  disease. 

To  say  the  truth,  I  shall  consider  convenience  and  usefulness,  in  frammg  my 
plan,  rather  than  an  appearance  of  scientific  precision;  and  if  I  make  one  principle 
of  arrangement  more  prominent  than  another,  it  will  be  that  which  relates  to  the 
anatomy  of  regions, — the  place  and  situation  of  organs.  At  the  same  time,  I  shall 
not  omit  to  borrow  in  part  from  some  of  those  other  methods  to  which  I  have  just 
been  referring. 

Before,  however,  we  treat  of  the  nahire  of  particular  diseases,  it  will  be  requisite 
to  give  some  general  account  of  the  different  waj-s  in  which  the  various  parts  of  the 
body  are  liable  to  be  altered  in  structure,  or  disordered  in  function  ;  and  before  we 
speak  of  the  signs  of  particular  diseases,  it  Avill  be  proper  to  take  a  general  view  of 
symptoms,  and  of  their  ascertained  relations  with  the  several  forms  of  altered  struc- 
ture :  for  doubtless  you  are  aware  that,  although  diseases  are  not  constituted  by 
symptoms,  they  are,  in  the  living  body,  disclosed  by  symptoms.  Sometimes  the 
symptoms  are  outward  signals  which  alone  reach  our  senses,  and  through  which 
internal  changes  declare  themselves  ;  and  we  then  have  to  decipher  and  to  interpret 
those  signals.  Sometimes  we  see  the  morbid  changes  themselves  on  the  surface  of 
the  body,  or  in  parts  within  our  ken.  Some  internal  changes  we  can  appreciate  as 
surely  by  the  touch,  or  by  the  sense  of  hearing ;  and  of  some  we  infer  the  existence 
from  alterations  in  the  chemical  or  in  the  sensible  qualities  of  the  natural  excretions. 

After  death,  diseases  are  often  to  be  traced  by  visible  changes  of  structure  in  the 
internal  parts  of  the  body.  These  changes  are  extremely  interesting,  as  illustrative 
of  morbid  processes  :  they  throw  light  upon  what  is  past ;  they  afford  some  guidance 
for  the  time  to  come.  But,  for  obvious  reasons,  those  signs  which  reveal  diseases 
during  life  are,  practically,  of  chief  moment.  In  trutli,  the  great  object  of  our  art 
is  to  prevent  or  postpone  the  disclosure  of  the  others.  The  instruction  afforded  by 
the  dead  body  comes  too  late  to  be  of  use  in  that  particular  case. 

I  have  already  intimated  that  the  morbid  physical  conditions  irom  which  the  symp- 
toms flow,  are  not  always  to  be  detected,  either  before  or  after  dissolution.  Neither, 
when  they  are  detected,  is  their  connection  with  the  symptoms  always  evident.^ 

Besides  inquiring  into  the  modes  in  which  the  various  organs  and  textures  of  the 
body  may  be  spoiled,  and  into  the  signals  or  symptoms  by  which  the  presence  of 
disease  may  be  ascertained,  it  will  \^  fcypedient  to  premise  something,  in  a  genen* 


20  INTRODUCTORY   LECTURE. 

manner,  of  the  causes  of  disease,  both  with  a  view  to  its  cure,  and,  what  is  much 
better,  to  its  prevention.  We  shall  also  find  it  very  useful  to  institute  a  short  inquiry 
into  the  different  ways  in  which  death  may  take  place — the  different  processes  of 
dying. 

There  is  one  morbid  condition  or  process,  to  which  all  parts  of  the  body  are 
liable,  and  which  contributes  so  largely  and  so  frequently  to  alterations  both  of  tex- 
ture and  function,  that  it  claims  our  especial  attention  when  discussing  the  more 
general  facts  and  doctrines  of  pathology :  I  allude  to  that  change,  or  series  of 
changes,  which  we  comprehend  under  the  term  injlammation. 

It  will  be  necessary,  therefore,  in  the  preliminary  part  of  the  course,  to  give  a 
general  account  of  inflammation  ;  and  this  account  must  chiefly  be  drawn  from  those 
of  its  phenomena  which  are  most  famihar  to  us — which  we  can  see  and  handle; 
those  which  we  witness  when  the  disorder  is  seated  in  or  near  the  surface,  in  the 
skin,  in  some  of  the  mucous  membranes,  or  in  the  subjacent  areolar  tissue.  Then 
we  shall  pursue  the  examination  of  its  peculiar  phenomena  as  they  are  presented  in 
the  other  tissues  of  the  body — the  mucous,  serous,  fibrous,  parenchymatous,  muscu- 
lar, and  nervous  tissues ;  and  here  the  general  principles  of  treatment  applicable  to 
inflammation  may  be  laid  down,  with  the  modifications  required  according  to  the 
tissues  interested. 

In  this  part  of  the  course  may  also  be  conveniently  discussed  the  modifications  ot 
inflammation,  and  of  morbid  conditions  generally,  by  the  influence  of  certain  diathe 
ses,  or  peculiar  dispositions  of  the  body.  Some  constitutional  morbific  tendencies 
we  shall  find  to  be  innate  or  hereditary ;  such  are  the  scrofulous  and  the  cancerous 
dispositions :  others,  again,  are  plainly  acquired,  as  that  in  which  the  whole  system 
is  tainted  for  a  longer  or  shorter  period  by  the  venereal  poison. 

Hemorrhages,  also,  and  serous  accumulations,  or  dropsies,  as  they  are  liable  to 
occur  in  all  parts  of  the  body,  require  to  be  treated  of  generally,  before  they  pass 
under  our  notice  in  the  hst  of  particular  maladies.  There  are  certain  facts  and  rea- 
sonings common  to  all  inflammations,  to  all  hemorrhages,  to  all  dropsies.  By  com- 
bining these  "generalities"  into  one  comprehensive  statement,  we  help  the  memory, 
avoid  needless  repetitions,  and  find  room  for  the  exposition  of  principles. 

Diseases  themselves,  in  the  mass,  are  sometimes  distinguished  according  as  they 
are  local,  or  general. 

Taking  these  epithets  in  their  popular  sense,  we  should  say  that  local  diseases  are 
those  which  occupy  a  definite  portion  only  of  the  body ;  general  diseases,  those 
which  pervade  the  whole  body. 

But  let  us  endeavour  to  obtain  clear  notions  upon  these  points. 

Certainly  there  are  many  diseases  which,  occupying  a  definite  portion  onl}'-  of  the 
body,  leave  all  the  remaining  parts,  and  the  system  at  large,  healthy  both  in  texture 
and  in  function.     Such  diseases  we  have  no  hesitation  in  calling  local. 

Again,  there  are  many  other  diseases  which,  occupying  a  definite  portion  only  of 
the  body,  yet  occasion  a  manifest  and  serious  disturbance  in  the  functions  of  various 
other  parts,  and  (it  may  perhaps  be  said)  of  the  whole  system.  Inflammation  of  a 
small  portion  of  the  frame  may  give  rise  to  much  secondary  or  symptomatic  fever, 
but  here  also  we  properly  speak  of  the  disease  as  being  local ;  the  secondary'  general 
disorder  resulting  from  the  local  and  primary,  following  it  in  point  of  time,  and  sub- 
siding upon  its  cessation. 

But  there  are  still  other  forms  of  disease  which  show  themselves,  not  like  inflam- 
mation now  in  this  and  now  in  that  part,  but  in  many  or  most  parts  of  the  body  at 
the  same  time.  I  will  take  the  complaint  called  purpura,  characterized  by  the  uni- 
versal appearance  of  purple  spots,  as  an  example  of  what  I  mean.  It  is  in  truth  a 
hemorrhage  afl^ecting  many  or  all  the  tissues  of  the  body  simultaneously.  For  this 
reason  it  is  commonly  regarded  as  a  general  disease. 

But  if  we  look  somewhat  closer  into  the  matter,  we  shall,  I  think,  perceive  that 
most,  if  not  aU,  of  those  which  have  been  thus  reputed  general,  are,  in  fact,  reduci- 
ble to  the  class  of  local  diseases.  The  fluids  are  as  much  parts  of  the  body  as  the 
»ohds ;  and  if  it  be  true,  as  I  believe  it  is,  that  the  essential  and  primary  change  in 
purpura  is  a  change  in  the  blood,  its  characteristic  phenomena  will  be  apt  to  present 


INTRODUCTORY    LECTURE.  21 

themselves  wherever  there  is  blood  circulating  —  that  is,  throughout  the  whole  syj- 
tem.  The  disease  is  local,  inasmuch  as  its  original  seat  is  in  that  particular  fluid, 
the  blood  :  it  appears  to  be  general,  because  the  morbid  blood  is  everywhere  present. 

The  same  observations  apply  to  a  large  class  of  febrile  contagious  diseases ;  to 
that  state  of  the  general  system  which  is  sometimes  called  anaemia ;  also  to  certain 
spasmodic  affections,  where  the  seat  of  the  actual  disorder  is  in  the  whole  nervous 
system. 

What  are  called  general  diseases,  therefore,  are  those  in  which  the  whole  of  some 
one  system  that  pervades  the  entire  body  happens  to  be  similarly  deranged.  Whe- 
ther diseases  can  ever  be  truly  called  general  in  any  more  strict  or  absolute  sense 
than  this,  is  much  to  be  doubted. 

I  have  mentioned  dropsy  as  a  malady  which,  like  hemorrhage  or  inflammation, 
may  occur  in  various  parts  of  the  body  separately.  It  may  also  extend  at  once  to 
all  parts  capable  of  receiving  and  retaining  serous  effusions  :  i.  e.,  besides  filhng  the 
large  serous  cavities,  the  effused  fluid  may  occupy  the  universal  areolar  tissue. 
But  even  this  apparently  general  dropsy  will  be  found,  upon  careful  investigation, 
to  resolve  itself,  in  most  cases  at  least,  into  local  disease  within  the  thorax,  or  the 
abdomen. 

The  diseases  which,  in  the  sense  now  explained,  may  be  called  general,  I  shall 
arrange  among  the  diseases  of  those  parts  of  the  system  from  which  they  have  been 
ascertained,  or  may  be  presumed,  to  arise. 

The  first  part,  then,  of  the  course  will  embrace  an  outUne  of  general  pathology, 
with  an  especial  reference  to  those  morbid  conditions  which  fall  to  the  care  of  the 
physician.  In  its  relations  to  surgery  and  to  midwifery,  pathology  will  be  more 
particularly  taught  by  the  respective  professors  of  those  distinct  though  kindred 
departments  of  medicine.  Do  not,  however,  imagine  that  I  take  no  interest  in 
these,  or  that  there  can  be  any  thing  different  in  the  principles  upon  which  the 
several  branches  of  pathological  knowledge  are  founded.  The  truth  is,  that  you 
cannot,  if  you  would,  separate  the  one  from  the  other.  You  can  neither  understand 
what  may  be  called  medical,  without  learning  much  which  as  strictly  belongs  to 
surgical  pathology  ;  nor  can  you  be  ignorant  of  either,  without  being  in  many 
important  respects  deficient  in  the  other  also.  But  the  open  field  of  pathology  is  of 
wide  extent,  and  although  we  may,  and  must,  survey  the  whole,  yet  its  artificial 
divisions,  its  enclosures  and  allotments,  will  be  cultivated  best,  and  most  improved, 
by  a  division  of  labour. 

Afterwards,  separate  diseases  are  to  be  described  and  considered  ;  all  such,  at  least, 
as  admit  of  being  individuahzed,  or  presented  under  a  definite  shape.  And  here,  I 
repeat,  I  shall  chiefly  pursue  an  anatomical  order,  as  being  comprehensive  and  inar- 
tificial, and  as  tending  to  facilitate  diagnosis.  The  diseases  of  parts  which  lie  near 
each  other  are  the  most  liable  to  be  confounded. 

I  shall  begin,  therefore,  with  the  diseases  of  the  parts  that  appertain  to  the  head 
and  spinal  cord,  and  then  proceed  in  succession  to  those  of  the  parts  belonging  to 
the  neck,  the  thorax,  and  the  abdomen  ;  to  those  of  the  joints,  the  muscles,  and  the 
skin.  I  shall  not  hesitate,  however,  to  deviate  from  this  order,  whenever,  by  doing 
so,  I  can  promote  your  convenience  or  advantage. 

With  that  portion  of  the  course  which  relates  to  particular  diseases,  I  shall  also 
interweave  certain  pathological  considerations,  applicable  not  so  much  to  the  whole 
body  as  to  the  several  great  systems  of  which  it  is  made  up.  Thus,  when  I  come 
to  the  brain,  I  shall  speak  of  the  functions  pecuhar  to  the  nervous  system,  and  of 
the  obstructions  and  disturbances  to  which  those  functions  are  obnoxious,  by  way  of 
preface  to  a  detailed  examination  of  the  various  afflictions  of  the  several  parts  of 
that  system.  Before  discussing  the  diseases  of  the  chest,  I  shall  bring  before  you, 
in  a  general  view,  the  manner  in  which  the  great  functions  of  respiration  and  of 
circulation  are  liable  to  be  impeded,  or  otherwise  disordered.  As  preparatory  to 
the  consideration  of  the  diseases  of  the  abdomen,  I  shall  treat,  in  the  same  way,  of 
the  function  of  nutrition;  and  of  waste,  which  implies  an  interruption  of  those 
functions. 

Still  ihere  would  remain  certain  diseases,  which  would  not  necessarily  find  a 


22  INTRODUCTORY    LECTURE. 

place  m  this  arrangement,  inasmuch  as  their  seat  is  uncertain  or  only  guessed  at. 
Ague  is  one  of  these.  Cholera,  perhaps,  another.  It  is  quite  unimportant  where- 
abouts in  the  course  such  maladies  are  considered.  I  feel  no  concern  about  any 
imputations  of  imperfect  or  clumsy  arrangement  with  which  the  plan  that  I  propose 
to  adopt  may  appear  chargeable.  I  had  rather  not  be  cramped  and  hampered  by 
attempting  what  abJer  heads  than  mine  have  failed  to  achieve,  and  what,  in  truth, 
I  beHeve,  in  the  present  state  of  our  science,  to  be  impossible,  a  complete  methodical 
system  of  nosology.  My  object  will  be  to  furnish  as  much  instruction  and  informa- 
tion as  I  can,  in  the  way  that  seems  most  likely  to  be  practically  useful  to  you. 

Ague  I  shall  take  leave  to  include  among  the  disorders  of  the  nervous  system ; 
and  with  it,  the  important  subject  of  malaria  will  necessarily  engage  much  of  our 
attention. 

The  great  question  of  contagion  I  shall  consider  in  connection  with  continued 
fever,  which  I  rank  among  that  remarkable  class  of  diseases,  the  contagious  exan- 
themata of  Cullen. 

Of  sympathetic  and  of  hectic  fever,  I  must  opeak  when  upon  the  subject  of 
inflammation. 

This,  then,  is  a  sketch  of  the  method  I  propose  to  follow.  In  the  earlier  lectures, 
with  the  general  pathology,  I  shall  endeavour  to  lay  down  principles.  To  these 
principles  I  shall  continually  refer,  as  occasions  offer,  both  in  those  prefatory  remarks 
with  which  I  purpose  to  introduce  the  diseases  belonging  to  the  several  great  sys- 
tems that  contribute  to  form  the  body  ;  and  also  in  what  I  shall  subsequently  have 
to  say  concerning  those  diseases  themselves  in  detail.  In  this  way  I  hope  to  com- 
bine the  advantage  of  repetition,  which  was  the  peculiar  advantage  of  two  short 
courses  in  a  season,  with  that  of  greater  completeness,  which  forms  the  recom- 
mendation of  a  single  extended  course.  The  same  great  advantage  of  repetition  — 
or  I  should  rather  say  of  recapitulation  —  will  be  further  aimed  at  in  the  stated  exa- 
minations of  the  class. 

Such  being  a  summary  of  the  topics  to  be  embraced  in  the  ensuing  series  of 
lectures,  and  of  the  order  in  which  I  hope  to  take  up  those  topics,  it  seems  proper 
that  I  should  now  say  a  few  words  in  explanation  of  the  scope  and  objects  of  the 
course.  The  prospectus  informs  you  that  it  will  comprehend  the  Principles  and 
Practice  of  Physic.     What  are  the  true  import  and  promise  of  these  words? 

By  ihc  principles  of  medicine  are  meant  those  general  truths  and  doctrines  which 
have  been  ascertained  and  estabUshed,  slowly,  indeed,  and  irregularly,  but  still 
with  considerable  precision,  by  the  continued  observation  of  attentive  minds  through- 
out the  entire  progress  of  medicine  as  a  science.  These  principles  I  profess  to  teach 
you.  The  practice  of  medicine,  or  the  particular  application  of  those  general  facts 
and  doctrines  I  shall  describe  to  you  ;  but  I  cannot  profess  to  teach  it  in  this  room : 
nor  can  you  learn  it,  except  in  a  very  imperfect  sense,  from  my  description  of  it. 
Ft  is  the  science  that  I  shall  here  endeavour  to  unfold.  Skill  and  facihly  in  turning 
that  science  to  useful  purposes  I  am  unable  to  impart.  These  are  qualities  that  do 
not  admit  of  being  communicated  from  one  mind  to  another.  The  practice  of 
physic,  like  every  other  practical  art,  is  to  be  learned  by  its  repeated  exercise ;  by 
habit ;  by  carrying  its  various  acts  into  direct  effect  again  and  again  ;  or,  if  they 
happen  to  require  no  manual  dexterity,  by  looking  on,  and  seeing  them  done  again 
and  again.  There  is  this  capital  difference,  however,  between  the  art  of  healing 
and  some  other  arts  :  that  the  blunders  of  early  attempts  may  be  both  grievous  and 
irremediable — may  hurt  or  spoil  the  goodly  and  precious  machine  they  are  intended 
to  repair.  There  is  this  also  peculiar  to  our  art — that  it  proceeds  upon  observations 
made  at  the  very  time  when  its  exercise  is  wanted  ;  and  that  it  requires  skill  in  ob- 
serving as  well  as  skill  in  acting.  You  will  find  what,  perhaps,  previously  to 
posmve  trial,  you  might  not  suspect,  that  the  senses — the  eye,  the  ear,  the  touch — 
nowever  sharp  or  delicate  they  may  naturally  be,  require  a  special  course  of  training 
and  education  before  their  evidence  can  be  trusted  in  the  investigation  of  di>^ease.  I 
do  not  know  that  these  views  are  capable  of  being  rendered  plainer  by  illustration  ; 
I'or  you  must  have  observed  a  similar  distinction  between  the  science  and  the  art  in 


f 


INTRODUCTORY    LECTURE.  23 

various  other  branches  of  human  knowledge.  The  principles  of  navigation  may- 
be thoroughly  comprehended  by  a  person  who  scarcely  knows  a  rudder  from  a  cable, 
and  who  would  not  be  trusted,  nay,  who  would  not  trust  himself,  with  the  conduct 
of  the  simplest  boat.  A  man  may  master  tlie  beautiful  science  of  astronomy — may 
acquire  the  power  of  working  upon  paper  its  sublimest  and  most  abstruse  problems 
—  and  yet  remain  in  complete  ignorance  of  the  method  of  adjusting  and  using  a 
telescope,  and  unable  to  ascertain  for  himself  the  position  or  the  movements  of  a 
single  star.  But  place  such  a  person  night  after  night  in  an  observatory — let  him 
notice  and  imitate  the  proceedings  of  some  one  already  skilled  in  examining  the  phe- 
nomena of  the  heavens — and  he  will  soon  acquire  the  requisite  tact  and  facility  him- 
self. Just  so  it  is  with  that  branch  of  knowledge  with  which  we  are  concerned.  It 
is  in  the  wards  of  a  hospital,  or  in  the  domestic  chamber — it  is  among  the  sick  and 
the  dying — and  there  alone — that  you  can  either  thoroughly  or  safely  learn  to  prac- 
tise physic. 

In  what,  then,  you  may  fairly  ask,  consists  the  value  or  the  use  of  lectures  on  the 
practice  of  physic,  if  the  practice  of  physic  cannot  be  taught  by  lectures  ? 

The  main  object  of  systematic  lectures,  explanatory  of  the  principles,  and  descrip- 
tive of  the  practice  of  medicine,  is  to  prepare  the  hearer  for  observing,  to  the  best 
advantage,  the  actual  phenomena  of  disease,  and  the  power  of  remedies  over  it. 
They  are  intended  to  fit  him  for  seeing  with  intelligence — to  enable  him  to  read,  and 
understand,  and  interpret,  the  book  of  nature  when  it  is  laid  open  before  him — in 
short,  to  qualify  him  for  clinical  study.  One  man  shall  travel  into  a  foreign  land, 
knowing  nothing  beforehand  of  its  scenery  or  its  climate,  of  its  natural  productions, 
its  manufactures,  or  its  works  of  art,  and  ignorant  alike  of  the  manners,  customs, 
history,  laws,  and  language  of  its  inhabitants  ;  another  shall  visit  it  after  having  fur- 
nished his  mind  Avith  information  on  these  subjects  by  reading,  and  by  conversing 
with  men  who  have  already  passed  over  the  same  ground.  Supposing  the  visit  to 
be  limited  in  each  case  to  a  certain,  but  not  long  period  of  time,  and  I  need  not  ask 
your  opinion  as  to  which  of  these  travellers  will  reap  the  greatest  harvest  of  enjoy- 
ment and  of  profitable  knowledge  from  his  journey.  Not  less  striking  is  the  dif- 
ference, in  point  of  instruction  and  of  interest,  perceived  by  different  students,  upon 
their  admission  to  the  bedsides  of  the  sick,  according  as  they  have  been  well  or  ill 
prepared  for  the  multiform  spectacle  of  bodily  suffering  then  first  displayed  before 
them.  There  are  persons,  indeed,  who  seriously,  and  I  make  no  doubt  in  perfect 
good  faith,  warn  the  student  against  bringing  to  the  contemplation  of  disease  any  pre- 
conceived opinions  ;  who  tell  him  that  he  must  come  with  a  free  and  unprejudiced 
mind,  and  see,  and  note,  and  judge  of  all  things  for  himself.  I  also  would  have  him 
exercise,  and  ultimately  abide  by,  his  own  judgment ;  but  surely  if  every  man  were 
to  depend  upon  his  own  unassisted  observation  for  his  knowledge  of  disease,  every 
man  would  be  marvellously  ignorant,  and  the  science  of  medicine  would  stand  still, 
or  cease  to  be.  "  If  no  use  be  made  (says  Dr.  Samuel  Johnson)  of  the  labours  of 
past  ages,  the  world  must  remain  always  in  the  infancy  of  knowledge."  In  truth,  a 
person  who,  without  any  previous  information  concerning  diseases,  should  betake 
himself  to  a  hospital  with  the  design  of  impartially  and  resolutely  investigating  their 
phenomena,  such  a  person,  however  clear  and  strong  his  intellect  might  be,  would 
find  himself,  for  a  long  time,  more  puzzled  than  instructed  by  what  he  saw  around 
him  He  would  be  perplexed  by  the  shifting  and  seemingly  contradictory  characters 
presented  by  the  same  malady  in  different  patients  ;  or  in  the  same  patient  at  dif- 
ferent times  ;  and  not  less  so  by  the  outward  resemblance  of  disorders  essentially  un- 
like. He  could  not  but  be  confused  by  the  multitude  of  symptoms  that  crowded 
upon  his  attention  on  every  side  ;  and  at  a  loss  to  distinguish  important  facts  from 
those  which,  for  the  chief  ends  of  his  pursuit,  were  trivial,  or  useless. 

The  business,  therefore,  of  a  lecturer  upon  the  Principles  and  Practice  of  Medi- 
cine, or,  as  it  is  sometimes  worded,  the  Nature  and  Treatment  of  Diseases,  is  first 
to  fix  upon  some  order  in  Avhich  to  treat  of  the  various  subjects  comprised  in  hi? 
course.  The  simpler  and  less  artificial  his  arrangement,  the  better.  The  chief  use 
of  this  classification  is  to  facilitate  the  recollection  of  particular  facts  ;  and  I  hava 
already  told  you  that  if  I  can  distribute  and  connect  the  multifarious  forms  of  diseasti 


24  INTRODUCTORY    LECTURE. 

in  such  a  manner  as  that  they  shall  appear  plain  to  your  understanding,  and  take  a 
secure  hold  upon  your  memory,  I  shall  not  trouble  myself  nor  you  with  a  vain  search 
after  that  phantom  —  a  perfect  methodical  nosology.  "  In  all  such  classifications," 
writes  Lord  Brougham,  "we  should  be  guided  by  views  of  convenience  rather  than 
by  any  desire  to  attain  perfect  symmetry  ;  and  that  arrangement  may  be  best  suited 
to  a  particular  purpose  which  plants  the  same  things  in  one  order,  and  separates 
them  and  unites  them  in  one  way,  when  an  arrangement  which  should  dispose  those 
thmgs  differently  might  be  preferable,  if  we  had  another  purpose  to  serve." 

Having  settled  this  framework  of  his  discourses,  the  next  aim  of  the  lecturer  must 
be  to  collect  and  arrange  from  the  voluminous  and  bewildering  records  of  medicine, 
and  from  the  necessarily  more  slender  stores  of  his  personal  experience,  whatever  it 
may  seem  of  consequence  that  his  hearers  should  know  concerning  each  distinct 
form  of  disease,  as  it  comes  before  them  for  consideration  :  to  state  all  the  facts  which 
are  well  ascertained,  and  which  tend  to  explain  its  symptoms,  to  elucidate  its  origin, 
to  identify  its  nature,  to  direct  its  treatment,  to  accomplish  its  prevention  :  to  sift  the 
true  facts  from  the  false,  the  important  from  the  trivial,  the  essential  from  the  acci- 
dental :  to  analyze  the  relations  of  these  facts,  and  ascending  from  particulars  to 
generals,  to  point  out  those  great  principles  and  precepts  which  constitute  the  keys 
both  to  the  knowledge  and  to  the  management  of  all  diseases  of  the  same  kind.  It 
may  even  sometimes  be  his  duty  to  notice  and  discuss  mere  theoretical  opinions ;  to 
express  his  own  sentiments  upon  disputed  or  undecided  questions  ;  and  to  admonish 
his  audience  against  the  danger  of  being  led  away  by  ingenious  refinements,  by  the 
speciousness  of  novelty,  or  the  boldness  of  speculation,  from  the  more  secure  and 
settled  results  of  careful  observation  improved  by  patient  thought. 

These  duties  of  a  lecturer  on  medicine  are  metaphorically,  but  aptly,  expressed  in 
the  following  passage  from  Lord  Bacon  : — 

"  Formica  colHgit,  et  utltur,  ut  faciunt  empirici ;  aranea  ex  se  fila  educit,  neque 
a  particularibus  materiam  petit,  ita  faciunt  medic  speculativi  ac  mere  sophistici ;  apis 
denique  ca^teris  se  melius  gerit.  Ha3c  indigesti  e  floribus  mella  colligit,  deinde  in 
viscerum  cellulis  concocta  maturat,  iisdem  tamdiu  insudat,  donee  ad  integram  perfec- 
tionem  perduxerit." 

I  may  venture  to  paraphrase  it  thus  : — 

The  lecturer  must  not  be  the  ant,  collecting  all  things  indiscriminatdy  from  all 
(juarters,  as  provender  for  his  discourses  ; 

Nor  the  spider,  seeking  no  materials  abroad,  but  spinning  his  web  of  speculative 
doctrine  from  within  himself; 

But  rather  the  bee,  extracting  crude  honey  from  various  flowers,  storing  it  up  in 
the  recesses  of  his  brain,  and  submitting  n  to  the  operation  of  his  internal  faculties, 
until  it  be  matured,  and  ready  for  use. 

Such,  gentlemen,  are  the  main  objects  which  I  shall  endeavour  to  keep  steadily 
in  view  during  the  series  of  lectures  I  am  about  to  commence ;  and  I  should  ill 
deserve  the  chair  I  have  the  honour  to  occupy,  if  I  did  not  feel  the  great  responsi- 
bility under  which  I  speak  to  you.  The  subjects  with  which  we  have  to  deal  are 
not  niatters  of  mere  speculative  curiosity  or  intellectual  amusement — to  be  taken  up 
to-day  and  dismissed  perhaps  with  unconcern  to-morrow — but  they  involve  ques- 
tions of  life  and  death.  The  opinions  you  are  now  to  form  or  to  embrace,  are  for 
the  most  part  the  opinions  upon  which  in  after  Hfe  you  will  confident!}''  and  con- 
stantly be  acting.  The  comfort  or  the  misery  of  many  families  may  probably  hang 
upon  the  notions  that  each  of  you  will  carry  from  this  place.  Therefore  it  is  that  I 
feel  myself  to  be  engaged  in  a  very  serious  undertaking.  Doctrines  and  maxims, 
good  or  bad,  flow  abroad  from  a  public  teacher  as  from  a  fountain,  and  his  faulty 
lessons  may  become  the  indirect  source  of  incalculable  mischief  and  suffering  to 
hundreds  who  have  never  even  heard  his  name.  These  reflections  fill  my  mind 
with  an  almost  painful  sense  of  the  obligation  imposed  upon  me,  by  my  present 
office,  of  closely  sifting  the  facts,  and  of  carefully  examining  the  principles  to  be 
derived  from  "those  facts,  which  I  propose  to  employ  for  your  instruction  and 
cruidunce 


PATHOLOGY.  25 

But  amid  all  the  responsibilities,  gentlemen,  both  of  teacher  and  of  learner,  the 
profession  which  you  and  I  have  chosen,  or  Aviiich  circumstances  have  prescribed  to 
us,  is  a  noble  profession,  and  worthy  the  devotion  of  a  hfetime.  If  you  fit  your- 
selves now  for  its  high  functions,  and  pursue  it  hereafter  in  earnestness  and  truth,  it 
will  probably  conduct  you  to  an  honourable  competence,  and  it  will  assuredly  prove 
a  salutary  school  of  mental  and  of  moral  discipline.  Trials,  no  doubt,  belong  to  it, 
and  difficulties  ;  but  it  has  also  privileges  and  immunities  peculiar  to  itself.  Afford- 
ing ample  scope  and  exercise  for  the  intellect,  it  is  conversant  with  objects  that  tend 
to  elevate  the  thoughts,  to  chastise  the  feehngs,  and  to  touch  the  heart.  I  have 
already  reminded  you  how  it  brings  beneath  our  minute  and  daily  notice  that  most 
remarkable  portion  of  matter,  which  is  destined  for  a  season  to  be  the  tabernacle  of 
the  human  spirit,  and  which,  apart  from  tho*^  singularly  interesting  thought,  excites 
increasing  wonder  and  admiration  the  more  closely  we  investigate  its  marvellous 
construction.  The  sad  varieties  of  human  pain  and  weakness  with  which  our  daily 
vocation  is  familiar,  should  rebuke  our  pride,  while  they  quicken  our  charity.  To 
us  are  entrusted,  in  more  than  ordinary  measure,  opportunities  of  doing  good  to  our 
afflicted  fellow-creatures — of  showing  love  towards  our  neighbour.  Let  us  bev^rare 
how  we  idly  neglect,  or  selfishly  abuse,  a  stewardship  so  precious,  yet  so  weighty. 
The  profession  of  medicine,  having  for  its  end  the  common  good  of  mankind,  knows 
nothing  of  national  enmities,  of  political  strife,  of  sectarian  dissensions.  Disease 
and  pain  the  sole  conditions  of  its  ministry,  it  is  disquieted  by  no  misgivings  con- 
cerning the  justice  and  honesty  of  its  client's  cause ;  but  dispenses  its  pecuhar 
benefits,  without  stint  or  scruple,  to  men  of  every  country,  and  party,  and  rank,  and 
religion,  and  to  men  of  no  religion  at  all.  And  like  the  quality  of  mercy,  of  which 
it  is  the  favourite  handmaid,  "it  blesseth  him  that  gives  and  him  that  takes;"  read- 
ing continually  to  our  own  hearts  and  understandings  the  most  impressive  lessons, 
the  most  solemn  warnings.  It  is  ours  to  know  in  how  many  instances,  formino- 
indeed  a  vast  majority  of  the  whole,  bodily  suffering  and  sickness  are  the  natural 
fruits  of  evil  courses ;  of  the  sins  of  our  fathers,  of  our  own  unbridled  passions,  of 
the  malevolent  spirit  of  others.  We  see,  too,  the  uses  of  these  judgments,  which 
are  mercifully  designed  to  recall  men  from  the  strong  allurements  of  vice,  and  the 
slumber  of  temporal  prosperity;  teaching  that  it  is  good  for  us  to, be  sometimes 
afflicted.  Familiar  with  death  in  its  manifold  shapes,  witnessing  from  day  to  day 
its  sudden  stroke,  its  slow  but  open  siege,  its  secret  and  insidious  approaches,  we  are 
not  permitted  to  be  unmindful  that  our  own  stay  also  is  brief  and  uncertain,  our 
opportunity  precarious,  and  our  time,  even  when  longest,  very  short,  if  measured  by 
our  moral  wants,  and  intellectual  cravings. 

Surely,  gentlemen,  you  will  not  dare,  without  adequate  and  earnest  preparation, 
to  embark  in  a  calling  like  this ;  so  capable  of  good  if  rightly  used,  so  full  of  peril 
to  yourselves  and  to  society  if  administered  ignorantly  or  unfaithfully.  And  even 
when  you  have  made  it,  as  you  may,  the  means  of  continual  self-improvement, 
and  the  channel  of  health  and  ease  to  those  around  you,  let  not  the  influence  you 
will  thus  obtain  beget  an  unbecoming  spirit  of  presumption ;  but  remember  that,  in 
your  most  successful  efforts,  you  are  but  the  honoured  instruments  of  a  superior 
power  —  that,  after  all,  "It  is  God  who  healeth  our  diseases,  and  redeemeth  our  life 
from  destruction." 


LECTURE  II. 


Pathology  —  meaning  of  the  term.  Pathology,  general  and  special.  Morbid 
alterations  of  the  solid  parts  of  the  body.  Alterations  in  bulk.  Hypertrophy 
—  law  of  its  production  —  its  effects.  Atrophy  —  its  causes  and  consequences. 
Changes  inform.    Alterations  in  consistence.     Induration  —  i/s  various  kinds. 

I  PROPOSE   to  devote  several  lectures,  in  the  commencement  of  the  course,  to 

pathology,  as  it  relates  to  medicine. 

o 


26  ALTERATIONS    OF    SOLIDS. 

And  I  must  first  of  all  explain  to  you  what  I  mean  by  the  word  Pathology. 

Many  persons  speak  of  pathology  as  if  it  were  the  same  thing  with  morbid 
anatomy.  That  is  not  the  sense  in  which  I  purpose  to  use  the  term.  Pathology  is 
morbid  anatomy,  but  it  is  something  more. 

A  knowledge  of  pathology  (in  the  full  and  proper  acceptation  of  the  word) 
implies  indeed  a  knowledge  of  altered  structures  and  of  diseased  conditions;  —  but 
it  implies  also  an  explanation  of  these — a  knowledge  of  what  precedes  them,  and  a 
knowledge  of  what  results  from  them. 

It  comprehends,  therefore,  the  following  particulars :  —  1.  A  knowledge  of  the 
material  changes  to  which  the  several  parts  of  the  living  body  are  subject :  2.  A 
knowledge  of  the  processes  or  actions  whereby  these  changes  may  be  wrought :  3. 
A  knowledge  of  the  causes  which  may  set  these  processes  on  foot:  and  4.  A 
knowledge  of  the  consequences  of  the  same  changes,  or  of  the  symptoms  they 
occasion. 

On  some  of  these  points  our  actual  knowledge  is  still  scanty  and  imperfect.  Yet 
a  good  deal  of  valuable  information  concerning  each  of  them  has  been  collected  ; 
and  this  I  shall  endeavour  to  place  before  you  as  distinctly,  and  at  the  same  time  in 
as  small  a  compass,  as  I  can. 

Pathology  is  general  or  special.  General  pathology  treats  of  the  morbid  condi-* 
lions  which  are  common  to  the  entire  system,  or  to  the  whole  of  each  of  the  several 
tissues  that  pervade  and  compose  the  system.  Special  pathology  contemplates  par- 
ticular diseases.  An  acquaintance  with  general  pathology  prepares  us  for,  and  con- 
ducts us  to,  that  which  is  special ;  and  w'hen  I  say  that  the  eariier  lectures  of  the 
course  will  be  given  to  a  consideration  of  the  leading  facts  and  doctrines  of  patho- 
logy, you  will  of  course  understand  me  to  speak  of  general  pathology. 

I  shall  begin  by  inquiring  what  are  the  changes  to  which  the  component  parts 
of  the  hving  frame  are  liable :  and  I  speak  chiefly  of  sensible  changes ;  leaving 
unnoticed  for  the  present  those  conditions  which  are  perceptible  only  through  the 
microscope. 

There  are,  then,  various  ways,  capable  of  intelligible  description,  in  which  the 
different  parts  of  the  body  may  be  sensibly  altered  by  disease. 

The  solid  garts  may  be  altered  in  bulk;  inform;  in  consistence ;  in  their  inti- 
mate texture,  i.  e.,  in  the  qualities  and  arrangement  of  their  component  particles ; 
and  in  situation. 

The  fluid  parts  may  also  be  altered  in  quantity ;  in  quality ;  and  in  place. 

And  many  of  these  alterations  may  exist  in  combination  wilh  each  other. 

Let  us  first  consider  the  solids. 

They  may  be  simply  altered  in  bulk  without  any  change  of  texture ;  and  that  in 
two  ways.  They  may  become  larger  than  natural,  or  smaller  than  natural.  In  the 
one  case  the  change  is  called  hypertrophy,  in  the  other  atrophy. 

We  find  the  best  illustrations  of  hypertrophy  in  the  muscular  system.  The 
huge  fleshy  masses  visibly  prominent  in  the  arm  of  a  blacksmith  or  a  pugilist, 
and  in  the  leg  of  an  opera  dancer,  afford  familiar  examples  of  it.  In  these  cases 
the  increased  bulk,  although  it  may  be  unsightly,  as  being  out  of  proportion  to  other 
parts,  is  not  disease,  and  does  not  interfere  with  the  most  perfect  health.  By  con- 
stant exercise  the  muscles  acquire  preternatural  volume,  and  weight,  and  power. 
It  seems  to  be  a  law  which  prevails  extensively  in  the  animal  economy,  that  increase 
of  function  should  lead  to  augmentation  of  bulk.  The  function  of  the  muscular 
system  is  contraction,  and  more  frequent  and  energetic  contraction  begets  an  ad- 
dition of  substance.  But  the  same  principle  obtains  in  various  other  parts  and 
tissues.  It  is  especially  noticeable  in  some  of  the  organs  that  are  double.  If  one 
kidney  wastes,  or  is  spoiled  by  disease,  an  increase  of  function  is  thrown  upon  the 
oiher,  and  by  a  beautiful  law  of  compensation,  the  sound  organ,  without  any  alter- 
ation of  its  peculiar  fabric,  enlarges.  The  same  is  observed  to  be  the  case  wilh  the 
lungs  The  law  resembles,  somewhat,  one  that  is  familiar  to  political  economists, 
and  is  expressed  by  them  in  the  maxim — that  the  supply  of  a  marketable  com- 
modity is  regulated  by  the  demand  for  it.  If,  in  respect  to  a  muscle,  increase  of 
force  be  habitually  needed,  the  necessity  generates  the  requisite  addition  of  bulk, 


ALTERATIONS  OF  SOLIDS.  Zi 

which  implies  an  augmentation  of  force.  One  kidney  becoming  inefficient,  it  is 
necessary  that  the  other  should  secrete  a  larger  quantity  of  urine  ;  and  this  faculty  is 
obtained  by  the  enlargement  of  the  secreting  organ. 

I  say  this  law  is  of  extensive  operation  in  the  living  body :  but  it  is  not  universal. 
[t  does  not  hold,  for  instance,  in  respect  to  the  organs  of  the  special  senses.  One 
eye  does  not  become  hypertrophic  when  the  other  is  blind ;  nor  one  ear  grow  larger 
or  longer  because  the  other  is  deaf.  And  we  see  at  once  why  the  law  in  question 
does  not  apply  in  such  cases.  These  organs  differ  from  such  as  I  mentioned  before 
— from  muscular  and  glandular  parts — in  this  :  that  increase  of  their  size  would  not 
further  or  facilitate  the  purpose  they  are  designed  to  serve.  A  muscular  arm  will 
strike  a  harder  blow  and  lift  a  heavier  weight,  in  proportion  to  the  greater  bulk  of 
its  muscles :  but  we  should  gain  nothing  in  distance  or  distinctness  of  vision  by  the 
enlargement  of  an  eye ;  nor  should  we  hear  more  acutely  or  more  clearly  if  our  ears 
were  of  twice  the  ordinary  magnitude. 

Hypertrophy  of  this  unmixed  kind — unattended  by  any  change  of  texture — (and 
It  is  10  this  that  the  term  should  as  much  as  possible  be  restricted) — is  believed  to 
depend  upon  more  active  nutrition  of  the  part  (vrtsp  *pcK|»;.)  More  materials  are  laid 
down  in  the  part  by  the  blood,  and  assimilated,  than  are  received  back  from  the  part 
into  the  blood  to  be  taken  out  of  the  body.  The  nutritive  process  preponderates  over 
the  re-absorbent.  That  hypertrophy  does  thus  result  from  an  excess  in  the  process 
by  which  parts  are  nourished  and  built  up,  and  not  from  a  defect  in  the  process  by 
which  they  are  continually  unmade  and  removed,  is  rendered  probable  by  the  fact 
that  an  increased  quantity  of  nutrient  blood  is  sent  to  the  hypertrophied  part ;  its 
arteries  grow  larger :  this  we  perceive  by  comparing  these  vessels  with  others  where 
no  accession  of  bulk  has  occurred.  This  opinion  is  further  strengthened  by  the 
converse  effect  produced  upon  an  hypertrophied  part  (the  thyreoid  gland,  for  in- 
stance), by  tying  its  principal  nutrient  artery.  The  magnitude  of  the  bronchocele 
diminishes.  It  is  curious  that  no  such  alteration  of  size  has  been  noticed  in  the 
nerves  supplying  the  hypertrophied  parts. 

Now  these  examples  of  hypertrophy  clearly  have  not  the  nature  of  disease.  But 
hypertrophy  is  often  plainly  connected  with  disease,  while  still  it  is  not  itself  a 
morbid  process.  Thus  we  have  it  in  the  hollow  contractile  organs,  the  office  of 
which  is  to  propel  fluids : — in  the  heart  when  the  progress  of  the  blood  suffers  some 
mechanical  impediment :  in  the  bladder  when  the  urine,  and  in  the  intestinal  canal 
when  its  contents  are  somehow  hindered  in  their  natural  course ;  or  when,  from 
some  undue  stimulus  or  irritation,  these  parts  respectively  are  urged  for  a  long  time 
together  to  excessive,  or  too  frequent  action.  I  show  you  preserved  specimens  ot 
each  of  these  changes.  You  will  find  that  muscular  tissue  may  become  apparent, 
under  the  influence  of  disease,  where  very  slight  traces  of  it,  or  none  at  all,  were 
visible  before.  We  sometimes  observe  this  in  the  air-tubes,  the  trachea  and  bronchi, 
when  the  respiratory  functions  have  been  long  embarrassed ;  and  in  the  gall-blad- 
der, when  the  exit  of  the  bile  has  been  chronically  obstructed.  And  it  is  worth 
remarking  that  this  new,  or  greatly  exaggerated  appearance  of  muscular  tissue, 
which  is  the  consequence  of  disease  in  the  human  body,  is  a  part  of  the  natural  and 
healthy  structure  in  the  corresponding  organ  of  some  of  the  inferior  animals. 

The  several  instances  of  hypertrophy  that  I  have  now  been  mentioning,  if  they 
are  to  be  looked  upon  as  morbid,  are  morbid  in  a  particular  and  limited  sense — 
morbid,  merely  as  being  associated  with  disease,  but  not  so  either  in  their  own  pro- 
cesses or  in  their  tendencies.  Many,  indeed,  of  the  writers  who  notice  them,  speak 
of  the  hypertrophy  as  constituting  a  source  of  disease,  and  a  cause  of  danger  to  the 
patient.  But  I  shall  have  occasion  to  show  you  hereafter  that  in  most  cases  it  is 
really  a  compensatory  change,  and  conservative  of  life ; — a  resource  of  nature  by 
which  impending  danger  is  postponed,  and  existence  prolonged. 

It  may  be  said  of  hypertrophy,  that  its  relation  to  disease  depends  very  much 
upon  its  seat.  As  regards  the  muscular  system — in  the  voluntary  muscles  it  is 
generally  innocent,  in  the  involuntary  it  is  generally  connected  with  disease ; 
sometimes  as  a  cause,  much  oftener  as  a  consequence,  sometimes  as  both  cause 
and  consequence.     One  way  in  which  hypertrophy  may  manifestly  be  a  cause  of 


28  HYPERTROPHY. 

disease  is  by  the  pressure'of  an  enlarged  organ  upon  the  parts  in  its  neighbour- 
hood, and  a  consequent  interference  with  the  functions  or  the  sensations  of  those 
parts. 

I  am  not  sure,  whether  to  those  among  you  who  are  beginners,  I  make  myself 
understood.     An  example  or  two  will  render  my  meaning  obvious. 

It  often  happens  that  the  aortic  orifice  of  the  left  ventricle  of  the  heart  becomes 
narrow  and  constricted,  in  consequence  of  disease  in  the  semilunar  valves  there 
situate.  Under  these  circumstances  it  is  requisite,  for  the  due  propulsion  of  the 
obstructed  blood,  that  the  ventricle  should  contract  with  increased  force :  and  its 
walls  become,  accordingly,  thicker  and  stronger.  Here  the  hypertrophy  of  the  left 
chamber  is  evidently  a  consequence  or  effect  of  the  disease  that  previously  existed 
at  its  outlet. 

On  the  other  hand,  when  the  thyreoid  gland  is  enlarged,  it  sometimes  presses  so 
much  upon  the  parts  that  lie  behind  it,  as  to  impede  the  breathing,  or  the  swallow- 
ing.    In  this  case  the  hypertrophy  is  the  cause  of  consecutive  disease. 

Hypertrophy  is  exceedingly  common  in  other  tissues  as  well  as  in  the  mus-* 
cular.  Of  its  affecting  the  glandular  system  we  have  good  examples  in  what  I 
have  just  mentioned,  the  true  bronchocele ;  in  certain  forms  of  enlarged  prostate ; 
in  the  thymus  gland  not  unfrequently.  Of  a  state  of  the  brain  which  is  considered 
to  constitute  hypertrophy,  I  shall  speak  more  particularly  when  we  come  to  the 
morbid  conditions  of  that  organ.  Hypertrophy  is  also  said  (I  am  not  certain  with 
how  much  propriety  always)  to  occur  in  the  cutaneous,  mucous,  and  vascular 
systems,  in  the  bronchial,  mesenteric,  and  mammary  glands,  in  the  liver,  spleen, 
and  pancreas.  Of  these  parts  I  suspect  that  the  enlargements  to  which  the  term 
hypertrophy  has  been  sometimes  applied,  most  frequently  combine  some  alter- 
ation of  texture  with  the  increase  of  size,  and  therefore  are  not  strict  examples  of 
hypertrophy. 

You  ought  to  be  aware  that  hypertrophy  of  one  or  more  of  the  component  tissues 
of  an  organ  may  exist,  while  the  others  either  remain  unaltered,  or  are  changed  in 
some  other  way.  It  frequently  happens  that  when  one  component  part  is  thus  over- 
nourished,  it  is  so  at  the  expense  (as  it  would  seem)  of  another  which  becomes  atro- 
phied. There  are  parts  of  the  heart  upon  which  a  certain  quantity  of  fat  is  usually 
deposited.  It  is  not  uncommon  to  meet  with  this  fat  in  excess,  and  at  the  same  time 
to  find  the  muscular  texture  of  that  organ  pale,  flabby,  soft,  and  wasted.  What  has 
been  deemed  hypertrojihy  of  the  female  breast  consists,  almost  always,  I  believe,  in 
excessive  development  of  its  adipose  tissue,  without  any  enlargement  of  the  gland 
itself — or  even  with  its  diminution. 

Hypertrophy  of  the  adipose  tissue  is  often  general  througiiout  the  body,  producing 
obesity ;  and  this  may  become  so  extreme  as  to  amount  to  disease,  when  it  is  called 
by  nosologists  polysarcia.  I  have  seen  one  fatal  instance  of  this  kind.  The  mother 
of  a  large  family,  whom  I  long  knew  as  a  slender  and  elegant  woman,  began  sud- 
denly to  grow  fat ;  and  in  about  fifteen  months,  without  any  other  discoverable 
malady,  she  gradually  enlarged  into  a  corpulent  unwieldy  monster.  At  length  her 
legs  and  thighs  became  a3dematous  as  well  as  fat,  her  lips  blue,  hei  breath  was 
short,  and  her  pulse  feeble.  One  night  she  was  found  dead  in  her  bed.  The  body 
was  not  examined ;  but  her  death  was  mainly  owing,  as  I  believe,  to  fat  collected 
upon  the  heart,  oppressing  its  movements,  and  at  last  stopping  them  altogether. 

[n  the  majority  of  cases  the  size  of  an  hypertrophied  organ  is  augmented  ;  it  has 
a  larger  superficies  than  is  natural :  and  therefore  I  have  introduced  hypertrophy  to 
your  notice  among  the  alterations  to  which  parts  are  hable  in  balk. 

But  it  is  not  always  so.  There  may  be  hypertrophy  of  an  organ  without  enlarge- 
ment— in  at  least  three  different  ways : — 

1st.  In  hollow  organs,  where  the  additional  substance  is  deposited  cenlrically,  and 
the  hypertrophy  takes  place  at  the  expense  of  the  cavity : 

2dly.  In  any  organ,  whereof  the  hypertrophy  is  confined  to  one  or  more  tissues, 
while  the  others  are  proportionably  wasted ;  and, 

3dly.  Hypertrophy  may  even  be  consistent  with  no  alteration  of  shape,  or  increase 
of  bulk  in  any  direction,  the  organ  occupying  exactly  the  same  <;p^ce,  and  preserving 


HYPERTROPHY.  29 

the  same  absolute  dimensions  as  before,  but  becoming  more  full  of  component  par 
tides,  more  compact,  heavier.  This  state  is  well  exemplified  in  certain  cases  of 
hypertrophy  of  bone :  the  spongy  or  cancelous  texture  of  the  bone  disappears ;  its 
specific  gravity  is  increased  ;  it  becomes  hard,  firm,  and  like  ivory.  The  structure 
appears,  to  the  eye,  to  be  changed,  yet  remains  the  same,  except  in  respect  of  its 
density. 

I  have  told  you  that  hypertrophy  is  usually  a  conservative  and  salutary  change. 
We  shall  meet  with  many  illustrations  of  this  as  we  proceed.  But  I  may  take  the 
present  occasion  for  pointing  out  to  you  some  of  the  beneficial  tendencies  of  this 
change  when  it  takes  place  in  bone.  For,  since  the  diseases  of  the  bones  do  not 
belong  to  my  province,  I  shall  have  no  other  opportunity. 

You  probably  know  that  in  the  disorder  called  rickets,  occurring  principally  during 
childhood,  the  bones  are  soft  and  deficient  in  their  more  solid  ingredient ;  so  that 
they  bend  under  the  weight  of  the  body,  or  the  contraction  of  the  muscles  attached 
to  them.  After  a  certain  period  this  disproportion  in  the  constituent  particles  of  the 
osseous  tissue  ceases  ;  but  the  bones  are  permanently  distorted,  and,  therefore,  less 
adapted  to  their  office,  and  less  strong,  than  if  they  had  remained  straight.  Now  the 
natural  remedy  that  ensues  is  very  striking  and  beautiful.  The  bent  bones  become 
hypertrophied  in  certain  places  ;  they  grow  thicker,  denser,  harder,  and  consequently 
strong,  at  the  very  concave  part  where  the  stress  of  the  pressure  is  the  greatest. 

The  following  experiment  showed  the  same  thing  in  a  somewhat  different  man- 
ner. An  inch  of  the  middle  part  of  the  fibula  of  a  quadruped  was  cut  out.  A  long 
time  afterwards  the  animal  was  killed.  The  tibia  was  then  found  to  have  become 
considerably  larger  exactly  in  that  part  of  it  which  corresponded  to  the  defect  in  the 
fibula.* 

The  same  principle  appears  still  more  conspicuously  in  a  case  of  disease  related 
by  Cruveilhier.  He  saw  in  the  hospital  at  Limoges  a  young  man  who  had  lost 
(from  necrosis  with  suppuration)  the  middle  third  of  his  tibia;  of  the  larger  of  the 
two  bones  of  the  leg.  The  lost  bone  had  not  been  reproduced,  but  the  fibula,  the 
naturally  slender  bone,  had  become  thick  and  strong  enough  to  support  the  whole 
weight  of  his  body. 

I  was  explaining  to  you  that  hypertrophy  may  exist  without  enlargement.  On 
the  other  hand  there  may  be  enlargement  without  any  change  of  structure,  and  yet 
no  hypertrophy.  The  liver  and  spleen  are  apt  to  acquire  a  considerable  increase  of 
bulk  from  mere  congestion  and  distension  of  their  vessels  by  blood.  An  immense 
spleen  will  shrink  into  its  proper  size  in  a  few  hours,  after" hemorrhage  from  the  sto- 
mach, whereby  the  gorged  venous  system  of  the  abdomen  has  been  relieved.  Dr. 
Townshend  mentions  a  remarkable  example  of  the  same  kind  respecting  the  liver. 
The  inferior  cava  has  been  compressed  by  an  aneurismal  tumour,  so  that  the  pas- 
sage of  blood  from  the  liver  was  greatly  impeded.  Under  these  ciioumstances  the 
liver  became  so  large  as  nearly  to  reach  the  crest  of  the  ilium.  Suddenly  the  aneur- 
ism burst,  the  pressure  was  taken  from  the  cava,  the  hepatic  veins  weie  allowed  to 
empty  themselves,  and  before  the  bod}  was  opened  for  inspection,  the  'iver  had 
nearly  resumed  its  natural  situation  and  dimensions. 

Of  the  causes  of  hypertrophy  little  more  is  known  than  I  have  already  told  you. 
The  most  important  circumstance  for  you  to  remember  is,  that  increase  of  function 
produces  increase  of  nutrition.  This  is  nearly  a  general  fact ;  but  whether  the  con- 
verse proposition  be  as  generally  true — whether  hypertrophy  of  a  part  always  de- 
notes increased  activity  in  its  function — is  much  less  certain.  If  that  were  ascer 
tained,  we  might  hope  to  discover  the  actual  office  of  certain  parts  of  the  body,  the 
uses  of  which  we  do  not  yet  understand  (of  the  thyreoid  gland,  for  example),  by 
investigating  the  circumstances  under  which  they  become  subject  to  hypertrophy. 
In  Mr.  Mayo's  Outlines  of  Human  Pathology,  a  case  is  related  of  hypertrophy  of 
the  tongue,  in  a  young  child,  treated  by  Mr.  Hodgson,  of  Birmingham.  It  would 
seem  to  be  impossible  to  account  for  this  by  any  increased  energy  in  the  known 
functions  of  that  member. 

*  Mr.  Stanley's  Lectures,  Coll   Si'rg. 
c3 


30  ATROPHY. 

A  few  isolated  facts,  bearing  upon  some  points  connected  witn  tins  inquiry,  hav3 
been  nnade  out. 

In  the  first  place,  certain  localities  appear  to  be  influential  in  the  profluction  of 
certain  forms  of  hypertrophy.  Thus  bronchocele  is  verj'  frequent  among  the  inha- 
bitants of  certain  districts ;  especially  in  close  or  marshy  valleys  at  the  feet  of  high 
mountains.  Its  real  cause  is  to  be  sought  in  some  condition,  hitherto  undetermined, 
of  the  air  in  those  places,  or  of  the  water,  or  of  both. 

2dly.  Certain  congenital  or  acquired  conditions  of  the  body  tend  to  produce  local 
hypertrophy.  In  that  peculiar  diathesis  which  we  call  the  strumous — and  of  which 
I  shall  have  much  to  say  hereafter — certain  parts  of  the  body,  as  the  upper  lip,  and 
the  extremities  of  the  long  bones,  undergo  a  kind  and  degree  of  enlargement  thai 
seem  properly  to  fall  within  the  definition  of  hypertrophy. 

3dly.  Certain  habits  of  life  have  a  distinct  effect  in  promoting  certain  forms  of 
hypertrophy.  Full  diet,  with  bodily  inactivity,  leads  to  hypertrophy  of  the  adipose 
tissue.  So  general  is  this  tendency,  that  we  confidently  act  upon  it  in  the  fattening 
of  animals.  Shut  a  healthy  pig  up  in  a  small  st}^,  and  give  him  as  much  food  as 
he  is  willing  to  eat,  and  you  insure  his  rapid  pinguescence.  If  you  cannot  so  cer- 
tainly attain  the  same  result  by  similar  means  in  the  human  animal,  it  is  chiefly,  I 
believe,  because  moral  causes,  and  especially  mental  anxiety,  will  effectually  coun- 
teract those  means.  A  healthy  man,  with  a  quiet  mind,  using  habitually  a  full  nu- 
tritious diet,  and  leading  a  sedentary  life,  will  fatten,  I  apprehend,  as  unfaihngly  as 
a  calf,  or  a  turkey.  Sometimes,  indeed,  fat  accumulates  to  an  enormous  extent,  in 
spite  of  abstinent  habits,  and  very  active  exercise. 

4thly.  It  is  a  curious  fact  that  the  removal  of  certain  parts  of  the  body,  as  the 
testicles  from  male  animals,  and  the  ovaries  from  females,  increases  the  disposition 
to  accumulate  fat.  The  same  tendency  appears  to  be  given,  for  a  time,  by  the 
extirpation  of  the  spleen. 

Of  the  curative  methods  that  hypertrophy  may  require  it  would  be  premature  to 
speak  at  present. 

The  bulk  of  parts  may  be  also  augmented  in  various  other  ways.  The  hollow 
organs  may  be  inordinately  distended  by  an  undue  accumulation  of  their  natural 
contents :  or  by  matters  that  do  not  enter  them  in  health.  The  solid  organs  may 
have  their  size  increased  by  the  presence  of  matter  foreign  to  their  natural  composi- 
tion, collected  in  their  interior,  or  distributed  through  the  insterstices  of  their  proper 
tissues,  or  deposited  upon  their  surface  :  and  in  either  case  the  functions  of  the  part 
itself  may  be  disturbed  or  suspended;  or  the  functions  of  parts  immediately  con- 
tiguous to  it  may  sustain  damage  from  its  pressure  ;  or  the  functions  of  distant  parts 
connected  with  it  by  dependency  of  ofliice  may  be  disordered  ;  or  all  these  conse- 
quences may  exist  together.  Numerous  examples  of  them  all  will  hereafter  be 
brought  under  your  notice. 

Let  us  next  attend  to  that  condition  which  is  the  opposite  of  hypertrophy — to 
atrophy,  namely,  in  which  parts  become  notably  smaller  than  natural,  without  other 
altemtion  of  texture. 

The  two  conditions  contrast  strongly  with  each  other  in  their  nature  and  origin,  as 
well  as  in  their  physical  character. 

Hypertrophy  depends  essentially  upon  an  increase — atrophy  upon  a  diminution 
or  defect,  of  the  nutritive  functions.  You  will  find  that  atrophy  plays  an  important 
part  in  altering  the  bodily  organs,  both  in  heakh  and  in  disease. 

Of  the  effect  of  atrophy  in  causing  alterations  consistent  with  health,  I  shall  merely 
remind  you  of  some  instances,  that  you  may  the  better  comprehend  its  morbid 
operation. 

There  are  parts  of  the  body,  as  you  well  know,  destined  for  a  temporary  purpose 
only.  Upon  the  cessation  of  their  especial  function  they  dwindle,  or  disappear.  We 
have  examples  of  this  in  the  thymus  gland,  in  the  supra-renal  capsules,  and  in  those 
parts  of  the  mechanism  of  the  circulation  which  are  pecuKar  to  the  fostal  state.  The 
atrophy  here  begins  as  soon  as  the  child  is  born,  and  is  not  only  consistent  with,  but 
necessary  to,  its  perfect  health.     As  life  advances,  we  see  the  same  principle  at 


ATROPHY.  31 

work,  remodelling  from  time  to  time  those  structures  of  which  the  office  has  only  a 
limited  duration.  After  the  child-bearing  period  in  women  is  over,  when  the  func- 
tions of  the  ovaries  expire,  these  organs  shrink,  through  atrophy.  It  is  so  with  the 
testes  of  old  men.  Indeed,  atrophy,  to  a  certain  extent,  pervades  all  parts  of  the 
system  in  old  age ;  the  muscles  diminish  in  size,  the  whole  body  is  less  plump,  the 
bones  lose  a  portion  of  their  substance,  and  become  brittle. 

Even  in  the  period  of  foetal  life  this  process,  by  which  parts  are  starved  and 
stunted,  sometimes  displays  itself.  But  here  it  is  no  longer  compatible  with  the 
integrity  and  well-being  of  the  system.  The  arrest  or  retardation  of  the  nutritive 
function  produces  changes  of  great  interest,  and  gives  rise  to  various  kinds  of  mon- 
strosity. Harelip — fissure  of  the  palate — certain  malformations  of  the  heart — are 
familiar  examples  of  the  consequences  of  intra-uterine  atrophy. 

Atrophy,  considered  as  a  morbid  change,  is  conspicuous,  no  less  than  hypertrophy, 
in  the  muscular  system.  We  see  it  in  the  voluntary  muscles,  whenever  a  limb 
remains  long  in  a  state  of  inaction — whether  from  palsy  depending  upon  disease  in 
the  brain  or  spinal  cord  ;  or  from  pain  connected  with  disease  of  a  joint ;  or  from 
perversion  of  the  will,  as  in  the  self-inflicted  penance  of  the  Fakir.  The  same  law, 
therefore,  obtains  here,  which  w^as  previously  announced;  the  development  of  a  part 
is  proportioned  to  the  activity  of  its  function.  In  most  cases,  I  believe,  the  atrophy 
will  be  found  to  resolve  itself  into  a  deficient  supply  of  healthy  arterial  blood.  Build- 
ing materials  are  not  provided,  or  are  provided  inadequately.  Mere  inaction  will 
produce  atrophy ;  but  it  is  probable  that  the  inaction  operates  simply  by  abridging 
the  flow  of  arterial  blood  to  the  muscle.  If  (as  some  suppose)  what  is  called  a 
change  in  the  innervation  of  a  part  tends  sometimes  to  occasion  its  atrophy ;  if,  for 
example,  the  altered  state  of  the  nervous  influence  has  some  share,  beyond  the  inac- 
tion which  it  produces,  in  causing  the  atrophy  of  a  paralyzed  limb — it  stiJl  acts,  I 
conceive,  indirectly,  and  by  reducing  somehow  the  supply  of  healthy  arterial  blood. 
The  nerves  belonging  to  palsied  and  atrophied  muscles  are  said  not  to  diminish  in 
size.  It  is  with  the  arterial  circulation,  certainly,  that  atrophy  is  most  concerned.  It 
is  upon  a  diminution  of  the  number  of  the  smaller,  and  perhaps  also  of  the  capacity 
of  the  larger  arteries,  that  senile  atrophy  depends.  We  find  atrophy  of  the  brain 
accompanying  certain  diseased  conditions  of  its  main  arteries.  So  the  testicles 
wither  when  the  spermatic  artery  is  tied  for  the  cure  of  varicocele. 

Pressure  of  any  kind,  exercised  either  upon  the  large  arterial  trunks,  or  upon  the 
capillary  vessels,  so  as  to  lessen  without  completely  preventing  the  supply  of  blood, 
will  be  found  to  give  rise  to  atrophy,  whenever  the  due  quantity  of  blood  is  not  fur- 
nished by  the  establishment  of  a  collateral  circulation.  Chronic  inflammation  is 
sometimes  attended  by  the  wasting  of  the  part  which  it  occupies.  It  acts,  in  all 
probability,  by  unfitting  the  capillary  arteries  for  transmitting  the  requisite  quantity 
of  blood.  Various  diseases,  by  which  the  supply  of  nutriment  to  all  parts  of  the 
body  is  checked  at  its  source  in  the  digestive  organs,  or  by  which  some  unnatural 
drain  upon  the  system  is  kept  up — by  which,  in  short,  the  quantity  of  the  nutrien* 
fluid  is  diminished,  or  its  quality  impaired — produce  a  greater  or  less  degree  of 
g^enera/ atrophy  ;  but  to  this  universal  wasting  we  usually  apply  the  term  emaciation. 

Atrophy,  then,  such  at  least  as  is  morbid  in  its  nature,  may  be  the  consequence  of 
inaction,  of  compression,  of  chronic  inflammation,  and  of  various  diseases  ;  but  in  all 
cases  the  defect  of  nutrition  which  constitutes  the  atrophy  seems  to  be  resolvable  into 
a  diminished  supply  of  healthy  blood  through  the  arteries. 

As  in  hypertrophy,  so  likewise  in  atrophy,  the  change  may  be  limited  to  some 
one  or  more  of  the  component  tissues  of  a  part ;  and  by  these  altered  proportions  of 
its  constituent  tissues  the  appearance  of  the  part  may  be  remarkably  modified. 

So,  also,  as  hypertrophy  may  exist  without  any  increase  of  absolute  size,  atrophy 
may  occur  without  any  decrease :  as  in  the  heart,  when  the  cavities  are  dilated  in 
the  exact  degree  in  which  their  walls  become  thinner.  Bones,  externally  sound  in 
appearance,  have  had  their  specific  gravity  so  greatly  reduced  by  internal  atrophy, 
tliat  they  would  float  upon  water  like  a  cork. 

It  is  a  curious  fact — which  I  mentioned  in  other  terms  before — that  an  atrophied 
part  is  sometimes  plentifully  encompassed  by  fat.     But  this  is  by  no  means  a  neces- 


32  INDURATION. 

sary  accompaniment.  Why  it  happens  in  one  case,  and  not  in  another — whether 
the  adipose  hypertrophy  is  ever  the  cause  of  tlae  atrophy  associated  with  it,  or  tho 
atrophy  the  cause  of  the  hypertrophy : — these  are  questions  which,  in  the  presem 
state  of  the  science  of  medicine,  do  not  admit  of  any  positive  soUuion. 

It  is  scarcely  necessary  to  observe  that  the  changes  of  bulk  which  we  have  been 
considering,  imply  often,  though  not  always,  changes  o[  form  also.  You  will  have 
one  or  two  of  the  chambers  of  the  heart  greatlj  enlarged,  while  the  others  remain  of 
their  natural  size.  Of  course  this  altered  proportion  modifies  the  shape  of  the  organ 

Signal  changes  of  form  are  produced  also  by  inflammation,  by  pressure,  and  in 
various  other  ways.  But,  after  all,  modifications  of  figure  are  rather  to  be  consi- 
dered as  accidents  of  disease  than  among  its  important  elements :  and  I  pass  on  to 
other  alterations. 

Various  parts  of  the  body  are  liable  to  be  changed  in  consistence.  They  may 
become  harder  and  firmer  than  before:  or  they  may  become  softer.  To' the  state 
of  increased  or  unnatural  hardness  the  term  induraiion  has  been  applied  :  the  same 
word  is  used  also  to  express  the  process  of  hardening.  To  the  state  of  diminished 
consistence  we  give  the  name  of  softening.  The  French  pathologists,  who  first 
noticed  this  condition  as  an  element  of  disease,  call  it  ramolUssement. 

You  are  already  aware — those  of  you  who  have  attended  the  lectures  of  the  pro- 
fessors of  midwifery  and  of  anatomy  —  that  a  slow  process  of  natural  and  healthy 
induration  is  going  on  throughout  the  body  from  the  earliest  period  of  uterine  life  to 
extreme  old  age. 

There  are  several  ways  in  which  wnnatural  induration  may  take  place. 

Induration  of  an  organ  may  happen,  without  any  other  alteration  of  its  proper 
tissue,  in  consequence  of  inordinate  fullness  of  its  blood-vessels.  This  is  apt  to  occur 
in  the  lungs,  or  liver,  whenever  the  free  exit  of  blood  from  these  organs  is  in  any 
way  impeded.     They  become  stretched,  tense,  resisting,  hard. 

In  Uke  manner  induration  of  the  hollow  organs,  or  of  cellular  parts,  will  arise 
/without  any  change  of  their  texture)  from  an  undue  accumulation  of  fluids  within 
<nem  ; — of  bile,  for  example,  in  the  gall-bladder  ;  of  urine,  in  its  receptacle  ;  of  gases 
in  the  stomach  and  intesti^ies ;  of  serosity  in  the  cellular  tissue. 

In  either  of  these  kinds  of  induration  the  unnatural  hardness  may  be  temporary 
only,  or  it  may  be  the  permanent  accompaniment  of  other  disease.  It  is  necessary 
that  you  should  be  aware  of  its  occurrence,  and  of  its  nature.  I  say  of  its  nature, 
because  this  is  not  always  understood.  In  the  induration  arising  from  the  last  cir- 
cumstance I  mentioned,  viz.,  from  infiltration  of  the  cellular  tissue  with  the  serous 
or  albuminous  parts  of  the  blood — from  oedema,  in  short — the  hardness  has  some- 
times been  erroneously  ascribed  to  some  other  morbid  condition.  Dr.  Carswell  has 
shown  that  in  the  curious  disease  of  new-born  children  who  are  said  to  be  skin-bound, 
the  hardness  of  the  surface  is  the  consequence  of  simple  osdema  of  the  subcutaneous 
cellular  tissue.  The  same  phenomenon  is  remarkable  in  oedema  of  the  tongue.  I 
believe  the  induration  belonging  to  oedema  will  be  found  to  be  the  greater,  in  propor- 
tion as  the  efiusion  is  recent,  and  has  taken  place  rapidly. 

Again,  induration  may  accompany,  and  be  a  consequence  of,  simple  hypertrophy. 
Of  this  I  have  already  shown  you  examples ;  especially  in  the  eburnation  (as  it  has 
been  called)  of  hypertrophied  bone. 

Induration  of  an  organ  may  also  result  from  the  compression  of  its  fluid,  and  the 
C07/jpression  of  its  solid  parts.  We  see  this  extremely  well  in  the  lung,  when  it  has 
been  thrust  and  flattened  against  the  vertebral  column  by  fluid  effused  into  the  pleura  ; 
or  when  it  is  still  more  tightly  bound  down  by  an  investing  layer  of  plastic  lymph. 
In  this  way,  therefore,  induration  may  be  consistent  with  atrophy.  That  the  natural 
structure  of  the  hardened  lung  is  not  always  lost  in  these  cases  we  know,  because 
vv^e  can  restore,  to  a  certain  extent  at  least,  its  bulk  and  spongy  feel,  by  forcibly 
mflating  it.  The  spleen  sometimes  exhibits  the  same  kind  of  induration,  under  the 
constrictive  force  of  an  investing  false  membrane.  I  am  mentioning  samples  only 
of  these  changes. 

More  frequently  induration  depends  upon  the  presence,  in  the  internal  texture  of 


SOFTEiMNG.  33 

parts,  in  the  little  spaces  left  between  their  compotent  tissues,  of  fluid  or  solid  matters 
which  are  not  found  there  in  the  healthy  state.  Bony  or  earthy  particles  are  some- 
times laid  down,  and  the  part  thus  changed  is  said  to  be  ossified.  There  are  few 
])arts  of  the  body  in  which  this  kind  of  induration  does  not  occasionally  take  place. 
It  is  especially  common  in  the  coats  of  arteries,  and  in  the  subserous  tissues.  Blood, 
or  fluids  separated  from  the  blood,  may  fill  and  obhterate  the  natural  interstices,  and 
concreting,  tend  to  solidify  and  harden  the  part  which  they  occupy.  What  is  called 
hepatization  of  the  lung  is  a  good  instance.  [  need  not  tell  you  that  the  healthy 
lung  is  spongy  and  crepitant  under  pressure  :  in  this  altered  state  it  no  longer  crackles 
between  the  fingers  ;  its  spongy  character  is  lost ;  it  resembles  liver  in  its  compact- 
ness and  colour,  and  it  is  therefore  said  to  be  "  hepatized."  This  is  a  consequence 
of  inflammation  ;  and  induration  of  this  kind  is  a  very  common  consequence  (as  we 
shall  see)  of-  the  same  morbid  process  in  various  other  parts  and  organs.  Another 
instance  of  induration  of  the  pulmonary  substance  we  have  in  what  is  badly  called 
pulmonary  apoplexy.  This  is  independent  of  inflammation.  Blood  is  collected  and 
coagulates  in  a  part  of  the  lung  which  should  contain  air — in  the  vesicle  of  one  or 
more  of  its  lobules ;  the  lobules  thus  gorged  with  blood  become  even  harder  and 
firmer  than  when  hepatized  ;  but  by  a  different  process. 

In  the  instances  last  mentioned,  fluids  after  escaping  from  their  proper  vessels. 
i.  e.,  in  technical  phrase,  after  being  extravasated,  pass  into  the  solid  form,  and  thereby 
render  the  parts  which  they  pervade  harder  and  more  firm.  But  fluids  may  con- 
crete and  harden  ivithin  their  proper  vessels,  and  so  lead  to  another  form  of  indu- 
ration. Thus  the  blood,  under  certain  circumstances,  coagulates  in  the  hving  veins 
— nay,  sometimes  even  in  the  heart  itself:  and  we  may  hereafter  have  to  consider 
the  conditions  under  which  this  coagulation  is  liable  to  occur,  and  the  serious  conse- 
quences which  it  involves.  The  bile,  again,  as  you  probably  know,  sometimes 
concretes,  by  a  rude  kind  of  crystallization,  into  what  are  called  gall  stones :  and 
the  passage  of  these  calcuK  through  the  narrow  ducts  that  connect  the  gall  bladder 
with  the  bowel,  is  apt  to  be  attended  with  pain  the  most  intense.  The  formation  of 
urinary  calculi  is  not  exactly  of  the  same  kind. 

Numerous  specimens  of  all  the  changes  I  have  been  describing  are  on  the  table 
before  you.     You  may  examine  them  at  leisure  after  lecture,  or  in  the  museum. 

I  have  j'et  to  notice  another  source  of  unnatural  induration,  in  the  deposition  or 
growth  of  irregular  masses  of  matter  within  me  body,  differing  remarkably  from  any 
of  the  solids  or  fluids  that  enter  into  its  healthy  composition.  These  unnatural  for- 
mations vary  considerably  in  their  nature  and  appearance,  and  in  their  consistence 
at  different  periods.  Sometimes  they  exist  in  distinct  and  separate  masses,  ana 
whether  hard  or  soft  in  themselves,  cause  induration  by  their  pressure  upon  surround- 
ing textures :  sometimes  they  are  diffused  through  or  among  the  natural  tissues  of  a 
part,  which  thus  they  indurate.  All  the  varieties  of  tubercle,  and  of  cancer,  and 
other  forms  of  disease  which  have  been  styled  mahgnant,  fall  under  this  head. 

These  new  and  morbid  products  play  a  fearful  part  in  disorganizing  the  bodily 
frame,  and  in  embittering  and  shortening  life.  They  will  necessarily  occupy  much 
of  our  attention  in  the  progress  of  the  course.  At  present  I  merely  point  them  out 
as  illustrations  of  the  manner  in  which  the  consistence  of  parts  may  be  increased. 


LECTURE  III. 

Softening ;  its  causes  and  varieties.  Transformation  of  Tissue ;  Changes  oj 
situation — in  the  Chest,  of  the  Lung,  of  the  Heart — in  the  Abdomen  and  Pelvis. 
Hernia,  Intussusception,  Prolapsus, 

We  were  occupied  with  that  branch  of  pathological  inquiry  which  relates  to  the 
various  ways  in  which  the  several  parts  and  organs  of  the  living  body  are  liable  l(t 
be  sensibly  ahered  by  disease. 
3 


31  SOFTENING. 

We  considered  the  changes  to  which  the  solid  parts  are  subject  in  bulk  and  form  f 
and  that  aheration  of  their  consistence  which  constitutes  hardening  or  induration. 

The  opposite  condition  to  this  is  softening,  diminished  consistence,  a  less  degree 
of  cohesion  of  parts  and  tissues  than  is  natural. 

This  is  also  a  state  of  Avhich  it  is  important  that  you  should  comprehend  the 
nature,  and  causes,  and  varieties  ;  and  the  share  that  it  often  has  in  breaking  down 
the  structure  of  organs,  and  in  destroying  life. 

There  is  scarcely  anj^  tissue  of  the  living  body  in  which  softening  may  not  take 
place.  I  shall  here,  however,  as  before,  mention  a  few  illustrations  only  of  its  occur- 
rence, taking  those  instances  in  which  the  phenomenon  is  most  evident,  or  is  best 
understood. 

Softening  is  perhaps  never  more  strikingly  obvious  to  our  senses  than  when  it 
affects  the  brain  or  spinal  cord.  We  find  portions  of  these  organs  manifestly  softer 
than  the  rest.  You  are  familiar  with  the  usual  consistence  of  the  adult  brain  :  you 
will  find  it  sometimes  reduced,  in  places,  to  the  consistence  of  cream  :  a  gentle  stream 
of  water  suffered  to  fall  upon  the  softened  pulp  suffices  to  wash  it  away,  and  a  cavity 
is  left  in  its  place. 

The  cellular  tissue — or  rather  let  us  call  it,  with  Professor  Todd,  the  areolar  tissue, 
since  minute  anatomists  now  affirm  that  all  the  tissues  in  their  embryonic  state  are 
cellular — the  areolar  tissue  is  another  part  in  which  softening  is  exceedingly  com- 
mon, although  the  change  is  not  so  readily  perceived.  This  is  the  great  connecting 
tissue  of  the  body;  and  we  are  made  sensible  of  its  diminished  consistence  when 
parts  which  it  unites  become  separable  with  unusual  ease.  Thus  you  may  some- 
times, by  exerting  a  very  slight  degree  of  force,  strip  off'  a  serous  membrane  from 
the  parts  which  it  invests,  or  a  mucous  membrane  from  the  surface  hned  by  it.  This 
ready  separation  is  a  consequence  of  the  diminished  consistence  of  the  subserous, 
or  the  submucous,  areolar  tissue.  The  membranes  themselves,  in  such  cases,  may 
be  in  a  perfectly  natural  state. 

Muscles,  again,  are  often  palpably  softer  than  they  should  be  :  the  fleshy  substance 
of  the  heart,  for  example.  Here  the  muscular  fibre  may  itself  have  undergone  a 
change  of  consistence ;  or  the  muscle  may  simply  appear  to  be  softened,  in  conse- 
quence of  the  softening  of  the  threads  of  areolar  tissue  by  which  its  fibres  are  tied 
together. 

The  mucous  membranes  very  frequently  present  the  phenomenon  of  softening. 
This  is  more  commonly  seen  in  the  stomach  than  elsewhere.  Instead  of  being 
raised  from  the  subjacent  tissues  in  large  flakes,  the  mucous  membrane,  when  seized 
between  the  forceps,  breaks  off"  in  small  fragments  ;  or  it  may  be  crushed  and  mashed 
by  the  pressure  of  the  finger,  or  washed  away  in  shapeless  pulp  by  a  little  current 
of  water.  This  condition  of  its  hning  membrane  is  usually  limited  to  parts  of  the 
stomach  ;  but  occasionally  it  is  general. 

Even  the  bones  are  liable  to  this  change  of  consistence.  There  is  a  disease  called 
mollifies  ossiiim,  in  which  the  bones  even  of  adults  become  soft  and  pliant,  and 
capable  of  bending  in  any  direction.  There  is  a  deficiency  in  their  earthy  consti- 
tuents ;  atrophy  of  that  particular  tissue.  Indeed,  softening  is  often  a  concomitant 
or  a  result  of  atrophy. 

The  accidental  products  to  which  I  adverted  when  speaking  of  induration — espe- 
cially some  of  the  varieties  of  cancer — are  sometimes  remarkably  soft,  resembling 
brain  in  consistence  and  appearance,  or  cream,  or  jelly.  But  in  these  cases  we  can 
scarcely  consider  the  change  as  an  example  of  softening  of  the  textures  of  the 
body  ;  it  rather  consists  in  the  addition  of  parts  that  are  themselves  soft  and  half  fluid. 

Now  softening  may  occur  under  very  different  circumstances.  One  very  general 
cause  of  softening  is  inflammation.  Every  part,  I  believe,  that  is  inflamed,  under- 
goes, in  the  first  instance,  a  diminution  of  its  consistence.  This  appears  to  be  almos* 
the  necessary  consequence  of  stagnation  of  the  blood,  the  effusion  of  serosity,  and 
ihe  suspension  of  healthy  nutrition.  These  are  circumstances  to  which  I  shall 
recur.  I  cannot  avoid  alluding  occasionally  to  things  with  which  you  are  supposed 
i(i  be  as  yet  but  little  acquainted,  and  which  will  engage  our  particular  attention  aa 
the  course  advances. 


TRANSFORMATION   OF   TISSUE.  35 

It  would  be  a  great  mistake,  however,  to  suppose  that  all  softening  results  from 
previous  inflammation.  Doubtless  it  often  proceeds  directly  and  simply  from  defi- 
ciency of  nutrition,  and  is  thru  closely  allied,  as  I  said  before,  to  atrophy.  Thus 
softening  of  the  brain  is,  sometimes,  due  to  inflammation  :  we  meet  with  it  where 
the  inflammation  has  been  unequivocal,  and  was  caused  by  external  injury;  but 
sometimes  also  it  is  quite  independent  of  inflammation,  and  is  owing  to  disease  of 
the  cerebral  arteries,  whereby  the  brain,  or  a  portion  of  it,  is  deprived  of  its  full 
supply  of  arieritil  blood,  and  ceases  to  be  properly  renovated  :  hence  a  loosening  of 
its  texture,  a  separation  of  its  component  particles,  an  approach  to  the  fluid  state.  I 
shall,  of  course,  hereatler  endeavour  to  point  out  to  you  more  particularly  the  means 
we  possess  of  distinguishing  these  two  forms  of  cerebral  softening ;  they  constitute 
morbid  conditions  of  the  highest  interest. 

I  may  observe,  that  we  have  an  illustration  of  the  principle  now  laid  down,  in  that 
general  softness,  flaccidity,  and  slight  cohesion  of  parts,  noticeable  in  children,  and 
others,  who  are  imperfectly  nourished.  We  find  this  general  absence  of  the  natural 
firmness  coincident  with  paleness,  and  a  thin  watery  condition  of  the  blood.  Ma- 
gendie  kept  animals  upon  food  unsuitable  to  them,  containing  no  azote,  and  incapa- 
ble of  supplying  sufficient  nourishment ;  and  one  curious  consequence  that  followed 
was  a  loss  of  substance  in  the  cornea,  which  melted  down  and  disappeared. 

There  is  another  source  of  softening  which  requires  to  be  mentioned — I  mean  the 
gastric  juice,  which  has  the  power  of  dissolving  not  only  food  that  is  submitted  to  its 
action,  but  the  mucous  membrane  of  the  stomach  itself,  and  even  all  its  tissues  and 
coats.  This  cause  of  softening  operates,  however,  in  the  dead  body  only ;  but  hs 
effects  have  often  been  mistaken  for  the  consequences  of  disease ;  and  therefore  it 
will  be  necessary  for  me  hereafter  to  call  your  attention  to  the  circumstances  under 
which  they  may  be  expected,  and  to  the  means  we  possess  of  discriminating  them 
from  similar  changes,  which  are  more  properly  called  morbid. 

Upon  the  v/hole,  it  may  be  said  that  every  form  and  kind  of  softening  in  the  living 
body — whether  it  proceed  from  inflammation,  from  disease  of  the  arteries,  from 
insufllcient  sustenance,  or  from  altered  qualities  of  the  blood — may  ultimately  (like 
atrophy)  be  resolved  into  suspended  or  defective  nutrition. 

Furthermore,  as  there  is  a  hardness  of  parts  resulting  from  repletion  and  disten- 
sion, so  there  is  a  softness  rather  than  a  softening,  from  their  emptiness  and  flac- 
cidity :  as  of  the  breast  immediately  after  the  child  has  sucked ;  of  the  abdomen 
soon  after  delivery  ;  of  the  integuments  in  those  who,  having  been  fat,  have  w^asted, 
either  from  disease  or  from  advancing  age  ;  and  so  on. 

On  former  occasions,  T  thought  it  right  to  lay  before  you  the  views  of  M.  Andral 
^vhich  appear  to  have  been  adopted  also  by  Dr.  Carswell)  respecting  what  has  been 
called  the  transformation  of  tissues.  "  In  the  proper  place  of  one  natural  tissue 
(I  remarked)  we  sometimes  find  another,  which  last  is  thus  toinatural  in  regard  to 
its  situation,  but  natural  in  all  other  respects.  The  new  tissue  is  such  as  we  meet 
with  elsewhere  in  the  body,  but  it  is  not  such  as  properly  belongs  to  the  place  it 
occupies.  Either  the  original  tissue  has  been  gradually  converted  into  the  new,  or 
the  original  tissue  has  disappeared,  and  the  new  tissue  has  been  substituted  for  it : 
that,  for  example,  which  should  be  cartilage  we  sometimes  find  to  be  bone." 

"In  most  cases  the  tissue  that  has  been  changed  or  displaced  is  in  one  of  the  twi< 
following  predicaments : 

"  Either  its  natural  function  has  been  for  a  long  time  suspended  ; 

"  Or,  it  has  been  accidentally  called  upon  to  fulfil  a  purpose  for  which  it  was  not 
originally  designed. 

"  In  the  former  case  it  gradually  approximates  towards  areolar  tissue,  which  at 
length  is  all  that  remains. 

"  In  the  latter,  it  assumes  the  characters  of  that  other  tissue  of  which  it  has  taken 
up  the  office." 

Now  the  analogy  which  M.  Andral  thought  he  could  perceive  between  changes 
of  this  kind,  and  those  changes  which  occur  during  the  growth  and  progressiva 
developement  of  the  human  body,  does  not  in  reality  obtain.    More  recent  and  more 


36  TRANSFORMATION    OF   TISSUE. 

exact  microscopical  researches  have  shown  that  the  several  tissues  do  not  comnience 
by  being  areolar  tissue — which  is  the  sense  in  which  M.  Andral  uses  the  word 
cellular — and  therefore,  that  in  the  dwindling  of  any  given  tissue  into  the  areolar, 
there  is  no  return,  as  he  had  supposed,  towards  the  primitive  state  of  the  tissue  so 
wasting.  A  muscle  remaining  for  a  long  time  in  complete  inaction,  loses  bulk,  but 
does  not  pass  from  the  condition  of  muscular  into  that  of  areolar  tissue  :  when  wasted 
to  the  utmost,  it  still  retains  its  proper  anatomical  elements.  The  areolar  tissue  is 
quite  as  complex  and  advanced  a  tissue  as  the  muscular.  There  is  no  true  conver- 
sion of  the  one  tissue  into  the  other.  It  is  commonly  stated,  indeed,  that  when  a 
muscle  comes  accidentally  to  invest  a  dislocated  joint,  the  dislocation  remaining  unre- 
duced, it  assumes  by  degrees  the  characters,  together  with  the  uses,  of  those  tissues 
which  naturally  inclose  the  joint,  and  is  converted  from  muscular  into  fibrous  or 
ligamentous  tissue — ^just  as  in  the  vegetable  kingdom,  the  cut  branch  of  a  willow 
tree,  planted  in  the  earth,  takes  up  the  office,  and  gradually  acquires  the  form  and 
properties  of  a  root.  But  here  again  the  analogy  is  more  fanciful  than  real.  The 
formation  of  a  false  joint  implies  no  actual  conversion  of  tissues.  The  muscular 
fibres  shrink  and  disappear,  while  the  areolar  tissue  augments,  and  is  transformed 
only  into  the  fibrous ;  these  two,  the  fibrous  and  the  areolar,  being  essentially  and 
primarily  the  same  tissue. 

The  change  from  cartilage  to  bone  approaches  more  nearl}''  than  any  other  to 
actual  transmutation ;  but  even  this  resolves  itself  into  a  simple  increase  of  one  of 
the  natural  constituents  of  both  the  tissues  concerned ;  phosphate  of  Hme,  which 
exists  in  healthy  cartilage. 

A  curious  and  common  change  is  the  so-called  transformation  of  other  tissues  into 
adipose  tissue.  The  fat,  however,  does  not  take  the  place  of  the  natural  elements 
of  the  tissue.  It  is  deposited  among  them,  and  wastes  them,  yet  they  still  remain, 
and  are  easily  distinguishable.  If  you  examine  a  fat  heart  —  such  as  is  not  unfre- 
quently  met  with  in  very  fat  persons  —  you  av ill  generally  find  a  combination  of 
hypertrophy  of  the  adipose  tissue  with  atrophy  of  the  muscular,  rather  than  any 
conversion  of  the  one  into  the  other.  The  fat  is  deposited  around  and  between  the 
attenuated  muscular  fibres,  and  the  two  may  usually  be  separated  from  each  other. 
It  would  seem  that  here  the  converse  of  one  of  the  propositions  which  I  lately  men- 
tioned holds  good — of  the  proposition,  namely,  that  suspension  of  the  function  of  a 
tissue  leads  to  its  degeneration  into  adipose  or  areolar  tissue.  In  the  instance  before 
us,  the  increase  of  adipose  tissue  tends  to  lessen,  and  at  length  to  destroy,  the  function 
of  the  part.  What  is  called  the  fatty  liv^er  affords  another  instance  of  this  morbid 
accumulation.  The  altered  liver  is  of  a  light  tawny  colour,  of  diminished  specific 
gravitj',  retains  the  impression  of  one's  finger,  is  tender,  and  tears  easily ;  it  greases 
the  knife  that  cuts  it,  or  bibulous  paper  in  which  it  is  wrapped.  B}^  boiling  it  you 
may  obtain  a  concrete  oil,  which  has  all  the  characters  of  fat.  The  change  is 
wrought  b}''  an  enormous  augmentation  in  quantity  of  the  fat  which  is  a  natural 
constituent  of  the  texture  of  the  liver,  and  which  thus  comes  to  prt'dominate  immea- 
surably over  all  its  other  elements. 

What  is  very  curious  in  respect  to  this  morbid  condition  of  the  liver  is,  that  we 
can  produce  it,  at  will,  in  some  at  least  of  the  lower  animals.  You  know  thai  the 
^"■foie  gras^^  procured  from  certain  birds,  is  an  article  of  great  luxury  among  epi- 
cures. It  is  obtained  by  a  very  cruel  process.  Geese  or  ducks  are  confined  in 
baskets  just  large  enough  to  contain  them,  but  not  large  enough  to  allow  them  any 
motion  ;  they  are  kept  continually  in  the  dark  also  ;  sometimes  even,  I  am  afraid, 
iheir  eyes  are  put  out,  but  this  I  should  imaa^ine  to  be  a  useless  and  superfluous 
piece  of  cruelty,  it  being  the  absence  of  light,  and  not  the  absence  of  the  power  of 
vision,  which  helps  to  bring  about  the  desired  efTcct.  At  the  same  time  the  birds 
are  sedulously  crammed  with  food.  Under  this  discipline  their  livers  acquire  the 
reouisite  size,  and  greasiness,  and  the  true  flavour. 

An  ingenious  tiieory  has  been  constructed,  in  reference  to  the  modus  operandi  of 
this  process.  The  excessive  supply  of  nutriment  tends,  no  doubt,  of  itself,  as  it 
always  does,  to  the  production  of  fat ;  the  constrained  state  of  inaction  interfeies 
pjobably  with  the  right  and  healthful  formation  of  blood,  a  matter  in  which  the  liver 


TRANSFORMATTON     OF    TISSUE.  37 

is  believed  to  be  a  good  deal  concerned  ;  then  we  know,  by  experience,  that  the 
privation  of  hght  has  the  effect  of  blanching  animals  as  well  as  vegetables,  and  thus 
further  interferes  with  the  due  renovation  of  the  blood.  In  this  way,  the  trans- 
formation of  the  liver  into  a  fatty  mass  has  been  sometimes  attempted  to  be  explained. 
To  what  extent  the  explanation  is  correct,  I  will  not  pretend  to  say:  but  it  is  worth 
remarking  that  the  fatty  liver  is  very  frequently  met  with  in  persons  who  die  of  con- 
sumption ;  and  in  that  disease  there  are  various  causes  in  operation  tending  to 
modify  the  constitution  of  the  blood. 

The  history  of  these  unfortunate  fowls  is  not  barren  of  instruction  in  respect  to 
the  more  limited  bad  effects  of  full  diet,  want  of  exercise,  and  a  short  allowance  of 
day-light,  upon  the  "  featherless  biped"  man. 

These  accumulations  of  fat  are  morbid  changes.  The  transformations  that  are 
effected  in  false  joints  are  evidently  methods  of  accommodation  and  repair.  The 
same  may  be  said  of  the  transformation — which  is  not  conversion — of  areolar  tissue 
into  synovial  membrane.  Synovial  membrane  consists  chiefly  of  condensed  areolar 
tissue.  Sir  B.  Brodie,  in  his  book  on  Diseases  of  the  Joints,  gives  instances  of 
synovial  membranes  being  formed,  where  none  before  existed.  "  In  a  young  lady 
who  had  attained  the  age  of  ten  or  twelve  years,  labouring  under  the  inconvenience 
of  a  club-foot,  a  large  bursa  was  distinctly  to  be  felt  on  that  part  of  the  instep  whicn 
came  in  contact  with  the  ground  in  walking.  In  another  young  lady,  who  had 
apparently  recovered  of  a  caries  of  the  spine,  attended  with  a  considerable  angular 
curvature,  a  bursa  appeared  to  have  been  formed  between  the  projecting  spinous 
process  and  the  skin." 

In  like  manner  we  find  that  sinuses,  fistulous  openings  and  tubes,  in  various  parts, 
become  lined,  through  the  intervention  of  the  areolar  tissue,  with  a  surface  which  in 
its  appearance  and  in  its  properties  resembles  the  mucous  membranes.  Like  them 
it  is  with  difficulty  made  to  take  on  adhesive  inflammation  :  and  therefore  it  is  that 
sinuses  of  this  kind,  and  chronic  abscesses,  are  often  so  troublesome  to  the  surgeon, 
and  require  to  be  laid  open  before  they  can  be  abohshed. 

On  the  other  hand,  the  mucous  membranes,  under  peculiar  circumstances, 
approximate  to  the  skin  in  their  physical  aspect  and  quahties.  When,  for  instance, 
a  portion  of  the  mucous  lining  of  the  rectum,  or  of  the  vagina,  protrudes  externally, 
is  permanently  exposed  to  the  air,  and  subject  to  the  friction  of  clothes  or  of  neigh 
bouring  parts  —  that  is  to  say,  when  it  is  placed  under  the  same  conditions  as  the 
skin  —  it  assumes  somewhat  the  characters  of  the  skin :  it  gradually  loses  its  red 
colour  and  approaches  the  tint  of  the  skin,  ceases  to  pour  forth  mucus,  becomes  dry, 
obtains  even  a  sort  of  permanent  cuticle,  acquires  firmness  and  density,  and  is  less 
sensible  to  the  contact  and  pressure  of  foreign  substances.  It  is  impossible  not  to 
perceive  the  beneficial  nature  of  this  transformation. 

The  greater  number,  then,  of  those  interesting  changes  in  the  living  body  which 
have  been  classed  under  the  head  of  transformations  of  tissue,  have  a  restorative 
tendency.  They  exemplify  the  working  of  what  the  older  pathologists  discerned, 
and  called  the  vis  mcdicatrix  nufrirx.  This  is  a  phrase  that  has  been  much  sneered 
at;  but  (as  I  conceive)  very  unjustly,  and  sometimes  ignorantly.  It  is  simply  a 
short  formulary  expressive  of  a  great  general  truth,  viz.,  that  the  animal  frame  is  so 
constituted  as  to  contain  within  itself  the  elements  of  repair,  and  of  conservative  adap- 
tation. To  a  certain  extent  it  is  a  self-mending  machine.  Surely  this  is  an  admirable 
provision,  and  clearly  indicative  both  of  wise  contrivance  and  of  beneficent  design. 

The  intimate  texture  of  parts  may  be  further  altered — not  simply  by  some  modi- 
fication or  reconstruction  of  the  ordinary  tissues,  but — by  an  absolute  disappearance 
or  confusion  of  all  regular  structure.  This  is  usually  a  consequence  either  of  the 
effusion,  in  the  natural  interstices  of  the  parts,  of  fluids,  which  afterwards  pass  inro 
the  solid  state,  or  it  is  a  consequence  of  the  growth  of  solids  which  do  not  belong  to 
the  healthy  body.  In  this  sketch  of  general  pafhology  I  must  content  myself  with 
thus  briefly  alluding  to  this  source  of  morbid  change. 

I  may  as  well  observe  here,  that  the  alterations  with  which  we  have  hitherto  been 
occupied,  of  the  solids  of  the  body,  fall,  almost  all  of  them,  under  ihS  head  of 
lesions  of  nulrilion,  QiS  the  French  pathologists  spe^k.     That  is  to  say,  the}-  "m 

D 

<^v-    at* in  ./.('■v—.-f- 


38  LESIONS    OF    KUTRITipN. 

mence,  and  have  their  priinilive  seat,  in  that  process  and  place  where  the  blood, 
havinij  reached  the  capillar)^  system  of  vessels,  performs  its  special  purposes,  ^  It  is 
in  or  Throuorh  the  capillaries  that  the  fluids  and  solids  accomplish  their  vital  union. 
Each  solid  receives  from  the  blood,  and  assimilates  with  its  proper  substance,  ma- 
terial particles,  identical  in  their  nature  with  those  of  which  it  already  consists. 
Each  solid  gives  up  also  to  the  blood,  and  so  dismisses  other  particles,  which  before 
formed  a  portion  of  itself,  but  which  have  become  unfit  or  superfluous.  Now  any 
departure  from  this  continual  building  up  and  pulling  down — any  excess  or  defect 
of  the  particles  added,  or  of  the  particles  subtracted — any  irregularity  in  the  manner 
in  which  they  are  deposited — any  variation  from  their  right  consistence,  or  in  their 
kind  and  quality — in  short  any  deviation  from  the  regular  process,  as  I  have  briefly 
described  it — is  called  a  lesion  ofnuirition. 

The  few  changes  already  spoken  of,  and  not  included  among  the  lesions  of  nu- 
trition, are : — 

The  distension  of  the  hollow  organs  by  an  undue  accumulation  of  fluids  within 
them ; 

The  coagulation  of  the  fluids  in  their  proper  vessels,  excluding,  however,  the 
capillaries ; 

The  escape  of  the  fluids,  as  such,  out  of  and  beyond  their  containing  vessels ;  and 

The  solution  of  tissues,  after  death,  by  the  chemical  agency  of  the  gastric  juice. 

None  of  these,  properly  speaking,  constitute  lesions  of  nutrition,  although  they 
sometimes  lead  to  them. 

Lastly,  let  us  take  a  glance  at  the  changes  of  situation  to  which  the  solid  parts  of 
the  body  are  liable.     They  are  sometimes  of  very  serious  import. 

These  changes  of  place — sometimes  the  consequence  of  disease,  sometimes  its 
cause,  and  not  unfrequently  the  cause  of  death — respect  chiefly  the  viscera;  and 
most  especially  the  viscera  of  the  chest,  abdomen,  and  pelvis.  I  omit  dislocations  of 
joints,  as  belonging  exclusively  to  surgery. 

In  the  chest,  a  whole  lung  may  be  displaced,  and  compressed  against  the  ver- 
tebral column,  bj'  blood,  or  serum,  or  air,  effused  into  the  cavity  of  the  pleura.  An 
alteration  of  this  kind,  whereby  one  half  of  the  respiratory  apparatus  is  rendered 
incapable  of  its  peculiar  function,  cannot  be  otherwise  than  full  of  peril. 

The  very  same  causes  operating  on  the  left  side  of  the  thorax  will  dislocate  the 
heart,  thrust  it  over  to  the  right  of  the  sternum,  where  it  may  be  felt,  and  heard,  and 
seen,  to  pulsate.  This  again  cannot  happen  without  greatly  disturbing  the  vital 
function  of  circulation,  and  putting  hfe  in  jeopardy. 

Yet  neither  of  these  serious  displacements  is  necessarily  fatal.  Both  admit, 
under  certain  circumstances,  of  remedial  treatment :  as  I  hope  to  prove  to  you 
hereafter. 

In  the  abdomen  and  pelvis,  the  various  forms  of  hernia  may  be  adduced  as 
involving  very  dangerous  changes  in  the  place  and  relative  position  of  part?. 
Portions  of  the  intestinal  tube  are  apt  to  pass  through  accidental  openings  in  the 
diaphragm^-or  between  the  edges  of  the  linea  alba  surrounding  the  navel — or  out 
at  the  abdominal  ring — or  through  some  other  natural  or  accidental  aperture.  I 
need  not  tell  you  how  fearfully  life  is  compromised  when,  in  consequence  of  such 
faulty  position,  the  bowel  becomes  constricted — when  its  contents  can  no  longer 
pass  onwards,  and  inflammation,  or  gangrene,  is  present  or  impending.  Even 
when  there  is  no  strangulation,  the  mere  displacements  to  which  the  escape  of 
the  contents  of  the  abdomen  and  pelvis  from  their  natural  limits  gives  rise,  may  be 
productive  of  much  discomfort,  deformity  and  hazard.  Of  this  the  historian  Gib- 
bun  presented  a  remarkable  example.  He  had  an  immense  scrotal  hernia ;  so 
large  it  was,  that  it  hung  down  very  nearly  as  low  as  his  knees.  After  his  death  it 
was  found  that  almost  the  whole  o^the  omentum,  and  the  greater  part  of  the  colon, 
had  descended  into  the  scrotum,  and  had  dragged  the  stomach  after  them ;  so  that 
Us  pyloric  orifice  lay  close  to  the  abdominal  ring. 

Akin  t»  hernia  is  that  partial  displacement  of  the  bowel  in  which  a  portion  of  it 
passes,  not  through  any  natural  or  accidental  opening,  but  into  the  bowel  itself; 


CHANGES    IN    THE    BLOOD.  39 

just  :is  one  portion  of  the  finger  of  a  glove  is  sometimes  pulled  into  the  remaining 
part,  by  the  withdrawal  of  one's  hand.  The  containcf/  portion  of  intestine  is  liable 
to  be  nipped  and  strangulated  by  the  contain/;?^  portion — and  all  the  peril  of  hernia 
results,  with  much  less  chance  of  relief  by  art.  This  state  of  things  is  called  intus- 
susception. 

Exactly  of  the  same  nature,  though  less  alarming,  is  prolapsus  of  the  rectum,  or 
of  the  vagina.  Here,  also,  a  portion  of  the  tube  passes  into  the  contiguous  portion ; 
but  being  near  the  extremity  of  the  canal,  the  inverted  part  protrudes  externally,  and 
becomes,  in  most  cases,  a  source  of  distress  and  suffering,  rather  than  of  danger. 
Inversion  of  the  uterus  is  another  example. 

Thus  much,  then,  of  the  changes  to  which  the  solid  parts  of  the  body  are  subject, 
in  bulk,  inform,  in  consistence,  in  texture,  in  situation. 

You  cannot  fail  to  perceive  the  injurious  effects  which  many  of  these  changes  in 
the  various  solids  are  calculated  to  produce  upon  the  movements  and  working  of  the 
living  machine ;  how  some  of  them  must  impede  or  derange  its  natural  action ; 
some  stop  that  action  altogether. 

Now,  the  fluid  parts  of  the  body  are  liable  also  to  alterations,  which,  if  they 
are  not  always  so  obvious  as  those  of  the  solids,  are  certainly  not  of  less  moment. 

You  are  probably  aware  that  for  many  centuries,  the  fluids  were  supposed  to  be 
the  primary  agents  in  every  form  of  disease ;  that  all  maladies  were  attributed  to 
some  acrimony  or  peccant  state  of  the  humours ;  and  that,  however  else  the  the- 
ories of  medicine  might  vary  and  fluctuate,  the  humoral  pathology,  till  a  compara- 
tively recent  period,  ran  through  almost  all  of  them.  At  length,  the  absurdity  of 
the  hypotheses,  and  still  more  the  dangerous  practice,  which  this  doctrine  gene- 
rated, began  to  be  manifest,  and  led  to  its  total  abandonment.  Rather  more  than  a 
century  and  a  half  ago,  the  foundation  of  the  opposite  doctrine  appears  to  have  been 
laid,  by  the  writings  of  Glisson  in  this  country,  and  by  those  of  Baglivi  in  Italy  ;  and 
presently  the  notion  came  to  prevail  throughout  the  schools,  that  all  the  morbid  con- 
ditions of  the  body  had  their  exclusive  origin  in  the  solids.  The  pendulum  of 
opinion  swung  at  once,  as  is  usual,  into  the  opposite  extreme  of  error.  It  promises, 
in  our  time,  to  settle  at  the  proper  medium.  Ine  old  extravagances  of  the  humoral 
doctrine  still,  indeed,  find  favour  among  the  ignorant,  and  are  commonly  adopted  by 
the  quack :  circumstances  which  illustrate  the  fact  that  the  mischievous  influence  of 
unsound  theories  survives  the  duration  of  the  theories  themselves.  The  scientific 
physician  of  the  present  day  can  only  wonder  how  exclusive  solidism,  or  exclusive 
humorahsm,  should  ever  have  found  advocates. 


LECTUUE  IV. 

Morbid  Alterations  of  the  Fluids,  especially  of  the  Blood.  Changes  in  its  quan- 
tity and  distribution.  General  and  Local  Plethora.  Poverty  of  Blood.  Active 
Congestion — its  Phenomena — State  of  the  Vessels,  as  seen  by  the  Microscope. 
Mechanical  Congestion.  Passive  Congestion.  Relations  of  these  forms  of 
Congestion  to  Inflammation — to  Hemorrhages — to  Dropsies. 

After  running  over  the  principal  alterations  to  which  the  solid  parts  of  the  body 
are  liable,  we  were  beginning  to  inquire  into  those  no  less  important  morbid  changes 
which  are  apt  to  take  place  in  its  fluid  constituents.  1  reminded  you  that,  respect- 
ing the  whole  of  this  subject,  pathologists  had  passed  from  one  extreme  of  opinion  to 
another :  that,  for  a  very  long  period,  the  humoral  pathology  prevailed  in  the 
schools,  and  that  in  times  not  very  remote  from  our  own,  it  was  entirely  superseded 
by  the  opposite  doctrine  of  exclusive  solidism.  It  is  strange  that  either  miscon- 
ception should  have  so  long  maintained  its  ground. 

Jf  we  consider  the  definite  relation  subsistinc:  between  the  solids  and  the  fluids  of 


40  CHANGES    IN    THE   BLOOD. 

the  body,  and  the  unceasing  agencies  which  ihej  mutually  exercise  on  each  other- 
how,  for  instance,  on  the  one  hand,  all  the  solids  are  originally  built  up,  and  are 
afterwards  perpetually  nourished  and  sustained  by  materials  furnished  from  the 
blood — how  again,  on  the  other  hand,  some  of  the  solids  are  continually  employed 
in  the  reciprocal  office  of  feeding  and  renewing  the  blood,  while  others  are  as  con- 
stantly at  work  in  decompounding  it  by  the  various  secretions  —  we  cannot  avoid 
perceiving  that  distinctions  of  the  kind  I  have  mentioned,  founded  upon  mere  differ- 
ences of  consistence,  are  futile.  Flesh  and  blood  are  almost  convertible  terms  :  their 
composition,  the  chemists  tell  us,  is  identically  the  same.  To  use  the  strong  expres- 
sion of  Borden,  Le  sang  est  de  la  chair  coidante.  You  may  be  certain  that  no 
notable  alteraiion  can  take  place  in  the  solids  of  the  body  which  will  not  soon  affect, 
in  some  way,  its  fluids ;  and  that  every  important  change  in  its  fluids  must  lead  to, 
or  proceed  from,  a  corresponding  and  proportionate  modification  of  its  sofids.  The 
long  dispute  between  the  solidists  and  the  humoralists  was  altogether  baseless  and 
unprofitable. 

The  animal  fluids  are  —  the  blood,  the  fluids  that  enter  the  blood,  and  the  fluids 
that  proceed  from  the  blood. 

The  fluids  that  enter  the  blood  are  of  two  kinds. 

1.  Those  by  which  it  is  renewed  and  enriched. 

2.  Those  w^hich  enter  it  in  order  that  they  may  be  conveyed  out  of  the  body. 
Now,  although  we  cannot  doubt  that  any  considerable  modification  or  defect  of  the 

fluids  that  feed  and  renovate  the  blood,  and  particularly  of  the  chyle,  must  have  a 
direct  influence  upon  its  composition  and  quality,  we  really  know  but  little  about 
them,  except  in  their  effects.  We  seldom  have  any  means  of  procuring  these,  the 
first  products  of  nutrition,  so  as  to  examine  them,  or  to  test  their  qualities;  yet  we 
can  perceive  causes  that  are  likely  to  deteriorate  or  deprave  those  fluids  (unfit  ali 
ment,  impure  air),  and  we  know  that,  under  the  continued  operation  of  such  causes, 
the  blood,  replenished  by  these  fluids,  is  actually  and  sensibly  modified. 

Again,  we  cannot  doubt  that  some  of  the  matters  derived  from  the  body  itself,  and 
taken  into  the  blood  in  order  to  be  conveyed  awa^^  may,  and  often  do,  directly  alter 
and  contaminate  the  blood,  and  act  as  poisons  upon  the  system  :  matters,  for  in- 
stance, absorbed  from  the  parts  of  the  body  that  are  diseased,  or  dead  and  putrefying ; 
in  this  way,  doubtless,  disorders  which  were  at  first  strictly  local,  may  come  to  affect 
the  whole  economy  : — matters,  again,  which,  though  harmless  while  merely  transi- 
tory, and  in  minute  quantity,  become  noxious  when  retained  and  accumulated  in  the 
blood,  in  consequence  of  fauity  or  deficient  action  of  the  organs  destined  to  eliminate 
them  from  the  circulating  fluid.  The  injurious  effects  of  some  of  the  substances 
which  thus  become  deleterious, — as  urea,  of  which  the  blood,  during  heakh,  is  con- 
tinually purified  by  the  kidneys;  and  bile,  which  is  naturally  separated  therefrom 
by  the  liver;  and  carbonic  acid,  which  if  is  the  office  of  the  lungs  to  excrete — will 
furnish  topics  of  interesting  inquiry  here-ifter. 

The  fluids  that  leave  the  blood  ma}^  bt  considered  under  a  threefold  division. 

1.  Those  which  are  directly  expende  J  in  the  growth  or  maintenance  of  parts, 
some  of  them  becoming  fixed  and  solid,  and  others  retaining  their  fluid  condition. 
Of  these,  the  principal  alterations  have  been  briefly  pointed  out  among  the  lesions 
of  nutrition. 

2.  Those  that  are  employed  in  aid  of  some  definite  function  of  the  body :  as  the 
saliva,  the  gastric  juice,  the  bile,  the  pancreatic  secretion,  the  tears,  the  synovia  of 
the  joints,  and  so  on.  Now  these  may  be  secreted  in  excessive  abundance,  or  in  too 
scanty  quantit3%  or  of  imperfect  quality,  or  not  at  all;  and  all,  or  an)%  of  these 
deviations  from  the  healthy  standard,  may  be  the  result  of  very  serious  disease,  or 
may  cause  very  serious  disease  ;  and  they  will  be  spoken  of  hereafter  when  the  dis- 
orders of  the  parts  or  functions  connected  with  each  shall  be  discussed. 

'3.  Those  which  are  separated  from  the  blood  merely  to  be  excreted,  as  the  urine, 
:.crtain  secretions  from  the  bowels,  and  from  the  bronchi  and  skin.  Some  of  these 
are  extremely  worthy  of  study,  as  furnishing,  in  their  altered  qualities,  indications 
'if  disease  ;  but  they  require  no  particular  consideration  in  this  part  of  the  course. 

Dismissing,  therefore,  for  the  present,  all  further  account,  as  well  of  the  fluids  that 


PLETHORA.  41 

concur  to  form  the  blood,  as  of  the  fluids  that  issue  from  the  blood,  let  us  inquire 
what  morbid  changes  the  blood  itself  is  liable  to  undergo. 

The  blood,  then,  is  subject,  first,  to  remarkable  variations  in  its  quantity,  both  in 
respect  to  the  whole  system,  and  in  respect  to  particular  organs  and  tissues. 

2.  Closely  connected  with  these  differences  of  quantity  is  the  variety  which  1;^ 
observable  in  regard>to  the  proportions  between  the  several  proximate  constituents 
of  the  blood.  The  changes  that  occur  of  this  kind  are  sometimes  strikingly  evident 
to  our  senses.  For  example,  we  not  unfrequently  perceive  that  the  blood  drawn 
from  a  vein  is  thinner,  manifestly  more  watery,  less  rich  in  fibrin,  and  in  colouring 
matter,  than  blood  of  the  standard  quality. 

3.  Again,  independently  of  mere  alterations  in  the  relative  proportions  of  its 
proximate  constituent  parts,  the  blood  is  liable  to  great  change  in  its  chemical  com- 
position, and,  therefore,  in  its  physical  quality.  This  appears  to  be  the  case  in  sea- 
scurvy,  and  in  the  analogous  disease  called  purpura,  and  it  is  doubtless  so  in  many 
other  complaints. 

The  composition  of  the  blood  cannot  fail  to  be  affected  by  a  deficient  supply  of  the 
elements  of  nutrition  from  without ;  by  diseases  of  the  digestive  organs,  interfering 
with  the  process  of  chylification  ;  by  diseases  of  the  organs  of  respiration,  interfering 
with  its  change  from  venous  to  arterial ;  by  diseases  of  other  channels  of  excretion — 
the  bowels,  the  biliary  apparatus,  the  skin — interfering  (as  I  have  already  hinted) 
with  its  appointed  purification ;  by  foreign  contaminating  matters,  finding  entrance 
(as  they  may  when  in  solution,  or  in  a  gaseous  form)  through  artery,  vein,  or  any 
membranous  substance,  such  as  bladder  and  intestine  :  lastly,  thfe  composition  of  the 
blood  may  be  altered,  there  is  good  reason  to  believe,  by  certain  states  of  the  nervous 
system. 

But  contenting  myself  with  having  indicated  these  latter  changes,  or  sources  of 
change,  I  shall  defer  giving  a  more  particular  account  of  any  except  those  that  relate 
to  the  quantity  and  the  distribution  of  the  blood. 

I  say  the  blood  may  undergo  important  alterations  in  its  quantify.  It  may  exist 
in  too  great  abundance  throughout  the  body ;  and  it  may  exist  in  too  great  abun- 
dance in  certain  parts  only  of  the  body.  These  states  have  been  recognized  for 
ages.  Sometimes  they  are  called  respectively  general  and  partial  plethora:  some- 
times general  and  local  congestions  of  blood  ;  people  speak  also  of  irregular  deter- 
minations of  blood  to  different  organs ;  and,  of  late,  the  term  hypersemia,  first 
invented  by  M.  Andral,  in  France,  has  been  imported  into  this  country,  and  much 
adopted  here.  All  these  words  and  phrases  mean,  in  truth,  the  same  thing;  and 
their  frequent  recurrence  in  medical  works,  is,  of  itself,  sufficient  evidence  of  the 
frequency  and  importance  of  the  conditions  which  they  express. 

If  we  comprehend  rightly  this  subject  of  plethora  or  congestion,  we  shall  be  pre- 
pared to  understand  some  most  important  morbid  states,  of  which  it  seems  to  be  in 
many,  if  not  in  all  cases,  the  earliest  approach  —  the  initial  step.  Inflammation, 
hemorrhage,  dropsy,  all  acknowledge  and  imply  a  previous  condition  of  congestion. 
"There  is  probably,"  says  Dr.  Alison,  "no  kind  of  diseased  action  of  which  any 
part  of  the  living  body  is  susceptible,  which  is  not  connected,  sooner  or  later,  with 
increased  afflux  of  blood  towards  that  part,  either  as  its  cause  or  its  effect ;  and  the 
immediate  object  of  all  our  most  powerful  remedies  is  to  act  on  these  irregularities 
of  the  circulation." 

That  the  blood  may  be  differently  distributed  in  the  capillaries  at  different  times, 
we  know  by  the  variable  colour  of  the  surface,  which  depends  upon  the  varying 
degrees  of  fulness  of  the  cutaneous  blood-vessels.  The  phenomenon  of  i)hishing,  the 
red  cheek  of  anger,  the  heightened  colour  of  the  skin  under  brisk  exercise,  are  fami- 
liar facts  illustrative  of  partial  plethora  of  the  capillaries,  consistent  with  health. 

There  are  reasons  (which  I  shall  hereafter  lay  before  you)  for  believing  that  a 
similar  sudden  accumulation  of  blood,  taking  place  in  internal  parts,  may  sensibly 
disturb  their  functions ;  causing  transient  fits  of  giddiness,  insensibili'v,  and  some- 
times depth  itself,  when  the  congestion  affects  the  cerebral  blood-vessels;  and  attacks 

D'2 


42  »  GENERAL    PLETHORA. 

of  difficult  breathing  when  the  capillaries  of  the  puhnonary  tissue  are  conceined; 
and  even  these  attacks,  for  aught  that  I  know,  may  end  fatally. 

It  oftt'n  happens  that  when  certain  portions  of  the  surface,  as  the  cheeks,  are 
visibly  redder  and  fuller  of  blood  than  usual,  or  when  such  symptoms  as  I  have  just 
referred  to  denote  the  probability  of  some  internal  congestion,  other  parts  of  the  sur- 
face, as  in  the  extremities,  are  visibly  paler :  and  there  are,  at  the  same  time,  cor- 
esponding  and  palpable  differences  of  temperature. 

Perha})s  it  may  not  be  so  obvious  that  the  whole  quantity  of  blood,  throughout  the 
bodv,  is  sometimes  in  excess. 

That  in  the  adult  state,  when  the  growth  or  increase  of  the  body  has  been  com- 
pleted, blood  may  be  made  in  greater  abundance,  and  more  rich  in  the  materials  of 
nutrition  than  the  wants  of  the  body  require,  is  not  only  conceivable,  but  true.  We 
are  able  to  assign  circumstances  in  which  this  is  likely  to  happen,  and  we  find  that 
under  such  circumstances  it  actually  does  happen.  Full  living,  and  a  sedentary 
life,  are  causes  likely  to  occasion  general  plethora — and  they  do  occasion  it.  The 
full  diet,  so  long  as  the  digestive  powers  are  perfect,  provides  more  chyle,  conducts 
into  the  blood  a  larger  quantity  of  its  proper  pabulum.  The  sedentary  life  precludes 
that  freer  circulation  of  the  blood,  and  that  more  liberal  expenditure  of  it  through  the^ 
skin,  and  by  means  of  the  other  organs  of  secretion,  which  would  occur  under  more 
active  habits.  Persons  thus  circumstanced  are  apt  to  grow  fat;  the  adipose  tissue 
seeming,  in  these  cases,  to  form  a  kind  of  safety  valve  for  the  diversion  of  the  super- 
fluous blood.  Such  persons  have  turgid  and  florid  cheeks,  red  lips,  red  mucous 
membranes,  and  (ncft  uncommonly)  ferrety  eyes.  Their  entire  vascular  system  is 
preternaturally  distended.  If  you  open  a  vein,  you  find  that  they  bear  a  large 
abstraction  of  blood  without  fainting,  and  are  even  refreshed  by  it ;  and  the  blood 
drawn  separates  into  a  large  and  firm  mass  of  coagulum,  with  but  little  serum. 
Keeping  to  the  nomenclature  we  have  already  employed,  we  might  say  that  there 
is  here  liypertrophy  of  the  blood. 

When  inflammation  arises  in  the  subjects  of  this  general  plethora,  it  runs  high, 
and  requires  active  treatment.  But  they  are  not,  as  you  might  naturally  exj^ect 
them  to  be,  and  as  many  writers  state  them  to  be,  peculiarly  prone  to  sufler  inflam- 
matory complaints.  There  is  a  general  fullness  of  the  vascular  system,  but  no  irre- 
gularity, nor  any  necessary  tendency  to  irregularity,  in  the  distribution  of  the  blood. 

You  will  observe  that  the  relative  proportion  of  the  more  solid  to  the  more  fluid 
constituents  of  the  blood  is  increased  in  these  cases  of  general  plethora :  the  blood  is 
not  only  more  abundant,  but  it  is  richer  also  in  fibrin,  and  in  red  particles. 

The  means  to  be  adopted  for  redressing  this  unnatural  and  unsafe  condition  of  the 
circulation,  are  those  which  common  sense  would  suggest.  The  removal  of  a  por- 
tion of  the  superfluous  blood,  a  more  restricted  diet,  a  larger  allowance  of  active 
exercise. 

It  will  be  worth  our  while  to  contrast  this  state  of  general  plethora  with  its 
opposite — that  in  which  the  blood  is  scanty  and  poor — what  Andral  calls  (though 
with  questionable  propriety)  anaemia.  Oligscmia  is  the  cacophonous  but  more 
exact  name  assigned  to  it  by  Gendrin  ;  hut  poverty  of  blood  is  the  ordinary  English 
phrase  for  it,  and  the  best  of  the  three.  This  is  a  state  which  we  can  produce  at 
will,  by  abstracting  blood  from  the  body  in  moderate  quantity,  but  repeatedly,  and  at 
short  intervals.  It  occurs,  also,  frequently,  in  spontaneous  disease,  and  from  various 
causes ;  from  a  privation  of  the  materials  destined  to  replenish  the  blood ;  and  in 
cases  in  which  these  materials  appear  to  be  turned  to  little  account,  as  in  chlorotic 
girls.  We  see  it  in  those  who  habitually  and  frequently  lose  a  certain  quan'iiy  of 
blood,  in  disease;  in  persons,  for  example,  who  are  subject  to  piles,  and  who  bleed 
daily  from  the  rectum  ;  still  oftener  in  women  who  sufler  repeated  hemorrhagi's  from 
the  uterus.  When  the  drain  has  been  long-continued,  these  persons  become  very 
pa)'^;  even  those  parts  which  are  naturally  most  red,  as  the  lips  and  tongue,  become 
almost  white,'  their  faces  look  like  wax;  and  if  still  you  draw  blood  from  a  vein, 
and  allow  it  to  coagulate,  you  v/ill  have  a  small  clot  floating  in  an  abundance  of 
ferum,  and  that  small  clot  will  be  of  a  light  rosy  colour;  showing  a  great  diminution 
*n  the  proportion  of  fibrin  ;  and  a  still  greater  deficiency  of  the  red  particles.     The 


ANEMIA.  43 

blood,  as  they  say,  is  "  turned  into  water."  It  is  a  curious  pathological  fact,  that  the 
red  particles  require  more  time  for  their  restoration  than  the  other  constituents  of  the 
blood.  And  I  may  mention  to  you  now,  what  I  shall  have  to  repeat,  that — in  con- 
junction with  the  obvious  curative  measures  comprised  in  arresting  tbe  habitual  loss 
of  the  vital  fluid,  and  in  aflbrding  sufficient  nutriment  to  the  system, — the  prepara- 
tions of  iron,  and  the  respiration  of  pure  air,  have  signal  efficacy  in  renewing  the  rea 
particles,  and  giving  back  again  their  native  hue  of  redness  to  the  cheek  and  lips. 

In  general  plethora  every  part  is  preternaturally  full  of  blood,  and  the  blood  itself 
is  full  of  the  elements  of  nutrition.  General  plethora,  therefore,  implies,  in  one 
sense,  local  plethora  of  every  organ  and  tissue.  In  strictness,  however,  local  plethora 
is  only  predicable  of  a  part  that  contains  more  than  its  share  of  red  blood. 

Now  the  converse  of  this  is  not  true,  as  it  might  be  expected  to  be,  of  the  opposite 
condition.  A  deficiency  in  the  whole  mass  of  blood  contained  in,  and  circulating 
through  the  body,  does  not  protect  the  parts  of  the  body  from  congestion — from 
having  an  undue  quantity  of  blood  sent  to  them.  Far  from  it.  Local  determinations 
of  blood  are  very  common  in  persons  in  whom  the  mass  of  that  fluid,  and  the  pro- 
portion of  its  nutritive  materials,  have  been  considerably  diminished  by  disease,  or 
by  hemorrhage. 

This  remarkable  tendency.  Tinder  such  circumstances,  to  an  unequal  distribution 
of  the  blood  in  the  capillaries,  admits  (I  think)  of  this  explanation.  A  due  supply 
of  healthy  blood  is  requisite  for  the  steady  and  equable  performance  of  the  function? 
of  the  brain  and  nerves.  When  this  supply  is  defective,  or  uncertain,  those  functions 
become  disordered  and  irregular,  and,  in  their  turn,  influence  the  various  solids,  dis- 
turb their  action,  and  derange  the  balance  of  the  circulation.  That  the  capillary 
blood-vessels  may  be  filled  to  excess,  or  completely  emptied,  by  causes  operating 
through  the  nervous  system — by  moral  emotions,  for  example — we  are  sure  from 
the  phenomena  just  now  adverted  to,  the  blush  of  shame  or  anger,  the  paleness  of 
fear ;  and  there  can  be  no  doubt  that  morbid  congestions,  which  sometimes  are 
separated  from  those  that  are  consistent  with  health  by  very  slight  shades  of  difTer- 
ence,  are  often  determined  through  the  agency  of  the  same  nervous  system.  And 
persons  endowed  Avith  great  sensibility  or  irritability  of  the  nervous  system  are  very 
liable  to  partial  and  irregular  congestions  of  blood. 

But  this  is  not  the  only  way  in  which  local  congestion  may  arise. 

We  can  produce  it,  upon  the  surface  of  the  body  at  least,  at  pleasure,  and  that  m 
various  ways ;  by  friction,  by  exposing  the  parts  to  a  high  temperature,  by  certain 
stimulating  applications,  mechanical  (as  a  cupping-glass),  or  chemical  (as  a  mustard 
poultice) :  we  produce  an  injection  of  the  small  cutaneous  blood-vessels ;  there  is, 
evidently,  more  than  the  usual  quantity  of  blood  attracted  to  the  part,  or  detained  in 
the  part — a  degree  of  redness,  which  soon  subsides  if  the  cause  of  it  be  withdrawn 
in  time. 

Congestion  thus  occasioned  is  not  inflammation,  but  it  is  the  first  obvious  Step 
towards  that  complex  process ;  and  for  this  reason  it  deserves  all  your  attention. 
Apply  the  exciting  cause  a  little  longer,  or  increase,  in  a  slight  degree,  its  intensity, 
and  the  phenomena  of  inflammation  begin  to  manifest  themselves. 

I  said  we  can  produce  local  congestion  when  we  please  upon  the  sinface  of  the 
body;  but  there  can  be  no  doubt  that  a  similar  state  may  be  produced  by  analogous 
causefi,  in  internal  parts.  Look  at  this  representation  of  the  stomach  of  a  dog  (one 
of  Dr.  RoupelV s  plates).  You  see  one  portion  of  it  of  a  bright  red  colour,  actively 
and  vividly  congested.  This  was  the  consequence  of  a  dose  of  alcohol.  We  may 
be  certain  that  something  of  the  same  kind  is  the  result  of  every  visit  to  the  gin 
shop. 

Local  congestion  thus  produced,  or  of  this  kind,  is  said  to  be  active.  M.  Andial, 
whose  nomenclature  has  come  much  into  fashion  of  late  years,  calls  it  sthenic,  or 
active  hyperemia.  The  arteries,  perhaps,  have  more  to  do  with  it,  in  the  first 
instance,  than  the  veins.  But  it  is  in  the  capillary  vessels,  which  are  distinct  from, 
and  interposed  between  the  minute  arteries  and  veins,  that  further  changes  aro 
wrought,  when  the  process  advances  a  stage  bej'ond  mere  local  plethora.      What 


44  LOCAL    PLETHORA. 

has  been  observed,  by  the  aid  of  the  microscope,  with  res^ject  to  the  blood-vessek,  1 
will  endeavour  to  describe  to  you. 

I  take  the  account  I  am  about  to  give  you  chiefly  from  Kaltenbrunner,  a  German 
pathologist,  who  has  recently  investigated  the  subject  experimentally,  and  whose 
observations  are  believed  to  have  been  most  carefully  and  skilfully  conducted,  and 
their  results  no  less  faithfully  narrated.  His  observations  were  made  upon  the 
circulation  as  it  appeared  in  the  web  of  a  frog's  foot,  under  a  powerful  microscope. 
It  would  be  idle,  and  something  like  committing  a  fraud  upon  you,  were  I  to  lay  any 
stress  upon  my  own  knowledge  or  experience  in  this  matter,  for  I  cannot  pretend  to 
any  great  skill  in  the  use  of  that  instrument,  and  my  opportunities  of  noticing,  by 
its  help,  the  phenomena  of  the  circulation,  have  been  too  few  to  render  their  results 
of  much  value.  Yet  it  may  be  in  some  degree  satisfactory  to  you  to  know  that  I 
am  not  blindly  repeating  the  remarks  of  others,  and  that  what  I  have  witnessed  is 
perfectly  in  accordance  with  the  statements  of  Kaltenbrunner,  and  affords  me  a  strong 
assurance  of  his  accuracy  and  fidelity.  There  is  another  reason,  too,  why  I  con- 
sider him  the  more  trustworthy — he  has  no  theories  to  which  he  might  be  disposed 
to  bend  or  accommodate  his  facts. 

Before  I  detail  to  you  his  account  of  the  phenomena  of  congestion,  I  may  briefly 
describe  the  scene  which  presents  itself  when  the  web  of  a  frog's  foot  is  looked  at 
through  a  good  microscope.  It  is  a  most  beautiful  and  wonderful  spectacle,  and 
particularly  interesting  to  those  who,  like  ourselves,  are  desirous  of  gaining  some 
insight  into  the  healthy  and  diseased  states  of  the  circulation.  It  is  a  sight  which  I 
hope  and  believe  you  also  will  have  many  opportunities  of  seeing  in  this  place. 
You  perceive,  then,  occupying  the  circular  field  of  the  instrument,  a  number  of 
blood-vessels,  through  which  the  blood,  with  its  globules,  is  in  active  motion  :  and 
you  see  at  once  that  there  are  three  different  kinds  of  vessels  before  you.  First, 
you  notice  the  blood  shooting  with  great  velocity  along  tubes  which  divide  and  sub- 
divide into  smaller  and  smaller  branches,  each  branch  (speaking  generally^  going 
off  at  an  obtuse  angle  :  these  are  plainly  arteries.  Then,  in  another  part  of  the  field 
of  view,  you  see  the  blood  moving  in  the  contrary  direction,  more  slowl}',  in  larger 
trunks,  which  are  formed  by  the  continual  union  and  accession  of  smaller  and 
tributary  vessels  of  the  same  kind,  that  meet,  for  the  most  part,  at  acute  angles : 
these  you  know  to  be  veins ;  and  all  the  intermediate  and  surrounding  surface  in 
view  is  occupied  with  other  vessels  or  channels,  which  connect  themselves  with  the 
ultimate  ramifications  of  the  arteries  on  the  one  hand,  and  with  the  primary  radicles 
of  the  veins  on  the  other,  but  which  differ  from  both  arteries  and  veins  in  these  par- 
ticulars— that  they  interlace  and  anastomose  in  all  parts,  in  a  very  irregular  manner, 
and  at  all  angles,  and  that  they  retain  everywhere  .the  same  uniform  size  ;  they 
neither  collect  into  larger  and  larger  trunks,  nor  separate  into  smaller  and  smaller 
branches,  but  are  disposed  like  the  threads  forming  the  meshes  of  a  net,  except  thart 
the  interstices  are  irregular  in  size  and  shape.  These  are  the  true  capillaric^  inter- 
mediate between  the  arteries  and  the  veins,  and  perfectly  distinct  in  character  from 
each,  but  communicating  and  continuous  with  both. 

If  now  you  press  upon  the  animal's  leg,  so  as  to  obstruct  the  circulation  a  little, 
the  motion  of  the  blood  is  retarded,  especially  in  the  capillaries.  You  see  the  red 
globules  slowly  following  one  another.  These  so-called  globules  are  not  really  little 
spheres,  but  circular  discs,  or  flat  cells.  You  may  sometimes  see  one  of  them 
sticking  to  the  side  of  a  capillary  channel,  and  damming  up  the  current ;  other  glo- 
bules accumulate  behind  it,  till  at  last  they  all  pass  on  again  together. 

Now  Kaltenbrunner  irritates  the  web  by  pricking  it,  and  soon  afterwards  the 
following  appearances  present  themselves : — There  is  an  increased  afflux  of  blood 
to  the  part,  so  that  arteries,  veins  and  capillaries  receive  a  column  of  blood  two  or 
♦.hrfe  times  as  great  as  usual ;  the  velocity  of  the  blood  is  accelerated  ;  the  distended 
sides  of  the  vesseis  seem  to  tighten  round  the  stream  of  blood  which  they  contain. 
With  this  alteration  of  the  circulation,  the  natural  functions  of  the  part  begin  to  be 
modified.  The  change  of  the  blood  from  arterial  to  venous  is  interrupted.  The 
globules,  passing  with  great  rapidity  through  all  the  vessels,  retain  the  characters  of 
arterial  globules  even  when  they  arrive  at  the  veins ;  they  present  a  bright  colour. 


ACTIVE    CONGESTION.  45 

Show  a  tendency  to  stick  together,  and  often  form  little  clots,  which  pass  through  the 
capillaries,  and  become  visible  in  the  veins. 

One  of  the  natural  functions  of  the  web  is  the  secretion  of  a  kind  of  lymph;  but 
this  secretion  is  now  suspended.  The  parenchyma  itself  begins  to  be  shghtly  tumid, 
and  assumes  a  brighter  tint  than  common. 

All  these  phenomena  begin  from  a  circumscribed  spot,  of  which  the  circumference 
gradually  expands  as  the  affection  increases ;  and  they  cease  insensibly  at  that 
circumference. 

This  is  active  congestion. 

A  certain  period  always  intervenes  between  the  first  action  of  the  irritant  cause, 
and  the  commencement  of  true  congestion.  This  period,  the  occurrence  of  which 
you  will  be  good  enough  to  bear  in  mind,  Kaltenbrunner  calls  the  period  of  incuba- 
tion ;  the  period  in  which  the  congestion  is  hatching. 

Active  congestion,  as  such,  does  not  continue  long.  It  either  passes  on  into 
inflammation,  as  I  shall  hereafter  explain,  or  it  begins  to  decrease.  When  it  has 
been  very  sHght,  the  quantity  of  blood,  and  the  rapidity  of  its  movement,  diminish 
gradually  from  the  circumference  towards  the  centre  ;  and  in  this  way  the  conges- 
tion insensibly  vanishes. 

But,  in  other  cases,  Avhen  it  has  not  been  so  slight,  the  congestion  terminates  by 
an  evident  crisis,  which  Kaltenbrunner  thus  describes  : — The  blood,  receaing  from 
the  circumference  of  the  congested  part  towards  the  centre,  gives  out,  by  exhalation, 
a  liquid.  The  exhalation  takes  place  by  fits,  and  here  and  there,  through  the  sides 
of  the  capillary  tubes,  and  generally  on  the  surface  of  the  organ.  The  moment  of 
exhalation  is  very  transient;  but  it  is  repeated  often,  and  in  different  spots,  until  the 
congestion  has  disappeared.  It  is  evidently  critical,  for  the  congestion  is  reheved 
and  extinguished  in  proportion  as  the  exhalation  is  repeated. 

I  shall  follow  these  consequences  of  active  and  continued  local  congestion  no 
further  at  present ;  but  merely  remind  you  again  that  the  changes  I  have  last  men- 
tioned constitute  the  earliest  appreciable  modification  of  structure  leading  or  belonging 
to  inflammation.  What  we  thus  may  see  (and  it  is  what  I  myself  have  had  some 
opportunities  of  seeing)  in  the  transparent  textj^res  of  animals,  we  reasonably  infer 
to  take  place,  under  analogous  circumstances,  in  those  parts  of  the  body  which  are 
internal  and  opaque,  and  consequently  hidden  from  our  view. 

I  will  just  observe,  also,  that  as  active  congestion  is  the  parent  of  inflammation,  so 
it  sometimes  causes  hemorrhage,  and  is  relieved  by  it.  But,  comparing  this  form  of 
congestion  with  another  which  I  am  about  to  mention,  the  connection  of  hemorrhage 
with  it  is,  relatively,  unfrequent. 

One  obvious  mode  of  remedying  this  congestion  is  the  mechanical  abstraction  of 
blood  from  the  loaded  part.  But  it  is  seldom  that  this  measure  alone  suffices  ;  and 
sometimes  it  would  be  ultimately  hurtful  to  adopt  it.  The  state  of  the  constitution 
may  be  such,  that  the  disposition  to  local  plethora  would  be  increased  by  the  loss 
qf  blood.  Undue  susceptibility  and  disordered  action  of  the  nervous  system  are  apt 
to  be  aggravated  by  bleeding;  and  in  proportion  as  the  nervous  functions  are  irregu- 
larly performed,  does  the  tendency  to  unequal  distribution  of  blood  in  the  capillary 
vessels  augment.  We  have  daily  examples  of  this  in  hysterical  young  women.  It 
IS  not,  therefore,  the  mere  congestion  that  we  have  to  consider  ;  we  must  look  deeper, 
for  its  cause.  Leave  a  small  thorn  in  the  finger :  the  blood  will  be  collected  there  in 
consequence  of  its  irritation,  and  will  continue  to  collect  in  spite  of  depletion.  But 
extract  the  thorn,  and  your  remedial  measure  of  taking  away  blood  is  at  once  suc- 
cessful. So  it  is  also  with  internal  congestions  of  blood — of  which  the  exciting  and 
sustaining  cause  is  not  always  so  well  known. 

Contrasted,  in  some  important  particulars,  with  active  congestion  such  as  I  have 
been  describing,  is  that  morbid  fullness  of  the  capillary  vessels  which  arises  when 
the  return  of  the  blood  from  them  towards  the  heart  through  the  veins,  is  impeded 
by  some  mechanical  obstacle.  With  this  mechanical  congestion  the  veins  are 
exclusively  concerned. 

Congestion  of  this  kind  may  be  strictly  local.  It  may  be  confined  to  a  smglo 
limb,  when  the  principal  venous  trunk  belonging  to  that  limb  -s  compressed,  or 


46  PASSIVE    CONGESTION. 

Otherwise  diminished  in  size ;  and  when  no  collateral  and  compensatory  channels 
for  the  returnirtg  blood  have  been  established.  If  there  be  disease  of  the  liver,  of 
such  a  nature  as  to  prevent  a  free  passage  of  the  blood  through  that  organ,  conges- 
tion will  ensue  in  all  those  parts  of  the  capillary  system  from  which  the  blood  is 
conveyed  by  the  veins  that  ultimately  concur  to  form  the  vena  porta?.  The  force  of 
gravity  alone  is  sufficient  to  produce  venous  congestion,  and  consequently  conges- 
tion of  the  capillaries,  in  parts  of  the  body  in  which,  under  ordinary  circumstances, 
the  circulation  through  the  veins  is  aided,  instead  of  being  opposed,  by  that  force. 
If,  for  instance,  the  head  be  suffered  to  hang  downwards  for  a  certain  lime,  we  see 
the  unequivocal  signs  of  such  congestion  in  the  tumid  condition  and  the  purplish  red 
colour  of  the  lips,  cheeks,  eyelids,  and  ears.  When  an  impediment  to  the  free 
transmission  of  blood  exists  in  the  heart  itself,  a  tendency  to  stagnation  is  produced, 
first  in  the  vence  cavse,  then  in  the  smaller  ramifications  by  which  these  veins  are 
fed,  and  at  length  in  the  general  system  of  capillary  vessels ;  and  thus  even  general 
congestion  may  proceed  from  a  fixed  mechanical  cause ;  the  parts  that  are  the  most 
vascular  being  also  the  most  readily  and  the  most  completely  gorged. 

There  is  yet  a  third  form  of  local  congestion,  differing,  in  some  respects,  both 
from  active  and  from  mechanical  congestion.  The  capillaries  become  loaded,  and 
the  course  of  the  blood  in  them  is  languid  and  sluggish,  without  any  previous 
increased  velocity  of  the  blood  in  the  arteries,  and  independently  of  any  mechanical 
obstacle  in  the  veins.  To  this  form  of  congestion  the  term  passive  is  applied. 
Andral  denominates  it  passive  or  asthenic  hyperagmia.  I  will  tell  you  the  class  of 
facts  from  the  observation  of  which  the  real  existence  of  this  passive  plethora  has 
been  ascertained. 

In  persons  enfeebled  by  age,  or  by  disease,  the  lower  parts  of  the  legs,  the  insteps 
and  ankles,  and  the  skin  which  forms  the  surface  of  old  scars,  are  often  habitually 
purplish,  or  violet  coloured.  There  is  congestion  of  dark  blood  in  those  parts. 
You  may,  perhaps,  be  ready  to  ascribe  this  to  the  mere  influence  of  gravity  upon 
the  blood,  but  this  cannot  be  the  whole  explanation,  because  the  force  of  gravity  is 
the  same  with  all  persons,  and  at  all  ages.  A  horizontal  position  of  the  limb  will 
perhaps  diminish  the  hvid  redness,  or  may  even  sometimes  entirely  remove  it.  But 
the  depending  position  ought  not  to  cause  it,  and  wonlu  not  cause  it,  if  the  blood- 
vessels were  in  a  healthy  condition.  Neither  can  the  difference  of  posture  be  any 
source  of  irritation  to  the  congested  part.  The  capillaries  themselves  appear  to 
have  lost,  in  a  great  degree,  their  natural  elasticity ;  they  easily  dilate  under  the 
pressure  of  the  blood,  which,  being  thus  retarded,  accumulates  in  the  part.  The 
employment  of  friction,  or  some  stimulating  application,  will  often  remove  this  con- 
gestion. 

I  say  all  this  is  often  to  be  noticed  when  there  has  been  no  cause  of  irritation 
operating  upon  the  part,  and  no  preceding  state  of  active  congestion.  But  it  is 
important  to  mark  the  very  frequent  connection  that  exists  between  these  con- 
trasted conditions.  The  one  very  often  succeeds  the  other :  the  vessels  become 
dilated  under  the  force  of  the  active  hypersemia,  and,  the  irritation  ceasing,  they  do 
not  at  once  recover  their  tone,  but  remain  passively  loaded  and  distended.  They 
are  frequently  left  in  the  same  state  upon  the  subsidence  of  inflammation. 

Take  another  illustration  from  what  you  may  any  day  witness  in  respect  to  indo- 
lent ulcers.  You  will  find  that  the  large,  flabby,  and  livid  granulations  which  they 
present,  may  be  made  to  contract,  and  to  assume  a  more  healthy  and  florid  hue,  by 
local  stimulants ;  these  evidently  act  by  quickening  the  previously  languid  circula- 
tion, and  unloading  the  congested  capillaries. 

Observe,  again,  what  not  unfrequently  happens  in  regard  to  the  eye ;  a  little 
crgan,  indeed,  but  one  that  supplies  us  with  more  striking  lessons  in  patnology  and 
therapeutics  than  any  other  portion  of  the  body.  You  know  that  the  conjunctiva 
and  sclerotica,  through  which,  while  healthj'-,  colourless  fluids  alone  circulate,  are 
traversed,  under  various  forms  of  disease,  by  innumerable  vessels  bearing  red  blood. 
Now  it  is  notorious  that,  in  certain  cases,  the  application  of  any  stimulating  sub- 
stance to  the  surface  of  the  organ  wiU  increase  the  existing  redness,  multiply  the 
number  of  visible  vessels,  and  aggravate  the  complaint.     These  are  cases  of  active 


PASSIVE    CONGESTION.  '  47 

congestion,  dependent  upon  irritation  that  is  still  subsisting.  But  it  is  equally  well 
known  to  practical  men  that  the  blood-vessels  of  the  eye  are  Kable  to  congestion  of  a 
very  different  kind.  They  are  seen  to  be  distended,  somewhat  tortuous,  almost  vari- 
cose, and  the  redness  has  a  browner  tinge,  and  is  less  vivid,  than  in  the  former  case. 
In  this  kind  of  vascular  fullness — or  in  this  stage  of  it,  for  it  sometimes  succeeds  to 
active  congestion,  —  emollient  applications  do  harm  rather  than  good,  while  strongly 
astringent  and  even  irritant  substances  will  often  promptly  dissipate  the  vascularity. 
These,  again,  are  cases  illustrative  of  congestion  of  the  asthenic  or  passive  character. 
The  strong  topical  irritants  restore  to  the  feeble  and  relaxed  vessels  their  natural  elas- 
ticity, stimulate  them  to  contract  upon  their  contents,  and  to  force  onward  the  red 
blood,  which  they  cease  to  admit  from  the  arteries  ;  and  the  redness  vanishes. 

In  the  production  of  active  congestion  the  arteries  appear  to  be  principally  con- 
cerned:  in  the  production  of  mechanical  congestion,  the  veins:  in  passive  conges- 
lion,  the  capillaries  —  which,  strictly,  are  neither  arteries  nor  veins,  but  lie  between 
the  arteries  and  the  veins — are  the  vessels  chiefly  in  fault. 

If  we  turn  our  thoughts  from  the  visible  textures  of  the  body  to  those  which  are 
hidden  internally,  we  shall  find  reason  to  believe  that  these  also  are  equally  liable  tn 
similar  conditions  of  passive  congestion.  Take  those  exceedingly  vascular  organs, 
the  Jungs,  through  which  the  whole  of  the  blood  circulating  in  the  living  body  nas 
to  pass.  The  lungs,  as  might  be  expected,  are  very  liable  to  congestion  and  engorge- 
ment of  their  capillary  vessels.  Ofc-times  this  is  clearly  active,  and  the  result  of 
some  irritating  cause.  But  it  is  not  always  so.  Many  of  you  recollect  the  epidemic 
disorder  called  the  influenza,  which  was  so  prevalent  here  in  the  spring  of  1831, 
and  again  in  the  early  part  of  1837.  Among  the  most  constant  and  striking  charac- 
ters of  the  disease  were  the  symptoms  of  pulmonary  catarrh  ;  and  it  was  remarkable 
how  long,  ih  some  persons,  these  symptoms  persisted.  After  the  pulse  had  regained 
its  natural  frequency  of  beat,  and  when  all  fever  had  ceased,  the  patient  would  con- 
tinue to  breathe  with  constraint  and  some  labour,  to  wheeze  a  little,  to  cough,  and  to 
expectorate  mucus.  As  all  febrile  disturbance  had  subsided,  and  no  further  benefit 
seemed  to  flow  from  adhering  to  what  is  called  the  antiphlogistic  system,  it  was  a 
reasonable  conjecture  that  this  disappointing  obstinacy  of  some  of  the  symptoms 
might  depend  upon  a  lingering  but  passive  congestion  of  the  pulmonary  mucous 
membrane.  And  the  nature  of  ihejuvantia  showed  the  correctness  of  this  con- 
jecture. Tonics  and  stimulants,  so  far  from  aggravating  the  pectoral  symptoms, 
speedily  removed  or  abated  them. 

You  cannot  fail,  I  think,  to  perceive  the  important  bearing  of  these  distinctions 
between  active  and  passive  congestion  upon  our  notions  of  disease  and  our  choice 
of  remedies.  These  distinctions  are  not  to  be  discovered  by  the  knife  of  the  anato- 
mist. You  must  take  care  not  to  confound  a  knowledge  of  pathology,  in  the  proper 
sense  of  that  word,  with  a  knowledge  of  morbid  anatomy.  Pathology  comprehend;; 
not  only  the  visible  changes  of  structure  which  accompany  disease,  and  are  disclosed 
by  death,  but  the  processes  by  which  those  changes  are  effected  in  the  hving  body, 
and  the  laws  which  govern  those  processes. 

There  is  one  important  law  ascertained  in  respect  to  both  active  and  passive  con- 
gestion :  viz.,  that  it  is  apt  to  recur;  that  those  parts  are  most  likely  to  suffer  it  (or 
inflammation,  which  implies  it)  that  have  suffered  it  before.  We  may  often  turn 
our  knowledge  of  this  general  fact  to  good  account,  in  what  is  termed  the  jirophy- 
laxis  of  disease — in  devising  means  for  warding  off  disorders. 

I  have  stated  that  active  and  passive  congestion  sometimes  occur  in  succession, 
the  latter  being  a  sequel  of  the  former.  So,  also,  it  may  be  said  of  passive  and  of 
mechanical  congestion,  that  they  often  exist  together.  If  the  capillaries  of  a  part  or 
organ  be  much  enfeebled,  the  mechanical  effect  of  the  gravity  of  the  blood  may  suf- 
fice to  bring  them  into  a  state  of  congestion.  It  is  thus  that  Andral  explains  the 
occurrence  of  a  gorged  condition  of  the  posterior  portions  of  the  lunrrs  (evinced  by 
symptoms  during  life,  as  well  as  by  inspection  of  those  parts  after  death),  in  persons 
who,  having  laboured  under  no  previous  pulmonary  affection,  have  been  confined  to 
a  supine  position  by  long-continued  disease  or  debihty.  This  state  of  the  capillaries 
is  called  by  Lerminier  the  "engorgement  of  position ;"  and  by  Laennic,  "th'^  pneu- 


48  CONDITIONS    OF    LIFE. 

moiiia  of  the  dying."  It  neither  proceeds  from  irritation,  nor  has  it  the  essential 
characters  of  inflammation  ;  although  it  is  ajit  to  be  considered  an  evidence  of  inflam- 
mation by  the  mere  morbid  anatomist. 

Again,  as  active  congestion,  when  continued  or  intense,  is  antecedent  and  con- 
ducive to  inflammation,  so  is  mechanical  congestion,  when  it  reaches  a  certain  point, 
the  prolific  source  of  hemorrhage,  and  the  almost  constant  precursor  and  immediate 
cause  of  a  large  class  of  dropsical  accumulations. 

I  spoke  a  little  while  ago  of  general  plethora,  as  a  state  in  which  the  whole  mass 
of  blood  circulating  in  the  body  is  excessive  in  quantity,  and  rich  in  quality — full  of 
fibrin  and  of  colouring  matter,  thick  with  globules.  But  the  blood,  as  a  mass,  may 
be  in  excessive  quantity,  yet  poor  in  its  materials,  serous,  deficient  in  globules,  and 
fibrin,  and  colour;  and  in  this  condition  of  the  blood,  also,  as  we  shall  hereafter  see, 
dropsies  are  apt  to  arise. 

We  have  now,  therefore,  laid  the  foundation  for  the  better  understanding  of  those 
three  great  classes  of  disease — InJIammations,  Hemorrhages,  and  Dropsies. 

There  is  no  region  or  organ  of  the  body  exempt  from  these  diseased  conditions 
and  their  consequences  ;  and  of  each  of  them  some  general  account  must  be  given, 
Defore  we  come  to  consider  the  special  diseases  incident  to  the  several  parts  and 
organs. 

But  previously  to  entering  upon  this  general  account  of  inflammation,  of  hemor- 
rhage, and  of  dropsy,  we  have  still  some  other  preliminary  matters  of  importance  to 
discuss.  The  causes  and  modes  of  death.  The  causes  of  disease.  A  sketch  of  the 
nature,  classification,  and  import  of  symptoms. 

Our  inquiries  hitherto  have  related  to  the  manner  in  which  the  physical  condi- 
tions of  the  various  parts  of  the  body  are  capable  of  being  altered,  and  their  functions 
disturbed  or  suspended,  in  disease.  But  how  it  happens  that  some  of  these  altera- 
tions of  structure,  or  interruptions  of  function,  are  incompatible  with  the  further  con- 
tinuance of  life,  and  put  a  stop  to  the  working  of  the  whole  machine,  is  an  inquiry 
nf  no  less  interest,  though  of  a  somewhat  difl"erent  kind. 


LECTURE  V. 

Different  modes  of  dying.  Pathology  of  Sudden  Death.  Death  by  Amemia; 
its  Course,  Phenomena,  and  Anatoinical  Characters.  Death  by  Asthenia  ;  its 
Course,  Phenomena,  and  Anatomical  Characters.  Syncope.  Death  by  Inani- 
tion. Death  by  Apnoea:  Death  by  Coma:  their  Course,  and  Phenomena,  and 
the  Anatomical  Characters  common  to  both.  Application  of  the  Principles  ob' 
tainedfrom  the  investigation  of  the  Phenomena  of  Sudden  Death,  in  elucidating 
the  Symptoms  and  Tendencies  of  Disease. 

I.  PROPOSE  to  devote  the  present  lecture  to  the  following  inquiry: — Wherefore  it 
IS,  and  how  it  is,  that  some  of  the  corporeal  changes  which  we  have  been  consider- 
ing, or  the  diseased  conditions  connected  with  those  changes,  come  to  be  incompatible 
with  the  further  continuance  of  life  ?  how  it  is  that  they  put  an  end  to  the  working 
of  the  living  animal  machine  ?  why  the  machine  should  not  continue  to  work,  though 
perhaps  imperfectly,  notwithstanding  such  changes  ? 

When  our  watches  stop,  we  take  them  to  a  watchmaker  to  ascertain  why  they 
have  stopped.  The  watchmaker  knows  that  there  are  various  ways  in  which  the 
movements  of  the  instrument  may  have  been  arrested.  The  main  spring  may  have 
broken  ;  or  the  little  chain  that  connects  the  barrel  with  the  fusee  may  have  parted  ; 
or  the  teeth  of  some  of  the  wheels  may  have  become  inextricably  entangled ;  or  the 
watch  may  have  ceased  to  go  (as  the  saying  is)  simply  because  it  has  not  been  wound 
up.  Now  the  examination  which  the  watchmaker  undertakes  in  respect  to  the 
watch,  I  am  desirous  of  making  in  respect  to  the  human  body.  I  am  going  to 
inquire  mto  the  several  processes  and  modes  of  dying — the  steps,  or  ways,  by  which 


CONDITIONS    OF   LIFE.  49 

the  vital  functions  of  the  body  are  extinguished.  A  very  Httle  experience  in  the 
sick  chamber,  or  in  the  wards  of  a  hospital,  will  suffice  to  teach  you  that,  although 
all  men  must  die,  all  do  not  die  in  the  same  manner.  In  one  instance  the  thread  of 
existence  is  suddenly  snapped ;  the  passage  from  Hfe,  and  apparent  health  perhaps, 
to  the  condition  of  a  corpse,  is  made  in  a  moment :  in  another  the  process  of  dissolu- 
tion is  slow  and  tedious,  and  we  scarcely  know  the  precise  instant  in  which  the 
solemn  change  is  completed.  One  man  retains  possession  of  his  intellect  up  to  his 
latest  breath :  another  hes  unconscious,  and  insensible  to  all  outward  impressions, 
for  hours  or  days  before  the  struggle  is  over. 

We  seek  to  assertain  the  laws  and  mechanism  of  these  mysterious  differences. 
The  inquiry  is  not  one  of  merely  curious  interest,  but  has  a  direct  bearing  upon 
the  proper  treatment  of  disease.  It  will  teach  us  what  we  have  to  guard  against, 
■what  we  must  strive  to  avert,  in  different  cases.  In  speaking  of  particular  diseases, 
I  shall  constantly  refer  to  the  facts  and  reasonings  which  I  am  now  about  to  lay 
before  you. 

In  pursuing  this  inquir}',  we  need  not  go  into  any  deep  physiological  disquisition 
respecting  the  conditions  that  are  essential  to  hfe.  It  is  sufficient  for  our  purpose  to 
remark  that  life  is  inseparably  connected  with  the  continued  circulation  of  the  blooa. 
So  long  as  the  circulation  goes  on,  life,  organic  Ufe  at  least,  remains.  When  the 
blood  no  longer  circulates,  life  is  presently  extinct :  and  our  investigation  of  the  dif- 
ferent modes  of  dying  resolves  itself  into  an  investigation  of  the  different  ways  in 
which  the  circulation  of  the  blood  may  be  brought  to  a  stand. 

Observe  the  ample  provision  that  is  made,  in  the  construction  of  the  body,  for  car- 
rying on  and  maintaining  this  essential  function.  First,  there  is  an  extensive  hy- 
draulic apparatus  distributed  throughout  the  frame,  and  consisting  of  the  heart  and 
othcT  blood-vessels.  Next,  there  is  a  large  pneumatic  machine,  forming  a  consi- 
derable part  of  the  whole  body,  and  composed  of  the  lungs,  and  the  case  in  which 
they  are  lodged.  Lastly,  the  power  by  which  this  machine  is  to  be  worked  and 
regulated  is  vested  in  the  nervous  system.  Each  of  these  systems  must  continue  in 
action,  or  the  circulation  will  stop,  and  hfe  will  come  to  an  end.  The  functions  ihey 
respectively  perform  are,  consequently,  called  vital  functions  :  and  their  main  organs 
— the  heart,  the  lungs,  the  brain  (by  which  I  understand  the  intercranial  nervous 
mass) — are  denominated  vital  organs.  The  functions  of  any  one  of  the  three  being 
arrested,  the  functions  of  the  other  two  are  also  speedily  extinguished.  But  the 
phenomena  of  dying  vary  remarkably  according  as  the  interruption  begins  in  the  one 
or  the  other  organ.  Hence  Bichat,  who  in  his  Recherches  siir  la  vie  et  la  mort,  laid 
the  foundation  of  the  distinctions  I  am  about  to  describe,  spoke  of  death  beginning 
at  the  head,  death  beginning  at  the  heart,  and  death  beginning  at  the  lungs.  This 
nomenclature  is,  however,  unsatisfactory  and  insufficient,  as  you  will  presently  per- 
ceive. 

That  the  heart  may  continue  to  propel  the  current  of  the  blood,  two  things  are 
necessary  :  first,  a  certain  power  or  faculty  of  contraction  ;  and,  secondly,  a  suffi- 
cient quantity  of  blood  in  its  chambers,  to  be  moved,  and  also  to  stimulate  theni  to 
contract.  If  this,  the  proper  stimulus  to  the  internal  surfaces  of  the  heart,  be  with- 
held, or  much  deficient,  it  will  soon  cease  to  beat.  There  are  plainly,  therefore, 
two  ways  in  which  death  might  be  said  to  begin  at  the  heart ;  and  these  require  to 
be  distinguished. 

The  respiration  is  entirely  subservient  to  the  circulation  of  the  blood.  The  two 
organs,  the  heart  and  lungs,  respond  intimately  to  each  other.  The  whole  of  the 
blood  is  sent  by  the  right  heart  to  the  lungs,  simply  that  it  may  there  be  submitted 
to  the  chemical  action  of  the  atmosphere.  The  respiratory  apparatus  is  added  to 
the  body  for  the  sole  purpose  of  thus  repeatedly  ventilating  the  blood. 

To  this  purpose  also  (setting  aside  all  accidental  impediments)  two  things  are  re 
quisite  ;  first,  circumfused  air  to  enter  and  depart  at  short  intervals  ;  and,  secondly, 
alternating  movements  of  the  chest  to  cause  its  entrance  and  exit. 

Now  these  movements,  although  they  admit  of  being  regulated  by  the  will,  are 
essentially  involuntary.    The  ordinary  acts  of  respiration  depend  upon  a  certain  con- 
4  E 


50  DEATH    BY    ASTHENIA. 

dition  of  the  medulla  oblongata.  If  this  condition  fails,  the  mechanical  part  of  the 
respiratory  process,  and,  consequently,  the  chemical  part  also,  ceases. 

The  respiration  hangs,  therefore,  directly  upon  the  nervous  system. 

On  the  other  hand,  the  action  of  the  heart  is  not  directly  or  necessarily  dependent 
upon  any  constant  nervous  mfluence  conveyed  to  it.  The  circulation  goes  on  in  an 
acephalous  foetus ;  it  may  be  kept  up,  by  maintaining  artificial  respiration,  in  a  deca- 
pitated animal ;  nay,  even  when  both  brain  and  spinal  cord  have  been  abstracted  from 
the  body. 

But  though  the  nervous  influence  is  not  necessary  to  the  movements  of  the  heart 
— further  than  as  it  is  necessary  to  the  respiration,  and  to  the  introduction  of  nutri- 
ment— it  has  been  clearly  ascertained  that  very  sudden  and  extensive  injury  or  shock 
to  the  nervous  system  may  instantly  paralyze  the  heart,  and  so  stop  its  action. 

There  are  certain  states,  then,  of  the  brain  and  nerves  which,  without  directly 
afTecting  the  heart,  bring  the  motions  of  respiration  to  a  pause :  and  there  are  cer- 
tain states  of  the  brain  and  nerves  Avhich  act  directly  on  the  heart  and  arrest  its  pla3^ 
That  is,  there  are  two  different  ways  in  which  death  might  be  said  to  begin  at  the 
head. 

Hence,  I  say,  the  nomenclature  employed  by  Bichat  is  defective  and  inaccurate. 

In  order  to  see  clearly  the  steps  by  which  the  circulation,  and  with  it  life,  finally 
terminates,  in  the  various  forms  of  dying,  we  must  study  the  problem  under  its  sim- 
plest forms.  We  must  examine  the  cases  in  which  the  vital  functions  are,  each  in 
their  turn,  suddenly  stopped,  by  some  known  cause,  operating  upon  this  or  that  vital 
organ.  We  must  take  advantage  of  tlie  experiment  (if  I  may  so  call  it)  which  is 
performed  before  our  eyes  whenever  a  healthv  man  is  cut  off  at  once  by  external 
violence,  or  by  poison,  acting  directly  upon  a  particular  organ  or  system  of  organs. 
The  inquiry  might  be  assisted,  and,  indeed,  it  has  been  mainly  carried  on,  by  ex- 
periments made  upon  living  animals  of  a  similar  conformation  with  man.  But  the 
pathology  of  sudden  death  is  happily  now  too  well  understood  to  require  any  further 
recurrence  to  that  painful  mode  of  "  interrogating  nature." 

Death,  as  it  takes  place  in  disease,  is  usually  complicated.  Many  parts  are  affected, 
and  different  functions  languish,  and  various  disturbing  causes  are  in  operation,  at 
the  same  time.  Occasionally,  however,  the  process  of  dissolution  is  as  simple  and 
obvious  as  in  death  produced  by  violence  ;  and  in  most  cases  some  primary  and  pre- 
dominant derangement  may  be  traced  of  this  or  that  vital  function  ;  and  a  tendency 
is  more  or  less  clearly  manifest  to  one  or  the  other  of  the  modes  of  dying,  which  we 
may  now  proceed  to  consider  in  succession. 

And  first  let  us  examine  that  form  of  death  which  is  caused  by  a  want  of  the 
due  supply  of  blood  to  the  heart.  This  is  caUed,  with  much  propriety,  death  by 
anaemia. 

The  best  examples  of  death  taking  place  in  this  way  are  those  in  which  it  is  the 
consequence  of  sudden  and  profuse  hemorrhage.  The  circulation  fails,  not  because 
the  heart  has  lost  its  power  of  contraction,  but  because  blood  does  not  arrive  in  its 
chambers  in  sufficient  quantity. 

We  assure  ourselves  of  this  in  two  ways.  In  the  first  place,  when  the  body  of 
an  animal  is  examined  immediately  after  death  from  sudden  and  copious  loss  of  blood, 
the  heart  is  not  found  dilated  and  full  of  blood,  as  it  would  be  if  it  had  ceased  to  act 
from  a  Avant  of  {)ower  to  contract  upon  its  contents ;  but  it  is  found  empty,  or  nearly 
so,  and  contracted.  Secondly :  this  conclusion  is  confirmed  by  the  reverse  expe- 
riment :  by  the  effect,  I  mean,  of  the  transfusion  of  blood.  It  is  a  fact  well  ascer- 
tained, first  by  experiments  made  upon  animals,  and  afterwards  by  most  happy  trials 
upon  the  human  subject,  that  in  cases  of  apparent  death  from  violent  hemorrhage 
the  suspended  functions  may  be  restored  by  conveying  a  timely  supply  of  blood  into 
the  vessels  of  the  seemingly  dead  animal  from  the  veins  of  a  hving  animal  of  the 
same  species.  Now  it  is  quite  clear  that  this  introduction  of  fresh  blood  could  be 
of  no  avail  in  a  case  where  the  heart  was  unable  to  act  upon  the  blood  which  had 
already  reached  it. 

The  phenomena  which  attend  this  mode  of  dying  are  paleness  of  the  countenance 
tjid  hps,  cold  sweats,  dimness  of  vision,  dilated  pupils,  vertigo,  a  slow  weak  irregular 


DEATH    BY    INANITION.  5J 

pulse,  and  speedy  insensibility.  With  these  symptoms  are  frequently  conjoined 
nausea,  and  even  vomiting,  restlessness  and  tossing  of  the  limbs,  transient  delirium : 
he  breathing  is  irregular,  sighing,  and,  at  last,  gasping  ;  and  convulsions  generally 
occur,  and  are  once  or  twice  repeated,  before  the  scene  closes. 

It  is  thus  that  women  often  die,  in  whom  "flooding"  happens  after  childbirth. 
Sometimes  the  sudden  bursting  of  an  aneurism  occasions  this  form  of  death.  It  is 
common  on  the  field  of  battle,  and  in  accidental  injuries  whereby  large  blood-vessels 
are  wounded.  Internal  hemorrhage,  depending  upon  diseases  to  be  hereafter 
described,  may  also  prove  fatal  in  the  same  manner. 

This,  then,  is  one  form  of  death  beginning  at  the  heart.  Another  form,  the  con- 
verse of  this,  but  spoken  of  also  as  death  beginning  at  the  heart,  is  that  in  which 
there  is  no  deficiency  of  the  proper  stimulus  to  the  heart's  action,  but  a  total  failure 
of  contractile  power  in  that  organ.     This  is  well  denominated  death  by  asthenia. 

Death  occurring  in  this  way  is  not  uncommon.  The  effects  of  some  kinds  of 
poison  furnish  a  good  illustration  of  it.  There  are  certain  substances  which,  applied 
to  some  part  or  other  of  the  bod}',  speedily  extinguish  fife :  and  when,  after  their 
fatal  operation,  the  thorax  is  opened,  each  chamber  of  the  heart  is  found  to  be  filled 
with  its  proper  stimulus,  upon  which  it  has  been  unable  to  contract. 

This  was  distinctly  made  out  by  Sir  Benjamin  Brodie,  in  his  able  and  scientific 
investigation  of  the  effects  of  different  poisons.  You  may  read  with  advantage  his 
papers  on  this  subject  in  the  Philosophical  Transactions  for  1811  and  1812.  He 
ascertained  upon  examining  the  chest  after  death  occasioned  by  the  upas  antiar,  that 
the  heart  was  not  empty,  but  full,  there  being  purple  blood  in  its  right,  and  scarlet 
blood  in  its  left  cavities.  These  are  the  anatomical  characters  of  this  kind  of  death  ; 
and  they  prove  that  the  action  of  the  heart  does  not  cease  from  a  defect  of  stimulus, 
but  from  a  loss  of  its  contractile  power. 

The  state  of  suspended  animation  common  to  both  these  forms  of  dying — (the 
ultimate  external  phenomena  being  nearly  the  same  in  each,  and  the  result  in 
each  being  the  simple  failure  of  the  circulation) — is  often  expressed  by  the  term 
syncope. 

Besides  the  essential  distinctions  between  them  already  mentioned,  there  is  this 
further  point  of  difference.  In  death  by  anramia,  the  suspension  of  the  functions  of 
the  nervous  system  arises  from  a  lack  of  blood  which  should  be  sent  to  the  brain 
from  the  heart.  Hence  the  well-known  effect  of  mere  position.  Syncope  is  sooner 
produced  by  venesection  when  the  person  bled  is  sitting  up  than  when  he  is  recum- 
bent :  and  the  first  remedy  for  the  fainting  state  is  to  lay  the  patient  flat  upon  the 
ground,  or  even  to  place  his  head  a  little  lower  than  the  trunk  of  his  body.  In  the 
one  posture  the  current  of  the  blood  towards  the  head  is  impeded  by  the  force  of 
gravity  ;  in  the  other  it  is  not.  In  sudden  death  by  asthenia  this  order  is  reversed  ; 
the  nervous  system  is  the  part  first  affected,  and  through  it,  consecutively,  the  heart. 
This  appears  from  the  fact  that  sudden  death  by  asthenia  is  sometimes  produced  by 
causes  which  we  know  to  act  primarily  upon  and  through  the  nervous  system ;  by 
strong  mental  emotion — as  intense  grief,  joy,  terror.  Cases  of  fatal  concussion, 
where  the  brain  is  jarred  by  some  bodily  shock — and  death  occurring  almost  instantly 
from  blows  on  the  epigastrium — are  of  this  kind.  Lightning  and  electricity  kill  too, 
when  they  kill  at  all,  in  the  same  way.  And  we  shall  hereafter  see  that  certain 
varieties  of  apoplexy,  and  several  other  diseased  conditions,  destroy  life  by  suddenly 
arresting  the  contractile  power  of  the  heart. 

When  death  by  asthenia  occurs  more  slowly,  from  disease,  the  phenomena  are 
somewhat  different.  The  pulse  becomes  very  feeble  and  frequent,  and  the  muscular 
debility  extreme  ;  but  the  senses  are  perfect,  the  hearing  is  sometimes  even  painfully 
acute,  and  the  intellect  remains  clear  to  the  last.  The  tendency  to  death  of  this  form 
is  remarkably  manifest  in  acute  inflammation  of  the  peritoneum,  in  what  is  called 
malignant  cholera,  and  in  cases  of  extensive  mortification. 

Akin  to  this  form  of  dying  is  that  in  which  the  living  povvers  are  slowly  exnausted 
by  fingering  and  wasting  disorders,  as  in  many  cases  of  phthisis,  in  diabetes,  and  in 
dysentery  ;  or  by  hemorrhages  moderate  in  amount,  but  frequently  repeated  ;  or  by 
any  other  long-continued  drain  upon  the  system.     The  death  is  partly,  however,  t(j 


52  DEATH    BY    APNCEA. 

be  ascribed  to  a  deficient  supply  of  the  natural  stimulus  to  the  heart's  action.  The 
type  of  these  mixed  modes  of  dying  is  seen  in  death  by  starvulion,  which  may  be 
considered  intermediate  between  death  by  anaemia,  and  death  by  asthenia.  Death 
from  inanition  can  never  be  sudden.  The  blood,  renewed  no  longer  from  without, 
and  fed  only  by  absorption  from  the  system  itself,  diminishes  gradually  in  quantity, 
while  its  quality  deteriorates.  Gradually  also  the  contractile  power  of  the  heart,  eis 
well  as  of  the  muscles  generally,  is  weakened ;  and  from  these  combined  causes  its 
movements  at  length  cease.  Accordingly  after  death  by  starvation  the  heart  is  not 
found  to  be  so  much  contracted,  nor  so  nearly  empty,  as  after  death  by  sudden  and 
copious  hemorrhage. 

Certain  diseases  of  the  throat  or  the  cesophagus,  prohibiting  the  introduction  of 
food ;  of  the  stomach,  preventing  its  retention ;  of  the  digestive  organs  generally, 
hindering  its  assimilation,  are  fatal  in  this  manner. 

We  have  yet  to  consider  how  death  is  produced  by  the  suspension  of  the  respi- 
ratory function — in  other  words,  by  a  want  of  the  due  arterialization  of  the  blood. 

There  are  two  perfectl}^  distinct  modes  in  which  this  cause  of  death  may  happen ; 
distinct,  i.  e.,  in  regard  to  the  steps  of  the  process,  although  identical  in  regard  to 
the  ultimate  result. 

1.  When  the  access  of  air  to  the  lungs  is  suddenly  denied  by  some  direct  obsta- 
cle to  its  entrance. 

2.  When  the  muscular  actions  required  for  breathing  cease  in  consequence  of 
insensibility,  caused  by  disease  or  injury  of  the  brain. 

The  first  of  these  two  forms  of  dying  is  commonly  called  death  by  ctspJiyxia. 
The  second  is  conveniently  termed  death  by  coina.  Bichat  spoke  of  them  respect- 
ively as  death  beginning  at  the  lungs,  and  at  the  head. 

It  is  of  much  importance  to  get  rid,  when  we  can,  of  improper  names.  They  are 
ver}'  apt  to  warp  our  notions  concerning  the  real  nature  of  the  things  they  are 
intended  to  express.  This  term  asphyxia,  which  is  in  every  body's  mouth,  is  very 
inappropriate,  if  we  look  to  its  etymology,  to  the  kind  of  death  which  it  has  come  to 
denote.  It  signifies,  you  know,  literally,  pulselessness,  the  want  of  pulse  ;  and  there- 
fore it  might  express  any  kind  of  death  whatever ;  or  if  applied  to  any  particular 
mode  of  dying,  it  would  seem  to  belong  to  that  we  have  just  been  considering, 
namely,  death  beginning  at  the  heart.  And  you  will  presently  see  that  it  is  pecu- 
liarly inapplicable  to  all  those  cases  where  death  results  from  the  non-arterialization 
of  the  venous  blood.  Its  current  signification  has,  I  am  afraid,  been  too  long  estab- 
lished by  custom,  to  allow  of  its  being  restored  to  its  proper  meaning  without  much 
confusion.  But  at  any  rate,  I  can  and  shall  avoid  its  use,  and  adopt  in  preference 
the  generic  term  o/j;2ffa  (privation  of  breath)  as  justly  expressive  of  the  mode  of 
death  to  which  the  word  asphyxia  is  commonly  given  by  authors.  The  generic 
English  term  is  suffocation. 

The  entrance  of  air  into  the  lungs  may  be  prevented  in  various  ways :  by  stop- 
page of  the  mouth  and  nostrils  {smothering): — by  submersion  of  the  same  inlets  in 
some  liquid  {droivning);  or  in  gases  which,  though  not  in  themselves  poisonous, 
contain  no  oxygen ;  such  are  hydrogen  and  azote : — by  mechanical  obstruction  of 
the  larynx  or  trachea  from  within,  as  by  a  morsel  of  food  (choking),  or  from  with- 
out, as  by  the  bowstring  [strangulation;  both  these  varieties  are  included  in  the  term 
thiottling): — by  forcible  pressure  made  at  once  upon  the  chest  and  abdomen,  pre- 
venting all  movement  of  the  ribs  and  of  the  diaphragm  ;  this  happens  sometimes  to 
workmen  employed  in  excavating,  who  are  buried,  their  heads  excepted,  by  the  falling 
of  a  mass  of  earth ;  it  was  near  happening,  Dr.  Roget  tells  us,  to  an  athletic  black 
man,  of  whose  body  a  cast  was  attempted  to  be  taken,  as  an  academic  model,  by  one 
operation,  and  in  one  entire  piece.  "As  soon  as  the  plaster  began  to  set,  he  felt  on 
a  sudden,  deprived  of  the  power  of  respiration,  and  to  add  to  his  misfortune,  was 
cut  off  from  the  means  of  expressing  his  distress  ;  his  siniation  was  perceived  just 
in  time  to  save  his  hfe ;"  in  this  way  the  victims  of  Burke  and  Hare  were  stifled ; 
and  the  same  immovable  state  of  the  lung-case  is  sometimes  produced  in  tetanus,  or 
oy  the  poisonous  influence  of  strj'chnine,  all  the  respiratory  muscles  being  fixed  in 
ri^  i  spasm  . — b)  paralysis  of  the  same  muscles,  from  injury  or  disease  of  the  spina' 


DEATH    BY    APNCEA.  53 

cord  above  the  origin  of  the  nerves  that  give  oif  the  phrenic  nerve,  and  therefore 
above  the  origin  of  the  intercostal  nerves  also ;  or  from  section  of  the  phrenic  and 
intercostal  nerves : — lastly,  by  such  breaches  in  the  walls  of  the  thorax  as  admit  air 
freely  to  the  surface  of  bolh  lungs,  and  spoil  the  pneumatic  machine,  as  a  pair  of 
bellows  is  spoiled  when  deprived  of  its  valve.  Of  course  the  same  consequences 
ensue  when  both  pleurce  become  filled  with  liquid  of  any  kind. 

Whenever  the  privation  of  air  is  sudden  and  complete,  the  following  external  phe- 
nomena present  themselves. — Strong  but  vain  contractions  occur  of  all  the  muscles 
concerned  in  breathing,  and  struggling  efforts  to  respire  are  made,  prompted  by  that 
uneasy  sensation  which  every  one  has  experienced  who  has  tried  how  long  he  can 
hold  his  breath,  and  which,  when  unappeased,  soon  rises  to  agony :  this  extreme 
distress  is  transient,  being  almost  immediately  succeeded  by  sensations,  not  unplea- 
sant, of  vertigo,  and  then  by  loss  of  consciousness,  and  convulsions  :  at  length  all 
effort  ceases,  a  few  irregular  twitchings  or  tremours  of  the  limbs  alone  perhaps 
remaining;  the  muscles  relax,  and  the  sphincters  yield:  but  still  the  movements  of 
the  heart,  and  even  the  pulse  at  the  wrist,  continue  for  a  short  time  after  all  other 
signs  of  hfe  are  over;  there  is  no  asphyxia  (properly  so  called)  till  the  very  last. 

During  this  process,  which  does  not  occupy  more  than  tw^o  or  three  minutes,  the 
face  at  first  becomes  flushed  and  turgid,  then  Hvid  and  purplish,  the  veins  of  the 
head  and  neck  swell,  and  the  eyeballs  seem  to  protrude  from  their  sockets  ;  at  length 
the  heart  ceases  to  palpitate,  and  life  is  extinct. 

The  internal  changes  which  correspond  with,  and  cause  these  outward  symptoms, 
have  been  carefully  studied,  and  accurately,  though  slowly  and  lately  ascertained. 
They  all  proceed  from  the  prevention  of  the  chemical  alteration  naturally  produced 
in  the  blood,  within  the  capillary  vessels  of  the  lungs.  The  blood,  continuing  venous, 
passes  at  first  in  considerable  quantity  through  the  pulmonary  veins,  into  the  left 
side  of  the  heart,  and  thence  through  the  arteries,  to  all  parts  of  the  body.  This 
venous  blood,  however,  is  inadequate  to  sustain,  or  sufficiently  to  excite,  the  functions 
of  the  parts  it  thus  reaches.  In  the  brain  the  effect  of  the  unnatural  circulation  is 
felt  at  once  ;  and  shown  by  the  convulsions  and  insensibility  that  ensue.  The  motion 
of  the  blood  in  the  pulmonary  capillaries  is  also,  from  the  first,  impeded,  and  its 
current  gradually  retarded,  until  it  stagnates  altogether ;  the  lungs  remaining  full, 
the  right  chambers  of  the  heart  distended,  and  therefore  less  capable  of  contracting. 
Meanwdiile  the  black  blood,  flowing  more  and  more  tardily  and  scantily  into  the  left 
chambers,  leads,  by  its  unnatural  quality,  as  well  as  its  deficient  supply,  to  feeble 
contractions  ;  and  this  side  of  the  heart  is  comparatively  empty. 

In  this  state,  even  after  |.he  heart  has  ceased  to  beat,  but  not  long  after,  if  the  i  ause 
which  has  excluded  the  air  be  withdrawn,  and  fresh  air  readmitted — in  other  words, 
if  artificial  respiration  be  instituted — the  blood  in  the  pulmonary  capillaries  under- 
goes the  required  change,  becomes  arterial,  begins  again  to  pass  onwards,  and  by 
degrees  the  circulation  is  restored,  and  the  patient  saved. 

In  this  mode  of  death  the  circulation  is  first  arrested,  and  death  truly  begin..,  in 
the  lungs. 

When  the  carcass  of  an  animal,  that  has  thus  perished  of  apnosa,  is  immediately 
afterwards  examined  (so  speedy  an  inspection  of  the  human  body  being,  for  obvious 
reasons,  seldom  practicable  or  proper),  the  left  side  of  the  heart  is  found  to  contain  a 
small  quantity  of  dark  blood,  while  its  right  cavities  are  greatly  distended,  and  the 
lungs,  the  cavce,  and  the  whole  venous  system,  are  gorged  with  blood  of  the  same 
character.  These  are,  in  few  words,  the  anatomical  characters  of  sudden  death  by 
apncea. 

The  pathology  of  this  mode  of  dying  has,  I  say,  been  thoroughly  understood  only 
of  late.  It  will  not  be  uninteresting,  and  may,  I  think,  be  useful,  to  trace  briefly 
the  successive  steps  by  which  the  true  explanation  has  been  attained.  Haller  was 
of  opinion  that  the  quiescence  of  the  lungs,  consequent  upon  the  cessation  of  the 
alternate  movements  of  the  thorax,  formed  a  mechanical  impediment  to  the  further 
transit  of  the  blood  through  them;  and  that  death  resulted  from  obstruction  of  the 
circulation  in  Ihe  lungs.  He  was  partly  right ;  but  he  erred  in  supposing  that  thir 
stream  of  blood  was  arrested  absolutely,  and  at  once,  and  by  a  mechanical  obstacle 

e2 


54  DEATH    RY    APNCEA. 

Apnoea,  with  all  its  peculiar  phenomena,  occurs,  when  atmospheric  air  is  excluded, 
although  the  lungs  continue  to  play  ;  as  in  persons  who  breathe  azote  or  hj^drogen 
gas.  It  was  clearly  shown  by  Dr.  Goodwyn,  in  his  Essay  upon  the  Connection  of 
Life  ivith  Respiration,  that  the  unaerated  blood  passed  through  the  lungs  and  entered 
the  left  auricle  and  ventricle  of  the  heart ;  but  he  thought  that  it  went  no  further. 
His  notion  was  that  arterial  blood  is  the  only  stimulus  which  can  excite  the  contrac- 
tion of  the  left  cavities  of  the  heart,  and  that,  when  venous  blood  arrives  in  them, 
the  organ  becomes  motionless  ;  and  no  blood  being  sent  to  the  brain,  the  person  dies. 
Had  this  theory  been  true,  the  left  chambers  would  be  found  full  of  blood  after  death 
(which  they  are  not),  and  the  mode  of  dying  would  not  have  differed  essentially  from 
that  which  we  have  already  considered  as  death  by  asthenia.  The  well-devised 
experiments  of  Bichat  carried  the  investigation  a  step  further,  and  proved  that  the 
unaerated  blood  not  only  reached  the  heart,  but  was  propelled  by  the  contractions  of 
that  organ  to  every  part  of  the  body,  through  the  arteries.  Having  applied  a  liga- 
ture upon  the  trachea  of  a  living  animal,  he  made  a  small  opening  in  one  of  its 
carotid  arteries.  Presently  the  slender  stream  of  blood  that  issued  began  to  lose  its 
florid  tint,  and  to  assume  the  dark  colour  of  venous  blood;  but  it  continued  to  floic, 
and  the  afflux  of  this  dark  blood  upon  the  brain  was  marked  by  convulsions  and 
insensibihty.  Bichat  conceived,  therefore,  the  erroneous  belief  that  the  blood  under- 
went no  obstruction  in  its  passage  through  the  lungs,  but  that,  remaining  unpurified 
and  venous,  it  acted  as  a  poison  upon  every  part  to  which  it  was  carried  by  the 
arteries — first  upon  the  nervous  S3'stem,  and  ultimately  (passing  through  the  coronary 
arteries)  upon  the  muscular  substance  of  the  heart  itself.  There  are,  however,  two 
well-known  facts,  which,  upon  this  theory,  would  be  inexplicable — the  comparative 
emptiness  of  the  left  chambers  of  the  heart,  and  the  restoration  of  the  suspended 
functions  by  the  timely  performance  of  artificial  respiration.  The  air  could  never 
reach  and  revivify  or  depurate  the  venous  blood,  stagnating  in  the  capillaries  of  the 
heart.  It  was  reserved  for  Dr.  Kay  to  correct  the  unsound  parts  of  Bichat's  doctrine, 
and  to  show  that  the  blood  begins  to  stagnate  in  the  capillaries  of  the  lungs,  in  con- 
sequence of  its  failing  to  undergo  the  change  from  venous  to  arterial ;  and  that  the 
movements  of  the  left  heart  are  brought  to  an  end,  principally  by  the  deficient  supply 
of  blood  from  the  lungs.  His  experiments  tend,  moreover,  to  prove  that  venous  blood 
circulating  through  the  arteries  has  no  directly  poisonous  operation,  but  is  capable, 
though  much  less  effectually  than  arterial  blood,  to  support,  in  some  degree,  the 
irritability  of  the  muscles.  A  muscle  will  continue  to  contract  longer  when  supplied 
with  venous  blood  by  its  arteries,  than  when  supplied  with  no  blood  at  all.  Doubt- 
less, in  death  by  apnoea,  the  movements  of  the  heart  are  weakened,  partly  in  conse- 
quence of  the  imperfect  stimulus  afforded  by  the  venous  blood  that  penetrates  its 
substance  ;  but  the  main  cause  of  the  failure  of  the  circulation  seems  to  be  the  diffi- 
culty with  which  the  non-arterialized  blood  finds  its  way  through  the  capillaries  of 
the  lungs.  This  theory  is  consistent  with  all  the  phenomena  observed.  For  a 
detailed  account  of  the  experiments  and  reasonings  upon  which  Dr.  Kay's  conclu- 
sions are  founded,  I  must  refer  you  to  his  work  on  Asphyxia. 

Sudden  death  by  apncea  is  not  very  often  witnessed  as  the  result  of  disease.  It 
sometimes  is  caused  by  a  spasmodic  closure  of  the  rima  glottidis.  It  is  no  uncom- 
mon consequence  of  accidents,  in  which  the  upper  cervical  vertebra?  are  broken  or 
displaced.  I  ii:ive  seen  several  instances  of  death  rapidty  produced,  with  all  the 
symptoms  of  sudden  suffocation,  generally  in  intoxicated  persons,  in  whom  the  chink 
of  the  glottis  has  been  found  closely  plugged  by  a  fragment  of  meat,  which  "had 
gone  the  wrong  way." 

But  there  are  numerous  forms  of  more  chronic  disease,  in  which  the  tendency  to 
death  by  apnoea  is  plainly  discehiible,  sometimes  for  a  long  while  before  their  fatal 
lermmation  arrives.  And  the  phenomena  are  similar  in  character  to  those  which  are 
noticed  when  the  struggle  is  short.  We  hear  the  patients  complain  of  the  "  want  of 
breath  ;"  we  see  how  they  labour  to  satisfy  this  want,  when  it  becomes  urgent,  by 
the  elevated  shoulders,  the  dilating  nostrils  the  energetic  action  of  all  the  muscles 
ihat  are  auxiliary  to  the  respiration;  we  perceive  by  the  dusky  and  loaded  coun- 
tenance, the  hvid  lips,  and  ears,  and  eyelids,  that  the  blood  is  but  imperfectly  arte 


DEATH   BY   APNGEA.  55 

rialized.  The  diminislied  capability  of  such  blood  to  support  the  functions  of  the 
brain  is  made  evident  by  the  vertiginous  sensations,  and  the  delirious  thoughts  of  the 
gasping  sufferers  ;  and  after  death  we  find  the  same  distension  of  the  right  chambers 
of  the  heart,  while  the  left  are  nearly  empty — the  same  gorged  condition  of  the 
pulmonary  arteries  and  venous  system  generally,  which  constitute  the  anatomical 
characters  of  this  mode  of  dying.  These  appearances  are  even  more  constandy 
visible  in  the  dead  body,  when  apncea  has  been  gradually  produced,  than  after  sudden 
suffocation  ;  simply,  I  believe,  because  they  are  more  permanent.  After  sudden 
death,  however  caused,  the  blood  seldom  coagulates;  and  the  venous  turgescence 
consequent  upon  rapid  apncea,  although  great  at  first,  has  time  to  subside  and  disap- 
pear before  the  body  is  examined. 

In  protracted  cases,  death  does  not  take  place  purely  in  the  way  of  apncea ;  the 
heart  is  weakened,  and  the  nervous  influence  impaired  by  the  continued  circulation 
of  imperfectly  arterialized  blood  ;  but  the  symptoms  belonging  to  apncea  are  plainlj'- 
predominant. 

When  (as  is  most  common)  the  privation  of  air  is  incomplete,  and  a  scanty  and 
insufficient  supply  is  admitted,  morbid  changes  take  place  in  the  lungs  themselves ; 
the  air-tubes  and  cells  become  charged  with  serous  fluid,  which  operates  as  an  addi- 
tional cause  of  suffocation.  The  saine  phenomenon  is  observed  when  the  par  vagum 
is  divided  on  both  sides. 

Death  by  apnoea  in  disease  is  extremely  common.  It  may  be  produced  by  any 
thing  which  narrows  the  chink  of  the  glottis  ;  by  warts  that  sometimes  grow  there, 
by  oedema  of  the  submucous  tissue  of  the  larynx,  by  inflammatory  tumefaction  of 
its  lining  membrane:  it  may  result  from  the  presence  of  what  are  called  false  mem- 
branes in  the  windpipe  and  bronchi,  such  as  are  formed  in  the  distemper  named 
croup  :  it  may  be  the  consequence  of  disease  situate  in  the  substance  of  the  lungs 
themselves,  rendering  them  incapable  of  receiving  the  requisite  quantity  of  air ;  of 
this  we  have  examples  in  pneumonia,  and  in  pulmonary  apoplexy :  or  it  may  pro- 
ceed from  disorders  of  the  pulmonary  mucous  membrane,  the  air-passages  becoming- 
blocked  up  with  excessive  and  unnatural  secretions,  as  in  bronchitis.  Phthisis  is 
sometimes  fatal  in  the  way  of  apna-a;  more  commonly  it  tends  to  death  by  asthenia. 
Diseases  of  the  pleurce  attended  with  effusion,  and  causing  pressure  upon  the  lungs : 
diseases  of  the  heart  and  great  thoracic  blood-vessels,  afiecting  the  quantity  of  blood 
in  those  organs ;  even  certain  abdominal  maladies,  accompanied  by  sweUing,  and 
thrusting  the  diaphragm  upwards — terminate  by  the  same  mode  of  dissolution. 

Death  by  coma,  akhough  common  enough,  and  of  much  importance  to  be  under- 
stood, need  not  detain  us  long.  Certain  morbid  states  of  the  brain  (it  is  unnecessary 
at  present  to  inquire  into  their  nature  and  origin)  produce  stupor,  more  or  less  pro- 
found ;  the  sensibility  to  outward  impressions  is  destroyed,  sometimes  wholly  and  at 
once,  much  oftener  gradually;  the  respiration  becomes  slow,  irregular,  stertorous ; 
all  voluntary  attention  to  the  act  of  breathing  is  lost,  but  the  instinctive  motions  con- 
tinue; the  stimulus  conveyed  by  the  pulmonary  branches  of  the  eighth  pair  of 
nerves,  and  probably  by  certain  branches  too  of  the  fifth,  still  excites,  though  per- 
haps imperfectly,  the  reflex  power  of  the  medulla  oblongata,  Avhich  sustains  the 
involuntary  movements  of  the  thorax.  At  length  this  function  fails  also — the  chest 
ceases  to  expand — the  blood  is  no  longer  aerated — and  thenceforward  precisely  the 
same  internal  changes  occur  as  in  death  by  apnosa. 

You  will  observe  that  the  extinction  of  organic  life  takes  place  in  exactly  the 
same  manner  in  both  cases  :  the  difference  between  the  two  forms  of  dying  being 
this — that  in  death  by  apnoea,  the  chemical  functions  of  the  lungs  cease  first,  and 
then  the  circulation  of  venous  blood  through  the  arteries  suspends  the  sensibility; 
whereas,  in  death  by  coma,  the  sensibility  ceases  first,  and  in  consequence  of  this  tin. 
movements  of  the  thorax,  and  the  chemical  functions  of  the  lungs,  cease  also.  So 
that  the  circulation  of  venous  blood  through  the  arteries  is  in  the  one  case  the  cause, 
and  in  the  other  the  effect,  of  the  cessation  of  animal  life. 

The  causes  that  destroy  the  sensibility  leave  no  constant  or  necessary  traces  >r 
their  operation.  The  essential  anatomical  characters  of  death  by  coma,  and  of  deain 
by  apnoea,  are  therefore  the  same. 


56  APPLICATION'    OF    PRINCIPLES. 

Death  occurring  in  the  way  of  coma  has  this  pecuHar  kind  of  interest  belonging 
to  it,  that  it  may  sometimes  be  efTectually  obviated  by  a  mechanical  expedient.  The 
circulation  ceases  because  the  actions  of  respiration  cease — and  the  failure  of  the  acts 
of  respiration  arises  from  a  suspension  of  the  nervous  power.  If  it  be  merely  a 
suspension — if  the  nervous  functions  are  within  the  verge  of  recovery — organic  life 
may  be  sustained  by  the  performance  of  artificial  respiration,  until  the  insensibility 
has  passed  away ;  and  thus  the  danger  to  life,  which  depended  on  that  insensible 
state,  may  be  escaped. 

.Many  years  ago,  in  the  course  of  those  researches  to  which  I  have  already 
referred,  Sir  Benjamin,  then  Mr.  Brodie,  was  led  to  think  that  by  continuing  the 
respiration  artificially  in  animals  labouring  under  the  influence  of  narcotic  poisons, 
the  heart  might  be  kept  in  action  until  the  stupefying  but  transitory  effect  of  the 
poison  upon  the  brain  had  gone  off.  This  idea  he  soon  brought  to  the  test  of 
experiment,  and  the  result  was  such  as  to  justify  his  ingenious  reasoning.  He. 
inserted  some  woorara  into  a  wound  which  he  had  made  in  a  young  cat.  After  a 
certain  time  the  respiration  had  entirely  ceased,  and  the  animal  appeared  to  he  dead, 
but  the  heart  could  be  still  felt  beating.  The  lungs  were  then  artificially  inflated 
about  forty  times  in  a  minute.  The  heart  continued  to  beat  regularly.  When  the 
artificial  breathing  had  been  kept  up  for  forty  minutes,  the  pupils  of  the  cat's  eyes 
were  observed  to  contract  and  dilate  upon  the  increase  or  diminution  of  light,  but  the 
animal  remained  perfectly  motionless  and  insensible.  At  the  end  of  an  hour  and 
forty  minutes  there  were  slight  involuntary  contractions  of  the  muscles,  and  every 
now  and  then  there  was  an  efTort  to  breathe.  At  the  end  of  another  hour  the  animal, 
for  the  first  time,  showed  some  signs  of  sensibihty  when  roused,  and  made  spon- 
taneous efforts  to  breathe  twenty-two  times  in  a  minute.  The  artificial  breathing 
was,  therefore,  now  discontinued.  She  lay,  as  in  a  state  of  profound  sleep,  for  forty 
minutes  longer,  when  she  suddenly  awoke,  and  began  to  walk  about. 

Sir  Benjamin  Brodie  had  indeed  been  anticipated  in  this  happy  proposition  for 
recovering  persons  apparently  dead  after  taking  narcotic  poison,  after  submersion, 
and  the  like, — although  he  does  not  seem  to  have  been  aware  of  it.  The  experiment 
had  once  been  tried  before,  and  on  the  human  subject,  and  with  success,  though  not 
upon  such  scientific  principles.  The  case  is  given  by  Mr.  Whately,  in  the  Medical 
Observations  and  Inquiries,  vol.  vi.  A  man  who  had  swallowed  an  immense 
quantity  of  solid  opium,  and  who  seemed  to  be  dead,  was  restored  by  the  patient 
continuance,  on  the  part  of  his  medical  attendants,  in  a  process  of  artificial  breathing 

It  is  seldom  that  we  can  hope  for  success  from  this  expedient  in  the  treatment  of 
disease ;  simply  because,  in  most  cases,  the  injury  of  the  nervous  system  which  has 
produced  the  insensibility  is  irretrievable. 

In  most  forms  of  apoplexy,  and  of  hydrocephalus,  death  occurs  in  the  way  of 
coma.  Sometimes,  however,  as  I  mentioned  before,  the  lesion  of  the  nervous  sub« 
stance  is  so  extensive  and  sudden,  as  to  operate  like  a  shock,  and  cause  death  by 
asthenia.  The  tendency  to  death  by  coma  is  also  strongly  pronounced  in  sundry 
afTections  of  the  brain,  both  acute  ond  chronic.  These  will  form  subjects  for  oui 
consideration  hereafter. 

The  several  modes  of  dying,  then,  in  cases  of  sudden  death,  are  clearly  enough 
made  out.  Let  me  briefly  sum  up  the  conclusions  at  which  we  have  arrived.  Life 
cannot  be  maintained  without  the  circulation  of  arterial  blood :  and  whenever  a 
person  dies,  he  dies  either  because  no  blood  circulates  through  his  arteries,  or 
because  venous  blood  circulates  through  them. 

When  it  comes  to  pass  that  no  blood  is  circulated  through  the  arteries,  we  say 
that  death  occurs  in  the  way  of  syncope;  and  this  is  of  two  kinds.  In  the  one  there 
IS  not  blood  enough  received  by  the  left  side  of  the  heart  to  stimulate  its  chambers  to 
contract,  or  to  be  sent  onwards  by  their  contraction  ;  in  the  other,  there  may  be 
blood  enough,  but  the  heart  has  not  sufficient  power  to  contract  upon  it. 

Also  there  are  two  ways  in  which  death  may  be  brought  about  in  consequence  of 
the  circulation  of  th'^  venous  blood  through  the  arteries.  In  one  of  .hese,  the  first 
step  is  tlic  sudden  shutting  out  of  air  from  the  lungs ;  the  blood  which  arrives  m 


CAUSE   OF   DISEASE.  Sf 

those  organs  is  not  aerated,  or  rendered  arterial,  but  circulates  again  as  venous  blood, 
producing  a  failure  of  the  animal  functions,  and  weakening  the  muscles,  till  it  finally 
stagnates  in  the  capillaries  of  the  lungs  themselves.  In  the  other,  the  animal  func- 
tions are  the  first  to  suffer — insensibility  occurs — the  power  which  governs  the 
movements  of  respiration  is  withheld — the  breathing  ceases — and  organic  life  is 
extinguished  as  in  the  former  case. 

I  trust  you  even  already  perceive  that  a  right  understanding  of  these  matters  is 
calculated  to  throw  both  light  and  interest  upon  our  study  of  the  symptoms  and  of 
the  tendencies  of  disease.  It  will  enable  us  to  aim  with  more  precision  at  ful- 
filling the  indication  so  often  inculcated  by  Cullen,  of  "  obviating  the  tendency  to 
death."  In  this  sketch  I  have  merely  been  able  to  hint  at  the  important  bearings 
of  such  views  upon  our  practice.  My  attention  was  first  called  to  them  by  the 
lectures  of  my  respected  instructor.  Dr.  Alison,  who  was  accustomed  to  illustrate 
them  by  reference  to  the  phenomena  of  one  large  class  of  disorders.  All  the 
modes  of  dying  that  I  have  described  are  apt  to  take  place  in  fevers.  Some- 
times we  have  to  combat  the  one,  sometimes  the  other  tendency.  The  disease 
often  proves  fatal  in  the  way  of  coma ;  this  happens  principally  when  the  brain 
has  been  a  good  deal  affected,  when  there  have  been  much  headache,  delirium, 
and  stupor ;  sometimes,  when  the  lungs  have  been  seriously  implicated,  hfe  is 
extinguished  in  the  way  of  suffocation  or  apnroa :  and  occasionally  fever  seems  to 
terminate  fatally  in  the  way  of  syncope,  especially  when  the  stress  of  the  disorder 
has  fallen  upon  the  bowels,  when  there  has  been  continued  diarrhea,  and  ulcer- 
ation of  the  intestinal  glands.  Or  if  death  does  not  occur  precisely  in  these  ways, 
at  least  it  resembles  more  in  different  cases,  sometimes  one  form  of  dying,  sometimes 
another. 

It  is  notorious  that  very  different  remedies,  and  even  different  plans  of  treatment, 
have  been  strongly  recommended,  in  fever,  by  different  practitioners.  One  probable 
reason  of  this  is,  that  one  plan  has  been  found  the  most  proper  to  avert  the  fatal 
event  in  one  form  of  the  disease,  and  one  in  another.  The  tendency  to  a  particular 
mode  of  death  will  prevail  in,  and  characterize,  a  whole  epidemic.  We  shall  resume 
these  considerations  hereafter :  in  the  mean  time  the  facts  we  have  been  reviewing 
may  teach  us  the  danger  of  applying,  with  too  much  confidence,  the  experience  we 
may  have  gained  of  one  epidemic  to  the  treatment  of  another ;  and  the  risk  we  are 
sometimes  liable  to,  of  misjudging,  and  criticising  unjustly,  the  practice  recom 
mended  by  other  physicians,  because  it  does  not  appear  to  accord  with  the  results  of 
our  own  observation. 


LECTURE  VI. 

Causes  of  Disease :  distindmi  between  predisposing  and  exciting  causes.  Enu- 
meration of  causes,  as  connected  with  the  Atmosphere — Food  and  Drink — 
Poisons — Exercise — Sleep — Mental  and  Moral  Conditions — Hereditary  Ten- 
dencies— Malformations.     Temperature.     Effects  of  Heat  and  Cold. 

The  causes  of  disease  are  commonly  arranged  under  three  heads — as  predis- 
posing, exciting,  or  proximate. 

Of  these  three,  the  last  mentioned,  or  the  proximate  cause,  is  nothing  else  than 
the  actual  disease  itself — the  actual  condition  of  that  part  of  the  body  from  which 
the  whole  train  of  morbid  phenomena  essentially  flows.  When  we  know  that  part, 
and  that  condition,  we  name  the  disease  accordingly.  It  may  be  inflammation  of 
the  lungs;  or  softening  of  the  brain.  When  we  do  not,  we  call  the  complaint 
after  the  group  of  symptoms  by  which  it  is  characterized :  intermittent  fever, 
perhaps ;  or  marasmus.  The  term  "  proximate  cause"  is,  therefore,  an  unnecessary 
term  :  it  is,  moreover,  to  learners,  a  puzzling  term,  and  tends  to  give  to  the  study  of 
the  disease  a  scholastic  and  repulsive  aspect.  I  wish  you  to  get  into  the  habit  of 
contemplating  the  whole  science  of  medicine  under  its  simplest  and  plainest  form 


58  CAUSE    OF    DISEASE. 

I  am  sure  we  may  very  well  abolish  the  term  "  proximate  cause"  altogether ;  and 
having  now  given  an  explanation  of  its  meaning,  for  your  guidance  when  you  meet 
with  it  in  books,  I  shall  never  employ  it,  in  these  lectures,  except  perhaps  in  a  quo- 
tation, again. 

In  strictness  of  language,  one  event  is  held  to  be  the  cause  of  another  event  which 
follows  it,  when  the  first  being  absent,  the  second  never  occurs  ;  and  the  first  being 
present,  the  second  never  fails  to  occur,  unless  some  other  event  intervene  to  prevent 
it.  But  the  causes  of  disease  will  not  bear  to  be  spoken  of  after  so  strict  a 
fashion.  We  perceive  that  certain  external  circumstances  [qux  nos  circumstant) 
often  precede  such  and  such  diseases ;  and  that  the  diseases  seldom  happen  when 
the  same  circumstances  are  not  previously  observable ;  and  we  begin  to  regard 
those  circumstances  as  exciting  causes  of  those  diseases.  We  find  that  the  dis- 
eases are  much  more  frequent  among  persons  known  to  have  been  exposed  to 
the  agency  of  the  presumed  causes  than  among  persons  who  are  not  known  to 
have  been  so  exposed.  The  evidence  at  first  is  presumptive  only.  But  the  more 
unifonn  their  conjunction,  and  the  more  rare  their  disjunction,  the  more  confi- 
dently do  we  assign  to  the  two  consecutive  events  the  relation  of  cause  and  efl^ct. 
By  this  kind  of  observation  a  number  of  exciting  causes  of  disease  have  been  clearly 
estabhshed  to  be  such. 

But  recollect,  certain  circumstances  being  present,  such  and  such  diseases  do 
often,  not  alwuys,  follow.  Some  persons  are  more  Hable  to  be  afl^ected  by  the  ope- 
ration of  many  of  these  ascertained  causes  than  others  are;  and  the  same  persons 
are  more  liable  to  be  influenced  by  the  same  cause  at  one  time  than  at  another. 
And  special  circunastances,  existing  in  particular  cases,  will  be  found  to  account  for 
this  variable  operation  of  known  exciting  causes  upon  the  bodily  health.  These 
special  circumstances  may  properly  be  called  predisposing  causes.  Thus,  of  twenty 
persons  exposed  to  the  same  noxious  influence — to  the  combined  agency  of  wet  and 
cold  during  a  shipwreck,  for  example — one  shall  have  cala: ih,  another  rheumatism, 
a  third  pleurisy,  a  fourth  ophthalmia,  a  fifth  inflammation  of  the  bowels,  and  fifteen 
shall  escape  without  any  illness  at  all.  A  man  does  that  with  impunity  to-day, 
which  shall  put  his  life  in  jeopardy  when  he  repeats  it  next  week.  It  is  not,  there- 
fore, the  exciting  cause  o/one  that  in  all  cases  determines  the  dis-..se.  Something 
— nay  much,  or  all — will  frequentl}^  depend  upon  the  conditio  .  of  the  body  at  the 
time  Vv-hen  the  exciting  cause  is  applied ;  and  this  condition  of  the  body,  which 
we  cai\l  predisposition,  will  depend  upon  circumstances  then  or  previously  in  ope- 
ration ;  and  these  circumstances  are,  in  our  language,  predisposing  causes. 

Do  not  confound,  as  many  seem  to  do,  the  predisposition  mth  the  circumstances 
creating  it.  The  predisposition  is  a  certain  state  of  the  body — the  predisposing 
cause  of  what  produces  that  state.  The  cause  of  the  predisposition  is  the  predis- 
posing cause  of  the  disease.  A  predisposing  cause  may  therefore  be  defined  to  be 
any  thing  whatever  which  has  had  such  a  previous  influence  upon  the  body  as 
to  have  rendered  it  unusually  susceptible  to  the  exciting  cause  of  the  particular 
disease. 

It  is  sometimes  difficult,  or  impossible,  to  say  of  a  given  cause  whether  it  ought  to 
he  ranked  among  the  exciting  or  among  the  predisposing  causes ;  whether  it  has 
prepared  the  system  for  being  affected  by  some  other  agent,  or  whether  it  has  itself 
produced  the  disease ;  but  for  the  most  part  the  distinction  is  real,  and  sufficiently 
well  marked,  and  of  great  importance  to  be  attended  to. 

Disease  may  sometimes  be  averted,  even  in  despite  of  strong  and  fixed  predis- 
"^osition  to  it,  if  we  know,  and  can  guard  against,  the  agencies  by  which  it  is 
capable  of  being  excited.  A  man  may  inherit  a  proclivity  to  consumption,  yet 
fortunately  escape  that  fatal  complaint  by  timely  removal  to  a  warm  and  equable 
chmate,  and  by  other  suitable  precautions ;  that  is,  by  avoiding  whatever  tends  to 
rouse  the  dormant  tendency  into  action.  On  the  other  hand,  disease  may  often 
be  warded  ofl',  notwithstanding  the  presence  and  application  of  its  exciting  cause, 
when  its  predisposing  causes  are  ascertained  and  can  be  prevented.  In  proportion 
js  the  body  is  weakened  or  exhausted,  it  yields  more  readily  to  the  pernicious 
influence  of  contagion,  or  of  malaria ;  but  by  obviating  all  causes  of  debility,  and 


CAUSE    OF    DISEASE.  0» 

fortifying  the  system,  we  walk  with  comparative  security  amid  surrounding  pes- 
tilence. 

Diseases  sometimes  occur  when  no  exciting  cause,  when  no  cause  at  all,  has  been 
apparent.  All  that  we  can  say  of  such  cases  (which  are  not,  however,  very  fre- 
quent) is,  that  the  causes  have  not  hitherto  been  discovered. 

Now  the  ascertained  causes  of  disease  are  many  and  various.  Whatever  minis- 
ters to  life,  health,  or  enjoyment,  may  become  the  medium,  under  changing  circum.- 
slanccs,  of  pain,  disease,  or  death.  The  atmosphere,  in  which  we  are  constantly 
immersed,  is  full  of  dangers.  Both  the  organic  and  the  inorganic  world  of  matter 
around  us  abound  in  poisons  ;  they  lurk  in  our  very  food,  which  becomes  pernicious 
when  taken  in  excess,  or  Avhen  it  consists  of  certain  substances,  or  certain  admix- 
tures of  substances ;  so  that  there  really  was  much  truth,  as  well  as  some  humour, 
in  the  startling  motto  to  Mr.  Accum's  book  on  adulterations — "  There,  is  death  in 
the  pot. ''^  Our  passions  and  emotions  also,  nay,  even  some  of  our  better  impulses, 
when  strained  or  perverted,  tend  t6  our  physical  destruction.  The  seeds  of  our 
decay  are  Avithin  as  well  as  around  us. 

Let  us  enumerate,  however,  a  httle  more  particularly,  the  various  known  sources 
of  disease,  with  the  view  of  making,  afterwards,  a  few  practical  comments  upon 
some  of  them. 

r  shall  pass  over,  in  this  enumeration,  nearly  all  chemical  and  mechanical  inju- 
ries ;  inasmuch  as  these  belong  to  surgery. 

If  we  look  to  atmospherical  causes,  we  shall  find  that  those  varieties  in  the  state 
of  the  air  which  proceed  from  mere  differences  of  degree  in  its  natural  qualities  may- 
be productive  of  disease.  Such  are,  extremes  of  heat  and  of  cold  ;  sudden  variations 
of_temperature  ;  excessive  moisture  or  excessive  dryness  ;  different  electric  condi- 
tions ;  differences  of  pressure,  as  measured  by  the  barometer;  a  deficiency  of  light. 

Again,  the  atmosphere  may  be  a  source  of  disease  in  consequence  of  its  being 
loaded  with  impurities.  Malaria,  contagions  of  various  kinds,  and  noxious  gases  in 
general,  may  be  considered  as  so  many  poisons. 

Under  the  head  of  nutriment  we  may  place  the  use  of  food  of  which  the  quality 
is  bad  and  hurtful ;  this  cause  also  strictly  belongs  to  the  class  of  poisons.  Again, 
an  insufficient  supply  of  healthy  food  ;  and  still  more  common  causes  are  excess  in 
eating,  and  intemperance  in  drinking. 

The  numerous  poisons  which  are  not  comprehended  under  either  of  the  foregoing 
heads  are  also  prolific  sources  of  disease. 

Another  great  class  among  the  causes  of  disease  might  be  formed  by  considering 
together  the  influence  of  various  trades  and  avocations  which  are  directly  injurious 
to  the  health  of  those  who  pursue  them. 

We  know,  by  ample  experience,  that  a  certain  amount  of  bodily  exercise  is  essen- 
tial to  good  health.  We  see  the  evil  consequences  of  much  overstepping  that 
amount,  in  tlie  deformities  and  disorders  which  result  from  labour  too  severe,  or  too 
long  continued.  But  a  much  more  numerous  train  of  complaints  follow  the  opposite 
state — that  in  Avhich,  from  indolence,  or  from  necessity,  but  little  exercise  is  used. 

Excessive  indulgence  in  sleep  on  the  one  hand,  and  long-continued  want  or  inter 
ruption  of  repose  on  the  other,  are  apt  to  give  rise  to  serious  maladies. 

Very  many  diseases  have  a  mental  origin.  Excessive  intellectual  toil — the  domi- 
nation of  violent  passions  —  the  frequent  recurrence  of  strong  mental  emotions  — 
vicious  and  exhausting  indulgences,  —  each  and  all  will  sap  the  strength,  and 
grievously  impair  the  health  of  the  body :  and  perhaps  there  is  no  cause  of  corpo- 
real disease  more  clearly  made  out,  or  more  certainly  effective,  than  protracted 
anxiety  and  distress  of  mind. 

When  we  add  to  this  catalogue  of  the  sources  of  disease  all  those  morbid  tenden- 
cies which  are  hereditary — and  those  which  flow  from  original  malformation,  and 
are  congenital — we  shall  have  a  tolerably  complete  list  of  the  manifold  dangers  to 
which  our  mortal  frames  are  continually  liable. 

There  are  several  points  of  view  under  which  the  consideration  of  these  causes 
of  disease  might  be  shown  to  be  interesting.  We  might  inquire,  for  example,  which 
of  them  are  commonly  predisposing,  which  exciting  causes;  and  what  are  the  cir- 


60      ,  CAUSE    OF    DISEASE. 

cumstances  which  are  found  to  render  the  same  agent  at  one  time  merely  a  predis- 
posing, and  at  another  time  an  exciting  cause. 

We  might  also  separate,  with  some  advantage,  those  causes  of  disease  to  which 
the  human  body  is  often  and  necessarily  exposed,  from  those  which  consist  in  agen- 
cies that  are  of  local  or  temporary  existence  only.  But  without  multiplying  these 
artificial  distinctions,  I  shall  take  occasion  to  advert  to  them  either  when  speaking 
more  in  detail  of  particular  causes,  or  when  speaking  of  the  disorders  they  have 
produced. 

In  our  investigations  into  the  causes  of  disease,  great  caution  is  necessary  in  order 
to  avoid  being  misled  by  individual  cases.  The  circumstances  capable  of  influ- 
encing the  bodily  health  are  so  various — so  many  of  them  are  apt  to  be  in  operation 
at  the  same  time  —  and  so  little  power  have  we  of  excluding  them,  one  after  the 
other,  so  as  to  ascertain  the  exact  efficacy  of  each — that  our  observations  respecting 
their  relative  or  their  actual  effects  are  open  to  much  fallacy.  We  endeavour  to 
escape  this  source  of  mistake  by  repeating  and  multiplying  our  observations.  But 
it  is  by  tracing  diseases  as  they  affect  considerable  masses  of  men,  placed  as  nearly 
as  possible  under  the  same  external  circumstances,  that  we  gain  the  surest  and  most 
satisfactory  evidence  in  respect  to  the  causes  of  disease.  And  hence  it  is  that  the 
experience  of  the  medical  officers  of  our  fleets  and  armies  is  so  valuable.  Dr.  Alison 
has  well  remarked,  that  all  the  circumstances  of  the  whole  number  of  men  whose 
diseases  fall  under  the  notice  of  military  and  naval  practitioners  are,  in  many  respects, 
exactly  alike:  the  men  are  generally  healthy  adults  in  the  first  instance  —  the  cir- 
cumstances in  which  they  are  placed  are  thoroughly  known  to  the  observer  —  and, 
indeed,  are  often  to  a  certain  degree  at  his  disposal ;  they  are  often  suddenly  changed 
also ;  and  changed  sometimes  as  to  one  portion  of  the  whole  mass  of  individuals, 
while  they  remain  unchanged  as  to  another  portion ;  so  that  his  opportunities  of 
observation  partake  in  some  measure  of  the  nature  of  experiments,  and  being  made 
upon  a  large  scale,  they  are  especially  interesting  and  conclusive.  In  point  of  fact 
a  great  deal  has  been  learned,  with  absolute  certainty,  upon  this  subject. 

Hitherto  I  have  simply  enuinerafcd  the  principal  causes  of  disease  :  —  but  con- 
ceiving a  bare  enumeration  of  this  kind  to  be  of  but  little  use,  I  shall  inquire  some- 
what more  nearly  into  the  nature  and  mode  of  operation  of  several  of  them  7ioiv  ;  of 
others  I  prefer  to  speak  in  connection  with  the  particular  diseases  to  which  they 
give  rise. 

You  will  not  consider  the  inquiry  superfluous.  To  know  the  cause  of  a  disease 
is  sometimes  to  be  able  to  cure,  often  to  be  able  to  prevent  it.  In  some  cases  the 
cause  is  beyond  our  power,  but  an  acquaintance  with  its  nature  may  teach  us  how 
to  moderate  or  to  remedy  its  consequences.  There  are  many  diseases  also  over 
which  medicine  has  very  little  control,  but  the  causes  of  which,  when  ascertained, 
may  be  avoided,  or  extinguished.  Such  causes,  when  they  do  not  happen  to  be 
removable  by  individual  efforts,  are  often  susceptible  of  extinction  by  the  united 
measures  of  a  community.  And  for  this  reason  it  is  very  desirable  that  correct 
opinions  respecting  the  causes  of  disease  should  be  widely  diffused  among  the  public  ; 
— and  there  is  now  no  way  in  which  information  of  this  kind  is  so  likely  to  be  made 
generally  known,  as  by  communicating  it  to  medical  students  who  are  about  to 
scatter  themselves  in  ail  directions  over  the  face  of  the  land. 

I  shall  proceed,  then,  in  the  first  place,  to  the  consideration  of  heat  and  cold,  as 
external  agencies  capable  of  producing  disease. 

The  range  of  atmospheric  temperature  compatible  with  human  life  is  very  con- 
siderable. Its  limits  are  probably  juit  those  extremes  of  heat  and  cold  that  belong 
to  the  lower  strata  of  the  air  in  the  different  parts  of  the  planet  on  which  man  is 
desdned  to  exist.  Under  the  burning  sunshine  of  the  tropics,  and  amid  the  pro- 
found frost  of  the  polar  regions,  we  alike  find  human  dwellers.  These  different 
degrees  of  external  temperature  impress  indeed  peculiar  physical  characters  upon 
those  who  are  subjected  to  them,  but  they  do  not,  of  necessity,  extinguish  life,  or 
even  cause  disease.  It  requires  more  care,  however,  to  preserve  life  under  intense 
cold  than  under  intense  heat.     In  some  parts  of  India  the  temperature  ranges  for  a 


CAUSE   OF   DISEASE.  61 

long  time  together  from  80  to  100,  and  even  110°  of  Fahrenheit's  thermometer:  I 
believe  it  sometimes  reaches  120°.  "VVe  can  form  some  estimate  of  this  heat  by 
remembering  the  oppressive  effect  of  the  lowest  of  these  temperatures — that  of  80° 
— to  which  the  thermometer  sometimes  rises  in  this  country  in  the  hot  weather  of 
summer.  But  these  tropical  cHmates  are  very  thickly  peopled.  In  the  arctic  coun- 
tries, on  the  other  hand — in  the  northernmost  parts  of  America,  for  example — where 
the  sun  appears  above  the  horizon  for  a  short  part  of  the  year  only,  and  where  the 
thermometer  sinks  to  40  or  50°  below  zero  —  we  still  find  inhabitants,  indeed,  but 
they  are  few,  and  thinly  scattered.  This  mainly  depends,  no  doubt,  upon  the  scanty 
supply  of  human  food  in  those  parts  of  the  world ;  but  something  also  is  to  be 
ascribed  to  the  depressing  influence  of  extreme  cold  upon  the  vital  powers.  Indeed, 
the  deficiency  of  human  food  is  itself  owing  to  the  restraining  effect  of  a  low  tem- 
perature upon  organic  life.  Under  a  degree  of  temperature  a  little  greater  than  that 
at  the  equator— or  a  little  less  than  the  lowest  around  the  poles — it  seems  probable 
that  man  would  soon  perish.  And  in  this  fact  we  have  one  striking  instance  of  the 
adaptation  of  external  nature  to  the  physical  constitution  of  the  human  race. 

But  for  a  short  time  —  and  imder  certain  circumstances  —  man  is  capable  of 
enduring  a  very  much  higher  degree  of  heat  than  the  open  and  general  atmosphere 
ever  attains  even  in  the  hottest  portions  of  the  earth.  Whether  he  could  continue 
to  exist,  even  for  a  little  while,  under  a  much  more  intense  cold  than  ever  occurs 
naturally  on  the  surface  of  the  globe,  is  more  questionable. 

It  was  long  believed  that  the  human  body  could  not  be  safely  exposed,  even  for  a 
short  time,  to  a  degree  of  heat  much  exceeding  that  which  is  met  with  in  hot  chmates. 
This  opinion,  which  we  now  know  to  have  been  erroneous,  was  strengthened  by  the 
result  of  some  experiments  made  by  the  celebrated  Fahrenheit  himself,  and  related 
by  Boerhaave  in  his  Chemistry.  Some  animals  were  shut  up  in  a  sugar-baker's 
stove,  where  the  mercury  stood  at  14G°.  A  sparrow  died  in  less  than  seven  minutes, 
a  cat  in  rather  more  than  a  quarter  of  an  hour,  and  a  dog  in  about  twenty-eight 
minutes.  The  noxious  air  of  the  stove  had  probably  more  to  do  with  the  speedy 
deaths  of  these  animals  than  the  heat.  The  truth,  upon  this  subject,  may  be  said  to 
have  been  discovered  by  accident.  In  the  year  17G0  and  1761,  jVIM.  Duhamel  and 
Tillet  were  appointed  to  devise  some  means  of  destroying  an  insect  which  consumed 
the  grain  in  the  province  of  Angoumais  in  France.  They  found  that  this  could  be 
done  by  subjecting  the  corn,  and  the  insects  contained  in  it,  in  an  oven,  to  a  degree 
of  heat  great  enough  to  kill  the  insect,  but  not  so  great  as  to  hurt  the  grain.  In 
order  to  ascertain  the  precise  heat  of  the  oven,  they  introduced  into  it  a  thermometer 
placed  upon  the  end  of  a  long  shovel.  The  mercury,  when  the  thermometer  was 
withdrawn,  was  found  to  indicate  a  degree  of  heat  considerably  above  that  of  boiling 
water.  But  M.  Tillet  was  aware  that  the  thermometer  had  sunk  several  degrees  as 
it  was  drawn  towards  the  mouth  of  the  oven.  While  he  was  puzzled  to  invent 
some  way  of  determining  more  exactly  the  actual  degree  of  heat,  a  girl,  who  was 
one  of  the  attendants  of  the  oven,  offered  to  go  in,  and  to  mark  with  a  pencil  the 
height  at  which  the  mercury  stood.  And  she  did  enter  the  oven,  and  remained 
there  two  or  three  minutes,  and  then  marked  the  thermometer  at  100°  of  Reaumur, 
which  nearly  equaUcd  2G0°  of  Fahrenheit.  M.  Tillet  then  began  to  express  some 
anxiety  for  the  safety  uf  the  girl,  but  she  assured  him  that  she  felt  no  inconvenience, 
and  remained  in  the  even  ten  minutes  longer,  during  which  time  the  mercury 
reached  the  288th  degree  ^f  Fahrenheit's  scale  —  denoUng  76°  of  heat  above  that 
of  water  when  it  boils.  When  she  came  out  her  complexion  was  considerably 
heightened,  but  her  respiration  was  by  no  means  quick  or  laborious.  This  experi- 
ment was  afterwards  repeated  Another  girl  remained  in  the  oven  as  long  as  the 
former  had  done,  at  the  same  temperature,  and  with  the  same  impunity.  Nay,  she 
even  breathed,  for  the  space  of  five  minutes,  air  heated  to  about  325°  of  Fahrenheit 
— or  113°  above  that  of  boiling  water. 

The  publication  of  these  facts  naturally  excited  the  curiosity  of  scientific  men,  and 
other  experiments  were  soon  instituted.  Dr.  Dobson,  of  Liverpool,  and  several 
other  persons  with  him,  shut  themselves  up  in  the  sweating  room  of  the  public  hos- 
pital there,  the  air  having  been  heated  till  the  quicksilver  stood  at  224°  of  Fahren- 


62  CAUSE    OF   DISEASE. 

heit.  They  did  not  experience  any  oppressive  or  painful  sensation  of  heat.  Dr. 
Fordyce  and  Dr.  Blagden  made  some  remarkable  trials  of  the  same  kind.  They 
entered  rooms  artificially  heated  to  a  very  high  degree,  sometimes  naked,  and  some- 
times with  their  clothes  on,  and  bore  the  extraordinary  temperature  of  240°,  and 
even  200°,  for  a  considerable  time,  with  very  little  inconvenience.  In  all  these 
experiments  it  was  found  that  the  animal  heat,  as  ascertained  by  thermometers  placed 
under  the  tongue,  or  grasped  in  the  hand,  was  scarcely  increased  at  all ;  and  the 
respiration  but  little  affected;  but  the  pulse  was  very  much  quickened.  The  fre- 
quency of  Dr.  Blagden's  pulse  in  one  instance  was  doubled.  You  may  read  -i 
detailed  account  of  these  experiments  in  the  Philosophical  Transactions  ',  but  to 
give  you  a  more  lively  notion  of  the  degree  of  heat  to  which  the  bodies  of  these 
gentlemen  were  exposed,  I  may  tell  you  that  their  watch-chains,  and  other  pieces  of 
metal  about  them,  became  so  hot  that  they  could  scarcely  be  touched;  when  they 
breathed  upon  the  thermometer,  the  mercury  immediately  sank  several  degrees ; 
each  act  of  expiration  produced  a  pleasant  feeling  of  coolness  in  the  nostrils,  and 
they  cooled  their  fingers  by  breathing  upon  them.  In  and  by  the  same  heated  air 
which  they  respired,  eggs  were  roasted  quite  hard  in  twenty  minutes,  and  beef-steaks 
were  dressed  in  thirty-three  minutes ;  and  when  the  air  was  blown  upon  the  meat  by 
means  of  bellows,  it  was  sufficiently  cooked  in  thirteen  minutes. 

It  is  ascertained,  then,  beyond  all  doubt,  that  the  human  body  is  capable  of 
sustaining  these  very  high  degrees  of  temperature,  for  a  short  time,  without 
detriment. 

Facts  of  this  kind  may,  perhaps,  appear  to  you  rather  curious  than  useful.  Man 
is  never  submitted  to  any  natural  heat  of  the  air  even  approaching  towards  that  to 
which  the  authors  of  the  experiments  I  have  been  describing  voluntarily  exposed 
themselves.  But  a  knowledge  of  extreme  cases  always  tends  to  throw  light  upon 
those  that  lie  between  the  extremes ;  and  the  direct  resuhs  arrived  at  in  these  philo- 
sophic inquiries  are  not  barren  of  practical  utility  to  members  of  our  profession.  It 
is  not  long  ago  that  a  man  was  found  almost  dead  in  an  oven  ;  he  expired  a  quarter 
of  an  hour  after  he  was  taken  to  one  of  the  borough  hospitals ;  and  an  inquest  was 
held  upon  his  bodj'-.  The  newspaper  report  of  the  case  (which  is  the  only  one  I 
have  seen)  states  the  temperature  of  the  oven  to  have  been  about  120° —  a  candle 
was  melted  by  it  in  half  a  minute.  Now  prior  to  the  trials  just  mentioned,  exposure 
to  such  a  degree  of  heat  would  have  been  held  a  sufficient  cause  of  death.  We  now 
know  (and  it  would  be  discreditable  if  we  could  not  support  our  opinion  in  a  court 
of  law,  or  before  a  coroner,  by  a  reference  to  authentic  facts)  that  something  else 
must  have  concurred  in  extinguishing  life  ;  and,  in  fact,  it  turned  out  that  the  man 
was  drunk  when  he  went  into  the  oven. 

But  what  are  the  effects,  upon  the  human  frame,  of  a  high,  yet  less  excessive, 
temperature  of  the  air? 

One  very  constant  effect  of  heat  is  that  of  stimulating  the  organic  functions  of 
the  body.  We  have  seen  that  the  temporary  application  of  great  heat  accelerates 
remarkably  the  action  of  the  heart :  the  pulse  was  uniformly  found  to  be  much 
increased  in  frequency  in  the  persons  who  made  trials  of  their  powers  of  endurance 
in  heated  rooms.  We  have  evidence  to  the  same  purpose  in  the  annual  changes 
that  take  place  in  the  vegetable  kingdom  at  a  given  place,  the  summer  renewing  its 
foliage  ;  the  winter  checking  and  repressing  it;  and  still  more  in  the  superior  luxu- 
riance of  vegetation  in  warm  climates  as  compared  with  cold.  And  the  same 
observation  applies  to  those  functions  which  animals  possess  in  common  with  plants. 
Towards  the  poles  both  man  and  the  lower  animals  are  smaller  than  at  the  equator. 
Linnaeus  remarks  that  the  hares,  partridges,  and  other  animals  which  inhabit  the 
northern  climes,  are  considerably  smaller  in  size  than  the  same  species  in  more 
southern  climes.  And  Mr.  Tooke,  in  his  Vierv  of  Bussia,  observes,  "As  we  ap- 
proach nearer  to  the  north  pole,  both  the  animal  and  vegetable  productions  of  nature 
become  more  and  more  stunted.  The  ordinary  stature  of  the  Samoyedes  seldom 
exceeds  four  or  five  feet,  and  their  whole  exterior  corresponds  Avith  their  dwarfish 
si^e."  The  stature  of  the  native  inhabitants  of  hot  cHmates  does  not,  I  behevc, 
fixceed  that  which  is  proper  to  the  temperate  zone  ;  but  if,  as  is  generally  beheved. 


I 


CAUSES    OF    DISEASE.  6-$ 

the  human  body,  like  plants  and  fruits,  grows  faster,  and  npens  sooner,  in  proportion 
as  we  approach  the  equator,  this  must  be  attributed  to  the  stimulus  of  heat  acting 
upon  the  or£!;anic  life. 

On  the  other  hand,  and  in  some  sort  as  a  contrast  with  this,  we  may  observe  that 
considerable  heat,  when  applied  for  some  time  together,  has  a  sedative  or  depressing 
influence  upon  the  animal  functions,  i.  e.,  upon  the  nervous  system  ;  causing  lan- 
guor and  lassitude,  want  of  energy,  a  disinclination  to  exertion  both  bodily  and 
mental. 

Under  favourable  circumstances,  and  where  due  precaution  is  exercised,  it  is  pro- 
bable that  a  very  high  degree  of  natural  temperature  of  the  atmosphere  may  be 
borne  with  impunity.  Sir  James  M'Grigor  informs  us  (in  his  account  of  the  passage 
of  the  army  in  1801  from  India  to  Egypt),  that  during  the  march  over  the  sandy 
desert  of  Thebes,  where  the  heat  was  uniform,  though  the  thermometer  in  the  sol- 
diers' tents  was  as  high  as  118°,  the  health  of  the  troops  was  equal  to  that  which  they 
had  enjoyed  in  any  former  period  in  India. 

But  there  are  some  forms  of  disease  w^hich  are  distinctly  traceable  to  heat  as  their 
cause. 

The  effect  of  hot  weather  in  promoting  the  cutaneous  perspiration  is  notorious. 
By  the  same  influence  the  hepatic  function  is  rendered  more  active.  Dr.  James  John- 
son first,  I  think,  distinctly  pointed  out  the  sympathy  or  consent  that  obtains  between 
the  liver  and  the  skin,  under  varying  conditions  of  external  warmth.  Whatever 
may  be  the  explanation  of  the  fact,  experience  has  taught  us  that  a  high  atmospheric 
temperature,  when  its  operation  is  continued  for  some  time,  has  a  marked  influence 
upon  the  liver,  increasing  the  quantity  of  bile  that  is  secreted,  and  altering  its  sen 
?ible  qualities  ;  and  this  disturbance  of  function  is  not  unfrcquently  followed  by  in- 
flammation of  the  gland  itself.  In  this  country  we  witness,  almost  annually,  the 
effects  of  a  succession  of  sultry  weather,  in  those  attacks  of  vomiting  and  diarrhoea 
which  are  so  common  towards  the  latter  end  of  summer,  and  in  the  autumn,  espe- 
cially when  the  season  happens  to  have  been  unusually  hot ;  and  which  result,  appa- 
rently, from  the  excessive  quantity  or  a  morbid  state  of  the  bile.  The  English 
cholera  (a  totally  different  disorder  from  that  which  has  of  late  years  been  called, 
most  improperly,  the  cholera),  is,  as  you  know,  so  frequent  and  general  in  some 
years,  as  to  be  fairly  considered  and  termed  an  epidemic  disease.  In  tropical  cli- 
mates the  same  morbific  operation  of  external  heat  is  still  more  conspicuous  ;  leading 
not  only  to  violent  disorder  of  the  stomach  and  intestines,  with  the  evacuation  of 
large  quantities  of  vitiated  and  acrid  bile,  but  also  to  acute  inflammation  of  the  liver 
going  on  to  suppuration,  and  the  formation  of  large  abscesses.  These  last  diseased 
conditions  are  extremely  rare  in  this  latitude.  The  yellow  complexions  of  those 
who  return  to  England  after  a  long  residence  in  India,  are  to  be  attributed  to  that 
disordered  state  of  the  liver,  and  of  its  functions,  to  which  such  persons  are  prover- 
bially subject,  and  which  has  in  them  been  brought  on  by  the  influence  of  a  hot  at- 
mosphere, operating  for  a  long  space  of  time  together.  Hepatic  affections,  acute  or 
chronic,  are  among  the  chief  diseases  to  which  Europeans,  at  least,  are  liable  in  that 
eh  mate. 

We  have  here  an  example  of  the  distinction  I  wish  you  to  notice  between  predis- 
posing and  exciting  causes.  The  heated  atmosphere  stimulates  unduly  the  secreting 
function  of  the  liver.  Now  a  secreting  organ  is  never  so  apt  to  be  affected  by  any 
exciting  cause  of  inflammation  as  when  the  process  of  secretion  is  going  on.  This 
law,  which  I  mention  by  anticipation,  depends,  no  doubt,  upon  the  increased  afflux 
cff  blood  that  accompanies  the  act  of  secretion.  The  excessive  activity  of  the  hepatic 
function  constitutes  thus  a  predisposition  to  inflammation  of  the  liver.  The  hot  at- 
mosphere, which  creates  this  predisposition,  holds  the  place  of  a  predisposing  cause 
in  respect  to  the  inflammation  that  ensues  ;  but  the  exciting  cause  is  exposure  to 
cold  :  one  of  the  most  common  and  best  ascertained  exciting  causes  of  inflammation 
in  general.  You  are  not  to  imagine  that  there  can  be  no  such  thing  as  exposure  to 
cold  in  a  climate  where  the  temperature  of  the  air  is  habitually  above  80°.  Dr. 
James  Johnson,  in  his  book  on  Tropical  Climates,  observes  that  on  the  coast  of 
Coromandel  the  temperature  is  steady  by  day,  and  the  nights  are  hot :  but  yet,  he  say.". 


64  CAUSES    OF    DISEASE. 

nothing  IS  more  common  than  exposure  to  cold  in  this  place.  The  European  soldier 
or  sailor,  after  the  heat  occasioned  by  his  employments  in  the  day,  strips  off  bis 
clothes,  and  lies  opposite  a  window  or  port,  his  shirt  wet  with  perspiration,  to  enjoy 
the  sea  breeze  at  night.  And  the  same  author  tells  us  that  the  application  of  cold 
after  or  during  perspiration,  commonl}-  produces  an  attack  of  hepatitis  in  some  one 
of  its  various  forms.  Now  the  effect  of  that  kind  of  exposure  here  described  does 
not  depend  upon  the  actual  temperature,  but  upon  the  sensation  that  is  produced, 
and  the  sensation  depends  upon  the  relative  temperature  ;  and  there  can  be  no  doubt 
that,  under  the  circumstances  mentioned  by  Dr.  Johnson,  a  strong  sensation  of  cold 
would  be  occasioned,  even  by  a  sea  breeze  as  warm  as  80°,  or  warmer.  Changes 
of  temperature  seem  to  be  as  readily  felt  at  one  part  of  the  thermometric  scale,  as  at 
another,  and  in  whichever  direction  they  take  place.  Dr.  Walsh  states,  that  while 
sailing  along  the  coast  of  Brazil,  after  having  been  long  accustomed  to  a  temperature 
of  72°,  a  strong  breeze  set  in  from  the  sea,  and  the  thermometer  fell  to  61°  ;  (i.  e., 
to  a  point  which  we  should  here  call  temperate  ;)  "  but,"  he  says,  "  the  sense  of  cold 
from  the  sudden  transition  of  temperature  was  quite  painful.  After  bearing  it  for 
some  time,  shivering  on  deck,  it  became  intolerable,  and  we  all  went  below,  put  on 
warm  clothing,  and  dreadnoughts  —  and  again  appeared  with  thick  woollen  jackets 
and  trowsers,  as  if  we  had  been  entering  Baffin's  Bay,  and  not  a  harbour  under  one 
of  the  tropics." 

It  is  interesting  to  compare  this  statement  with  Capt.  PaiTj'-'s  account  of  a  change 
of  temperature  at  the  opposite  extreme  of  the  scale,  and  in  the  other  direction.  Having 
previously  said  that  the  thermometer  had  fallen  to  13°  below  zero  in  the  night  of  the 
21st  of  October,  he  goes  on  thus  : — "  The  wind  veering  to  the  southeast  on  the  24tli 
and  25th,  the  thermometer  gradually  rose  to  2:3°.  I  may  possibly  incur  the  charge 
of  affectation  in  stating  that  this  temperature  was  much  too  high  to  be  agreeable  to 
us  ;  but  it  was  nevertheless  the  fact,  that  everybody  felt  and  complained  of  the 
change.  We  had  often  before  remarked  that  considerable  alterations  of  the  tempe- 
rature of  the  atmosphere  are  as  sensibly  felt  by  the  human  frame  at  a  very  low  part 
of  the  scale  as  in  the  higher.  The  difference  consists  only  in  this,  that  a  change  from 
40°  upwards  to  about  zero,  is  usually  a  very  welcome  one ;  while  from  zero  up- 
wards to  the  freezing  point,  as  in  the  instance  just  alluded  to,  it  becomes,  to  persons 
in  our  situation,  rather  an  inconvenience  than  otherwise." 

Besides  the  more  gradual  effects  of  great  heat,  direct  or  indirect,  upon  the  human 
body,  it  sometimes  operates  distinctly  as  an  exciting  cause,  and  gives  rise  to  more 
sudden  attacks  of  illness.  Persons  who  are  exposed  to  the  direct  beams  of  a  hot  sun, 
especially  during  any  labour  or  active  exercise,  are  apt  to  be  affected  by  what  is 
called  the  sun-stroke,  the  coup  de  soleil,  insolation  :  they  fall  down  insensible,  and 
often  die  in  a  very  short  time.  This  disorder  is  common  among  troops  in  long 
marches  in  India.  It  is  a  complaint  of  which  the  cause  has  long  been  known  by 
the  inhabitants  of  hot  climates.  There  is  a  case  of  it  related  in  the  Bible.  "And 
Manasses  was  her  husband,  of  her  tribe  and  kindred,  who  died  in  the  barley  harvest. 
For,  as  he  stood  overseeing  them,  and  bound  sheaves  in  the  field,  the  heat  came  upon 
his  head,  and  he  fell  on  his  bed,  and  died  in  the  city  of  Bethulia." 

Pathologists  are  not  agreed  respecting  the  intimate  nature  of  this  distemper;  noi 
about  the  manner  in  which  it  destroys  life.  Some  regard  it  as  a  sort  of  apoplexy  : 
and  hold  that  death  takes  place  in  the  way  of  coma.  But  the  most  approved  reme- 
dies of  apoplexy — bleeding  and  other  eA'acuations — have  not  proved  successful  in 
relieving  it.  The  natives  of  India  prefer  the  pouring  of  cold  water  upon  the  head 
to  every  other  curative  measure.  Our  army  sergeants  also  found  that  stimulants — 
rum  and  water,  for  instance — answered  better  than  depletion.  I  have  never  seen 
this  affection,  but  I  should  conjecture  that  it  is  more  akin  to  the  state  we  call  concus- 
sion than  to  true  apoplexy.  It  would  appear  that  the  sun's  rays  act  upon  the  brain 
hke  a  shock.  The  nervous  system  is  suddenly  and  extensively  influenced,  and  the 
heart's  movements  arrested,  as  in  syncope.  One  of  Sir  Benjamin  Brodie's  experi- 
ments is  in  favour  of  this  opinion.  He  placed  a  rabbit  in  a  basket  in  an  oven,  the 
jemperatuie  of  which  was  not  more  than  150",  and  it  died  in  a  few  minutes,  without 


CAUSES    OF   DISEASE.  G5 

any  apparent  suffering.     The  heart  was  afterwards  found  distended  with  blood,  on 
both  sides,  as  after  death  by  asthenia. 

Great  heat  tends  also  to  the  production  of  certain  cutaneous  diseases :  it  is  said 
that  kw  Europeans  escape,  on  their  first  settUng  in  tropical  cUmates,  an  eruption  of 
pimples,  attended  with  almost  intolerable  itching  and  pricking,  and  lasting  for  some 
weeks.     It  is  called  in  India  the  prickly  heat. 

Before  considering  that  most  prohfic  source  of  disease  which  is  familiar  to  the 
commonest  observation  in  sudden  transitions  of  temperature,  let  us  inquire  what  are 
the  ascertained  effects  of  extreme  cold  upon  the  human  frame.  Of  course  I  use  the 
term  cold  in  its  popular  acceptation,  as  if  it  were  something  positive,  instead  of  sig- 
nifying the  mere  privation  of  heat.  It  is  much  more  convenient  to  speak  of  it  in 
this  way,  and  there  is  no  risk  of  your  being  misled  by  my  doing  so. 

Now  this  inquiry  is  of  more  practical  interest  to  us  than  that  which  is  concerned 
with  the  immediate  effects  of  extreme  heat.  Even  in  this  climate  medical  men  are 
not  unfrequently  called  upon,  in  cases  of  injury  or  death  produced  by  intense  cold, 
either  to  remedy  the  morbid  conditions  it  has  caused,  or  to  explain  the  mode  and 
probability  of  its  operation  in  extinguishing  life. 

The  effects  of  cold,  as  might  well  be  imagined,  are  in  many  respects  the  direct 
opposites  of  the  effects  of  heat.  When  its  application  is  continued,  it  acts  as  a 
sedative  upon  the  organic  functions  both  of  animals  and  of  plants.  This  appears 
from  the  shrinking  of  the  external  parts :  the  superficial  arteries  become  unable  to 
transmit  the  blood  in  the  usual  quantity  through  the  integuments.  Hence  the  skin 
becomes  pale,  and  contracting  round  the  sebaceous  glands  and  the  hair-bulbs,  exhi- 
bits a  roughness  which  is  compared  to  that  of  the  skin  of  a  plucked  goose,  and  is 
technically  called  cutis  anserina.  By  the  same  contraction  of  the  smaller  vessels, 
and  repressed  circulation,  the  extreme  and  projecting  parts  are  diminished  in  size. 
Thus,  rings  which  are  tight  on  the  fingers  while  the  body  is  warm,  drop  off  in  cold 
weather — and  even  the  shoes  fall  from  the  feet  during  extreme  exposure.  The 
heart  with  the  whole  arterial  system  becomes  weak.  I  have  already,  when  speaking 
of  the  contrasted  operation  of  heat,  illustrated  the  withering  influence  of  a  continued 
low  atmospheric  temperature  upon  the  organic  functions,  by  referring  to  the  dwarfish 
size  of  both  men  and  the  lower  animals,  as  well  as  of  plants,  in  cold  regions.  We 
have  evidence  of  the  same  fact  in  the  tardy  development  of  the  functions,  and  par- 
ticularly, as  many  travellers  affirm,  of  the  sexual  functions,  in  cold  climates  as  corn- 
pared  with  hot ;  and  in  the  winter  torpor  of  certain  animals,  which  is  very  analogous 
with  the  state  of  trees  and  shrubs  in  that  season. 

I  need  not  tell  you  that  to  judge  of  the  effects  of  mere  coldness  of  the  atmosphere 
we  must  take  the  case  of  the  atmosphere  at  rest.  The  air  is  a  bad  conductor  of 
caloric,  and  for  that  reason,  a  much  lower,  as  well  as  a  much  higher  degree  of 
temperature,  can  be  borne  when  it  is  in  a  state  of  quiescence,  than  when  fresh  por- 
tions of  it  are  perpetually  brought  into  contact  with  the  surface  of  the  body  by 
currents  of  air.  "  With  the  thermometer,"  says  Captain  Parry,  "at  -55°,"  (a  most 
fearful  degree  of  cold,  you  will  observe,  55°  below  zero,  i.  e.,  87°  below  the  freezing 
point,)  "  with  the  thermometer  at  -55°,  and  no  wind  stirring,  the  hands  may  remain 
uncovered  for  ten  minutes  or  a  quarter  of  an  ho'ur  without  inconvenience ;  while 
with  a  fresh  breeze,  and  the  thermometer  nearly  as  high  as  zero,  k\v  people  can 
keep  them  exposed  so  long  without  considerabk  pain."  And  speaking  in  another 
place  of  the  cold,  when  the  thermometer  was  49°  below  zero ;  9  or  10°,  that  is, 
below  the  point  at  which  mercury  freezes,  he  says,  "  The  weather  being  quite  cahn, 
we  walked  on  shore  for  an  hour  without  inconvenience,  the  sensation  of  cold  de- 
pending: much  more  on  the  degree  of  wind  at  the  time,  than  on  the  absolute  tempe 
rature  of  the  atmosphere  as  indicated  by  the  thermometer.  In  several  of  the  accounts 
given  of  those  countries,  in  which  an  intense  degree  of  natural  cold  is  experienced, 
some  effects  are  attributed  to  which  it  certainly  did  not  come  under  our  observation 
in  the  course  of  this  winter.  The  first  of  these  is  the  dreadful  sensation  said  to  be. 
produced  in  the  lungs,  causing  them  to  feel  as  if  torn  asunder  when  the  air  is 
inhaled  at  a  very  low  temperature.  No  such  sensation  was  ever  experienced  by  us. 
5  f2 


66  CAUSES    OF    DISEASE. 

though  in  going  from  the  cabin  into  the  open  air,  and  vice  vcrsct,  we  were  constantly 
in  the  habit,  for  some  months,  of  undergoing  a  change  of  from  80°  to  100°,  and  in 
seviM-a.  iuftunces  120' of  temperature,  in  less  than  one  minute:  and  what  is  still 
more  extraordinary,  noc  a  single  inflammatory  complaint  (beyond  a  slight  cold, 
which  was  cured  by  common  care  in  a  day  or  two),  occurred  during  this  particular 
period." 

But  when  the  cold  air  is  in  motion,  in  other  words,  when  there  is  wind,  so  that 
fresh  portions  of  cold  air  are  brought,  successi'vly.  \n  '^mtact  with  the  surface  ;  or 
when  It  is  accompanied  with  moisture,  or  occurs  under  other  circumstances  favour- 
able to  its  operation,  and  to  be  spoken  of  more  particularly  presently  ;  then  cold  of  a 
much  inferior  degree  of  intensity  may  very  speedily  occasion  partial  or  total  death. 
By  partial  death  I  mean  the  loss  of  vitality  in  certain  parts  of  the  body  only — the 
ears,  nose,  fingers,  toes,  and  feet.  The  parts  thus  affected  are  said  to  be  frost-bitten: 
and  the  mode  of  managing  such  accidents  falling  Avithin  the  province  of  surgery,  I 
shall  confine  my  remarks  almost  entirely  to  the  case  where  general  death — death  in 
its  full  and  ordinary  meaning — is  either  brought  about,  or  impending,  in  consequence 
of  exposure  to  cold. 

One  of  the  earliest  effects  of  extreme  cold  upon  the  system  at  large  has  been  said 
to  be  a  remarkable  and  overpowering  drowsiness.  But  I  believe  you  will  find  that 
most  or  all  of  the  persons  in  whom  this  torpor  has  been  noticed  had  not  only  been 
exposed  to  severe  cold,  but  had  been  using  also  a  great  deal  of  exercise  :  and  per- 
haps the  drowsiness  ought  to  be  ascribed,  in  some  measure  at  least,  to  that  exercise. 
They  who  attribute  it  to  the  cold  alone  explain  the  comatose  state  in  this  way.  They 
say  that  the  chilling  of  the  surface  and  extremities  drives  the  blood  inwards,  causes 
it  to  accumulate  internall}^  and  increases  the  flow  of  blood  towards  the  head.  One 
thing,  however,  is  certain,  viz.,  that  drowsiness  is  not  a  necessary  consequence  of 
exposure  to  severe  cold,  although  it  is  a  very  common  consequence.  Dr.  Currie,  in 
his  Medical  Reports,  gives  a  very  interesting  account  of  the  shipwreck  of  an  Ame- 
rican vessel  on  the  coast  of  Ireland.  Most  of  the  crew,  fourteen  in  all,  were  im- 
mersed, to  a  considerable  depth,  for  twenty-three  hours,  in  water  of  which  the 
temperature  was  believed  not  to  exceed  33  or  34°  of  Fahrenheit :  and  he  states 
expressly  that  none  of  the  men  were  drowsy,  and  that  in  no  one  of  the  three  that 
perished  was  death  preceded  by  sleep. 

The  overpowering  tendency  of  cold  when  combined  with  fatigue  (and  perhaps, 
under  certain  circumstances,  of  intense  cold  alone),  to  induce  sleep,  was  strikingly 
exemplified  in  what  befel  Dr.  Solander  among  the  hills  of  Terra  del  Fuego.  The 
story,  as  given  in  Captain  Cook's  Voyages,  is  well  known.  Sir  Joseph  Banks  and 
Dr.  Solander  had  been  out  botanizing.  On  their  return  towards  the  ship,  after 
various  hardships,  and  after  having  travelled  through  swamps  for  a  considerable 
way,  the  weather,  which  had  been  very  fine,  became  gloomy  and  cold,  with  sudden 
blasts  of  piercing  wind,  accompanied  by  snow.  Finding  it  impossible  to  get  back 
to  the  ship  before  the  morning,  they  resolved  to  push  on  through  another  swamp 
that  lay  in  their  way,  into  the  sheher  of  a  wood,  where  they  might  build  a  wigwam 
and  kindle  a  fire.  Mr.  Banks  (as  he  was  then)  undertook  to  bring  up  the  rear.  Dr. 
Solander,  who  had  more  than  once  crossed  the  mountains  that  divide  Sweden  from 
Norway,  and  who  well  knew  that  extreme  cold,  especially  when  joined  with  fatigue, 
produces  a  torpor  and  sleepiness  that  are  almost  irresistible,  conjured  the  company 
to  keep  moving,  whatever  pain  it  might  cost  them,  and  whatever  relief  they  might 
be  promised  by  an  inclination  to  rest.  "  Whoever  sits  down"  said  he,  "  will  sleep, 
and  whoever  sleeps  will  wake  no  more."  Thus  at  once  admonished  and  alarmed, 
they  set  forwards;  but  they  had  not  gone  far  before  the  cold  became  suddenly  so 
intense  as  to  produce  the  effects  that  had  been  most  dreaded.  Dr.  Solander  was  the 
first  who  found  the  inclination,  against  which  he  had  warned  others,  invincible,  and 
ne  insisted  on  being  suffered  to  lie  down.  Mr.  Banks  entreated  and  remonstrated 
with  him  in  vain :  down  he  lay  upon  the  ground,  ahhough  it  was  covered  with 
snow,  and  it  was  with  much  difficulty  that  his  friend  kept  him  from  sleeping.  Rich- 
mond, also,  one  of  the  black  servants,  began  to  linger  in  the  same  manner.  When 
lie  was  told  that  if  he  did  not  go  on  he  would  in  a  short  time  be  frozen  to  d^ath,  bis 


CAUSES    OF   DISEASE.  67 

answer  was  that  he  desired  nothing  but  to  lie  down  and  die.  The  doctor  said  he 
was  willing  to  go  on,  but  that  he  must  first  take  some  sleep ;  although  but  a  short 
time  before  he  had  told  the  company  that  to  sleep  was  to  perish.  Mr.  Banks  and 
the  rest  found  it  impossible  to  carry  them,  and  there  being  no  remedy,  they  were 
both  at  length  suffered  to  lie  down,  being  partly  supported  by  some  bushes  ;  and  in 
a  few  minutes  they  fell  into  a  profound  sleep.  Soon  after  some  of  the  people  who 
had  been  sent  forward  returned  with  the  welcome  news  that  a  fire  was  kindled  about 
a  quarter  of  a  mile  on  the  way.  Mr.  Banks  then  endeavoured  to  wake  Dr.  Solander, 
and  happily  succeeded ;  but,  though  he  had  not  slept  five  minutes,  he  had  almost 
lost  the  use  of  his  hmbs,  and  the  flesh  was  so  shrunk,  that  his  shoes  fell  from  his 
feet.  He  consented  to  go  forward  with  such  assistance  as  could  be  given  him ;  but 
no  attempts  to  relieve  poor  Richmond  were  successful.  He,  together  with  another 
black  left  with  him,  died. 

In  many  instances,  before  this  complete  torpor  comes  on,  intense  cold  has  a  curi- 
ous effect  upon  the  nervous  system,  blunting  the  sensations,  and  confusing  the  intel- 
lect, and  giving  to  the  person  exposed  to  it  the  appearance  of  one  intoxicated.  It  is 
very  necessary  that  you  should  be  aware  of  this,  for  there  is  too  much  reason  to 
beheve  that  poor  wretches  who  have  been  picked  up  by  the  constables  in  the  streets 
at  night,  during  periods  of  hard  frost,  have  been  supposed  to  be  drunk,  when,  in 
truth,  they  were  only  stupefied  by  the  cold.  Such  a  mistake  is  most  likely  to  be 
fatal  to  them  :  instead  of  receiving  the  attention  and  treatment  proper  for  persons  in 
their  condition,  they  are  hable  to  be  laid  aside,  by  themselves,  to  sleep  off  their  sup- 
posed debauch,  and  the  morning  finds  them  corpses.  It  is  not  at  all  improbable  that 
some  of  you  may  be  called  upon  to  investigate  such  cases  :  and  as  actual  instances 
are  more  readily  impressed  upon  the  memory  than  any  general  description,  I  will 
read  you  a  short  history  illustrative  of  what  I  have  just  been  saying,  from  Captain 
Parry's  Journal. 

"  John  Pearson  *  *  *  had  his  hands  severely  frost-bitten,  having  unfortunately 
gone  without  mittens,  and  with  a  musket  in  his  hand.  A  party  of  our  people  most 
providentially  found  him,  although  the  night  was  very  dark,  just  as  he  had  fallen 
down  a  steep  bank  of  snow,  and  was  beginning  to  feel  that  degree  of  torpor  and 
drowsiness  which,  if  indulged,  inevitably  proves  fatal.  When  he  was  brought  on 
board  his  fingers  were  quite  stiff,  and  bent  into  the  shape  of  that  part  of  the  musket 
which  he  had  been  carrying :  and  the  frost  had  so  far  destroyed  the  animation  in 
his  fingers  on  one  hand,  that  it  was  necessary  to  amputate  three  of  them  a  short 
time  after." 

It  is  what  immediately  follows  this,  that  I  was  desirous  of  pointing  out  to  your 
attention. 

"The  effect  which  exposure  to  severe  frost  has  in  benumbing  the  mental  as  well 
as  the  corporeal  faculties,  was  very  striking  in  this  man,  as  well  as  in  two  of  the 
young  gentlemen  who  returned  after  dark,  and  of  whom  we  were  anxious  to  make 
inquiries  respecting  Pearson.  When  I  sent  for  them  into  my  cabin,  they  looked 
wild,  and  spoke  thick  and  indistinctly,  and  it  was  impossible  to  draw  from  them  a 
rational  answer  to  any  of  our  questions.  After  being  on  board  for  a  short  time,  the 
mental  faculties  appeared  gradually  to  return  with  the  returning  circulation ;  and  it 
was  not  until  then  that  a  looker-on  could  easily  persuade  himself  that  they  had  not 
been  drinking  too  freely.  To  those  who  have  been  much  accustomed  to  cold  coun- 
tries, this  will  be  no  new  remark,  but  I  cannot  help  thinking  (and  it  is  with  this  view 
that  I  speak  of  it)  that  many  a  man  may  have  been  punished  for  intoxication,  who 
was  only  suffering  from  the  benumbing  effects  of  frost :  for  I  have  more  than  once 
seen  our  people  in  a  state  so  exactly  resembling  that  of  the  most  stupid  intoxication 
that  I  should  certainly  have  charged  them  with  that  offence,  had  I  not  been  quite 
sure  that  no  possible  means  were  afforded  them  on  Melville  Island  to  procure  any 
thing  stronger  than  snow-water." 

When  persons  in  this  state  are  suffered  to  sleep,  and  the  operation  of  the  cyld 
continues,  they  become  less  and  less  sensible  to  external  impressions,  until  death 
closes  the  scene. 


CAUSES   OF   DISEASE. 


LECTURE  VII. 

Causes  of  Disease,  continued.  Laws  by  tvhich.  the  operation  of  Cold  upon  the 
Bodily  Health  is  regulated.  Circumstances  that  favour  its  injurious  Effects, 
and  respect,  first,  the  Body  itself;  secondly,  the  manner  in  which  the  Cold  is 
applied.  Modifying  influence  of  certain  states  of  the  Mind — of  Sleep — of 
Habit.  Means  of  protection.  Influence  of  the  different  Seasojis.  Impurity 
of  the  Air.     Hereditary  tendencies  to  Disease. 

In  the  last  lecture  I  commenced  the  consideration  of  some  of  the  causes  of 
disease. 

We  learned,  by  the  evidence  of  authentic  facts,  that  the  human  body  is  capable  of 
bearing  a  very  high  degree  of  external  temperature,  for  a  short  time,  without  detri- 
ment— and  even  without  much  inconvenience ;  and  we  learned — also  by  the  testi- 
mony of  facts — that  the  body  is  equally  well  calculated  to  endure,  under  favourable 
circumstances,  a  very  low  degree  of  atmospheric  temperature  —  or,  to  speak  in 
popular  language,  a  very  intense  degree  of  cold. 

It  appears  also  that  a  high,  but  not  extreme,  atmospheric  temperature,  when  long 
continued,  has  a  stimulating  effect  upon  the  organic  functions,  and  a  depressing  or 
sedative  effect  upon  the  animal  functions  of  the  body.  Long-continued  heat  predis- 
poses the  body  to  be  injuriously  influenced  by  exposure  to  cold :  the  diseases  apt  to 
follow  such  exposure,  under  such  circumstances,  being  derangement  of  the  hepatic 
functions — violent  disturbances  of  the  stomach  and  bowels,  with  a  copious  discharge 
of  vitiated  and  acrid  bile — and  acute  inflammation  of  the  hver  itself.  As  more 
direct  consequences  of  exposure  to  extreme  heat — in  other  Avords,  as  examples  of 
disorders  of  which  extreme  heat  sometimes  proves  an  exciting  cause — I  mentioned 
the  coup  de  soldi,  and  the  eruption  called  the  prickly  heat. 

With  respect  to  external  cold,  I  pointed  out  to  you  its  depressing  effects  upon  the 
organic  functions  of  the  body — and,  when  it  becomes  very  intense,  indeed,  its  directly 
sedative  influence  upon  the  animal  functions  also — producing  a  state  resembling 
intoxication,  overpowering  drowsiness,  and  coma,  especially  when  the  cold  has  had 
an  auxiliary  in  fatigue ;  and,  ultimately,  death  itself. 

I  hardly  need  say  that  the  effect  of  external  cold  upon  the  body,  within  certain 
limits  of  intensity  and  duration,  is  totally  different  from  all  this.  When  it  is  not 
intense — or  when,  though  intense,  it  is  applied  for  a  short  time  only — or  when  its 
refrigerating  and  sedative  properties  can  be  sufficiently  counteracted  by  exercise  and 
warm  clothing — cold  becomes  a  tonic;  stimulating,  refreshing, and  invigorating  both 
mind  and  body.  Instead  of  benumbing,  it  heightens  the  sensibility ;  instead  of 
stupefying,  it  clears  and  sharpens  the  faculties,  and  bestows  alacrity  and  cheerful- 
ness ot  spirit;  and  in  this  way,  among  others,  cold  becomes  a  very  important  curative 
agent. 

Here  also,  therefore,  the  contrast  obtains;  a  high  external  temperature  relaxes  and 
depresses — a  low  one,  under  the  circumstances  just  mentioned,  braces  and  enlivens. 

Nevertheless,  exposure  to  cold  is  one  of  the  most  common  causes  of  various  com- 
plaints. Many  or  most  of  the  internal  inflammations  acknowledge  cold  as  their 
ordinary  exciting  cause.  Acute  rheumatism  has,  perhaps,  no  other  external  origin. 
Apoplexy  and  palsy,  and  dropsy,  are  its  frequent  consequences.  "With  the  excep- 
tion," says  Dr.  Bateman,  in  his  Observations  on  the  Diseases  of  London,  "  with  the 
exception  of  a  small  number  of  diseases  occasioned  by  unwholesome  occupations, 
and  by  the  contagions,  the  great  mass  of  human  malai-^  in  this  metropolis  is  refer- 
able to  the  climate  or  state  of  the  seasons,  and  to  intemperance  :  but,  of  these  two 
causes,  the  vicissitudes  of  the  weather,  especially  its  cold,  are  by  far  the  most  prolific 
bources  of  mischief." 

It  must,  therefore,  to  every  one  who  is  engaged,  or  likely  to  be  engaged,  in  the 
practice  of  physic,  be  a  matter  of  first-rate  importance,  and  of  great  interest,  to  asce-- 
ta'n  the  circumstances  under  which  the  application  of  cold  is  the  most  prejudicial,  or 


I 


CAUSES    OF    DISEASE.  .69 

has  the  greatest  influence  upon  the  body — as  well  as  the  means  by  which  the  bad 
effects  of  exposure  to  cold  may  often,  in  a  great  degree,  be  prevented. 

There  are  some  short  but  valuable  hints  upon  this  subject  in  Cu lien's  First 
Lines.  The  late  Dr.  Currie,  of  Liverpool,  was,  however,  the  first  person  who  dis- 
tinctly pointed  out  the  laws  that  regulate  the  operation  of  cold  as  a  cause  of  health 
and  disease. 

Of  the  circumstances  which  favour  the  morbific  effects  of  cold,  some  relate  to  the 
condition  of  the  body  itself,  some  to  the  particular  manner  in  which  the  cold  is 
applied.  The  former  are  predisposing  circumstances;  the  latter  accessory.  We 
will  glance  at  these  in  succession. 

It  has  long  been  a  popular,  as  well  as  a  professional  axiom,  that  sudden  vicissi- 
tudes of  temperature  are  dangerous  ;  that  a  previous  hot  state  of  the  body  augments 
the  hurtful  effect  of  cold,  whether  applied  externally  or  internally.  But  the  proposi- 
tion thus  broadly  stated  is  not  universally  true.  It  is  well  known  that  the  inhabitants 
of  Russia  are  in  the  habit,  while  reeking  from  their  vapour  baths,  of  rolling  imme- 
diately in  the  snow,  or  plunging  into  cold  water,  without  suffering  from  the  change. 
Sir  Charles  Blagden,  describing  some  of  the  experiments  which  I  mentioned  in  the 
last  lecture,  says,  "  During  the  whole  day  we  passed  out  of  the  heated  room  (of 
which  the  temperature  ranged  from  240°  to  2(50°),  after  every  experiment,  imme- 
diately into  the  cold  air  without  any  precaution.  After  exposing  our  naked  bodies 
to  the  heat,  and  sweating  most  violently,  we  instantly  went  into  a  cold  room,  and 
stayed  there  even  some  minutes  before  we  began  to  dress,  yet  no  one  received  the 
least  injury."  And  Captain  Scoresby,  speaking  of  the  arctic  regions,  tells  us  that 
he  has  often  gone  from  the  breakfast-room  of  the  vessel,  where  the  temperature  was 
50°  or  60°,  to  the  mast-head,  where  it  was  only  10°,  without  any  additional  clothing, 
except  a  cap — "  yet,"  says  he,  "  I  never  received  any  injury,  and  seldom  much 
inconvenience  from  the  uncommon  transition." 

It  is  plain,  therefore,  that  the  proposition  which  assigns  danger  to  sudden  vicissi- 
tudes of  temperature  requires  limitation.  The  effects  of  a  sudden  descent  from  one 
point  to  another  in  the  scale  of  atmospheric  temperature  vary  according  to  the  state 
of  the  body  at  the  time.  Without  going  into  any  physiological  discussion  respecting 
the  source  of  animal  heat,  I  may  just  remind  you  of  the  faculty  of  evolving  heat 
possessed  by  man  and  the  warm-blooded  animals ;  by  which  faculty  very  nearly  the 
same  degree  of  inward  temperature  is  steadily  maintained  under  very  different 
degrees  of  outward  temperature.  If  the  external  temperature  be  lower  than  that  of 
the  body,  the  caloric  thereby  carried  off'  is  speedily  replaced,  in  a  healthy  adult,  by 
this  evolution  of  heat  from  within,  aided  by  clothing,  or  by  exercise.  When  the 
external  temperature  approaches  the  standard  heat  of  the  body,  sweat  soon  breaks 
forth,  and  the  superfluous  heat  is  removed  by  evaporation :  for  so  constant  is  the 
internal  evolution  of  caloric,  that  an  atmosphere  which  does  not  as  constantly  abstract 
any  of  it  is  excessively  incommoding :  an  external  temperature  of  98°,  which  is 
about  the  average  heat  of  the  blood  in  man,  is,  as  you  know,  extremely  oppressive. 
The  terms  hot,  warm,  cool,  cold,  as  applied  to  the  surrounding  air,  are  regulated  by 
the  sensations  that  it  produces  upon  the  avepage  of  persons.  If  the  heat  be  carried  off 
as  fast  as  it  is  generated,  and  no  faster,  no  particular  sensation  is  felt,  and  the  bodily 
powers  are  neither  stimulated  nor  exhausted.  This  equilibrium  is  maintained  (sup- 
posing that  no  extraordinary  exertions  are  made),  when  the  thermometer  stands  at 
62°,  or  thereabouts.  We  call  that  point  in  the  scale  temperate.  All  degrees  above 
that  point,  up  to  70,  are  reckoned  7varm  ;  all  above  70,  hot.  Descending  in  the 
scale,  we  speak  of  the  temperature  denoted  by  any  degree  between  the  60th  and  the 
50th,  as  being  cool ;  and  every  lower  degree  of  temperature  is  cold.  1  am  speaking 
of  the  average  of  healthy  men  :  for  remarkable  diversities  occur  among  individuals  in 
respect  to  the  epithets  Avhich  they  assign,  under  the  guidance  of  their  sensations,  tu 
particular  degrees  of  the  thermometric  scale  ;  their  sensations  differing  according  to 
the  power  which  their  constitutions  respectively  possess  of  evolving  heat.  Now  if 
this  power  of  evolving  heat,  thus  inherent  in  the  system,  be  entire,  and  active,  aiid 
persistent — if  it  have  not  been  weakened  by  any  of  those  circumstances  which  ai«3 
known  to  have  the  effect  of  weakening  it — no  peril  need  attend  even  violent  'liters- 


/O  CAUSES    OF    DISEASE. 

tions  of  external  temperature.  Unusual  heat  of  the  body  at  the  time  when  the  cold 
is  applied,  so  far  from  implying  danger,  is  really  the  condition  of  safety,  provided  the 
heat  is  steady  and  permanent.  You  may  read,  in  Dr.  Currie's  book,  numerous 
instances  of  the  cold  affusion  being  employed  in  the  hot  stage  of  fever,  and  particu- 
larly in  cases  of  scarlet  fever,  not  only  with  impunity,  but  with  great  benefit  to  the 
patient.  The  same  holds  true  of  the  application  of  cold  when  the  body  has  been 
heated  by  exercise — and,  indeed,  whatever  may  have  been  the  cause  of  the  increased 
heat — provided  always  that  that  cause  remains  steadily  in  action,  that  there  is  no 
local  disease,  and  that  the  body  is  not  fatigued,  and  fast  losing  its  heat.  But  if  a 
person  be  already  exhausted  and  weakened  by  exercise — if  he  be  sweating  and 
rapidlv  parting  with  his  heat — and  especially  if  the  exercise  be  over,  and  he  remain 
at  rest  immediately  after  and  during  the  application  of  the  cold — then  it  becomes 
highly  perilous,  and  likely  to  produce  internal  mischief. 

The  more  correct  statement,  therefore,  respecting  the  application  of  cold  is,  that 
it  is  dangerous — not  when  the  body  is  koi — but  when  the  body  is  cooling  after 
havi7ig  been  heated. 

This  principle  obtains  alike,  I  say,  whether  the  cold  be  applied  externally  or 
internally;  to  the  surface  of  the  bodj',  or  to  the  mucous  membrane  of  the  stomach. 
Very  many  instances  are  recorded  of  death  taking  place  immediately  after  a  copious 
draught  of  cold  water.  I  beheve  it  will  be  found  that  in  all  these  cases,  the  body 
after  having  been  much  heated  and  enfeebled  by  severe  exertion,  was  losing  its 
preternatural  heat  from  profuse  perspiration,  and,  in  general,  from  the  cessation  also 
of  the  exertion  by  which  this  heat  was  accumulated.  Celsus  was  aware  of  the 
danger:  "  ex  labore  sudanti  frigida  potio  perniciosissima  est."  The  fatal  influence 
of  cold  water  thus  apphed  was  experienced,  on  a  large  scale,  among  the  troops  of 
Alexander  the  Great,  upon  their  reaching  the  banks  of  the  River  Oxvis,  thirsty, 
fatigued,  and  perspiring  from  their  toilsome  march  of  forty-six  miles  across  the 
scorching  sands  of  the  desert.  According  to  Quintus  Curtius,  Alexander  lost  more 
of  his  soldiers  on  that  occasion  than  in  any  one  of  his  battles.  "  Sed  qui  intempe- 
rantius  hauserant  intercluso  spiritu  extincti  sunt;  multoque  major  horum  numerua 
fuit,  quam  ullo  amiserat  prrelio."  Dr.  Currie  relates  a  striking  example,  which  fell 
under  his  own  observation,  of  sudden  death  thus  produced.  A  young  man  had  been 
playing  a  severe  match  at  fives,  and  had  violently  heated  himself.  When  it  was 
over  he  sat  down  on  the  ground  panting  for  breath,  and  covered  with  perspiration. 
In  this  state  he  called  to  a  servant  to  bring  him  a  pitcher  of  cold  water  just  drawn 
from  a  neighbouring  pump.  After  holding  it  in  his  hand  a  little  while,  till  he 
recovered  his  breath,  he  put  it  to  his  mouth,  and  drank  a  large  quantity  at  once.  He 
laid  his  head  on  his  shoulder,  and  bent  forwards ;  his  countenance  became  pale,  his 
breath  laborious,  and  in  a  few  minutes  he  expired. 

I  may  take  the  opportunit}'^  of  telling  you  that  the  remedies  to  be  administered, 
when  life  is  in  jeopardy  from  this  cause,  are  warmth  to  the  epigastrium ;  and  lauda- 
num in  free  doses. 

If  death  does  not  speedily  follow  the  external  or  internal  application  of  cold  to  the 
body  under  the  untoward  circumstances  I  have  described,  inflammation  of  some 
internal  part  is  very  apt  to  arise. 

By  attending  to  the  principles  now  laid  down,  you  will  be  enabled  to  furnish  those 
whom  it  may  be  your  business  to  advise  with  many  useful  suggestions,  and  to  cau- 
tion them  against  some  common  mistakes :  mistaKes  which  have  had  their  origin  in 
the  unqualified  credit  given  to  the  maxim,  that  sudden  vicissitudes  of  external  tem- 
perature, and  exposure  to  cold  while  the  body  is  hot,  are  dangerous ;  whereas  these 
things  are  dangerous  under  certain  circumstances  only.  Thus,  you  may  tell  the 
sportsman  that  wet  feet,  or  a  wet  skin,  need  cause  him  no  apprehension,  so  that  he 
continue.*  in  active  exercise ;  and  changes  his  clothes,  and  avoids  all  further  appU- 
cation  of  cold,  as  soon  as  his  exercise  ends.  You  may  admonish  the  bather  that 
after  walking  in  a  hot  day  to  the  river's  side,  he  had  better  not  wait  to  cool  himself 
a  httle  oefore  he  plunges  into  the  stream  ;  and  in  like  manner  you  may  venture  to 
counsel  the  young  lady  who  has  heated  herself  with  dancing,  not  to  linger  in  the 
entrance  hall  till  the  glow  has  somewhat  subsided,  but  to  make  the  best  of  her  way 


CAUSES    OF    DISEASE.  71 

to  her  carriage,  and  thence  to  her  bed ;  and  you  may  tell  your  male  friends,  who 
happen  to  be  similarly  circumstanced,  that  the  best  thing  they  can  do  is  to  walk 
briskly  home  in  their  great-coats.  The  main  points  to  be  remembered  are,  that  "the 
heat  which  is  preternaturally  accumulated  by  exercise  is  held  with  little  tenacity,  is 
dissipated  by  profuse  perspiration,  and  is  speedily  lost  when  to  this  perspiration  is 
added  a  state  of  rest  after  fatigue  ;"  and  that,  in  these  circumstances,  the  application 
of  cold  is  most  apt  to  be  prejudicial. 

Among  the  circumstances  which  favour  the  morbific  effects  of  cold,  and  relate  to 
the  condition  of  the  body  itself,  is  to  be  included  —  for  reasons  that  must  now  be 
obvious  to  you — whatever  has  the  effect  of  weakening  the  system,  and  so  diminish- 
ing its  capability  of  evolving  heat.  The  most  common  of  these  debilitating  circum- 
stances are  enumerated  by  Cullen  — "  fasting,  evacuations,  fatigue,  a  last  night's 
debauch,  excess  in  venery,  long  watching,  much  study,  rest  immediately  after  great 
exercise,  sleep,  and  preceding  disease."  All  these,  you  will  observe,  tend  to  lessen 
the  vigour  of  the  circulation,  and  to  depress  the  power  of  generating  heat.  Con- 
sistent with  the  same  principle  is  the  fact  ascertained  by  Dr.  M.  Edwards,  that  the 
faculty  of  evolving  heat  is  very  feeble  in  old  persons,  and  in  the  newly  born ;  it 
being  in  these  classes  that  we  find  the  greatest  number  of  victims  to  the  power  of 
cold. 

The  bad  effects  of  cold  upon  the  system  depend  partly  upon  the  intensity  of  the 
sensation  it  produces  —  but  still  more  upon  the  duration  of  that  sensation.  We  are 
seldom  the  worse  for  a  momentary  sensation  of  cold,  however  lively  it  may  have 
been ;  whereas  even  slight  feelings  of  chilliness,  if  long  protracted,  are  apt  to  termi- 
nate in  some  form  of  disease. 

By  the  help  of  this  principle  we  may  explain  most  of  the  circumstances  which, 
relating  to  the  manner  in  which  the  cold  is  applied,  have  been  found  by  experience 
to  aggravate  its  hurtful  influence. 

Cold  is  more  likely,  cxteris  paribus,  to  prove  injurious  when  it  is  applied  by  a 
wind,  or  current  of  air.  The  sensation  of  cold  is  sustained  by  the  continual  acces- 
sion of  fresh  particles  of  frigid  air  to  the  surface  of  the  body.  Some  striking  facts 
in  illustration  of  the  refrigerating  and  depressing  effects  of  a  stream  of  cold  air  were 
mentioned  in  the  last  lecture. 

Again,  the  injurious  operation  of  cold  is  augmented,  when  it  is  accompanied  with 
moisture.  Wetness  is  notoriously  the  worst  way  in  which  cold  can  be  applied.  The 
contact  of  wet  or  damp  clothes  with  the  skin  both  increases  and  prolongs  the  sensa- 
tion of  cold.  For  the  same  reason,  a  cold  foggy  atmosphere  is  more  prejudicial  than 
a  clear,  and  therefore  drier  one,  of  the  same  temperature.  The  heat  of  the  body  is 
abstracted  more  rapidly  than  it  is  generated  from  within,  and  if  it  be  not  replaced 
by  exercise,  or  cordials,  the  balance  of  the  circulation  is  deranged,  and  internal  mis- 
chief often  follows. 

The  same  principles  serve  to  illustrate  the  effect  of  certain  other  circumstances, 
adverted  to  by  Cullen,  as  being  counteractive  of  the  morbific  tendency  of  exposure 
to  cold:  "passions  engaging  a  close  attention  to  one  object,"  —  "that  state  of  the 
body  in  which  sensibility  is  greatly  diminished,  as  in  maniacs,"  —  and  "the  power 
of  habit."     These  circumstances  are  worthy  of  a  moment's  notice. 

Impressions  which  are  unheeded  are  unfelt  and  inoperative.  As  it  is  scarcely 
possible,  when  the  attention  is  engrossed  by  bodily  pain,  to  carry  on  any  connected 
train  of  thought  —  so  on  the  other  hand  the  senses  become  impassive  in  proportion 
as  the  mind  is  fixed  upon  some  absorbing  subject  of  reflection,  or  enchained  by  some 
powerful  emotion :  impressions  made  upon  the  organs  of  sense  are  no  longer  taken 
notice  of;  the  corresponding  sensations,  if  they  are  excited  at  all,  are  not  remem- 
bered, and  the  effect  of  such  impressions  is  as  if  they  had  never  been ;  they  are  no! 
followed  by  the  usual  consequences.  Persons  gasping  for  breath  in  spasmoaic 
asthma  will  remain  for  hours  at  an  open  window,  with  scarcely  any  clothing  during 
severe  frost,  and  without  suffering  from  the  cold  ;  their  attention  is  so  anxiously  and 
exclusively  bestowed  upon  the  distress  in  their  breathing,  that  the  coldness  of  the  an 
is  unnoticed  and  unperceived,  and  has  no  sensible  effect. 

For  where  the  greater  malady  is  fixed 
The  lesser  V  anstrr.o  Mt. 


72  CAUSES    OF   DISEASE. 

The  morbific  effect  of  cold  upon  the  system  is  certainly  modified  by  the  degree  of 
attention  that  is  paid  to  the  sensation  it  excites. 

Upon  the  veiy  same  principle  may  be  explained  the  impunity  with  which  some 
maniacs  undergo  exposure  to  cold  —  even  when  suffering  no  fever  which  might 
regenerate  the  lost  heat.  "I  have  seen,"  says  Dr.  Carrie,  "a  young  woman,  once 
of  the  greatest  delicacy  of  frame,  struck  with  madness,  lie  all  night  on  a  cold  floor, 
with  hardly  the  covering  that  decency  requires,  when  the  water  was  frozen  on  the 
table  by  her,  and  the  milk  that  she  was  to  feed  on  Avas  a  mass  of  ice." 

Sleep  is  enumerated  by  Dr.  Cullen  among  those  conditions  of  the  body  which 
diminish  its  power  of  resisting  cold.  And  certainly  cold  is  very  readily  caught  (as 
the  phrase  is),  when  its  causes  are  present,  during  sleep.  But  while  we  sleep  sensa- 
tion is  in  a  great  measure  suspended.  This  would  seem,  therefore,  to  furnish  a 
contradiction  to  the  principle  that  the  effect  of  cold  upon  the  bodily  health  depends 
upon  the  strength  and  the  duration  of  the  sensation  excited  by  it.  Dr.  Alison  —  I 
speak  from  recollection  of  his  observations  heard  many  years  ago — disposes  of  this 
difficulty  by  affirming  that  the  sleeper  who  thus  suffers,  does  really  feel,  and  is  con- 
scious of,  the  sensation  of  cold,  and  that  it  mingles  with  and  probably  suggests  his 
dreams.  Lord  Brougham,  in  his  Discourse  of  Natural  Theology,  gives  a  very 
lively  picture  of  dreams  so  excited  —  drawn,  as  1  should  guess,  from  his  own  expe- 
rience. Probably  somethingf  of  the  same  kind  has  occurred  to  most  of  us.  "  Every 
one  knows  (he  says)  the  effect  of  a  bottle  of  hot  water,  applied  during  sleep,  to  the 
soles  of  the  feet :  you  instantly  dream  of  walking  over  hot  mould,  or  ashes,  or  a 
stream  of  lava,  or  having  your  feet  burnt  by  coming  too  near  the  fire.  But  the 
efl^ect  of  falling  asleep  in  a  stream  of  cold  air,  as  in  an  open  carriage,  varies  this 
experiment  in  a  very  interesting,  and  indeed  instructive  manner :  you  will,  instantly 
that  the  wind  begins  to  blow,  dream  of  being  upon  some  exposed  point,  and 
anxious  for  shelter,  but  unable  to  reach  it ;  then  you  are  on  the  deck  of  a  ship, 
suffering  from  the  gale — you  run  behind  a  sail  for  shelter,  and  the  wind  changes,  so 
that  it  still  blows  upon  you ;  you  are  driven  to  the  cabin,  but  the  ladder  is  removed, 
or  the  door  locked.  Presently  you  are  on  shore  in  a  house  with  all  the  windows 
open,  and  endeavour  to  shut  them  in  vain  ;  or,  seeing  a  smith's  forge,  you  are 
attracted  by  the  fire,  and  suddenly  a  hundred  bellows  play  upon  it,  and  extinguish  it  in 
an  instant,  but  fill  the  whole  smithy  with  their  blast,  till  you  are  as  cold  as  on  the  road." 

Certain  it  is,  that  though  while  sleeping  we  are  not  sensible  of,  or  (what  perhaps 
is  the  same  thing)  do  not  remember,  ordinary  impressions,  we  are  nevertheless  con- 
scious of  unusual  sensations  ;  so  that  the  facility  with  which  we  take  cold  during 
sleep  is  no  real  exception  to  the  general  law,  that  the  sensation  produced  by  cold  is 
concerned  in  its  injurious  effects. 

The  last  of  the  accessory  circumstances  mentioned  by  Cullen  is  "  the  power  of 
habit."  No  one  can  doubt  the  effect  of  custom  in  enabling  the  body  to  resist  the 
operation  of  cold,  who  has  had  opportunities  of  observing  how  differently  an 
inclement  temperature  is  borne  by  persons  whose  employments  oblige  them  to 
live  much  under  the  open  sky,  as  shepherds,  sailors,  stage-coachmen  ;  and  by  such 
as  pursue  in-door  occupations — mechanics,  tailors,  shopmen,  and  the  like.  Pro- 
bably the  sensibihty  of  the  surface  is  blunted  by  habitual  exposure.  We  may 
believe  too  that  the  purer  air  breathed  by  the  out-door  labourer,  and  his  more  active 
life,  confer  a  more  vigorous  state  of  health,  and  endow  him  with  an  ampler  faculty  of 
evolving  animal  heat.  The  fact  is  unquestionable ;  and  we  may  sometimes  turn 
our  knowledge  of  it  to  good  account,  in  gradually  fortifying  the  system  against  the 
influence  of  cold  that  cannot  be  avoided.  An  ill-directed  application  of  this  prin- 
ciple has  led,  however,  to  grave  errors,  and  cost  many  lives.  You  will  now  and  then 
hear  parents  talk  of  hardening  their  children,  by  causing  them  to  brave  all  sorts  of 
weather,  by  teachintr  them  to  be  indifferent  about  variations  of  temperature,  to  sit 
in  winter  time  Avithout  a  fire  in  the  room,  and  to  despise  great-coats,  flannel, 
and  other  additions  to  their  usual  dress.  Fearing  to  render  them  effeminate  by 
wver  care  and  cockering,  they  run  into  the  opposite  and  more  dangerous  extreme. 

Tins  process  is  often  attempted  with  children  originally  delicate,  and  to  such  it  is 
doubly  hazardous.     During  the  early  periods  of  life  the  inherent  protective  power 


CAUSES    OF   DISEASE.  73 

of  evolving  heat  is  comparatively  feeble  ;  and  in  this  climate  it  requires  to  be  care- 
fully cherished. 

The  experiment  of  hardening  should  never  be  tried  on  any  child  or  person  who 
is  ailing  or  unsound  ;  who  shows  any  sign  of  present  disease  ;  or  any  marked  dis- 
position to  future,  and  especially  to  scrofulous,  disease.  Whenever  it  is  tried  it 
must  be  conducted  in  conformity  with  the  principles  already  laid  down.  The  subject 
of  the  experiment  must  be  sufficiently  clothed,  and  he  must  not  fail  to  use  such  ex- 
ercise during  the  exposure  as  may  be  requisite  to  excite  and  sustain  the  adequate 
generation  of  animal  heat.  An  abiding  sense  even  of  chilliness  must  never  be  aimed 
at  nor  permitted. 

The  most  direct  and  certain  mode  of  fortifying  the  body  against  injury  from  ac 
cidental  exposure  to  cold,  is  afforded  by  the  use  of  the  cold  bath,  and  especially  of 
the  shower  bath.  When  this  is  regularly  taken  in  the  morning,  the  surface  of  the 
body  becomes  inured  to  a  degree  of  cold  greater  than  it  is  Hkely  to  encounter  during 
the  remainder  of  the  day.  It  is  fortunate  that  we  have  an  easy  criterion  of  the  pro- 
priety of  continuing  this  expedient.  When  the  sense  of  cold  does  not  remain  long, 
and  is  followed  by  a  glow  of  warmth,  the  cold  shower  bath  is  sure  to  do  good.  If, 
however,  after  the  bath,  the  person  suffers  headache,  and  continues  to  be  chilly, 
languid,  and  uncomfortable,  it  should  at  once  be  given  up  as  useless,  and  even 
hazardous. 

By  observing  these  simple  rules,  a  healthy  child  may  be  made  hardy  also,  without 
the  risk  which  their  neglect  would  impose,  of  damage  to  his  bodily  fabric,  and  of 
abbreviating,  by  what  was  meant  to  prolong,  his  mortal  span. 

Closely  connected  with  the  effects  of  temperature  upon  the  health  is  the  influence 
of  the  different  seasons  of  the  year.  A  few  remarks  upon  that  influence,  as  it  is 
witnessed  in  our  own  climate  and  country,  may  properly  conclude  our  present 
subject. 

It  is  open  to  the  commonest  observation  that  the  general  health  of  the  community 
fluctuates  with  the  changing  seasons.  Catarrhs,  and  coughs,  and  pectoral  complaints 
of  all  kinds,  are  most  apt  to  commence,  or  to  grow  worse,  in  the  winter  and  spring 
months  ;  while  bowel-complaints  are  more  numerous  and  distressing  in  the  summer 
and  autumn.  The  mucous  membranes  of  the  air-passages  sympathize  with  the  skin 
under  the  agency  of  external  cold  ;  those  of  the  stomach  and  intestines  under  that  of 
continued  atmospheric  heat. 

The  thoracic  disorders  are  more  serious  and  fatal  than  the  abdominal.  Various 
other  maladies  are  likewise  aggravated  by  cold,  or  by  vicissitudes  of  temperature. 
Hence  the  mortality  of  the  winter  is  always  larger  than  that  of  the  summer ;  unless, 
mdeed,  this  rule  happens  to  be  disturbed  by  the  intervention  of  some  widely- 
spread  epidemic.  I  am  not  sure  that  the  superior  salubrity  of  the  hotter  over  the 
colder  portion  of  the  year  is  generally  acknowledged,  even  in  this  age  of  enlight 
ment. 

It  is  the  cold  that,  more  than  any  other  element  of  the  weather,  occasions  the 
difference. 

There  are  two  small  pubhcations  by  the  present  Dr.  Heberden,  to  which  I 
would  direct  your  attention,  as  being  singularly  instructive  upon  these  points. 
One  you  will  find  in  the  eighty-sixth  volume  of  the  Philosophical  Transactions : 
Of  the  influence  of  Cold  vpon  the  Health  of  the  inhabitants  of  London.  The  other 
is  a  separate  pamphlet :  Observations  on  the  Increase  and  Decrease  of  differoxt 
Diseases. 

From  a  number  of  tables,  framed  chiefly  upon  the  weekly  bills  of  mortality,  Dt- 
Heberden  (in  the  last-named  paper)  draws  the  conclusion  that  the  whole  number 
of  deaths  is  greatest  in  Januarj',  February,  and  March,  and  least  in  June,  July,  and 
August.  This  is  contrary  to  the  notions  of  the  ancients,  and  perhaps  of  many  of  the 
moderns  iJso.  Celsus  says,  "  Tgitur  saluberrimum  ver  est ;  proxime  deinde  ab  hoc. 
hiems  ;  periculosior  testes;  autumnus  longe  periculosissimus." 

The  (iifference  of  place  may  perhaps  account  for  this  difference  of  opinion.  Celsui 
'ived  m  Rome.    That  city,  and  the  surrounding  district,  abound  in  malaria;  a  caus« 

a 


74  CAUSES   OF   DISEASE. 

of  disease  which,  happily,  is  now  scarcely  known  in  London,  but  which,  wherevei 
it  exists,  operates  most  powerfully  and  most  extensively  during  the  autumn.  The 
comparative  healthiness  of  the  several  seasons  may  doubtless  be  disturbed,  and 
even  reversed,  by  endemic  peculiarities  of  this  kind. 

In  his  paper  in  the  Philosophical  Transactions,  Dr.  Heberden  compares  the  number 
of  deaths  that  took  place  in  London  in  January,  1795,  which  was  an  unusually 
severe  month,  Avith  the  number  that  occurred  in  January,  1796,  which  was  an  un- 
commonly mild  month.  Of  those  two  successive  Avinters  one  Avas  the  coldest,  and 
the  other  the  Avarmest,  of  Avhich  any  regular  account  had  been  kept  in  this  counlr}'. 
In  the  month  of  January,  1795,  the  thermometer,  upon  an  average,  stood  at  2;^°  in 
the  morning,  and  29°.4  in  the  afternoon;  ahvays,  you  Avill  observe,  beloAv  the 
freezing  point.  In  the  same  month  in  1796,  it  stood  at  43^.5  in  the  morning,  and 
at  50°  in  the  afternoon ;  ahvays  much  above  the  freezing  point.  The  average  differ- 
ence in  the  tAvo  months  AA-as  more  than  20°. 

In  the  fiA^e  AA-eeks  beginning  upon  January  1st,  1795,  there  Avere  2823  deaths: 
in  the  five  AA'eeks  beginning  upon  January  1st,  1796,  there  were  only  1471.  The 
difference,  1352,  is  enormous.  The  mortality  in  the  former  year  was  nearly  double 
of  that  in  the  latter. 

One  object  Avhich  Dr.  Heberden  had  in  vieAv  in  making  this  comparison  Avas  to 
disabuse  his  countrymen  of  the  notion  that,  in  Avinter,  frosty  Aveather  is  more  favour- 
able to  health  than  mild  Aveather ;  a  notion  Avhich  has  been  embodied  in  the  pro- 
verb, that  "  a  green  Christinas  makes  a  fat  churchyard." 

It  is  very  instructive  to  remark  in  Avhat  classes  of  persons  the  injurious  effects  of 
the  severe  Aveather  of  winter  is  most  felt.  The  increased  mortality  Avas  found  to  be 
chiefly  among  the  very  young,  and  the  very  old ;  in  other  Avords,  among  those  in 
whom  the  recuperative  poAver  of  generating  heat  is  the  feeblest. 

In  January,  1795,  there  AA'-ere  in  London  717  deaths  of  persons  above  sixty  years 
old,  Avhile  in  January,  1796,  there  Avere  only  153  such  deaths;  or  scarcely  more 
than  one-fifth  of  the  former  number. 

I  have  often  been  struck  by  the  unusual  length  of  the  neAA-spaper  obituaries  during 
periods  of  hard  frost ;  and  by  observing  how  man}'  of  the  individuals  Avhose  deaths 
they  record  were  far  adA'anced  in  years.  Dr.  Heberden  remarks  that  among  per- 
sons older  than  sixty,  the  tide  of  mortality,  as  measured  by  the  AA"eekly  bills,  folloAA's 
regularly  the  degree  of  coldness  of  the  weather;  so  that  any  one  accustomed  to 
examine  these  lists  may  form  a  tolerably  accurate  judgment  of  the  severity  of  any 
of  our  Avintcr  months,  by  noting  the  ratio  of  the  mortality  in  persons  aboA'e  sixty. 

The  deaths  from  asthma  (under  Avhich  vague  term  all  kinds  of  pectoral  disorder 
attended  with  shortness  of  breath  appear  to  have  been  included)  Avere  249  in  Janu- 
ary, 1795;  only  29  in  January,  1796.  In  the  former  of  these  months  there  Avere 
825  deaths  attributed  to  consumption  ;  in  the  latter,  342. 

All  this  accords  AA'ith  what  I  mentioned  before  of  the  effect  of  cold  AA'eather  in 
producing  or  exasperating  diseases  of  the  respiratory  organs. 

One  of  the  conclusions  deduced  by  Dr.  Heberden  from  his  examination  of  the 
bills  of  mortality  is,  that  "the  number  of  deaths  bj'  palsies  and  apoplexies  is  in  this 
country  al\A'ays  greatest  in  Avinter."  There  are  intelligible  reasons  for  this.  When 
the  surface  is  chilled,  and  the  blood  driven  out  of  the  superficial  vessels  by  the  cold, 
it  must  accumulate  in  internal  parts,  and  so  press  Avilh  increased  force  toAA-ards  the 
head.  And  there  is  another  reason  for  the  frequency  of  these  affections  in  the 
winter  season :  it  is,  as  Ave  have  seen,  the  season  of  pectoral  complaints,  and  of  em 
barrasscd  respiration.  DA'spncra  and  fits  of  coughing  greatly  impede  the  return  of 
the  blood  from  the  head  through  the  \'eins :  and  cerebral  congestion  tends  m  the 
production  of  cerebral  hemorrhage,  especially  Avhen  the  arteries  of  the  bnuii  are 
diseased ;  and  they  often  are  so.  Accordingly  Ave  find  that  in  January,  1795,  there 
were  fifty-tAvo  deaths  from  apoplexy  and  palsy ;  Avhile  in  January,  1796,  the  num- 
ber AA-as  only  thirty-one. 

Since  these  lectures  were  first  deliA^ered,  three  Jinnnal  Reports  of  the  Registrar- 
General  of  Births,  Marriuges,  and  Deaths  in  England,  have  been  printed,  and 
liberally  circulated,  by  the  obliging  attention  of  Mr.  Lister,  among  the  members  of 


CAUSES    OF   DISEASE.  75 

our  protession.  Much  of  the  practical  information  afforded  by  these  interesting 
vohinnes  is  rendered  accessible,  even  to  a  cursory  reader,  by  Mr.  Farr's  able  analy- 
sis of  the  registered  facts  ;  which  amply  illustrate  and  confirm  most  of  the  inferences 
drawn  by  Dr.  Heberden  from  the  old  tables  of  mortality. 

For  example,  under  the  head  of  "Influence  of  the  seasons,"  Mr.  Farr  shows,  by 
numerical  statements,  especially  in  the  ildrd  Annual  Report,  that  in  London  the 
degree  to  which  the  mean  monthly  temperature  descends  in  December,  January,  or 
February,  determines,  to  a  great  extent,  the  mortality  of  the  winter. 

Again,  "  The  causes  of  death  which  prove  most  fatal  in  the  cold  months  belong 
principally  to  the  pulmonary  class,  and  the  cerebral  diseases  of  the  aged:  those 
which  prove  most  fatal  in  summer  belong  to  diseases  of  the  bowels." 

The  mean  temperature  of  the  external  atmosphere  in  London  is  505°.  In  pro- 
portion as  the  mean  temperature  of  the  day  and  night  falls  beneath  that  point,  the 
mortality  progressively  increases. 

"The  rise  in  the  mortality,"  says  Mr.  Farr,  "is  immediate ;  but  the  effects  of  the 
low  temperature  go  on  accumulating,  and  continue  to  be  felt  thirty  or  forty  days 
after  the  extremities  of  the  cold  have  passed  away.  The  cold  destroys  a  certain 
number  of  persons  rapidly;  and  in  others  occasions  diseases  which  prove  fatal  in  a 
month  or  six  weeks.  The  practical  lesson  taught  by  these  facts  is  obvious.  A 
great  number  of  the  aged,  and  of  those  afflicted  with  difficulty  of  breathing,  cannot 
resist  cold  sunk  so  low  as  32^.  The  temperature  of  the  atmosphere  in  which  they 
sleep  can  never  safely  descend  lower  than  40°:  for  if  the  cold  that  freezes  water  in 
their  chamber  does  not  freeze  their  blood,  it  impedes  respiration,  and  life  ceases 
when  the  blood  heat  has  sunk  a  few  degrees  below  the  standard." 

The  immense  body  of  authentic  facts  thus  yearly  accumulating  in  these  Reports 
constitute  most  valuable  contributions  to  the  science  of  vital  statistics ;  and  cannot 
fail  to  throw  hght  upon  the  sources,  and  to  point  towards  the  prevention,  of  many 
very  dangerous  and  destructive  disorders.  To  ascertain  the  causes  of  any  disease, 
and  to  display  them  before  the  public  mind,  are,  I  repeat,  large  steps  towards  the 
ultimate  removal  of  such  as  human  endeavours  are  competent  to  remove. 

You  may  trace  the  influence  of  the  seasons,  not  only  in  the  prevalence  of  parti- 
cular diseases  in  certain  portions  of  the  year,  but  also  in  the  character  of  other  dis- 
orders that  are  liable  to  occur  in  all  periods  of  the  year  alike ;  in  the  character,  for 
example,  of  fevers.  In  the  majority  of  cases  of  continued  fever,  you  will  find  that 
the  pectoral  symptoms  are  most  troublesome  in  the  spring,  and  the  abdominal  symp- 
toms in  the  autumn.  It  is  said,  also,  but  I  do  not  know  that  this  is  so  generally  true, 
that  affections  of  the  head,  in  continued  fever,  are  more  frequent  and  severe  in  the 
winter  than  at  other  periods  of  the  year. 

Mere  impurity  of  the  air — by  which  I  mean  impurity  that  does  not  result  from 
the  admixture  of  any  specific  poison,  such  as  the  marsh  poison,  and  the  various  con- 
tagions— is  a  powerful  predisposing  cause  of  disease.  The  prejudicial  effect  of  im- 
pure air  is  seen,  on  a  large  scale,  by  comparing  the  inhabitants  of  great  towns,  in 
respect  of  health  and  longevity,  with  those  who  live  in  the  country.  If  we  again 
refer  to  Mr.  Farr's  calculations,  founded  upon  the  returns  made  to  the  Registrar- 
General,  we  find  it  stated,  in  the  third  Annual  Report,  that  in  cities,  as  contrasted 
with  rural  districts,  the  deaths  from  consumption  are  increased  24  per  cent. ;  those 
from  typhus  55  per  cent. ;  those  from  childbirth  59  per  cent. ;  and  so  of  several 
other  disorders.  "  The  diseases  chiefly  incidental  to  childhood  are  twice  as  fatal  in 
the  town  districts  as  they  are  in  the  country."  The  mean  duration  of  life  in  the 
two  classes  of  districts  differs  nearly  17  years  ;  being  in  the  proportion  of  55  years 
{country)  to  38  years  (toivns). 

These  differences  we  can  explain  only  by  attributing  them  to  the  weakening  influ 
ence  of  impure  air,  and  the  want  of  sufficient  exercise:  for,  as  Dr.  Alison  has 
remarked,  "it  is  hardly  possible  to  observe  separately  the  effect  on  the  animal  eco- 
nomy of  deficiency  of  exercise,  and  deficiency  of  fresh  air,  these  two  causes  being 
very  generally  applied  together.  But  it  is  perfectly  ascertained  on  an  extensive 
Bcale,  in  regard  to  the  inhabitants  of  large  and  crowded  cities  as  compared  with  th« 


76  CAUSES    OF    DISEASE. 

rural  population  of  the  same  climate,  that  their  mortalitj'  is  very  much  greater, 
especially  in  early  life — and  the  probability  of  life  very  much  less."  There  is  one 
circumstance  which  shows  that  impure  air  is  the  more  noxious  agent  of  the  two, 
namely,  the  great  comparative  mortahty,  in  towns,  of  children  under  two  years  of 
age,  even  although  they  get  as  much  exercise  as  their  time  of  life  would  allow  of 
anywhere. 

The  noxious  and  depressing  influence  of  vitiated  air  is  made  strikingly  manifest 
by  the  effect  of  removal  to  a  purer  atmosphere.  We  are  continually  obliged  to 
recommend  "  change  of  air"  to  our  patients.  We  advise  them  to  go  out  of  London, 
that  their  recovery  from  acute  disorders  may  be  accelerated,  and  that  they  may 
regain  the  degree  of  general  strength  which  is  necessary  to  the  cure  of  many  chro- 
nic complaints  ;  of  all  those  especially  that  require  the  use  of  tonic  medicines,  among 
which  class  of  remedies  no  one  is  so  effectual,  in  constitutions  that  have  been  weak- 
ened by  a  town  life,  as  migration  to  the  clear  and  pure  air  of  the  country. 

It  is  necessary,  however,  to  remember  that  although  impure  air  has  most  unques- 
tionably a  very  hurtful  effect  upon  the  general  health,  there  is  no  specific  diseas*^ 
which  can  be  distinctly  traced  to  it  as  an  exciting  cause.  It  is  as  a  predisposing  in- 
fluence that  the  impurity  operates.  For  instance,  it  never  generates  (as  I  believe) 
continued  fever,  yet  it  will  most  certainly  aggravate  the  sjmiptoms,  and  favour  the 
propagation,  and  augment  the  mortality,  of  that,  and  of  other  diseases,  in  a  great 
degree.  If  there  be"  any  diseased  condition  that  is  strictly  the  product  of  impure  air, 
it  is  scrofula.  Scrofula  (as  I  shall  presently  show  you)  depends  in  part  upon  here- 
ditary constitution ;  it  partly  arises  also  from  exposure  to  cold  and  wet ;  but  there  is 
much  reason  for  beheving  that  impure  air  is  a  very  powerful  agent  in  caUing  scrofula 
into  action,  and  in  aggravating  the  strumous  diathesis. 

[This  statement  of  Dr.  W.  is  not  strictly  correct.  That  specific  disease  is  produced  by  im- 
pure air  is  a  fact  established  by  the  most  abundant  and  conclusive  testimony.  Wherever  we 
find  individuals  crowded  together  in  localities  where  filth  is  accumulated,  and  a  free  venti- 
lation is  prevented,  there,  also,  we  find  diseases  to  prevail,  evidently  dependent  upon  the 
impure  and  stagnant  state  of  the  atmosphere  ;  though  other  causes,  no  doubt,  conspire  to  their 
development,  and  to  augment  their  malignancy.  It  cannot,  certainly,  be  denied,  that  it  is  to 
the  impurity  of  the  air,  produced  by  decomposition  of  the  exhalations  and  excretions  of  indi- 
viduals regardless  of  personal  and  domestic  cleanliness,  when  crowded  together  in  confined 
apartments,  that  we  are  to  refer  the  production  of  the  typhus  fever,  so  apt  to  prevail  under 
such  circumstances,  as  well  as  the  typhoid  character  of  most  of  the  diseases  with  which  such 
individuals  may  become  aflected  from  other  causes.  Typhus  fever,  we  know,  is  particularly 
liable  to  be  produced  in  camps,  barracks,  hospitals,  prisons,  besieged  fortresses,  and  on  board 
of  ships,  whenever  in  such  situations  a  number  of  persons  are  crowded  together,  and  cleanli- 
ness and  ventilation  are  neglected ;  and  it  is  seldom,  if  ever,  generated  when  the  sources  of 
impurity  are  carefully  removed,  and  a  free  and  constant  ventilation  secured. 

The  dependence  of  yellow  fever  upon  an  impure  state  of  the  atmosphere  is  shown  by  the 
fact,  that  it  is  almost  exclusively  confined  to  towns  or  other  situations  where  the  population 
is  dense,  and  many  causes  exist  calculated  to  impair  the  purity  of  the  atmosphere;  and  by  its 
being  very  generally  confined,  when  it  occurs  in  cities,  to  the  vicinity  of  the  wharves  and 
docks,  into  which  the  common  sewers  empty  and  various  impurities  are  allowed  to  accu- 
mulate, and  which,  when  acted  upon  by  heat,  cannot  fail  to  give  rise  to  a  miasm,  by  which 
the  purity  of  the  surrounding  atmosphere  is  very  materially  impaired. 

In  regaird  to  the  agency  of  an  impure  air  "in  calling  scrofula  into  action,  and  in  aggravating 
the  strumous  diathesis,"  the  evidence  is  by  no  means  so  strong  as  the  language  of  Dr.  W. 
would  imply.  Dr.  Phillips,  h\  his  late  work  on  the  Nature  and  Causes  of  Scrofula,  has 
examined  this  question  with  a  great  deal  of  care;  his  conclusions  are,  that  '-if  we  regard 
scrofula  in  the  widest  signification  of  the  term,  so  as  to  include  all  diseases  in  which  a 
tubercle-like  deposit  seems  to  determine  the  loss  of  life,  namely,  phthisis,  scrofula,  and  tabes 
mesenterica,  the  result  may  be  thus  stated : — The  mortality  from  those  diseases  is  larger  in 
towns  than  in  country  districts,  but  it  is  not  found  that  the  densest  portion  of  a  town  is  that 
in  which  the  mortality  is  the  largest.  Thus,  in  the  four  districts  in  London  in  which  the 
crowding  is  the  greatest,  the  average  deaths  from  these  affections  is  under  0.46,  whilst  in  four 
othfr  districts,  in  which  there  is  less  crowding,  the  average  deaUis  amount  to  0.51.  and  in 
Fietiinal  Green  they  are  under  0.40.  If  we  now  narrow  the  question  to  the  influence  of  a 
residence  in  towns  and  bad  air  in  developing  scrofula  alone,  the  result  may  be  thus  stated  : — 
In  the  four  years'  mortality  included  in  the  fifth  report  of  the  Registrar-General,  namely,  from 
i?,38  to  loll,  in  a  district  comprising  towns  having  a  population  of  3,759,186,  the  deaths 
from  scrofula  amounted  to  758  ;  and  in  a  district  having  a  rural  population  o£  3,440,501  '^uls, 


CAUSES   OF   DISEASE.  77 

the  deaths  amounted  to  1333 ;  or,  to  state  the  question  more  simply,  the  proportion  of  deaths 
from  scrofula  to  1,000,000  living  was,  in  the  town  districts,  50  per  annum,  and  in  the  country 
districts,  97.  And  if,  with  scrofula,  tabes  mesenterica  be  included,  the  numbers  would  stand 
as  122  deaths  in  towns  to  IGO  deaths  in  the  country.  Again,  let  us  observe  the  south-eastern, 
the  south  midland,  and  the  south-western  districts  ;  there  the  mortality  from  scrofula  amounted 
to  1  in  12,000,  whilst  in  the  densely-packed  factory  districts  of  Yorkshire,  Lancashire,  and 
Cheshire,  the  mortality  from  scrofula  will  be  seen  to  be  less  than  half  the  preceding  mor- 
tality from  the  same  cause,  namely,  about  1  in  25,000.  And  suppose  we  go  one  step  further, 
and  compare  one  portion  of  the  metropolis  with  another,  we  find  that  the  total  deaths  from 
scrofula  in  the  metropolis,  when  compared  with  the  population,  are  as  5-6  to  100,000  living, 
whilst  in  tlie  most  densely  populated  districts,  comprising  the  East  and  West  London  Union, 
the  Strand,  Holborn,  or  St.  Giles,  Whitechapel,  and  Bethnal  Green,  the  proportion  is  as  51  to 
100,000;  Bethnal  Green  being  represented  by  4-8,  and  Whitechapel  by  4-7  to  100,000  living. 
So  in  the  low,  dense,  and  poor  districts  of  Bethnal  Green,  Poplar,  Stepney,  Whitechapel, 
Shoreditch,  Westminster,  Bermondsey,  Rotherhithe,  and  Lambeth,  with  a  total  mortality 
amounting  to  21,522,  the  deaths  from  scrofula  are  45,  or  1  in  478;  while  in  the  district  em- 
bracing Kensington,  St.  George's,  Hanover  Square,  and  St.  Marylebone,  with  a  total  mortality 
amounting  to  14,734,  the  deaths  from  scrofula  are  30,  or  1  in  490.  Thus  the  difference  in 
these  districts  is  scarcely  appreciable ;  but  if  we  compare  the  western  districts  of  the  me- 
tropolis with  those  of  Bethnal  Green,  Shoreditch,  and  Whitechapel,  we  find  that  the  propor- 
tion of  deaths  from  scrofula  to  the  general  mortality  in  the  former  is  as  1  to  490,  and  in  the 
latter  to  as  1  to  1000.  Again,  if  from  considering  the  influence  of  localities,  we  turn  to  the 
csomparative  mortality  of  the  sexes,  it  will  be  found  that  20  per  cent,  more  boys  die  of  scro- 
fula than  girls ;  and  yet  it  must  be  admitted  that  girls  are  more  exposed  than  boys  to  the 
eifects,  whatever  they  may  be,  of  crowded  rooms,  and  exclusion  from  out-door  employ- 
ments.'"— C] 

I  have  entered  the  more  fully  into  the  consideration  of  certain  states  of  the  atmos- 
phere, its  extremes  and  its  variations  of  temperature,  and  its  impurity,  as  causes  of 
disease,  because  there  is  no  part  of  the  course  in  which  I  could  more  conveniently 
introduce  them.  Most  of  the  other  causes  of  disease,  enumerated  in  my  last  lec- 
ture, will  be  discussed  in  connection  with  the  disorders  to  which  they  give  birth : 
malaria,  for  example,  when  I  speak  of  ague  ;  contagions,  when  we  come  to  the 
exanthemata  and  to  continued  fever ;  epidemic  influences,  with  epidemic  distem- 
pers ;  improper  or  insufficient  diet,  and  intemperance  generally,  with  indigestion, 
and  the  disorders  of  the  alimentary  canal ;  and  so  on.  There  is,  however,  one  re- 
markable predisposing  cause  of  disease,  a  few  observations  upon  which  may  serve 
to  fill  up  the  little  that  remains  of  the  present  hour.  I  mean,  that  disposition  to  cer- 
tain diseases  which  is  apt  to  descend  from  parents  to  children  :  hereditary  tendencies 
to  disease. 

We  must  distinguish  between  susceptibility  of  disease,  and  a  tendency  to  disease. 
In  one  sense  all  persons  are  born  with  a  predisposition  to  most  forms  of  disorder.  No 
one  is  protected  by  nature  against  inflammation  when  the  causes  of  inflammation 
come  into  play.  Poisons  of  various  kinds,  and  specific  contagions,  which  indeed  are 
poisons,  operate  with  tolerable  uniformity  upon  cill  men  alike. 

But  there  are  certain  complaints  which  we  may  separate  in  this  respect  from  the 
others :  which  complaints  some  persons  have  a  tendency  to,  and  some  have  not. 
The  tendency  is  sometimes  strong  and  evident,  sometimes  feeble  and  faintly  marked  ; 
sometimes  it  displays  itself  in  the  midst  of  circumstances  the  most  favourable  lo 
health,  sometimes  it  requires  for  its  development  conditions  the  most  adverse  and 
trying.  To  mention  some  of  these  diseases  :  scrofula,  which  I  soon  shall  describe 
more  particularly,  gout,  mania,  and  (I  believe  I  may  add)  spasmodic  asthma. 

Not  only  is  a  disposition  to  these  complaints  strikingly  pronounced  in  some  per- 
sons, but  other  persons  appear  wholly  free  from  such  a  tendency — nay,  even  devoid 
of  the  susceptibility  of  them.  Gout,  in  those  capable  of  it,  may  be  acquired  by 
habits,  as  it  may  be  repressed  and  prevented  by  the  opposite  habits.  The  habits 
that,  in  certain  persons,  bring  it  on,  are  the  intemperate  use  of  the  luxuries  of  the 
table,  and  an  indolent  or  sedentary  manner  of  life  :  but  there  are  many  people  in 
whom  no  amount  of  rich  living  or  idleness  will  generate  gout.  So  there  are  some 
m  whom  no  exposure  to  impure  air,  cold,  and  wet,  and  no  privations  —  in  other 
words,  no  appliance  of  the  influences  calculated  to  bring  the  strumous  diathesis  into 
play — will  ever  produce  any  form  of  scrofula  ;  will  ever  render  them  consumptive 

g2 


78  CAUSES   OF   DISEASE. 

for  instance,  Consumption  being  one  of  the  most  common  and  fatal  shapes  of  scro- 
fulous disease.  There  are  many  who  endure  the  utmost  distress  and  excitement 
of  mind,  yet  never  become  insane.  There  are  many  who  never  become  afliicted 
with  asthma,  although  surrounded  by  the  most  powerful  exciting  causes  of  that 
complaint. 

Now  with  respect  to  these  diseases,  and  perhaps  a  few  others,  it  is  matter  of  tact 
that  they  occur  much  more  frequently  in  persons,  some  one  or  more  of  whose  an- 
cestors have  suffered  from  them,  than  in  other  persons :  the  tendency  is  transmitted, 
is  hereditary. 

That  the  circumstances  of  the  parents  do  influence  the  physical  characters  of  the 
children,  no  one  can  doubt :  it  is  matter  of  daily  observation ;  and  one  of  the  best 
possible  illustrations  of  the  fact  is  to  be  found  in  what  are  called  family-likenesses. 
We  see  children  resembling  their  father,  or  their  mother ;  or  both  parents  at  once,  as 
mulaltoes. 

It  has  been  suggested  that  the  similarity  in  features  and  expression,  and  even  in 
moral  chamcter,  which  cannot  be  denied  to  exist,  may  be  ascribed  to  training  and 
imitation.  But  allowing  something  to  that  cause,  it  cannot  be  all.  It  was,  I  re- 
member, a  common  remark  when  I  was  at  Cambridge,  that  the  followers  and 
admirers  of  a  very  good  man,  the  late  Mr.  Simeon,  appeared  to  come  at  last  to  re- 
semble him.  So  man  and  v/ife  are  sometimes  fancied  to  grow  like  each  other.  That 
is,  the  same  prevailing  cast  of  thought  and  feeling,  the  idem  sentire  et  idem  velle, 
may  give  such  an  habitual  expression  and  character  to  the  countenance,  as  shall  con- 
stitute, to  superficial  observers,  a  likeness.  But  there  are  family-hkenesses  which 
will  not  admit  of  such  an  explanation  as  this :  similarities  in  the  shape  or  size,  or 
disposition  of  peculiar  features.  Every  one  has  heard  of,  or  may  remark  in  por- 
traits, the  hereditary  thick  lip  of  the  imperial  house  of  Austria.  Many  persons  now 
living  have  had  the  opportunity  of  tracing  the  lineaments  of  our  own  royal  family 
through  at  least  three  generations.  The  sisters  of  one  of  our  English  dukes  are  re- 
markably handsome  young  women,  and  bear,  to  this  day,  a  striking  resemblance  to 
the  portraits  of  their  beautiful  ancestress,  the  celebrated  Nell  Gwyn.  And  inde- 
pendently of  the  general  cast  of  features,  we  trace  these  family-likenesses  in  minute 
or  unequivocal  particulars,  as  the  colour  of  the  hair  and  eyes,  the  shape  of  the  limbs, 
the  stature  of  the  body,  and  so  on :  nay,  in  more  decided  peculiarities  than  these, 
in  points  of  unusual  formation.  You  have  heard,  probably,  of  the  American  calcu- 
lating boy,  Zerah  Colburn.  A  great  number  of  individuals  of  his  family,  descended 
from  a  common  ancestor,  had  six  fingers  and  six  toes  instead  of  five.  The  pecu- 
liarity was  transmitted  through  four  successive  generations  ;  and  probably,  could  his 
pedigree  have  been  further  traced,  through  many  more.  I  am  myself  acquainted 
with  a  gentleman  who  had  the  misfortune  some  years  ago  to  have  a  bastard  child 
laid  to  his  charge.  At  first  he  had  some  misgivings  on  the  subject,  and  suspected 
that  he  might  have  no  title  to  the  credit  (or  I  should  rather  say  to  the  discredit)  of 
the  imputed  paternity ;  but  all  his  scruples  Avere  satisfied  when  he  found  that  the 
child  had  six  fingers  on  each  hand,  for  he  had  himself  possessed  two  small  super- 
numerary fingers,  which  had  been  amputated  when  he  was  an  infant.  Haller  gives 
an  account  of  a  web-footed  family,  descended  from  a  mother  in  whom  that  configu- 
ration existed.  There  is  now  living  in  London  a  musical  composer  of  some  celebrity, 
in  whose  person  nature  has  played  a  similar  freak  ;  and  whose  father,  grandfather, 
and  great-grandfather,  were  all  web-footed  before  him.  Beyond  this  point  his  infor- 
mation does  not  reach.  I  am  indebted  for  the  knowledge  of  this  instance  to  one  of 
my  former  pupils,  Mr.  Cooper,  of  Grafton  street. 

Now  there  is  one  very  curious  circumstance  observable  in  regard  to  these  family- 
likenesses,  namely,  that  they  may  fail  to  appear  in  the  child,  and  yet  appear  in  the 
grandchild ;  may  skip  over  a  generation  or  two ;  may,  after  lying  dormant,  break 
out,  as  it  were,  in  some  collateral  branch  of  the  family  tree. 

This  not  only  proves  that  certain  physical  peculiarities  may  be  transmitted,  but  it 
discloses  this  remarkable  property,  that  peculiarities  no/ /Jossfsser/ by  the  parent  may 
nevertheiesi  ue  transmitted  by  him.  And  this  evidently  opens  a  wide  field  for  the 
operatioi   oi^  hereditary  tendencies.     A  person  is  not  to  consider  himself  as  neces- 


SYMPTOMS.  ■''9 

sarily  free  from  a  disposition  to  consumptioa  or  gout,  because  his  parents  have  ne-er 
shown  any  symptoms  of  those  disorders. 

When  one  parent  only  bears  the  transmissible  tendency,  the  disease  appears  to  be 
most  apt  to  break  out  in  the  children  who  most  resemble  that  parent  in  their  physical 
conformation  and  appearance.  Yet  this  is  a  most  universal  rule.  I  am  acquainted 
with  a  gentleman  who  had  lost  several  brothers  or  sisters  by  phthisis.  The  fatal 
disposition  is  known  to  exist  on  his  mother's  side,  while  his  father's  pedigree  is  be- 
lieved to  be  quite  free  from  it.  All  the  children  that  have  hitherto  become  consump- 
tive have  resembled  the  mother  in  bodily  configuration  and  features,  except  this 
gentleman,  who  is  like  his  father's  family,  but  who,  nevertheless,  labours  under  un- 
equivocal consumption.* 

It  becomes  a  very  interesting,  and  a  very  important  question,  whether  acquired 
peculiarities  can  be  transmitted.  I  have  been  told,  by  a  gentleman  attending  the 
class,  that  he  knew  a  man  who,  having  been  accidentally  deprived  of  sight,  after- 
wards propagated  bUnd  children.  I  believe,  however,  such  an  event  to  be  uncom- 
mon. Dr.  Prichard  is  of  opinion  that  all  original  or  connate  bodily  peculiarities 
lend  to  become  hereditary,  while  changes  in  the  organic  structure  of  the  individual 
from  external  causes  during  hfe,  end  with  him,  and  have  no  obvious  influence  on  his 
progeny.  Although  this  general  law  is  probably  true,  I  doubt  whether  it  be  yet 
sufficiently  established  by  a  reference  to  actual  facts. 

I  need  scarcely  say  a  word  respecting  the  importance  to  medical  men,  and  indeed 
to  all  men,  of  a  knowledge  of  these  hereditary  dispositions.  Such  knowledge  ourrht 
to  regulate,  in  some  degree,  the  choice  of  persons  wishing  to  marry.  Where  both 
parents  have  a  decided  tendency  to  any  complaint,  there  will  be  a  double  probability 
of  a  diseased  offspring.  Lawful  intermarriages  between  members  of  the  same 
family  are  often  highly  objectionable  on  the  same  score.  Any  inherent  defect  or 
.  morbid  propensity  is  aggravated  by  what  cattle-dealers  call  "  breeding  in  and  in." 

Again,  if  it  be  known  that  in  any  family  an  hereditary  proclivity  exists — to  gout 
and  gravel,  for  instance,  or  to  consumption — this  knowledge  ought  to  warn  every 
individual  of  that  family  sedulously  to  avoid  the  causes  which  foster  and  develop 
these  diseases ;  and  medical  men,  possessed  of  the  requisite  information,  may  give 
most  valuable  advice  and  instruction  on  these  points. 


LECTURE  VIII. 

Symptoms.  Their  Uses  in  relation  to  the  Diagnosis,  the  Prognosis  and  the 
Treatment  of  Diseases.  Signs,  as  distinguished  from  Symptoms.  Pathog- 
nomomic,  Commemorative,  Direct  and  Indirect  Symptoms.  Examples  of  Symp- 
toms as  they  consist  of  uneasy  Sensations,  disordered  Functions,  or  changes  of 
Sensible  Qualities. 

We  are  perpetually  reading  and  talking  about  symptoms  ;  and  no  wonder,  for 
symptoms  are  the  signals  by  which  we  learn  that  disease  is  present ;  the  evidence 
upon  which  our  whole  art  proceeds.  We  are  always,  therefore,  observing  symp- 
toms, analyzing  them,  striving  to  interpret  their  meaning,  to  ascertain  what  they 
signify.  Without  a  knowledge  of  symptoms  we  can  have  no  knowledge  of  the  art 
of  physic.  Sagacity  in  penetrating  the  import  of  symptoms  constitutes  a  great  pan 
of  the  skill  of  an  able  physician.  We  shall  find  it  useful  to  take  a  cursory  view  of 
semeiology,  and  to  famihurize  our  thoughts  with  some  of  the  cardinal  symptoms 
themselves,  before  we  speak  of  them  in  connection  with  particulai  diseases. 

What  do  we  mean  by  a  symptom  ?  XvixTttuifia — "  Something  that  happens  concur 
rently  with  something  else."  Symptoms,  they  say,  are  coincidences,  but  this  i& 
merely  translating  the  word  svuHtufw/ta  into  English  through  the  Latin.     Symptoms 

•  This  gentleman,  an  eminent  London  physician,  has  died  since  this  lecture  was  given 


so  SYMPTOMS. 

are  sometimes  defined  to  be  morbid  phenomena — "  any  thing  (5bserved  in  a  patient 
out  of  the  course  of  health."  But  in  forming  our  estimate  of  disease  we  must  often 
lake  into  account  functions  that  are  regular  and  undisturbed :  tliese  have  been  said 
to  furnish  negative  symptoms.  For  my  own  part,  if  I  were  called  upon  to  dclino  a 
symptom,  I  should  say,  "  Every  thing  or  circumstance  happening  in  the  body  of  a 
S'ck  person,  and  capable  of  being  perceived  by  himself  or  by  others,  which  can  be 
made  to  assist  our  judgment  concerning  the  seat  or  the  nature  of  his  disease,  its  pro- 
bable course  and  termination,  or  its  proper  treatment:  every  such  thing  or  circum- 
stance is  a  symptom^ 

And  1  wish  you  to  take  notice  at  once,  that  it  is  for  the  three  purposes  just  adverted 
to,  that  we  cultivate  the  study  of  symptoms,  viz.: — 

First,  To  ascertain  the  seat  and  the  nature  of  the  disease  under  which  our  patient 
is  labouring  :  in  technical  language  to  form  the  diagnosis.  1  am  no  great  friend  to 
technical  phrases  where  they  can  be  avoided  without  inconvenience  ;  but  in  some 
cases  short  terms  of  art  save  us  a  great  deal  of  tiresome  periphrasis  and  circum 
locution. 

A  second  object  of  the  study  of  symptoms  is  to  enable  us  to  foresee  and  foretell 
the  probable  course  and  issue  of  the  disease  ;  in  other  words,  to  frame  the  prognosis. 

And  a  thii'd,  and  paramount  use  of  a  knowledge  of  symptoms,  is  to  direct  oui 
treatment  of  the  disease. 

I  suspect  that  the  immense  importance  of  the  first  mentioned  of  these  three 
objects — the  diagnosis  or  recognition  of  disease,  is  not  always  clearly  seen,  either  by 
students  or  practitioners  of  medicine.  Sometimes  we  are  obliged  to  prescribe  for  a 
malady,  although  we  are  in  great  uncertainty,  perhaps  in  total  ignorance,  respecting 
its  nature  or  its  situation.  But  this  is  always  unsatisfactory.  On  the  other  hand, 
when  we  have  ascertained  where  and  what  the  disease  is,  we  apply  with  much 
more  confidence,  precision  and  comfort,  those  rules  for  its  relief  which  w^e  have 
picked  up  by  our  own  observation,  or  have  been  taught  by  others.  This,  however, 
is  a  very  limited  view  of  the  importance  of  an  exact  and  true  diagnosis.  Diagnosis 
forms  the  indispensable  basis  of  all  advances  in  physic  as  a  practical  art.  There  is 
a  common  saying,  that  the  knowledge  of  what  a  disease  is,  is  half  its  cure.  In  one 
sense  this  may  sometimes  be  true,  but  in  another  sense  it  is  not  so.  Almost  all  that 
we  know  concerning  the  proper  treatment  of  the  sick  is  originally  derived  from 
observation,  not  of  the  nature  of  diseases,  but  of  the  ejects  of  remedies.  That 
rhubarb  will  purge,  and  opium  lull  to  sleep,  and  loss  of  blood  occasion  faintness,  are 
truths  which  experience  alone  could  suggest,  aid  successive  trials  alone  confirm. 
They  are  purely  empirical  truths.  No  one  could  guess  them  beforehand.  No  skill 
in  the  discrimination  of  disease  has  even  a  tendency  to  teach  them.  In  some  few 
cases,  indeed,  we  see  that  certain  mechanical  derangements  exist,  which  are  mani- 
festly capable  of  mechanical  relief.  When  parts  of  the  body  are  displaced,  as  in 
hernia  and  dislocations ;  or  when  distension  and  pressure  are  evidently  produced  by 
accumulated  fluids ;  the  mechanical  remedies  are  at  once  suggested  by  the  physical 
and  obvious  faults.  But  with  such  exceptions,  diagnosis  does  not,  of  itself,  afford  us 
any  direct  information  as  to  the  cure  of  diseases;  but  it  does  this — it  defines  and 
fixes  the  objects  about  which  observation  is  to  be  exercised,  and  experience  collected. 
When  Ave  can  once  identify  a  given  diseased  condition,  we  obtain  the  privilege  of 
watching  the  behaviour  of  that  diseased  condition,  again  and  again,  under  the  opera- 
tion of  therapeutic  measures ;  and  from  that  time  the  increase  of  our  knowledge 
concerning  the  appropriate  management  of  that  particular  disease  becomes  progressive 
and  sure.  The  term  experience  is  obviously  misapplied,  and  the  results  of  all 
observation  are  vitiated,  when  any  doubt  exists  about  the  sameness  of  the  objects 
contemplated.  It  is  mainly  to  this  imperfection  in  the  diagnostic  part  of  medicine 
that  we  must  attribute  the  uncertainty  and  variation,  both  of  doctrine  and  practice, 
which  have  brought  so  much  suspicion,  and  reproach,  and  ridicule  upon  the  science 
we  profess.  False  experience,  if  I  may  use  such  a  term,  has  greatly  hindered  the 
progress  of  the  heaUng  art ;  and  false  experience  springs  from  false  diagnosis.  A 
man  will  tell  you  that  he  has  cured  a  score  of  cases  of  advanced  phthisis  ;  but  he 
has  deceived  himself :  they  were  not  cases  of  true  phthisis,  but  simply  cases  of 


SYMPTOMS.  SI 

chronic  inflammation,  with  puriform  discharge  of  the  mucous  membrane  of  the 
bronchi.  He  publishes  an  account  of  his  success,  and  of  his  plan  of  treatment ;  and 
thus  he  deceives  others  also :  and  thus  he  retards  the  science  which  he  fondly  and 
conscientiously  beheves  he  is  promoting.  Accuracy  of  diagnosis,  then,  cannot  be 
too  highly  estimated,  nor  too  diligently  sought  after.  It  has  been  wonderfully  im- 
proved within  the  last  twenty  years. 

'Ihe  prognonis,  or  foreknowledge  of  the  course  and  event  of  diseases,  has  but 
httle  connection  with  the  promotion  of  the  art  of  healing ;  but  it  is  not  on  that 
account  less  worthy  of  our  attention.  Both  physician  and  patient  find  their  advan- 
tage in  the  capability  of  the  former  to  determine  whether  a  disease  be  remediable — 
to  foresee  the  changes  that  may  be  expected  in  its  progress  —  to  predict  the  manner 
in  which  it  will  terminate.  Knowledge  of  this  kind  opens  to  us  a  fair  and  honour- 
able source  of  credit  and  reputation  ;  and  it  begets  a  degree  of  confidence  towards 
us,  which  is  beneficial,  not  merely  to  ourselves,  but  to  our  clients.  Our  influence 
over  a  sick  person,  and  the  efficacy  of  many  of  our  remedial  measures,  are  remark- 
ably mcreased  by  the  reliance  he  places  on  our  skill,  and  by  our  apparent  acquaint- 
ance with  the  nature  of  his  complaint.  It  is  often  of  material  consequence,  in  another 
point  of  view,  that  the  fatal  character  of  a  disease  should  be  plainly  perceived.  A 
sick  man,  made  aware  of  his  danger,  is  furnished  with  a  motive  and  an  opportunity 
for  arramjmg  his  worldly  affairs,  in  the  settlement  of  which  the  future  comfort  and 
happiness  of  his  family  may  be  very  deeply  concerned ;  for  making  his  will ;  and 
also  for  more  solemn  preparation  for  the  awful  change  that  awaits  him.  For  these 
reasons  medical  men  have,  in  all  periods,  endeavoured  to  read,  in  the  phenomena 
presented  to  them  by  diseases,  the  event  to  which  those  diseases  severally  tend.  To 
form  an  accurate  opinion  on  this  head  is,  however,  one  thing  —  to  divulge  it,  ano- 
ther. There  is  always  some  risk  of  losing,  instead  of  gaining  credit,  by  strong  state- 
ments, and  confident  predictions  of  the  death  or  the  recovery  of  a  patient.  If  you 
give  an  unfavourable  prognosis,  you  have  a  good  chance  of  losing  your  patient  alto- 
gether; his  friends  argue  very  naturally,  that  you  are  not  inAUUble,  that  you  may  be 
wrong,  that  i^  you  know  of  no  means  of  safety  for  him,  some  other  practitioner  may, 
and  they  will  grasp  at  v/hatever  straw  comes  near  them.  Do  not  suppose  that  this 
is  merely  a  selfish  view  of  the  matter :  it  is  often  of  much  moment  to  the  patient 
himself,  that  he  should  not  be  tempted  to  put  his  life  under  the  charge  of  impostors, 
who  will  feed  his  hopes,  and  promise  largely,  and  torture  him  perhaps  with  their 
discipline,  and  have  no  mercy  upon  his  pocket.  Many  an  instance  have  I  known 
of  persons  dying  of  consumption,  who,  when  given  over  by  their  regular  attendants, 
have  been  brought  to  London  at  considerable  expense,  exchanging  the  many  com- 
forts of  home  for  the  inconveniences  of  a  hired  lodging,  that  they  might  be  cured 
by  that  ignorant  and  cruel  and  rapacious  quack,  iVlr.  St.  John  Long.  There  are 
other  reasons,  too,  why  we  must  sometimes  conceal  the  truth  from  our  patients.  It 
often  happens  that  a  person  is  extremely  ill,  and  in  great  danger,  but  may  yet  reco- 
ver if  he  is  not  informed  of  his  peril.  To  agitate  a  person  in  these  circumstances 
by  telling  him  he  is  likely  to  die,  is  to  lessen,  perhaps  to  destroy,  his  chance  of 
recovery.  You  kill  him  if  you  take  away  his  hope  of  hving.  It  must  be  confessed 
that  the  duty  of  the  medical  man  in  these  cases  is  very  painful  and  embarrassing: 
the  patient  and  the  patient's  friends  are  urgently  inquisitive  to  know  whether  there 
is  any  danger ;  or  whether  he  is  not  yet  out  of  danger.  The  rule  which  I  have 
always  adopted  in  circumstances  of  this  kind,  when  I  see  clearly  that  the  case  is 
hopeless  of  cure,  is  to  fix  as  well  as  I  can  upon  that  person  among  the  family  c" 
friends  of  the  patient  to  whose  prudence  the  real  state  of  the  matter  may  be  the 
most  safely  confided.  If  I  think  that  there  is  a  possible  chance  of  recovery,  and 
that  a  knowledge  of  his  danger  by  the  patient  would  diminish  that  chance,  of  course. 
I  urge  the  necessity  of  speaking  to  him  with  assumed  cheerfulness  and  confidence  ■ 
if  I  see  that  the  case  is  absolutely  and  inevitably  mortal,  either  soon  or  at  some  littL 
distance  of  time,  I  leave  it  to  the  discretion  of  the  person  with  whom  I  communicate 
to  disclose  or  conceal  my  opinion  as  he  or  she  may  think  best.  There  are,  I  bekevc. 
practitioners,  who  make  it  a  point,  on  principles  of  worldly  policy,  never  to  speak 


82  SYMPTOMS. 

des])airingly  of  a  patient ;  but  1  cannot  regard  such  a  rule  of  conduct  as  honest,  or 
justifiable,  or  consistent  with  one's  Christian  duty. 

Now  I  would  have  you  observe  that  symptoms  do  not  serve  equally  or  indiffer- 
ently the  three  several  purposes  that  I  have  spoken  of.  The  same  symptom  or  set 
of  symptoms  may  indeed  at  once  reveal  the  nature  of  the  disease,  arid  foreshow  it3 
result,  and  indicate  its  treatment.  When  we  have  discovered  what  the  disease  is, 
we  may  want  no  further  information  to  tell  us  how  it  will  terminate,  or  how  we  are 
to  prescribe  for  it.  A  man  previously  sound  and  well,  shivers,  then  becomes  hot, 
and  afterwards  sweats,  and  then  reverts  to  his  natural  state  of  comfort  and  good 
heahh :  and  the  same  series  of  phenomena  recur  every  other  day.  We  pronounce 
the  disease  to  be  ague ;  we  predict  that,  in  this  climate  at  least,  the  patient  will 
recover ;  and  we  give  him  quinia ;  all  upon  the  strength  of  the  same  set  of  symp- 
toms. But  this  is  not  necessarily  the  case  :  certain  symptoms  may  disclose  to  us  what 
the  malady  is,  and  where  it  is  situated  ;  other  symptoms  teach  us  whether  our  patient 
is  hkely  'o  survive  or  not ;  and  a  still  different  set  instruct  us  what  is  the  proper 
method  of  cure  to  be  attempted.  We  see  a  number  of  httle  pustules  scattered  over 
his  skin,  and  we  know  that  our  patient  is  labouring  under  small-pox.  His  chance 
of  recovery  will  be  singularly  different,  according  as  the  spots  upon  his  face  run 
together,  or  remain  separate  and  distinct  from  each  other ;  and  we  investigate  the 
state  of  his  pulse,  and  his  breathing,  of  his  bowels  and  his  brain,  before  we  can  ven- 
ture to  prescribe  for  him.  Those  s3'mptoms,  or  combinations  of  symptoms,  which 
disclose  the  place  and  nature  of  the  disease,  we  call  signs  of  disease  ;  those  which 
teach  us  what  to  do,  we  call  indications  of  treatment.  We  speak  also  of  prognos- 
tic signs.  By  keeping  these  distinct  ends  of  the  study  of  symptoms  in  mind,  Ave 
shall  be  enabled  to  group  them  to  advantage,  and  to  avoid  huddling  confusedly 
together  symptoms  that  speak,  not  indeed  a  different  language,  but  upon  a  different 
topic.  The  ancients,  who  knew  but  little  of  the  intimate  nature  of  diseases,  but 
who  paid  great  attention  to  symptoms,  have  laid  down  most  admirable  rules  in 
respect  to  prognosis :  which  shows  not  only  that  the  prognostic  signs  are  more 
easily  made  out,  in  many  cases,  than  the  diagnostic,  but  also  that  they  may  be  inde- 
pendent of  them. 

I  have  just  spoken  of  symptoms  as  being,  signs.  These  words  are  not,  however 
exactly  synonymous,  ahhough  they  are  frequently  employed  as  if  they  were  so. 
Even  those  medical  writers  who  admit  a  distinction  between  them,  have  not  alwaj's 
succeeded  in  clearly  pointing  out  the  difference.  Signs  are  deduced  from  symptoms, 
by  arranging  and  comparing  them,  and  noticing  the  circumstances  under  which  they 
occur.  Symptoms  are  obvious  to  all  persons  alike  —  to  the  nurse  as  well  as  to  the 
physician  :  signs,  for  the  most  part,  are  such  to  medical  eyes  alone.  Let  me  try  to 
make  this  plainer  by  the  help  of  an  illustration.  Symptoms  may  be  considered  as 
resembling  so  many  words.  When  taken  separately,  or  when  put  together  at  ran- 
dom, the  words  have  no  force  or  siiinification.  Arrange  them  in  due  order,  reduce 
them  mto  a  sentence,  and  they  convey  a  meaning.  The  sentence  is  a  sign  or 
expression  of  something  which  is  thus  revealed.  Symptoms  become  signs  when 
their  import  can  be  interpreted. 

A  certain  crackling  sound,  of  which  T  shall  have  much  to  say  hereafter,  is  heard 
(we  will  suppose)  in  some  part  of  a  patient's  lung,  by  the  ear  applied  outside  his 
thorax.  The  sound  is  a  symptom ;  any  one  who  listens  may  perceive  it.  It  is 
even  so  far  a  sign  that  it  denotes  the  unnatural  presence  of  a  liquid  in  the  lung,  and 
the  passage  of  air  through  that  liquid.  But  the  liquid  may  be  one  of  several  — 
mucus,  or  serum,  or  pus,  or  blood  :  we  cannot  tell  by  the  sound  alone  which  of 
these  it  is.  But  if  we  learn  that  the  person  in  whose  lung  the  sound  is  audible  has 
been  ill  for  a  day  or  two  only,  that  he  has  pain  in  his  chest,  cough,  embarrassed 
breathing,  and  fever,  we  conclude  that  he  is  labouring  under  that  serious  disease, 
inflammation  of  the  lung.  The  crackhng  sound  alone  could  not  assure  us  of  this ; 
nor  without  the  addition  of  this  sound  could  the  pain,  the  laboured  breathing,  the 
cough,  or  the  fever.  Taken  collectively,  the  symptoms  constitute  a  diagnostic  sign, 
luid  bespeak  the  existence  of  pneumonia. 

Sometimes  a  symptom,  or  set  of  symptoms,  becomes  a  sign,  by  its  relation  to  whaJ 


SYMPTOMS.  83 

has  gone  before  and  what  follows  it.     To  adhere  to  our  illustration,  the  meaning 
becomes  evident  from  the  context.     By  comparing,  at  short  intervals,  in  the  sup- 
posed case  of  pneumonia,  the  extent  and  character  of  the  sounds  heard  during  respi- 
ration, we  ascertain  whether  the  disease  be  advancing  or  receding;  and  thus  con 
vert  the  sounds,  or  their  variations  from  day  to  day,  injo  a  prognostic  sign. 

We  always  strive,  then,  to  penetrate  beyond  the  symptoms  to  the  disease  of  which 
they  are  significant.  But  we  do  not  always  succeed  in  this,  and  when  we  do  not 
(as  in  the  case  of  ague),  we  are  driven  to  the  necessity  of  regarding  the  combina- 
tion of  symptoms  as  the  disease. 

You  will  often  hear  of  pathognomonic  symptoms.  A  pathognomonic  symptom 
is  one  which,  when  it  occurs,  settles  infallibly  the  nature  of  the  malady  ;  becomes  a 
positive  sign  or  token  of  a  particular  morbid  condition.  But  there  are  very  few 
symptoms,  if  there  be  any,  which,  taken  singly,  can  ever  be  said  to  be  strictly  pa- 
thognomonic signs ;  yet  a  symptom  which  in  itself  possesses  httle  or  no  value  may 
become  very  significant  when  conjoined  with  others. 

Much  light  is  often  thrown  upon  symptoms  by  what  the  French  call  commemo- 
rative circumstances — that  is,  by  a  knowledge  of  the  previous  history  and  condition 
of  the  patient.  For  example,  a  person  may  have  palpitation  and  other  marks  of  dis- 
ordered action  of  the  heart,  and  doubts  may  exist  whether  these  symptoms  depend 
or  not  upon  organic  disease  of  that  organ.  The  question  is  often  determined  in  the 
affirmative,  by  our  learning  that  the  patient  has  had  one  or  more  attacks  of  acute 
rheumatism  of  the  joints. 

There  are  some  other  general  division  of  symptoms,  which  it  is  useful  to  attend 
to.  Thus  some  symptoms  are  said  to  be  direct,  and  others  to  be  indirect  symptoms. 
Direct  symptoms  relate  to  the  very  part  which  is  affected ;  indirect  symptoms  are 
such  as  "  declare  themselves  through  the  medium  of  some  other  parts,  or  through 
the  medium  of  the  constitution  at  large."  There  are  some  cases  in  which  the  direct 
symptoms  are  of  much  more  value  than  the  indirect ;  and  there  are  other  cases  in 
which  those  which  are  indirect  are  the  most  important;  and  there  are  yet  many 
more  which  require  for  their  elucidation  a  knowledge  of  both  the  direct  and  the 
indirect  symptoms. 

Again,  there  are  many  symptoms  of  which  we  receive  no  information,  except 
through  the  statements  made  by  the  patient  himself;  and  there  are  many  others  of 
Avhich  we  learn  the  existence  by  means  of  our  own  observation,  by  the  exercise  of 
our  several  senses.  The  relative  importance  of  these  varies  too  in  different  cases. 
Of  course  those  symptoms  which  we  are  able  to  ascertain  for  ourselves  ar^  the  most 
trustioorthy ;  but  both  sorts  of  symptoms  shed  mutual  light  upon  each  other.  We 
should  constantly  be  making  mistakes  if  we  relied  solely  upon  what  our  patients  tell 
us.  On  the  other  hand,  the  value  of  the  information  we  derive  from  their  state- 
ments is  made  apparent  by  the  difficulty  we  are  apt  to  experience  in  investigating 
the  diseases  of  children ;  of  those  who  are  dumb  ;  or,  what  is  much  the  same  thing, 
who  speak  no  language  that  we  understand. 

Now,  setting  aside  that  notice  of  the  healthy  functions  which  is  sometimes  neces- 
sary in  order  to  determine  the  relative  value  and  meaning  of  other  symptoms,  and 
regarding  those  symptoms  only  which  consist  of  morbid  changes,  they  may  all  be 
classed  under  three  heads:  1.  Uneasy,  unnatural,  or  impaired  sensations:  2.  Dis- 
ordered or  impeded  functions :  and  3.  Alterations  of  structure  or  of  appearance  ; 
changes  of  sensible  qualities.  When  these  last  come  within  the  direct  cognizance 
01  our  senses,  they  are  called,  usually,  physical  signs. 

Uneasy  or  altered  sensations  we  can  only  be  aware  of  through  the  testimony  of 
the  patients  themselves.  The  symptoms  belonging  to  the  other  classes  fall,  gene- 
rally, under  our  own  notice. 

Uneasy  or  altered  sensations  comprehend  a  large  class  of  morbid  symptoms.  By 
their  occurrence  persons  sometimes  become  conscious  that  they  are  unwell  before 
any  other  symptoms  are  observable.  Of  all  the  uneasy  sensations  pain  is  the  most 
common  and  the  most  important.  It  rarely  happens  that  it  is  not  felt,  at  one  period 
or  another,  in  inflammatory  disorders ;  and  it  very  often  occurs,  and  is  very  acuK; 
too,  when  there  is  no  inflammation  at  all.     I  shall  have  occasion,  in  a  subsequent 


84  SYMPTOMS. 

lecture,  to  lay  before  you  the  criteria  between  pains  that  accompany  inflammalicn. 
and  pains  that  are  independent  of  it.  Upon  that  point  of  distinction  the  whoio  ques- 
tion of  treatment  commonly  depends ;  and  it  is  often  a  most  difficult  point  to  de- 
termine. 

There  are  many  different  kinds  and  degrees  of  pain.  Different  kinds  of  morbid 
action  are  accompanied  by  different  kinds  of  pain ;  and  the  same  kind  of  morbid 
action — inflammation,  for  example — produces  different  modifications  of  pain,  accord- 
ing as  it  affects  different  parts.  The  pain  that  belongs  to  inflammation  of  the  lungs 
differs  from  that  which  is  felt  in  inflammation  of  the  bowels.  Bones,  muscles,  ten- 
dons, ligaments — the  bladder,  the  kidney,  the  uterus — all  modify,  in  a  manner  pecu- 
liar to  themselves,  the  pain  that  is  produced  in  them  by  injury  or  disease.  Differ- 
ent epithets  are  given  to  the  different  varieties  of  pain — i.  e.,  persons  endeavour  to 
explain  how  they  feel  by  likening  their  sensations  to  something  which  they  have 
felt  before,  or  fancy  they  have  felt.  Thus  we  hear  of  s/iurp  pain — shooting  pain- — • 
dull  pain — gnawing  pain — burning  pain — tearing  pain  ;  and  so  on. 

If  pain  be  felt  in  a  part  only  when  it  is  touched,  i.  e.,  when  pressure  is  made 
upon  it,  the  heightened  sensibility  is  called  tenderness : — the  part  is  said  to  be  ten- 
der. This  is  a  very  important  kind  of  pain,  as  we  shall  see  hereafter.  A  part  may 
be  both  painful  and  tender:  or  painful  without  being  tender:  or  tender  without 
being  otherwise  painful. 

Pain  often  takes  place,  not  in  the  part  really  affected  by  disease,  but  in  some  dis- 
tant part.  Inflammation  of  the  liver  or  diaphragm  will  cause  pain  of  the  right 
shoulder :  the  mechanical  irritation  of  a  stone  in  the  bladder  produces  pain  at  the 
extremity  of  the  urethra  :  inflammation  of  the  hip-joint  occasions  pain  in  the  knee  : 
disease  of  the  heart  is  often  attended  with  pain  running  down  the  left  arm :  many 
headaches  result  from  irritation  of  the  stomach.  We  call  these  instances  of  inai/ic:; 
or  sympathetic  pain.  Some  of  them  admit  of  no  very  obvious  explanation  : — others 
have  been  ascribed  to  connections  between  the  sentient  nerves  of  the  two  parts; 
"especially  when  the  part  really  injured  is  internal,  and  that  to  which  the  feeling  is 
referred  is  external,  and  both  derive  their  sentient  nerves  from  the  same  larger 
branches."  You  will  perceive  that  a  due  estimation  of  these  sympathetic  pains  is 
of  no  small  importance. 

I  may  observe  of  pain  in  general,  that  it  is  differently  felt — or  at  any  rate  differ- 
ently complained  of — by  persons  of  different  constitutions  and  temperaments.  There 
are  even,  I  fancy,  national  differences  in  this  respect.  I  have  been  present,  as  you 
may  believe,  at  a  great  number  of  surgical  operations,  and  I  have  been  struck  with 
the  different  degrees  of  patience  with  which  the  same  operation  has  been  borne  by 
Irishmen  and  by  Scotchmen.  The  Irishman,  generally  speaking,  either  feels  more 
acutely,  or  gives  more  free  vent  to  his  feelings  in  cries  and  exclamations  :  the  Scotch- 
man, on  the  contrary,  most  commonly  preserves  a  resolute  silence.  In  complaints 
that  are  attended  with  low  spirits,  and  hypochondriacal  symptoms,  there  is  reason 
to  believe  that  the  pain  spoken  of  often  depends,  in  a  great  degree,  upon  the  eager 
attention  that  is  paid  to  it.  The  accounts  given  by  such  patients  of  their  suflerings 
are  always  to  be  received  with  a  grain  of  allowance ;  and  this  is  often  an  embar- 
rassing circumstance  in  practice.  Patients  take  it  ill  if  they  do  not  seem  to  be  im- 
phcitly  credited  ;  and  yet  if  they  are  not  convinced  that  much  of  what  they  suffer 
depends  on  their  great  attention  to  it,  they  will  never  get  well.  You  will  often  find 
that  they  cease  to  feel  pain — i.  c,  they  forget  to  attend  to  their  complaints — when 
their  attention  is  otherwise  strongly  arrested  ;  as  by  conversation,  or  music.  I  ad- 
verted to  this  principle  in  my  last  lecture. 

Besides  pain,  in  all  its  modifications,  there  are  man 3^  other,  and  very  interesting, 
uneasy  sensations.  Itching  is  an  uneasy  sensation  nearly  allied  to  pain.  As  severe 
mechanical  irritation  will  cause  pain,  so  a  slighter  degree  of  it  will  cause  itching. 
Itching  occurs  in  many  cutaneous  diseases,  and  it  gives  a  name  to  one  of  them, 
whicn  is  emphatically  called  the  itch.-  And  the  Latin  word  signifying  the  same 
sensation,  prurigo,  is  made  use  of  to  denote  other  forms  of  disease  of  which  itching 
is  the  most  prominent  symptom.  It  often  affects  some  one  of  the  natural  outlets  of 
the  body.     It  occurs  about  the  rectum,  from  the  motions  of  little  Avorms  that  nestle 


UNEASY    SENSATIONS.  85 

in  the  lower  part  of  that  gut.  This  prurigo  podicis,  which  does  not  always  depend 
on  the  cause  just  mentioned — and  the  prurigo  pudendi  in  the  female — are  some- 
times most  distressing  complaints  ;  harassing  the  patients  continually,  preventing 
sleep,  excluding  them  from  society,  and  requiring  medical  treatment.  Acrid 
matters  in  the  intestines  will  sometimes  produce  a  kind  of  itching  there  ;  and  the 
call  to  void  the  fajces  is  perhaps  more  akin  to  itching  than  to  any  other  sensa- 
tion :  sometimes,  indeed,  it  amounts  to  ])ain.  The  tickling  often  felt  in  the  wind- 
pipe, and  provoking  the  person  to  cough,  appears  to  be  of  the  same  nature. 
Tingling  and  pricking  are  sensations  which  have  also  some  analogy  with  itching. 
Nausea  is  another  uneasy  sensation.  It  is  sometimes  a  dir'ect  symptom  of  disease 
or  disorder  of  the  stomach,  to  which  the  sensation  is  referred.  Sometimes  it  is  a 
very  important  indirect  symptom,  taken  in  conjunction  with  others,  of  disease  in 
some  part  at  a  distance  from  the  stomach — in  the  kidney,  for  example,  or  in  the 
brain.  The  nausea  which  is  so  troublesome  to  pregnant  women  is  another  in- 
stance of  a  morbid  sensation  sympathetic  of  irritation  in  a  distant  organ. 

Another  example  o."  an  uneasy  sensation  we  have  in  giddiness,  or  dizziness — 
technically,  vertigo.  It  sometimes  results  from  disease  within  tlie  head;  some- 
times it  is  an  indirect  consequence  of  disorder  of  the  stomach  ;  or  of  mere  de- 
bility and  an  approach  to  syncope. 

Patients  will  also  complain  of  an  undefinable  sensation  which  they  usually 
call  sinking — a  sensation  which  is  referred  to  the  epigastric  region.  This  is 
frequently  a  source  of  much  distress  to  hysterical  women ;  and  it  is  occasionally 
the  forerunner  of  death  at  the  close  of  severe  diseases  which  have  a  tendency  to 
end  fatf  Ily  in  the  way  of  syncope. 

Many  other  symptoms  might  be  mentioned  which  belong  to  this  class  of  uneasy 
sensations,  and  for  our  knowledge  of  the  existence  of  which  we  must  depend  upon 
the  accounts  given  us  by  the  patients  themselves.  Sensations  of  weight;  and  of 
tightness  and  fullness ;  drowsiness,  tenesmus,  strangury,  heartburn ;  and  various 
depraved  conditions  of  the  special  senses.  In  the  majority  of  diseases  the  appetite 
is  lost  or  impaired  ;  but  sometimes  excessive  hunger  accompanies  and  denotes 
disease.  We  sometimes  derive  the  first  suspicion  of  the  existence  of  diabetes  from 
the  preternatural  keenness  of  the  appetite.  Thirst  is  a  very  constant  and  striking 
symptom  in  all  febrile  and  inflammatory  disorders ;  and  in  the  disease  just  now 
mentioned,  diabetes,  it  frequently  constitutes  the  whole  distress  of  which  the  patient 
is  sensible.  The  appetite  may  be  perverted,  as  well  as  deficient  or  excessive. 
Chlorotic  girls  will  eat  cinders,  sealing-wax,  slate-pencil,  and  such  trash.  So  women 
who  are  pregnant  either  have  or  pretend  to  have  inordinate  longings  for  particular 
kinds  of  food — longings  which  are  evidently  fostered  by  encouragement.  They  are 
not,  I  believe,  common  at  present  in  this  country  ;  and  they  are  less  frequently  heard 
of  among  the  poor,  who  have  not  the  means  of  gratifying  them,  than  in  the  higher 
classes  of  society. 

The  class  of  uneasy  sensations  you  see  then  is  a  very  large  one,  and  some  of  the 
morbid  feelings  are  of  very  great  moment.  However,  there  are  not  many  diseases 
which  consist  altogether  of  uneasy  sensations ;  and  when  we  find  that  pain  or 
uneasiness  is  complained  of  in  any  part  or  organ,  we  next  proceed  to  inquire  whether 
the  functions  of  that  part  or  organ  are  disturbed  or  suspended.  If  we  discover  any 
interruption  or  derangement  of  function,  we  have  additional  reason  for  concludino- 
that  the  part  so  affected  in  its  sensations  and  in  its  functions  is  actually  the  seat  of 
disease.  This  is  an  inquiry  which  we  can  prosecute  with  much  less  assistance  from 
the  patient  himself;  and  mostly  with  no  assistance  at  all ;  and  even  in  spite  of  any 
erroneous  opinions  which  he  may  have  formed,  and  is  anxious  to  state  upon  the 
subject.     The  study  of  disordered  functions  is  of  great  practical  value. 

The  functions  of  the  brain  and  nerves — of  the  heart  and  blood-vessels — of  the 
respiratory  apparatus — and  of  the  digestive  organs — are  all  of  vital  consequence. 

Some  of  the  impeded  or  disordered  functions  which  relate  to  the  brain  and  nerves 
are  in  fact  identical  with  the  last  class  of  symptoms,  and  consist  of  altered  or  morbid 
sensations :  sensation  being  one  of  the  natural  functions  of  those  parts.  Deprava 
tions,  for  instance,  of  the  sense  of  touch ;  numbness ;  the  total  absence  of  senfation* 

u 


86  SYMPTOMS. 

which  we  call  anaesthesia.  Symptoms  of  this  kind  do  not  constitute  primary  dl«r;ases 
but  they  often  portend  or  accompany  very  serious  alterations  in  the  brain,  or  in  some 
part  of  the  nervous  system :  and  it  is  from  that  circumstance  that  they  derive  the 
great  interest  and  importance  which  belong  to  them.  The  same  may  be  said  of 
perverted  conditions  of  the  other  senses.  The  sense  of  vision  is  often  impaired,  and 
in  various  ways  and  degrees,  from  mere  dimness  or  imperfection  of  sight,  to  total 
blindness.  And  this  total  blindness  may  occur  without  any  other  apparent  disease, 
the  humours  and  fabric  of  the  eye  itself  being  in  all  evident  respects  healthy  and 
right ;  it  may  come  on,  too,  so  gradually,  and  increase  so  slowly,  as  not  to  be  disco- 
vered for  a  long  time,  even  by  the  patient  himself.  Mr.  Day,  the  great  blacking  man, 
of  the  firm  of  Day  and  Martin,  who  died  not  long  since,  was  almost  entirely  bhnd. 
He  told  me  he  first  discovered  that  the  sight  of  one  eye  was  gone,  one  day  when  he 
attempted  to  look  at  a  distant  object  through  a  telescope.  He  could  see  nothing,  and 
he  imagined  that  the  little  brass  plate  which  slides  over  the  eye-glass  had  not  been 
withdrawn.  There  was,  however,  no  such  obstacle ;  and  he  too  soon  found  that 
when  the  other  ej^e  alone  was  closed,  he  was  in  total  darkness.  This  state  of  blind- 
ness is  called  amaurosis,  and  it  may  depend  upon  pressure  made  upon  the  retina,  or 
upon  the  optic  nerves,  or  upon  the  brain  at  the  origin  of  those  nerves.  There  are 
other  causes  also,  to  be  mentioned  hereafter,  of  amaurosis.  Its  approach  is  some- 
times marked  by  the  fallacious  appearance  of  black  spots  upon  the  objects  the  patient 
is  looking  at,  or  floating  before  him  in  the  air — muscx  volitantes.  Some  of  the 
other  depravations  of  sight  are  still  more  extraordinary,  and  except  that  they  are  not 
uncommon,  might  almost  be  considered  fabulous.  Thus  persons  sometimes  see  things 
around  them  apparently  in  motion,  when  in  truth  they  are  not  so.  This  is,  in  fact, 
a  symptom  I  have  mentioned  before — vertigo.  If  the  patient  shuts  his  eyes,  and 
consequently  can  see  nothing,  he  feels  as  if  he  were  himself  turning  round,  while 
in  reality  he  is  at  rest.  Persons  in  this  state  fancy  sometimes  that  the  bed  on  which 
they  lie  is  sinking  rapidly  down  with  them  into  some  abyss.  A  still  stranger  depra- 
vation of  the  sense  of  vision  is  that  in  which  a  person  sees  only  one  half  of  an 
object  at  which  he  is  steadfastly  looking.  One  man,  in  passing  along  the  street, 
imagined  that  every  body  he  met  had  only  one  eye.  The  late  Dr.  Wollaston  was 
subject  to  this  optical  delusion :  he  frequently  found  that  only  one  half  of  the  object 
he  looked  at  was  visible :  and  he  wrote  an  ingenious  paper  in  the  Philosophical 
Transactions  to  explain  this.  After  his  death  a  tumour  was  found  in  his  brain, 
interfering  with  the  optic  nerves.  The  celebrated  Mr.  Abernethy  had  once  a  tem- 
porary afjection  of  the  same  kind,  dependent  no  doubt  upon  some  shght  and  transient 
injury  of  the  brain.  He  was  thrown,  I  believe,  from  his  horse — at  any  rate  he 
received  a  violent  blow  on  his  head,  which  stunned  him  ;  and  when  he  had  recovered 
a  little,  he  was  taken  home  in  a  hackney-coach.  On  his  way  he  amused  himself 
with  reading  the  names  of  the  tradespeople  placed  in  front  of  the  shops,  and  he  wag 
greatly  surprised  to  find  that  one  half  of  each  name — the  last  half — seemed  blotted 
out.  He  describes  this  in  his  lectures,  in  his  whimsical  wa)%  by  taking  his  own 
name  as  an  example :  "  I  could  see  as  far  as  the  ne  (said  he),  but  I  could  not  see  a 
bit  of  the  thy:'' 

Those  very  Avonderful  cases  of  spectral  illusion  which  sometimes  occur,  come 
within  the  class  of  symptoms  we  are  now  considering ;  they  throw  a  strong  light 
upon  many  of  the  well-authenticated  ghost-stories — which  were  in  fact  merely 
instances  of  disease  or  derangement  in  the  brains  of  the  ghost-seers.  It  would  be 
out  of  place  to  go  into  any  detail  upon  this  interesting  subject  here.  You  will  find 
some  excellent  examples  of  these  spectral  illusions  in  Dr.  Hibbert's  book  on  .Ippari- 
tions,  in  Sir  David  Brewster's  Natural  Magic,  and  in  Sir  Waller  Scott's  Letters  on 
Jlemonolugy. 

The  sense  of  hearing  is  liable  to  analogous  disorders.  Sometimes  it  becomes  pre- 
ternaturally  acute ;  and  this  is  a  bad  symj)tom  when  it  does  occur.  I  was  called,  a 
}^ear  or  two  ago,  to  see  a  gentleman  in  the  Temple ;  he  had  been  taken  ill  only  a. 
lew  hours  before,  but  I  found  him  dying;  the  pulse  was  gone  from  his  wrist,  and 
his  skin  was  cold,  but  his  intellect  was  entire,  and  he  complained  of  nothing  but  the 
distress  he  felt  from  the  loud  noises  that  were  made  by  those  around  him,  in  mo^mgr 


DISORDERED    FUNCTIONS.  S7 

about  and  in  speaking,  although,  in  fact,  all  noise  was  as  much  as  possible  suppressed, 
and  conversation  was  carried  on  in  whispers :  but  his  hearing  was  painfully  acute. 
He  died  the  same  evening;  I  believe  of  an  irregular  form  of  cholera.  It  is  always 
right  that  patients  should  be  protected  from  the  irritation  which  might  arise  from  this 
source  ;  for  that  degree  of  noise  which  would  not  interfere  with  the  sleep  of  a  healthy 
person  will  often  not  only  prevent  it  in  a  sick  man,  but  bring  on  delirium,  and  aggra- 
vate greatly  the  disease  under  which  he  labours.  The  custom  of  strewing  the  streets 
with  straw  before  the  houses  of  those  who  are  seriously  ill,  is,  in  many  cases,  a  very 
proper  precautionary  measure. 

The  opposite  fault,  obtuseness  of  hearing,  is  much  more  common.  Deafness  is 
frequently  attributable  to  some  physical  imperfection  in  the  organ  of  hearing.  But 
it  is  with  cases  in  which  it  has  a  deeper  origin,  that  the  physician  is  chiefly  con- 
cerned. It  often  occurs  in  fever,  and  is  not  then  thought  a  bad  symptom :  it  cer- 
tainly is  a  much  less  unfavourable  circumstance  than  morbid  acuteness  of  hearing ; 
and  it  probably  depends  upon  a  disordered  state  of  the  brain,  which  is  not  in  itself 
very  dangerous. 

What  is  called  tinnitus  aurium,  is  an  instance  of  the  depravation  of  the  sense  of 
hearing.  It  seems  sometimes  to  result  from  the  too  strong  throbbing  of  the  arteries. 
It  occurs  in  many  disorders,  and  is  not  unfrequently  a  symptom  of  diseased  cerebral 
vessels,  and  a  precursor  of  apoplexy  or  palsy.  It  is  sometimes  in  itself  extremely 
annoying.  Curious  and  undefinable  sounds  are  heard  by  some  patients — sounds 
like  a  rushing  wind,  like  the  falling  of  a  cataract,  the  ringing  of  a  bell,  or  the  beat 
of  a  drum.  A  female  patient  of  mine,  in  the  Middlesex  Hospital,  last  year,  who  had 
disease  of  the  bones  of  the  ear,  with  symptoms  that  threatened  some  implication  of 
the  brain,  affirmed  that  she  heard  a  perpetual  noise  in  her  ear  like  the  singing  of  a 
tea-kettle.  I  have  lately  been  consulted  by  a  gentleman  from  the  country,  who  had 
no  other  complaint  than  a  constant  hissing,  which  worried  him  greatly,  in  one  ear. 
Another  had  watched  with  curious  anxiety,  and  described  to  me  very  graphically, 
the  successive  variations  which  this  troublesome  symptom  underwent  in  his  own 
person.  It  began  suddenly,  with  some  headache,  and  had  lasted  six  vveeks.  At 
first  it  w-as  a  loud  roaring,  like  that  of  the  sea ;  in  a  few  days  it  came  to  resemble 
exactly  the  w^histling  of  the  wind  among  the  trees  in  Avinter ;  afterwards  he  could 
have  beUeved  that  the  room  was  filled  with  humming  gnats ;  and  finally  the  noise 
settled  down  into  the  gentle  sound  of  a  distant  waterfall.  It  haunted  him  incessantly. 
Sir  David  Brewster  relates  the  case  of  a  lady,  subject  to  spectral  illusions,  whose  ear 
was  mocked  by  unreal  sounds,  as  her  eye  by  unreal  visions.  Being  in  her  right 
mind,  and  perfectly  aware  of  the  infidelity  of  her  senses,  she  repeatedly  heard,  not 
vague  noises  merely,  but  voices  and  sentences,  when  none  were  uttered. 

Affections  of  the  intellect — of  what  are  sometimes  called  the  internal  senses,  are 
very  common  and  very  important  symptoms  of  disease.  Incoherence  of  the  trains 
of  thought — palpably  false  belief — extravagant  perv^ersions  of  the  judgment.  These 
affections  are  sometimes  considered  as  primary  diseases  themselves  ;  they  very  fre- 
quently accompany  certain  febrile  diseases  ;  and  they  are  not  uncommon  in  diseases 
that  are  unattended  with  fever.  There  is  more  or  less  derangement  of  the  internal 
senses  from  the  very  beginning  of  continued  fever.  The  power  of  attention  is  im- 
paired. That  kind  and  degree  of  mental  exertion  which  would  afford  gratification 
and  amusement  when  we  are  well,  become  laborious  and  irksome  when  we  are  ill ; 
and  to  compel,  or  to  urge  the  attention,  under  such  circumstances,  is  injurious. 
This  state  is  probably  only  the  first  degree  of  delirium,  and  therefore  these  slight 
approaches  to  derangement  of  the  internal  senses  are  by  no  means  to  be  disregarded 
It  is  curious  that  the  delirium  of  fever  is  always  most  marked  during  the  night ;  this 
seems  to  be  owing  to  the  circumstance  that  the  erroneous  notions  and  wandering 
thoughts  of  the  patient  are  not  corrected  by  impressions  made  upon  his  externa! 
senses.  You  will  find,  conformably  with  the  same  principle,  that  your  patient 
sometimes  ceases  to  be  delirious  upon  your  visiting  him :  the  sight  of  a  new  face 
rouses  him  for  a  time,  but  he  soon  relapses. 

Voluntary  motion  is  another  function  connected  with  the  nervous  system,  and  ono 
which  affords  a  great  variety  of  important  symptoms.    I  Jke  the  power  of  the  sense*, 


88  SYMPTOMS. 

It  may  be  excessive,  or  deficient,  or  perverted.  Excess  of  voluntary  motion  is  not 
common,  nor  very  important.  Maniacal  patients  sometimes  exhibit  an  extraordinary 
degree  of  muscular  strength  ;  indeed,  in  the  delirium  of  fever  something  of  the  same 
kind  may  be  observed. 

But  the  opposite  state,  that  in  which  the  power  of  voluntary  motion  is  deficient, 
muscular  debility  is  exceedingly  common.  Debility  is  an  original  and  essential 
part  of  fevers.  It  appears  before  there  has  been  time  for  it  to  be  produced  by  the 
exhaustion  of  disease.  It  is  not  always  proportional  to  the  other  symptoms,  and 
does  not  necessarily  imply  any  great  degree  of  danger.  This  sudden  and  early 
weakness  has  been  a  very  striking  symptom  in  our  two  recent  visitations  of  influ- 
enza. Persons  previously  in  apparent  good  health  would  be  seized  as  they  walked 
along  the  street,  and  be  glad  to  sit  down  in  a  shop,  or  a  carriage,  and  to  get  home 
and  go  to  bed.     Young  and  strong  persons  would  be  thus  rapidly  prostrated. 

In  some  instances  debility  does  not  appear  till  late  in  the  disease,  of  which  it  then 
forms  an  important  prognostic  symptom,  and  an  important  guide  for  our  treatment. 
It  shows  us  that  there  is  a  tendency  to  death  by  asthenia,  and  we  have  to  endeavour 
to  keep  the  patient  alive  by  supporting  his  strength  as  well  as  we  can,  this  being  the 
chief  or  the  only  indication. 

Debility  is  occasionally  the  principal  symptom  of  the  whole  disease — as  in  hemi- 
plegia, paraplegia,  or  in  more  partial  palsy,  palsy  of  one  limb,  even  of  a  finger,  or  of 
a  single  muscle,  as  of  the  levator  palpebrarum.  This,  though  it  may  seem  trivial  in 
itself,  is  far  from  being  so  in  reality  ;  it  often  forms  a  fragment  only  of  a  most  serious 
disease.  From  such  partial  manifestations  of  palsy  we  presage  a  more  general  and 
alarming  attack ;  as  the  loosening  of  a  few  stones  in  the  wall  announces  the  com- 
mencing earthquake.  A  shght  degree  of  paralysis,  affecting  some  of  the  muscles  of 
the  eye,  will  j)roduce  a  squint,  and  consequent  double  vision ;  and  this  occurs  not 
only  in  hydrocephalus,  when  it  is  a  most  significant  phenomenon,  but  also  as  a  pre- 
lude to  more  extensive  palsy.  General  palsy  is  sometimes  prefaced  by  a  similar 
affection  of  the  tongue,  producing  a  faltering  and  indistinctness  of  speech. 

Spasm  is  an  instance  of  disturbance  and  perversion  of  the  power  of  voluntary 
motion.  It  consists  in  an  irregular  and  violent  contraction  of  muscular  parts — 
involuntary,  even  when  the  voluntary  muscles  are  concerned.  Cramp  is  a  famihar 
example  of  it ;  and  we  have  been  taught,  since  the  cholera  came  among  us,  to  regard 
cramp  as  sometimes  a  very  formidable  symptom  :  not  formidable  in  itself,  but 
formidable  in  respect  to  the  condition  that  gives  rise  to  it.  Tonic  spasm  is  the  prin- 
cipal symptom,  also,  of  that  frightful  disease — frightful  in  its  phenomena  and  in  its 
frequent  fatality — tetanus.  The  convulsions  of  epilepsy  and  hysteria,  and  the 
jactitation  of  chorea,  are  ordinary  examples  of  the  perversion  of  the  function  of 
voluntary  motion.    Sometimes  convulsions  bode  great  danger,  sometimes  none  at  all. 

So,  also,  tremor,  which  is  near  akin  to  spasm,  is  a  sign,  frequently,  of  a  morbid 
state  of  the  greatest  peril;  while  it  is  sometimes  violent  without  being  attended  with 
the  smallest  hazard. 

If  we  now  turn  to  the  greatest  function  of  respiration,  we  shall  find  that  it  affords 
a  very  large  number  of  morbid  symptoms,  and  those  of  the  highest  importance. 

Dijspncea,  difficulty  of  respiration,  is  one  of  the  most  prominent  of  those  symp- 
toms. It  may  depend  upon  various  causes.  In  inflammation  of  the  lungs  or  pleurae, 
'.here  are  several  circumstances  in  operation  to  impede  the  breathing;  for  example, 
pain,  which  would  be  enough  of  itself ;  the  effusion  of  lymph  into  the  texture  of  the 
lUng,  or  of  serum  into  the  cavitj'  of  the  pleurcp,  mechanically  resisting  the  entrance 
of  air.  In  dyspnoea  the  breathing  is  almost  always  most  difficult  when  the  patient 
is  lying  flat  on  his  back.  One  reason  for  this  is  plain.  In  the  supine  horizontal 
posture  the  action  of  the  diaphragm  is  obstructed  by  the  weight  and  pressure  of  the 
viscera;  and  the  erect  position  obviates  this.  Upright  breathing,  or//iO/)nfl"o,  has 
rome  to  be  considered  as  a  distinct  modification  of  dyspnoea.  The  patient  cannot  lie 
down. 

Sometimes,  as  in  asthma,  the  difficulty  of  breathing  comes  on  in  separate  parox- 
ysms ;  the  respiration  becomes  all  at  once  noisy,  wheezing,  and  laborious.  A 
person  who  had  never  seen  any  cases  of  this  kind  would  imagine  that  the  patient 


DISORDERED    FUNCTIONS.  89 

was  at  the  point  of  death — that  it  was  all  over  with  him  ;  but  the  most  frightfuJ  ot 
these  attacks  are  seldom  attended  with  any  immediate  danger.  They  depend 
frequently  upon  organic  disease  of  the  lungs,  heart,  or  aorta  ;  sometimes  they  seem 
to  be  purely  spasmodic;  sometimes  to  result  from  transient  congestion  of  blood  in 
the  lungs. 

Cough  is  a  violent  spasmodic  action.  A  full  inspiration  is  taken  ;  then  the  glottis 
is  closed  pretty  firmly;  and  in  expiration  the  air  is  forced  suddenly  out,  and  with 
it,  frequently,  mucous  or  other  matters  which  had  irritated  the  air-passages.  It  seems 
to  be  one  of  the  efforts  of  nature  to  expel  from  the  lungs  things  which  ought  not  to 
be  there.  There  are  several  varieties  of  cough.  It  is  a  symptom  belonging  to  so 
many  dangerous  complaints — pneumonia,  puhnonary  consumption,  and  diseases  of 
the  heart — that  it  always  demands  strict  attention.  No  one  who  has  once  heard  it 
can  ever  mistake  the  hooping  cough.  There  is  also  a  startling  obstreperous  sort  of 
cough,  shattering  one's  ears  almost,  like  the  noise  of  a  person  coughing  through  a 
brass  trumpet — which  depends  upon  some  peculiar  state  of  the  nervous  system, 
imphes  no  danger,  and  is  more  distressing  to  the  bystanders  than  to  the  person  who 
utters  it.  I  beheve  you  may  often  distinguish  the  cough  of  inflammation  of  the 
lungs  from  that  of  phthisis,  and  each  from  the  cough  of  hysteria,  by  their  respective 
sounds  :  but  we  have  much  better  methods  of  distinguishing  them — viz.,  by  the 
concurrence  or  the  absence  of  certain  other  sounds  belonging  to  the  breathing,  and 
ascertained  by  auscultation. 

Sneezing  is  another  morbid  symptom,  which,  though  it  may  appear  trifling,  is  not 
to  be  overlooked.  It  is  a  very  common  symptom  in  catarrhal  affections.  When 
sneezing  occurs  in  combination  with  cough,  it  affords  a  presumption  that  the 
cough  is  not  phthisical.  Sneezing  may  even  happen  as  a  primary  disorder,  occur- 
ring in  long-continued  paroxysms.  1  have  at  present  under  my  care  a  young 
lady  of  an  hysterical  disposition,  whose  main  distress  consists  in  violent  and  pro- 
tracted attacks  of  sternutation,  which  have  harassed  her  almost  daily  for  many 
months.  One  of  our  bishops  is  subject  to  very  inconvenient  fits  of  this  kind.  He 
will  begin  to  sneeze  and  go  on  sneezing  incessantly  for  a  long  time  together.  I 
believe  that  he  finds  an  effectual  remedy  for  these  attacks  in  plunging  his  head  into 
cold  water. 

I  say  nothing  here  of  those  direct  symptoms  of  pulmonary  disease  which  are 
ascertained  by  the  sense  of  hearing — by  auscultation  and  percussion.  I  shall 
enter  fully  into  that  subject  hereafter.  A  systematic  account  of  symptoms,  if  this 
were  the  fitting  place  for  it,  which  it  is  not,  would  require  a  dozen  or  twenty  lec- 
tures. In  order  to  perceive  the  relation  of  symptoms,  taken  one  by  one  or  in  diverse 
combinations,  to  the  various  known  forms  of  disease,  you  must  have  some  prior 
knowledge  of  diseases.  But  I  am  oWiged  to  suppose  (however  incorrect  the 
supposition  may  be  in  respect  to  some  among  you),  that  you  are  mere  beginners, 
and  have  still  to  learn  even  the  rudiments  of  such  knowledge.  Different  dis- 
eases may  have  many  symptoms  in  common.  The  same  symptom  may  bear  a 
very  different  import  according  as  it  is  combined  with  other  symptoms ;  or  con- 
nected with  this  or  that  disorder.  The  proper  place  for  a  comprehensive  and 
complete  review  of  symptoms  would,  therefore,  be  at  the  etui  of  a  course  of  lec- 
tures on  the  practice  of  physic.  When  the  various  forms  of  disease  had  been 
gone  through,  in  reference  to  the  symptoms  belonging  to  them,  then  would  be  the 
time  to  take  the  converse  aspect  of  the  case,  and  to  consider  ihe  long  list  of  symp- 
toms in  reference  to  the  diseases  they  denote  or  accompany.  All  that  I  am  at 
present  attempting,  is  to  give  you  some  general  notion  of  what  symptoms  are ;  to 
put  before  you,  as  samples,  a  few  of  the  most  prominent ;  and  to  show  you,  even 
by  this  cursory  and  imperfect  view  of  them,  of  how  great  importance  it  is  that  we 
should  make  their  relations  to  each  other  and  to  different  diseases,  and  their  sig 
nificaiion,  diagnostic,  prognostic,  and  therapeutic,  the  objects  of  our  most  diligent 
attention. 

I  might  find  matter  for  two  or  three  lectures,  if  my  present  purpose  would  admit 
of  them,  in  the  symptoms  that  are  drawn  from  the  functions  belonging  to*the  a>- 
culation.     Everybody  knows  how  much  importance  is  attributed  to  the  sta.e  of  tne 

h2 


90  SYMPTOMS. 

arterial  pulse.  It  is  expected  of  us,  as  a  matter  of  course,  that  before  we  th  nk  of 
prescribing  for  a  patient  we  should  at  any  rate  feel  his  pulse.  And  really  the  in- 
fonnalion  obtained  by  that  little  touch  of  the  wrist  is  often  of  the  most  interesting  and 
instructive  kind.  But  it  requires  practice  and  intelligence  to  appreciate  that  infor- 
mation. The  qualities  that  we  most  attend  to  in  the  pulse  are  its  frequency,  its 
regularity,  iis  fulness,  and  its  force.  It  is  necessary  that  we  should  know  the  number 
of  beats  which  the  heart  habitually  makes  in  heakh ;  for  it  varies  much  in  different 
persons.  Its  average  number  of  pulsations  in  a  healthy  adult  is  from  70  to  75  ;  but 
there  are  persons  who,  when  they  are  quite  well,  have  always  a  pulse  of  80  or  90 ; 
and  there  are  others  in  whom  the  ])ulse  seldom  rises  above  60.  In  early  life  the 
pulse  is  more  frequent,  in  old  age  it  is  more  slow,  than  the  standard  I  have  given. 
Cheteris  paribus,  its  beats  are  more  numerous  in  the  standing  than  in  the  sitting  pos- 
ture ;  in  the  sitting  than  in  the  recumbent.  If  we  do  not  inform  ourselves  of  these 
peculiarities,  we  may  fall  into  great  mistakes.  In  disease  the  pulse  may  acquire  a 
degree  of  frequency  which  is  scarcely  calculable;  and  the  less  so  because,  when 
it  is  extremely  frequent,  it  is  also  extremely  feeble  ;  it  will  reach  150,  160,  or 
even  200  beats  in  a  minute.  In  other  cases, — as  in  apoplexy  sometimes,  and  in 
some  organic  affections  of  the  heart — the  pulse  will  become  extremely  slow.  The 
slowest  pulse  I  ever  felt  was  that  of  a  man  sixty-eight  years  old,  who  was  for  some 
time  a  patient  of  mine,  with  diseased  heart  and  dropsy.  His  pulse  was  often  no  more 
than  25  in  the  minute.  He  died  suddenly  in  his  chair,  and  I  was  very  desirous  of 
examining  his  body,  but  his  widow  would  not  allow  it.  In  the  17th  volume  of  Dun- 
call's  Medical  Commentaries  a  case  is  related  in  which  the  pulse  was  as  slow  as 
nine  beats  in  the  minute.  We  learn  a  good  deal  in  certain  disorders  from  the  vari- 
ations and  JJuctuations  of  the  pulse  in  respect  to  frequency — in  hydrocephalus,  for 
example,  and  in  continued  fever. 

Irregularity  of  the  pulse  is  another  condition  which  is  often  full  of  meaning,  and 
of  interest.  I  hope,  as  the  lectures  proceed,  to  be  able  to  point  out  the  bearings  of 
these  several  qualities  of  the  pulse  upon  our  views  of  disease,  and  especially  upon 
its  treatment.  At  present  I  must  repeat  that  I  pretend  to  do  no  more  than  furnish 
you  with  a  few  samples  of  the  phenomena  that  characterize  disease.  Irregularity 
of  the  pulse  is  natural  to  some  persons.  I  have  a  brother  who  enjoys  very  good 
health,  and  whose  pulse  is  habitually  irregular ;  I  have  been  told  that  when  he  was 
ill  with  a  fever  at  school,  it  became  regular.  I  have  heard  of  several  precisely  similar 
cases.  There  are  two  varieties  of  irregular  pulse — in  one  the  motions  of  the  artery 
are  unequal  in  number  and  force,  a  few  beats  being  from  time  to  time  more  rapid 
and  feeble  than  the  rest :  in  the  other  variety  a  pulsation  is  from  time  to  time  entirely 
left  out — the  pulse  is  said  to  intermit.  These  two  varieties  may  coincide  in  the 
same  person,  or  they  may  exist  independently  of  each  other. 

Irregularity  of  the  pulse  may  be  caused  by  disease  within  the  head  ;  by  organic 
disease  of  the  heart;  by  simple  disorder  of  the  stomach;  or  it  may  be  merely  the 
result  of  debihty  and  the  prelude  to  the  complete  stoppage  of  the  heart's  action  from 
asthenia.  How  important  it  must  be  to  ascertain  and  construe  each  of  these  mean- 
ings of  the  same  symptom !  It  may  indicate  mortal  disease — it  may  imply  no  danger 
at  all ;  it  may  afford  no  clue  to  any  available  treatment ;  or  it  may  teach  us  how  to 
■ward  off  impending  dissolution. 

Another  most  important  quality  of  the  pulse  is  what  is  called  its  hardness,  or 
incompressibility.  You  find  that  you  can  scarcely  abolish  the  pulsation  by  any 
degree  of  pressure ;  the  blood  still  forces  its  way  through  the  artery  beneath  your 
finger.  Sometimes  it  is  felt  to  strike  a  large  portion,  also,  of  the  finger,  and  then 
we  say  that  the  pulse  is  full,  or  large,  as  well  as  hard.  When  it  strikes  a  very 
narrow  portion  of  the  surface  of  the  finger,  it  is  compared  to  a  thread  ;  it  is  a  small 
pulse  :  and  if  at  the  same  time  it  be  hard,  such  a  pulse  is  often  described  as  a  wiry 
pulse.  It  requires  some  education  of  the  finger  to  appreciate  with  exactness  the 
several  varieties  of  the  pulse,  even  those  which  are  practically  important ;  for  many 
liave  been  mentioned  by  authors  which  are  purely  fanciful  or  useless  and  unneces- 
sary refinements. 

^ow  this  hard  pulse  I  shall  soon  have  to  speak  of  again,  in  connection  with  the 


I 


I 


DISORDERED    FUNCTIONS.  99 

freatrnent  required  in  inflammation.  It  is  one  of  the  best  warrants  we  have,  in 
many  cases,  of  the  propriety  of  bleeding  our  patient.  It  does  not  occur,  however, 
m  all  inflammations,  and  it  may  occur  when  there  is  no  inflammation.  It  may 
depend  upon  hypertrophy  of  the  left  ventricle  of  the  heart,  and  then  it  is  beyond 
the  reach  of  blood-letting  as  a  remedy.  It  often  seems  to  be  connected  with  a 
morbid  condition  of  the  artery  itself,  brought  on,  as  Dr.  Latham  has  suggested,  by 
the  pernicious  habit  of  dram-drinking.  It  is,  however,  at  all  times  considered  so 
much  a  guide  to  our  practice,  that  whenever  it  occurs,  it  is  very  necessary  to  make 
careful  inquiry  into  its  real  cause. 

Before  1  conclude  this  rough  review  of  symptoms,  I  must  point  out  one  or  two 
that  belong  to  the  third  class  mentioned  ;  viz.,  changes  of  sensible  quahties.  These 
include  variations  in  the  temperature  of  the  body ;  in  the  colour  of  the  surface,  and 
especially  of  the  face  ;  the  diminution  or  increase  of  bulk  ;  the  latter,  when  general, 
we  call  corpulence  ;  when  partial,  swelling ;  and  various  other  symptoms,  especially 
those  which  are  detected  by  auscultation. 

Wasting,  or  emaciation,  is  sometimes  the  first  observable  symptom  of  disease.  It 
occurs  in  complaints  that  are  not  commonly  dangerous — as  in  dyspepsia,  and  in 
hypochondriasis,  which  is  often  connected  with  dyspepsia  :  and  when  it  does  appear, 
it  marks  the  reality  of  the  disease.  This  wasting  happens  also  in  many  fatal  mala- 
dies— in  phthisis  pulmonalis,  for  example — and  in  dropsy,  although  the  dropsical 
enlargement  sometimes  masks  it.  It  accompanies  many  acute  diseases,  and  is 
reckoned  an  unfavourable  symptom  ;  for  it  shows  that  the  body  is  not  properly  nour- 
ished. Sometimes  the  emaciation  is  so  extreme  that  the  integuments  give  way — 
the  bones  of  the  patient  are  said  to  come  through  his  skin. 

We  have  examples  of  symptoms  that  consist  in  changes  of  colour,  in  the  flushed 
face  of  fever;  in  the  pallor  belonging  to  many  diseases;  in  the  contrast  exhibited 
by  the  white  cheek  with  its  central  red  spot,  so  characteristic  of  hectic  fever;  in  the 
yellowness  of  the  skin  and  conjunctiva  in  jaundice ;  in  the  dusky  hue  of  the  coun- 
tenance and  the  lividity  of  the  lips  noticeable  whenever  the  due  arterializaticn  of 
the  blood  in  the  lungs  is  interfered  with ;  and  in  a  long  catalogue  of  cutaneous 
disorders. 

Various  and  full  of  meaning  are  the  conditions  and  appearances  presented  by  the 
tongue.  A  patient  would  think  you  careless,  or  ignorant  of  your  craft,  if  you  did 
not,  at  every  visit,  look  at  his  tongue,  as  well  as  feel  his  pulse. 

Let  me  once  more  remind  you  of  the  peculiar  importance  of  accustoming  your- 
selves to  take  notice  of  the  symptoms  comprised  in  the  last  two  classes,  and  especially 
in  the  last  class,  that  you  may  attain  to  a  quick  perception  of  them.  Changes  of 
sensible  quahties  speak  for  themselves,  and  speak  the  truth.  They  cannot  deceive 
us,  as  the  verbal  statements  of  even  conscientious  patients  respecting  their  uneasy 
feelings  might.  They  direct  us  in  the  choice  and  order  of  our  inquiries  :  nay,  they 
frequently  spare  us  the  necessity  of  putting  many  questions ;  questions  that  might 
be  irksome  or  fatiguing  to  our  patients,  or  offensive  to  their  natural  delicacy,  or  even 
hurtful  by  letting  them  know  our  thoughts  respecting  their  disorders.  Of  the  changes 
in  sensible  qualities  we  judge  by  our  own  eyes,  and  ears,  and  fingers,  and  often  by 
our  noses  also ;  and  the  change  is  sometimes,  of  itself,  perfectly  characteristic  of  the 
complaint. 

Many  more  morbid  phenomena,  or  symptoms,  or  tokens  of  disease,  might  have 
been  mentioned ;  but  I  have  said  enough,  I  hope,  to  rouse  your  attention  to  the 
extent  and  the  fertility  of  this  field  of  study.  When  we  next  meet  I  shall  begin  to 
consider  one  of  the  special  forms  of  disease  to  which  all  parts  of  the  body  are  liable 
—a  disease  that  meets  us  at  every  turn — I  mean  injlammalion. 


92  INFLAMMATION. 


LECTURE  IX. 

InJJammation.  Its  Morbid  and  its  Salutary  Effects.  Sketch  of  the  Local  ana 
Constitutional  Fhenoinena  of  Inflammation  as  it  occurs  in  External  Farts. 
Examination  of  the  Symptoms  of  Inflammation ;  Pain ;  Heat ;  Redness ; 
Swelling.  State  of  the  Capillary  Blood-vessels  and  of  the  Blood  in  a  part 
inflamed. 

Inflammation  must  needs  occupy  a  large  share  of  the  attention  of  both  the  sur- 
geon and  the  physician.  In  nine  cases  out  of  ten  the  first  question  which  either  of 
them  asks  himself  upon  being  summoned  to  a  patient  is,  "  Have  I  to  deal  with 
inflammation  here  ?"  It  is  continually  the  object  of  his  treatment  and  watchful 
care.  It  affects  all  parts  that  are  furnished  with  blood-vessels,  and  it  affects  different 
parts  very  variously.  It  is  more  easily  excited  by  many  external  causes,  and  there- 
fore it  is  more  common  than  any  other  special  disease.  A  great  majority  of  all  the 
disorders  to  which  the  human  frame  is  liable  begin  with  inflammation,  or  end  in 
inflammation,  or  are  accompanied  by  inflammation  during  some  part  of  their  course, 
or  resemble  inflammation  in  their  symptoms.  Most  of  the  organic  changes  of 
different  parts  of  the  body  recognize  inflammation  as  their  cause,  or  lead  to  it  as 
their  effect.  In  short,  a  very  large  share  of  the  premature  extinction  of  human  life 
in  general,  is  more  or  less  attributable  to  inflammation. 

Again,  inflammation  is  highly  interesting  not  only  in  its  morbid  phenomena  and 
destructive  consequences,  but  in  its  healing  tendencies  also.  It  is  by  inflammation 
that  wounds  are  closed,  and  fractures  repaired — that  parts  adhere  together  when  their 
adhesion  is  essential  to  the  preservation  of  the  individual — and  that  foreign  and 
hurtful  matters  are  conveyed  safely  out  of  the  body.  A  cut  finger,  a  deep  sabre 
wound,  alike  require  inflammation  to  re-unite  the  divided  parts.  Does  ulceration 
occur  in  the  stomach  or  intestines,  and  threaten  to  penetrate  through  them  ?  Inflam- 
mation will  often  forerun  and  provide  against  the  danger — glue  the  threatened  mem- 
brane to  whatever  surface  may  be  next  it — and  so  prevent  that  worse  and  universal 
inflammation  of  the  peritoneum,  and  the  almost  certain  death,  which  the  escape  of 
the  contents  of  the  alimentary  canal  into  that  serous  bag  would  infallibly  occasion. 

[We  doubt  very  much  the  correctness  of  this  statement.  Is  it  true,  that  wounds  are  closed 
and  fractures  united  by  inflammation,  in  the  proper  acceptation  of  the  term  1  Union  of 
divided  surfaces,  it  is  true,  may  be  a  resuh  of  inflammation  ;  but,  that  what  has  been  tf  rmed 
by  surgeons  "union  by  the  first  intention,"  takes  place  altogether  independent  of  inflamma- 
tion, and  that  the  occurrence  of  the  latter  is  calculated  to  impede  or  prevent  it,  must  be  evi- 
dent, we  think,  to  any  one  who  will  carefully  watch  its  phenomena.  Neither  is  it,  we  con- 
ceive, correct  to  describe  the  adhesions  of  the  peritoneum  which  often  precede  the  perforation 
by  an  ulcer  of  the  coats  of  the  stomach  or  intestines,  and  prevent  the  escape  of  the  contents 
of  the  latter  organs  into  the  cavity  of  the  abdomen,  as  a  provision  to  guard  against  the  uni- 
versal and  fatal  peritonitis  that  would  otherwise  occur.  The  inflammation  by  which  the 
adhesions  alluded  to  are  produced,  is  as  strictly  a  morbid  process  as  that  which  caused  the 
ulceration  of  the  alimentary  canal,  and  cannot,  with  any  propriety,  be  viewed  as  a  process 
setup,  in  anticipation  of  the  escape  of  the  contents  of  the  alimentary  canal  into  the  peritoneal 
sac,  and  to  guard  against  the  danger  that  would  hence  result.  The  danger  is,  we  admit, 
occasionally  lessened  or  even  entirely  prevented  by  the  adhesions,  but  we  have  no  right  to 
■lifer  from  this  circumstance,  that  the  adhesions  occurred  to  provide  against  its  occtir- 
ience--C.] 

The  foot  mortifies  ;  is  killed  by  injury  or  by  exposure  to  cold ; — inflammation,  if 
1L  be  not  anticipated  by  the  knife  of  the  surgeon,  will  cut  off  the  dead  and  useless 
part.  An  abscess  forms  in  the  liver — or  a  large  calculus  concretes  in  the  gall- 
bladder: how  is  the  pus  or  the  stone  to  be  got  rid  of?  If  they  make  their  way  to 
the  external  surface  of  the  organ,  as  they  always  tend  to  do,  they  enter  the  cavity  of 
the  abdomen,  and  excite  fatal  peritonitis.  But  a  natural  safeguard  arises ;  partial 
'Uflammation  precedes  and  prepares  for  the  expulsion;  the  liver  or  the  gall-bladder, 
8s  the  case  may  be,  becomes  adherent  to  the  Avails  of  the  abdomen  on  the  one  hand, 


1 


INFLAMMATION.  Q^ 

or  to  the  intestinal  canal  on  the  other;  and  then  the  surgeon  may  plunge  his  lancet 
into  the  collection  of  pus — or  the  abscess  or  the  calculus  may  eat  their  own  way 
safely  out  of  the  body — through  the  skin,  or  into  the  bowel.  Inflammation,  hmited 
in  extent  and  moderate  in  degree,  becomes  conservative  by  preventing  inflammation 
more  severe  and  more  widely  spread,  which  would  be  fatal.  This  is  what  I  mean 
when  I  speak  of  the  curative  properties  of  inflammation ;  and  surely  this  process, 
which  may  save  hfe  or  destroy  it,  deserves  and  demands  our  most  careful  study. 

But  inflammation  has  a  still  further  and  peculiar  claim  upon  our  attention.  The 
salutary  acts  of  restoration  and  prevention  just  adverted  to,  are  such  as  nature  con- 
ducts and  originates.  But  we  are  ourselves  able,  in  many  instances,  to  direct  and 
control  the  effects  of  inflammation — nay,  we  can  excite  it  at  our  pleasure  ;  and  hav- 
ing excited  it,  we  are  able,  in  a  great  degree,  to  regulate  its  course.  And  for  this 
reason  it  becomes  in  skilful  hands  an  instrument  of  cure.  This  instrument  the 
surgeon  employs  when,  after  letting  out  the  water  of  a  hydrocele,  he  wilfully  excites 
inflammation  of  the  tunica  vaginahs,  whereby  its  cavity  is  obhterated,  and  the  re- 
accumulation  of  the  fluid  rendered  impossible.  It  is  by  avaihng  himself  of  the  same 
agent  that  he  is  enabled  to  remedy  many  afliicting  deformities : — to  unite  the  cleft 
lip ;  to  close  up  the  fissured  palate ;  to  restore  the  dilapidated  nose.  There  is  no 
other  special  disease  which  is  thus  at  our  command ;  we  cannot,  if  we  would,  pro- 
duce a  tubercle  or  a  cancer.  For  all  these  reasons  inflammation  possesses  a  very 
high  degree  of  interest  for  us — and  for  every  one  who  would  inquire,  with  any  pros- 
pect of  success,  into  either  the  pathology  or  the  treatment  of  diseases. 

Of  the  amount  of  our  knowledge  respecting  the  intimate  nature  of  inflammation, 
[  shall  have  occasion  to  say  a  few  words  by  and  by.  We  first  become  acquainted 
with  inflammation  in  its  symptoms,  and  as  it  displays  itself  externally.  After  we 
know  what  they  are,  it  may  be  right,  and  cannot  but  be  interesting,  to  inquire  how 
they  come  about.  Now  the  symptoms  which,  when  they  exist  together  in  an  ex- 
ternal or  visible  part,  betoken  or  denote  inflammation  of  that  part,  are  four  in  number: 
pain — redness — heat — swelling;  preternatural  redness,  and  'preternatural  heat. 
These,  from  the  earliest  ages,  have  been  recognized  as  the  signals  of  outward  inflam- 
mation, "  Not83  inflammationis  (says  Celsus)  sunt  quatuor — rubor  et  tumor  cum 
calore  et  dolore." 

No  definition,  however,  or  general  description,  can  be  made  to  embrace  all  the 
forms  in  which  inflammation  presents  itself.  We  can  give  no  useful  account  of  it 
in  the  abstract ;  and  therefore  I  shall  first  sketch  the  phenomena  of  inflammation 
under  one  of  its  most  common  external  forms ;  and  taking  this  as  a  type  of  the 
disease,  proceed  afterwards  to  trace  its  modifications  and  varieties,  and  to  fill  up  the 
picture. 

Let  us  suppose,  then,  that  a  healthy  man  receives  some  local  mechanical  injury — 
that  he  falls,  for  instance,  against  a  window,  and  gets  a  piece  of  glass  stuck  into  his 
arm.  In  a  short  time  he  begins  to  have  pain  in  that  part  of  the  arm,  and  this  is  soon 
succeeded  by  redness,  and  increased  heat  and  swelling.  The  skin  becomes  of  a 
bright  red  colour;  the  swelling  increases.  In  the  immediate  place  of  the  injury  the 
swelhng  is  firm  and  hard,  and  exquisitely  tender :  at  some  distance  from  that  centre, 
although  there  is  still  swelling,  the  parts  are  softer  and  more  yielding.  In  the  seat 
of  the  redness  and  swelling  the  patient  experiences  a  sense  of  heat,  a  burning  pain  ; 
the  part  is  sensibly  hotter  than  natural  to  the  touch  of  a  bystander ;  and  if  its  actual 
temperature  be  measured  by  means  of  a  thermometer,  it  will  be  found  to  exceed  the 
temperature  of  the  neighbouring  surface.  The  part  is  injlamed.  This  is  what  is 
called  phlegmonous  inflammation.  ^"Ktyfiovfi  is  a  Greek  word,  and  inflammatio  is  a 
Latin  word,  and  they  both  mean  the  same  thing,  viz.,  a  burning,  or  a  flame.  Phleg- 
monous inflammation  is,  therefore,  in  truth,  a  tautological  phrase.  But  custom  has 
assigned  a  particular  signification  to  the  epithet  phlegmonous  ; — it  denotes  that  kind 
of  violent  inflammation  in  which  the  affected  part  seems  all  on  fire ;  and  chemistry 
teaches  that,  philosophically  speaking,  there  is  actual  and  excessive  combustion  going 
on  in  that  part. 


94-  INFLAMMATION. 

If  the  inflammation  reach  a  certain  degree  of  intensity,  other  signs  of  disorder 
piesent  themselves  at  a  distance  from  the  injured  spot.  The  patient  usually  at  first 
feels  chilly  and  feeble;  but  soon  the  temperature  of  the  whole  of  the  surface  rises, 
the  skin  becomes  hot  and  dry,  the  pulse  more  frequent  and  fuller  and  harder  than  is 
usual ;  lassitude  comes  on,  with  headache,  and  wandering  pains  in  the  limbs.  The 
patient  is  unable  or  unwilling  to  exert  himself,  and  finds  that  he  is  unapt  for  any 
mental  effort ;  he  cannot  command  his  attention,  gets  confused,  and  restless,  and 
sleeps  ill ;  he  loses  his  appetite,  his  tongue  becomes  white,  his  mouth  is  parched, 
he  is  unusually  thirsty,  and  the  various  secretions  of  the  body  are  deranged  and 
diminished. 

This  is  wJJammatory  fever.  This  is  an  indirect  symptom  of  inflammation,  mani- 
festing itself  through  the  medium,  of  the  system  at  large.  Various  names  have 
been  given  to  this  general  derangement  of  the  vascular  and  nervous  systems :  con- 
stitutional disturbance — sympathetic  fever — symptomatic  fever.  It  matters  little  what 
term  is  used,  provided  that  we  affix  alwaj^s  the  same  meaning  to  it :  but  inasmuch 
as  the  word  fever,  in  this  and  in  other  languages,  is  taken  to  express  a  specific  dis- 
ease, it  would  perhaps  be  better  to  employ  the  term  pyrexia,  as  Cullen  and  others 
have  done,  to  denote  that  secondary  febrile  state  which  grows  out  of,  or  is  associated 
with  prirjary  local  inflammation. 

Now  what  is  the  end  of  this  remarkable  state  of  things  ?  Wh}^  it  may  end  in 
one  of  two  or  three  different  ways.  Supposing  the  piece  of  glass  to  have  been 
extracted,  and  proper  measures  to  have  been  taken  for  subduing  the  inflammation,  or 
even  supposing  that  no  other  measure  has  been  adopted  except  removing  the  bit  of 
glass,  then  it  will  often  happen  that  the  phenomena  just  described  will  gradually 
recede  and  disappear ;  the  pain  will  abate,  the  redness  fade,  the  swelling  diminish, 
the  heat  decline,  the  pyrexia  cease;  until  the  part  at  length  regains  its  usual  sensa- 
tions and  its  natural  appearance.  When  inflammation  subsides  in  this  waj'-  it  is  said 
to  be  resolved,  to  tenTiinate  by  resolution  ;  and  this  is  its  most  favourable  and  desira- 
ble mode  of  terminating,  whenever  inflammation  occurs  as  a  morbid  process. 

But  in  many  instances  the  inflammation  does  not  thus  subside.  The  irritant  cause 
jtill  remains  in  action — or  the  original  intensity  of  the  inflammation  has  been  too 
great  to  admit  of  resolution — or  the  means  proper  to  abate  it  have  not  been  used — 
or  ha^e  not  succeeded.  The  symptoms  already  described  continue,  and  are  aggra- 
vated in  degree :  at  length  the  swelling  begins  to  assume  a  more  projecting  and 
pointed  form,  and  the  skin  in  its  centre  to  look  white ;  the  central  part  of  the  swell- 
ing, formerly  so  hard,  becomes  softer — the  pain  is  of  a  throbbing  kind :  a  pulsative 
sensation,  keeping  time  with  the  beats  of  the  heart,  is  experienced  in  the  part,  and 
often  a  feeling  occurs  as  if  something  had  given  way  within  it :  at  last  (if  art  does 
not  interpose)  the  cuticle  breaks,  and  a  yellow  cream-like  fluid  is  poured  out,  which 
we  call  pus,  and  upon  its  escape  there  generallj''  ensues  a  considerable  and  speedy 
abatement  of  all  the  local  symptoms  of  inflammation — of  the  pain,  the  heat,  the 
redness,  the  tumour. 

This  is  suppuration. 

Meanwhile,  especially  if  the  suppuration  be  long-continued,  and  the  discharge  of 
pus  profuse,  the  character  of  the  general  febrile  excitement  undergoes  a  change. 
Slight  but  frequent  shiverings,  or  feehngs  of  chilliness,  take  place,  followed  by  flushes 
of  heat,  which  end  in  perspiration. 

This  is  hectic  fever. 

If  the  injury  has  been  still  more  serious,  and  the  inflammation  more  intense,  the 
part  which  it  has  invaded  perishes  by  the  violence  of  the  disease  :  there  is  a  partial 
death.  In  that  case  the  vivid  red  colour  alters  to  a  purplish  or  livid,  or  even  a 
black,  or  greenish-black  hue,  the  tension  of  the  part  exists  no  longer,  the  cuticle  is 
elevated  by  a  sanious  fluid,  the  pain  ceases,  the  part  is  devoid  of  all  sensation  —  is 
dead  and  putrid,  and  exhales  a  pecuhar  and  offensive  odour. 

This  is  mortificaiion. 

When  ttie  mjury  has  been  extensive,  a  corresponding  and  characteristic  change 
is  again  observable  in  the  constitutional  febrile  disturbance.  The  patient  grows 
more  and  more  feeble,  and  delirious ;  he  has  involuntary  startings  of  the  tendons  of 


INFLAMMATION.  95 

the  voluntary  muscles ;  his  pulse  is  weak  and  very  frequent ;  his  tongue  becomes 
dry,  brown,  tremulous  ;  his  lips  are  black  with  accumulated  sordes  ;  his  countenance 
is  shrunk,  haggard,  damp,  and  ghastly ;  his  stools  and  urine  escape  from  him  with- 
out his  appearing  to  be  conscious  that  they  do  so. 

This  is  typhoid  fever. 

Under  more  favourable  circumstances  the  dead  or  mortified  part,  which  is  called 
a  slough,  separates  from  the  hving  parts,  and  leaves  a  breach  of  surface.  The  sepa 
ration  is  effected  by  a  vital  process  which  is  denominated  ulceration  ;  but  which  1 
need  not  now  describe.  The  cavity  thus  formed  gradually  fills  up,  and  heals  in  a 
peculiar  way. 

There  is  one  other  circumstance,  not  to  be  omitted  in  this  rough  outline  of  the 
local  and  general  phenomena  and  effects  of  inflammation.  If  during  its  progress 
blood  be  drawn  from  a  vein,  it  exhibits,  after  standing  and  coagulating,  the  peculiar 
appearance  known  by  the  name  of  the  bifffy  coat,  i.  e.,  on  the  surface  of  the  coagu- 
lum,  and  to  a  certain  depth  in  its  substance,  the  colouring  matter  of  the  blood  leaves 
the  fibrin,  which  is  therefore  seen  of  a  yellowish  hue,  or  buff  colour. 

Taking  the  preceding  statement  as  a  groundwork,  let  us  look  back  upon  it,  and 
trace  its  particulars  a  little  more  in  full.  The  four  characteristic  signs  of  inflamma- 
tion being  pain,  heat,  redness,  and  swelling,  it  will  be  useful  to  examine  more  closely 
each  of  these  symptoms  in  its  turn. 

The  pain  varies  much  in  different  cases  of  inflammation,  both  in  degree  and  in 
kind.  It  is  differently  felt,  ceteris  paribus,  by  different  persons,  according  to  their 
natural  susceptibihties.  It  varies  from  the  shghtest  degree  of  sensibility  to  the  utmost 
agony  and  torment.  Parts  which,  when  sound,  are  endowed  with  little  or  no  capa- 
city of  sensation  (as  tendons,  ligaments,  cartilage,  bone),  become  often  exquisitely 
sensible  under  inflammation.  The  organs  of  sense  are  variously  affected  in  this 
respect.  Thus  the  specific  sensibihties  of  the  mouth  and  nose  are  blunted  by  inflam- 
mation— those  of  the  eye  and  ear  are  often  rendered  painfully  acute.  There  are 
great  diversities  also  in  the  kinds  of  pain.  Sometimes  it  is  of  a  dull  aching  charac- 
ter, as  in  toothache  ;  sometimes  it  is  a  pricking,  tingling,  smarting  sensation — this  is 
the  case  in  some  forms  of  inflammation  of  the  skin,  as  in  erysipelas  for  example,  and 
in  herpes ;  sometimes  it  is  sharp  and  piercing,  as  if  the  part  were  stabbed  or  cut 
with  a  knife  —  such  is  frequently  the  feehng  in  inflammation  of  the  serous  mem- 
branes, in  pleurisy  for  instance  ;  sometimes  the  pain  is  tensive  or  stretching ;  and 
sometimes  there  is  scarcely  any  pain  at  all.  This  last  chiefly  happens  in  the  mu- 
cous membranes  and  in  the  parenchymatous  textures  of  organs.  Very  often  thu 
pain  is  a  "bulking"  or  throbbing  pain — every  beat  of  the  heart  makes  itself  felt  in 
the  tender  part.  The  pain  of  inflammation  results,  no  doubt,  from  the  implication 
of  the  nerves  in  the  diseased  process.  The  stretching  of  the  vessels  and  textures 
adds  to  the  pain.  Everybody  who  has  been  plagued  by  boils  (and  few  escape  them) 
has  had  proof  of  this :  the  pain  is  most  harassing  a  short  time  before  the  ripening 
little  tumour  gives  way,  or  is  laid  open  by  means  of  a  scalpel ;  but  as  soon  as  the 
distension  is  thus  relieved,  perfect  ease  and  comfort  ensue.  It  is  the  same  in  com- 
mon earache.  It  is  upon  this  principle,  I  beheve,  that  the  differences  in  regard  to 
pain,  which  occur  in  different  structures  under  inflammation,  are  partly  to  be  ex- 
plained. Speaking  generally,  there  is  more  pain  felt  in  external  inflammations,  and 
in  the  inflammation  of  investing  membranes,  than  in  inflammation  of  the  substance 
of  the  viscera,  or  of  the  lining  membranes ;  and  it  has  been  conjectured  that  this 
may  be  because,  in  the  latter  cases,  the  parts  affected  have  fewer  nerves  of  common 
sensation.  But  I  do  not  think  this  explanation  satisfactory.  If  it  were  well  founded 
we  should  not  have  such  exquisite  pain  in  some  of  the  textures  already  mentioned, 
which  appear  to  be  furnished  with  very  few  nerves  of  common  sensation,  and 
scarcely  feel  at  all  in  their  healthy  state :  tendons,  ligaments,  and  cartilages,  I  mean 
I  think  it  will  be  found  that  most  pain  is  felt  in  those  parts  which  are  least  capable 
of  yielding  —  in  which  the  tension  produced  by  the  swelling,  or  the  tendency  to 
swell,  is  the  greatest.  The  substance  of  the  liver,  spleen,  and  viscera  generally,  is 
soft  and  yielding  —  the  mucous  membranes  are  spongy  in  their  texture,  and  oftett 
attached  to  the  subjacent  parts  in  loose  folds,  and  they  allow  of  an  accumulation  o-' 


96  INFLAMMATION. 

blood  within  them  without  becoming  much  stretched,  or  very  tense.  The  investmg 
serous  and  fibrous  membranes  are  more  tightly  appHod,  and  much  less  capabl^i  of 
yielding :  and  their  inflammation  is  usually  attended  with  severe  pain. 

The  pain  that  belongs  to  inflammation  sometimes  precedes  any  other  apparen 
change.  This  is  specially  observable  in  respect  to  internal  parts.  Sometimes  the 
pain  is  continued  and  uniform.  Sometimes  it  is  continued,  but  irregular  in  severity, 
having  periods  of  great  exasperation :  sometimes  again  it  is  intermittent,  and  even 
periodic. 

It  is  an  unsettled  question  that  has  often  been  mooted,  whether  in  inflammation, 
:he  slate  of  the  blood-vessels  is  determined  by  that  of  the  nerves,  or  the  reverse. 
Mere  nervous  pains  are  known  sometimes  to  be  followed  by  congestion  of  the  part 
in  which  they  are  felt.  Whatever  may  be  the  true  state  of  this  question  of  priority, 
it  is  certain  that  the  disordered  condition  of  the  blood-vessels,  when  produced,  greatly 
augments  the  sensibility  of  the  part.  We  may  suppose  that  this  depends,  partly  on 
over-distension  and  stretching  of  the  vessels  and  fibres,  partly  on  pressure  made  upon 
the  nerves  by  the  swelling. 

It  is  important  to  remark  of  the  pain  belonging  to  inflammation,  that  it  is  usually 
aggravated  by  pressure:  frequently  it  is  not  felt  at  all,  except  when  pressure  is 
somehow  made  upon  the  afft'cted  part — intentionally  by  the  medical  man — or  acci- 
dentally, from  the  movements  or  position  of  the  patient.     This  is  tenderness. 

And  this  is  a  point  which  requires  a  little  further  notice.  I  say  the  aggravation 
of  the  pain  by  pressure  is  an  important  circumstance,  because  it  continually  helps 
us  to  distinguish  pain  that  is  inflammatory  from  pain  that  is  not  inflammatory.  Thus 
pain  of  the  abdomen  may  result  from  colic,  or  spasm — from  a  distension  of  the  intes- 
tines by  air,  and  a  stretching  of  the  textures  and  nerves  belonging  to  them :  and  this 
sort  of  pain  will  mostly  be  relieved  by  pressure ;  you  will  find  patients  lying  upon 
their  bellies  across  the  back  of  a  chair  for  the  sake  of  obtaining  ease  :  but  if  the  pain 
proceed,  as  it  may,  from  inflammation  of  the  peritoneum  —  oh!  then  the  gentlest 
pressure,  even  that  of  the  superincumbent  bed-clothes,  causes  intolerable  torture. 
The  suddenness  with  which  the  pressure  is  made  —  and  its  being  made  on  a  part 
only  of  the  suffering  organ — these  circumstances  have  much  to  do  with  the  augment- 
ation of  the  pain  ;  and  it  is  curious,  and  instructive  too,  to  know  that  gradual  pres- 
sure, applied  uniformly  to  the  whole  organ  or  part  under  inflammation,  is  sometimes 
so  far  from  enhancing  the  pain,  that  it  relieves  or  removes  it.  Dr.  Elliotson  puts  a 
very  good  case  in  illustration  of  this.  "  If  (he  says)  you  have  a  blister  upon  the  sole 
of  the  foot,  or  at  the  ball  of  the  great  toe,  and  you  rest  gradually  upon  the  part,  the 
pain  becomes  mitigated,  till  at  last  it  seems  to  be  almost  entirely  removed  ;  but  the 
moment  you  take  off  the  pressure,  and  raise  the  foot  from  the  ground,  you  feel  the 
part  begin  to  throb — to  throb  with  violent  pain." 

Now  all  this  exemplifies  what  I  said  just  now — that  though  a  deranged  condition 
of  the  nerves,  marked  by  pain,  may,  for  aught  I  know,  first  lead  to  the  vascular  full- 
ness— yet  the  same  fullness,  and  the  distension  which  it  implies,  will  greatly  increase 
the  pain.  In  fact,  the  expulsion  of  the  blood  by  means  of  well-regulated  pressure 
is  made  the  foundation  of  certain  proposed  methods  of  cure.  This  has  been  lately 
recommended  in  hernia  humoralis,  or  swelled  testicle  —  what  is  now  more  scienti- 
fically called  orchitis.  It  gives  one  a  sort  of  horror  even  to  think  of  pressure  being 
made  on  the  healthy  testicle  —  much  more  when  it  is  rendered  preternaturally  sen- 
sible by  inflammation :  yet,  when  properly  managed,  it  is  said  (by  Dr.  Fricke,  of 
Hamburgh,  and  others)  not  to  increase  the  pain,  but  entirely  to  remove  it,  so  that 
the  patient  can  at  once  walk  about  the  room  ;  and  the  disease  is  thus  ultimately  cured. 
In  the  same  way  it  has  been  proposed  to  cure  eiysipelas,  and  gout,  and  rheumatism. 
Without  inquiring  here  into  the  general  merits  of  this  remedial  expedient,  I  may 
remark  that  pressure,  so  employed  as  to  benefit  an  inflamed  part  by  supporting  its 
strained  and  oppressed  capillaries,  must  be  steady,  gentle,  continued,  and  (above  all) 
uniform  pressure.  All  these  conditions  are  strictly  supplied  in  an  apparatus  recently 
devised  by  !>•  Arnott ;  whose  air-press  promises  to  be  scarcely  less  useful  to  suffer- 
ing humanity  than  his  earlier  contribution  to  the  comfort  of  the  sick — the  water-bed. 

It  is  sometimes  necessary  to  recollect,  especially  when  the  existence  of  internal 


HEAT.  '  97 

inflammation  is  suspected,  that  all  expression  of  the  sense  of  pam,  and  probably  ail 
sensation  of  pain,  may  be  prevented  or  abolished  by  ihe  presence  of  stupor  or  coma. 
So  also,  if  the  nervous  connection  between  the  inflamed  part  and  the  sensonum  be 
cut  ofT,  no  pain  is  felt.  Limbs  in  a  state  of  palsy  are  often  (though  not  always)  des- 
titute of  sensibility  also ;  and  inflammation  readily  occurs  in  them,  but  is  accom- 
panied with  no  pain. 

That  mere  pain  will  not  constitute  inflammation,  must,  I  think,  be  plain  to  you. 
Spasmodic  contractions  of  the  muscles,  slretchincf  and  tension  of  the  tissues,  a  par- 
ticular state  of  the  nerves,  and  other  conditions  which  do  not  imply  inflammation, 
may,  nevertheless,  be  attended  with  severe  pain. 

Let  us  next  consider  the  heat. 

Of  course,  as  I  hinted  before,  this  means  prefernatural  heat :  the  temperature  of 
the  part  exceeds  that  which  belongs  to  it  in  health ;  but  in  truth,  the  heat  is  not  in 
general  so  much  increased  as  the  sensations  of  the  patient  or  his  heightened  sensi- 
bility would  persuade  him  it  is  ;  nor  even  so  much  as  a  bystander  might  suppose. 
The  heat  of  inflammation  does  not  rise  above  the  maximum  heat  of  the  blood  in  the 
central  parts  of  the  body.  The  natural  heat  of  the  blood  is  about  9S°  or  100°,  but 
n  fevers  and  inflammatory  diseases  it  has  been  known  to  reach  107°,  and  the 
laximum  heat  of  the  blood  in  fever  is  probably  the  limit  of  the  temperature  as  it 
exists  in  inflamed  parts.  The  surface  of  the  body,  in  its  natural  state,  is  not  quite 
so  warm  as  the  internal  parts,  and  the  extremities  are  generally  less  warm  than  the 
trunk ;  so  that  the  contrast  between  an  inflamed  and  a  healthy  part,  in  respect  to 
heat,  is  greater  in  the  extremities  than  on  the  trunk.  Thus  if  a  bhstcr  be  placed 
upon  the  chest,  the  heat  of  the  part  inflamed  by  its  application  will  not  exceed  that 
of  the  neighbouring  healthy  surface  by  more  than  a  degree  or  two ;  while  a  blister 
applied  upon  the  leg  may  occasion  a  difference  of  five  or  six  degrees.  John  Hunter 
took  great  pains  to  ascertain  the  degree  of  heat  produced  in  inflammation.  He  ex- 
cited inflammation  in  the  cavity  of  the  thorax  of  a  dog,  and  in  the  vagina  and  rectum 
of  an  ass,  and  he  could  not  find  that  the  temperature  of  the  parts  thus  inflamed  ever 
exceeded  that  of  the  blood  at  the  centre  of  the  circulation.  He  did  not  neglect  the 
opportunities  that  came  before  him  of  making  similar  observations  on  the  human 
body.  He  had  occasion  to  tap  a  patient  in  St.  George's  Hospital  for  hydrocele  :  as 
soon  as  he  had  let  the  fluid  out,  he  introduced  a  thermometer  through  the  puncture 
made  by  the  trocar,  and  placed  it  in  contact  with  the  testicle.  He  found  the  tempe- 
rature to  be  92°.  He  repeated  this  experiment  the  next  day,  when  inflammation  had 
set  in,  and  then  the  thermometer  rose  to  98|°.  So  that  here  an  increase  of  6?°  had 
taken  place  in  consequence  of  the  inflammation  ;  but  even  this,  you  see,  did  not  go 
beyond  the  natural  warmth  of  the  blood. 

The  increase  of  heat  depends  upon  the  increased  influx  of  arterial  blood,  and 
therefore  of  oxygen,  into  the  part.  Animal  heat  appears  to  be  derived,  in  all  cases, 
from  the  mutual  action  that  takes  place  between  oxygen  and  the  elements  of  the; 
tissues,  their  carbon  and  hydrogen  ;  the  tissues  themselves  undergoing  meanwhile 
perpetual  changes,  which,  in  the  natural  condition  of  the  body,  belong  and  are 
necessary  to  health.  In  a  part  that  is  inflamed  this  kind  of  combustion  is,  I  say, 
excessive  in  amount ;  while  unnatural  metamorphoses  occur  in  the  affected  tissues. 
It  is,  however,  a  curious  fact,  a  fact  worth  remembering,  that  the  heat  of  inflam- 
mation does  not  transgress  or  surpass  that  of  the  blood  in  the  central  parts  of  the 
body. 

Heat  alone  neither  constitutes  nor  impHes  inflammation  :  for  parts  of  the  body  may 
be  made  preternaturally  hot  by  holding  them  before  the  fire,  by  friction,  by  exercise, 
while  there  is  no  inflammation. 

I  apprehend  that  increased  heat  is  essential  to  inflammation,  in  some  stage  or  other 
of  its  progress,  although  there  are  cases  in  which  the  augmented  temperature  is  not 
perceived  or  appreciated.  Sometimes  the  increase  of  heat  is  very  slight,  and  may 
be  easily  overlooked,  there  being,  nevertheless,  unequivocal  inflammation,  redness  and 
swelling,  which  go  slowly  into  suppuration.  The  heat  is  often  concealed  from  the 
observation  of  the  physician  or  the  surgeon,  by  the  situation  of  the  part  afl>3Cted,  anu 
it  escapes  the  notice  of  the  sufferer,  because  the  sensibihty  to  heat  is  less  gencn It v 
7  I 


\)S  SWELLING. 

diffused  through  the  bodj'  than  the  susceptibility  of  common  sensation.  The  heat 
of  inflammation  is  usually  less  felt  and  less  complained  of  by  the  patient  than  the 
pain.     A  vivid  sensalion  of  heat  is  pain. 

The  redness  of  inflammation  must  also  be  prdernalural  in  degree,  for  many  parts 
of  the  body  are  by  nature,  and  in  health,  more  or  less  red.  This  phenomenon 
depends  upon  the  greater  quantity  of  blood  contained  in  the  vessels  of  the  part,  and 
sometimes  also  upon  the  extravasation  of  a  portion  of  the  blood  into  the  affected  tex- 
ture. There  is  more  blood  than  usual  in  those  vessels  which  naturally  carry  red 
blood ;  red  blood  enters  too  into  vessels  which  in  the  healthy  state  are  destined  to 
receive  and  convey  colourless  fluids  only,  or  which  naturally  admit  so  few  of  the  red 
particles,  that  from  their  paucitj^  and  the  quickness  of  their  motion,  they  cannot  be 
seen.  We  are  sure  of  this  from  v.-hat  takes  place  in  ophthahnia.  Doubtless,  also, 
the  redness  is  sometimes  increased  by  the  formation  of  new  vessels  which  admit  the 
colouring  particles  of  the  blood  in  visible  numbers. 

That  the  vessels  which  naturally  circulate  red  blood  are  actually  distended  and  en- 
larged in  inflammation,  there  can  be  no  doubt,  John  Hunter  (whose  treatise  on  in- 
flammation is  a  mine  in  which  all  succeeding  writers  have  dug),  excited  inflammation 
in  one  of  the  ears  of  a  rabbit,  and  then  killed  the  animal.  He  next  injected  the 
head  and  ears  from  the  aorta,  so  that  the  fluid  injected,  passing  through  both  the 
carotids,  was  driven  with  equal  force  towards  each  ear.  The  arteries  of  the  in- 
flamed ear  were  enlarged  one-third  beyond  their  natural  size,  and  arteries  in  it  were 
injected  which  had  no  visible  counterparts  in  the  sound  ear.  That  the  apparent 
increase  in  the  number  of  blood-vessels  is  often  owing  to  the  circumstance  that  red 
blood  enters  tubes  Avhich  already  existed,  but  which  did  not  previously  admit  the 
colouring  matter,  or  did  not  admit  it  in  sufficient  quantity  to  be  visible,  is  evident 
from  the  rapidity  with  which  the  redness  may  be  produced  in  many  textures  :  in  the 
eye,  for  example,  it  may  be  effected  in  a  few  seconds ;  and  many  of  the  vessels 
which  become  suddenly  apparent  are  evidently  continuulions  of  the  trunks  that 
could  be  seen  before. 

There  is  much  variety  in  the  tint  of  the  redness  of  inflammation,  depending  on 
the  kind  and  degree  of  the  inflammation,  and  on  the  nature  of  the  part  aflected. 
Sometimes  the  redness  is  bright  and  vivid,  as  if  the  part  were  full  of  arterial  blood : 
this  generally  happens  in  the  acuter  forms  and  the  earlier  stages  of  inflammation. 
Sometimes  the  redness  is  dark,  or  livid,  or  purphsh ;  more  as  if  the  part  were 
gorged  with  venous  blood :  this  occurs  in  some  of  the  chronic  or  sluggish  forms  of 
inflammation,  and  it  is  often  the  case  when  there  is  a  tendency  to  gangrene.  Some- 
times the  redness  is  distinctly  circumscribed,  or  in  patches ;  and  sometimes  it  is  dif- 
fused in  a  general  blush  over  a  large  space. 

The  redness  may,  and  often  does,  remain  for  some  time  after  the  inflammation  has 
ceased. 

Now  seeing  that  redness  accompanies  inflammation  of  the  external  parts,  we  pre- 
sume that  it  exists  also  in  internal  inflammation  :  indeed  we  may  convince  ourselves 
that  it  is  so.  If  a  portion  of  intestine  be  drawn  out  through  a  slit  in  the  parietes  of 
the  belly  of  a  dog,  and  suffered  to  remain  exposed  to  the  air,  it  will  soon  inflame  ; 
and  inflaming,  it  grows  red.  We  see  also  that  internal  parts  are  left  red  after  death, 
which  parts  we  have  no  other  reasons  for  knowing  had  been  inflamed  duiing  life: 
and  we  infer  that  redness  may  have  been  present  during  life,  although  we  find  none 
remaining  when  the  body  is  examined.  That  when  it  has  been  owing  to  mere  full- 
ness of  the  natural  blood-vessels,  it  may  disappear  with  parting  life  we  know,  because 
.he  same  thing  happens  externally,  as  in  erysipelas  and  scarlet  fever:  but  in  such 
cases  the  inflammation  has  not  gone  to  any  great  height. 

It  is  proper  to  remark  that,  as  the  absence  of  redness  is  no  proof  that  there  has 
not  been  inflammation,  so  its  presence  is  no  proof  of  the  contrary.  There  are  many 
kinds  of  redness,  both  within  the  body  and  on  its  surface,  that  have  nothing  to  do 
with  inflammation :  yet  some  of  these  are  very  apt  to  be  mistaken  for  traces  of 
inflammation.  I  shall  endeavour  to  instruct  you  how  to  avoid  such  a  mistake,  when 
wf  come  to  examine  the  morbid  anatomy  of  particular  forms  of  disease. 


1 


INFLAMMATION. 


Qti 


While  inflammation  actually  exists,  redness,  of  some  shade  or  degree-,  is  seldom 
absent,  even  though  the  other  symptoms  may  be  scarcely  apparent. 

Lastly,  let  us  take  a  glance  at  the  swelling.  This  also  depends,  in  some  degree, 
upon  the  distension  of  the  blood-vessels ;  but  no  great  amount  of  swelhng  can  be 
attributed  to  this  cause  ;  and  as  much  as  does  proceed  from  it  occurs  early  in  the  dis- 
ease. Some,  also,  and  usually  almost  the  whole,  of  the  swelling,  results  from  the 
presence  of  matters  poured  out  into  the  interstices  of  the  affected  part.  These 
effused  matters  are  of  very  different  kinds,  although  they  are  all  modifications  of  the 
same  hquid,  the  blood.  I  mentioned,  in  describing  the  condition  of  the  part  inflamed, 
that  the  central  portion  of  the  swelling  is,  at  first,  hard  and  resisting,  while,  at  a 
greater  distance  from  the  centre,  the  swelling  is  softer,  and  yields  more  readily  when 
pressed  by  the  point  of  the  finger,  and,  sometimes,  even  pits  a  little  under  that 
pressure.  Now,  the  central  hardness  is  to  be  ascribed  to  an  effusion  into  the  areolar 
texture  of  the  part,  of  a  fluid,  which,  transparent  at  first,  speedily  becomes  opaque 
and  more  consistent,  and  at  last  assumes  a  sohd  form.  This  is  what  is  commonly 
called,  in  this  country,  coagulable  lymph.  The  softer  swelling  at  the  circumference 
of  the  tumid  part  proceeds  from  the  effusion  of  a  thinner  fluid  of  serum  into  the 
areolar  tissue.  Under  very  violent  inflammation,  blood,  in  substance,  is  poured  out 
into  the  same  parts.  When  the  central  portion  of  the  swelhng  softens  and  becomes 
pointed,  this  part  of  the  whole  enlargement  is  owing  to  the  presence  of  a  quant'ty 
of  pus.  The  different  hquids  that  I  have  now  been  mentioning  are  of  great  import- 
ance, and  play  a  conspicuous  but  diversified  part  in  altering  textures.  Blood,  serum, 
albuminous  fluid  or  coagulable  lymph,  pus.  They  are  called  the  products  of  inflam- 
mation. We  are  sure  that  inflammation  has  been  at  work,  if  we  meet  with  certain 
of  these  products.  We  are  not  sure  that  there  has  been  inflammation  if  we  perceive 
mere  redness  :  —  we  are  not  always  sure  if  we  find  serum  only :  — we  are  not  sure 
if  we  find  blood  alone  :  —  we  are  tolerably  certain  if  we  discover  pus  ;  we  are  cer- 
tain, at  least,  that  there  has  been  inflammation  somewhere,  though  doubts  have  been 
started  whether  the  pus  is  not  sometimes  conveyed  from  an  inflamed  part  to  other 
parts  of  the  body.  We  are  quite  sure  that  there  has  been  inflammation  in  a  part  if 
we  find  coagulable  lymph  in  that  part.  This  often  remains,  as  a  monument  of  the 
inflanamation,  during  life ;  it  frequently  becomes  organized,  furnished  with  blood- 
vessels;  and  a  great  number  of  changes,  some  reparative,  some  morbid,  depend 
upon  its  presence.  I  shall  have  to  recur  to  these  products  of  inflammation  here- 
after. 

The  degree  of  swelling  in  different  cases  depends  partly  on  the  intensity  of  the 
inflammation,  partly  on  the  nature  and  texture  of  the  structures  affected. 

I  need  scarcely  observe  that  swelling  may  exist  without  any  inflammation.  Her- 
nia, simple  anasarcous  enlargements,  dislocations,  will  occur  to  you  as  every  day 
examples  of  swellings  that  have  no  necessary  connection  with  inflanamation. 

On  the  other  hand,  inflammation  may  exist  without  any  appreciable  swelling. 
Inflammation  of  the  sclerotic  coat  of  the  eye,  for  instance,  may  be  present,  without 
aiiy  swelling  cognizable  by  our  senses. 

We  have  seen,  in  this  review  of  the  symptoms  of  inflammation,  how  much  they 
severally  depend,  the  pain,  the  swelling,  the  redness,  and  the  heat,  upon  the  increased 
influx  of  blood  into  the  part. 

It  may  not  be  uninteresting  to  pause  here  for  a  moment  to  mquire  what  has  been 
ascertained  in  respect  to  the  actual  condition  of  the  capillaries  of  an  inflamed  part, 
and  of  the  blood  they  contain.  Much  has  been  learned  on  these  points  by  patient 
and  minute  observation  with  the  microscope,  and  by  reasoning  upon  the  facts  thus 
brought  to  light.  Kaltenbrunner,  Gendrin,  Miiller,  and  others,  have  corrected  many 
erroneous  notions  which  formerly  prevailed  upon  this  subject. 

In  or  Jer  to  comprehend  the  minute  phenomena  of  inflammation,  you  must  have  a 
clear  conception  of  the  constituent  elements  of  the  blood,  and  of  the  main  changes  u 
is  liable  to  undergo.  The  rough  anatomy,  rather  than  the  chemistr)'^  of  the  blood,  L«; 
what  I  allude  to. 

The  blood  consists  of  red  particles,  or  globules,  and  of  a  transparent  colourlestt 
fluid  called  lymph,  or  fiquor  sanguinis.     Muller  succeeded  in  separating  theso  two 


100  BLOOD    AND    BLOOD-VESSELS. 

constituents  of  the  blood  b}'-  filtering  through  paper  that  of  a  frog,  which  contains 
very  large  red  globules.  The  liquor  sanguinis  thus  obtained  separates  spontaneously, 
by  coagulation,  into  two  parts,  into  serum  and  fibrin,  the  last  having  previously  ex- 
isted in  solution  in  the  liquor  sanguinis. 

When  the  coagulation  is  sufl^ered  to  take  place  Avithout  any  attempt  to  remove  the 
red  particles,  these  are  entangled  and  enclosed  in  the  fibrin  as  it  becomes  solid;  and 
the  common  well-known  appearance  of  clot  and  serum  results.  You  may  even  then 
wash  out  the  red  particles  from  the  clot,  and  leave  the  fibrin. 

I  must  now  recur  to  the  experiments  and  observations  of  Kaltenbrunner.  I  should 
have  told  you,  on  a  previous  occasion,  that  various  stimulant  substances,  mechanical 
or  chemical,  when  applied  to  the  web  of  a  frog's  foot,  will  produce  irregular  dis- 
turbances in  the  circulation,  which  irregular  disturbances  you  are  not  to  confound 
with  true  congestion :  in  like  manner  you  must  avoid  confounding  them  with  the 
phenomena  of  inflammation,  which  are  always  preceded  by  those  of  true  conges- 
tion. Kaltenbrunner  ibund,  hkewise,  that  (just  as  in  congestion)  a  certain  interval 
of  time  generally  happened  between  the  application  of  the  exciting  cause  and  the 
apparent  development  of  the  inflammation.  This  accords  with  what  we  observe  to 
be  the  case  in  respect  to  local  injuries,  and  to  those  local  internal  inflammations  that 
are  apt  to  be  produced  by  exposure  to  cold.  There  is  a  pause  before  the  mischief 
lights  up:  or  (to  take  the  metaphor  from  the  eggs  of  birds)  there  is  a  period  during 
which  the  inflammation  seems  to  be  hatching,  and  it  is  called  accordingly  the  period 
of  incubation.  Kaltenbrunner  describes  inflammation  to  be  a  regular  process  —  as 
he  had  also  described  congestion  to  be. 

On  looking,  then,  at  the  web,  to  which  some  violence  had  been  done,  he  observed, 
after  the  first  irregular  disturbances  were  over,  and  when  the  period  of  mcubation 
had  elapsed — he  found  (I  say)  that  an  afflux  of  blood  took  place  to  the  part  about  to 
be  inflamed ;  the  velocity  of  the  blood  in  the  vessels  was  srreatly  accelerated ;  the 
vessels  themselves  were  distended  and  tense,  and  therefore  disposed  to  tighten  upon 
the  blood  they  contained — the  functions  of  the  part,  that  is  to  say,  the  secretion  and 
absorption  of  lymph,  were  interrupted ;  the  blood  underwent  an  evident  change — ■ 
or  it  failed  to  undergo  the  proper  changes :  its  globules  stuck  together,  and  the 
parenchyma  of  the  web  became  tumefied.  Now  all  this  is  just  what  I  represented 
to  you  in  a  former  lecture  as  constituting  the  state  of  the  blood-vessels  under  active 
congestion  ;  and  I  also  told  you,  at  the  same  time,  that  such  congestion  was  just  one 
step  short  of  inflammation.  The  congestion  now  described  increases,  until,  at  length, 
this  remarkable  alteration  happens :  the  capillary  tubes,  instead  of  tightening  upon 
their  contents,  dilate,  or  grow  larger;  the  circulation,  at  first  so  rapid,  begins  to  be 
delayed  in  some  of  the  capillaries  ;  the  direction  of  its  motion  becomes  uncertain  ;  it 
oscillates,  as  it  were,  irregularly  in  those  vessels,  and  at  last  stops  altogether,  the 
globules  cohering  in  irregular  masses,  and  thus  points  of  sJagnution  are  formed  ; 
and  these  points  of  stagnation,  if  the  affection  goes  on  increasing,  augment  in  .«ize, 
and  multiply  in  number.  Around  them,  beyond  their  circumference,  the  circulation 
remains  still  very  rapid,  and  the  congestion  persists.  This  is  injlammation — of 
which  the  characteristic  or  pathognomonic  feature  is  the  formation  of  these  points 
of  stagnation. 

Now  one  early  consequence  of  the  stagnation  of  the  blood  is,  that  a  portion  of  it 
transudes  through  the  sides  cf  the  vessels  containing  it :  the  serum,  or  the  liquor 
sanguinis,  or  even  sometimes  the  blood  itself;  red  particles  and  all.  The  effitsed 
serum  remains,  or  is  absorbed,  as  serum.  The  fibrin,  when  it  has  so  transuded, 
concretes,  and  thus  the  interstices  of  tissue  are  filled  up,  and  layers  of  coagulable  or 
coagulated  lymph  are  formed  upon  the  surfaces  of  inflamed  parts,  constituting  false 
membranes.  Under  certain  circumstances,  already  adverted  to,  other  or  further 
changes  take  place.  Microscopic  investigation  has  recently  discovered  a  number  of 
colourless  corpuscles  floating  in  the  liquor  sanguinis.  These  corpuscles,  passing  into 
the  interstices  of  the  inflamed  tissue,  or  stagnating  in  its  capillaries,  suffer  remarkable 
changes,  assume  a  yellow  colour,  and  are  thus  transformed  into  globules  of  pus.  So 
that  pus  is  nothing  else  than  altered  blood.  During  the  inflammatory  state,  the  cor 
puscles  sometimes  appear  to  muhiply  with  surprising  rapidity  ;  and  are  poured  forth, 


BLOOD    AND    BLOOD-VESSELS.  101 

in  their  new  shape,  like  a  secretion.  Pus  streams,  almost,  from  certain  mucous 
membranes  under  inflammation.  Whether  the  colourless  corpuscles  be  independent 
of  the  red  globules  of  the  blood ;  or  whether,  as  some  suppose,  they  are  originally 
derived  from  the  red  particles,  are  questions  which  must  be  regarded  as  being  a;//i»c 
sub  judice. 

Certainly  much  which  used  to  be  thought  mysterious  in  the  process  of  inflamma- 
tion has  been  rendered  more  simple  and  intelligible  by  modern  research.  Most  of 
the  events  or  consequences  of  that  process  are  traceable  to  the  stagnation  of  the 
blood  in  the  capillaries,  and  to  the  changes  which  the  stagnant  blood  subsequently 
undergoes. 

I  must  not  omit  to  tell  you  what  Kaltenbrunner  says  about  the  direct  absorption 
that  takes  place  in  the  inflamed  part.  He  found  that  the  colouring  matter,  and  the 
adipose  matter,  were  thus  taken  away.  The  web  of  a  frog's  foot  is  speckled  over 
with  little  stars  of  five  rays,  caused  by  a  black  pigment.  The  extremities  of  these 
rays  gradually  disappear  until  mere  black  points  are  left  in  the  places  of  the  stars. 
He  says  that  he  has  been  lucky  enough  to  catch  the  exact  moment  when  the  blood, 
circulating  rapidly  in  the  canals,  has  detached  a  particle  from  one  of  the  rays,  and 
carried  it  into  the  torrent  of  the  circulation.  In  the  sound  state,  the  mesenteric  vessels 
of  the  rabbit  are  surrounded  with  much  fat.  When  the  mesentery  is  inflamed,  the 
adipose  cells  soon  empty  themselves :  a  number  of  capillary  canals  are  developed 
upon  the  walls  of  those  cells,  and  it  is  probable  that  the  fat  is  carried  off  by  the 
blood  circulating  in  these  canals. 

Another  curious  and  interesting  sight  witnessed  by  Kaltenbrunner,  was  the  form- 
ation of  new  blood  canals.  He  says  that  in  an  organ  recently  inflamed,  when  th-e 
circulation  is  accelerated,  globules  of  blood  may  be  seen  to  sally,  all  of  a  sudden, 
from  some  capillary,  pass  into  the  surrounding  parenchyma,  force  themselves  a 
channel,  and  reach  another  capillary  canal.  Thus  a  new  capillary  channel  is 
formed ;  the  blood  circulates  through  it ;  its  formation  is  often  the  work  of  a  few 
seconds  only.  As  the  same  thing  is  repeated  in  different  parts,  a  rich  net-work  of 
new  capillary  canals  is  added  to  the  original  set,  whereby  it  happens  that  organs 
which  in  the  sound  state  are  but  slenderly  furnished  with  capillary  vessels  (as  the 
mesentery  of  the  rabbit)  present  an  astonishing  number  of  them  under  inflammation. 

W^hile  new  capillary  vessels  form,  the  old  ones  dilate,  and  assume  the  appearance 
of  small  arteries  or  veins  according  as  they,  are  continuous  with  the  arteries,  or 
border  on  the  veins. 

The  fact  has  long  been  known  that  when  coagulable  lymph  has  been  poured  out, 
in  inflammation,  blood-vessels  gradually  form  in  it,  whereby  it  obtains  a  vascular 
connection  with  the  surrounding  textures,  and  becomes  a  living  portion  of  the  body : 
and  these  microscopic  disclosures  of  the  manner  in  which  they  form  appear  to  me 
to  possess  a  peculiar  interest. 

I  should  be  making  a  very  wasteful  use  of  your  time  and  of  my  own,  if  I  entered 
into  the  undecided  and  unprofitable  disputes  that  have  been  raised  respecting  the 
vital  conditions  of  the  vessels  engaged  in  inflammation.  While  some  have  pretended 
that  the  action  of  the  smaU  vessels  is  increased,  others  assert  that  it  is  diminished  : 
that  the  vessels  are  in  a  state  of  atony.  For  my  own  part  I  have  never  yet  seen 
any  conclusive  evidence  that  the  capillaries  possess  any  vital  contractile  power  dis- 
tinct from  their  elasticity.  And  granting  them  such  a  power,  it  is  extremely  difficult 
to  conceive  how  any  increase  in  their  vital  contraction  should  produce  the  changes 
that  are  observed  in  inflammation.  Certainly  we  have  no  warrant  that  any  such 
contraction  takes  place,  in  the  results  of  microsco[)ical  examination  of  the  vessels  of 
an  inflamed  part.  The  inquiry  might  be  more  properly  directed,  I  think,  towards 
the  vital  conditions  of  the  nerves  of  the  part :  but  here  we  are  wholly  in  the  dark, 

1  do  not  think  it  so  evident  as  some  have  supposed  it  to  be,  that  a  greater  quantity 
of  blood  than  is  natural  passes  through  an  inflamed  part  in  a  given  time.  It  is  quite 
true — and  it  is  proper  that  you  should  be  aware  of  it — that  the  arterial  trunks  leading 
to  an  inflamed  part  often  pulsate  vvith  more  than  ordinary  force,  and,  if  opened,  pro- 
iect  a  jet  of  blood  further  than  they  would  naturally  project  it.     It  is  true  also  that 

1 2 


102  INFLAMMATION. 

a  venous  trunk  leading  from  an  inflamed  part  will  discharge  blood  faster  and  more 
copiously  than  a  corresponding  vein  leading  from  a  sound  part.  Mr.  Lawrence 
declares  that  he  has  frequently  tried  this  experiment,  and  always  with  similar  results. 
Finding  it  necessary  to  bleed  a  patient  whose  hand  and  forearm  were  inflamed,  he 
has  directed  a  vein  to  be  opened  in  both  arms  at  the  same  moment ;  and  he  has 
ascertained  that  about  three  times  more  blood  flowed,  in  a  given  time,  from  the  vein 
of  the  inflamed  limb  than  from  that  of  the  sound.  But  it  scarcely  follows  from  this 
that  more  blood  circulates  through  the  whole  of  the  part  actually  inflamed  :  the 
activity  of  the  circulation  in  the  vessels  that  remain  pervious,  and  are  merely  con- 
gested, around  the  focus  of  inflammation,  is  greatly  increased,  and  more  blood  circu- 
lates through  the  limb:  and  yet  the  blood  may  be  stagnant,  or  scarcely  circulate  at 
all,  in  the  very  part  that  is  strictly  and  truly  inflamed.  However,  the  fact  of  this 
increased  afflux  of  blood  towards  the  parts  concerned  in  the  inflammatory  process  13 
an  important  one. 


LECTURE  X. 

Inflammation  continued.  Bitffy  Coat  of  the  Blood.  Terminations  or  Events  of 
inflammation.  Fesohifion  —  Delitescence — Metastasis.  Effusion  of  Serum. 
Effusion  of  Coagrdable  Lymph,  or  Fibrin.  Organization  of  this  Lymph. 
Suppuration.     Ulceration. 

In  the  last  lecture,  after  giving  a  very  general  sketch  of  the  phenomena  of  inflam- 
mation, I  particularly  considered  its  four  characteristic  symptoms,  pain,  heat,  redness, 
and  swelling:  and  endeavoured  to  describe  the  changes  that  take  place  in  an 
inflamed  part,  as  they  are  seen  through  a  microscope. 

There  is  one  very  remarkable  and  important  circumstance  which  is  not  often 
absent  in  cases  of  inflammation,  but  which  hitherto  I  have  barely  mentioned :  I 
mean  a  peculiar  appearance  of  the  blood  itself  after  it  has  been  drawn  from  a  vein. 
A  portion  of  the  fibrin  at  the  upper  surface  of  the  coagulum  parts  with  its  colouring 
matter;  so  that  upon  the  deep  red  clot  there  is  to  be  seen  a  layer  of  yellowish,  or 
sometimes  of  a  bluish  white  colour,  varying  in  thickness  from  a  line  or  two  to  per- 
haps three-fourths  of  an  inch.  This  uppermost  whitish  layer  of  the  coagulum  is 
called  in  this  country  the  buffy  coat  of  the  blood.  Sometimes  the  surface  of  the  buff^y 
coat  is  flat  and  wide ;  but  often  it  is  contracted  and  concave ;  i.  e.,  the  diameter  of 
the  buffy  surface  is  less  than  the  diameter  of  the  lower  portion  of  the  clot,  and  it  is 
hollowed  out  into  a  cup-hke  form.  Accordingly  the  blood  is  said,  in  these  circum- 
stances, to  be  both  buffed  and  cupped.  The  formation  of  this  buffy  coat  appears  to 
be  favoured  by  many  circumstances  which  have  nothing  to  do  with  the  disease  under 
which  the  person  may  be  labouring ;  such  as  the  size  of  the  aperture  in  the  vein, 
the  manner  in  which  the  blood  flows,  the  form  and  size  of  the  vessel  that  receives  it: 
but  it  does  not  occur  at  all  except  in  certain  conditions  of  the  system  ;  and  it  belongs 
so  especially  to  the  state  of  inflammation,  that  blood  having  the  buffy  coat  upon  it  is 
often  spoken  of  as  inflammatory  blood,  or,  with  less  propriety,  as  inflamed  blood. 
Both  these  expressions  indeed  are  incorrect,  for  inflammation  sometimes  exists  with- 
out bufiy  blood ;  and  buffy  blood  sometimes  occur  without  inflammation.  The  phe- 
nomenon is,  however,  upon  the  whole,  a  very  valuable  index  of  the  nature  of  many 
cases  of  disease,  and  an  important  guide  in  their  treatment. 

Now  this  crust,  or  upper  layer,  or  buffy  coat,  consists  of  pure  fibrin,  mixed  with  a 
certain  quantity  of  serum,  which  M.  Gendrin  says  is  fuller  of  albumen  than  the  rest 
of  the  serum.  You  will  not  fail  to  notice  the  great  analogy  that  subsists  between  the 
buffy  coat,  and  the  coagulable  lymph  poured  out  in  inflammation,  either  into  the 
texture  of  the  part,  or  (as  I  shall  show  you  more  particularly  by  and  by)  upon  its 
surface,  forming  what  are  called  false  membranes.  Both  in  appearance,  and  in 
chemical  composition,  the  two  seem  to  be  identical;  and  no  doubt  exists  in  my  mind 


BUFFY  COAT  OF  THE  BLOOD.  103 

of  their  being  actually  the  same  substance:  the  separation  in  the  one  case  taking 
place  from  the  blood  while  contained  in  its  proper  vessels ;  in  the  other  case  from 
the  blood  after  it  has  been  removed  from  the  body. 

There  has  been  a  great  deal  of  speculation  among  pathologists  as  to  the  cause  of 
this  buffy  coat.  From  its  situation  it  is  piain  that  gravity  has  something  to  do  with 
its  formation:  that  the  red  particles,  leavmg  the  colourless  fibrin  before  it  coagulates, 
sink  downwards  by  their  own  weight.  But  though  the  subsidence  of  the  red  par- 
ticles is  occasioned  by  their  greater  specific  gravity,  their  separu'ion  from  the  fibrin 
is  not  to  be  explained  upon  that  principle  alone.  If  it  were,  then  it  would  follow 
that  the  slower  the  coagulation  of  the  blood,  the  more  time  would  there  be  for  the 
sinking  of  the  red  particles,  and  the  thicker  and  more  decided  would  be  the  buffy 
crust :  and  it  used  to  be  supposed  that  this  was  the  true  explanation  of  the  phenome- 
non. Careful  observations,  however,  have  shown  that  the  formation  of  the  buffy 
coat  often  takes  place  when  the  coagulation  of  the  blood  is  unusually  rapid.  Dr. 
Davy  and  M.  Gendrin  both  state,  as  the  result  of  much  attention  to  the  subject,  that 
the  coagulation  of  blood  drawn  from  a  vein  during  inflammation  begins  sooner,  and 
is  more  quickly  completed,  than  that  of  healthy  blood.  But  certain  observations 
made  and  published  by  Dr.  Stokes  have  settled  this  question.  He  noted  the  appear- 
ance of  the  blood  in  twenty-seven  cases.  In  fifteen  of  these  the  buffy  coat  presented 
itself;  in  twelve  it  did  not.  Now  in  three  of  these  twelve,  the  coagulation  of  the 
blood  did  not  begin  till  from  tv^enty  to  forty  minutes  after  it  was  drawn ;  and  in  four 
others  there  was  no  coagulation  for  eight  minutes.  So  that  theij  was  plenty  of  time 
for  the  red  particles  to  have  left  the  fibrin,  and  subsided ;  but  they  did  not  do  so.  On 
the  other  hand,  in  twelve  out  of  the  fifteen  cases  in  which  the  blood  was  buffed,  the 
coagulation  took  place  in  five  minutes ;  and  in  the  remaining  three  it  was  delayed 
only  fourteen  minutes. 

The  slowness  of  the  coagulation,  therefore,  although  it  may  and  doubtless  does 
favour  the  subsidence  of  the  red  particles  when  they  have  a  tendency  to  subside, 
cannot  be  regarded  as  the  cause  of  the  buffy  coat.  The  red  particles  very  soon  begin 
to  subside  when  they  subside  at  all :  you  may  tell,  immediately  after  it  has  been 
drawn,  and  prior  to  any  coagulation,  that  blood  is  about  to  buff,  by  a  peculiar  bluish 
hue  on  its  surface.  A  German  writer,  Shroeder  Van  der  Kolk,  has  stated  observa- 
tions to  the  same  purpose,  showing  that  in  the  blood  abstracted  by  venesection  during 
inflammation  there  is  an  unusual  disposition  to  a  separation  of  the  fibrin  from  the  red 
particles ;  a  sort  of  repulsion  between  them.  This  separation  takes  place  in  mere 
films  of  blood,  so  thin  as  not  to  permit  a  buffy  stratum  to  lie  above  a  red  stratum. 
The  fibrin  and  the  red  particles  then  separate  from  each  other  latterly  by  horizontal 
movements,  and  the  films  acquire  a  speckled  or  mottled  appearance,  quite  at,  charac- 
teristic of  the  state  of  the  blood  as  the  buffy  coat  itself. 

That  the  formation  of  the  buffy  coat  depends,  however,  upon  some  vital  change 
in  the  blood  appears  probable,,  from  this — that  it  will  sometimes  vary  greatly  in 
different  portions  of  blood  abstracted  at  the  same  bleeding.  Thus,  if  the  blood  be 
received  into  four  different  cups  in  succession,  it  will,  perhaps,  be  buffy  in  the  first, 
and  in  none  of  the  others;  or  it  will  be  buffy  in  the  last  only ;  or  in  the  second  and 
third  only,  the  first  and  fourth  cups  being  free  from  buff.  Attempts  have  been 
made  to  explain  these  rapid  variations.  Some  have  fancied  that  the  inflammator' 
.?tate  having  been  remedied  by  the  removal  of  a  certain  quantity  of  blood,  the  blood 
that  flows  subsequently  is,  therefore,  without  the  usual  index  of  the  presence  of 
inflammation ;  but  this  explanation  will  not  apply  at  all  to  those  cases  in  which  the 
portions  last  drawn  are  the  only  portions  that  exhibit  the  buffy  crust.  Others  have 
suggested  that  the  state  of  the  nervous  system  is  principally  concerned  in  these 
sudden  changes ;  that  the  depression  caused  in  the  outset  of  the  bleeding  by  fear, 
and  the  faintishness  produced  towards  its  termination  by  the  lo^s  of  blood,  may  pre- 
vent the  appearance  of  the  buffy  coat  on  the  first  and  last  cups,  when  it  shows  itself 
only  in  those  that  are  intermediate  between  the  first  and  last.  We  cannot  rely 
much  on  those  hypothetical  explanations :  I  mention  them  to  impress  upon  your 
memory  the  facts  which  they  are  intended  to  explain. 


104  INFLAMMATION. 

There  are  two  or  three  different  forms  presented  by  buffy  blood ;  and  with  these 
you  ought  to  be  familiar. 

In  one  form  the  buffy  coat  is  thick,  tough,  contracted,  puckered  at  its  circum- 
ference, and  its  surface  is  cupped.  There  is  a  complete  separation  of  the  red  parti- 
cles, and  a  strong  aggregation  of  the  particles  of  the  fibrin  among  themselves.  The 
red  portion  of  the  coagulum  is  also,  in  these  cases,  round  and  contracted,  of  a  globu- 
lar shape,  firm,  detached  from  the  sides  of  the  vessel,  and  floating,  generally,  in 
transparent  serum. 

This  is  usually  seen  when  the  inflammation  is  violent ;  when  it  occurs  in  strong 
and  vigorous  constitutions;  and  more  I  believe  when  it  has  its  seat  in  certain  tissues, 
in  fibrous  and  serous  parts  especially. 

In  another  form,  the  w'hole  coagulum  is  large,  like  a  cake,  or  of  the  figure  of  the 
vessel  containing  it,  not  so  much  collected  into  a  spherical  shape  ;  and  the  buffy  coat 
is  thin  and  flat,  and  easily  broken.  Here  there  is  an  imperfect  separation  of  the 
colouring  matter  from  the  fibrin,  and  no  great  aggregation  of  the  particles  of  the 
latter.  This  kind  of  buffy  blood  is  apt  to  accompany  slight  or  partial  inflam- 
mation. 

In  a  third  form,  the  buffy  coat  is  thick  and  abundant,  but  it  is  flat  and  soft,  loose 
and  flabby,  like  paste ;  and  the  coagulum  often  adheres  by  its  edges  to  the  vessel  in 
which  the  blood  has  been  received :  there  has  been  considerable  separation,  and  but 
slight  aggregation.  The  serum  is  apt  to  contain  a  few  red  particles  distinct  from  the 
clot.  Such  blood  is  commonly  said  to  be  sizy.  Dr.  Alison  states  that  when  it  is  ob- 
served, some  other  cause  of  general  disorder  of  the  system  (continued  fever,  for 
example)  usually  co-exists  with  the  local  inflammation.  Probably  the  qualities  of 
the  blood  are  altered,  independently  of  the  inflammation  :  the  bufly  coat  taking  place, 
in  consequence  of  the  inflammation,  upon  blood  which  was  previously  in  a  diseased 
or  unnatural  condition. 

It  is  a  curious  fact  that  blood  drawn  by  leeches  never  exhibits  the  buffy  coat.  It 
seldom  appears  (yet  I  have  seen  it)  upon  blood  that  has  been  removed  by  means  of 
cupping  glasses. 

Ariirial  blood  is  liable  to  the  buffy  coat.  I  have  myself,  twice  at  least,  seen  it 
upon  blood  drawn  from  the  temporal  artery.  One  of  the  patients  was  violently 
maniacal  Avhea  the  blood  was  taken.  The  other  was  labouring  under  acute  inflam- 
mation of  the  membranes  of  the  spinal  cord,  of  which  inflammation  he  died. 

Blood  is  more  likely  to  buff",  cxieris  paribus,  when  it  is  made  to  flow  in  a  full 
stream,  and  when  it  is  received  in  a  deep  and  narrow  vessel. 

On  the  other  hand,  the  formation  of  the  buffy  coat  appears  to  be  hindered,  when 
the  blood  'rickles  from  a  small  opening  in  the  vein,  and  when  it  is  caught  in  a  large 
flat  vessel.  It  is  said  also,  that  the  buffy  coat  may  be  prevented  by  adding  to  the 
blood  a  solution  of  caustic  potass  ;  by  keeping  it  for  some  time  in  a  state  of  agitation  ; 
by  receiving  it  in  a  very  cold  vessel ;  or  by  suffering  it  to  fall  from  a  height  of  three 
or  four  feet,  [n  this  last  case  M.  Gendrin  supposes  that  the  prevention  is  owing 
partly  to  the  agitation  which  the  descent  of  the  stream  produces  in  the  blood  already 
in  the  vessel,  and  partly  to  the  circumstance  that  the  blood  is  cooled  as  it  passes 
through  the  air. 

It  is  seldom,  I  believe,  that  the  buffy  coat  appears  on  blood  drawn  at  the  very 
outset  of  inflammation ;  generally  a  day  or  two  elapses  before  it  shows  itself.  This 
is  just  what  we  might  expect  if  it  be  true,  as  it  has  been  conjectured,  that  this  un- 
natural property  of  the  blood  is  acquin^d  only  in  the  course  of  its  transit  through  the 
vessels  of  the  inflamed  part. 

I  have  dwelt  the  longer  upon  this  peculiar  appearance  of  the  blood,  because  it 
really  is  of  very  great  importance  in  determining  the  nature  of  various  complaints, 
and  in  directing  our  treatment  of  them.  Speaking  generally,  when  a  given  organ 
is  inflamed,  the  buffy  coat  is  more  marked  in  proportion  to  the  intensity  of  the  iii- 
llammation :  when  the  organ  is  not  known,  it  is  more  likely  to  be  of  a  fibrous  or  a 
serous  texture,  in  proportion  as  the  blood  is  more  decidedly  buffed.  The  api)earance 
hi  the  buffy  coat  is  especially  valuable  as  an  indication  of  treatment  in  cases  con- 
ccrnmg  wnich  we  are  in  doubt  whether  they  are  inflammatory  or  not.      On  the 


BUFFY    COAT   OF   THE    BLOOD.  105 

Other  hand,  if  we  have  good  evidence,  in  other  symptoms,  of  the  existence  of  m- 
flammation,  we  are  not  to  be  shaken  in  our  opinion  by  the  absence  of  the  buffy 
coat.  Inflammation  may  certainly  exist  without  it.  I  am  not  speakino;  now  of  shVht 
cases  of  inflammation,  which  do  not  disturb  the  general  system.  You  would  not 
look  for  buffy  blood  in  the  inflammation  that  supervenes  on  a  cut  finger,  or  in  a 
small  boil;  but  in  serious  inflammation,  attended  with  pyrexia,  the  buffy  coat  may 
be  wanting.  It  is  not  unfrequently  absent  in  inflammation  of  the  mucous  mem- 
branes, especially  in  inflammation  of  the  mucous  hning  of  the  bronchi. 

I  stated  before — what  is  quite  necessary  to  remember — that  buffy  blood  is  not  con- 
fined to  cases  of  inflammation.  The  blood  of  persons  affected  with  general  plethora 
is  often  found  to  present  a  buffy  coat:  and  the  same  thing  is  true  in  respect  to 
pregnant  women. 

Buffy  blood  is  no  necessary  measure  of  the  danger  of  the  disease.  The  blood 
drawn  in  acute  rheumatism  is  always  very  much  buffed  and  cupped :  yet  so  long 
as  the  disease  is  confined  to  the  joints,  it  is  quite  free  from  danger. 

Neither  is  the  appearance  of  buff"  on  the  blood,  taken  by  itself,  a  sufficient  war- 
rant for  abstracting  more  blood :  for  the  blood  will  sometimes,  in  common  inflam- 
mation, continue  to  be  buffy,  long  after  it  has  ceased  to  be  useful,  or  safe,  to  bleed 
the  patient. 

[In  nearly  all  the  strongly  developed  acute  inflammations,  there  is  an  excess  of  fibrin  and  of 
the  colourless  or  lymph  globules  of  the  blood.  From  three  parts  in  a  thousand,  which,  accord- 
ing to  Andral,  is  the  average  proportion  in  health,  the  fibrin  has  been  found  to  rise  to  six  or 
eight  parts.  In  some  cases,  MM.  Andral  and  Gavarret  found  it  as  high  as  ten  parts  in  the 
thousand  ;  namely,  in  pneumonia  and  acute  articular  rheumatism.  The  excess  of  fibrin  was 
noticed  by  Andral  in  cellular  inflammation,  or  simple  phlegmon,  in  acute  inflammations  of 
the  skin,  as  in  burns  and  erysipelas,  in  mercurial  stomatitis,  in  phlegmasice  of  the  mucous 
membrane  of  the  respiratory  and  digestive  organs,  in  acute  cystitis,  either  simple  or  com- 
bined with  nephritis,  in  all  of  the  phjegmasise  of  the  serous  membranes,  in  inflammation 
of  the  lymphatic  glands,  and  in  softening  of  the  brain.  But  it  does  not  follow  the  pustules 
of  small  jjox,  the  exantheme  of  measles  or  scarlatina,  or  the  patches  in  dothinenteritis. 

The  increase  of  fibrin  in  the  blood  is  manifested  so  soon  as  the  inflammation  begins.  M. 
Andral  is  inclined  to  believe,  from  what  he  has  remarked  in  cases  of  burns,  that  the  disease 
commences  in  the  solids  before  the  change  occurs  in  the  blood.  The  sympathetic  fever  in 
the  phlegmasiae  is,  he  thinks,  due  to  the  alteration  in  the  blood  from  the  excess  of  its  fibrin. 
With  the  increase  of  fibrin,  the  proportion  of  red  particles  remains  unafiected.  Even  in 
anemic  cases,  and  in  low  fevers,  in  which  there  is  a  diminution  in  the  proportion  of  fibrin, 
tlie  latter  becomes  abnormally  increased  whenever  inflammation  supervenes. 

To  this  it  may  be  objected,  remarks  Williams,  that  this  fever  frequently  rises  high  before 
the  blood  has  begun  to  exhibit  the  buSy  coat,  often  subsides  when  the  buffy  coat  is  most 
abundant,  and  is  sometimes  wholly  absent  when  the  blood  is  both  buffy  and  cupped,  as  in 
sub-acute  rheumatism.  But  he  admits  that  it  is  very  probable  the  excess  of  fibrin  may  con- 
tribute to  the  excitement,  and  it  certainly  materially  aflfects  the  duration  and  products  of 
inflammation. 

It  would  appear  very  certain  that  the  formation  of  the  buffy  coat  in  inflammatory  diseases 
is  in  a  great  degree  dependent  upon  this  excess  of  fibrin.  It  is  found  only  in  cases  where 
the  proportion  of  fibrin  is  abnormally  augmented.  In  ann?mia,  the  only  disease  excepting 
inflammation,  in  which  the  bufl^y  coat  is  observed,  notwithstanding  the  quantity  of  fibrin 
may  be  abnormally  small,  still  it  is  very  generally  in  excess  in  relation  to  the  red  globules. 
The  buffy  coat  forms,  also,  upon  the  blood  drawn  during  the  latter  period  of  pregnancy: 
when  the  blood  also  presents  an  excess  of  fibrin.  In  inflammation  the  buffy  coat  is  fre- 
quently not  present  in  the  blood  drawn  in  the  early  period  of  the  disease,  the  fibrin  no; 
being  as  yet  sufficiently  abundant,  while  it  becomes  less  and  less  marked  as  the  intensity  of 
the  disease  and  the  excess  of  fibrin  diminish. 

In  cases  of  indirect  prostration,  incident  upon  great  intensity  of  inflammation,  the  blood 
first  drawn  may  be  without  the  buffy  coat;  it  becoming  api)arent  only  as  the  pulse  and  heat 
of  the  surface  rise,  as  they  often  do  in  such  cases,  under  the  use  vi  the  lancet. 

According  to  Andral,  the  newly-formed  fibrin  in  inflammation  coagulates  more  slowly 
than  the  old. — See  Andral,  Patholog.  HcBmatol. ;  and  Williams,  Frincijiles  of  Medicine. — C] 

Some  pathologists  enumerate  several  terminations  of  inflammation.  Others  quai- 
rel  with  that  word,  as  inappropriate  ;  alleging,  with  great  truth,  that  the  inflamma- 
tion does  not  necessarily  cease  or  terminate  whenever  these  so-called  "  terminationjs" 
happen.     Some  of  them  are  in  fact  "co-existent  states,  or  successive  stages  in  the 


106  INFLAMMATION. 

progress  of  the  same  inflammatory  disease."  It  has  been  proposed  to  speak  ratlier 
of  the  local  effects  of  inflammation  :  but  even  this  phrase  is  not  free  from  objection, 
for  sometimes  (though  rarel}^)  there  are  no  local  effects  produced,  beyond  the  four 
symptoms  which  characterize  the  inflammation  itself.  I  think  the  events  of  iiijhtm- 
mation  is  an  expression  not  open  to  similar  cavils.  I  have  no  ambition  to  introduce 
new  modes  of  speech,  unless  when  those  already  in  use  are  inexact  or  inapplicable. 
It  is  enough  if  you  clearly  comprehend  the  meaning  of  the  teraas  I  employ.  Among 
the  events  of  inflammation  I  include  only  the  local  changes  observed  in  its  course. 
To  those  which  are  constitutional  I  must  afterwards  revert. 

You  will  recollect  that  I  did  allude,  in  the  last  lecture,  though  in  a  very  briet 
manner,  to  these  local  events  of  inflammation.  Their  frequency  and  importance 
render  it  necessary  that  we  should  consider  them  somewhat  more  particularly. 

One  of  these  events  is  the  simple  subsidence  or  resolution  of  the  inflammation : 
this  may  strictly  be  called  a  termination  also.  The  congestion  of  the  blood-vessels 
increases  till  the  blood  stagnates  in  some  of  the  capillary  canals  towards  the  centre  of 
the  affected  part,  which  is  then  said  to  be  inffatned;  but  the  disease  goes  no  further ; 
there  is  no  escape  of  the  blood,  nor  of  any  part  of  the  blood,  nor  of  any  of  the  con- 
stituents of  the  blood,  beyond  its  natural  channels  :  or,  at  any  rate,  there  is  no  sensible 
evacuation  into  the  inflamed  tissue,  or  next  to  none.  The  inflammation  begins  to 
recede ;  the  stagnant  blood  is  again  set  in  motion ;  if  there  have  been  some  slight 
effusion,  it  is  re-absorbed ;  the  rapidity  of  the  circulation  in  the  surrounding  vessels 
diminishes  ;  and  the  part  returns,  in  all  respects,  to  its  former  condition  and  integrity. 
This  may  be  considered  the  spontaneous  cure  of  inflammation  ;  and  to  this  event 
there  seems  to  be  always  a  natural  tendency.  It  may  be  promoted,  sometimes,  by 
art. 

When  the  process  of  resolution  is  unusually  stidden  and  rapid,  (as  it  occasion- 
ally is,  the  well-marked  phenomena  of  inflammation  completelj'-  disappearing  in  a 
few  hours,)  it  is  called  by  our  neighbours,  the  French,  delitescence.  And  when  the 
symptoms  of  inflammation  thus  suddenly  desert  one  part,  and  show  themselves  im- 
mediately afterwards  in  another  (as  not  unfrequently  happens  in  respect  to  the  joints 
in  acute  rheumatism,  and  between  the  parotid  gland  and  the  testicle  or  mamma  in 
the  mumps),  metastasis  is  said  to  take  place. 

This  transference,  as  it  were,  of  morbid  action  from  one  part  to  another  is  a  very 
curious  circumstance.  It  is  one  which  we  sometimes  endeavour  to  imitate.  We 
excite  inflammation  upon  the  surface,  where  we  know  its  effects  will  be  of  com- 
paratively little  consequence,  in  the  hope  of  diverting  it  from  some  internal  organ  in 
which  it  threatens  to  work  serious  or  even  fatal  changes.  We  follow  the  same 
principle  perhaps  when  we  apply  purgative  medicines  to  the  mucous  membrane  of 
the  aUmentary  canal.  To  denote  the  mode  of  cure,  by  stimulating  distant  parts,  the 
terms  o[  counter-irritation,  derivation,  and  revulsion  are  employed. 

Most  commonly,  even  under  moderate  inflammation,  some  amount  of  extravasation 
takes  place  into  the  texture  or  from  the  surface  of  the  part. 

The  first  effect  or  event  of  that  kind  which  we  notice,  is  the  pouring  out  or  effusion 
01  serous  liquid.  The  liquid  is  so  like  the  serum  of  the  blood,  that  it  is  called  serosity 
or  serous  liquid ;  and  there  can  be  no  doubt,  1  conceive,  that  it  consists  of  the  serum 
of  the  blood,  slightly  modified  perhaps.  You  will  recollect  my  stating  that  the 
swellirtg  which  accompanies  phlegmonous  inflammation  is  not  equally  firm  through- 
out the  wliole  extent  of  the  inflamed  part ;  that  it  is  hard  in  the  centre,  softer  towards 
the  circumference ;  and  that  in  the  latter  situation  it  sometimes  retains  for  a  few- 
seconds  the  impression  of  one's  finger; — pits.  Now  this  results  from  the  effusion 
of  serous  fluid  into  the  areolar  tissue  immediately  surrounding  the  part  inflamed :  ii 
is  neither  more  nor  less  than  (edema,  —  oedema  (which  may  exist  aiso  quite  inde- 
pendently of  inflammation)  being  a  filling  or  infiltration  of  the  areolar  tissue  with 
serous  fluid.  Anasarca  is  an  example  of  the  same  state,  on  a  larger  scale.  Now 
anasarca  is  very  constantly  produced  by  some  impediment  to  the  passage  of  the 
blood  along  the  veins ;  the  serous  portion  of  the  stagnating  blood  transudes  through 
the  coats  of  the  vessels :  and  I  apprehend  that  the  same  explanation  may  be  given 


COAGULABLE    LYMPH.  J 07 

of  the  less  extensive  oedema  which  takes  place  around   a  phlegmon ;   the   blood 
being  stagnant  in  the  neighbouring  capillaries. 

But  whatever  may  be  the  intimate  cause  of  serous  effusion,  it  is  one  of  the  earHest 
events  of  inflammation;  and  in  some  cases  it  is  its  most  important  event;  producing, 
mechanically,  new  symptoms,  and  giving  rise  to  conditions  of  the  most  perilous  kind. 
The  quantity  of  serous  fluid  poured  out  in  a  short  time  is  often  immense.  One  of 
the  pleura  may  be  thus  filled  in  a  few  hours,  and  the  whole  of  one  lung  strongly 
compressed,  and  the  respiratory  apparatus  reduced  to  one  half  of  its  customary  effi- 
ciency. And  if  inflammation  and  effusion  should  take  place  on  both  sides  of  the 
chest  at  once — if  double  pleurisy  should  occur,  as  it  sometimes  does — the  patient 
must  presently  perish  by  apnosa,  unless  his  condition  is  recognized,  and  free  vent  is 
given  to  the  fluid.  More  than  once  or  twice  have  I  seen  persons  snatched  from  the 
brink  of  suffocation  by  what  is  called  tapping  the  chest.  Fatal  coma  is  no  uncom- 
mon result  of  the  eflfusion  of  serosity,  as  an  event  of  inflammation,  into  the  ventricles 
of  the  brain. 

Even  in  the  areolar  tissue,  where  it  is  properly  enough  called  oedema,  a  very 
trifling  amount  of  this  serous  effusion  may  be  sufficient  to  destroy  life :  when,  for 
instance,  it  takes  place  into  the  submucous  areolar  tissue  of  the  glottis,  closing  up 
by  its  pressure  that  little  chink,  the  rima  gloltidis,  and  suffocating  the  patient  after 
another  fashion.  Here  also  art  may  come  to  the  rescue  :  an  urtijidal  chink  or  hole 
is  made  for  the  entrance  and  exit  of  air,  below  that  part  of  the  larynx  in  which  the 
disease  is  situated,  and  the  patient  is  deUvered  from  imminent  death.  I  have  had 
two  cases  under  my  own  care,  and  have  seen  several  others,  in  which  life  loas  so 
preserved.  I  allude  to  such  cases  now,  merely  to  convince  you  of  the  importance 
of  attending  to  this  event  of  inflammation,  and  of  studying  the  indications  of  its 
existence. 

Sometimes  some  of  the  small  vessels  give  way,  and  hemorrhage  into  the  part 
becomes  an  event  of  inflammation.  Some  slight  degree  of  this  occurs  probably  in 
most  cases ;  and  we  frequently  find  that  the  colouring  matter  of  the  blood  is  mixed 
with  other  effusions,  giving  to  the  serous  liquid  a  deep  tinge  of  red. 

1  hinted  before,  that  we  must  not  infer  inflammation  from  the  presence  of  serous 
effusion  alone.  Serum  will  exude,  I  believe,  from  loaded  veins,  even  after  death ; 
but  this  never  can  be  much  in  amount.  It  is  certain  that  dropsical  effusions  may  be, 
and  very  often  are,  the  result  of  congestion  of  a  purely  mechanical  kind. 

A  third  event  of  inflammation  is  the  efilision  of  what  is  called  coagulahle  hpnph, 
which,  as  I  explained  to  you  before,  appears  to  be  nothing  else  than  the  fibrin  sepa- 
rated from  the  other  constituents  of  the  blood,  and  concreted.  It  is  poured  forth,  at 
first,  in  a  state  of  solution,  or  in  a  soft  semi-fluid  condition,  and  mixed  with  more  or 
less  serosity  ;  but  the  fluider  parts  of  the  effusion  are  either  soon  reabsorbed,  or  soon 
separate  themselves  from  the  fibrin,  which  becomes  firmer,  and  at  length  solid.  The 
hard  central  portion  of  a  phlegmon,  in  its  earliest  stages,  owes  its  hardness  to  the 
presence  of  coagulahle  lymph  in  the  natural  interstices  of  the  inflamed  part ;  and  a 
similar  interstitial  deposit  of  the  same  substance  is  common  in  various  parts  of  the 
body,  as  a  result  or  concomitant  of  inflammation.  What  is  called  hepatization  of 
the  lung  is  one  instance :  the  spongy  texture  of  the  lung  is  blocked  up  and  solidified 
by  this  lymph.  In  certain  cases  of  erysipelas,  as  well  as  in  phlegmonous  inflam- 
mation, the  subcutaneous  areolar  tissue  is  rendered  dense  and  hard  in  the  same  way. 
The  white  Opaque  spots  which  are  often  seen  upon  the  cornea  are  produced  by 
lymph  interposed  between  the  layers  of  that  naturally  transparent  structure.  But 
the  most  striking  examples  of  the  effusion  of  coagulahle  lymph  are  to  be  seen  upon 
the  surfaces  of  inflamed  membranes :  it  forms  a  web  or  layer  which  by  decrees 
assumes,  itself,  a  membranous  appearance :  and  is  accordingly  called  by  morbid 
anatomists  a  false  or  an  adventitious  membrane.  Sometimes  several  layers  of  this 
kind  are  spread  over  each  other,  forming  adventitious  membranes  of  great  thickness. 
When  coagulahle  lymph  is  thus  poured  out  between  membranes  that  are  habitually 
in  contact  with  each  other,  it  often  causes  them  to  cohere :  just  as  two  leaves  of  a 
book  may  be  made  to  stick  together  by  a  layer  of  paste  put  between  them.  Thi.s 
result  is  very  common  indeed  with  serous  membranes,  especiai'v  the  pleurce.  the 


08  INFLAMMATION. 

pericard'mr.i,  and  the  peritoneum.  Lymph  is  said  also  to  be  poured  out,  under 
violent  inflammation,  from  mucous  surfaces.  In  croup,  the  interior  of  the  trachea  is 
inflamed,  and  a  substance  exudes  which  assumes  a  membranous  form,  and  adheres 
more  or  less  firmly  to  the  sides  of  that  tube,  or  is  coughed  up  in  ragged  fragments 
A  similar  effusion  takes  place  occasionally  from  the  mucous  lining  of  the  alimentary 
canal,  and  is  expelled,  with  the  othe**  contents  of  the  bowels,  in  shreds,  or  in  tubukr 
portions,  which  are,  in  fact,  casts  of  the  interior  of  the  gut.  I  say  coagidabh  lymph  is 
said  to  be  thus  poured  out ;  but  it  is  more  than  doubtful  whether  the  false  membranes 
in  these  cases  are  really  composed  of  fibrin.  Similar  films  form  within  the  uterus, 
and  are  moulded  to  the  exact  shape  of  its  cavity,  and  marked  with  indentations  that 
correspond  to  its  rugce ;  and  these  membrane-like  casts  are  at  length  separated  and 
extruded.  These  last  are  not  very  common  ;  but  I  show  you  one  which  came  from 
the  uterus  of  a  young  woman  who  was  a  patient  of  mine  in  the  Middlesex  Hospital 
not  very  long  ago.  You  may  see  lymph  deposited  like  beads,  upon  the  anterior 
surface  of  the  iris  under  inflammation ;  or  gluing  its  posterior  surface  to  the  crystal- 
hne  lens  behind  it,  and  rendering  the  pupil  irregular,  and  sometimes  immovable. 
The  internal  surface  of  the  heart,  and  especially  its  valves,  are  often  studded  with 
portions  of  lymph  much  resembling  warts.  When  the  opposite  sides  of  an  artery 
are  brought  together  by  a  ligature,  they  inflame,  and  become  united  by  the  same 
medium.  Coagulable  lymph  is  effused,  in  the  course  of  a  few  hours,  upon  the 
edges  of  a  cut  wound ;  and  they  adhere,  under  favourable  circumstances,  when 
placed  in  mutual  apposition.  This  surgeons  call  union  by  the  fust  intention;  and 
the  inflammation  which  is  accompanied  by  all  kinds  of  exudation  of  lymph,  or  fibrin, 
is  called  adhesive  inflammation  ;  or  the  adhesive  stage  of  inflammation. 

It  is  seldom  that  coagulable  lymph  alone  is  thus  poured  out.  Sometimes  it  is 
tinged  with  the  colouring  matter  of  the  blood.  Oftener  it  is  mingled  with,  or  at  first 
dissolved  in,  a  large  quantity  of  serous  fluid.  When  this  happens  in  serous  bags — 
as  in  the  pericardium  or  pleura — the  thinner  fluid  may  keep  the  opposite  membranes 
apart ;  and  for  some  time,  or  entirely,  prevent  their  agglutination.  Sometimes  the 
agglutination  is  partial,  and  the  uniting  portions  of  lymph  are  stretched  out,  by  the 
distending  effect  of  the  fluid  effusion,  or  by  the  natural  movements  of  the  parts,  into 
strips  or  bridles  of  adhesion. 

1  must  call  upon  you  to  notice,  in  passing,  that  although  this  event  of  inflamma- 
tion may  sometimes  perhaps  have  a  detrimental  or  destructiv^e  consequence,  yet  that 
in  a  vast  majority  of  instances  it  is  distinctly  a  salutary  and  conservative  event. 
Vision  may,  no  doubt,  be  destroyed  by  a  plug  of  lymph  which  shuts  up  the  pupil 
of  the  eye.  A  portion  of  intestine  may  become  strangulated  by  a  band  of  adhesion. 
Of  this,  which  is  a  mere  accident  of  the  adhesion,  I  have  seen  some  fatal  examples. 
The  closure  of  the  trachea  by  the  membrane  of  croup  is  not,  in  my  opinion,  a  fair 
case  in  point.  There  are,  at  any  rate,  but  few  exceptions  to  the  rule,  that  the  effu- 
sion of  coagulable  lymph  proves  beneficial  by  preventing  some  worse  event  of  the 
inflammation.  It  is  better  that  inflammation  of  the  areolar  tissue  should  be  limited 
and  hemmed  in  by  a  barrier  of  lymph,  than  that  it  should  extensively  diffuse  itself. 
It  is  better  that  the  bag  surrounding  the  heart,  when  it  happens  to  be  inflamed, 
should  become  adherent  to  that  organ,  than  that  the  inflammation  should  run  on  into 
suppuration,  and  fill  the  pericardium,  and  oppress  the  heart,  with  pus.  In  the  one 
case  life  may  continue  for  several  years ;  in  the  other  it  seldom  lasts  many  days.  It 
is  clearly  more  desirable,  and  more  consistent  with  the  safety  and  comfort  of  the 
patient,  that  his  lungs  should  be  fastened  to  his  ribs,  than  that  they  should  be  com- 
pressed and  flattened  against  his  vertebral  column.  I  shall  have  occasion  so  fre- 
quently to  speak  of  this  protecting  and  reparative  tendency  of  adhesive  inflammation, 
that  I  do  not  more  than  point  it  out  to  you  at  present. 

When  lymph  has  been  effused  upon  an  inflamed  surface,  it  very  readily  becomes 
vascular  and  organized.  Red  streaks  begin  to  be  visible  in  it.  These  are  incipient 
blood-ves.'^els,  which  may  soon  be  seen  to  communicate  freely,  and  to  be  continuous 
with  the  blood-vessels  of  the  inflamed  part.  The  plastic  lymph  is  fashioned  into  a 
definite  structure,  and  made  a  living  constituent  portion  of  the  body.  It  is  in  truth 
this  remarkable  plastic  property  belonging  to  the  effused  lymph,  tliis  aptitude  for 


COAGULABLE   LYMPH.  109 

Deing  organized,  which  invests  the  adhesive  inflammation  Avith  its  guardian  and  repa- 
rative character.  None  of  the  other  fluids  poured  out  under  inflammation  are  capable 
of  this  change.  It  is  in  this  way  that  the  lips  of  recent  wounds,  and  the  surfaces  of 
inflamed  membranes  in  contact  with  each  other,  are  permanently  stitched  together 
(if  I  may  use  so  homely  a  metaphor!,  by  living  vascular  threads.  By  this  needle- 
work of  nature  parts  recently  severea  from  the  body  may  sometimes  be  replaced  ; 
or  even  transferred  and  affixed  to  other  situations,  as  in  the  Talicotian  operation, 
whereby  a  new  nose  is  engrafted  in  the  place  of  that  which  had  been  lost.  It  is 
thus  that  ulcers  fill  up ;  successive  layers  of  lymph  exude,  and  are  in  succession 
attached  to  the  ulcerated  surface,  and  incorporated  by  tliis  organizing  process,  until 
the  breach  of  texture  is  repaired.  The  lymph  thus  organized  comes  at  last  to  resem- 
ble, very  exactly,  areolar  tissue,  more  or  less  condensed. 

The  length  of  time  required  for  the  pouring  out  of  coagulable  lymph  in  inflamma- 
tion— and  for  its  organization  after  it  has  been  poured  out — is  variable  under  differ- 
ent circumstances.  It  is  often  effused  very  early.  Dr.  John  Thompson  found  a 
distinct  layer  of  it  covering  wounds  he  had  made  in  an  animal,  in  less  than  four 
hours  after  they  were  inflicted ;  and  cases  are  related,  in  which  vascular  organiza- 
tion of  the  effused  lymph  ha^  appeared  to  have  been  effected  within  the  space  of 
twenty-four  or  thirty-six  hours.  Sometimes,  on  the  other  hand,  many  days  seem  to 
elapse  before  any  such  organization  is  observable. 

When  serous  fluid  and  coagulable  lymph  have  been  poured  out  in  considerable 
quantity,  and  simultaneously,  the  serous  fluid  is  often  rendered  turbid  by  the  admix- 
ture of  small  portions  of  lymph,  or  of  albumen,  diffused  through  it ;  and  flakes  of 
lymph  sometimes  float  in  it,  or  settle,  in  virtue  of  their  specific  gravity,  at  the  lowest 
part  of  the  cavity  containing  the  effused  matters. 

Several  conditions  seem  necessary  to  ensure  this  adliesive  form,  or  adhesive  stage 
of  inflammation.  The  inflammation  must  reach  a  certain  degree  of  intensity,  or  no 
lymph  will  be  effused ;  it  must  not  go  beyond  a  certain  degree  of  intensity,  or  the 
next  event  I  have  to  mention,  the  formation  of  pus,  will  interfere  with  the  adhesive 
process.  We  learn  also  from  what  takes  place  in  recent  wounds,  that  seclusion 
from  the  air,  and  the  absence  of  all  other  causes  of  irritation,  are  necessary  for  adhe- 
sion, or  union  by  the  first  intention. 

The  formation  oi  pus — suppuration — is  a  fourth  event  of  inflammation,  to  which 
brief  allusion  has  already  been  made. 

Many  opinions  have  been  broached  respecting  the  nature  of  pus,  and  the  manner 
in  which  it  is  formed.  I  shall  not  trouble  you  by  discussing,  nor  even  by  narrating 
them,  but  hmit  myself  to  stating  what  are  the  notions  held  on  these  points  by  the 
most  able  and  the  most  recent  observers. 

Pus,  then,  as  I  told  you  before,  is  altered  blood.  It  is  an  opaque,  smooth,  yellow 
ish  fluid,  of  the  consistence  of  cream,  and  having  no  smell.  I  speak  now  of  well- 
formed,  or  what  is  called  good,  or  healthy  pus ;  what  the  old  writers  spoke  of  as 
pus  laudabih.  This  has  been  thought  an  absurd  epithet:  but  it  serves  as  well  as 
any  other  to  express  what  was  meant,  viz.,  that  kind  of  pus  which  accompanies 
benign  forms  of  inflammation,  and  indicates  that  all  is  gomg  on  regularly,  and  pro- 
mises a  fortunate  ending :  pus,  in  short,  the  appearance  of  which  was  to  he  com- 
mended. It  is  certainly  not  more  absurd  than  the  term  healthy  pus.  This  pus 
laudabile  was  described  as  being  album,  Ixve,  et  xquale  —  light-coloured,  smooth, 
and  homogeneous.     This  description  of  good  pus  has  de^scended  from  the  time  of 

Hippocrates,  who  says.  To  hi  nvov,  a^intov  Xtvxov  ti  hui,  xai  uuaXov,  xai  Uiov,  xai  <o{  r^xn^fa 

8v(jw63j.  It  consists  of  yellowish  globules,  difflised  through  a  thinner  fluid,  which 
resembles  in  some  respects  the  serum  of  the  blood.  "  If  six  or  eight  ounces  of  good 
pus  be  suffered  to  stand  in  a  phial,  it  will  separate  into  two  portions ;  a  yellowish 
matter  will  sink  to  the  bottom,  and  there  will  be  a  slightly  yellow,  clear,  superna- 
tant fluid,  like  oil  in  appearance,  but  not  greasy  to  the  touch."  The  sediment  con- 
sists of  the  globules ;  which  Gendrin  supposed  to  be  the  red  globules  of  the  blood, 
altered ;  deprived  of  their  coloured  envelops,  an.d  swollen  or  enlarged.  But,  as  I 
stated  before,  the  opinion  now  prevalent  among  pathologists  is  that  these  pus-globules 
are  transmitted  "  colourless  corpuscles ;"  moreover,  that  they  are  hollow  cells. 

K 


110  INFLAMMATION. 

There  are  various  modifications  of  pus  ;  and  its  qualities  are  liable  to  rapid  altera- 
tion by  various  circumstances.  Sometimes  the  globules  are  few  in  proportion  to  the 
more  watery  part ;  and  then  the  pus  is  said  to  be  ichorous.  It  is  sroiioiis  when 
some  of  the  colouring  matter  of  the  blood  is  poured  out  with  it.  It  is  sometimes 
viscid  and  slimy,  from  an  admixture  of  mucus ;  or  flaky  and  curdled,  which  is  com- 
mon in  scrofulous  persons.  Sometimes,  also,  instead  of  being  inodorous,  it  is  horribly 
fetid.  Ail  abscesses  that  form  in  or  about  the  alimentary  canal  are  apt  to  contain 
pus  of  an  offensive  odour;  as  those  which  occur  in  the  tonsils  and  near  the  rectum. 
A  patient  of  mine,  in  the  hospital,  had  a  fluctuating  tumour  in  the  epigastrium, 
which  Mr.  Arnott  opened.  There  came  out  the  collapsed  bags  of  two  or  three 
hydatids,  and  a  quantity  of  stinking  pus.  The  liver,  no  doubt,  was  the  seat  of  the 
suppuration  in  this  case — and  perhaps  the  stench  might  be  owing  to  the  death  and 
decomposition  of  the  hydatids. 

Great  pains  have  been  taken  by  many  persons  to  discover  some  sure  criterion 
between  pus  and  mucus.  Healthy  pus  and  healthy  mucus  are  so  totally  unhke 
each  other,  that  they  never  can  be  confounded  together.  But  sometimes  we  can 
scarcely  say  whether  Ave  are  looking  at  mucus  so  altered  as  to  resemble  pus,  puri- 
form  mucus — or  at  genuine,  though  not  perhaps  praiseworthy,  pus.  I  shall  tell  you 
what  has  been  made  out  upon  this  point  hereafter,  when  I  ti-eat  of  phthisis ;  and  I 
shall  show^  you  at  the  same  time  that  the  distinction  has  not  that  great  importance 
which  is  sometimes  assigned  to  it. 

Pus  may  be  poured  out  into  one  of  the  natural  cavities  of  the  body,  and  then  it  is 
called  purulent  effusion.  It  may  be  contained  in  a  closed  cavity,  which  is  not  natu- 
ral, but  formed  by  lymph  and  condensed  areolar  tissue  ;  and  then  the  collection  of 
pus  is  called  an  abscess.  It  may  also  proceed  from  a  free  surface  of  the  bodjr — as 
the  skin,  or  a  mucous  membrane,  or  a  superficial  sore. 

In  the  natural  cavities  of  the  body  pus  seems,  sometimes,  to  mingle  gradually 
with  the  serous  effusion,  which  grows  turbid  and  whitish,  and  at  length  distinctly 
assumes  a  puriform  character.  But  in  much  the  greater  number  of  cases  the  forma- 
tion of  pus  is  preceded  by  the  effusion  of  coagulable  lymph,  with  or  without  the 
effusion  of  serous  fluid.  The  pus  in  these  cases  appears  to  be  poured  forth  or 
secreted  by  the  coagulable  lymph  after  it  has  become  organized.  Its  formation 
seems  to  characterize  a  more  advanced  stage  of  inflammation  —  to  denote  that  the 
inflammation  has  been  pressed  a  httle  beyond  the  adhesive  stage.  This  was  the 
opinion  of  John  Hunter,  who  was  the  first  to  teach  us  any  thing  w^orth  knowing 
about  the  process  of  inflammation.  It  is  also  the  opinion  of  Gendrin,  one  of  the 
latest  and  most  successful  investigators  of  that  process.  Hunter  thus  expresses  him 
self  on  this  subject : — "  The  new  formed  matter  peculiar  to  suppuration  is  a  remove 
further  from  the  nature  of  the  blood  than  the  matter  formed  by  adhesive  inflamma- 
tion." And  Gendrin  says,  "  between  the  purulent  fluid  of  inflamed  tissues,  and  the 
organizable  coagulable  fluid  (i.  e.,  between  pus  and  coagulable  lymph),  there  is  but 
0)2e  degree  of  more.'''' 

Even  the  preventing  or  the  allowing  the  access  of  air  to  the  surface  of  a  recent 
cut  will  make  all  the  difference  between  adhesion  and  suppuration.  And  the  same 
influence  of  the  air  in  promoting  the  suppurative  process  in  preference  to  the  adhe- 
sive is  remarkably  seen  in  various  other  cases.  In  simple  pleurisy — from  exposure 
to  cold — we  seldom  have  any  liquids  effused,  except  coagulable  lymph  and  serous 
fluid.  But  if  the  inflammation  has  been  caused  by  a  punctured  wound  from  without, 
or  by  laceration  of  the  pulmonanj  pleura  by  the  sharp  end  of  a  fractured  rib,  or  by 
a  perforation  of  the  pulmonary  pleura  by  the  extension  of  a  vomica  in  the  lung — in 
all  which  cases  air  finds  its  way  into  the  cavity  of  the  pleura — then  true  empyema 
lesull.^ — pus  is  formed.  S'  jso  in  pneumonia:  at  first  the  inflamed  lung  is  rendered 
solid  by  the  effusion  o*"  i<  ;. -liable  lymph  into  the  air  cells;  but  if  the  inflammation 
persists,  the  next  thing  iha  uappens  is  what  is  called  by  Laennec  gray  hepatization 
— a  puriform  infiltration  takes  the  place  of  the  lymph,  ^he  same  principle  is  exem- 
plified in  the  case  of  the  urethra ;  inflammation  of  the  free  surface  of  its  mucous 
membrane  leads  rapidly  to  the  formation  of  pus;  inflammation  of  its  attached  surface 
occasions  the  pouring  out  of  lymph,  which  produces  stricture.     And  in  general  I 


ULCERATION.  Ill 

think  it  may  be  said  of  surfaces  that  are  open  to  the  air,  of  teguraentary  membranes, 
that  either  pus  is  formed  upon  them,  under  inflammation,  without  any  previous 
effusion  of  plastic  lymph,  or  the  lymph  is  slight  in  amount,  and  transient  in  duration, 
and  presently  superseded  by  a  puriform  discharge.  We  have  every-day  examples 
of  this,  in  inflammation  of  the  conjunctiva,  of  the  bronchi,  and  of  the  bladder.  Per- 
haps it  is  in  this  principle  that  we  may  find  an  explanation  of  the  fact  that  whereas 
in  the  inflammation  of  the  areolar  tissue,  of  glandular  organs,  and  of  the  parenchyma 
of  the  viscera  generally,  the  pus  which  forms  is  collected  into  an  abscess ;  circum- 
ecribed  abscess  in  the  substance  of  the  lung,  from  common  inflammation,  such  as  we 
are  now  considering,  is  very  rare  indeed.  This  is  a  point  which  wUl  of  course 
come  under  our  consideration  again. 

There  is,  however,  manifestly  a  close  connection  in  many  cases  between  the  effu- 
sion of  lymph  and  the  effusion  of  pus ;  although  the  progress  and  effects  of  adhesion 
and  suppuration  are  very  different.  When  suppuration  takes  place,  the  pain  belong- 
ing to  the  inflammation  usually  abates,  or  ceases,  except  when  the  pus  is  imprisoned 
so  as  to  keep  up  the  pre-existing  tension.  Certain  remarkable  constitutional  pheno- 
mena also  declare  themselves,  which  I  shall  notice  again  hereafter. 

The  effusion  is  longer  continued  in  the  case  of  suppuration ;  and  the  quantity  of 
pus  is  more  copious  generally  than  of  lymph,  especially  in  the  serous  and  tegu- 
mentary  membranes.  When  pus  is  diffused  through  the  natural  textures  it  tends  to 
soften  and  separate  them — to  break  them  down :  whereas  the  direct  effect  of  the 
deposition  of  lymph  in  the  same  parts  is  to  consolidate  and  harden. 

The  time  required  for  the  formation  of  pus  is  extremely  variable.  Suppuration 
sometimes  very  quickly  follows  the  commencement  of  the  inflammation;  within  a 
few  hours,  as  in  gonorrhcsa.  Sometimes  it  is  postponed  to  a  very  distant  period, 
even  for  weeks. 

The  duration  of  the  suppurative  process  is  also  uncertain,  and  seems  to  have  no 
fixed  relation  to  the  intensity  of  the  inflammation  by  which  it  has  been  preceded  or 
accompanied. 

A  fiflh  event  o[  inflammation  is  ulceration.  You  may  remember  my  telling  you 
that  ivaltenbrunner  observed  the  progress  of  absorption  in  the  inflamed  tissues  which 
he  examined  by  the  help  of  the  microscope :  how  the  stellated  spots  gradually 
vanished  from  the  web  of  a  frog's  foot,  and  the  fat  from  the  mesentery  of  the  rabbit. 

Independently  of  these  microscopical  observations,  it  is  quite  evident  that  absorp- 
tion goes  on,  often  very  actively,  during  the  continuance  of  inflammation.  The 
effused  fluids,  or  products  of  inflammation,  the  serum,  the  lymph,  the  pus,  are  partly 
taken  up  again ;  and  not  only  are  these  products  of  inflammation  liable  to  be  so 
removed,  but  the  original  textures  of  the  body  are  carried  off  by  absorption.  We 
cannot  have  a  better  proof  of  this  than  the  progress  that  an  abscess  makes  to  the 
nearest  surface  at  which  the  pus  it  contains  may  be  discharged ;  the  intervening 
textures  are  gradually  absorbed.  Perhaps  a  great  part  of  the  principle  concerned  in 
this  progressive  approach  to  the  surface  is  pressure.  The  harder  tissues  of  the 
body,  the  bones  themselves,  yield  and  disappear  before  the  increasing  pressure  of  an 
aneurismal  tumour.  In  this  case  the  absorption  appears  to  be  independent  of 
inflammation. 

But  taking  the  process  as  one  of  the  events  of  inflammation,  we  may  say  with  Dr. 
Alison  that,  whenever  the  absorption  of  the  effused  lymph,  and  of  the  surrounding 
textures,  takes  place  in  excess — in  a  greater  degree,  that  is,  and  more  irregularly 
than  seems  to  be  required  for  any  useful  purpose — the  result  is  ulceration.  Th& 
term  is,  however,  commonly  restricted  to  those  cases  in  which  the  loss  of  ^substance 
occurs  upon  some  surface,  internal  or  external. 

Many  circumstances  influence  the  occurrence  and  progress  of  ulceration  ;  ami 
great  differences  are  observable  between  the  different  tissues,  in  respect  to  the  facility 
with  which  they  severally  ulcerate.  Ulceration  is  most  common  in  the  tegumentacy 
membranes.  It  is  frequently  met  with,  also,  in  the  inner  coats  of  the  arteries,  in 
cartilages  and  in  bones.  But  we  are  not  always  sure  that  it  is  in  these  cases  an 
event  of  inflammation.  Ulceration  is  rare  in  fibrous  tissues  of  all  kinds,  in  serous 
membranes,  and  in  the  outer  coat  of  arteries.     These  differences  have  importam 


112  INFLAMMATION. 

pathological  bearings.  But  I  may  not  slop  to  consider  these  at  present :  they  will 
be  particularly  noticed  as  the  course  proceeds.  When  I  state  that  ulceratfon  may 
lead  to  perforations  of  the  alimentary  canal — of  the  air-tubes — of  the  gall  and  urinary 
bladders — of  the  blood-vessels ;  and  to  the  fatal  escape  of  the  natural  contents  of 
these  organs ;  I  have  said  enough  to  convince  you  that  ulceration,  so  frequently  the 
object  of  the  surgeon's  care,  requires  no  less  attention  on  the  part  of  the  physician. 

There  are  certain  forms  of  ulceration  that  are  specific  in  their  nature :  with  these 
I  do  not  at  present  meddle.  The  process  of  ulceration  is  very  clearly  explained  in 
Dr.  Alison's  admirable  Ou/lines  of  PatJiology. 

There  are  three  things  generally  going  on  at  the  same  time  in  an  ulcerated  sur- 
face. First,  there  is  an  effusion  of  plastic  lymph,  by  which  what  are  called  granu- 
lations are  formed.  Granulations  consist  of  coagulable  lymph  which  has  become 
organized;  furnished  with  numerous  delicate  blood-vessels.  Secondly,  there  is 
suppuration  ;  and,  thirdly,  there  is  absorption  or  the  removal  of  parts. 

Sometimes,  apparently,  there  is  no  SKppuration  ;  we  see  no  pus  in  ulcers  of  the 
cornea,  nor  in  certain  cases  of  absorption  of  articular  cartilages. 

When  the  first  of  these  three  processes  gets  the  better,  if  I  may  so  speak,  of  the 
others,  the  lymph  overspreads  the  surface  of  the  ulcer,  fills  up  the  cavity,  and  the 
ulcer  heals  :  cicatrization  takes  place. 

When,  on  the  other  hand,  the  absorbing  process  predominates,  the  ulcer  extends 
itself — the  excavation  grows  larger,  or  deeper — or  both  larger  and  deeper :  and 
when  this  excess  of  absorption  is  great,  and  the  extension  of  the  ulceration  rapid,  it 
is  called  phagedenic  ulceration.  When  a  part  of  the  textures  perishes  during  the 
process  of  the  ulceration,  and  is  separated  in  entire  and  sensible  masses,  the  ulcer  is 
said  to  be  a  sloughing  ulcer.  "  When  the  process  is  slow,  the  lymph  effused  at  the 
base  and  round  the  edge  of  the  ulcer  is  hardened,  and  the  granulations  on  its  surface 
are  deficient,  the  ulcer  is  then  said  to  be  cullovs  or  indolent :  and  when  the  granu- 
lations are  larger  and  softer,  and  more  flabby  than  usual,  and  require  to  be  repressed 
before  the  ulcer  will  heal:  to  this  variety  of  ulcer  the  name  oi  fungous  ulcer  is 
given :"  and  the  coarse  and  too  luxuriant  granulations  are  called,  by  the  vulgar, 
proud  flesh.  These  several  terms,  in  the  senses  now  assigned  to  them,  you  will 
please  to  remember. 

It  is  by  regulating  the  three  processes  now  described — so  far  as  they  are  capable 
of  being  regulated  by  art — that  the  surgeon  and  the  physician  endeavour  to  obviate 
the  threatened  ill  consequences  of  ulceration,  and  to  promote  the  repair  of  the  tex- 
tures Avhich  have  been  destroyed. 

I  explained  to  you,  in  a  former  lecture,  that  inflammation  may  lead  to  a  wasting 
of  parts,  although  there  is  no  suppuration  or  ulceration.  The  testis  sometimes  withers 
as  a  consequence  of  inflammation  :  interstitial  absorption  takes  place.  Atrophy,  in 
short. 


LECTURE  XI. 

Mortification,  as  an  event  of  Inflammation.  Inflammatory  Fever.  Hectic 
Fever.  Typhoid  Fever.  Modification  of  Inflammation  by  differences  of 
Tissue;  Areolar  Tissue;  substance  of  Glands  and  Solid  Viscera;  Serous 
Membranes ;  Synovial  Membranes  :  Tegumentary  Membranes — Skin — Mu- 
cous Membranes;  Muscular  Tissue;  Arteries;  Veins;  substance  of  the 
Brah^ 

We  were  occupied,  when  last  we  met,  with  what  may  be  properly  called  the 
events  of  inflammation.  We  passed  in  review,  1st,  resolution  as  an  event  of  in- 
flammation ;  2diy,  serous  effusion  ;  3rdly,  the  pouring  out  of  coagulable  lymph,  con- 
stituting the  adnesive  form  or  stage  of  inflammation  ;  4thly,  the  fonnation  of  pus,  or 
suppuration ;  and  5thly,  ulceration.  The  pathology  of  these  several  events,  so  far 
ivi  it  is  understood,  and  the  change  of  symptoms  to  which  they  may  respectively  lead. 


MORTIFICATION.  113 

were  also  treated  of  as  fully  as  the  limits  of  my  course  allow.  At  the  close  of  the 
lecture  I  was  about  to  speak  of  the  sixth  and  last  event  of  inflammation  that  requires 
to  be  noticed:  vi2.  gangrene,  sphacelus,  mortijication. 

When  mortification  thus  succeeds  to  inflammation,  the  part  dies  ;  it  becomes  cold  ; 
all  circulation  through  it  is  at  an  end ;  all  sensation  in  it  is  over.  If  it  be  an 
external  part,  its  colour  changes  ;  from  being  red,  it  becomes  mottled,  purplish,  green 
or  black ;  decomposition  takes  place ;  vesications  appear,  filled  with  dark-coloured 
liquids  ;  air  is  extricated  also.  If  there  be  a  great  accumulation  of  fluid  in  the 
part  there  will  still  remain  tension ;  but  usually  the  mortified  part  is  flaccid  and 
boggy  ;  and  it  emits  a  cadaverous  smell. 

When  internal  parts  mortify  under  inflammation,  they  do  not  always  assume  this 
black  appearance ;  often  they  are  yellowish ;  or  the  soft  tissue  of  the  dead  part 
readily  imbibes  fluid,  and  takes  the  colour  of  the  substances  with  which  it  has  been 
in  contact.  We  see  sloughs  of  the  mucous  membrane  of  the  intestines  presenting 
the  ochrey  hue  of  the  fa3cal  matters  which  had  rested  upon  them. 

What  1  have  described  as  mortification,  occurring  externally,  and  succeeding  to 
inflammation,  is  such  as  the  surgeon  witnesses.  Sometimes  it  spreads,  and  loses  and 
confounds  itself,  insensibly,  with  the  adjoining  parts,  which  still  retain  life ;  and 
which  may  continue  actively  inflamed,  and  subsequently  perish  also.  Under  more 
favourable  circumstances,  a  distinct  boundary  line  is  formed  between  the  dead  and 
living  parts ;  and  nature  proceeds  to  amputate  the  portion  which  has  lost  its  vitality. 
7^he  process  by  which  this  is  effected  is  extremely  interesting.  Adhesive  inflam- 
mation constructs  a  barrier  of  lymph  against  any  further  advance  of  the  mortifi- 
cation ;  a  furrow  of  ulceration  marks  out  upon  the  surface  the  commencing 
separation,  and  (supposing  a  part  of  one  limb  to  have  become  gangrenous,  the  foot 
for  example)  the  furrow  gradually  deepens,  until  the  dead  part  is  completely  cut  off'. 
This  very  fact  shows  that  all  the  textures  of  the  body,  skin,  muscle,  nerve,  blood- 
vessel and  bone,  are  capable  of  being  removed  by  the  ulcerative  process.  Mean- 
while very  interesting  changes  occur  in  the  part  that  lives:  the  large  vessels  are 
Jilugged  up,  to  a  certain  distance,  by  the  coagulation  of  the  blood  contained  in  them 
the  coagulation  of  the  blood  following  its  stagnation.  They  are  further  sealed  up 
and  the  smaller  vessels  also  are  closed,  by  coagulable  lymph.  Were  it  not  for  these 
changes,  fatal  hemorrhage  would  follow  the  separation  of  the  dead  part.  Now  this 
is  just  what  a  surgeon  rudely  imitates  when  he  amputates  a  hmb ;  he  cuts  through 
the  parts  with  knife  and  saw,  and  he  ties  the  larger  blood-vessels  as  he  goes  along. 
He  follows  the  path  which  the  natural  processes  point  out ;  and,  in  truth,  a  great 
part  of  both  physic  and  surgery  consists  in  learning  what  are  the  expedients  of  rejiair 
and  preservation  for  which  provision  has  been  made  in  the  living  body ;  in  exciting, 
or  repressing,  or  directing,  or  imitating  those  natural  actions  which  generally  tend, 
and  often  suffice,  to  restore  health  and  to  save  life. 

Mortification  is  more  common  in  some  internal  parts  than  in  others.  It  is  frequent 
in  the  areolar  tissue ;  and  in  the  mucous  and  submucous  tissues  of  the  alimentary 
canal ;  in  the  throat,  for  example,  in  cynanche  maligna;  and  in  the  glandular  parts 
of  the  intestines  in  fever. 

[The  affection  of  the  throat  in  cynanche  mah'gna  is  not,  strictly  speaking,  mortification.  It 
has  been  shown  by  Bretonneau  and  others,  to  be  a  true  pellicular  inflammation.  The  false 
membranes,  by  which  the  fauces  are  covered,  either  in  part  or  entirely,  becoming  tinged  with 
blood,  assume  a  dark  or  almost  black  appearance,  and  exhale  an  intolerable  fcetor — whicli 
circumstances  have  caused  them  to  be  mistaken  for  sloughs — but  when  they  become  de- 
tached the  mucous  membrane  is  found  to  be  perfectly  entire,  and  without  any  appearance 
of  softening;  the  peculiar  odour  of  gangrene,  also,  is  absent. — C] 

Mortification  seldom  affects  the  other  mucous  systems — those  which  belong  to  the 
air-passages  and  the  urinary  organs.  It  occurs  sometimes — but  not  very  often — 
ill  the  substance  of  the  lungs.  It  is  seldom  met  with  in  serous  and  fibrous  tissues 
It  is  not  at  all  uncommon  in  bone  :  producing  exfoliation  when  it  is  slight  and  su- 
perficial ;  necrosis  when  the  entire  shaft  of  a  long  bone  dies.  In  these  cas^^s  the 
process  is  slow,  and  we  can  watch  its  repair ;  and  a  beautiful  process  it  is :  but  I 
must  not  stop  even  to  admire  it. 

8  K  2 


11 4  INFLAMMATION. 

Novv  mortification  is  no  certain  or  constant  event  of  inflammation.  It  depends, 
more  or  less  upon  various  causes  and  conditions.  Sometimes,  upon  the  mere  in- 
tensity of  the  inflammation,  as  sloughing  inflammation  of  the  genitals  ;  the  progress 
of  the  mortification  being  best  checked  by  those  measures  which  are  calculated  to 
abate  the  violence  of  the  inflammation.  The  sloughing  of  the  cornea  in  gonorrhoea! 
ophthalmia  is  another  example  to  the  same  purpose. 

1  Again  whatever  tends  to  weaken  the  circulation  in  the  part  affected — or  in  the 
system  at  large — tends  also  to  promote  the  perishing  of  the  textures  that  are  inflamed. 
In  persons  who  are  debihtated  by  fever,  the  mere  pressure  of  the  body  against  the 
bed  is  enough  to  produce  sloughing  of  the  integuments  of  the  sacrum,  hips,  and 
elbows.  The  same  phenomena  are  apt  to  occur  in  parts  that  are  palsied.  In  drop- 
sical patients,  with  feeble  and  impeded  circulation,  we  find  that  a  blister  on  the 
extremities,  where  the  circulation  is  the  most  feeble,  will  sometimes  cause  mortifi- 
cation ;  while  it  might  be  apphed  to  the  chest  without  any  risk  of  that  event.  Pro- 
bably, in  each  of  these  instances,  the  unhealthy  condition  of  the  blood  conduces  to 
the  sloughing  process.  Inflammation  of  the  stomach  and  intestines  is  marked  by 
a  strong  disposition  to  run  into  gangrene — and  this  again  is  consistent  w^ith  what 
I  formerly  mentioned,  of  the  depressing  influence  of  inflammation  of  these  organs 
upon  the  heart. 

It  is  necessary  to  remember  that  mortification  is  capable  of  being  produced  by 
other  causes,  as  well  as  by  inflammation.  The  death  of  frost-bitten  parts  is  perhaps 
scarcely  an  exception — the  phenomena  of  mortification  occur  in  them  after  the  re- 
application  of  a  certain  degree  of  heat — sufficient,  probably,  to  give  rise  to  more 
action  than  the  frozen  parts  can  bear  without  perishing.  But  the  mere  cutting-  off 
the  supply  of  arterial  blood,  independently  of  any  inflammation,  will  cause  mortifi- 
cation. Ossification  of  the  arterial  trunks,  and  consequent  stagnation  and  coagulation 
of  the  blood  in  them,  is  the  commonest  cause  of  the  dry  gangrene  of  old  persons — 
gangrena  senilis;  which,  by  the  way,  is  not  always  dry.  In  the  majority,  however, 
of  these  cases,  the  gangrenous  part,  not  being  preternaturally  loaded  with  fluid,  docs 
not  so  rapidly  putrefy ;  but  remains  dry  and  shrinks  up  again.  Again,  whatever 
tends  to  prevent  the  return  of  the  venous  blood  from  a  part  (as  a  firm  ligature  placed 
round  a  limb — or  the  constriction  of  the  gut  in  strangulated  hernia),  is  favourable, 
also,  to  the  production  of  mortification.  Probably,  here,  too,  the  direct  or  indirect 
pressure  made  upon  the  arteries  is  chiefly  concerned  in  occasioning  the  death  of  the 
part.  We  see  limbs  mortify  sometimes  after  their  principal  artery  has  been  tied  for 
the  cure  of  aneurism,  when  the  collateral  arterial  circulation  fails  sufficiently  to 
establish  itself:  we  see  the  same  thing  when  the  passage  of  the  blood  through  the 
main  artery  is  stopped  by  external  injuries. 

There  is  also  a  very  curious  form  of  chronic  and  dry  gangrene,  produced  by  the 
continued  u..e  of  diseased  grain  as  food — and  particularly  of  the  spurred  rye ;  and 
to  this,  as  a  distinct  disease,  I  may  perhaps  have  occasion  to  direct  your  attention 
hereafter. 

The  different  stages  and  events  of  inflammation  that  have  now  been  described  are 
accompanied  by  corresponding  disturbances  of  the  system  at  large.  These  were 
touched  upon  (barely  mentioned,  however)  in  that  rough  and  general  oulhne  which 
I  attempted  to  sketch  in  the  outset,  of  the  various  phenomena  of  inflammation  ;  and 
to  which  I  have  since  referred  as  a  type.  They  require,  for  many  reasons,  to  he 
considered  somewhat  more  minutely. 

When,  as  surgeons,  you  have  to  deal  with  external  inflammation,  you  have  no 
difficulty,  in  the  first  place,  in  ascertaining  its  actual  existence  :  you  see  it ;  and  you 
know,  besides,  merely  by  looking  at  the  part,  and  perhaps  handling  it,  whnt  changes 
it  has  undergone.  You  may  perceive  that  the  opposite  lips  of  a  wound  have  ad- 
hered :  or  that  a  phlegmon,  in  which  you  can  also  detect  fluctuation,  has  assumed  a 
pyramidal  form,  and  begins  to  look  white  upon  its  summit ;  or  you  observe  that  the 
abscess  has  broken  and  left  an  ulcer  behind  it,  which  pours  out  pus,  and  which 
shows  a  tendency  to  contract,  or  to  enlarge  itself:  or  you  may  remark  the  alteration 
of  colour  and  of  temperature  which  denotes  the  approach  of  mortification,  or  the 
uctual  death  of  the  part.     The  mere  exercise  of  your  external  senses  apprises  you. 


INFLAMMATION.  115 

not  merely  that  there  is  inflammaiion,  but  also  whether  it  is  of  the  adhesive  kind ; 
or  has  reached  the  degree  of  suppitration;  or  has  produced  gangrene.  At  the 
same  time  you  do  not  fail  to  notice  the  nature  of  the  constitutional  disturbance  that 
may  be  present ;  and  the  knowledge  thus  obtained  of  the  local  and  of  the  general 
symptoms  determines  your  plan  of  treatment. 

But  when,  as  physicians,  we  have  to  do  with  inflammation  of  internal  parts  of 
the  body,  and  when  the  local  changes  attendant  upon  that  process  are  concealed 
from  our  view,  the  case  is  very  different.  We  should  often  be  unable  to  make  out 
the  nature  of  the  disease  at  all,  if  the  presence  of  pyrexia  did  not  instruct  us.  Some- 
times the  constitutional  disturbance  is  all  that  is  apparent  until  after  death.  And, 
as  the  disease  proceeds,  we  frequently  are  able  to  judge  that  this  or  that  event  of 
inflammation  has  taken  place,  only  by  observing  the  indirect  symptoms  which  de- 
clare themselves  through  the  medium  of  the  system  at  large.  Yet  it  is  in  many 
cases  of  the  greatest  importance  to  mark  the  transition  from  one  stage  or  event  of 
inflammation  to  another ;  and  to  learn  whether,  and  in  what  degree,  the  more  urgent 
of  the  symptoms  depend  upon  the  inflammation  itself;  or  upon  the  effects  which  it 
has  produced.  I  do  not  mean  to  say  that  we  have  not,  sometimes,  as  sure  indica- 
tions afforded  us  by  direct  symptoms,  cognizable  by  the  sense  of  hearing  or  of  touch, 
of  the  state  of  internal  organs,  as  we  could  have  if  they  were  exposed  to  our  view. 
To  these  direct  symptoms  I  am  not  now  about  to  refer ;  they  must  be  spoken  of  in 
connection  with  the  diseases  to  which  they  belong.  But  the  information  which  the 
physician  gains  from  what  may  be  called  constitutional  symptoms  is  always  highly 
valuable :  and  it  is  sometimes  the  only  information  that  offers  any  guidance  to  the 
remedial  measures  he  ought  to  adopt. 

Inflammation  sufficiently  extensive  or  intense  to  disturb  the  general  system  at  all, 
is  attended  with  pyrexia ;  and  the  presence  of  pyrexia,  when  the  part  affected  is 
unseen,  marks  the  nature  of  the  disease.  The  most  prominent  of  the  symptoms 
that  denote  the  existence  of  inflammatory  fever  are  debiHty  and  chilUness,  followed 
by,  or  alternating  with,  increased  heat  of  skin,  and  increased  frequency  and  force, 
and  often  hardness  of  the  pulse,  with  considerable  derangement  of  most  of  the  natural 
functions  of  the  body.  Commonly  there  is  headache  and  confusion  of  thought,  lan- 
guor, thirst,  loss  of  appetite,  a  furred  or  white  tongue. 

Among  these  leading  symptoms,  the  chilhness,  often  amounting  to  shivering,  has 
this  particular  importance  attached  to  it,  that  it  marks  the  date  of  the  febrile  disturb- 
ance. And  it  is  worth  observing,  that  rigors  more  commonly  attend  the  commence- 
ment of  spontaneous  inflammation  than  of  inflammation  caused  by  external  injury. 

Now,  without  going  more  into  detail  —  of  this  febrile  condition  belonging  to  the 
early  stage  of  inflammation,  I  make  the  following  remarks  : 

1.  That  it  generally  succeeds  the  manifestation  of  the  local  symptoms  of  the  inflam- 
mation :  and  that  we  cannot,  therefore,  help  considering  the  fever  as  the  natural 
effect  of  the  inflammation. 

Kaltenbrunner  describes  an  experiment  of  this  kind.  He  says,  if  a  drop  of  alcohol 
be  applied  to  the  web  of  a  frog's  foot,  the  blood  presently  flows  towards  the  part  irri- 
tated, and  the  circulation  in  it  is  accelerated ;  congestion  takes  place,  and  follows  its 
known  march. 

If  the  dose  of  alcohol  be  augmented,  the  phenomena  of  congestion  increast  con- 
siderably, and  extend  over  a  larger  space  :  at  length  points  of  stagnation  appearing 
in  the  focus  of  the  affected  part  announce  the  establishment  of  inflammation. 

If  the  dose  of  alcohol  be  still  further  increased,  we  observe  that,  on  the  one  hant 
the  inflammatory  points  of  stagnation  become  larger  and  more  numerous ;  and  that, 
on  the  other,  the  circumferential  disturbances  of  the  circulation  extend  themselves, 
so  as  at  length  to  implicate  the  whole  of  the  circulating  system :  they  give  rise  to  a 
fever  which  is  added  to  the  iriflammation.  The  circulation  in  the  web  of  the  oppo- 
site foot  is  as  much  accelerated  as  in  the  vessels  surrounding  the  inflamed  part  in  the 
first  foot.  If  the  word  congestion  had  not  a  local  meaning,  we  might  call  fever  (he 
says)  a  general  congestion. 

Perhaps  the  fever  may  be  owing  to  the  circulation  of  altered  blood  throughout  the 
body.     We  know  that  the  blood  is  altered  in  these  cases,  inasmuch  as  it  is  found  to 


116  INFLAMMATION. 

contain  an  unusually  large  proportion  of  fibrin  ;  and  it  has  acquired  the  unnatura 
quality  whereby,  when  withdrawn  from  the  body,  and  allowed  to  coagulate,  it  exhi- 
bits the  buffy  coat. 

That  the  febrile  state  follows  the  local  inflammation  in  point  of  time,  is  then  the 
rule ;  but  this  rule  has  frequent  exceptions.  Erysipelas,  and  all  the  febrile  exanthe- 
mata, afford  instances  of  exception ;  the  fever  sets  in  before  any  manifestation  at 
least  of  the  local  symptoms.  These  are  indeed  diseases  of  a  specific  kind  :  but  the 
same  is  true  sometimes  of  diseases  that  appear  to  be  simply  inflammatory ;  such  as 
inflammatioB  of  the  lungs,  and  cynanche  tonsillaris.  There  are  other  cases  in  whicli 
the  local  symptoms  and  the  general  febrile  disturbance  appear  to  burst  forth  simul- 
taneously :  this  is  seen  in  certain  instances  of  pleurisy,  and  of  peritonitis. 

2.  Again,  it  is  a  curious  circumstance  that  the  inflammatory  fever  is  not  always 
proportioned,  in  its  degree  of  violence,  to  either  the  size  or  the  importance  of  the 
part  inflamed.  The  pyrexia  is  often  very  strongly  marked  in  ihat  common  com- 
plaint, the  quinsy,  inflammatory  sore-throat,  cynanche  tonsillaris — which  can  scarcely 
ever  be  said  to  imply  much  danger. 

3.  The  situation,  the  extent,  and  the  degree,  of  the  local  inflammation  being  the 
same,  the  fever  commouiy  runs  higher  in  young,  and  in  plethoric  persons,  and  in 
those  of  sanguine  temperament,  than  under  the  opposite  conditions. 

4.  The  inflammatory  fever  may  be  modified  in  the  outset,  or  very  early  indeed, 
by  the  nature  of  the  part  upon  which  the  inflammation  has  seized.  I  have  several 
limes  mentioned  the  peculiar  depressing  effect  upon  the  action  of  the  heart,  pro- 
duced by  inflammation  of  the  stomach  and  bowels,  and  of  some  other  of  the  abdo- 
minal organs  ;  and  particularly  by  inflammation  involving  their  peritoneal  covering. 
This  lowering  influence  (which  is  analogous  to  that  of  certain  mechanical  injuries 
to  the  abdomen)  has  been  supposed  to  depend  upon  the  subduing  and  sickening  kind 
of  pain  which  is  apt  to  accompany  inflammation  of  these  parts.  Probably  such 
pain  accompanies,  rather  than  causes,  the  depression.  However  the  latter  may 
arise,  it  gives  a  pecuhar  character  to  the  inflammatory  fever :  lessens  the  amount  of 
reaction,  or  abridges  its  duration ;  affects  especially  the  quality  of  the  pulse ;  and 
carries  with  it  a  strong  tendency  towards  death  by  asthenia. 

5.  There  is  no  doubt  either  that  the  character  of  the  inflammatory  fever  is  liable 
to  be  considerably  modified,  from  the  first,  by  the  previous  habits  of  the  patient.  In 
persons  who  have  been  habitually  intemperate — or  who  have  been  subject  to  long- 
continued  excitement  of  the  nervous  system  of  any  kind — the  fever  which  attends 
inflammation  approaches  more  or  less  to  the  typhoid  form,  from  the  very  beginning. 
The  febrile  reaction  is  less  strongly  pronounced.  The  functions  of  animal  life  are 
sooner  and  more  deeply  involved  in  the  train  of  morbid  actions.  Stupor  and  delirium 
are  apt  to  occur;  with  extreme  debility  and  irregular  movements  of  the  voluntary 
muscles.  Still  more  conspicuous  are  these  peculiarities  in  some  cases  of  inflamed 
veins ;  and  whenever  inflammation  is  produced  or  accompanied  by  the  introduction 
of  certain  animal  poisons  into  the  system. 

0.  The  relative  duration  of  the  inflammatory  fever  is  subject  to  some  variety.  Ii 
may  persist  for  a  little  while,  for  a  few  days,  even,  after  all  the  local  signs  of  inflam- 
mation have  disappeared:  this  happens  chiefly  in  persons  of  an  irritable  habit.  W© 
watch  such  cases  narrowly,  not  without  some  apprehensions  of  a  relapse.  On  the 
other  hand,  a  rapid  abatement  of  the  febrile  symptoms  sometimes  takes  place,  while 
the  local  changes  continue,  or  even  for  a  time  increase  in  extent.  Nevertheless,  we 
hail  this  change  as  a  favourable  augury  of  the  ultimate  result. 

When  inflammation,  external  or  internal,  has  gone  on  to  the  formation  of  pus,  ihat 
event  is  frequently  marked  by  the  supervention  of  pecuhar  symptoms ;  and  the 
character  of  the  fever  undergoes,  for  the  most  pan.  a  striking  alteration. 

It  IS  very  important  to  ascertain  the  time  when  this  event  of  inflammation  takes 
place,  or  is  at  hand  ;  for  the  measures  which  might  have  been  proper  and  necessary 
while  any  prospect  remained  of  the  resolulion  of  the  inflammation,  may  be  useless, 
and  even  hurtful,  if  continued  after  that  prospect  is  at  an  end. 

When  the  surgeon  perceives  any  indication  of  the  formation  of  pus  in  an  external 
part,  he  mostly  despairs  of  being  able  to  bring  about  resolution :  ceases  to  abstract 


HECTIC    FEVER.  117 

blood  from  the  part,  or  from  the  system ;  and  applies  perhaps  warmth  and  moisture, 
by  means  of  a  hnseed  poultice,  to  promote  the  suppuration.  And  a  corresponding 
change  of  plan  is  required  in  internal  inflammations. 

Now  the  commencement  of  suppuration  is  often  marked  by  rigors  ;  and  its  con' 
tiniiance  by  hectic  fever. 

If,  after  the  symptoms  of  inflammation  have  lasted  for  a  certain  time,  the  patient 
is  attacked  by  cold  shiverings,  followed  by  some  increase  of  heat,  that  circumstance 
alone  is  enough  to  make  us  suspect  that  pus  is  formed,  or  is  about  to  be  formed  :  and 
to  teach  us  that  the  measures  employed  to  effect  a  resolution  of  the  inflammation 
have  not  been  successful. 

Rigors  are  very  striking  symptoms ;  but  they  are  by  no  means  necessarily  con- 
nected with  suppuration.  They  usher  in,  as  I  presume  you  know,  most  forms  of 
fever,  appearing  at  the  very  outset  of  the  disease.  They  recur,  at  regular  intervals, 
in  intermittent  fevers.  SHght  causes  will,  sometimes,  produce  them.  They  often 
follow  the  introduction  of  a  bougie  into  the  urethra.  But  when  they  occur  after 
symptoms  of  infernal  inflammation  have  been  for  some  time  present,  they  denote, 
in  most  cases,  the  production  of  pus  in  the  part  of  the  organ  inflamed.  Sometimes 
one  such  shaking  fit  only  is  observed  :  sometimes  several  take  place.  When  they 
recur  it  is  usually  at  irregular  intervals  ;  but  cases  do  happen  in  which  the  shiverings 
indicative  of  internal  suppuration  are  so  strictly  periodic,  that  unless  all  the  circum- 
stances be  carefully  taken  into  the  account,  they  may  be  mistaken  for  signs  of  ague. 

The  leading  symptoms  of  hectic  fever  (by  which,  I  say,  the  continuance  of  sup- 
puration is  commonly  marked)  are  an  abiding  frequency  of  pulse ;  alternations  of 
chilliness  with  heat  and  flushing,  followed  by  perspiration ;  a  gradual  wasting  of  the 
bod)'' ;  and  progressive  debility. 

I  shall  hereafter  have  to  speak  of  a  very  difl'erent  kind  of  disease,  in  which,  how- 
ever, there  is  a  succession  of  symptoms  resembling  more  or  less  closely  the  series 
that  characterizes  hectic  ;  I  mean  remittent  fever  ;  the  succession  of  symptoms  being 
chilliness,  heat,  perspiration.  But  these  two  disorders  are  in  most  cases  discriminated 
from  each  other  by  the  circumstances  under  which  they  occur. 

The  symptoms  of  hectic  fever  often  creep  on,  at  the  outset,  insidiously,  and  almost 
imperceptibly.  "A  very  slight  degree  of  emaciation,  a  pulse  a  little  quicker  than 
ordinary,  with  a  small  increase  of  heat,  especially  after  meals,  are  often  the  first 
symptoms  which  can  lead  us  to  suspect  the  formation  of  hectic."  CuUen  has  de- 
scribed hectic  fever  as  consisting  of  two  exacerbations  in  the  twenty-four  hours- 
one  about  noon,  the  other  towards  evening ;  but  in  many  cases  the  latter  alone  is 
distinctly  marked.  The  patient  feels  shivery  and  cold  towards  night ;  then  the  skin 
becomes  hot  and  dry,  especially  in  the  palms  of  the  hands  and  the  soles  of  the  feet, 
and  the  pulse  more  frequent ;  and  in  the  middle  of  the  night  or  towards  morning,  he 
wakes  from  short  and  uneasy  sleep,  in  perspiration,  which  is  often  profuse.  Some- 
times, however,  there  are  two  or  three  fits  in  a  day.  The  paroxysms  are  shorter, 
and  less  regular,  than  those  of  intermittent  or  remittent  fever.  Each  of  the  three 
phenomena  constituting  the  series  may,  in  its  turn,  be  wanting:  and  even  if  the 
paroxysms  are  regular  for  two  or  three  times  together,  they  never  continue  to  be  so. 
Many  circumstances  connected  with  the  paroxysm  itself  are  very  distinctive.  "  The 
hectic  patient,"  says  Dr.  Heberden,  who  has  left  us  a  very  good  account  of  this 
affection  in  his  Commentaries,  "  is  very  little  or  not  at  all  relieved  by  the  breaking 
out  of  the  sweat ;  but  is  often  as  restless  and  uneasy  after  he  begins  to  perspire  as 
he  was  while  he  shivered  or  burned.  All  the  signs  of  fever  are  sometimes  found 
the  same  after  the  perspiration  is  over:  and  during  their  height  the  chilliness  will  in 
some  patients  return,  which  is  an  infallible  character  of  this  disorder.  Almost  all 
other  fevers  begin  with  a  sense  of  cold,  but  in  them  it  is  never  known  to  return  and 
to  last  twenty  minutes  or  half  an  hour,  while  the  fever  seems  at  its  height,  which  in 
hectic  will  sometimes  happen." 

Hectic  fever  is  one  of  the  fearful  accompaniments,  and  sometimes  the  most  strongly 
marked  symptom,  of  pulmonary  consumption :  and  where  the  existence  of  thai 
complaint  is  suspected,  yet  a  matter  of  doubt,  we  look  for  indications  of  hectic  fever 
with  the  greatest  anxieiy  and  dread. 


118  LNFLAMMATION. 

With  relation  to  hectic  fever,  considered  as  an  indirect  s3-mptom  that  suppuTTtion 
has  succeeded  to  inflammation,  and  is  still  going  on,  it  will  be  worth  your  while  to 
notice  the  strong  contrast  it  offers,  in  many  particulars,  with  the  injiammatory  fever 
that  attends  the  earlier  stages  of  inflammation. 

The  pulse  loses  much  or  all  of  its  hardness  and  strength,  but  it  remains  perma- 
nently more  frequent  than  the  pulse  of  health  :  the  appetite  returns  in  great  measure  ; 
the  thirst  abates ;  the  tongue,  instead  of  being  covered  with  a  white  fur,  becomes 
clean  and  moist  and  towards  the  end  is  sometimes  unnaturally  red,  or  speckled  with 
aphthoE  :  there  is  no  longer  headache  or  confusion  of  thought. 

A  few  more  touches  will  suffice  to  fill  up  the  picture  of  hectic  fever. 

The  face  is  usually  pale  ;  but  during  the  exacerbations  it  is  partially  flushed,  and 
very  often  a  characteristic  circumscribed  red  spot  appears  upon  either  cheek.  Besides 
the  evident  emaciation,  various  minor  changes  mark  the  want  of  proper  nourishment: 
the  skin,  when  not  perspiring,  is  harsh  and  scurfy ;  little  branny  scales  may  be 
rubbed  from  the  legs,  merely  by  the  friction  produced  in  drawing  off  the  stockings  ; 
the  hairs  become  fine  and  fall  off;  the  finger-nails  are  incurvated  into  an  adunque 
form;  and  the  sclerotic  coat  of  the  eye,  as  seen  through  the  conjunctiva,  becomes  of 
a  pearl}'  white.  As  the  disease  advances  osdematous  swellings  of  the  ankles  are 
very  apt  to  come  on. 

The  connection  between  hectic  fever  and  the  formation  of  pus  in  some  part  oi 
other  of  the  body  is  so  frequent,  that  it  has  been  deemed,  by  persons  of  great  expe- 
rience and  sagacity,  a  universal  fact.  Dr.  Cullen  tells  us,  in  his  First  Lines,  that 
he  had  never  seen  hectic  in  any  case,  when  there  was  not  evidenth^  or  when  he  had 
not  ground  to  suppose  there  was,  a  permanent  purulency  or  ulceration  in  some  ex- 
ternal or  internal  part.  And  Dr.  J.  Thomson,  speaking  of  the  opinion  that  hectic 
might  occur  independently  of  suppuration,  uses  these  words:  "But  till  facts  more 
decisive,  and  cases  more  accurately  described  than  any  which  have  yet  appeared 
are  produced  in  proof  of  that  opinion,  I  shall  think  myself  justified  in  adopting  the 
common  opinion ;  and  in  believing  that  hectic  fever  is  in  every  instance  connected, 
if  not  with  the  absorption,  at  least  with  the  formation  of  pus." 

The  notion  alluded  to  in  the  latter  part  of  this  quotation  was  at  one  time  very 
commonly  entertained,  viz.,  that  hectic  fever  resulted  from  the  reabsorption  of  pus 
into  the  blood  ;  but  there  are  many  facts  decidedly  opposed  to  this  behef.  Consider- 
able collections  of  matter  not  unfrequently  disappear,  i.  e.,  are  taken  up  again  into 
the  blood,  without  occasioning  the  slightest  approach  to  hectic.  Again,  hectic  will 
accompany,  and  be  kept  up  by,  a  scrofulous  joint  attended  with  an  open  sore,  and  it 
will  sometimes  cease  at  once,  and  completely,  upon  the  removal  of  the  diseased  limb 
by  amputation  ;  although  a  greater  quantity  of  pus  is  secreted  by  the  stump,  than 
had  been  secreted  in  the  diseased  part  previously  to  the  operation.  Facts  like  these 
prove,  I  think,  that  hectic  is  not  simply  a  consequence  of  the  absorption  of  pus  into 
the  blood  :  and  they  seem  to  have  suggested  to  Mr.  Abernethy  the  notion  (which 
was  held  indeed  by  John  Hunter  also)  that  sympathetic  hectic  fever  is  a  teased 
action  of  the  system,  endeavouring  to  throw  ofl'  what  annoys  it ;  the  cause  of  irrita- 
tion  being  removed,  it  ceases  forthwith.  | 

And  there  is  another  conclusive  circumstance  to  be  mentioned.  Notwithstanding 
the  opinions  I  have  just  now  quoted  from  Cullen  and  Dr.  Thomson,  I  believe  few 
persons  who  have  attended  to  the  subject,  doubt,  now,  that  there  is  such  a  thing  as 
idiopathic  hectic ;  hectic  unconnected  at  least  with  suppuration  anywhere.  We 
often  see  hectic,  or  a  general  state  of  the  system  not  to  be  distinguished  from  hectic, 
in  mothers  who  have  suckled  their  infants  too  long ;  we  see  it,  too,  sometimes,  if  I 
mistake  not,  in  newly  married  husbands :  and  it  may  be  noticed  as  occurring  more 
or  less  distinctly  in  those  who  labour  under  diabetes.  What  is  common  to  all  these 
cases  is,  that  there  is  an  habitual  drain  upon  the  system  beyond  what  the  nutriment 
taken  into  it  can  supply  and  counterbalance.  It  is  certain,  too,  that  hectic  fever 
sometimes  happens  in  phthisis,  not  only  before  there  has  been  any  expectoration  of 
puriform  matter,  but  prior  even  to  the  softening  and  suppuration  of  a  single  tubercle. 
J  call  to  mind  one  instance  in  particular  of  this.  The  hectic  was  distinctly  marked, 
znd  continued  long.    The  patient  died,  at  last,  comatose,  after  two  attacks  of  convul- 


MORTIFICATION.  119 

sion.  Two  or  three  large  scrofulous  tumours  were  found  imbedded  in  the  substance 
of  his  brain.  Various  other  organs  were  infested  with  tubercles ;  but  the  tubercles 
were  all  of  them  still  hard  and  crude. 

However,  setting  aside  these  rarer  cases  of  exception,  there  can  be  no  doubt  that 
hectic  fever,  considered  as  a  constitutional  symptom  of  mischief  that  may  reveal 
itself  by  scarcely  any  other  token,  and  especially  as  a  sign  of  suppuration,  deserves 
all  the  attention  we  can  give  it ;  and  for  that  reason  have  1  spoken  of  it  rather  at 
large.  Whenever  I  mention  hectic  fever  in  the  progress  of  these  lectures,  you  will 
know  all  that  I  wish  to  express  by  that  term. 

I  have  very  little  to  say  at  present  respecting  that  modification  of  the  general 
febrile  disturbance,  which  sometimes  attends  niortijication  as  an  event  of  inflamma- 
tion. I  stated  before  that  the  fever  is  apt  in  these  cases  to  assume  the  typhoid  form  ; 
and  to  be  characterized  by  sinking  of  the  pulse,  shrunken  features,  coldness  and 
clamminess  of  the  skin,  a  dry  and  black  tongue,  low  muttering  delirium  or  stupor, 
tremors  of  the  voluntary  muscles,  with  spasmodic  startings  of  their  tendons,  and 
insensibility  to  the  passage  of  fceces  and  of  urine.  I  must,  however,  now  inform  you 
that  these  typhoid  symptoms  are  no  constant  or  necessary  concomitants  of  mortifica- 
tion. The  natural  mode  of  death,  under  gangrene,  is  death  by  asthenia.  But  the 
tyohoid  state  involves  the  nervous  functions,  and  tends  to  death  by  coma.  When- 
ever, therefore,  typhoid  symptoms  supervene  upon  inflammation  which  ends  in 
sphacelus,  they  may  with  much  probability  be  attributed  to  some  contamination  of 
the  blood  by  an  animal  poison ;  and  such  contamination  may  have  taken  place  pre- 
vioudy  to  the  mortification,  and  have  even  helped  to  produce  it,  as  when  inflamma- 
tion arises  during  the  progress  of  the  contagious  febrile  disorders;  or  it  may  occur 
as  a  consequence  of  the  mortification  itself,  by  the  direct  absorption  into  the  system 
of  some  of  the  putrefying  and  poisonous  elements,  into  which  the  dead  part  has  been 
resolved. 

One  circumstance,  worth  bearing  in  mind,  as  sometimes  indicating  the  superven- 
tion of  internal  mortification,  is  the  sudden  cessation  of  pain :  giving  hope  to  the 
pati:3nt  and  his  friends  that  the  danger  is  over ;  but  not  deceiving  the  experienced 
physician. 

So  much,  then,  for  the  local  and  constitutional  events  of  inflammation,  considered 
generally. 

It  remains  for  me  to  make  some  observations  upon  the  modifications  of  inflamma 
tion,  according  as  it  affects  the  different  tissues  of  which  the  body  is  composed. 
Many  of  these  observations  I  have,  indeed,  already  anticipated  ;  but  it  will  be  useful 
to  bring  together,  under  one  view,  the  most  material  facts  ascertained  on  this  matter 

When  inflammation  affects  the  areolar  tissue,  all  the  events  of  inflammation 
which  I  have  taken  some  pains  to  describe  are  apt  to  occur ;  and  for  that  reason, 
inflammation  of  this  tissue,  as  it  exists  beneath  the  skin,  was  chosen  by  me  as  a 
convenient  type,  or  general  representative  of  the  inflammatory  process.  It  is,  there- 
fore, the  less  needful  that  I  should  take  up  much  of  your  time  in  speaking  of  the 
characters  of  inflammation  exhibited  in  areolar  tissue.  There  is  a  strong  tendency 
to  form  circumscribed  abscesses :  the  extension  of  the  suppuration  is  prevented  by  a 
wall  of  lymph  built  up  around  it.  The  adhesive  inflammation  sets  bounds  to  the 
suppurative.  There  is  a  good  deal  of  pain  when  the  areolar  tissue  is  so  situated 
that  tension  is  occasioned  by  its  swelling. 

But  sometimes  no  such  boundary  wall  is  erected,  and  the  inflammation  spreads 
and  diffuses  itself,  and  becomes  a  very  terrible  disease,  destroying  the  areolar  tissue 
over  a  large  and  undefined  space  by  a  process  compounded  of  sloughing  and  of  bad 
suppuration.  When  the  skin  also  is  implicated  in  the  inflammation,  the  disease  is 
usually  called  erysipelas  phlegmonoides :  when  the  skin  is  not  involved,  it  has  been 
called  diffused  injlammution  of  the  cellular  membrane.  This  difilised  foim  of  in 
jiammation  frequently  follows  the  introduction  of  animal  poisons  into  the  systenj , 
and  accompanies  the  inflammation  of  veins  and  of  absorbent  vessels.  It  is  this 
disease  which  is  so  often  fatal  to  members  of  our  profession,  when  it  results  from 


120  INFLAMMATION. 

\vounds  or  punctures  received  in  opening  dead  bodies.  Dr.  Craigie  has  recently  put 
forth  the  opinion  that  in  these  cases  of  spreading  inflammation  it  is  the  adipose 
tissue  that  is  affected. 

The  substance  of  the  larger  glands,  and  of  the  solid  viscera  of  the  body,  suffers 
changes  analogous  to  those  observed  in  the  areolar  tissue  :  probably  because  areolar 
tissue  enters  largely  into  their  composition.  Acute  inflammation  of  the  liver,  when 
ii  does  not  terminate  in  resolution,  leads  to  abscess  in  that  organ.  Abscess  is  rare  in 
the  lungs,  perhaps  for  the  reasons  mentioned  in  the  last  lecture.  Gangrene  is  also 
uncommon  in  the  pulmonary  substance :  and  quite  unknown,  I  believe,  in  the  hver, 
and  very  rare  in  the  kidney.  Inflammation  of  the  latter  organ  is  not  unfrequently 
attended  by  purulent  collections.  Inflammation  of  the  substance  of  the  viscera  is 
not,  in  general,  attended  with  much  pain. 

The  areolar  tissue  is  hable  to  be  rendered  permanently  thick  and  hardy  by  chro- 
nic inflammation,  as  well  in  the  parenchyma  of  internal  organs  as  where  it  is  spread 
out  beneath  the  skin,  or  beneath  serous  or  mucous  membranes.  Chronic  induration 
and  thickening  of  the  areolar  tissue  which  composes  Glisson's  capsule  is  no  unfre- 
quent  result  of  slow  inflammation  ;  producing  that  particular  change  in  the  liver 
which  the  French  pathologists  denominate  cirrliose ;  but  of  which  the  essence  is 
atrophy  of  its  lobules  from  compression  of  its  nutrient  arteries. 

The  inflammation  of  serous  membranes  is  characterized  by  sharp  and  severe  pain  ; 
l)y  hardness  of  the  pulse  ;  and  by  bufly  blood ;  by  its  tendency  to  spread ;  by  the 
efTusion  of  serous  fluid,  and  of  coagulable  lymph  ;  and  sometimes,  when  the  inflam- 
mation is  very  violent,  or  air  gets  admitted  to  the  inflamed  surface,  by  the  effusion 
of  j)us.  Speaking  generally,  however,  it  is  adhesive  inJJammation  which  we  most 
expect  in  this  tissue.  False  membranes,  consisting  of  organized  lymph,  belong  to 
it :  and  the  agglutination  of  contiguous  surfaces.  Sometimes  the  l3-mph,  instead  of 
being  deposited  in  flakes  or  layers,  appears  in  the  form  of  numerous  small  granules  : 
this  is  a  phenomenon  frequently  observable  in  inflammation  of  the  arachnoid,  and 
of  the  peritoneum.  Sometimes  it  has  a  villous  or  papillary  or  shaggy  arrangement ; 
or  is  cellular  like  a  honeycomb.  This  is  common  in  the  ]iericardium.  The  surface 
(to  use  the  happy  simile  of  Laennec)  resembles  that  which  may  be  produced  by 
separating  two  flat  plates  between  which  a  layer  of  soft  butter  had  been  spread  :  and 
it  probably  depends  upon  a  similar  cause  ;  since  in  health  a  perpetual  sliding  mo- 
tion of  the  pericardium  over  the  heart  is  going  on.  Ulceration  of  a  serous  membrane 
is  very  uncommon.  I  mean  ulceration  coinmencing  in  that  tissue  ;  for  these  mem- 
branes are  frequently  perforated  by  ulcers  which  approach  them  on  their  attached 
side,  and  which  begin  in  other  tissues,  especially  the  mucous.  Neither  does  morti- 
fication occur  in  serous  membranes,  except  sometimes  by  communication  from  other 
parts.  The  effect  of  chronic  inflammation  of  the  serous  surfaces  is  to  thicken,  harden, 
and  pucker  them.  We  see  this  efl!ect  in  the  omentum  frequently  ;  in  the  peritoneal 
cover  of  the  liver ;  in  the  serous  membrane  which  forms  so  large  a  portion  of  the 
valves  of  the  heart. 

The  synovial  membranes  have  a  strong  analogy  with  the  serous.  Gendrin  includes 
the  two  in  the  same  category :  yet  their  behaviour  under  inflammation  offers,  in 
some  respects,  a  marked  distinction  between  them.  They  are  less  liable  to  inflam- 
mation than  the  serous  membranes:  they  rarely  throw  out  coagulable  lymph,  and, 
consequently,  adhesion  of  their  opposite  surfaces  is  very  uncommon.  Joints  do  not 
become  immovable,  or  what  is  called  anchylosed,  in  consequence  of  the  agglutina- 
tion of  their  synovial  surfaces  ;  but,  generally,  by  means  of  granulations  arising  upon 
those  surfaces  after  they  have  ulcerated.  Very  seldom,  indeed,  does  pus  form  in 
the  synovial  sacs,  except  (again)  the  inflammation  has  been  caused  by  mechanical 
injury,  which  has  laid  open  the  joint,  and  admitted  air.  When  this  is  the  case,  very 
serious  constitutional  disturbance  is  apt  to  take  place,  and  the  existence  of  the  sufferer 
is  endangered.  That  this  does  not  depend  upon  the  mere  violence  of  the  exciting 
cause  is  evident  from  the  circumstance  that  the  same  acute  inflammation,  the  same 
general  affection  of  the  system,  and  equal  danger,  often  result  from  the  careful  inci- 
sion made  into  a  joint  by  the  surgeon,  for  the  purpose  of  removing  loose  portions  of 
«:artilage.     I  have  now  at  the  hospital  an  out-patient  who  has,  among  other  ills,  a 


TEGUMENTARY  MEMBRANES.  121 

large  cartilage  floating  about  in  fluid  in  one  of  his  knee-joints  :  but  I  believe  that  Mr. 
Aniott,  whom  I  have  consulted  on  the  case,  will  be  very  slow  to  recommend  its 
removal,  until  the  inconvenience  produced  by  it  is  so  great  as  to  incapacitate  the 
patient  from  pursuing  his  employment,  and  until  other  methods  of  relief  have  failed. 
Suppuration  of  the  joints  is  also  one  of  the  occasional  consequences  of  phlebitis.  In- 
flammation of  the  synovial  membrane  speedily  leads  to  a  serous  elusion  into  the 
joint,  which  often,  especially  in  rheumatism,  is  as  speedily  taken  up  again. 

Let  us  next  inquire  into  the  modifications  which  inflammation  undergoes  when  it 
atiects  the  tegunientary  membranes. 

Considering  the  skin  as  one  membrane,  and  neglecting  its  subdivisions  into  epi- 
dermis, rete  mucosum,  and  cutis  vera,  we  find  that  inflammation  assumes  a  variety 
of  forms  in  this  external  covering  of  the  body.  Many  of  these  belong  to  specific 
diseases,  and  do  not  fall  within  my  present  purpose,  which  is  that  of  noting  how 
common  inflammation  varies  in  the  different  tissues. 

When  the  inflammation  is  superficial,  it  frequently  is  denoted  by  a  diffused  red 
blush  only,  which  may  be  banished  for  a  moment  by  the  pressure  of  the  finger,  and 
which,  after  a  certain  time,  disappears  of  its  own  accord — terminates  by  resolution  ; 
the  only  consequence  of  the  inflammation  being  the  separation  of  the  cuticle  in  small 
branny  fragments  ;  in  one  word,  desqtiamation.  We  call  the  superficial  inflamma- 
tion, in  this  case,  erythema.  If  the  inflammation  has  been  a  little  more  intense — as 
in  some  cases  of  erysipelas,  in  scalds,  and  in  that  which  we  are  every  day  exciting 
by  caatharides — a  serous  fluid  is  poured  out,  which  elevates  the  cuticle  in  larger  or 
smaller  patches  of  vesication.  Remove  the  cuticle  and  admit  air,  and  the  serous 
effusion  becomes  purulent  effusion :  and  if  the  inflammation  be  pressed  beyond  a 
certain  point  by  any  other  stimulus  besides  that  of  air,  we  may  have  pus  poured 
out.  Erysipelatous  (which  is  also  a  specific)  inflammation  of  the  skin,  is  character- 
ized by  its  remarkable  tendency  to  spread  ;  and  a  most  singular  circumstance  attends 
several  of  the  other  specific  inflammations  of  the  skin,  viz. :  that  having  occurred 
once,  they  never  occur  again  ;  this  peculiarity  belongs,  however,  to  the  great  consti- 
tutional diseases,  of  which  the  cutaneous  affection  forms  merely  a  part. 

Inflammations  of  the  internal  tegumentary  membranes — of  the  three  internal  sur- 
faces that  communicate  with  the  air,  and  are  clothed  with  mucous  membrane — are 
very  interesting  to  the  physician :  and  the  first  thing  which  strikes  our  attention  in 
respect  to  them  is  the  indisposition  they  manifest  to  adhesive  inflammation  :  and  we 
are  struck  at  the  same  time  with  the  beauty  of  this  provision.  If  the  mucous  mem- 
branes were  as  ready  to  throw  out  coagulable  lymph,  and  to  adhere  to  each  other  as 
the  serous,  almost  every  occurrence  of  inflammation  in  them  would  prove  necessa- 
rily fatal ;  by  closing  up  the  inlets  of  the  air  passages  ;  or  the  outlets  of  the  urinary 
passages  ;  or  any  part  of  that  long  mucous  canal  which,  passing  through  the  body, 
requires  a  free  opening  at  both  of  its  extremities.  But  the  inflamed  mucous  mem- 
brane pours  out  serous  fluid,  or  viscid  mucus,  or  pus,  or  blood.  Inflammation  of 
these  membranes  is,  however,  sometimes  [in  children  very  frequently]  attended 
with  the  exudation  of  something  which  is  very  like  coagulable  lymph,  and  which 
has  been  considered  fbut  in  my  opinion  erroneously  considered)  to  be  such  lymph. 
The  tracheal,  bronchial,  and  pulmonary  mucous  membrane,  the  oesophageal,  the 
intestinal,  and  that  which  lines  the  uterus,  are  all  more  or  less  subject  to  the  forma- 
tion of  adventitious  membranes  under  inflammation.  Casts  of  the  smaller  branches 
of  the  air-tubes  have,  in  rare  instances,  been  repeatedly  coughed  up  in  large  quan- 
tity;  constituting  what  have  been  very  inaptly  called  bronchial  polypi.  The  mem- 
branous exudation  of  croup  is  well  known :  a  tubular  substance  is  formed  in  the 
trachea,  and,  sometimes,  fortunately  expelled  :  but  too  often  it  suffocates  the  patient. 
Similar  concrete  exudations,  broken  into  irregular  shreds,  are  occasionally  voided  by 
stool.  It  is  said  that  a  long  membranous  mass  of  the  same  kind,  in  size  and  shape 
like  an  earth-worm,  has  been  discharged  from  the  urethra ;  having  formed  there  in 
coiisequence  of  the  injudicious  use  of  stimulating  substances,  injected  with  the  view 
of  checking  the  more  innocent  effusion  of  pus.  The  films,  or  membrane-like  flakes 
which  are  thus  incidental  to  inflammation  of  the  mucous  surfaces,  resemble,  I  say, 
n  their  general  appearance  and  disposition,  the  strata  or  layers  of  coagulable  lymph 


122  INFLAMMATION. 

which  are  the  ordinary  product  of  inflammation  of  the  closed  serous  surfaces.  Bat 
they  differ  from  these  in  some  remarkable  points.  They  are  softer.  They  never 
contract  permanent  or  strong  adhesions  to  the  subjacent  inflamed  membrane ;  but 
are  partially  separated  from  it  by  the  intervention  of  thinner  matters,  serous  or  puri- 
form.  Abov-e  all,  they  never  become  organized.  They  appear  to  consist  of  inspis- 
sated and  altered  mucus  ;  and  are  composed,  in  a  great  measure,  of  albumen.  An 
opinion  has  been  entertained  that  the  locmt  of  apposition  of  the  opposite  surfaces 
has  a  great  deal  to  do  with  their  indisposition  to  cohere.  The  mucous  «?>  tubes  are 
kept  open  and  apart  by  i\\e\Y  structure :  the  stomach  and  intestines  by  their  con- 
tents,  or  by  the  frequent  passage  of  solids  and  fluids  through  them :  and  therefore 
(it  has  been  supposed)  they  have  no  opporttrnify  of  adhering.  But  there  can  be  no 
doubt  that  these  mucous  membranes  are  but  little  disposed  to  throw  out  true  lymph 
at  all :  and  when  their  opposite  surfaces  do  grow  together,  I  believe  it  will  almost 
always  be  found  that  some  abrasion  or  ulceration  of  the  mucous  surface  had  previ- 
ously happened. 

Inflammation  affecting  the  mucous  membranes  has  sometimes  a  strong  tendency 
to  spread  and  wander :  sometimes,  on  the  contrary,  it  is  strictly  confined  to  a  small 
and  definite  space.  In  the  former  case  it  commonly  restricts  itself  for  a  long  time, 
or  altogether,  to  the  mucous  tissue,  leaving  the  neighbouring  tissues  untouched.  In 
the  latter  it  is  apt  to  penetrate  to  the  subjacent  parts,  and  to  produce  obvious  and  en- 
during alterations  of  structure.  The  membrane  becomes  faster  3d  to  the  parts  which 
it  should,  loosely  clothe,  and  not  unfrequently  it  ulcerates  or  sloughs. 

The  spreading  form  of  inflammation  is  most  often  met  Avilh  in  the  air-passages. 
Ulceration  and  sloughing,  and  circumscribed  inflammation,  are  more  common  in  the 
ahmentary  canal. 

There  is  a  remarkable  contrast  between  the  serous  membranes  and  the  mucous, 
in  respect  to  pain  which  attends  t/heir  inflammation.  Very  little  pain  is  experienced 
in  many  cases,  when  inflammation  affects  the  mucous  lining  in  any  of  the  three 
systems,  except  towards  their  openings,  where  the  membranes  are  about  to  become 
continuous  with  the  external  skin :  in  the  mouth  and  throat,  for  example,  the  pha- 
rynx, the  rectum,  the  vagina,  the  extremity  of  the  urethra.  And  as  inflammation 
of  the  mucous  membranes  is  attended  with  less  pain,  so  also  it  is  accompanied  by 
less  fever  than  when  the  serous  membranes  are  attacked  ;  and  the  blood  more  seldom 
exhibits  the  buffy  coat. 

The  muscular  tissue  appears  to  take  on  the  actions  of  inflammation  ver)'^  reluc- 
tantly :  and  its  vessels  seldom,  if  ever,  pour  forth  any  of  the  products  of  inflammation. 
The  chief  effect  of  inflammation  upon  muscle,  is  the  destruction  of  its  contractile  proper- 
ties. Serum  and  lymph,  and  even  pus,  are  sometimes  found  diffused  through  mus- 
cular parts ;  bi.it  there  is  reason  to  believe  that  these  eflusions  are  rather  the 
consequence  of  inflammation  of  the  areolar  tissue  which  enters  into  the  composition 
of  the  muscle,  and  ties  together  its  fleshy  fibres,  than  of  inflammation  of  those  fibres 
themselves." 

I  have  remarked  already  that  inflammation  of  an  artery  presently  leads  to  tho 
effusion  of  lymph,  and  the  coagulation  of  the  blood,  within  the  artery.  But  arteries 
do  not  readily  inflame,  except  under  mechanical  injury  ;  they  do  not  often  suppurate 
either:  and  they  possess  a  singular  power  of  resisting  mortification.  Dr.  J.  Thomp- 
son declares  that  he  has  seen  cases  of  phlegmonous  erysipelas,  in  which  "  several 
inches  of  the  femoral  artery  were  laid  completely  bare  by  the  gangrene,  ulceration 
and  sphacelus  of  the  parts  covering  it,  without  its  giving  way  before  death." 

Inflammation  of  the  veins  is  much  more  common  than  that  of  the  arteries  :  and  it  is 
a  disease  of  fearful  interest.  In  some  cases  it  leads  to  a  deposit  of  fibrin  upon  the  inside 
of  the  vessel,  "furring  it  over,"  as  Mr.  Hunter  says.  The  blood  soon  coagulates, 
and  blocks  up  the  inflamed  vein,  or  leaves,  perhaps,  a  narrow  passage  in  its  centre. 
From  this  mechanical  obstruction  to  the  current  of  the  blood  new  symptoms  arise 
The  part  from  which  the  venous  trunk  receives  its  tributary  branches  becomes  osde- 
niatous  or  dropsical.  Inflammation  of  the  femoral  vein,  obliterating  its  cavity,  is  the 
essence  of  the  complaint  known  to  pathologists   under  the   name  of  phlegmasia 


INFLAMMATION    OF   THE   BRAIN.  123 

dolens :  a  complaint  which  majr  happen  to  persons  of  any  age,  and  of  either  sex ; 
but  which  is  most  common,  in  women  soon  after  parturition. 

This,  which  may  be  considered  the  adhesive  form  of  phlebitis,  is  also  its  most  • 
innocent  form.  Too  frequently  the  inflammation  runs  into  suppuration :  and  then  it 
proves  a  most  terrible  and  almost  hopeless  disorder.  The  vein  remains  pervious: 
pus,  of  an  unwholesome  and  poisonous  qualitj^ — or  some  morbid  product  of  the  in- 
flammation— is  carried  into  the  blood ;  which  thus  scatters,  in  its  course,  the  seeds  of 
inflammation,  and  determines  the  rapid  formation  of  purulent  collections,  in  various 
and  distant  parts  of  the  body,  and  especially  in  the  lungs,  the  liver  and  the  larger 
joints.  Great  constitutional  disturbance  ensues,  and  fever  of  a  typhoid  type  is  often 
established.  To  this,  the  destructive  form  of  the  disease,  parturient  Avomen  are  also 
peculiarly  liable.  Phlebitis  of ^  the  uterine  veins  constitutes  the  source  of  the  most 
dangerous  and  deadly  varieties  of  puerperal  fever.  It  is  the  same  disease  which 
gives  to  a  vast  majority  of  those  surgical  operations  that  are  followed  by  death,  their 
fatal  character. 

We  hear  continually  of  inflammation  of  the  bram  ;  but  what  is  so  called  is,  most 
commonly,  inflammation  of  the  membranes  which  invest  the  brain.  Inflammation  of 
the  cerebral  substance  itself  is,  however,  not  very  uncommon ;  but  it  is  more  fre- 
quently the  result  of  injury  than  of  spontaneous  disease,  and  it  is  usually  confined 
to  a  limited  portion  of  the  brain.  Softening  and  suppuration  are  its  ordinary  events. 
Sometimes  pus  is  met  with,  occupying  a  distinctly  circumscribed  space  ;  the  pus  is 
collected  into  an  abscess.  Sometimes,  on  the  other  hand,  it  lies  loose,  as  it  were, 
and  surrounded  by  broken-down  cerebral  matter,  or  it  is  infiltrated  into  the  cerebral 
pulp.  Around  the  softened  portions  the  inflamed  substance  of  the  brain  is  more 
dense  and  firm,  sometimes,  than  is  natural.  Whether  this  be  owing  to  the  presence 
of  coagulable  lymph,  has  not  (so  far  as  I  know)  been  clearly  ascertained.  Mortifi- 
cation must  be  very  rare  in  the  nervous  substance.  Dr.  Bailhe  has  described  it  as 
occurring  after  violent  injury.  Once  or  twice  in  my  Hfe,  portions  of  brain  have  been 
shown  to  me,  protruding  through  an  aperture  in  the  skull,  dead,  of  a  dark  colour, 
and  having  an  offensive  smell.  Excepting  in  these  cases  of  hernia  cerebri,  I  have 
never  seen  sphacelus  of  the  brain  from  any  cause. 

Perhaps,  however,  I  am  incorrect  in  saying  this.  I  formerly  told  you  that  portions 
of  the  brain  often  become  soft  and  diffluent,  when  there  has  been  no  inflammation : 
but  simply  from  atrophy,  depending  on  a  diseased  state  of  the  nutrient  arteries  of 
the  brain.  Now  some  persons  call  this,  mortification  of  the  cerebral  substance. 
They  consider  it  quite  analogous  to  the  gangrena  senilis,  which  results  from  a  similar 
cause,  although  it  happens  in  another  part  of  the  body. 

The  nature  of  the  change,  they  say,  is  the  same,  although  the  physical  cha- 
racters of  it  differ.  If  this  be  so,  I  have  seen  gangrene  of  the  brain  some  scores  of 
times ;  but  still  I  should  be  able  to  declare,  that  with,  perhaps,  the  exception  already 
mentioned,  I  have  never  seen  unequivocal  mortification  of  the  cerebral  substance 
as  the  result  of  injlammation :  which  is  what  we  have  now  been  considering. 

This  concludes,  gentlemen,  what  I  have  to  say  concerning  the  phenomena  of 
common  inflammation,  as  they  are  perpetually  witnessed  in  the  various  textures  of 
the  body.  1  have  not,  indeed,  gone  through  aU  the  tissues  ;  I  have  said  nothing  of 
the  peculiar  effects  of  inflammation  in  cartilages,  for  example,  and  in  bones ;  but 
I  have  glanced  at  all  those  tissues  in  the  inflammation  of  which  the  physician  is 
chiefly  concerned.  Upon  such  points  as  I  have  purposely  omitted,  you  will  be 
amply  instructed  by  mv  colleaa-iie.  the  professor  of  surgery. 


124  INFLAMMATION. 


LECTURE  XII. 

Varieties  of  Injlammation:  Acute  and  Chronic;  Latent;  Specific.  Scrofulous 
Inflammation.  Tubercles.  Relative  frequency  of  Scrofulous  Disease  in  liifjer- 
ent  Organs.     Signs  of  the  Strumous  Diathesis. 

We  have  now,  gentlemen,  considered  the  phenomena  of  inflammation,  local  and 
general ;  its  symptoms  and  its  events ;  and  the  intimation  of  those  events  which  is 
aflx)rded  by  the  state  of  the  system  at  large ;  and  we  have  surveyed  the  principal 
tissues  of  the  body,  and  observed  the  modifications  and  peculiarities  to  which  the 
process  of  inflammation  is  liable,  according  as  it  is  situated  in  the  one  or  the  other 
of  those  tissues. 

There  are  still  some  varieties  of  inflammation ;  and  some  epithets  applied  to 
inflammation  ;  which  require  to  be  explained. 

Acute,  and  chronic,  inflammation  :  these  are  words  perpetually  in  our  mouths.  I 
have  frequently  employed  them  already.  What  do  they  mean  ?  Is  acute  inflam- 
mation difffc>rent  from  chronic  in  kind?     No:  they  differ  only  in  degree. 

When  the  disease  runs  its  course  rapidly,  and  is  attended  with  much  general  as 
well  as  local  disturbance,  it  is  said  to  be  acute.  When,  on  the  other  hand,  the  local 
and  constitutional  symptoms  are  less  violent,  and  the  inflammation  runs  a  longer 
course,  its  phenomena  following  each  other  in  slower  succession,  it  is  said  to  be  chro- 
nic. The  process  is  the  same,  but  its  features  are  less  strongly  expressed.  The  dis- 
ease passes  through  similar  stages  in  both  cases,  but  it  travels  at  a  different  pace. 
The  characters,  then,  of  acute  inflammation  are  intensity  of  symptoms  and  rapidity 
of  progress :  and  the  characters  of  chronic  inflammation  are  mildness  of  symptoms 
and  slowness  of  progress.  Inflammation  can  scarcely  be  very  violent,  and  at  the 
same  time  of  very  long  duration.  When  violent  it  has  been  likened  (by  Mr.  Law- 
rence, Avhose  language  I  have  here  adopted)  to  a  blazing  fire,  which  soon  burns  itself 
out.  It  may,  however,  be  mild  in  its  symptoms,  and  yet  quickly  over.  The  two 
terms  acute  and  chronic  are  not  directly  opposed  to  each  other :  acute  has  more  rela- 
tion to  the  intensity,  chronic  to  the  duration  of  the  disease  ;  and  some  term  is  wanted 
— althoueh  it  is  hardly  worth  seeking  for — to  denote  such  a  degree  of  inflammation 
as  exists  in  a  pimple  :  which  is  neither  severe  nor  long-continued. 

Now,  in  respect  to  intensity  of  duration,  there  are  innumerable  shades  of  difl^er- 
ence  in  difitrent  cases  of  inflammation;  and  the  same  difficulty  occurs  here  which 
always  occurs  when  general  terms  are  employed  to  express  mere  differences  of 
degree.  We  feel  no  uncertainty  or  hesitation  about  those  cases  which  occupy  the 
two  extremes  of  the  scale ;  but  with  regard  to  those  which  lie  in  the  middle  we  are 
often  at  a  loss.  To  meet  this  difficulty  some  pathologists  have  invented  a  third  epi- 
thet, viz.,  sub-acute,  intending  to  designate  thereby  cases  which  hold  an  equivocal 
rank  ;  which  are  neither  decidedly  acute  nor  plainly  chronic ;  in  which  the  inflam- 
mation may  run  a  brief  course,  and  be  attended  with  a  certain  degree  of  fever;  but 
attains  no  great  intensity,  works  no  profound  changes,  and  does  not  require  very 
tmergetic  remedies  to  control  it. 

You  must  not  suppose  that,  because  chronic  inflammation  is  attended  with  less 
tumult  and  disturbance,  it  is  necessarily  on  that  account  less  dangerous  or  less  de- 
structive than  acute.  The  latter  is  commonly  more  obedient  to  the  influence  of 
remedies  than  the  former:  it  is  usually  soon  brought  to  an  end:  whereas  chronic 
inflammation  is  often  obstinate  and  abiding,  and  leads  to  very  serious  changes  in  the 
part  upon  which  it  fastens.  Speaking,  generally,  it  tends  to  thicken  and  indurate 
when  it  is  situated  in  the  interior  of  organs,  and  to  the  effusion  of  pus  when  it  affects 
membranes,  or  surfaces.  It  is  more  common  in  weakly  and  debilitated  persons  than 
.n  others ;  but  you  must  not  forget  that  such  persons  are  also  very  liable  to  acute 
<nflaminaticn. 

Chronic  inflammation  is  not  unfrequently  a  sequel  of  acute  inflammation.  And 
vnat  the  two  differ  me'-ely  in  degree,  and  not  in  kind,  is  evident  from  this  :  that  acute 


VARIETIES   OF   INFLAMMATION.  125 

inflammation  may  sink  or  subside  into  chronic  ;  and  that,  on  the  other  hand,  chronic 
inflammation  may  readily  be  aggravated  into  acute. 

There  is  another,  but  less  inteUigible  division  of  inflammation  into  active  and 
passive.  I  believe  that  they  who  use  the  term  passive  inflammation  intend  to  signify 
by  it  that  languid  and  sluggish  kind  of  inflammation  which  is  apt  to  occur  under  the 
same  circumstances,  and  in  the  same  conditions,  with  passive  congestion.  When 
the  granulations  of  an  ulcer  are  in  that  state  in  which  they  may  be  made  brighter, 
smaller,  and  healthier,  by  the  application  of  a  stimulus;  when  the  blood-vessels  of 
the  eye  are  left,  after  acute  inflammation,  turgid  and  tortuous  ;  and  that  condition  is 
improved,  instead  of  being  worsened,  by  the  use  of  a  stimulating  lotion :  in  such 
cases  as  these,  some  persons  would  say  there  was  passive  inflammation.  But  I  see 
little  difference  between  this  and  chronic  inflammation ;  nor  do  I  know  any  differ- 
ence between  active  and  acute  inflammation. 

The  term  latent  inflammation  is  one  of  modern  introduction.  It  is  applicable  to 
those  cases  in  which  internal  inflammation  runs  its  course  silently,  treacherously, 
and  unperceived ;  without  the  usual  warning  tokens  of  its  presence ;  without  its 
more  striking  and  prominent  signs.  Pneumonia,  going  on  to  disorganization  of  the 
lung,  may  arise,  proceed,  and  even  prove  fatal,  without  any  of  the  symptoms  which 
ordinarily  announce  that  disorder :  without  notable  cough,  or  obvious  dyspnoea,  or 
complaint  of  pain,  or  the  expectoration  proper  to  pneumonia.  And  the  same  is  true 
of  other  inflammations.  We  discover,  with  surprise  and  horror,  the  traces  of  their 
operation,  when  we  come  to  examine  our  patient's  dead  body. 

This  is  a  most  important  form  of  inflammation ;  for  though  it  does  not  declare 
itself  to  ordinary  observation,  neither  does  it  occur  absolutely  without  symptoms ; 
but  it  requires  that  the  symptoms  should  be  looked  for.  The  auscultatory  signs  of 
pneumonia,  all  those  symptoms  which  are  furnished  by  the  physical  condition  of  the 
affected  organ,  are  present,  and  speak  as  clearly  as  in  the  more  flagrant  cases. 

Latent  inflammation  is  apt  to  creep  on  during  the  progress  of  certain  disorders, 
whereby  it  is  modified  and  masked.  It  belongs  to  those  states  of  the  system  in  which 
the  sensibility  is  dull,  and  the  vital  powers  languid.  In  continued  fever  not  only 
have  I  known  the  lung  pass  into  suppuration,  when  the  existence  of  pneumonia  had 
been  unsuspected :  but  I  even  have  seen  one  case  in  which  that  usually  torturing 
accident,  perforation  of  the  bowel,  took  place,  with  the  escape  of  its  contents  into  the 
cavity  of  the  abdomen,  and  extensive  peritonitis — yet  the  patient  expressed  no  sense 
of  pain,  and  the  inflammation  was  revealed,  while  he  continued  to  live,  by  no  intel- 
ligible symptom. 

Inflammation  of  this  insidious  and  lurking  character  is  most  to  be  apprehended  in 
the  aged,  in  those  who  are  habitually  intemperate,  and  in  persons  of  sluggish  tem- 
perament.    It  sometimes  occurs  during  convalescence  from  acute  diseases. 

Besides  the  varieties  which  have  been  mentioned  in  degree,  there  are  also  difl^er- 
ences  in  hind  among  inflammations.  What  I  have  been  speaking  of  during  the 
preceding  lectures  I  have  called  common  inflammation.  It  is  the  most  common  form 
in  which  that  process  displays  itself.  All  persons  are  liable  to  it ;  and  that  again 
and  again.  None  are  at  any  time  privileged  from  its  attacks.  But  there  are  several 
forms  of  inflammation  different  from  this,  which  are  called  specific.  There  are  vari- 
ous forms  of  specific  inflammation  affecting  the  skin,  discriminated  from  each  other 
by  the  local  appearances  they  exhibit,  and  by  the  constitutional  disorder  which 
attends  them.  The  rash  and  the  fever  of  measles,  are  very  unhke  the  rash  and  the 
fever  of  scarlatina  ;  and  both  differ  remarkably  from  those  of  small-pox,  the  eruption 
of  which  consists  of  little  phlegmons.  In  each  of  these  diseases  the  application  of  a 
specific  poison  is  required  for  its  production :  and  whereas  common  inflammatii;«L 
has  a  tendency,  when  once  it  has  happened,  to  happen  in  the  same  part  again — tc 
recur — these  forms  of  specific  inflammation  never,  or  almost  never,  occur  more  than 
once. 

There  is  again  the  gouty  inflammation — differing  from  common  inflammation  m 
<ieveral  signal  respects ;  in  the  production  of  chalk-stones ;  in  its  attacking  those 
who  are  descended  from  ancestors  who  have  had  the  disease,  and  scarcely  an/ 
others.     Then  there  is  rheumatic  inflammation,  cousin-german  to  the  gouty,  yet  dis- 

l2 


126  INFLAMMATION. 

linguishable  from  it.     And  another  variety  of  inflammation  is  that  which  arises  from 
•he  introduction  of  the  syphihtic  poison  into  the  system. 

Of  the  specific  forms  of  inflammation  now  adverted  to  I  shall  speak  when  I  come 
to  consider  gout  and  rheumatism,  and  the  contagious  exanthemata,  as  distinct  diseases. 
But  there  is  one  variety  of  inflammation — I  mean  the  scrofulous — which  meets  us 
on  everj^  side  ;  and  is  apt  to  afiect  so  many  parts  of  the  body,  and  so  great  a  number 
of  persons  ;  and  has  so  fatal  a  tendency  in  most  cases  :  that  it  cannot  be  left  out  of 
the  account  that  I  have  been  desirous  to  give  you  of  inflammation  in  general. 

Scrofulous  or  strumous  inflammation  (for  struma  and  scrofula  are  convertible 
terms)  is  a  slow  process  ;  it  falls  therefore  within  the  class  of  chronic  inflammations. 
It  is  not  attended  with  much  pain,  or  heat,  nor  for  some  time  with  much  change  of 
colour;  and  the  redness  which  does  accompany  it  has  often  a  livid  or  purplish 
tinge. 

These,  however,  are  the  negative  properties  of  merel}*  chronic  inflammation.  But 
suppuration  at  length  occurs,  which  also  lasts  long :  and  the  pus  formed  is  peculiar 
and  characteristic ;  and  by  no  means  laudable.  It  is  not  homogeneous  or  smooth,  but 
consists  partly  of  a  thin  serous  whey-like  fluid,  and  partly  of  fragments  of  a  substance 
resembling  curd :  and  the  ulceration  that  ensues  is  marked  by  corresponding  pecu- 
liarities. The  ulcers  are  indolent ;  show  but  little  disposition  to  heal.  Scrofulous 
inflammation,  compared  with  common,  or  what  is  called  healthy  inflammation,  is  in 
general  but  little  influenced  by  remedies. 

Besides  this  scrofulous  hiflammation,  it  is  necessary  that  I  should  now  direct 
your  attention  to  another  form  of  disease,  which  is  likewise  properly  denominated 
scrofulous.  It  is  marked  by  the  appearance,  in  various  parts  of  the  body,  of  what 
are  called  tubercles.  These  tubercles  are  masses  of  unorganized  matter  —  also 
resembhng  curd  or  new  cheese,  more  or  less  ;  but  of  various  shapes  and  sizes.  They 
suffer  gradual  changes ;  soften  or  break  down  ;  undergo  a  sort  of  suppuration  ;  and 
the  softer  matter  into  which  they  thus  (as  it  were)  mek,  has  the  characters  that  dis- 
tinguish the  pus  of  a  scrofulous  ulcer  or  abscess. 

Now  tubercles  and  scrofulous  injiamnuition  occur  very  continually  in  the  same 
individuals :  and  what  is  remarkable,  although  thej''  affect  a  very  large  portion  of 
the  whole  human  race,  and  conduce  more  often  and  more  surely  than  any  one  thing 
else  to  shorten  the  natural  period  of  human  life,  yet  they  belong,  almost  exclusiveh% 
to  certain  classes  of  persons.  We  can  tell,  beforehand,  that  such  and  such  persons 
are  likely  to  become  affected  with  scrofulous  inflammation,  or  with  tubercles :  and 
we  say  of  those  persons  that  they  hav  ■;  the  scrofulous  diathesis.  I  will  not  posi- 
tively affirm  that  these  forms  of  disease  cannot  be  produced  in  any  or  in  all  persons ; 
but  thus  much  is  certain — that  some  persons  are  particularly  prone  to  them :  fall 
into  them  as  it  were  spontaneously :  or  on  the  operation  of  very  slight  external 
causes ;  and  even  when  all  possible  care  is  taken  to  prevent  the  operation  of  every 
ascertained  cause ;  while  other  persons  never  show  any  tendency  to  scrofula,  even 
when  continually  exposed  in  the  same  manner ;  or  if  they  do  become  scrofulous  at 
all,  it  is  only  when  the  external  circumstances  most  favourable  to  the  production  of 
such  disease  have  been  extreme  in  degree,  and  protracted  in  their  application. 

The  occurrence  of  scrofulous  injlammation  in  various  parts  constitutes  distinct 
diseases ;  and  the  occurrence  of  tubercles  in  various  organs  constitutes  other 
diseases.  It  will  facilitate  our  future  inquiries  into  these  several  diseases,  if  I  take 
this  opportunity  of  staling  to  you  what  is  known  respecting  the  scrofulous  diathesis 
generally ;  and  of  the  modifications  of  inflammation  which  are  determined  by  its 
presence. 

A  good  deal  of  discrepancy,  obscuring  the  whole  subject,  and  puzzling  the 
student,  has  existed — and  I  believe  I  may  say  still  exists — among  pathologists,  as  to 
the  nature,  and  origin,  and  precise  seat  of  tubercles,  and  as  to  the  changes  which 
they  undergo. 

In  general  they  have  been  loosely  described  as  being  round  masses  of  firm  but 
friable  matter,  deposited  in  various  parts  of  the  body.  Laennec,  who  paid  great 
attention  to  tubercles,  states  that  they  are,  at  first,  small,  firm,  grayish,  semi-transpa 
rent  bodies,  which  gradually  enlarge  and  become  opaque.    In  that  condition  he  calL* 


TUBERCLES.  127 

them  crude  tubercles.  At  length,  after  an  indefinite  period,  these  crule  tubercles 
begin  to  grow  soft  in  their  centres,  and  are  by  degrees  converted  each  into  a  liquid 
mass,  having  the  consistence  of  cream.     There  is  much  error  in  this  description. 

Andral,  another  great  authority,  says  that  tubercles  are,  m  the  outset,  small,  round, 
opaque,  yellowish  bodies,  unorganized,  and  of  various  degrees  of  consistence.  He 
ascribes  their  softening  (not  to  any  spontaneous  changes  in  their  central  parts,  but) 
to  the  admixture  of  pus,  poured  out  by  the  textures  immediately  surrounding  the 
tubercle ;  which  has  irritated  and  inflamed  those  textures  as  any  other  foreign  body 
might. 

In  some  respects  this  statement  is  nearer  the  truth  than  Laennec's. 

But  in  the  account  which  I  am  about  to  give  you,  I  shall  chiefly  follow  our  coun- 
tryman. Dr.  Carswell,  the  first  Professor  of  Pathological  Anatomy  in  University 
College ;  who  is  one  of  the  latest,  and,  as  I  think,  most  satisfactory  writers  on  the 
subject.  His  opinions  were  formed  after  a  long  and  careful  examination,  for  himself, 
of  the  parts  infested  by  these  tubercles.  He  devoted  several  years  to  the  study  of 
morbid  anatomy,  in  Paris,  where  he  made  a  very  large  collection  of  drawings,  in 
which  various  diseased  appearances  are  beautifully,  and  doubtless  faithfully  deli- 
neated. Some  of  these  he  has  since  published,  1  show  you  enlarged  copies  of 
those  which  relate  to  tubercle.  They  bear  out  some  novel  opinions  which  are  stated 
in  the  letter-press  which  accompanies  them. 

After  all,  the  points  in  question  possess  more  of  curious  interest  than  of  practical 
importance.  But  as  you  cannot  help  forming  some  notions  respecting  them,  I  think 
myself  bound  to  lay  before  you  those  which  most  recommend  themselves  to  my  own 
judgment.  At  the  same  time  you  are  to  understand  that  I  do  not  vouch  for  their 
absolute  correctness. 

Tubercles,  then — or  rather  tubercular  matter,  is  deposited  from  the  blood.  Whether 
it  is  something  totally  new,  something  foreign  to  the  natural  materials  of  the  body, 
introduced  into  the  blood  from  without — or  whether,  as  seems  more  likely,  it  is  the 
result  of  some  defect  or  error  in  the  due  elaboration  of  the  blood  itself — I  cannot 
satisfy  you.  If,  as  has  been  supposed,  the  deposit  is  at  first  fluid,  it  afterwards  be- 
comes firmer,  through  the  absorption  of  its  more  watery  particles ;  and  there  then 
remains  a  "  pale  yellow,  or  yellowish  gray,  opaque,  unorganized  substance."  This 
tubercular  matter,  so  deposited,  does  not  always  assume  a  round  form:  far  from  it; 
the  shape  in  which  it  appears  depends  upon  the  nature  of  the  part  wherein  it  is 
planted.  It  used  to  be  held  that  the  tubercular  matter  was  always  laid  down  in  the 
areolar  tissue.  But  Dr.  Carswell  asserts  that  its  most  favourite  seat  (if  one  may  so 
speak)  is  the  free  surface  of  mucous  membranes.  In  whatever  organ  it  is  met  with, 
if  mucous  tissue  enters  into  the  composition  of  that  organ,  that  particular  tissue  is 
either  (he  says)  exclusively  affected,  or  much  more  extensively  affected  than  any  of 
the  other  component  tissues.  These  remarks  apply  to  the  lungs,  the  alimentary 
canal,  the  liver,  the  urinary  organs,  and  the  organs  of  generation ;  but  the  presence 
of  the  tubercular  matter  is  much  more  easily  detected  in  the  mucous  tissue  of  some 
of  these  organs  than  in  that  of  others.  It  is  very  conspicuous  in  the  Fallopian  tubes 
and  uterus. 

But  tubercular  matter  is  often  deposited  on  serous  surfaces  also;  among  which  Dr. 
Carswell  includes  the  plates  of  the  areolar  tissue.  It  is  even  to  be  seen  sometimes 
in  the  blood  itself:  not  indeed  while  it  is  retained  in  its  proper  vessels,  but  when  it 
is  collected  in  the  cells  of  the  spleen.  You  know  that  the  spongy  texture  of  that 
organ  allows  the  blood  to  accumulate  in  it  in  considerable  quantity :  and  the  tuber- 
cular matter  may  be  seen  forming  in  the  blood  at  some  distance  from  the  walls  of  the 
cells  in  which  the  blood  is  contained.  In  one  cell,  according  to  Dr.  Carswell,  you 
may  perceive  simply  the  blood  coagulated :  in  another,  it  will  be  coagulated  and 
deprived  of  its  colouring  matter;  and  in  another,  converted  into  a  mass  of  sohd 
fibrin,  having  in  its  centre  a  small  module  of  tubercular  matter. 

Now  when  a  speck  or  morsel  of  tubercular  matter  has  been  deposited  anywhere, 
il  is  liable  to  increase.  It  grows  larger  by  continued  accretion  ;  by  additional  deposits 
upon  its  surface.  This  being  the  case,  we  see  plainly  enough  how  it  happens  that 
tubercles  assume  different  shapes,  according  as  they  occur  in  different  parts.     Thn 


128  INFLAMMATION. 

round  form  which  is  so  often  observed  is  purely  accidental.  When  a  tubercle  is 
deposited  in  the  substance  of  the  brain — and  becomes  larger  by  the  repeated  acces- 
sion of  fresh  tubercular  matter  upon  and  around  it — it  naturally  takes  a  spherica. 
form,  because  there  is  nothing  to  limit  its  enlargement,  except  the  soft  cerebral  matter 
Itself,  nhich  presses  it  with  equal  force  on  every  side.  For  the  same  reason  tuber- 
cles deposited  in  the  areolar  tissue  are  globular.  In  like  manner,  if  tubercular 
matter  be  laid  down  in  one  of  the  pulmonary  vesicles,  so  as  to  fill  it  up,  it  exhibits 
the  roundish  form  of  the  vesicle.  When  it  fills  the  cavity  of  a  mucous  follicle,  it 
has  a  similar  figure.  But  in  the  smaller  bronchi  it  takes  a  more  cylindrical  arrange- 
ment. When  (as  often  happens)  it  occupies  one  of  these  tubes,  and  also  all  the  air- 
cells  to  which  that  tube  leads,  then  we  have  twigs  of  tubercular  matter,  with  cauli- 
flower terminations.  You  see  this  depicted  in  the  drawings  before  you.  In  the 
cavity  of  the  uterus,  and  the  Fallopian  tubes ;  in  the  infundibula  and  pelvis  of  the 
kidney,  and  in  the  ureters  ;  and  in  the  lacteal  and  lymphatic  vessels  ;  the  tubercular 
matter  is  moulded  to  the  forms  of  these  parts  respectively.  We  are  more  in  the 
habit  of  examining  tubercles  in  the  lungs  than  anywhere  ^Ise  ;  and  you  will  observe 
mat  in  making  sections  of  these  organs,  and  looking  only  at  the  surfaces  of  those 
sections,  we  may  easily  overlook  the  branch-like  disposition  of  the  tubercular  matter 
in  the  smaller  bronchial  tubes.  We  see  the  transverse  section  only  of  the  tubes, 
which  is  necessarily  more  or  less  circular.  On  the  surfaces  of  serous  membranes, 
whether  natural  or  adventitious,  the  tubercular  matter  will  assume  a  rounded,  or  a 
lamellated  form,  according  as  the  morbid  secretion  in  which  it  originates  has  taken 
place  from  separate  points,  or  from  a  continuous  surface. 

From  what  has  now  been  stated  you  will  perceive  that  no  alteration  can  be  ex- 
pected to  take  place  in  the  tubercular  matter  after  once  it  has  been  deposited,  except 
throucrh  the  agency  of  the  parts  around  it  and  in  contact  with  it.  It  is  never  org-an- 
ized,  or  capable  of  organization ;  md,  consequently,  no  vital  change  in  its  consist- 
ence can  originate  in  the  tubercle  itself.  If  any  spontaneous  change  arises,  it  must 
be  a  chemical  one :  and  of  such  we  have  no  evidence  at  all. 

It  may  therefore  seem  odd,  that  so  accurate  an  observer  as  Laennec  should  have 
persuaded  himself  that  the  softening  of  tubercles  begins  in  their  centre. 

Now  Dr.  Carswell  has  given  what  appears  to  me  a  sufficient  explanation  of  this 
mistake.  Take  the  lungs  ;  the  morbid  conditions  of  which  were  the  most  especial 
object  of  Laennec's  investigations.  The  tubercular  matter  is  effused  (principally) 
upon  the  mucous  surface  ;  upon  the  inner  hning  of  the  air-cells,  and  of  the  bronchial 
tubes  communicating  with  them.  Yet  it  need  not  so  accumulate  as  to  Jill  these 
cavities ;  and  it  often  does  not ;  there  is  left  a  central  vacuity,  which  contains  mu- 
cus, or  other  secreted  fluids  :  and  if  the  lung  be  cut  across  under  these  circumstances, 
the  divided  air-vesicles  will  look  like  rings  of  tubercular  matter  grouped  together; 
and  each  divided  bronchial  tube  will  present  also  the  appearance  of  a  tubercle,  with 
a  central  depression,  or  soft  central  point.  On  the  other  hand,  when  the  tubercular 
matter  has  completely  filled  and  blocked  up  these  cavities,  both  vesicles  and  bron- 
chial tubes  will  look,  when  divided,  like  sections  of  round  solid  tubercles.  These 
Laennec  seems,  in  fact,  to  have  regarded  as  crude  tubercles:  while  he  mistook  the 
former  appearances  for  tubercles  which  were  beginning  to  soften  in  their  centres. 

But  you  sometimes  find  large  masses  of  tubercular  matter  in  the  lungs  or  else- 
where :  and  in  these  masses  you  see  that  the  process  of  softening  is  going  on  at 
several  points,  within  the  mass,  at  the  same  time.  How  is  this  to  be  explained  ? 
Why  these  large  masses  are  formed,  in  fact,  by  the  aggregation  of  many  smaller 
masses,  Avhich  lying  near  each  other,  have  coalesced  as  the  deposit  continued  to 
increase :  and  the  areolar  and  other  tissues  originally  intervening  between  these 
coalescinor  masses  at  length  suppurate,  by  reason  of  the  augmenting  pressure  ;  and 
by  their  suppuration,  they  soften,  and  gradually  break  down  the  tubercular  matter 
•"hich  they  enclose,  and  by  which  they  are  also  enclosed.  This  is  just  the  process 
Dy  which  tubercles  are  frequently  expelled  from  the  body.  They  increase  till  the 
surrounding  parts  take  on  inflammation,  just  as  they  might  do  if  any  foreign  body 
exercised  the  same  degree  of  pressure  upon  them.  The  inflammation  thus  excited 
'..s  of  the  scrofulous  kind ;  the  thin  pus  which  is  thrown  out  pervades  and  loosens 


TUBERCLES.  129 

the  tubercular  matter ;  a  process  of  ulceration  which  goes  on  in  the  surrounding  tex 
tures  ;  and  at  length  (supposing  the  lung  to  have  been  the  seat  of  disease)  the  detritus 
of  the  tubercle  is  brought  up,  gradually,  by  coughing. 

Both  Laennec  and  Louis,  the  latter  also  being  a  very  close  observer,  describe  the 
nascent  tubercle  as  a  gray  semitransparent  corpuscle.  I  have  frequently  seen  such  ; 
but  the  appearance  is  rare,  in  comparison  with  the  more  opaque  form  of  tubercle. 
Of  this,  too,  Dr.  Carswell  offers  what  I  think  a  very  probable  explanation.  He  says 
that  the  mucous  membrane  of  the  air-tubes  separates  from  the  blood,  not  only  the 
matter  of  tubercle,  but  also  its  own  proper  secretion :  and  that,  frequently,  when  the 
two  have  been  poured  out  together,  a  dull  yellow  opaque  point  of  tubercular  matter 
becomes  set,  as  it  were,  in  a  portion  of  gray,  semitransparent,  and,  sometimes,  in- 
spissated mucus.  The  same  deceptive  appearance  is  common  on  serous  membranes  : 
in  tubercular  peritonitis,  coagulable  lymph  exudes,  portions  of  which  envelop  little 
globular  masses  of  tubercular  matter. 

The  account  which  I  have  now  given  you,  and  which  I  hope  I  have  made  intelli- 
gible, is,  I  think,  extremely  interesting — and  much  credit  is  due  to  Dr.  Carswell  for 
having  so  greatly  simplified  our  views  of  a  subject  which  had  previously  been 
wrapped  in  profound  obscurity.  In  no  other  writer,  that  I  know  of,  is  there  to  be 
found  so  complete  and  credible  an  explanation  of  the  origin  of  tubercles ;  of  the 
forms  they  assume,  of  the  phenomena  attending  their  enlargement  and  subsequent 
softening,  and  occasional  expulsion. 

[According  to  Barthez  and  Rilliet,  who  have  given  the  most  complete  and  accurate 
description  of  tubercle,  tlie  various  forms  under  which  tubercle  is  found  are  the  following: — 
the  miliary  or  gray  tubercle,  the  yellow  or  crude  tubercle,  the  gray  and  yellow  forms  of  infil- 
tration, the  gelatinous  infiltration,  and  tuberculous  dust.  There  is  no  reason  for  ascribing 
these  forms  of  tuberculous  matter  solely  to  tubercle  of  the  lung.  As  M.  Valleix  remarks, 
incontestable  proofs  may  be  adduced  to  prove  that  the  gray  granulations  of  Laennec  occur  in 
all  the  organs,  and  as  the  researches  in  pathological  anatomy  have  been  more  carefully  con- 
ducted, these  proofs  have  been  multiplied.  M.  Papavoine,  in  his  interesting  memoir  "  On 
Tubercle  considered  particularly  in  Children"  expresses  himself  thus: — "We  cannot  admit  the 
seat  of  the  gray  granulations  to  be  only  in  the  pulmonary  vesicles :  forms  of  alteration 
exactly  similar,  are  to  be  met  with  in  the  lymphatic  glands,  in  the  liver,  the  spleen,  and  on 
the  serous  membranes,  especially  in  certain  cases  of  general  and  acute  tuberculization." 
The  statement  of  M.  Nelaton  leaves  no  doubt  of  the  development  of  gray  semitransparent 
granulations  in  the  osseous  tissue.  He  has  been  able,  repeatedly,  to  determine  that  the 
Pubercles  of  the  bones,  like  those  of  the  lungs,  recognize  for  points  of  departure,  the  gray 
semitransparent  granulatione  described  by  Laennec,  Louis,  and  others  {Rccherches  sur  I'affcction 
tuberculeuse  des  os,  1836).  Dr.  Glover  has  observed,  in  granular  meningitis,  the  forms  of 
gray  granulation,  and  yellow  particles,  answering  very  well  to  the  yellow  points  which 
appear  in  the  gray  granulations  of  the  lungs.  The  miliary  tubercle  may  exist  in  all  the 
organs,  and  it  is  in  the  form  of  gray  infiltrated  matter,  granular  to  the  microscope,  more  or 
less  dilfused  through  the  aibstance  of  a  gland  that  we  detect  the  first  occurrence  of  mesen- 
teric tubercle  ;  afterwards  we  find  a  more  crude  or  yellow  appearance  of  the  tubercle  matter. 
as  in  the  bxngs.  The  appearance  of  infiltrated  gray  matter  is  especially  marked  in  effusions 
organized  between  the  tunics  of  the  intestinal  canal.  Some  of  the  illustrations  presented 
by  Dr.  Glover  (^Pathology  and  Treatment  of  Scrofula')  show  the  tubercular  effusion  in  a 
mesenteric  gland  : — Istly,  ia  a  diifused  form  throughout  the  hypertrophied  tissue  of  the  organ  ; 
2dly.  forming  strise  and  patches,  varying  in  hue  from  gray  to  yellow;  3dly,  in  cysts  filled 
either  with  a  tuberculous  powder  or  with  a  curdy  matter;  4thly,  in  masses  of  lardaceous 
consistence,  implicating  either  the  whole  gland,  or  more  or  less  of  its  structure.  We  have 
specimens,  likewise,  remarks  the  same  author,  of  bronchial  glands,  and  bronchi  sprinkled 
over,  as  it  were,  with  a  tuberculous  powder,  and  studded  with  cretaceous  particles. 

"The  gray  granulation,"  as  Barthez  and  Rilliet  observe,  "exists  in  all  the  organs,  not  only 
in  the  intestines,  peritoneum,  and  pleura,  but  in  the  spleen,  the  liver,  the  kidneys,  th% 
lymphatic  glands  and  cerebral  meninges." — (Maladies  des  Enfans^  In  fact  all  the  forms  of 
tubercle  which  occur  in  the  ditferent  organs  are  brought  about  chiefly  by  mechanical  cause.-, 
and  differ  very  slightly  in  a  physiological  sense,  never  in  their  more  minute  anatomy.  Thus, 
for  example,  the  liver  is  an  organ,  in  which  tumours  generally  are  of  large  size,  and  of 
various  and  irregular  shapes  ;  in  the  lungs,  the  air-cells  and  the  membranous  charactei  of 
the  tissue  tend  much,  if  the  effusion  be  not  rapid,  to  surround  it,  while  progressing  and 
stiffening,  with  envelops  of  a  membranous  nature.  The  brain,  from  its  structure,  mus: 
oppose  pressure  in  every  direction  in  which  the  progress  of  a  deposit  in  its  interior  can  takrt 
place,  and  thus  we  find  tubercles  of  the  brain  generally  of  small  size  and  regularly  circuni 
9 


130  INFLAMMATION. 

scribed.  Between  layers  of  membrane  we  find  the  deposit  stretched  out  in  flakes.  In  the 
sub-cutaneous  cellular  tissue  it  forms  irregular  masses.  On  the  free  surfaces  of  mucous  or 
serous  membranes  its  figure  is  irregular,  or  it  occurs  in  superficial  layers.  In  the  bones,  in 
general,  it  is  in  little  round  granules,  or  in  very  circumscribed  masses. — C] 

These  processes  —  of  softening,  produced  by  surrounding  inflammation,  and  of 
ultimate  expulsion — may  be  regarded  as  a  natural  mode  of  cure.  Such  a  cure  is  in 
truth  occasionally  accomplished.  A  scrofulous  abscess  forms  in  the  glands  of  the 
neck;  and  pus  and  tubercular  matter  are  discharged.  At  length  the  ulcer  heals, 
and  no  trace  of  the  diseased  process  remains,  beyond  a  scar.  The  same  thing  takes 
place  also  in  the  lungs ;  and,  if  there  have  been  only  one  or  two  masses  of  tubercle 
deposited,  the  patient  may  thus  get  quite  well:  but  unfortunatelj'-,  as  the  scrofulous 
matter  is  extirpated  from  one  part  of  the  lung,  it  is  apt  to  be  multiplied  in  another, 
till  at  length  we  have  death  by  hectic,  and  all  its  melancholy  accompaniments. 

But  I  am  desirous  of  pointing  out  to  you  another  way  in  which  tubercular  disease 
may  be  said  to  be  cured  by  a  natural  process.  And  this  also  has  been  better  described 
by  Dr.  Carswell  than  by  any  other  writer.  One  form  of  scrofulous  disease,  exceed- 
ingly common  too,  especially  among  children,  is  what  is  called  '•  tabes  mesentej-ica." 
Tabes  and  phthisis,  the  one  a  Latin  and  the  other  a  Greek  word,  signify,  I  need 
scarcely  tell  you,  the  same  thing:  a  wasting  away,  or  a  consuming:  and  phthisis  is 
applied  to  the  same  disease  in  the  chest,  to  which  tabes  is  applied  in  the  belly.  The 
common  English  word  is  consumption ;  and  we  might  very  well  speak  of  thoracic 
consumption,  and  of  abdominal  consumption  ;  but  the  technical  name  of  the  latter 
complaint  is  tabes  mesenterica.  This  is  not  only  a  very  common  but  a  very  fatal 
disease  in  children  and  young  persons.  The  glands  of  the  mesentery  enlarge  and 
become  charged  with  tubercular  matter :  but  then  they  very  rarely  suppurate.  Their 
enlargement  is  commonly  connected  with  scrofulous  disease  and  ulceration  of  the 
mucous  follicles  of  the  intestines;  and  the  little  patients  die,  because  the  lacteals  are 
no  longer  able  to  take  up  from  the  food  a  sufficient  supply  of  nutriment :  they  die 
starved.  But  some  few  do  recover  from  tabes  mesenterica.  Dr.  Carswell  relates 
an  interesting  case  in  which  such  recovery  took  place,  and  in  which  he  had  an  op- 
portunity of  examining  the  glands  at  a  subsequent  period :  it  is  the  only  case  of  the 
kind  perhaps  on  record.  He  says,  "  the  patient  who  when  a  child  had  been  affected 
with  tabes  mesenterica,  and  also  with  swellings  of  the  cervical  glands,  some  of  which 
ulcerated,  died  at  the  age  of  21,  of  inflammation  of  the  uterus,  seven  days  after 
dehvery.  Several  of  the  mesenteric  glands  contained  a  dry  cheesy  matter,  mixed 
with  a  chalky-looking  substance  ;  others  were  composed  of  a  cretaceous  substance  ; 
and  a  tumour,  as  large  as  a  hen's  egg,  included  within  the  folds  of  the  peritoneum, 
and  which  appeared  to  be  the  remains  of  a  large  agglomerated  mass  of  glands,  was 
filled  with  a  substance  resembling  a  mixture  of  putty  and  dried  mortar,  moistened 
with  a  small  quantity  of  serosity.  In  the  neck,  and  immediatelj^  beneath  an  old 
cicatrix  in  the  skin,  there  were  two  glands  containing  in  several  points  of  their  sub- 
stance (which  was  otherwise  healthy),  small  masses  of  hard  cretaceous  matter." 

Now  what  Dr.  Carswell  here  saw  in  the  mesentery  and  in  the  neck,  is  what 
sometimes  occurs  in  other  parts  of  the  body  ;  in  the  lungs  ;  and  particularly  in  the 
bronchial  glands  at  their  root,  and  about  the  bifurcation  of  the  trachea.  From  these 
situations,  the  hard  chalky  matter  left  by  the  absorption  of  all  the  more  watery  part 
of  the  morbid  deposit,  and  by  the  concretion  of  its  earthy  salts,  is  often  coughed  up. 
But  it  may  remain,  when  the  tubercles  are  few,  and  there  is  no  tendency  to  their 
increase,  for  years,  as  an  inert,  and  almost  harmless  miss. 

I  mentioned  just  now  that  the  secretion  or  separation  of  the  matter  of  tubercle 
from  the  blood,  takes  place,  by  preference,  upon  the  free  surface  of  mucous  mem- 
branes, and  very  frequently  also  upon  the  surface  of  serous  tissues,  including  the 
areolar. 

It  may  not  be  uninterestmg  to  inquire  into  the  relative  frequency  of  scrofulous 
disease  in  different  organs,  or  in  different  parts  of  the  same  organ.  The  facts 
which  we  possess  on  this  head  afford  us  very  valuable  assistance  sometimes  in 
respect  of  diagnosis. 

During  the  periods  of  childhood  and  youth  the  lymphatic  glands  are  excee  Jingly 


TUBERCLES.  131 

prone  to  scrofulous  inflammation  ;  especially  the  mesenteric  and  the  cervical  glands. 
But  in  adult  age  tubercles  are,  beyond  all  comparison,  most  frequent  in  the  respira- 
tory organs  ;  and  they  occupy  the  summit  of  the  lung  much  more  commonly  and 
thickly  than  any  other  part.  The  superior  and  posterior  portion  of  the  upper  lobe 
is  the  spot  in  which,  if  any  tubercles  at  all  exist  in  the  lung,  they  are  almost  sure  to 
be  found.  It  is  here  also  that  they  first  begin  to  suppurate  or  soften.  This  law  has 
long  been  well  known :  and  so  constant  is  it,  that  Dr.  Carswell  holds  the  formation 
of  tubercles  in  any  other  portions  of  the  lung  to  be  always  of  secondary  occurrence. 
He  declares  it  to  be  the  result  of  his  experience  (and  few  persons  can  have  had 
more  opportunities  of  examining  diseased  lungs),  that  there  is  no  deviation  from  this 
rule,  except  when  some  other  portion  of  the  lung  may  have  been  the  seat  of  an  in- 
flammatory attack,  which  has  determined  the  priority  of  tubercular  disease  in  that 
portion.  We  shall  see  hereafter  what  a  very  important  bearing  a  knowledge  of 
this  law  has,  in  settling  the  nature  of  a  complaint  which  might,  without  it,  be 
doubtful. 

Scrofulous  ulceration  of  the  larynx  and  trachea,  when  they  occur,  are  usually 
concomitants  of  tubercular  deposits  in  the  lungs. 

Next,  tubercular  or  strumous  disease  is  exceedingly  common  in  the  digestive 
organs :  most  of  all  in  the  mucous  follicles  of  the  small  intestines ;  both  in  those 
follicles  which  are  separate,  and  are  called  glandulse  solitarice ;  and  in  those  which 
are  collected  into  roundish  or  oblong  groups,  the  glandulse  agminatas.  It  is  second- 
arily to  these  affections  of  the  follicles,  in  many  cases  at  least,  that  the  glands  of  the 
mesentery  become  implicated.  Tubercular  deposits  are  frequent  also  in  the  solitary 
glands  belonging  to  the  CiECum.  The  ulceration  which  follows  the  evacuation  of  the 
strumous  matter  from  these  parts  gives  the  interior  of  the  bowel  an  appearance 
somewhat  resembling  that  of  a  moth-eaten  garment.  Tubercular  matter  is  seldom 
deposited  in  any  other  parts  of  the  intestines,  great  or  small,  than  those  which  I  have 
mentioned.  Dr.  Carswell  supposes  that  it  may  often  be  secreted  upon  the  free  sur- 
face of  the  membrane,  but  that,  not  being  entangled  or  confined  in  any  mucous 
crypt,  it  is  removed  as  soon  as  it  forms.  It  is  not  often  that  scrofulous  tubercles  are 
found  in  the  liver  of  adults :  they  are  not  very  uncommon  in  that  organ  in  children, 
but  even  then  they  are  few  in  number  and  small  in  size.  It  is  a  curious  fact  that 
they  are  much  more  frequently  seen  in  the  spleen  also  in  children,  than  in  grown 
up  persons.  The  uterus,  the  testicle,  the  proscate  gland,  are  all  liable  to  them  :  they 
are  common  enough  upon  the  surface  of  the  peritoneum. 

In  the  nervous  system,  tubercles  are  by  no  means  unfrequent :  they  are  met  with 
oftener  in  the  brain  than  in  the  spinal  cord.  That  fearful  disorder  of  childhood, 
known  by  the  name  of  hydrocephalus,  occurs  principally,  if  not  altogether,  in  con- 
nection with  the  scrofulous  diathesis. 

Strumous  deposits  are  rare  in  the  organs  of  circulation.  Tubercles  have  been  seen, 
I  believe,  in  the  muscular  substance  of  the  heart :  but  this  must  be  a  very  uncom- 
mon thing.  Scrofulous  disease  is  not  at  all  unfrequent  in  bone,  ebpeciaily  ''n  tho 
bodies  of  the  vertebrjE,  and  in  the  spongy  extremities  of  the  long  bones. 

It  is  very  seldom,  indeed,  that  scrofulous  tubercles  occur  in  any  one  organ  only. 
Almost  always  they  are  met  with  in  at  kast  two,  and  frequently  in  all  the  parts  at 
once  which  are  liable  to  be  infested  by  them.  Sometimes  the  lungs  alone  are  affected ; 
but  generally  both  the  lungs  and  the  intestines  are  occupied  by  the  disease.  It  ha.s 
been  affirmed,  by  a  ffreat  hving  pathologist,  M.  Louis,  that  if  you  find  tubercles  in 
any  other  organ,  you  are  sure  to  find  them  also,  and  in  greater  number,  and  further 
advanced  in  the  lungs.  But  this,  though  true  as  a  general  rule,  is  not  without  ex- 
ceptions. I  have  seen  the  peritoneum  crowded  with  myriads  of  these  tubercles, 
when  the  most  careful  examination  could  not  detect  a  single  one  in  the  lungs.  And 
similar  examples  have  fallen  under  Dr.  Carswell's  observation. 

[The  general  diffusion  of  tubercular  matter  is  much  more  common  in  children  Aan  in 
adults.  Thus,  in  358  cases  where  tubercles  existed  in  the  lungs  in  adults,  M.  Louis  notices 
the  existence  of  tubercular  matter  in  the  brain  or  its  membranes  only  once  ;  in  the  bronchial 
glands  it  was  detected  in  about  one-fifth  of  the  cases  ;  in  the  mesenteric  glands,  in  ont-fxflh  ;  \n 
the  liver,  only  twice  ;  in  the  kidneys,  five  times  in  one  hundred  and  seventy  cases ;  on  the  otiaer 


132  INFLAMMATION. 

hand  ulceration  of  the  larynx,  existed  in  one-fourth  ;  ulceration  of  the  hovels,  in  five-sixths  of 
the  cases.  In  180  cases  in  which  tubercles  of  the  lungs  existed  in  children,  Dr.  Green  found  the 
brain  to  be  affected  with  tubercles  in  one-ni7ith  of  the  cases  ;  the  bronchial  glands,  in  100  out 
of  112  ;  the  mesenteric  glands  were  tuberculous,  in  one-half :  the  liver,  in  one-ninth ;  the  kidneys 
in  one  eighteenth  of  the  cases  ;  but  ulceration  of  the  larynx  occurred  only  once,  and  ulceration 
of  the  bowels,  sixteen  times  in  112  cases. 

M.  Cless,  of  Stuttgard,  his  also  published  the  results  obtained  from  the  examination  of  up- 
wards of  ISO  bodies  affected  with  tubercular  disease.  In  152  examinations  of  adults,  M. 
Cless  found  the  hmgs  free  from  tubercles  six  times.  In  21  examinations  of  children,  he  only 
found  the  lungs  free  from  tubercles  once.  This  was  in  a  boy  eleven  years  of  age,  who,  besides 
a  considerable  serous  efiusion  into  the  ventricles  of  the  brain,  had  two  large  masses  of  tubercle 
in  the  cerebellum,  many  small  ones  on  the  surace  of  the  liver,  and  caries  of  the  vertebrae. 

In  146  adults  allected  with  tubercles  in  the  lungs,  there  were  only  thirty-five  in  whom  tlve 
disease  was  confined  exclusively  to  the  lungs.  In  children  there  were  only  three  cases  out 
of  twenty  in  which  all  the  other  organs  were  free.  M.  Cless  never  found  the  bronchial  glands 
in  children  affected  with  tubercular  deposit  without  the  existence  of  tubercles  in  the  lungs 
also.  In  thirteen  adults  and  one  child  there  were  tubercles  in  the  pleura.  In  sixty-one  adults, 
nnd  four  children,  the  tubercles  were  limited  to  the  peritoneum  eight  times.  The  four  chil 
dren  were  between  six  months  and  ten  years  of  age.  In  152  adults  affected  with  tubercles, 
the  small  intestines  were  affected  eighty-three  tiixies,  and  the  large  intestines  thirty-seven  times, 
and  jji  twenty-one  children,  the  small  intestines  were  affected  seven  times,  the  large  ones  only 
once.  Among  152  adults,  thirty-two  had  tubercles  of  the  mesenteric  glands,  while  they  occurred 
in  these  glands  in  seven  out  of  ^u-ejify-one  children.  In  all  the  cases  tubercles  were  found  in  the 
other  organs.  Tubercles  of  the  liver  occurred  once  in  an  adult,  twice  in  children,  while  other 
organs  were  also  affected.  In  four  adults,  and  twelve  children,  the  spleen  was  affected  with 
tubercles,  these  at  the  same  time  existing  in  other  parts  of  the  body.  In  children  M.  Cless 
remarks,  the  parenchyma  of  the  spleen  is  often  completely  invaded  by  tubercles.  In  the 
kidneys,  tubercles  were  met  witli  four  times  in  adults,  and  three  times  in  children;  of  five 
children,  aged  from  eight  months  to  eleven  years,  in  whom  the  membranes  of  the  brain  pre- 
sented tubercles,  four  died  of  acute  hydrocephalus.  In  all  these  there  ■svere  tubercles  in  the 
lungs  and  other  organs  also.  The  tubercular  granulations  had  always  their  seat  on  the  ex- 
ternal surface  of  the  arachnoid,  between  this  membrane  and  the  pia  mater,  never  within  the 
cavity  of  the  arachnoid.  In  twenty-seven  children  who  died  from  tubercles, /owr  had  tubercles 
of  the  brain,  as  also  in  other  organs ;  M.  Cless  never  found  any  in  the  brain  of  adults.  Be- 
sides their  existence  in  the  mesenteric  and  bronchial  glands,  M.  Cless  found  tubercles  in  the 
glands  of  the  neck  in  five  adults,  and  one  child.  See  Condie  on  Diseases  of  Children,  2d 
edition. — C] 

The  question  has  been  much  and  eagerly  discussed,  whether  the  deposition  of 
tubercular  matter  be  not,  what  I  should  call,  an  event  of  inflammation.  Some  persons 
have  strenuously  argued  that  the  curd-hke  substance  is  nothing  more  than  a  parti- 
cular kind  of  vitiated  lymph,  and  that  it  is  never  poured  out  except  as  a  consequence 
of  inflammation ;  and  they  cite  cases  of  persons  who  always  had  enjoyed  good 
health,  until  inflammation  was  accidentally  excited  in  their  lungs,  immediately  after 
which  the  well-known  signs  of  phthisis  began  to  display  themselves ;  and,  after 
death,  the  lungs  were  found  full  of  tubercles.  But  they  forget  to  take  into  the 
account  another  fact  equally  well  established,  viz. :  that  tubercles  are  found,  in  great 
abundance,  in  the  lungs  of  persons  who  were  never  known,  in  their  lives,  to  have 
any  functional  disturbance  of  those  organs ;  and  whose  lungs  present,  after  death,  no 
other  traces  of  having  been  inflamed.  We  even  find  tubercles  in  the  lungs  of  unborn 
children.  Not  that  this  is  conclusive  ;  for  inflammation  does  sometimes  attack  th«» 
foetus  in  utero,  aud  leave  permanent  and  unequivocal  traces  of  its  action. 

Moreover,  inflammation  continually  happens,  in  all  the  component  textures  of  the 
lung,  in  the  forms  of  bronchitis,  pneumonia,  and  pleurisy,  without  the  subsequent 
development  of  tubercles.  I  admit  that  this  fact,  to  be  of  weight,  should  be  proved 
of  persons  who  possess  the  scrofulous  diathesis  ;  and  I  believe  the  proof  might  be 
found ;  but  the  search  for  it  would  require  much  carefulness  and  candour. 

In  my  own  opinion,  there  is  not  a  shadow  of  evidence  to  show  that  the  deposit  ot 
tubercular  matter  is  always  and  necessarily  preceded  by  inflammation.  Yet 
an  undoubted  and  most  important  connection  obtains  between  the  occurrence  of  in- 
flammation and  the  occurrence  of  tubercles.  Tubercles  will  cause  inflammation,  and 
inflammation  will  determine  the  development  of  tubercles.  The  enlarging  tubercles 
excite  inflammation  in  the  surrounding  textures  by  the  pressure  they  exert  upon 
ihem ;  and  probabl}"  in  other  ways ;  by  mechanically  interfering  with  the  healthy 


TUBERCLES.  133 

circulation  of  the  blood,  for  example  :  and  the  inflammation  lit  up  is  usually  of  tho 
scrofulous  kind  ;  it  is  slow,  and  partial,  and  easily  quicled  by  treatment,  though 
scarcely  to  be  cured.  On  the  other  hand,  there  are  numerous  facts  to  prove  thut, 
in  a  person  having  the  scrofulous  diathesis,  the  occurrence  of  inflammation  with  the 
chest  may  rouse  that  previously  dormant  tendency  into  action,  and  become  the  ex- 
citing cause  of  the  secretion  or  separation  of  tubercular  matter  from  the  blood.  The 
cases  in  which  other  parts  of  the  lung  than  the  apex  are  found  exclusively  occupied 
with  tubercles,  are  also  cases  in  which,  apparently,  the  same  parts  had  been  the  seat 
of  inflammatory  action  :'  of  which  we  sometimes  see  other  traces  in  adhesions  of  the 
neighbouring  pleura. 

The  connection  between  tubercles  and  inflammation  is  shown  also  by  their  occur- 
rence in  the  substance  of  false  membranes.  And  the  same  phenomenon  marks  the 
fact  that  they  are  something  distinct  and  different  from  coagulable  lymph. 

You  must  not  suppose,  from  any  thing  I  have  said,  that  persons  of  the  scrofulous 
habit  are  not  susceptible  of  common  inflammation  ;  we  know  that  they  are,  by  the 
readiness  with  which  slight  injuries  often  heal  in  such  persons  ;  but  there  is  always 
much  reason  to  apprehend  that  inflammation  occurring  in  them  will  take  on  the 
scrofulous  form  ;  become  chronic,  if  it  was  not  so  at  first,  suppurate  tardily,  and  pro- 
duce that  unhealthy  kind  of  puriform  secretion  which  is  characteristic  of  strumous 
disease. 

Another  question  relating  to  tubercular  diseases  is,  whether  they  are  contagious  : 
capable,  i.  e.,  of  being  communicated  from  one  individual  to  another.  The  general 
belief,  in  this  country,  is  that  they  are  not.  Indeed  their  very  dependence  upon  a 
pecuHar  diathesis  would  seem  to  disprove  the  supposition.  Yet  some  practitioners, 
even  here,  have,  I  know,  misgivings  on  the  subject :  and  in  some  parts  of  the  con- 
tinent, in  Italy  particularly,  consumptive  patients  are  shunned,  from  the  persuasion 
that  their  complaint  is  infectious.  I  shall  revive  this  question  when  I  speak  of 
phthisis  hereafter. 

I  have  stated  that  scrofulous  disease  appears,  almost  exclusively,  in  certain  classes 
of  persons,  of  whom,  therefore,  we  say,  that  they  have  the  scrofulous  diathesis. 

It  is  both  interesting  and  useful  to  be  able  to  distinguish  those  in  whom  the  scro- 
fulous habit  of  body,  or  the  predisposition  to  strumous  disease,  exists. 

Now  there  are  certain  physical  and  moral  characters  which  teach  us  to  apprehend 
the  existence  of  a  tendency  to  scrofulous  disease,  even  when  there  has  not,  hitherto, 
been  any  local  manifestation  of  such  disease. 

Again,  we  infer  the  scrofulous  diathesis,  in  many  persons,  from  knowing  that 
scrofula  has  existed  among  their  progenitors. 

On  these  two  points  I  have  a  few  observations  to  make :  and  first,  on  what  may 
be  considered  the  external  tokens  of  a  scrofulous  constitntion. 

The  persons,  in  whom  scrofulous  disease  is  most  apt  to  declare  itself,  are  marked, 
during  childhood,  by  pale  and  pasty  complexions,  large  heads,  narrow  chests,  pro- 
tuberant bellies,  soft  and  flabby  muscles,  and  a  languid  and  feeble  circulation.  They 
present  many  of  the  features  belonging  to  that  pattern  of  body  which  is  denominated 
the  leucophlegmatic.  But  the  strumous  disposition  very  often,  indeed,  accompanies 
a  variety  of  the  sanguine  temperament  also  ;  and  is  indicated  by  light  or  red  hair, 
gray  or  blue  ej^es,  with  large  and  sluggish  pupils,  and  long  silky  lashes,  a  fair  trans- 
parent brilliancy  of  skin,  and  rosy  cheeks.  This  red  colour,  which  is  well  defined 
in  general,  is  easily  changed,  however,  by  cold,  to  purple  or  livid  ;  the  skin  is  thin 
and  readily  irritated  ;  the  sclerotic  has  often  a  peculiar  pearly  lustre  ;  and  the  extre- 
mities are  subject  to  chilblains.  Such  children  are,  many  of  them,  extremely  clever 
and  ready  of  apprehension,  of  eager  tempers,  and  warm  afltctions,  lively,  ardent, 
imaginative,  and  susceptible.  This  precocity  of  mmd  and  intellect,  while  it  delights 
the  fondness  of  the  parent,  awakens  the  fears  of  the  more  far-seeing  physician. 

But  the  disposition  to  scrofula  is  by  no  means  confined  to  persons  of  the  serous  or 
of  the  sanguine  temperament.  It  is  frequent,  though  less  common,  in  what  has  been 
called  the  melancholic  or  bilious  temperament ;  in  persons  of  dark  muddy  com- 
plexion, and  harsh  skin  ;  in  whom  the  mental  and  bodily  energies  are  rnore  slujrgish 

M 


134  INFLAMMATION. 

and  dull.     And  it  is  remarliod  that  in  persons  of  this  cast,  scrofula,  when  it  does 
occur,  is  even  more  than  usually  obstinate  and  intractable. 

Scrofula  does  often,  indeed,  appear  in  persons  who  exhibit  none  of  those  signs  of  a 
strumous  disposition  which  I  have  been  enumerating;  but  is  move  likely  to  appear, 
ceteris  paribus,  where  those  signs  are  observed. 

There  are  several  alleged  marks  of  a  scrofulous  diathesis  Avhich  are,  in  fact,  in- 
stances of  scrofulous  disease.  Such,  for  example,  is  that  chronic  lippitudo,  which 
so  frequently  disfigures  strumous  children,  rendering  them  what  is  called  blear-eyed  ; 
and  chronic  inflammation  of  the  conjunctiva,  lasting  long,  without  much  redness  or 
heat,  and  with  extreme  impatience  of  light,  and  a  tendency  to  form  little  pusiules 
near  the  edge  of  the  cornea.  The  tumid  and  chapped  upper  lips,  the  redness  and 
swelling  of  "the  columna  nasi,  and  lower  parts  of  the  nostrils,  so  common  in  children, 
especially  during  winter,  are  early  fruits  of  the  strumous  taint.  Certain  maladies 
of  the  joints,  what  are  popularly  called  white  swellings,  are  instances  of  scrofulous 
disease.  So  may,  perhaps,  rickets  be  considered  :  at  any  rate,  rickeiy  children  are 
very  often  affected  with  scrofula  also.  Moist  eruptions  behind  the  ears  ;  chronic  en- 
largement of  the  glands  of  the  neck  ;  that  slow,  eating  ulceration  of  the  nares,  termed 
lupus  ;  may  all  be  included  within  the  class  of  strumous  disorders. 

When  any  one  of  these  scrofulous  affections  has  once  showm  itself  in  any  person, 
we  know,  by  that  circumstance,  that  he  possesses  the  strumous  constitution ; 
and  we  look  for  the  recurrence  of  his  complaint  in  the  same  part,  or  in  other 
parts. 

In  a  former  lecture  I  mentioned  scrofula  as  one  of  those  distempers  the  hereditary 
tendency  to  which  is  indisputable.  The  scrofulous  diathesis  is  hereditarj' :  and 
sometimes  scrofulous  disease  is  so  too.  I  have  seen  lungs,  taken  from  the  body  of  a 
foetus,  stuffed  with  tubercles.  There  were  some  fine  examples  of  this  in  Mr.  Lang- 
staff's  museum  in  the  city.  We  have,  therefore,  in  respect  to  scrofula,  the  rare  con- 
junction of  congenital  disease,  and  hereditary  disposition.  I  need  not  repeat  here 
the  remarks  I  made  before  respecting  hereditary  diseases  in  general.  No  one,  of 
the  least  observation,  can  doubt  that  the  disposition  to  consumption  is  very  often 
transmitted  from  parent  to  child.  AVe  see  whole  families  swept  away  by  its  ravages. 
Like  other  hereditary  tendencies,  it  may  skip  over  one  or  two  generations,  and  re- 
appear in  the  next,  just  as  family-likenesses  are  known  to  do.  There  are  other 
families  in  which  you  can  trace  no  such  predisposition ;  but  such  families  are  per- 
haps few.  A  little  leaven  is  sufficient,  sometimes,  effectually  to  taint  a  whole  pedi- 
gree. The  tendency,  however,  exists  in  various  degrees.  It  may  be  so  strong  that 
no  care,  no  favourable  combination  of  circumstances,  will  prevent  its  local  manifes- 
tation ;  and  it  may  be  so  faint  that  it  would  never  break  out  into  actual  mischief  if 
the  exciting  causes  of  scrofulous  diseases  could  be  warded  off.  it  is  important, 
therefore,  to  know  what  these  exciting  causes  are. 

"  They  may  all  be  ranked  together  (to  use  the  language  of  Dr.  Aiison)  as  causes 
of  debility,  acting  permanently,  or  habitually  for  a  length  of  tin.e,  although  not  so 
powerfully  as  to  produce  sudden  or  violent  effects." 

The  circumstances  to  which,  acting  separately,  or  in  combiTiation,  we  most  con- 
fidently ascribe  the  power  of  developing  scrofula,  are  insufficient  nutriment,  exposure 
to  wet  and  cold,  impurity  of  the  atmosphere,  the  want  of  natural  exercise,  and  mental 
disquietude.  To  estimate  the  separate  effect  of  each  of  these  causes  may  be  diffi- 
cult ;  but  their  combined  influence  is  unquestionable. 

There  can  be  no  doubt  that  improper  diet,  or  rather  imperfect  nourishment,  is 
one  main  exciting  cause  of  scrofulous  disease.  Yet  of  this  it  is  not  an  easy  thing 
to  oDtam  evidence,  which  shall  be  entirely  free  from  fallacy.  The  disease  occurs 
very  often  among  the  poor;  but  then  it  very  often  occurs  also  in  the  famihes  of  the 
rich.  There  is  one  fact  which  has  always  struck  me  as  very  instructive  and  con- 
vincing on  this  point.  Infants  at  the  breast,  having  good  milk  and  plenty  of  it, 
seldom  show  any  signs  of  scrofulous  disorder :  whereas,  as  soon  as  they  are  weaned, 
uiey  become  subject  to  various  complaints  of  a  strumous  kind.  When  an  unweaned 
'cnild  is  brought  to  us  with  ophthalmia,  we  expect  almost  always  to  discover  inflam- 
mation of  the  common  and  acute  kind ;  the  purulent  eye.     In  nine  children  out  of 


SCROFULOUS    DISEASE.  ISi) 

ten  who  come  after  weaning,  we  look  for  and  find  some  form  of  scrofulous  inflarn 
mation,  such  as  pustular  ophthahnia. 

[Mr.  Phillips  (^Scrofula,  its  nature  and  causes),  lias  succeeded  in  establishing  very  conclu- 
sively the  influence  of  bad  and  deficient  food,  and  of  an  excess  of  vegetable  food,  in  the 
production  of  scrofula. — C] 

The  greater  prevalence  of  scrofulous  disease  among  the  poor  may  be  ascribed,  in 
great  measure,  to  their  frequent  exposure  to  wet  and  cold. 

[Barthez  and  Rilliet  were  only  able  to  find  two  cases  out  of  314  tuberculous  children, 
where  exposure  to  humidity  appeared  to  be  the  sole  cause  of  the  tubercles.  The  researches 
of  Mr.  Phillips  would  tend  also  to  prove  that  the  influence  of  humidity  has  been  much  over- 
rated.— C] 

Scrofula  seldom  breaks  out  in  the  mild  and  dry  weather  of  summer.  The  influ- 
ence of  climate  in  fostering  or  repressing  the  disease  is  notorious.  There  is  no  cli- 
mate in  which  it  flourishes  more  than  in  our  own.  Consumption  is  called,  in  some 
parts  of  the  continent,  the  English  disease.  Persons  w^ho  migrate  from  this  country 
to  warmer  and  more  equable  chmates,  seldom  become  scrofulous  ;  nay,  it  very  often 
happens  that  the  incipient  indications  of  strumous  disease  are  completely  arrested  or 
quieted  by  the  change.  Phthisical  patients,  much  troubled  by  symptoms  here,  are 
sometimes  so  thoroughly  freed  from  them  soon  after  their  arrival  in  Madeira,  as  to 
be  deceived  into  a  belief  that  their  case  had  been  mistaken.  They  think  themselves 
well.  A  return  to  this  country  undeceives  them.  The  native  inhabitants  of  hot 
regions  are  by  no  means,  however,  exempt  from  struma,  in  any  of  its  forms.  When 
they  come  into  these  latitudes  they  are  more  subject  to  scrofula  than  we  ourselves 
are.  And  the  same  effect  of  climate  is  very  distinctly  visible  in  the  lower  animals. 
The  physicians  in  ordinary  to  the  inmates  of  the  Zoological  Gardens  will  tell  you 
that  the  beasts  and  birds  which  are  brought  hither  from  warm  latitudes  perish  in 
great  numbers  from  scrofulous  diseases.  John  Hunter  observed  this  long  ago  in 
respect  to  monkeys. 

Of  the  debilitating  influence  of  impure  air  I  spoke  in  a  previous  lecture.  That  it 
promotes  the  evolution  of  scrofulous  disorders  we  have  proof,  on  a  large  scale,  in 
the  great  mortality  produced  by  such  disorders  among  the  lower  classes  in  large 
cities  as  compared  with  agricultural  districts.  The  per-centage  of  deaths  from  con- 
sumption, hydrocephalus,  and  various  other  diseases  which  spring  from  a  strumous 
habit,  is  much  greater  in  London  than  in  the  country.  Even  in  individual  cases  this 
mfluence  is  too  manifest  to  be  overlooked  or  mistaken.  It  is  impossible  to  question 
the  beneficial  efltct,  upon  children  afflicted  with  scrofula,  of  a  removal  from  London 
to  the  sea-coast. 

I  said,  when  I  first  began  to  speak  to  you  of  inflammation,  that  it  was  the  only 
disease  which  we  were  able  to  excite  at  w'ill :  that  we  could  cause  inflamma- 
tion, in  various  ways,  whenever  we  desired  to  do  so ;  but  that  to  make  a  cancer  or 
a  tubercle  was  beyond  our  power.  Now  in  strictness  of  language,  and  in  the  prac- 
tical meaning  of  these  words,  the  assertion  is  quite  true.  But  it  is  not  so  exact  if 
we  extend  it  to  all  the  predisposmg  causes  of  disease.  We  are  able  to  bring  about 
the  formation  of  tubercles,  in  the  lower  animals  at  least,  by  so  arranging  external 
influences  as  to  concentrate  their  prejudicial  effects.  By  shutting  rabbits  up  in  a 
cold,  damp,  dark,  and  narrow  place — and  feeding  them  on  food  not  natural  or  suited 
to  them — we  can  produce  or  evolve  in  them  tubercular  disease.  Of  course  no  ex- 
periment of  that  kind  can  be  purposely  made  upon  a  healthy  man  ;  but  accidental 
opportunities  arise  of  witnessing  an  approach  to  a  similar  trial  of  the  human  species. 
Instances  are  recorded  of  persons,  previously  well  (but  having  probably  the  slrumou?: 
diathesis),  becoming  affected  with  scrofula  after  being  confined  in  the  dungeons  of  a 
prison,  and  there  scantily  fed. 

Something  of  this  kind  I  have,  very  recently,  had  the  opportunity  of  seeing 

A  number  of  male  prisoners,  chiefly  young  men,  became  affected  with  glandular 
swellings  of  the  neck,  after  incarceration  for  some  length  of  time  in  the  Penitentiary 
at  Milbank.  The  circumstances  of  their  health  led  to  a  relaxation  of  their  punish- 
n>ent.     Instead  of  being  kept  in  solitary  confinement  in  a  coldish  cell,  and  on  th^■• 


136  INFLAMMATION. 

prison  diet,  they  were  permitted  to  work,  for  several  hours  daily,  in  each  others' 
company  in  the  garden  of  the  establishment.  Some  porter  was  at  the  same  time 
given  them,  and  their  allowance  of  meat  was  increased.  The  improvement  in  their 
condition  was  rapid  and  striking.  Here  we  have  the  disorder  germinating  under 
one  state  of  external  circumstances,  and  checked  immediately  under  the  opposite 
state. 

If  you  consider  the  way  of  life  of  the  children  of  the  poorer  classes  in  this  me- 
tropolis, and  in  our  large  manufacturing  towns,  you  will  find  that 'they  are  much 
exposed  (though  in  a  less  degree)  to  the  same  injurious  influences,  the  combination 
of  which  appears  to  generate  tubercles  in  the  rabbit.  They  live,  for  the  most  part, 
in  an  atmosphere  made  stagnant  by  narrow  streets ;  and  in  small,  crowded,  ill-ven- 
tilated and  dark  rooms  in  those  narrow  streets ;  the  stagnant  atmosphere  is  contami- 
nated in  a  thousand  ways ;  they  are  very  insufficiently  protected  from  transitions  of 
temperature,  against  cold  and  wet,  by  their  clothing ;  they  are  commonly  ill-fed — 
their  diet  being  frequently  scanty,  and  generally  of  a  kind  quite  unsuited  to  their 
growing  years.  We  need  not  be  surprised,  therefore,  at  the  ravages  which  scrofula, 
in  its  manifold  shapes,  makes  among  the  children  of  the  poor  in  large  and  populous 
towns.  If  ever  scrofula  be  generated,  in  this  country,  independently  of  any  heredi- 
tary strumous  taint  in  the  constitution,  it  is  in  them.  But  in  most  cases  I  believe  it 
is  the  latent  disposition  that  is  called  into  action.  Moderate  exercise,  in  pure  air,  and 
in  the  open  daylight,  with  suitable  nourishment,  sufficient  clothing,  and  attention 
to  the  state  of  the  bowels :  these  circumstances  comprise  nearly  all  that  we  can 
attempt,  in  a  given  chmate,  towards  preventing  the  development  of  struma :  and 
from  each,  and  all  of  them  many  of  these  poor  children  are  habitually  debarred. 


LECTURE  XIII. 

Cancel ;  its  Specks  or  Varieties.    Scirrhus;  Encephaloid  Cancer ;  Colloid  Cancer 

Its  mode  of  Groicth  and  Dissemination.     Habitudes  of  the  several  Varieties. 
Treatment  of  Inflammation.     Antiphlogistic  Regimen.     Blood-letting. 

I  HAVE  more  than  once  coupled  cancer  and  tubercle  in  the  same  sentence. 
Though  very  different  in  many  respects,  they  are  alike  in  their  intractable  cha- 
racter and  destructive  tendencies.  Of  the  two,  cancer,  while  it  is  happily  much  the 
more  rare,  is  also  much  the  more  painful,  loathsome,  and  hideous  in  its  consequences. 
It  is  to  cancerous  diseases  that  the  epithet  malignant  especially  belongs.  Not  re- 
sulting from  any  change  in  the  natural  textures  of  the  body,  but  constituting  an 
addition  to  them,  and  therefore  assuming,  usually,  the  shape  of  tumours,  they  are 
commonly  and  correctly  spoken  of  as  cancerous  grotvihs.  But  there  are  other 
growths  Avhich,  by  comparison,  are  innocent ;  which  do  not  imply  any  necessary 
destruction  of  contiguous  parts,  nor  any,  inevitable  danger  to  life,  nor  even  any 
marked  deterioration  of  the  general  health.  Such  are  certain  fatty  tumours,  and 
fibrous  tumours,  and  osseous  tumours.  All  these  last,  as  their  names  denote,  re- 
semble in  their  sensible  qualities  some  of  the  healthy  and  natural  textures.  They 
have  accordingly  been  styled  analogous,  or  homologous  growths;  while  cancer 
and  tubercle,  which  find  no  counterparts  in  the  sound  body,  are  said  to  be  hetero- 
logous. Some  varieties  of  cancer  are,  however,  very  similar  in  outward  appearance 
to^he  substance  of  the  brain;  and  microscopic  observers  say  that  in  their  minute 
and  original  structure  there  is  no  perceptible  distinction  between  the  most  innocent 
and  the  most  malignant  growths ;  nay,  that  both  agree  in  their  primary  corpuscular 
elements  with  the  healthy  tissues  of  animals,  and  even  of  plants. 

[This  statement  is  not  perfectly  accurate.  The  microscope  has  not,  it  is  true,  thrown  much 
IS^ht  upon  the  nature  and  causes  of  morbid  growths;  it  has,  however,  shown  that  in  many 


CANCER.  137 

of  the  particulars  of  their  intimate  structure,  they  not  only  differ  from  the  healthy  tissues  of 
the  body,  but  that  they  differ  in  this  respect  from  each  other. 

That  such  is  the  case,  is  rendered  evident  by  the  result  of  all  the  more  recent  researches 
into  the  intimate  structure  of  cancerous  formations. 

By  Miiller  and  other  pathologists,  cancerous  formations  have  been  arranged  in  two  great 
families  or  groups  —  the  encepkaloid  and  the  scirrhous.  —  Of  the  first  there  are  three  sub- 
divisions. 

1.  Medullary  Carcinoma;  in  which  there  is  a  predominance  in  the  inedullary  mass,  of 
round  globules  over  loose  fibrous  tissue.  The  globules  are  of  various  sizes;  but  the  smallest 
are  la.^er  than  pus-corpuscules.  Each  contains  a  granular  substance  or  nucleus  within. 
They  are  very  similar,  in  many  respects,  to  those  of  common  cancer,  and  of  reticulated  car- 
cinoma or  scirrhus. 

2.  Medullary  Carcinoma,  consisting  of  pale,  elliptic,  non-elongated  corpuscles,  and  of  a  funda- 
mental cerebrilorm  mass.  These  corpuscles  are  usually  twice  or  three  times  as  large  as  the 
globules  of  the  blood.  There  is  never  any  appearance  of  fibres  proceeding  from  their  sur- 
face, and  they  rarely  exhibit  any  traces  of  nuclei  within  them. 

3.  Medullary  Carcinoma,  •with  Jjbrated  or  punform  corpuscles.  This  species  of  encephaloid 
structure  has,  at  times,  on  laceration,  a  sort  of  fibrous  aspect,  when  the  puriform  corpuscles 
are  arranged  in  a  somewhat  determinate  direction;  according  to  which  the  morbid  mass 
will  present  a  radiated  or  a  tufted  appearance.  In  many  cases  their  directions  are  so  various 
that  the  lacerated  surface  exhibits  no  traces  of  fibres  anywhere.  The  puriform  corpuscles 
are  sometimes  nucleated,  at  others  they  contain  granular  points,  but  without  distinct  nuclei. 
They  are  elongated,  on  one  or  two  sides,  into  fibres  of  different  lengths.  They  may  be  con- 
sidered as  cells  that  are  arrested  at  the  period  of  transition  from  the  cellular  to  the  fibrous 
condition. 

The  three  forms  of  disease  now  described,  may,  most  probably,  be  regarded  as  so  many 
degrees  or  stages  in  the  development  of  the  same  tissue;  these  successive  stages  being  cha- 
racterized, 1,  by  rounded  nucleated  globules ;  2,  by  elongated  oviform  globules,  which  are 
eitner  non-nucleated  or  indistinctly  so ;  and  3,  by  puriform  globules. 

These  several  kinds  of  globules  may  be  regarded  as  so  many  successive  epochs  of  evolu- 
tion through  which  a  cell  must  pass  before  it  can  become  a.  fibre.  Thus  we  find,  it  is  true, 
tliat  in  an  encephaloid  mass  there  is  the  same  transformation  of  the  primitive  elements,  as 
occurs  in  many  normal  tissues  —  with  this  difference  only,  that  the  process  of  evolution  is 
not  complete — being  arrested  before  the  fibrin  is  perfectly  formed. 

The  essential  element  of  an  encephaloid  tumour  is  the  presence  of  cells.  In  some  cases 
die  entire  mass  is  composed  of  them,  placed  one  alongside  of  the  other,  but  without  hav- 
ing any  perceptible  bond  of  union,  while  in  others  there  is  a  network  of  fibrous  or  cellular 
tissue  interposed  between  the  cells.  When  the  fibrous  tissue  prevails,  the  encephaloid  then 
approaches  in  character  to  the  scirrhous  structure.  In  the  latter  the  existence  of  the  two 
elements,  cells  and  fibres,  is  always  more  distinctly  marked  than  in  the  former.  The  fibres 
are  often  quite  perceptible  to  the  naked  eye.  Sometimes  they  are  lengthened,  and  run 
parallel  to  each  other ;  at  others,  they  form  rounded  capsules,  within  which  the  globules  are 
contained.  As  in  the  case  of  the  newly  formed  fibres  of  the  cellular  tissue,  so  those  of  a 
scirrhous  formation  are  destroyed  by  acetic  acid,  leaving  nuclei  or  nucleated  fibres  behind. 
The  fibres  sometimes  exhibit,  at  different  points,  a  sort  of  varicose  enlargement,  within  each 
of  which  a  nucleus  is  found.  This  appearance  is  often  observed  in  fibrous  tumours  —  no« 
genuine  scirrhus — of  the  uterus  and  other  parts. 

In  the  reticular  carcinoma  of  Miiller,  the  white  network  which  encloses  the  scirrhous  glo- 
bules in  its  meshes,  is  formed  of  round,  opaque  granulations,  three  or  four  times  as  large  as 
the  blood  globules  ;  they  are,  occasionally,  agglomerated  into  roundetl  masses.  The  genuine 
scirrhous  tissue,  of  a  pale  grayish  colour,  is  composed  of  globules  that,  on  the  whole,  resem 
ble  those  of  the  first  stage  of  an  encephaloid  formation.  These  globules  are  either  round  or 
somewhat  oval ;  along  with  them,  according  to  Vogel,  we  find  free  nuclei  with  their  nucleoli. 

From  a  variety  of  observations,  it  may  be  reasonably  concluded  that  the  cells  of  scirrhus 
are  formed  around  the  nuclei  of  which  M.  Vogel  speaks ;  their  contents  are  at  first  granular 
and  almost  opaque.  When  the  process  of  softening  commences,  the  granulations  disapjpear, 
the  globules  become  transparent,  and  within  them  are  formed  new  cells,  which  at  first  are 
few  in  number,  and  gradually  multiply,  until  they  entirely  fill  the  parent  cell.  M.  Valentin, 
who,  in  part  at  least,  admits  this  account  of  the  progress  of  the  cell,  declares,  that  the  parent 
cells  eventually  burst  and  discharge  their  cellules ;  we  may  thus  account  for  the  presenca 
of  young  free  cells  in  scirrhous  formations  that  have  become  softened. 

The  inter-cellular  substance  seems  to  undergo  certain  modifications  corresponding  with 
the  evolution  of  the  cells;  the  granulations  or  granular  points  which  it  often  contains, 
usually  disappear,  and  it  becomes  limpid,  while,  at  the  same  time,  the  space  which  it  occu- 
pies is  diminished  by  the  enhargement  and  multiplication  of  the  cells. 

The  fibrous  network  does  not  appear  to  follow,  in  its  alterations,  the  development  of  the 
cells:  it  may  remain  firm  and  resisting  while  the  cells  are  far  advanced  in  their  evoluUon 

m3 


138  INFLAMMA  nON. 

Even  when  a  scirrhous  tumour  has  become  completely  softened,  this  tissue  sometimes  foims 
shreds  that  retain  their  original  character. 

In  alveolar  cancer,  the  basis  of  the  morbid  tissue  consists  of  white  fibres  and  lamellcB, 
which  cross  and  intercrois  with  each  other,  containing,  between  the  meshes  thus  formed, 
limpid  cells,  either  closed  or  communicating  with  each  other,  of  various  sizes,  from  that  of 
a  grain  of  sand  to  that  of  a  large  pea,  and  filled  with  a  transparent,  gelatinous  substance. 
In  this  substance  there  are  cells,  wliich  contain  other  cells  more  minute.  The  smallest  of 
tliese  cells  exhibit,  at  one  point  of  their  parietes,  a  distinct  dark  yellowish  nucleus,  and 
sometimes,  also,  many  free  and  unattached  granules  floating  within  them.  .  To  this  species 
Miiller  refers  the  gelatiniform  and  areolar  cancers  of  Laennec  and  Cruveilhiir.  The  cells  of 
diis  species  of  the  disease  appear  to  be  only  an  advanced  or  more  mature  degree  of  the 
cells  of  scirrhus. — C] 

This  very  agreement,  if  it  really  be  so  complete,  shows  that  in  classifying  morbid 
growtk«  we  must  reject  the  aid  of  the  microscope,  and  attend  to  their  grosser  and 
more  palpable  features.  And,  inasmuch  as  cancerous  formations  have,  by  some 
pathologists,  been  ascribed  (very  erroneously,  in  my  opinion)  to  injiammulion  as 
their  cause,  I  shall  scarcely  be  going  out  of  my  way  if  I  state  here  some  of  the 
broad  facts  which  have  been  ascertained  upon  this  very  interesting  subject. 

Cancer,  or  carcinoma,  considered  as  a  genus  of  disease,  comprehends  two  or  three 
species,  which  present  among  themselves  very  striking  differences,  and  of  which  the 
varieties  have  received  a  puzzling  multiplicity  of  names ;  scirrhus,  stone  cancer, 
medullary  sarcoma,  encephaloid  or  cerebriform  disease,  soft  cancer,  fungus  hcema- 
todcs,  colloid  or  gum  cancer,  and  several  more.  The  simplest  division,  founded 
upon  the  consistence  of  the  morbid  growth,  is  into  hard  and  soft  cancer.  But  the 
most  modern  and  scientific  system  recognizes  three  species,  viz.,  scirrhus ;  encepha^ 
loid,  or  brain-like  cancer  ;  and  colloid,  or  gum-like  cancer.  The  physical  characters 
of  these  three  species  offer  strong  points,  not  merely  of  difference,  but  even  of 
contrast. 

Scirrhus,  as  that  word  implies,  is  remarkable  in  its  early  stages,  for  its  hardness. 
It  is  as  firm  as  cartilage,  and  creaks  when  divided  by  a  sharp  knife."  The  surfaces 
exposed  by  its  division  present  a  glistening,  satiny  appearance,  and  a  white,  or  gray, 
or  bluish-white  colour.  Athwart  this  grayish  and  semi-transparent  substance  run 
opaque  intersecting  bands,  having  a  fibrous  aspect.  By  strong  pressure  a  thin  juice 
may  be  made  to  ooze  from  a  slice  of  the  scirrhous  tumour. 

Encephaloid  cancer  is  also  well  named.  It  is  composed,  in  great  measure,  of  a 
soft,  white,  opaque  pulpy  substance,  very  closely  resembling,  both  in  colour  and  in 
consistence,  that  of  the  healthy  brain.  This  cerebriform  pulp  is  traversed  and  cir- 
cumscribed by  fi-brous  septa,  w^iich  are  sometimes  extremely  thin  and  dehcate.  In 
both  these  species  of  cancerous  growth,  therefore,  there  is  a  contained  and  a  containing 
element. 

The  same  feature  is  still  more  distinctly  marked  in  the  third  species,  the  colloid 
cancer,  which  exhibits  the  appearance  of  small  portions  of  a  greenish-yellow  trans- 
parent gum,  or  jelly,  arranged  in  regular  cells.  Hence  it  is  sometimes  denominated 
alveolar  cancer. 

You  niay  ask  upon  what  principle  structures  so  dissimilar  in  their  physical  ap- 
pearance have  been  assigned  to  the  same  genus  1  Why,  for  these  reasons.  They 
are  all  strictly  destructive  or  mahgnant  forms  of  disease.  Although  in  any  shape 
they  are  of  somewhat  rare  occurrence,  yet  when  they  do  occur,  two,  or  all  three 
of  the  species  are  often  found  to  coexist  in  different  organs  of  the  same  individual ; 
nay,  in  contiguous  parts  of  the  same  organ.  ^Nlore  than  this  :  if  a  tumour  consisting 
of  one  species  be  amputated,  and  a  fresh  growth  springs  (as  too  often  it  does)  from 
the  same  spot,  this  secondary  growth  is  frequently  of  another  species.  There  can 
be  no  doubt  that  all  are  connected  by  some  very  intimate  bond  of  union;  and  the 
facts  I  have  'ust  stated  suggest  the  question,  whether  instead  of  being  different  spe- 
cies of  the  same  genus,  they  ought  not  rather  to  be  regarded  as  mere  varieties  of  tht 
same  species. 

Of  all  three  it  has  been  ascertained,  by  much  and  fatal  experience,  that  occurnng 
m  any  one  part  of  the  body  they  are  prone  to  multiply  in  various  other  parts ;  that 
•hey  are  commonly  attended,  during  some  part  at  least  of  their  progress,  with  very 


CANCER.  139 

gew  re  pain  ;  that  they  are  incontroUable  by  any  known  remedy  ;  and  tend  always, 
sometimes  slowly,  sometimes  with  frightful  rapidity,  to  augment  in  bulk;  eating 
away  contiguous  parts  by  their  invasion  and  pressure  ;  breaking  out,  when  near  the 
surface,  into  foul  and  repulsive  ulceration;  producing  often  the  most  ghastly  disfi- 
gurement ;  and  ultimately  destroying  life.  Sometimes  vital  parts  are  slowly  disor- 
ganized by  the  corroding  extension  of  these  tumours;  sometimes  large  blood-vessels 
are  laid  open,  and  death  is  suddenly  brought  about  by  hemorrhage ;  and  sometimes 
the  powers  of  hfe  sink  gradually  under  the  wearing  influence  of  the  disease,  and 
that  degeneracy  of  the  Wood  which  it  causes  or  accompanies. 

There  is  scarcely  an  organ  or  a  texture  of  the  body  which  is  not  liable  to  be 
attacked  by  this  terrible  foe  :  the  brain,  the  eye,  the  lip  and  face,  the  lungs,  the 
stomach,  the  intestines,  the  liver,  the  kidneys,  the  breast,  the  womb,  the  testicle,  the 
bones.  But  some  parts  are  more  often  the  seat  of  cancer  than  others.  Among 
these  may  be  reckoned  the  female  mamma,  the  uterus,  the  stomach,  the  liver,  and 
the  testicle. 

The  mode  in  which  cancer  originates  is  uncertain  ;  the  modes  in  which  it  spreads 
and  multiplies  are  better  understood.  An  individual  tumour  may  enlarge  by  ihe 
progressive  insinuation  of  the  cancerous  matter  into  the  interstices  of  the  neighbour- 
ing tissues,  which,  thus  fastening  upon,  it  consolidates.  The  disease  may  be  com- 
municated, by  imbibition,  from  one  organ  to  another  which  is  in  mere  contact^vith 
it.  But  how  does  it  come  to  occupy  at  the  same  time,  or  in  quick  succession,  several 
separate  and  distant  organs  ?  This  is  a  question  of  the  greatest  interest  and  im- 
portance, and  it  admits  of  a  distinct  reply. 

Cancer  often  makes  its  appearance  in  a  single  spot  on  the  surface  of  the  body ;  in 
the  female  breast,  for  instance.  We  see  and  feel  it  there  while  it  is  yet  small,  and 
while  the  general  health  of  the  patient  seems  to  be  otherwise  perfect.  By  degrees 
the  tumour  increases,  and  at  length  it  softens  in  some  places  ;  the  glands  of  the  axilla 
become  swollen,  hard,  painful,  and  filled  sometimes  with  cancerous  matter ;  the 
tumour  breaks  perhaps  through  the  skin,  and  presents  the  shocking  spectacle  of 
"open  cancer  ;"  the  general  health  gives  way,  and  the  skin  assumes  a  straw-coloured 
tint.  During  this  process,  unless  the  patient  dies  prematurely,  or  the  original  disease 
is  removed  by  a  surgical  operation,  cancerous  tumours  form  in  one  or  in  several  of 
the  internal  organs,  and  give  notice  of  their  presence  by  appropriate  symptoms.  There 
is  an  original  morbid  growth,  and  there  are  subsequent  morbid  growths ;  a  prin:iary 
tumour,  and  secondary  tumours  ;  and  the  latter  are  caused  by  the  former.  This  is 
a  most  important  fact,  if  indeed  it  be  true. 

Now  Miiller  has  discovered,  by  means  of  the  microscope,  and  the  discovery  has 
been  confirmed  by  other  observers,  that  the  contained  matter,  in  the  several  species 
or  varieties  of  cancer,  consists  of  very  minute  cells,  with  nuclei  attached  to  their 
w^Us,  and  of  granules  still  more  minute,  which  are  supposed  to  be  the  rudiments  of 
new  cells.  It  is  (apparently)  by  the  amplification  of  these  granules  into  cells,  and 
by  the  development  of  the  nuclei  into  other  cells,  and  by  the  growth  and  evolution 
of  young  cells,  which  in  some  instances  are  included  generation  after  generation 
within  parent  cells,  that  the  original  tumours  enlarge  and  extend  themselves ;  and  it 
IS  by  the  transference  of  certain  of  these  cells  and  granules  from  the  original  tumour 
that  a  crop  of  secondary  tumours  is  sown  in  remote  parts  of  the  body.  The  cells, 
and  probably  the  granules  also,  are  endowed  with  the  power  of  self-increase  and 
propagation,  whenever  they  find  a  fitting  nidus.  Possessing,  like  the  seeds  of  plants, 
an  inherent  vitality  of  their  own,  they  merely  require,  in  order  to  germinate,  to  be 
placed  in  contact  with  some  living  tissue,  wherewith  they  may  form  vascular  con- 
nections, and  wherefrom  they  may  draw  the  materials  of  their  nourishment.  Co- 
hering together,  for  the  most  part,  with  but  httle  force,  they  are  easily  detached  from 
the  parent  mass.  It  is  matter  of  fact  that  the  secondary  tumours  form  most  surely 
and  most  rapidly  when  the  primary  tumour  is  of  a  soft  kind ;  and  that  when  they 
succeed  to  scirrhus,  it  is  after  the  process  of  softening  has  commenced  in  that  origin- 
ally hard  structure.  These  germs  —  which  present,  in  their  forms  and  mode  of 
generation,  striking  analogies  to  those  of  some  of  the  lower  animals,  as  well  as  to 
tlio«e  of  plants — these,  germs  are  probably  carried  sometimes  through  the  lymphatic 


140  INFLAMMATION. 

vessels  to  absorbent  glands  in  the  vicinity  of  the  primary  growth;  hut  tnere  can 
scarcely  be  a  doubt  that  the  blood  is  the  main  channel  by  which  the  seeds  of  this 
dreadful  malady  are  conveyed  from  its  first  to  its  subsequent  sites,  and  thence  per- 
haps, if  life  continues  long  enough,  to  tertiary  locations.  The  gross  matter  of  cancer 
is  often  to  be  found  in  the  veins  t^hat  proceed  from  the  primary  tumour — nay,  in  large 
venous  trunks  at  a  distance  :  so  that  some  distinguished  pathologists  have  too  hastily 
conjectured  that  it  may  originate  in  the  veins.  You  are  probably  aware  that  foreign 
substances,  circulating  with  the  blood,  stop  or  are  entangled  more  often  in  some 
organs  than  in  others.  Minute  globules  of  mercury,  where  that  metal  has  been 
introduced  into  the  veins,  are  found  strewed  through  the  substance  of  the  lungs,  and 
of  the  liver.  Pus,  received  into  the  blood  in  phlebitis,  is  arrested,  and  forms  scat- 
tered points  of  inflammation  and  abscess,  in  the  same  organs ;  and  it  is  in  the  liver 
and  the  lungs  that  separate  tumours  of  secondary  cancer  are  most  commonly  met 
with.  If  this  be  the  true  theory  of  secondary  cancerous  formations,  I  need  scarcely 
point  out  to  you  the  urgent  importance  of  the  rule  which  prescribes  to  the  surgeon 
the  most  complete  extirpation  of  the  primary  tumour,  at  the  earliest  possible  period 
of  its  existence. 

Of  these  primary  formations  the  origin  is  involved  in  much  obscurity.  It  seems, 
however  (and  this,  after  what  has  just  been  stated,  you  might  expect)  that  the  germs 
of  the  disease  are  capable  of  being  transferred  from  one  human  being  to  another ; 
and  even  to  an  animal  of  a  different  species.  Langenbeck  injected  cancerous  matter, 
just  taken  from  a  living  body,  into  the  veins  of  a  dog.  After  some  weeks  the  dog 
began  to  pine  away,  and  was  then  killed,  and  cancerous  growths  were  found  in  its 
lungs.  Several  instances  have  occurred — I  have  myself  known  of  two — of  cancer 
of  the  penis  ,in  men  whose  wives  laboured  under  cancer  of  the  uterus.  Here  it  is 
presumable  that  the  cancerous  germs,  received  upon  a  delicate  and  vascular  surface, 
and  suffered  perhaps  to  lodge  there  through  neglect  of  cleanliness,  might  fasten  upon 
the  part,  take  root  there  as  it  were,  and  grow.  One  very  curious  circumstance  con 
nected  with  this  subject  is,  that  the  frequent  contact  of  common  soot  seems  to  have 
the  power  of  producing  cancer.  There  is  a  form  of  carcinoma,  affecting  chiefly  the 
sciotum,  and  familiar  to  surgeons  as  the  chimney-sweeper's  cancer.  A  case  is 
recorded  of  cancer  of  the  same  variety  occurring  in  the  right  hand  of  a  gardener, 
who  for  years  had  been  in  the  habit  of  sprinkling  soot  over  his  flower-beds  with  his 
hands. 

There  are  not  wanting,  then,  plausible  grounds  for  the  hypothesis,  that  the  seeds 
of  cancer  may  be  introduced,  in  some  way  which  eludes  observation,  from  without 
that  cancerous  growths  are  strictly  parasitic,  and  independent  of  the  body,  excepting 
so  far  as  they  derive  their  pabulum  from  its  juices.  The  difficulties  involved  in 
this  supposition  are  not  greater  (as  we  shall  see  hereafter)  than  those  which  hang 
over  the  source  and  origin  of  certain  entozoa,  whereby  the  body  is  liable  to  be 
infested.  But  whether  this  hypothesis  be  true,  or  whether  the  cancer  cells  and  germs 
are  merely  morbid  elements  of  the  native  tissues  of  the  body,  developed  by  some 
perverted  energy  of  the  formative  process,  remains  yet  to  be  determined. 

From  the  tables  contained  in  the  Reports  of  the  Registrar-General,  it  would 
appear  that  women  are  more  subject  to  this  fearful  disorder  than  men,  in  the  large 
ratio  of  five  to  two.  It  fixes  chiefly  upon  the  female  organs  of  reproduction ;  the 
mammce  and  the  uterus. 

The  mortality  from  cancer,  estimated  with  due  reference  to  the  whole  number  of 
persons  existing  at  different  ages,  increases  steadily  as  hfe  advances. 

There  are  still  some  general  habitudes  of  the  different  varieties  of  cancer,  with 
which  I  should  wish  you  to  be  acquainted. 

The  secondary  formations  are  most  commonly  of  the  encephaloid  kind,  whatever 
the  primary  form  may  have  been. 

Encephaloid  cancer,  as  compared  with  scirrhus,  is  abundantly  furnished  with 
blood-vessels  ;  and  upon  this  difference  in  their  degree  of  vascularity,'  other  reniark- 
able  differences  between  the  two  varieties  seem  to  depend.  First,  encephaloid 
tumours  generally  augment  w'ith  much  greater  rapidity,  and  attain  a  much  larger 
size,  than  scirrhous  tumours.     Occasionally  their  magnitude  comes  to  be  enormous 


ENCEPHALOID    CANCER.  141 

Again,  cerebriform  growths  seldom  happen  singly,  but  occupy  several  organs  of  the 
body  at  once.  Scirrhus,  increasing  slowly,  occurs  also  in  fewer  sites ;  it  is  some- 
times even  solitary.  More  tissues,  too,  appear  to  be  obnoxious  to  the  soft  than  to  the 
hard  variety. 

Now  (as  Dr.  William  Budd  has  well  remarked)  a  large  apparatus  of  blood-vessels, 
bringing  a  proportionally  plentiful  supply  of  nourishment  to  the  parasitic  tumour, 
accounts  sufficiently  for  its  rank  and  rapid  growth ;  and  the  same  condition,  espe- 
cially when  conjoined  with  softness  of  the  parent  mass,  affords  obvious  facilities  foi 
the  hberal  dissemination  of  its  germs  through  numerous  returning  channels.  In 
fact,  the  soft  varieties  alone  have,  as  yet,  been  found  in  the  veins. 

The  same  multitude  of  its  blood-vessels,  and  slender  cohesion  of  its  component 
parts,  serve  to  explain  another  peculiarity  of  the  cerebriform  species.  Intermixed 
with,  or  diffused  through,  the  brain-hke  substance,  there  is  often  to  be  seen  a  quan- 
tity of  extravasated  blood ;  and  when  the  disease  breaks  out  into  ulceration,  red, 
ragged,  and  bleeding  growths,  of  fungous  aspect,  sprout  rapidly  from  the  cpen  sur- 
face. To  these  accidents  of  cancer  the  term  fungus  haematodes  is  to  be  traced.  We 
do  not  find  scirrhus  to  be  the  seat  of  similar  interstitial  hemorrhages. 

Encephaloid  cancer  has  less  tendency  to  contract  adhesions  with  contiguous  partj 
than  scirrhus  has. 

Of  the  alveolar  variety,  which  has  been  more  lately  discriminated,  from  the  others, 
and  less  studied,  less  is  known.  It  occurs  principally  in  the  abdomen,  affecting  the 
pyloric  orifice  of  the  stomach,  and  the  omentum.  It  appears  also  occasionally  in . 
the  bones,  and  the  breast  and  testicle.  Although  sometimes  combined  with  the  two 
other  species  in  the  same  person,  it  is  often  alone,  and  hmited.  to  a  single  organ.  I 
believe  it  has  not  been  met  with  except  in  adults.  • 

For  more  minute  information  upon  this  subject,  so  interesting  and  important  both 
in  its  pathological  relations  and  in  its  practical  bearings,  I  must  refer  you  to  a  very 
able  and  elaborate  article  on  cancer,  in  the  Cyclopxdia  of  Surgery,  by  Professor 
Walshe,  and  to  a  shorter  but  admirable  essay  on  the  same  topic,  by  Dr.  Wilham 
Budd,  published  in  the  Lancet.  From  these  sources  has  been  derived  much  of 
what  I  have  now  been  stating.  [We  may  also  refer  the  reader  to  the  full  and  excel- 
lent paper  of  Dr.  Carswell,  on  Scirrhus,  in  the  Cyclopaedia  of  Practical  Medi^ 

cine. — C.I 

s 

Returning  to  our  current  the^me,  I  proceed,  in  the  next  place,  to  speak,  in  a  gene- 
ral manner,  of  the  measures  to  be  adopted  when  we  are  called  upon  to  administer  to 
the  relief  of  a  person  labouring  under  inflammation :  of  what  is  sometimes  called 
the  cure;  but,  more  correctly,  of  the  treatment  of  inflammation. 

In  describing  the  phenomena  and  progress  of  inflammation,  I  took  external  inflam- 
mation as  a  type,  and  I  shall  keep  that  type  principally  in  view  in  what  1  have  to 
say  respecting  its  treatment :  making,  however,  such  reference  to  the  inflammation 
of  internal  parts  as  the  subject  will  permit.  You  will  bear  in  mind  that  my  design 
at  present  is  merely  to  explain  the  principles  of  treatment,  generally :  I  shall  point 
out,  by  and  by,  the  application  of  those  principles,  and  the  modifications  they  may 
require,  in  respect  to  particular  cases.  I  speak  also,  now,  of  common  inflammation, 
occurring  in  a  previously  healthy  person.  There  are  many  observations  that  con- 
cern all  inflammations  alike,  whether  external  or  internal,  and  by  despatching  these 
in  the  outset,  I  hope  to  avoid  much  repetition  hereafter. 

In  all  cases  of  inflammation,  our  first  object  is,  if  possible,  to  obtain  resolution: 
and  if  that  be  not  possible,  we  next  aim  at  securing  that  event  of  inflammation 
which  would  be  the  most  fortunate  in  the  particular  case  before  us.  In  external 
inflammations  good  suppuration  will  generally,  next  to  resolution,  be  the  most 
desirable  event :  in  internal  inflammations  it  will  be  sometimes  suppuration,  some- 
times adhesion. 

It  is  necessary  to  keep  in  view  the  distinction  between  the  treatment  proper  for 
the  inflammation  itself,  and  the  treatment  that  may  be  required  for  the  effects  of 
the  inflammation.     At  present  we  are  concerned  only  with  the  inflammation  itself. 

I  stated  to  you  in  a  former  lecture,  that  a  knowledge  of  the  cause  of  a  disease 


142  TREATMENT    OF    INFLAMMATION. 

might  help  us  in  its  treatment.  Knowing  the  cause,  our  first  care  must  be  to 
remove  it,  if  we  can.  In  the  case  formerly  supposed,  we  should  extract  from  the 
inflamed  arm  the  fragment  of  glass.  If  the  inflammation  has  been  excited  by  the 
extremity  of  di  fractured  bone,  of  a  broken  rib,  for  example,  we  take  measures  for 
bringing  the  separated  bones  into  their  proper  places,  and  for  keeping  them  there  : 
if  the  mere  displacement  of  a  part  has  occasioned  the  inflam.mation,  as  the  disloca- 
tion of  a  joint,  the  protrusion  of  the  bowel  in  hernia,  the  first  thing  to  be  attended  to 
is  the  restoration  of  the  part  to  its  natural  situation :  if  there  be  any  chemical  source 
of  irritation  (in  the  stomach,  for  instance,  threatening  or  producing  inflammation 
there,)  we  eject,  neutralize,  or  dilute  it. 

I  know  of  but  one  exception  to  this  rule,  and  it  belongs  to  surgery:  to  wif,  when 
a  bullet  or  splinter  is  so  lodged  in  the  interior  of  the  bod 3%  that  its  extraction  would 
be  more  hurtful  or  hazardous  than  its  remaining  where  it  is. 

A  knowledge  of  the  cause  of  an  inflammator)^  disease  may  help  us  in  another 
way.  We  do  not  treat  a  joint  that  is  inflamed  in  consequence  of  external  violence 
as  we  should  treat  the  same  joint  when  inflamed  in  rheumatism. 

But  it  is  very  seldom,  except  when  the  inflammation  is  external,  that  we  can 
accomplish  the  removal  of  its  cause.  In  most  internal  cases,  either  it  cajinot  be  got 
at,  or  it  has  already  ceased  to  be  applied;  as  when  the  inflammation  has  been  excited 
by  exposure  to  cold.  But  it  may  be  possible,  and  it  is  of  the  utmost  importance 
M'hen  possible,  to  prevent  any  ?'e-application  or  repetition  of  the  same  cause,  which 
would  be  L'kelyto  frustrate  our  endeavours  to  bring  about  resolution. 

Next  in  importance  to  the  removal  and  avoidance  of  the  exciting  cause,  must  be 
placed  in  most  instances,  the  observance  of  what  is  called  the  antiphlogistic  regi- 
men. This  may  seem  an.  old-fashioned,  phrase,  but  it  is  a  very  convenient  one ; 
being  a  brief  form  of  expressing  the  sum  of  several  distinct  provisions  for  the  wel- 
fare of  the  sick,  and  for  the  conduct  of  their  attendants.  The  word  antiphlogistic  is 
derived,  indeed,  from  an  obsolete  theory ;  but  we  retain  it  as  a  useful  arbitrary  term, 
without  reference  to  its  etymology^  or  to  its  original  meaning. 

The  object  of  the  antiphlogistic  regimen  is  to  put  and  keep  the  patient  in  that 
state  which  is  most  favourable  for  the  spontaneous  subsidence  of  the  disease,  or  for 
the  sanative  influence  of  remedies.  This  regimen  consists  in  the  avoidance  of  every 
stimulus  that  can  be  avoided,  whether  external  or  internal.  Common  sense  will 
suggest  to  you  the  details.  It  implies  a  total  abstinence  from  animal  food,  and  from 
strong  drink  of  all  kinds.  It  prescribes  the  exclusion  of  all  that  might  excite  or 
exercise  the  mind,  or  produce  a  strong  impression  upon  the  senses :  noise ;  bright 
light ;  great  heat  or  cold.  The  patient  should  be  kept  in  a  temperature  of  about  G2^, 
and  in  a  well-ventilated  apartment.  He  must  not  be  allowed  to  converse,  nor  to 
attend  to  matters  of  business ;  unless,  indeed,  his  mind  happens  to  be  disturbed  and 
anxious  about  some  point  which  one  short  interview  with  a  friend  may  effectually 
settle.  All  causes  of  strong  emotion,  and  mental  agitation,  should  be  strictly  guarded 
against.  Whatever  tends  to  quicken  the  circulation  is  to  be  shunned  ;  and  therefore 
not  only  those  influences  which  operate  through  the  nervous  system,  but  also  all 
needless  bodily  effort  and  exertion,  must  be  prohibited.  The  patient  (in  the  serious 
cases  I  am  now  contemplating)  must  remain  in  bed  :  and  in  a  position  which  facili- 
tates, or  at  least  does  not  impede,  the  free  return  of  blood  by  the  veins  from  the  suf- 
fering organ.  If  the  inflammation  is  seated  in  or  about  the  head,  that  part  should 
be  elevated  by  pillows.  If  one  of  the  lower  extremities  is  affected,  even  when  the 
disease  is  not  so  intense  as  to  require  confinement  to  bed,  the  lijnb  must  be  sustained 
horizontally,  or  be  even  still  more  raised  up.  On  the  same  principle  it  is  that  we 
suspend  an  inflamed  hand  or  fore-arm  in  a  sling.  In  some  cases  of  internal  inflam- 
mation— in  pleurisy,  for  example — the  patient  will  choose  his  own  position.  He  is 
admonished,  by  the  pain  and  distress  they  occasion,  that  certain  postures  would  be 
hurtful  or  dangerous,  and  he  carefully  avoids  them.  We  often  derive  much  informa- 
tion from  this  instinctive  caution  on  the  part  of  our  patient. 

The  function  of  the  organ  inflamed  should  also  be  spared  its  exercise,  whenever 
and  in  as  great  a  degree  as  that  can  be  done.  As  you  would  not  allow  a  patient  to 
Tiove  an  inflamed  joint,  so  you  must  not  permit  him  to  use  an  inflamed  eye ;  to 


ANTIPHLOGISTIC    REGIMEN.  143 

sp^ak  more  than  may  be  absolutely  necessary  with  inflamed  lungs ;  to  exert  by 
thinking,  and  by  attention  to  external  excitements,  an  inflamed  brain.  This  last  rule 
IS  essential,  even  when  the  brain  is  not  the  seat  of  the  inflammation :  it  is  to  be 
observed  in  all  febrile  disorders. 

The  adoption  of  this  antiphlogistic  regimen  is  not,  indeed,  necessary,  nor  even 
proper,  in  all  cases  and  stages  of  inflammation.  The  iaiflammation  may  be  so  slight 
as  not  to  require  it ;  particularly  in  external  cases,  of  which  the  causes  and  the  extent 
are  known  ;  as  slight  contusions,  trifling  wounds,  and  some  kinds  of  eruption.  But 
this  exception  must  always  be  applied  with  great  caution  to  cases  of  internal  inflam- 
mation, about  the  causes  and  extent,  and  tendencies  of  which  we  may  be  less  sure. 
In  chronic  forms  of  inflammation  again,  as  in  scrofulous  inflammation  of  the  lympha- 
tic glands,  or  of  the  eyes,  attended  with  but  little  pain  or  heat,  the  antiphlogistic  regi- 
men would  often  fail  to  be  beneficial :  the  state  of  the  general  system  being  such  as 
to  require  support  and  strengthening  measures,  more  than  the  local  symptoms  call 
for  an  opposite  treatment.  So  also  when  suppuration  or  gangrene  have  supervened, 
the  antiphlogistic  regimen  must  generally  be  modified,  or  abandoned. 

But  in  the  outset  of  all  cases  of  serious  inflammation,  when  the  strength  is  entire, 
and  the  inflammation  intense  enough  to  produce  pyrexia,  all  the  particulars  of  the 
antiphlogistic  regimen  may  require  to  be  observed. 

Of  all  the  direct  remedies  of  inflammation,  the  abstraction  of  blood,  bleeding,  or 
hlooA-letting,  as  it  is  called,  is  by  much  the  most  effectual  and  important.  We 
should,  I  think,  be  prepared  to  expect  this,  prior  to  any  experience  of  it.  Blood 
being  the  natural  stimulus  of  the  heart,  we  should  deem  it  probable  that  the  removal 
of  a  portion  of  that  fluid  would  diminish  the  force  with  which  the  heart  contracts : 
and  as  an  inflamed  part  contains  a  preternatural  quantity  of  blood,  and  as  (with  the 
exception  of  resolution  and  mortification,  which  really  are  terminations  of  inflamma- 
tion— as  with  these  exceptions)  all  the  events  of  inflammation  depend  upon  the  effu- 
sion of  certain  parts  of  the  blood  from  its  containing  blood-vessels,  we  should  be 
inclined,  «  priori,  to  believe  that  the  amount  of  those  effusions  would  be  checked  and 
limited  by  lessening  the  supply  of  blood  to  the  inflamed  organ,  as  well  as  by  abating 
the  force  with  Avhich  the  blood  reaches  it.  And  we  find  it  in  fact  to  be  so.  The 
results  of  experience  confirm,  in  this  matter,  the  suggestions  of  our  reason.  Blood 
forms  the  pabulum  of  the  whole  process.  "If,"  (says  Mr.  Lawrence,)  "we  may  be 
allowed  to  use  figurative  language,  the  obvious  increase  of  heat  in  the  part  is  analo- 
gous to  that  of  fire  ;  and  blood  is  the  fuel  by  which  the  flame  is  kept  up :  in  fact, 
if  we  could  completely  take  away  its  blood  from  the  part,  we  should  be  able  entirely 
to  control  or  arrest  the  increased  action," 

But  it  is  not  every  case  of  inflammation  that  requires  or  warrants  the  abstraction 
of  blood  :  and  when  blood-letting  is  requisite,  the  mode  of  taking  away  the  blood, 
the  proper  quantity  to  be  taken,  and  the  propriety  of  repeating  the  bleeding,  all  vary 
greatly  in  difl!erent  cases.  It  is  obviously  of  vast  importance  that  you  should  learn 
so  to  use  this  valuable  remedy  as  not  to  abuse  it.  Its  power  is  great  for  evil  as  well 
as  for  good  ;  and  in  rash  or  inexperienced  hands  it  too  often  becomes  an  instrument 
of  flital  mischief. 

There  are,  as  you  are  all  aware,  several  modes  of  abstracting  blood :  phlebotomy, 
arteriotomy,  scarification,  cupping  (which  is  merely  a  variety  of  scarification),  the 
application  of  leeches.  Bleeding  performed  in'either  of  the  first  two  of  these  me- 
thods is  called  general  bleeding.  The  rest  are,  in  most  instances,  topical  or  local: 
but  they  are  not  merely  topical  in  all  cases.  The  main  object  of  general  bleeding 
is  to  diminish  the  whole  quantity  of  blood  in  the  system,  and  thus  to  lessen  the  force 
of  the  heart's  action.  The  object  of  local  bleeding  is,  in  most  instances,  that  of  emp 
tying  the  gorged  and  loaded  capillaries  of  the  inflamed  part.  Sometimes  the  blood 
is  thus  taken  directly  from  the  turgid  vessels  themselves ;  more  often,  I  fancy,  topi- 
cal blood-letting  produces  its  efTect  by  diverting  the  flow  of  blood  from  the  affected 
part,  and  giving  it  a  new  direction,  and  so  indirectly  relieving  the  inflammatory  con- 
gestion. General  bleeding  has  also  incidentally  a  similar  tendency  to  deplete  the 
vessels  concerned  in  the  diseased  process :  and,  on  the  other  hand,  a  dexterous  cup- 
per, under  favourable  circumstances,  will  take  away  blood  from  a  part  as  copiously 


144  INFLAMMATION. 

and  rapidly  as  if  it  were  made  to  flow  from  an  opened  vein :  and  then  the  eflee.. 
upon  the  system  will  be  alike  in  the  one  case  and  in  the  other.  The  same  rnay 
be  said  of  leeches,  when  they  are  applied  in  the  enormous  numbers  which  our 
neighbours,  the  French,  are  fond  of  using.  In  whatever  way  the  blood  is  drawn, 
Avhether  from  a  vein  or  from  an  artery,  or  by  the  pressure  of  a  cupping-glass  around 
a  surface  previously  scarified,  or  by  the  suction  of  leeches,  the  general  effect  upon 
the  system  will  be  in  proportion  to  the  quantity  of  blood  abstracted  in  a  given  time. 
The  most  convenient  and  effectual  mode  of  general  bleeding,  upon  the  whole,  is 
certainly  the  common  one,  from  the  veins  at  the  bend  of  the  arm.  But  sometimes 
those  veins  are  small  or  deep,  especially  in  fat  people ;  and  we  fail  in  our  efforts  to 
get  the  blood  to  flow  from  them  in  a  full  stream :  and  then  we  may  open  some  other 
vein  or  an  artery,  or  call  in  the  cupper  to  our  assistance,  or  cover  the  neighbouring 
■surface  with  leeches ;  according  to  the  situation  of  the  part  inflamed,  and  other  cir- 
cumstances. 

Let  us  now  briefly  consider  what  the  indications  are  by  which  we  judge  of  the 
"Expediency  of  taking  away  blood.  We  are  guided  very  much  by  the  degree  of 
pyrexia ;  by  the  quality  of  the  pulse ;  by  the  importance  of  the  organ  affected  ;  by 
the  intensity  of  the  inflammation,  in  what  manner  soever  that  may  be  measured  ;  by 
the  period  or  stage  of  the  disease  ;  by  the  age,  and  sex,  and  general  condition  of  the 
patient;  and  frequently  also  by  the  ordinary  character  and  course  of  the  disease, 
when  inflammation  happens  to  be,  or  to  accompany,  an  epidemic  disorder.  It  is  not 
one  of  these  circumstances  alone,  but  several  of  them,  that  we  have  to  take  into  the 
account,  in  most  cases  :  and  what  I  have  now  to  say  in  reference  to  them  must  needs 
be  very  general. 

The  presence  of  pyrexia,  especially  when  the  febrile  disturbance  is  well  marked, 
admonishes  us,  indeed,  to  search  after  other  indications  of  the  propriety  of  blood- 
letting, and  confirms  them  if  they  are  found  ;  but  is  not,  of  itself,  a  sufficient  reason 
for  resorting  to  that  remedy.  There  may  be  high  febrile  symptoms  without  any 
inflammation  at  all ;  as  in  the  hot  stage  of  an  ague  fit :  and  a  smart  attack  of  fever 
may  spnng  out  of  local  inflammation,  and  yet  the  known  course  of  the  disease,  or 
the  nature  of  the  part  affected,  may  render  the  abstraction  of  blood  unnecessary,  and 
therefore  improper. 

Our  judgment  is  more  often  determined  by  the  quality  of  the  pulse,  although  we 
are  by  no  means  to  be  wholly  directed  by  this.  The  quality  of  the  pulse  which — 
other  things  being  the  same — bespeak  the  necessity  of  blood-letting,  is  hardness.  I 
described  this  quality  to  you  in  a  former  lecture  :  it  may  coexist  with  a  large  or  a 
small,  a  slow  or  a  frequent  pulse.  Most  commonly  (and  "yet  the  exceptions  are  nu- 
merous)  in  acute  inflammations  the  pulse  is  full  and  frequent  as  well  as  hard.  The 
hardness  is  ascertained  and  measured  by  the  resistance  which  the  throb  of  the  artery 
makes  to  the  pressure  of  your  finger.  The  pulse  is  sometimes  said  to  be  incom- 
pressible ;  which  means  that,  although  you  apply  your  finger  with  considerable  firm- 
ness, the  blood  still  forces  its  way  tlirough  the  vessel  beneath  it. 

Now  this  hardness  of  the  pulse  is  sometimes  our  best  warrant  for  active  depiction 
by  means  of  the  lancet :  yet  I  say  we  must  not  trust  to  this  alone ;  for  a  hard  pulse 
may  habitually  exist,  where  there  is  no  inflammation.  Certain  chronic  diseased 
conditions  of  the  heart  may  occasion  it;  and  it  probably  results  also  sometimes 
from  some  unnatural  state,  which  is  not  inflammation,  of  the  whole  of  the  circulating 
system.  When  you  happen  to  know  your  patient,  and  have  ascertained  what  kind 
of  pulse  he  has  when  he  is  well,  and  are  previously  aware  that  his  pulse  during 
health  is  tiot  a  hard  pulse,  you  learn  from  that  circumstance  that  the  new  quality  it 
has  now  acquired  denotes  the  presence  of  inflammation ;  and  usually  of  active  inflam- 
mation, likely  to  go  on,  if  not  controlled,  to  the  destruction  of  the  pan  it  has  seized 
upon 

Many  persons,  and  young  practitioners  in  particular,  are  apt  to  look  to  the  fre- 
quency of  the  pulse,  when  they  wish  to  ascertain  the  expediency  of  blood-letting: 
but  really  its  frequency  is  very  subordinate  in  itnportance  to  its  hardness  or  softness: 
and  this  is  very  unlucky,  because  any  body  with  his  stop-watch  in  his  hand  can 
tount  a  pulse :  but  it  is  not  every  one  who  can  tell  a  hard  pulse  when  he  feels  it. 


BLOOD-LETTING.  145 

The  finger  requires  a  certain  education  for  that  purpose  ;  and  there  are  some  persons 
who  seem  never  to  attain  the  tactus  eruditus.  I  should  advise  you  to  attend  par- 
ticularly to  this  quality  of  the  pulse,  and  to  compare  your  perceptions  to  the  hardness 
or  softness  of  the  pulse  in  individual  cases,  with  those  of  other  medical  men. 

The  frequency  of  an  inflammatory  pulse  ranges  for  the  most  part  between  90  and 
120.  When  the  hard  pulse  is  much  more  frequent  than  this,  it  commonly  occurs 
either  in  young  children,  or  in  persons  who  are  more  than  usually  nervous  and  sus- 
ceptible ;  or  in  persons  who  were  previously  labouring  under  some  chronic  and 
wasting  complaint,  in  which  the  pulse  was  already  frequent,  though  not  hard  :  as, 
for  example,  in  phthisical  patients,  when  acute  pleurisy  supervenes  upon  tubercular 
disease  of  the  lungs. 

As  the  hardness  of  the  pulse  is,  with  certain  exceptions  at  which  I  have  just 
glanced,  our  lawful  warrant  for  general  bleeding,  so  the  disappearance  of  that  hard- 
ness is  a  token  that  the  blood-letting  has  been  carried  far  enough. 

Again,  the  nature  and  importance  of  the  organ  affected  will  influence  our  judg- 
ment in  respect  to  the  question  of  abstracting  blood.  If  the  organ  inflamed  be  a  vital 
organ ;  or  if  we  are  not  sure  about  that,  but  have  any  reason  to  suspect  that  it  may 
be  a  vital  organ  ;  I  need  scarcely  say  that  we  must  act  upon  the  worst  supposition, 
and  bleed.  But  if  the  part  be  of  less  importance  in  the  economy  of  the  body;  or  if 
uiflammation  is  known  ordinarily  to  run  its  course  in  that  part  without  producing 
any  abiding  damage  ;  it  may  not  be  worth  while,  even  though  the  fever  be  high  and 
the  pulse  hard,  to  have  recourse  to  this  potent  remedy,  for  the  sake  of  subduing 
inflammation  which  is  attended  with  so  Httle  danger.  In  this  predicament  may  be 
placed  many  instances  of  cynanche  tonsillaris,  and  of  acute  rheumatism.  The  sub- 
sequent debilitating  effects  of  the  loss  of  blood  upon  the  system  may  be  more  certain 
and  more  hurtful  than  the  effect  of  the  bleeding  upon  the  local  inflammation  is  likely 
to  be  beneficial. 

[Without  pretending  to  advocate  the  employment  of  blood-letting  in  every  case  of  cynanche 
tonsillaris  and  of  acute  rheumatism,  we  must  dissent  from  the  correctness  of  Dr.  Watson's 
position,  that  "  even  though  the  fever  be  high  and  the  pulse  hard,"  it  may  not  be  worth 
while  to  bleed  "  for  the  sake  of  subduing  inflammation  which,  in  these  afTections,  is  attended 
with  so  little  danger."  When  acute  rheumatism  occurs  in  young,  robust,  and  plethoric  habits, 
and  is  attended  with  considerable  fever  and  a  hard  and  accelerated  pulse,  we  know  of  no 
remedy  from  which  such  decided  advantage  is  to  be  obtained  as  from  a  well-timed  resort 
to  the  lancet.  The  extent  to  which  the  bleeding  is  to  be  carried  and  the  propriety  of  its 
repetition,  must  be  determined  by  the  circumstances  of  each  case,  and  the  effects  produced 
by  the  first  operation.  We  are  no  advocate,  under  any  circumstances,  for  the  profuse  and 
repeated  bleedings  recommended  by  M.  Bouillaud  as  a  means  of  cutting  short  an  attack  of 
acute  rheumatism  ;  we  have  had,  however,  ample  experience  of  the  very  decided  relief 
obtained  by  a  prudent  and  well-timed  use  of  the  lancet  in  this  disease. 

In  many  cases  of  cynanche  tonsillaris,  al.'^o.  an  early  and  full  bleeding  will  have  the  effect 
of  arresting  the  inflainmation,  and  thus  of  saving  the  patient  from  much  suffering,  if  not 
danger.  Even  when  the  arrest  of  the  disease  is  not  affected  by  it,  the  inflammation  is 
reduced  in  violence  and  shortened  in  duration. — C] 

The  period  or  stage  of  the  disease  forms  a  most  important  element  in  the  question 
before  us.  It  is  of  inflammation  while  yet  in  its  early  progress,  that  blootl-lettino- 
may  emphatically  be  pronounced  the  cure ;  while  the  disease  is  still  within  the  pos- 
sibility of  resolution ;  before  there  is  any  great  amount  of  effusion,  or  any  serious 
disorganization  of  structure.  The  sooner  we  bleed,  the  more  surely  will  the  inflam- 
matory process  be  moderated  and  limited,  even  when  it  cannot  be  wholly  quenched. 
In  no  case  within  the  range  of  medical  practice  is  the  maxim  "  principiis  obsta" 
more  imperative.  Those  among  you  who  happen  to  be  attending  the  wards  of  the 
Middlesex  Hospital  may  wonder,  indeed,  after  hearing  my  estimate  of  the  power  of 
blood-letting  over  inflammation,  that  I  so  seldom  prescribe  venesection  there.  The 
truth  is,  not  that  I  undervalue  the  remedy,  but  that  the  time  for  its  employment 
has  generally  gone  by.  The  poor  are  unwilling  to  relinquish  the  occupations  bv 
which  they  subsist :  they  struggle  on  as  long  as  they  can,  and  resort  to  hospital's 
only  when  they  are  compelled  to  do  so  by  the  exigency  of  their  malady.  Many  of 
them  labouring  under  inflammation,  have  been  freely  bled  before  admission.     It  \n 

10  N 


146  INFLAMMATION. 

commonly  too  late,  when  they  present  themselves,  to  expect  that  the  course  of  the 
disease  can  be  so  arrested.  The  first  effect  of  blood-letting  is  to  deplete  and  relieve 
the  labouring  circulation.  But  when  it  is  again  and  ag-ain  repeated,  it  becomes  (as 
the  French  say)  spolialive;  it  robs  the  vital  fluid  of  its  nutrient  and  plastic  materials. 
Pushed  still  further,  it  produces  a  peculiar  state  of  the  nervous  sj'stem,  marked  by 
great  weakness  and  irritability.  Now  although  blood-letting  is  the  summum  remedium 
for  inflammation  at  its  commencement,  there  is  a  point  beyond  which  it  not  only 
does  no  good,  but  is  positively  injurious.  And  this  point  it  is  not  always  easy  to 
hit.  On  one  side  is  the  danger  that  the  inflammatory  action  may  continue  and 
extend :  on  the  other  the  danger  that  the  strength  of  the  system  may  be  so  reduced 
as  to  prove  unequal  to  the  process  of  restoration ;  for,  to  remove  the  interstitial  extra- 
vasations, and  to  repair  the  damage  that  has  accrued,  a  certain  degree  of  vital  power 
is  requisite,  and  a  suflicient  quantity  of  healthy  blood.  Bleeding  will  cure  inflam- 
mation, but  it  will  not  always  cure  the  effects  of  inflammation  ;  nay,  it  may  render 
them  lingering  in  their  departure,  or  even  determine  their  fatality.  I  cannot  too 
often,  or  too  strongly  inculcate  the  precept,  that  in  order  to  check  and  extinguish 
acute  inflammation,  you  must,  above  all,  bleed  early. 

We  judge  that  the  bleeding  has  been  carried  far  enough  when  the  inflammatory 
fever  subsides,  or  changes  its  character;  when  the  pulse  regams  its  softness,  or 
undergoes  some  marked  alteration  ;  when  any  of  the  signs  (already  specified)  of  sup- 
puration appear.  Upon  these  points  I  hope  to  give  you  more  explicit  instruction 
when  we  come  to  special  instances  of  inflammation. 

Whenever  inflammation  supervenes  on  other  chronic  disease  :  whenever  it  arises 
in  the  progress  of  idiopathic  fever,  or  whilst  the  constitution  is  contaminated  by  some 
specific  poison  :  whenever  suppuration  is  inevitable,  or  even  probable  :  in  all  these 
cases  general  bloodletting  may  be  necessary,  but  it  must  be  employed  with  great 
caution. 

Nor  can  w^e,  safely,  neglect  the  age,  and  sex,  and  general  condition,  of  the  sick 
person,  when  we  are  turning  in  our  minds  the  propriety  of  bleeding.  The  very 
young,  the  old  and  the  feeble,  do  not  bear  well  the  loss  of  much  blood.  This  con- 
sideration is  not  to  deter  you  from  bleeding  such  persons  when  they  are  attacked  by 
dangerous  inflammation ;  but  it  especially  enforces,  with  respect  to  them,  the  gene' 
ral  rule,  that  no  more  blood  should  be  abstracted  than  is  absolutely  required  to  con- 
trol  the  disease. 

It  is  also  very  necessary  to  study  the  character  and  tendency  of  the  reigning  epi- 
demic :  whether  that  may  depend  upon  some  predisposition  silently  and  gradually 
produced  in  men's  bodies  by  the  agency  of  causes  that  are  but  little  understood  :  or 
whether  it  may  result  from  some  peculiarity  in  the  exciting  cause  of  a  particular 
epidemic  disease.  I  have  been  long  enough  in  practice  in  London  to  have  learned, 
in  common  with  others,  how  much  the  character  of  continued  fever  may  alter.  Since 
about  the  time  when  the  virulent  form  of  cholera  made  its  first  appearance  among 
us,  continued  fever  has  nehher  required  nor  borne  the  abstraction  of  blood  as  it  did 
bear  and  require  it  for  some  years  prior  to  that  period.  Perhaps  some  variation  in 
the  intensity  of  the  poison  may  partly  explain  the  comparative  malignity  —  the 
greater  tendency,  I  mean,  to  the  typhoid  type — v/hich  marks  certain  epidemics  of 
scarlet  fever,  small-pox  and  measles.  The  influenza,  or  epidemic  catarrh,  which 
was  almost  universal  in  this  town  and  kingdom  in  the  years  1833  and  1837,  afforded 
a  striking  illustration  of  the  point  I  am  endeavouring  to  set  before  you.  The  iuHnm- 
matory  symptoms — the  bronchitis,  and  sometimes  pneumonia — were  in  many  crises 
strongly  marked,  and  it  was  necessary  to  abstract  blood  ;  but  persons  suffering  under 
.iifluenza  bore  bleeding  exceedingly  ill,  and  where  the  use  of  the  lancet  could  not  be 
avoided,  it  was  never  resorted  to  without  reluctance  and  misgiving. 

When  we  bleed  in  acute  inflammation  of  an  important  organ,  we  endeavour,  I 
say,  to  effect  our  purpose  as  speedily  as  possible,  and  with  as  little  expenditure  of 
the  vital  fluid  as  possible.  It  would  be  quite  ridiculous  to  pretend  to  give  any  precise 
direction  as  to  the  number  of  ounces  of  blood  that  should  be  taken.  You  must  stay 
by  the  patient,  and  bleed,  in  such  cases  as  I  am  now  contemplating,  until  you  pro- 
duce some  distinct  impression  by  the  bleeding ;  and  one  of  the  best  guides  in  this 


BLOOD-LETTING.  147 

matter  is  the  state  of  the  pulse.  If  you  find,  as  you  sometimes  will  do,  that  the  most 
pressing  symptoms  give  way  while  the  blood  is  still  flowing — that  the  pain,  for 
instance,  is  mitigated — that  the  respiration  (when  the  lungs  are  concerned)  becomes 
easier  and  deeper — that  (in  affections  of  the  brain)  the  patient  emerges  from  a  state 
of  stupor  or  delirium — you  may  be  sure  that  you  are  doing  right  in  bleeding ;  but 
you  must  keep  your  finger  upon  your  patient's  wrist,  and  suffer  the  blood  to  flow, 
until  the  hard  pulse  is  sensibly  softer,  or  until  symptoms  of  impending  syncope 
appear  ;  and  then  you  had  better  tie  up  the  arm,  and  wait  a  few  hours,  and  repeat  the 
bleeding  if  the  symptoms  which  at  first  demanded  it  again  become  urgent. 

As  it  is  desirable  to  produce  the  necessary  effect  upon  the  system  as  quickly  as 
may  be,  the  blood  should  be  taken  pleno  rivo  ;  i.  e.,  a  sufficiently  large  orifice  should 
be  made  in  the  vein :  and  sometimes  it  may  be  right  to  open  a  vein  in  both  arms  : 
and  the  patient  should  be  bled  in  the  upright  position.  Faintness  and  syncope 
depend  upon  a  defective  supply  of  blood  to  the  brain ;  and  therefore  will  be  Ukely 
to  occur  the  sooner  when  the  force  of  gravity  facihtates  the  descent  of  the  blood  from 
the  head  through  the  veins,  and  retards  its  ascent  towards  the  head  through  the 
arteries.  And  conversely,  the  first  thing  to  be  done  towards  remedying  syncope 
is  to  lay  the  person  flat  in  a  horizontal  posture,  or  even  with  his  head  lower  than 
his  trunk. 

If  you  neglect  these  smaller  matters,  and  make  an  insignificant  slit  in  the  vein, 
and  suffer  your  patient  to  lay  down  whilst  you  are  bleeding  him,  you  will  be  obliged 
to  take  much  more  blood  in  the  end  ;  or  you  may  drain  him  of  his  blood  and  of 
his  strength  by  repeated  bleedings  of  this  sort,  and  make  no  impression  after  all 
upon  the  disease.  It  is  one  of  the  numerous  cases  in  which  parsimony  is  not  true 
economy. 

The  quantity  of  blood  requisite  to  be  taken  in  order  to  produce  the  due  effect  is 
exceedingly  various.  It  is  a  remarkable  circumstance,  well  worth  attending  to,  and 
much  insisted  upon  of  late  years,  especially  by  Dr.  Marshall  Hall,  that  a  patient 
under  the  influence  of  mere  inflammation  will  bear  to  lose  a  far  greater  quantity  of 
blood  without  becoming  faint,  than  he  could  bear  in  health :  that  the  state  of  the 
system  produced  by  the  presence  of  inflammation  protects  it  from  the  ordinary  con-« 
sequences  of  loss  of  blood.  The  amount  of  the  bleeding  necessary  to  occasion  syn- 
cope will  be  in  proportion  to  the  exigency  of  the  case.  This  fact — if  it  be  really  a 
fact,  as,  indeed,  I  beheve  it  is — is  evidently  one  of  the  highest  value  and  importance, 
for  it  furnishes,  what  is  always  so  desirable,  especially  in  an  uncertain  art  like  ours, 
a  simple  rule  of  practice.  Yet  it  is  not  a  rule  so  firmly  established  as  not  to  admit 
of  exceptions.  If  the  mere  state  of  syncope  was  the  curative  influence  required, 
Ave  should  have  no  difficulty.  That  the  faintness  does  constitute  a  part  of  that  influ- 
ence I  fully  believe.  Dr.  M.  Solon  even  relates  a  case  in  which  it  sufficed  to  the 
cure  of  erysipelas  of  the  head  and  face,  attended  with  high  fever.  The  patient 
fainted  from  alarm,  before  the  vein  was  opened.  The  inflammatory  symptoms  there- 
upon ceased  :  but  with  returning  animation  they  presently  recurred.  Again,  prepa- 
ration was  made  for  venesection  ;  and  again  the  young  lady  lapsed  into  syncope  : 
and  this  time  the  inflammation  and  fever  disappeared,  never  to  return.  She  is 
described  as  having  been  quite  well  the  next  day.  I  cannot,  however,  entertain  a 
doubt  that  the  withdrawal  of  a  certain  quantity  of  blood  is,  in  almost  every  case, 
essential  to  the  permanent  control  of  common  acute  inflammation,  attended  with 
pyrexia :  and  it  may  be  advisable  to  keep  persons  who,  like  M.  Solon's  patient,  are 
of  a  timid  disposition,  and  liable  to  syncope  from  slight  causes,  in  a  recumbent 
posture,  in  order  that  the  requisite  discharge  of  blood  from  the  system  may  be 
obtained. 

In  equivocal  cases  (and  there  are  many  such),  where  it  is  questionable  whether 
the  symptoms  proceed  from  inflammation  or  not,  the  diagnosis  may  often  be  settled 
by  observing  the  quantity  of  blood  which,  taken  in  the  upright  posture,  suffices  to 
bring  on  incipient  syncope. 

Dr.  Hall's  book.  On  the  Effects  of  Loss  of  Blood,  is  well  worth  your  attentive 
perusal.  He  suggests  that  a  scale  of  diseases  might  be  formed,  representing  the 
protective  influence  of  some  maladies  against  the  effects  of  blood-letting ;  and  the 


148  INFLAMMATION. 

opposite  influence  of  some  others  in  producing  preternatural  susceptibility  of  those 
effects.  "  It  would  begin  (he  says)  with  congestion  of  the  head,  or  tendency  to  apo- 
plexy ;  inflammation  of  the  serous  membranes,  and  of  the  parenchymatous  substance 
of  various  organs,  would  follow ;  then  acute  anasarca ;  and  lastly,  inflammation  of 
the  mucous  membranes.  This  part  of  the  scale  would  be  divided  from  the  next  by 
the  condition  of  the  system  in  health.  Below  this  would  be  arranged  fever ;  the 
effects  of  intestinal  irritation  ;  some  cases  of  dehrium  ;  reaction  from  loss  of  blood  ; 
and  disorders  of  the  same  class  with  hysteria,  dyspepsia,  chlorosis,  and  cholera 
morbus." 

With  respect  to  the  propriety  of  repeating  venesection,  it  is  his  remark,  that  if,  at 
the  first  blood-letting,  much  blood  flowed  before  any  tendency  to  syncope  manifested 
itself,  an  early  repetition  of  that  remedy  ^^^ll  probably  be  required — and  at  any  rate 
an  early  repetition  of  our  visit  to  the  patient  will  be  proper.  But  this  last  precept 
is  of  universal  obhgation  in  all  cases  of  serious  inflammation. 

I  am  ahnost  afraid  to  tell  you  how  much  blood  I  have  seen  taken  at  one  bleeding, 
lest  I  should  seem  to  encourage  you  to  imitate  such  heroic  practice.  I  once  slood 
by  and  saw,  not  without  trembling — although  I  was  quite  free  from  responsibility 
in  the  matter — a  vein  in  the  arm  kept  open  until  seventy-two  ounces  (four  pints  and 
a  half)  of  blood  had  issued  from  it :  and  then,  and  not  till  then,  did  the  patient 
become  faint.  The  event  of  the  case  quite  justified  the  bleeding  in  that  instance,  for 
the  man  got  perfectly  well.  It  was  a  case  of  general  dropsy,  which  had  come  on 
suddenl}',  in  a  young  and  robust  man.  It  occurred  in  the  clinical  wards  of  the 
Infirmary  at  Edinburgh  ;  the  physician  had  desired  the  clinical  clerk  to  bleed  the 
patient  in  the  erect  posture,  until  some  sensible  effect  was  produced  upon  his  pulse  : 
and  no  such  effect  could  be  perceived  until  the  enormous  quantity  I  have  mentioned 
had  been  abstracted.  It  is  very  seldom  that  such  large  bleedings  are  required  ;  you 
will  generally  find  that  five-and-twenty  or  thirty  ounces,  taken  properly,  will  be  suffi- 
cient to  accomplish  the  purpose  of  the  measure.  Sometimes  one  such  bleeding  will 
extinguish,  as  it  were,  the  inflammation ;  sometimes  two  or  three,  or  half-a-dozen 
may  be  necessary  :  and  we  judge  of  the  propriety  of  repeating  the  venesection  by 
the  effect  of  the  former  bleeding ;  by  the  character  of  the  pulse  ;  by  the  appearance 
of  the  blood  already  drawn.  It  would  be  impossible,  in  a  general  account  like  the 
present,  to  lay  down  any  minute  directions  on  this  head. 

I  have  hitherto  been  speaking  of  bleeding  as  we  perform  it  for  the  cure  of  active 
inflammation,  occurring  in  a  person  previously  healthy,  affecting  an  important  organ, 
and  attended  with  febrile  disturbance  of  the  system.  But  the  abstraction  of  blood 
is  scarcely  less  valuable  as  a  remedial  measure  in  chronic  inflammation,  when  the 
system  at  large  scarcely  sympathizes  at  all  with  the  local  disease.  And  here  it  is 
that  what  is  properly  called  local  bleeding  is  so  useful  —  by  cupping  glasses,  or  a 
moderate  number  of  leeches.  The  object  is  always  the  same,  viz. :  to  unload  and 
relieve  the  turgid  capillary  vessels  of  the  part :  and  this  we  could  not  do  by  general 
bleeding  without  carrying  it  to  an  extent  which  would  be  dangerous  to  our  patient's 
existence.  These  local  bleedings  for  chronic  inflammation  usually  require  to  be  often 
repeated.  Considered  as  a  remedy,  blood-letting  resembles  some  other  remedies  in 
this,  that  it  must  be  proportioned  and  adjusted  to  the  rate  of  progress,  and  the  dura- 
tion of  the  disease.  The  remedy  must  be  used  chronically  when  the  malady  is 
chronic.  A  patient  may  lose,  on  the  whole,  much  more  blood  for  the  cure  of  a 
chronic  inflammation,  than  for  the  cure  of  one  that  is  violent  and  acute  ;  but  then 
the  bleeding  must  be  spread  over  a  larger  space  of  time. 

With  respect  to  the  relative  merits  and  advantages  of  cupping  and  of  leeches,  as 
topical  remedies  for  local  inflammation  ;  it  maj'  be  said  in  favour  of  cupping,  that 
the  precise  quantity  of  blood  taken  away  is  more  accurately  determined  in  that 
manner,  and  the  operation  is  sooner  over,  and  is  less  fatiguing,  than  the  suction  of 
leeches.  But  on  the  other  hand,  the  leeches  seldom  bungle  in  the  operation,  while 
the  surgeon  often  does  It  requires  a  good  deal  of  practice  to  become  handy  and 
dexterous  in  the  applicuuon  of  the  glasses — to  avoid  torturing  and  burning  the  patient 
— and  therefore  it  is  that  in  large  towns,  as  in  this  metropolis,  rupping  is  an  art  car- 


BLOOD-LETTING.  149 

ried  on  bj^  a  distinct  class  of  persons.  You  may  apply  leeches  also  to  parts  where 
the  cupping-glasses  could  scarcely  be  used. 

General  bleeding,  then,  is  best  adapted  to  acute  inflammation  ;  and  topical  bleed- 
ing is  most  appropriate  in  that  which  is  chronic  and  slow.  But  a  combination  of 
the  two  is  often  highly  proper  and  useful.  You  may  lessen  the  force  of  the  general 
circulation  by  venesection  :  but  the  small  vessels  of  the  inflamed  part  may  remain 
unable  to  rid  themselves  of  their  excess  of  blood,  and  continue  dilated  and  full. 
Such,  at  least,  we  may  reasonably  suppose  to  be  sometimes  the  case ;  and  certainly 
we  often  act  successfully  upon  that  theory  ;  that  is,  we  bleed  from  the  arm,  and  at 
the  same  time,  or  presently  after,  we  empty  the  capillaries  of  the  labouring  organ, 
or  the  neighbouring  vessels,  by  the  help  of  leeches,  or  by  the  scarificator  and  ex- 
hausted cup.  The  good  effect  of  local  bleeding,  after  the  general  febrile  disturbance 
has  abated  under  venesection,  is  often  very  marked  in  the  relief  of  pain. 

I  have  recommended  blood-letting  to  you  when,  among  other  circumstances,  the 
pulse  is  full  and  hard  ;  and  have  stated  that  the  blood  should  be  suffered  to  flow 
until  some  distinct  impression  is  made  upon  the  system.  But  I  wish  also  to  apprise 
you,  that  you  ought  not  to  be  deterred  from  bleeding  merely  because  the  pulse  is 
small.  It  is  very  apt  to  be  so  in  dangerous  inflammations  within  the  abdomen  ;  and 
it  is  a  very  curious  thing  that  the  pulse  will  often  rise,  and  the  artery  develop  or 
expand  itself,  during  the  time  the  blood  is  flowing.  Now  you  must  look  upon  that 
circumstance  as  a  distinct  impression  made  upon  the  system,  although  it  is  one  of  a 
rather  different  kind  from  what  I  spoke  of  before.  You  had  better,  in  my  opinion, 
pause  when  this  effect  is  fairly  obtained :  for  so  great  is  the  tendency  to  death  by 
syncope  in  abdominal  inflammation  that  it  would  not  be  prudent  to  urge  the  influence 
of  the  blood-letting  further,  at  one  time,  than  the  change  I  have  just  mentioned. 
Wait,  therefore,  and  repeat  the  venesection  if  the  circumstances  should  again  render 
it  necessary. 


LECTURE  XIV. 


Treatment  of  Inflammation,  continued.    Recapitulation.    Bleeding.    Purgatives. 

Mercury.     Jlntimony.     Digitalis.     Colchicum.     Opium, 
Local  Remedies.     External  Cold.     External  warmth.     Counter-Irritation. 

After  pointing  out  to  you,  yesterday,  the  necessity  of  guarding  your  patient,  as 
much  as  possible,  from  all  stimulants  or  sources  of  irritation,  both  internal  and  ex- 
ternal, the  avoidance  of  which  constitutes  what  is  called  the  antiphlogistic  regimen, 
I  began  to  speak  of  the  remedies  of  inflammation. 

Now  the  great  remedy  in  acute  and  dangerous  inflammation  is  blood-letting;  and 
when  this  remedy  is  used  at  afl,  it  should  be  used  freely,  and  so  as  to  produce  a 
decided  impression :  and  its  efficacy  will  always  be  the  greater,  in  proportion  as  it 
is  applied  in  the  earlier  stages  of  the  inflammation.  The  objects  of  the  abstraction 
of  blood  are  two-fold  :  to  lessen  the  force  of  the  heart's  action  is  one  object ;  to  empty 
the  gorged  capillaries  of  the  part  inflamed  is  the  other.  We  effect  the  first  of  these 
objects,  or  both  of  them  at  once  it  may  be,  by  making  an  orifice  with  a  lancet,  m  the 
trunk  of  some  convenient  vein  or  artery,  and  allowing  the  blood  to  escape  ;  we  ac- 
complish the  second  by  making  little  incisions  with  a  scarifier  through  the  skin  as 
near  the  inflamed  part  as  we  can,  and  forcing  the  blood  through  these  little  wounds 
by  the  pressure  of  the  atmosphere :  i.  e.,  we  take  off  the  pressure  from  the  part  sca- 
rified, by  placing  over  it  a  glass  cup,  from  which  the  air  has  been  in  great  measure 
exhausted,  and  then  the  unbalanced  weight  of  the  atmosphere  upon  the  surrounding 
surface  forces  out  the  blood  :  or  we  suffer  leeches  to  scarify  the  skin,  and  to  suck 
out  the  blood.  These  two  modes  of  drawing  blood,  from  the  trunks  of  the  blood- 
vessels on  the  one  hand,  and  from  the  capillaries  on  the  other,  we  call,  respi^ctively, 
general  bleeding,  and  topical  bleeding. 

I  say  the  main  point  to  be  achieved  in  general  bleeding  is  so  to  manage  the  opera- 

n2 


150  INFLAMMATION. 

lion  as  to  make  a  decided  impression,  as  quickly  as  possible,  upon  the  pu.se  or  the 
heart .  and  to  do  this  we  place  our  patient  in  an  upright  position,  and  make  a  free 
orifice  in  the  vein  of  one  or  both  arms. 

And  when  the  force  of  the  general  circulation  has  been  thus  abated,  it  will  in 
many  cases  be  proper  and  necessary  to  take  away  blood  from  the  capillaries  also,  in 
the  neighbourhood  of  the  suffering  organ ;  this  is  almost  always  safe  and  good  prac- 
tice :  there  can  seldom  be  any  reason  for  abstaining  from  it,  except  when  the  general 
bleeding  has  brought  the  patient  so  low  that  the  abstraction  of  a  few  more  ounces  in 
any  way  might  be  hazardous.  But  the  employment  of  local  depletion  presently 
after  general  is  then  especially  indicated,  when  the  /oca/ symptoms  remain  unrelieved 
when,  although  the  indirect  symptoms  which  manifest  themselves  through  the 
medium  of  the  system  at  large  have  been  moderated  by  the  general  blood-letting, 
yet  the  direct  symptoms  belonging  to  the  part,  and  disturbing  its  functions,  the  pain 
for  example,  or  the  labouring  breath,  or  the  stupor,  have  not  undergone  a  propor- 
tional improvement.  Under  such  circumstances,  the  unloading  the  oppressed  capil- 
laries by  means  of  leeches  or  cupping-glasses  will  often  be  attended  with  the  hap- 
piest effects. 

I  mentioned  that  the  most  common  way  of  performing  general  blood-letting  in 
this  country  is  by  venesection  ;  and  that  the  veins  chosen,  as  the  most  suitable  for 
that  purpose,  are  the  cephahc  and  basilic  veins  at  the  bend  of  the  arm :  but  that 
Avhen,  from  accidental  circumstances,  blood  cannot  be  obtained  easily  and  abundantly 
from  those  veins,  any  other  large  and  superficial  blood-vessel  may  be  opened.  It 
matters  little  which,  in  my  opinion,  so  far  as  regards  the  effect  of  the  abstraction  of 
blood  upon  the  disease.  Some  persons  are  fond  of  opening  the  temporal  artery  when 
the  inflammatorj'  disease  is  situated  in  or  about  the  head  :  and  certainly,  when  we 
see  this  vessel  starting  from  the  surface  hke  a  cord,  and  tortuous  from  its  fullness,  and 
visibly  throbbing,  we  feel  tempted  to  give  vent  to  the  blood  which  is  distending  it. 
But  arteriotomy  is  not  so  easily  managed  as  phlebotomy.  It  is  sometimes  difficult 
to  get  the  blood  to  flow  properly  ;  and  it  is  sometimes  difficult  to  stop  its  egress  when 
we  wish  to  do  so ;  and  sometimes  there  are  after-consequences  which  are  far  from 
being  pleasant :  little  aneurismal  tumours  are  apt  to  arise.  It  is,  besides,  desirable 
to  avoid  the  necessity  of  bandaging  the  head,  in  order  to  restrain  the  further  efflux 
of  blood  from  the  artery.  Other  practitioners  recommend  opening  the  external 
jugular  vein  in  head  cases,  especially  in  children,  whose  veins  in  the  arm  are  small. 
This  is  a  plan  which  I  have  very  seldom  adopted,  and  which,  I  am  bound  to  tell 
3'ou,  I  do  not  much  like  :  first,  because  I  think  it  is  seldom  necessary  ;  secondly, 
because  I  think  it  is  often  unsafe. 

It  is  seldom  necessary :  for  in  children  we  can  always  get  as  much  blood  by  topi- 
cal bleeding  as  will  be  equivalent  to  a  general  blood-letting.  And  it  is  unsafe  in 
two  ways.  In  the  first  place,  it  is  not  always  an  easy  matter  to  stop  the  bleeding 
from  the  jugular  vein,  especially  in  a  struggling  and  unmanageable  child;  and  the 
difference  of  a  few  ounces  of  blood  may  be  a  fatal  difference.  Here  also  any  com- 
pression of  the  neck,  to  stay  the  hemorrhage,  might  affect  injuriously  the  cerebral 
circulation.  Again,  there  is  a  distinct  and  peculiar  danger  attending  the  incision  of 
this  vein,  that,  namely,  of  admitting  air  into  it.  You  perhaps  are  aware  that  if  air 
enters  a  large  vein  near  the  heart,  and  passes  on  to  that  organ,  it  kills  outright.  If 
you  open  the  jugular  vein  of  a  horse,  and  blow  forcibly  into  it  towards  the  heart, 
the  animal  drops  down  dead.  The  celebrated  Dupuytren  was  performing  some  ope- 
ration about  the  neck,  in  the  course  of  which  he  cut  across  one  of  the  veins  there 
situate :  some  bubbles  of  air  rushed  in  at  its  open  mouth,  with  an  audible  clucking 
noise,  and,  in  an  instant,  his  patient  expired.  The  same  frightful  accident  has 
occurred  in  operations  performed  in  this  country,  and  in  America,  I  was  told  very 
lately  that  in  one  of  our  metropolitan  hospitals  it  was  thought  right,  for  some  reason 
or  other,  to  bleed  an  adult  patient  by  opening  his  jugular  vein :  the  opening  was 
made  very  near  the  clavicle,  so  that  pressure  between  the  orifice  and  the  heart  was 
difficult  to  effect.  Of  course  the  blood  soon  leaves  the  portion  of  the  vein  nearest  the 
heart ;  and  whether  by  some  suction  power  of  the  heart  itself  upon  the  veins,  or  how. 
one  scarcely  knows,  but  air  rushed  in,  and  the  patient  was  presently  a  dead  man. 


BLEEDING.  151 

Perhaps  misadventures  of  this  kind  may  be  capable  of  being  prevented  by  using 
great  caution  in  such  cases ;  but  as  it  is  the  etiquette  for  physicians  to  direct  but  not 
to  perform  these  manual  services  towards  the  sick,  and  as,  therefore,  I  should  incur 
all  the  responsibility,  and  at  the  same  time  be  able  to  ensure  none  of  the  necessary 
care,  I  confess  that  I  am  shy  of  recommending  venesection  to  be  made  in  that  parti- 
cular place. 

Whether,  all  other  things  being  the  same,  the  abstraction  of  arterial  blood  may  be 
more  or  less  effectual  in  restraining  inflammation  than  the  abstraction  of  venous,  is 
more  than  I  can  tell  you. 

When  topical  bleeding  is  employed  with  the  view  of  disburdening  the  turgid 
capillaries,  either  in  chronic  inflammation,  or  in  acute  inflammation  as  an  auxiliary 
to  general  bleeding,  it  would  seem  most  expedient  to  get  as  near  to  the  part  affected 
as  we  can.  To  apply,  for  example,  our  cupping-glasses  or  our  leeches  to  the  tem- 
ples, or  behind  the  ears,  or  just  below  the  occiput  in  inflammatory  affections  of  the 
head ;  to  the  chest  or  the  precordia,  when  the  lungs  or  heart  are  the  seat  of  the  dis- 
ease ;  to  the  surface  of  the  abdomen,  in  inflammation  of  the  liver,  or  stomach,  or 
intestines,  and  so  on.  And  this  is  the  plan  which  I  have  almost  always  adopted ; 
and  with  such  satisfactory  results  that  I  have  felt  Httle  inclination  to  try  any  other. 
But  many  persons  do  believe  that  local  bleeding  is  more  useful  when  it  is  performed 
at  some  distance  from  the  affected  part :  they  would  put  leeches,  for  instance,  on  the 
insteps,  to  reheve  an  inflamed  throat ;  and  they  attribute  the  benefit  that  ensues  to 
what  is  called  revulsion :  they  suppose  that  the  suction  of  the  leeches  solicits  the 
blood,  as  it  were,  to  that  quarter,  and  diverts  it  from  the  vessels  of  the  part  that  is 
inflamed.  It  seems  to  me  that  the  revulsive  influence  of  topical  bleeding  would  be 
greater  in  the  neighbourhood  of  the  inflamed  part  than  far  from  it.  I  know,  how- 
ever, some  very  practical  men  who  have  been  much  struck  with  the  results  of  thia 
distant  blood-letting,  which  they  had  seen  practised  in  the  Parisian  hospitals. 
Leeches  are  also  sometimes  applied  at  a  distance  from  the  seat  of  the  inflammation, 
on  another  principle — that  of  drawing  the  blood  directly  from  the  veins  which  com- 
municate with  the  diseased  part.  In  abdominal  affections,  in  inflammation  of  the 
liver  or  intestines,  the  French  are  in  the  habit  of  applying  leeches  in  great  numbers 
to  the  verge  of  the  anus :  because,  they  say,  the  blood  is  then  abstracted  from  the 
very  veins  through  which  it  is  returning  towards  the  already  overloaded  organs.  It 
is  right  that  you  should  be  aware  of  these  opinions,  and  of  this  practice.  I  can  say 
but  little  of  it  from  my  own  knowledge.  I  can  well  believe,  however,  that  it  is  good 
and  useful  practice  :  but  in  this  country  we  should  find  it  difficult  to  persuade  many 
of  our  patients  to  submit  to  have  leeches  planted  round  the  anus ;  and  I  have  seldom 
been  disappointed  of  the  benefit  I  expected  from  topical  bleeding,  when  it  has  been 
employed  at  the  surface,  as  near  the  part  inflamed  as  possible. 

The  evacuation  next  in  importance  to  blood-letting,  is  purging.  This  is  an  expe- 
dient which  in  cases  of  violent  inflammation,  or  high  general  fever,  should  scarcely 
ever  be  omitted.  To  keep  the  bowels  what  is  called  opoi,  forms  indeed  a  part  of 
the  antiphlogistic  reg-zmpn ;  but  in  acute  inflammatory  diseases,  active  purging  is 
of  very  great  service.  These  two  points  are  gained  by  it.  The  stomach  and  intes- 
tines are  freed  from  accumulated  faeces,  or  other  matters  which,  by  their  bulk  or 
their  acrimony,  might  prove  irritating:  and  at  the  same  time  depletion  is  carried  on 
by  means  of  the  serous  discharge  which  is  produced  from  that  large  extent  of  mucous 
merribrane.  There  are  some  cases  of  inflammation  in  which  the  operation  of  purga- 
tive medicines  is  of  especial  benefit ;  as  in  inflammatory  affections  of  the  head,  eitner 
external  or  internal,  of  which  part  these  medicines  assist  or  cause  the  depletion  in  a 
very  sensible  manner.  We  have  an  illustration  of  this  in  the  paleness  of  the  face, 
which  often,  during  health,  accompanies  the  action  of  a  brisk  cathartic.  The  use 
fulness  of  repeated  purgatives  is  less  distinctly  seen  in  inflammations  situated  be- 
tween the  thorax;  although  in  these  cases  also  they  are  often  highly  beneficial. 
They  are  efficient  remedies,  too,  in  all  inflammatoiy  conditions  of  the  liver.  Bui 
when  inflammation  has  fastened  upon  the  stomach  or  bowels  themselves,  although 
it  may  be  indispensable  that  they  should  be  unloaded  of  their  contents,  which  are 
often  composed  of  irritating,  ill-digested  food,  and  of  morbid  secretions  no  less  feasinjj 


152  INFLAMMATION. 

and  hurtful,  the  propriety  of  going  beyond  this  point  is  extremely  questionable.  I 
believe  that  much  harm  is  often  done  by  pressing  the  inflamed  alimentary  canal 
with  active  purgatives.     But  to  all  those  points  I  shall  have  occasion  to  return. 

Next  to  blood-letting,  as  a  remedy,  and  of  vastly  superior  value  upon  the  whole, 
to  purgation,  in  serious  inflammations  of  various  kinds,  is  mercury.  This  mineral 
is  really  a  very  powerful  agent  in  controlling  inflammation  ;  especially  acute, 
phlegmonous,  adhesive  inflammation ;  such  as  glues  parts  together,  and  spoils  the 
texture  of  organs.  It  is  of  the  greatest  importance  that  you  should  accurately  inform 
yourselves  concerning  the  various  effects  of  mercury  upon  the  system  :  the  changes 
it  produces ;  the  changes  it  arrests  or  prevents ;  the  cases  in  which  it  does  good ; 
the  cases  in  which  it  does  harm ;  that  you  should  learn,  in  short,  how  to  wield  a 
very  potent,  but  a  two-edged  weapon. 

If  we  inquire  what  mercury  does  when  it  is  administered  to  a  person  in  health, 
we  find  three  very  marked  effects  following  its  internal  use.  They  vary,  indeed,  in 
different  cases,  and  under  different  circumstances :  but  we  know  that  the  employ- 
ment of  mercury  under  any  of  its  usual  forms  of  exhibition  is  often  followed  by 
increased  watery  evacuations  from  the  intestines ;  or  by  an  increased  discharge  of 
bile  ;  or  by  an  increased  flow  of  saliva  ;  that  is  to  say,  it  determines  (as  the  phrase 
is)  to  certain  secreting  organs — the  mucous  membrane  of  the  bowels,  the  liver,  the 
salivary  glands ;  it  augments  their  natural  secretion ;  and  in  this  augmentation  of 
s-ecretion  is  implied  an  increased  afflux  of  blood  to  the  secreting  part.  It  is  probable 
that  mercury  has  a  similar  influence  on  most  or  all  the  secreting  surfaces  of  the  body, 
altering  the  "condition  of  the  capillary  circulation  throughout.  And  an  explanation 
of  its  curative  power  in  inflammation  has  been  drawn  from  this  fact :  it  has  been 
supposed  that  mercury  thus  tends  to  equalize  the  circulation  ;  that  by  causing  the 
blood  to  be  distributed  in  larger  quantity  than  common  upon  several  surfaces  at  the 
same  time,  it  obviates,  ^jro  tanto,  its  excessive  congestion  or  accumulation  in  any  one 
organ.  Whether  this  hypothesis  in  respect  to  the  modus  operandi  of  mercury  be 
true  or  not,  I  will  not  pretend  to  say;  but  it  certainly  is  not  an  unreasonable  hypo- 
thesis. 

If  you  push  this  remedy  in  healthy  persons,  other  effects  ensue  :  inflammation  is 
actually  ;;rorf»ce(/;  the  gums  become  tender,  and  red,  and  swollen,  and  at  length 
they  ulcerate  ;  and  in  extreme  cases,  and  in  young  children  especially,  the  inflamed 
parts  ma)'-  perish  :  the  cheeks,  for  example,  sometimes  slough  internally.  Not  only 
the  gums,  but  the  throat  and  fauces,  grow  red,  and  sore  and  sloughy. 

Now  you  will  do  well  to  observe  what  is  the  character  of  the  inflammation  thus 
produced.  It  is  superficial,  spreading,  erysipelatous  :  it  leads  to  ulceration  without 
any  distinct  occurrence  of  suppuration ;  the  ulcers  enlarge.  Of  the  three  processes 
which  I  formerly  pointed  out  as  going  on  in  different  degrees,  at  the  same  time,  in 
an  ulcerated  surface,  that  of  absorption  is  vastly  predominant ;  and  you  will  find  that 
persons  in  whom  this  local  aflfection,  this  condition  of  the  parts  within  the  mouth, 
has  been  produced,  get  rapidly  thin  ;  their  fat  disappears  ;  they  become  emaciated. 
That  is,  the  absorption  of  the  old  materials  throughout  the  body  exceeds  the  deposit 
of  new  matter.  Patients  who  are  kept  under  the  influence  of  mercury  grow  pale 
as  well  as  thin :  and  Dr.  Farre,  who  has  paid  great  attention  to  the  effects,  remedial 
and  injurious,  of  this  drug,  holds  that  it  quickly  destroys  red  blood  :  as  efft-ctually 
as  u  may  be  destroyed  by  venesection.  As  an  example  of  this  he  was  in  the  habit 
of  relating  in  his  lectures  the  case  of  a  lady  who  was  attacked  with  hematemesis : 
and  whose  gastric  sj'stem  and  liver  were  gorged  with  blood,  "  Her  complexion," 
said  the  doctor,  "was  compounded  of  the  rose  and  the  violet.  Under  a  course  of 
■nercury  she  was  blanched,  in  six  weeks,  as  white  as  a  lily." 

There  are  still  other,  occasional,  effects  of  the  continued  introduction  of  mercury 
into  the  system:  a  peculiar  eruptive  disease;  a  peculiar  condition  of  the  nervous 
system  :  but  with  these  I  do  not  now  meddle  ;  they  will  come  under  our  more  parti- 
cular consideraliou  hereafter.  At  present  I  am  desirous  to  place  such  facts  before 
you  as  may  help  you  to  determine  in  what  cases  mercury  is  a  fit  remedy  for  inflam 
mation  ,  In  what  oases  it  would  be  improper  to  give  it.     The  facts  T  have  already 


MERCURY.  153 

mentioned  show  that  it  has  a  loosening  effect  upon  certain  textures  ;  that  it  works  by 
pulling  down  parts  of  the  building. 

But  the  great  remedial  property  of  mercury  is  that  of  stopping,  controlling,  or 
altogether  preventing  the  effusion  of  coagulable  lymph  ;  of  bridling  adhesive  injiam- 
mation;  and  if  we,  in  our  turn,  could  always  bridle  and  limit  the  influence  of 
mercury  itself,  it  would  be  a  still  more  valuable  resource. 

From  the  little  I  have  now  said  you  will  readily  understand  in  what  description 
of  cases  mercury  is  likely  to  be  useful.  In  common  adhesive  inflammation,  whether 
of  the  serous  or  the  areolar  tissues ;  whenever,  in  fact,  you  have  reason  to  suppose 
that  coagulable  lymph  is  effused,  or  about  to  be  effused,  and  mischief  is  likely  to 
result  from  its  presence,  then  you  may  expect  much  benefit  from  the  proper  admi- 
nistration of  mercury ;  as  an  auxiliary,  however,  to  blood-letting,  not  as  a  substitute 
for  it. 

On  the  other  hand,  mercury  is  likely  to  be  hurtful  in  those  forms  of  disease 
"  where  the  morbid  action  approximates  to  its  own  action."  In  cases  of  erysipela- 
tous inflammation  having  a  disposition  to  gangrene ;  in  scrofulous  diseases ;  in 
inflammatory  complaints  attended  with  general  debility,  and  an  irritable  condition  of 
the  nervous  system,  or  a  manifest  tendency  to  take  on  a  typhoid  character. 

When  we  have  to  contend  with  acute  inflammation,  and  desire  to  prevent  or  arrest 
the  deposition  of  coagulable  lymph,  our  object  is,  after  such  bleeding  as  may  have 
been  proper,  to  bring  the  system  as  speedily  as  possible  under  the  specific  influence 
of  mercury.  How  may  tliis  best  be  done  ?  and  how  are  we  to  know  that  it  has  beea 
achieved  ? 

I  will  answer  the  last  of  these  questions  first.  We  know  that  the  whole  system 
has  been  brought  under  the  specific  influence  of  mercury,  as  soon  as  its  effects 
become  even  slightly  perceptible  in  the  gums  and  breath  of  the  patient ;  and  in 
adults  we  cannot  be  sure  of  it  before.  The  gums  grow  red  and  spongy  ;  the  patient 
complains  that  his  gums  are  sore :  and  that  he  has  a  metaUic  taste,  a  taste  hke  that 
of  copper,  in  his  mouth ;  and  an  unpleasant  and  very  peculiar  foetor,  easily  recog- 
nized again  when  it  has  been  once  perceived,  is  smelt  in  his  breath.  These  symp- 
toms are  enough :  you  need  not  in  general  look  for  any  more  decided  affection  of 
the  mouth,  such  as  ulceration  of  the  gums,  swelling  of  the  glands  beneath  the  jaw, 
and  of  the  tongue,  and  a  profuse  flow  of  saliva.  Formerly,  when  it  was  believed 
that  the  material  cause  of  the  disease  was  carried  out  of  the  body  with  the  saliva, 
the  mercurial  treatment  was  continued  with  a  view  of  producing  the  discharge  of 
many  ounces,  and  even  of  a  pint  or  two,  in  the  twenty-four  hours  :  but  all  that  is 
requisite  is  that  the  gums  should  become  distinctly  tender,  and  that  the  mercurial 
foetor  should  be  unequivocally  manifest,  and  that  these  symptoms  should  be  kept  up 
for  a  certain  time. 

Now  this  is  best  effected,  usually,  by  giving  some  form  of  niercury  in  equal  and 
repeated  doses,  by  the  mouth.  For  urgent  cases  calomel  is  the  best  form  in  which 
it  can  be  administered :  two  or  three  grains,  given  every  four  or  six  hours,  will 
generally  suffice  to  touch  the  gums  in  the  course  of  thirty-six  or  forty-eight  hours. 
If  it  acts  as  a  purgative  its  specific  effect  upon  the  whole  system  will  be  postponed 
by  that  circumstance ;  and  it  then  becomes  expedient  to  combine  with  it  just  so 
much  opium  as  will  prevent  its  passing  off'  by  the  bowels.  A  quarter  of  a  grain  of 
opium  with  two  grains  of  calomel — or  a  third  of  a  grain  of  opium  with  three  or  four 
grains  of  calomel — will  generally  be  sufficient  to  restrain  the  purgative  operation  of 
the  latter.  When  a  speedier  effect  is  desirable  we  give  larger  doses ;  such  as  five 
or  ten  grains  every  three,  or  even  every  two  hours:  or  we  combine  mercurial 
inunction  with  the  exhibition  of  calomel  by  the  mouth.  It  is  impossible  to  lay  down 
any  precise  rule  that  will  fit  all  cases. 

Blue  pill,  or  the  hydrargyrum  cum  creta,  may,  in  certain  cases,  be  preferable  to 
calomel ;  but  they  must  be  given  in  greater  quantity.  Some  practitioners  believe 
•.hat  a  combination  of  blue  pill  and  calomel  acts  sooner,  and  answers  better,  than  a 
proportional  dose  of  either,  given  alone. 

This  mode  of  administering  mercury,  so  as  to  affect  the  system  at  large,  is  emi- 
nently useful  in  many  instances  of  acute  phlegmonous  inflammation,  after  "ii'peding 


154  INFLAMMATION. 

has  been  carried  as  far  as  the  circumstances  of  the  case  may  warrant.  I  repeat  that 
it  must  not  be  allowed  to  supersede  blood-letting.  Previous  bleeding  renders  the 
body  more  readily  susceptible  of  the  influence  of  mercury ;  and  the  operation  of 
the  mercury  comes  in  aid  of  the  salutary  effect  of  the  abstraction  of  blood.  The 
two  remedies  accomplish  by  their  joint  power  what  neither  of  them  could  accom- 
plish singly. 

It  is  important  to  know  that  different  persons  admit  of,  or  resist,  the  specific  agency 
of  mercury,  in  very  different  degrees ;  so  that  in  some  patients  the  remedy  becomes 
unmanageable  and  hazardous ;  while  in  others  it  is  inert  and  useless.  It  is  most 
grievously  disappointing  to  Avatch  a  patient  labouring  under  inflammation  which  is 
hkely  to  spoil  some  important  organ,  and  to  find,  after  bleeding  has  been  pushed 
as  far  as  we  dare  push  it,  that  no  impression  is  made  upon  his  gums  by  the 
freest  use  of  mercury.  Such  cases  are  not  uncommon ;  and  unfortunately  they 
seem  most  apt  to  occur  when  the  controlling  agency  of  mercury  is  most  urgently 
required.  On  the  other  hand,  there  are  persons  in  whom  very  small  quantities  of 
mercury  act  as  a  violent  poison  ;  a  single  dose  producing  the  severest  salivation  and 
bringing  the  patient's  existence  into  jeopardy.  This  history  was  told  to  Dr.  Farre 
by  a  medical  man,  under  whose  notice  it  fell.  A  lady,  whom  he  attended,  said  to 
him,  at  his  first  professional  visit  to  her,  "  Now,  without  asking  why,  or  speculating 
about  it,  never  give  me  mercury,  for  it  poisons  me."  Some  time  afterwards  she  met 
with  the  late  Mr.  Chevalier,  and  spoke  to  him  about  her  complaints ;  and  he  pre- 
scribed for  her,  as  a  purgative,  once,  two  grains  of  calomel,  with  some  cathartic 
extract.  She  took  the  dose  ;  and  the  next  morning  showed  the  prescription  to  her 
ordinary  attendant.  "  Why  (said  he)  you  have  done  the  very  thing  you  were  so 
anxious  to  avoid ;  you  have  taken  mercury."  She  replied,  "  I  thought  as  much, 
from  the  sensations  I  have  in  my  mouth."  Furious  salivation  came  on  in  a  few 
hours  ;  and  she  died,  at  the  end  of  two  years,  worn  out  by  the  effects  of  the  mercury, 
and  having  lost  portions  of  the  jaw-bone  by  necrosis. 

Another  medical  man  informed  me  that  he  knew  a  person  so  susceptible  of  the 
influence  of  mercury,  that  when  his  wife  had  rubbed  a  very  small  quantity  of  white 
precipitate  ointment  upon  her  neck  for  some  cutaneous  affection,  after  sleeping  with 
her  his  gums  were  tender  for  three  or  four  days,  and  slight  salivation  took  place. 
This  did  not  happen  once  only,  but  three  several  times.  On  one  occasion  this  same 
man  took  two  blue  pills,  as  preliminary  to  a  common  purge,  and  he  was  salivated 
profusely  for  six  weeks.  Cases  similar  to  these  occur  now  and  then  to  most  medical 
men :  we  cannot  tell  beforehand  in  whom  such  effects  are  to  be  looked  for ;  but  it  is 
never  prudent  to  neglect  any  warning  which  the  patient  gives  of  his  own  previous 
experience  on  this  point.  You  will  generally  find  that  where  the  affection  of  the 
gums  and  salivary  organs  goes  on  to  a  troublesome  or  distressing  extent,  it  has  super- 
vened upon  the  employment  of  a  very  moderate  quantity  of  mercury. 

So  distressing  sometimes  are  these  effects  of  mercury  upon  the  mouth,  that  I  may 
pause  a  moment  to  tell  you  what  I  know  about  the  means  of  remedying  them.  You 
will  constantly  be  called  upon  to  do  something  for  the  relief  of  this  disease  (for  so 
we  must  call  it),  which  you  yourselves,  or  some  of  your  brethren,  have  with  the  best 
intentions  inflicted.  I  have  tried  all  sorts  of  expedients;  and  I  have  asked  a  great 
number  of  my  friends  what  is  the  best  pfan  to  adopt  in  such  cases :  but  I  never 
f  ould  get  mucn  satisfactory  information  from  them.  Some  thought  purging  was  the 
best  thing.  Others  recommended  alum  gargles ;  or  gargles  made  with  the  chloride 
of  soda ;  and  these  last  certainly  have  one  good  effect,  that  of  correcting  the  foctor. 
A  dilute  solution  of  chlorine  in  water,  much  used  at  the  Middlesex  Hospital,  is  better 
still.  Others  believed  that  sulphur,  which  has  long  been  prescribed  in  such  emer- 
gencies, was  really  of  service ;  and  some  advised  that  the  patient  should  be  as  much 
as  possible  in  the  open  air:  a  few  commended  iodine.  All  admitted  that  they  knevir 
of  no  certain  remedy.  Neither  do  I.  But  there  are  two  or  three  expedients  which 
I  am  confident  are  often  of  very  great  use  in  checking  the  violence  of  the  salivation, 
and  in  removing  the  most  distressing  of  its  accompaniments.  If  there  be  much 
external  swelling,  treat  the  case  as  being,  what  it  really  is,  a  case  of  local  injlamma- 
iton :  apply  eight  or  ten  leeches  beneath  the  edge  of  the  jaw  bones,  and  wrap  a  soft 


MERCURY.  155 

poultice  round  the  neck,  into  which  the  orifices  made  by  the  leeches  may  bleed ; 
and  I  can  promise  you  that,  in  nine  cases  out  of  ten,  you  will  receive  the  thanks  ot 
your  patient  for  the  great  comfort  this  measure  has  afforded  him.  Pure  tannin, 
moistened  and  smeared  upon  the  spongy  gums,  is  remarkably  efficacious  in  render- 
ing them  firmer  and  more  comfortable.  But  this  is  not  always  to  be  procured :  and 
when  the  flow  of  saliva,  and  the  soreness  of  the  gums,  formed  the  chief  part  of  the 
grievance,  I  have  found  nothing  more  generally  useful  than  a  gargle  made  of  brandy 
and  water ;  in  the  proportion  of  one  part  of  brandy  to  four  or  five  of  water.  This 
last-  piece  of  practice  I  learned  from  the  present  apothecary  to  the  Middlesex  Hos- 
pital;  I  have  tried  it  over  and  over  again ;  and  I  tell  it  to  you  as  a  thing  worth 
remembering.  These  little  points  are  by  no  means  to  be  despised.  A  very  fashion- 
able and  successful  physician,  now  dead,  used  sometimes  to  say  when  he  met  others 
of  his  brethren  in  consultation,  "  It  is  all  very  well  to  speculate  about  the  exact  situa- 
tion, and  the  precise  nature  of  the  disorder,  but  the  question  with  me  is,  '  what  is 
good  for  this,  that,  or  t'other  thing  V  "  A  wise  phj'sician  will  seek  to  combine  with  an 
accurate  knowledge  of  disease,  and  settled  principles  of  treatment,  those  practical 
expedients  and  minor  appliances  which  are  picked  up  by  casual  experience  ;  which 
could  never  have  been  reasoned  out :  and  which  sometimes  constitute  nearly  all  that 
we  can  do  for  our  patient's  benefit. 

But  to  return  to  mercury  as  a  remedy  against  inflammation.  Tt  is  of  great  service 
m  many  cases  of  chronic  inflammation ;  and  I  may  repeat  here  the  observation  I 
formerly  made  when  speaking  of  blood-letting — that  the  treatment  must  keep  pace, 
as  it  were,  with  the  disease.  When  textures  have  been  slowly  altered  by  a  gradual 
deposition  of  coagulable  lymph,  we  should  gain  but  little  by  suddenly  or  speedily 
salivating  our  patient.  The  lymph,  if  it  can  be  dispersed  at  all,  must  be  gradually 
taken  up  again  :  and  mercury,  given  with  the  view  of  promoting  its  absorption, 
must  be  slowly  and  gradually  introduced  into  the  system  ;  and  its  specific  influence, 
when  at  length  it  is  felt,  must  be  sustained  for  a  considerable  length  of  time. 

You  must  not  expect  any  good,  but  the  contrary,  from  the  exhibition  of  mercury 
in  scrofulous  inflammations  ;  and  where  the  scrofulous  diathesis  is  well  marked,  you 
should  be  cautious  in  giving  mercury  at  any  time.  But  I  am  certain  that  many 
men  are  too  scrupulous  in  this  respect ;  and  that,  through  over  tenderness  of  your 
patient's  constitution,  you  may  risk  his  life,  by  withholding  mercury  because  he 
shows  tokens  of  scrofula.  You  may  recollect  my  stating  that  scrofulous  persons  are 
not  exempt  from  attacks  of  common  inflammation ;  and  in  some  such  cases  the  pos- 
sible aggravation  of  their  general  ill  health,  by  mercury,  is  not  to  be  put  in  competi- 
tion with  the  immediate  danger  from  the  local  inflammation.  I  have  again  and 
again  seen  scrofulous  patients  benefited  by  moderate  salivation  ;  which,  if  it  proved 
injurious  at  all  to  their  general  condition,  Avas  certainly  less  injurious  than  the 
unchecked  local  complaint  would  have  been. 

'  There  are  some  other  remedies  for  acute  inflammation  which,  in  this  general 
account  of  its  treatment,  I  must  briefly  notice.  Antimoyiy  is  one  of  them ;  and  a 
very  valuable  remedy  it  is  in  some  forms  of  inflammatory,  disease.  Antimony, 
properly  administered,  subdues  the  action  of  the  heart  and  arteries,  producing  nausea, 
paleness,  and  sinking  of  the  pulse,  and  frequently  great  relief  to  the  local  symptoms. 
You  bring  the  circulation  into  that  state  into  which  it  may  be  brought  by  free  blood- 
letting. But  when  the  violence  of  the  inflammatory  symptoms  recurs  again  and 
again,  you  cannot  again  and  again  employ  the  lancet :  or  if  you  do  so  employ  it  as 
at  length  to  extinguish  the  inflammation,  you  reduce  your  patient  to  a  state  of  pitiable, 
and  even  perilous,  debility.  Now  you  may  continue  or  repeat  the  depression  of  the 
circulation  by  means  of  antimony,  without  any  dread  of  such  subsequent  Aveakness. 
Antimony,  so  far  as  m_y  own  observation  goes,  is  admirably  suited  to  cases  of  active 
inflammation,  in  which  mercury  would  either  be  not  so  useful,  or  could  not  be 
brought  to  bear.  It  is  in  inflammation  of  the  mucous  membrane  of  the  air  passages 
that  antimony  is  so  signally  beneficial.  You  will  see  a  patient  labouring  for  breath, 
unable  perhaps  to  he  down,  with  a  turgid  and  livid  countenance  from  imperfect 
arterialization  of  the  blood.  He  has  been  ill  but  a  short  time ;  it  is  an  acute  aflTec- 
tion  ;  and  upon  listening  at  his  chest  you  hear  that  pecuhar  wheezmg  sound  which 


156  INFLAMMATION. 

we  call  sibilus,  in  every  part  of  his  lungs.  I  shall  have  to  describe  this  sound,  and 
•jts  causes,  and  its  meaning,  in  a  future  part  of  the  course.  You  give  such  a  patient 
repeated  doses  of  antimony  ;  he  becomes  sick,  vomits  perhaps,  but  he  feels  nausea : 
his  pulse  becomes  less  forcible,  his  face  grows  pale,  and  he  can  breathe  again.  The 
nausea  is  not  a  pleasant  sensation ;  but  the  want  of  breath  is  a  far  more  distressing 
one ;  and  that  is  greatly  mitigated.  Perhaps  free  secretion  takes  place  from  the 
congested  membrane,  and  then  the  patient  is  easy  and  safe.  Now  you  could  not 
effect  this  change  so  quickly  and  readily,  or  so  conveniently,  by  mercury,  and  per- 
haps not  at  all.  Bronchitic  affections  are  very  common  in  children,  in  whom  it  is 
usually  difficult  to  induce  the  specific  influence  of  mercury. 

On  the  other  hand,  antimony  does  not  appear  to  be  nearly  so  valuable  a  r^edy 
as  mercury,  when  serous  membranes  are  inflamed. 

The  French  and  Italian  physicians  place  much  rehance  upon  antimony  for  the 
cure  of  inflammation ;  and  they  seem  to  know  Httle  or  nothing  of  the  remarkable 
agency  of  mercury  upon  that  disease.  For  my  own  part  I  do  not  see  how  any 
useful  comparison  can  be  made  between  these  two  substances  in  respect  to  inflam- 
mation, considered  generally,  as  we  are  now  considering  it.  There  are  some  par- 
ticular forms  of  inflammation  to  which  the  one  remedy  is  better  suited,  and  there  are 
others  in  which  the  other  is  most  effectual.  I  must  content  myself  for  the  present 
with  having  adverted  to  these  distinctions. 

As  to  the  form  in  which  the  antimony  should  be  exhibited,  I  apprehend  that  we 
hall  all  come  at  last  to  freshly  dissolved  tartar  emetic.  The  antimonial  powder  is 
of  ver}^  uncertain  strength;  and  the  antimonial  wine  contains  too  much  spirit  to  allow 
of  its  being  given  in  large  and  frequently  repeated  doses.  It  is  a  curious  circum- 
stance, that  akhough  vomiting  and  purging  are  apt  to  be  produced  by  the  first  two 
or  three  doses,  they  usually  cease  when  the  same  quantity  is  persevered  with. 
Tolerance  of  the  remedy  is  established.  But  akhough  these  unpleasant  primary 
effects  cease,  the  curative  agency  of  the  antimony  appears  to  continue.  When  you 
desire  to  obtain  its  full  influence  in  a  short  time,  you  may  dissolve  a  grain  of  the 
tartar  emetic  in  two  ounces  of  hot  water,  and  give  a  fourth  part  of  the  solution  every 
half  hour.  If  the  patient  becomes  pale  and  sick,  you  pause  awhile  and  allow  him 
to  recover  himself;  and  if  the  inflammatory  symptoms  return,  you  repeat  the  medi- 
cine. It  sometimes  acts  violently  upon  the  bowels,  and  then  it  is  necessary  to  add  a 
few  drops  of  laudanum  to  each  dose. 

[The  remarks  of  Dr.  Watson  upon  the  remedial  effects  of  tartar  emetic  in  inflammatory 
affections,  are  perfectly  correct  in  reference  to  these  diseases  as  they  occur  in  the  adult;  in 
the  inflammatory  diseases  of  infants  and  young  children,  however,  the  tartar  emetic  is  not  a 
remedy  that  can  be  safely  employed  ;  it  produces  in  them  always  very  considerable  and 
enduring  disturbance  of  the  stomach,  and  in  many  cases  a  state  of  extreme  and,  as  remarked 
by  a  late  writer  —  Dr.  Wilton,  (Prov.  Med.  and  Surg.  Journ.)  —  even  fatal  depression  of  the 
vital  powers. — C] 

Digilalis  is  another  powerful  medicine,  from  which,  as  a  remedy  for  active  inflam- 
mation, much  Avas  at  one  time  hoped ;  but  this  hope  has  been  in  a  great  measure 
disappointed.  It  is  not  a  manageable  remedy  in  such  cases.  Its  singular  property 
of  retarding  the  circulation,  of  bringing  down  the  number  of  the  heart's  pulsations, 
and  abating  its  force,  led  to  the  expectation  that  it  might  render  the  use  of  the  lancet 
unnecessary ;  that  it  might  check  the  inflammatory  process  without  permanently 
reducing  the  strength  of  the  patient.  But  if  you  give  moderate  doses  of  digitalis, 
Its  peculiar  effect  upon  the  pulse  comes  on  at  very  uncertain  periods,  and  may  be 
postponed  until  it  is  tO'  late  to  be  of  any  service.  If,  on  the  other  hand,  you  give  it 
in  such  quantity  as  speedilj''  to  affect  the  heart's  action  (which  is  what  we  want  in 
acute  and  serous  inflammation),  then  you  are  never  secure  against  what  may  b" 
called  its  poisonous  effects  ;  deadly  faintness,  frightful  syncope,  and  even  death  itself. 
Most  practitioners  can  tell  of  cases  in  which  patients,  who  were  taking  full  doses  of 
digitalis,  have  suddenly  expired ;  and  when  the  remedy  has  appeared  to  have  had 
more  to  do  with  the  fatal  event  than  the  disease.  There  are  practitioners,  however, 
and  I  know  one  of  them,  who  affirm  that  digitalis  may  be  given,  after  due  depletion, 
and  in  acute  inflammation,  in  very  large,  and  I  should  say  starthng  doses,  with  tho 


COLCHICUM,    OPIUM.  157 

very  best  «ffects — doses  which  range  from  half  a  drachm  to  half  an  ounce,  and  even 
six  drachms,  of  the  officinal  tincture.  I  confess  to  you  that  I  should  be  very  unwill- 
ing to  sanction  this  mode  of  using  digitalis.  I  never  attempt  to  employ  it  with  the 
view  of  knocking  down  acute  inflammation — to  which  alone  you  will  observe  that 
my  present  remarks  apply.  Digitalis  is  often  of  great  service  in  other  complaints  ; 
but  I  am  not  at  present  discussing  the  remedial  virtues  of  digitalis,  or  of  any  other 
drug,  except  so  far  as  they  relate  to  the  cure  of  recent  and  active  inflammation. 

Colchicinn  is  a  drug  which  is  often  prescribed  in  inflammation.  It  is  a  most  valu- 
able remedy  in  certain  specific  forms  of  inflammation.  But  for  repressing  common 
phlegmonous  inflammation  we  have  much  more  certain  and  better  remedies.  For 
this  purpose  colchicum  is,  I  believe  a  very  unimportant  medicine. 

I  have  formerly  been  asked,  by  students  attending  here  —  and  therefore  \  antici 
pate  the  question  now — respecting  the  utility  of  opium  as  a  remedy  in  inflammation. 
Certainly  opium,  like  most  of  our  powerful  medicines,  may  do  much  good,  as  it  may 
do  much  harm,  in  different  inflammatory  diseases ;  and  it  is  not  very  easy  to  point 
out  clearly,  in  a  general  view  of  the  treatment  of  inflammation,  the  rules  for  its 
administration  by  which  we  must  be  guided  in  diflferent  cases.  Yet  there  are  a  few 
general  observations  which  I  may  make  now  on  this  subject. 

The  administration  of  a  full  dose  of  opium  has  been  strongly  recommended  after 
that  free  and  effective  bleeding  which  I  have  already  described.  It  prevents  the 
rekindling  of  the  inflammation  which  is  apt  to  result  from  irritation  of  the  nervous 
system  —  a  kind  of  irritation,  you  will  remark,  which  the  copious  abstraction  of 
blood  is  calculated  to  produce  ;  or  to  augment,  if  it  flnds  it  already  existing.  The 
opium  soothes  this  nervous  irritability,  and  it  must  be  given,  when  given  at  all,  in 
doses  which  will  have  that  effect.  It  is  best  adapted  to  those  cases  in  which  a 
natural  irritability  is  inherent  in  the  constitution  of  the  patient  —  to  those  in  which 
.such  irritability  has  been  acquired  by  bad  habits  of  life  —  and  to  those  in  which  the 
local  disease  is  attended  with  much  pain,  which  is  in  all  constitutions  a  source  of 
irritation. 

However,  this  is  a  remedy  which  requires  to  be  used,  in  inflammation,  with  great 
caution  and  discrimination.  In  cases  of  active  inflammation  within  the  cranium,  its 
propriety  is  very  questionable.  It  is  apt  to  confuse  both  the  patient  and  his  physi- 
cian, who  is  unable  to  say,  after  a  full  dose  of  opium  has  been  given,  how  much  of 
the  stupor  that  follows  is  owing  to  the  disease,  and  how  much  to  the  drug.  It  is  a 
very  ticklish  remedy  in  pectoral  inflammations.  I  believe  that  by  the  free  use  of 
opium  I  saved  the  life  of  a  relation  of  my  own,  an  old  lady,  who  was  in  danger  of 
being  worn  out  by  the  cough  and  bronchial  affection  which  attended  the  influenza. 
On  the  other  hand  I  certainly  have  known  more  than  one  person,  labouring  under 
extensive  and  severe  bronchitis,  so  effectually  quieted  by  a  dose  of  the  same  medi- 
cine, that  they  never  woke  again.  As  a  general  rule  I  should  say  that  you  must  be 
very  careful  how  you  venture  upon  opium  in  inflammatory  diseases  that  tend  to  pro- 
duce death  by  coma,  or  apnrea.  If  there  be  any  unnatural  duskiness  of  the  face,  if 
ever  so  sHght  a  tinge  of  purple  mingles  itself  with  the  red  colour  of  the  lips,  this  is 
an  appearance  which  (with  certain  exceptions,  to  be  specified  hereafter)  should  warn 
you  against  opium.  It  shows  that  the  blood  is  imperfectly  arterialized  :  and  imper- 
fect arterialization  of  the  blood,  as  I  hope  you  all  know,  either  results  from,  or  con- 
duces to,  a  state  of  coma. 

On  the  other  hand,  it  is,  cseteris  paribus,  in  cases  where  the  tendency  is  towards 
death  by  asthenia,  that  the  use  of  opium,  as  a  remedy  for  inflammation,  is  most 
serviceable.  It  has  a  capital  effect  often,  after  free  bleeding,  in  cases  of  peritonitis, 
and  of  enteritis.  It  probably  does  good  in  various  ways  :  by  quieting  the  nerves  — 
by  sustaining  the  faltering  action  of  the  heart — by  keeping  the  inflamed  parts  at 
rest.  There  are  some  frightful  accidents  in  which  we  can  expect  little  from  blood- 
letting, but  in  which  the  judicious  employment  of  opium  affords  some  glimmering 
of  hope.  I  allude  to  those  cases  of  intense  and  general  peritonitis  which  arise  upon 
the  escape  of  irritating  substances  into  the  cavity  of  the  belly ;  the  contents  of  the 
intestines,  from  ulceration  or  from  external  injury ;  urine  from  rupture  of  the  blad- 
der ;  and  so  on.     If  there  be  any  hope  in  such  cases,  it  is  to  be  found  in  the  con 

o 


158  INFLAMMATION. 

tinucd  exhibition  of  opium  in  considerable  doses.     But  upon  all  these  points  I  shall 
go  more  into  detail  when  we  come  to  consider  individual  diseases. 

A  very  few  remarks,  in  respect  to  external  remedies  in  cases  of  inflammation, 
will  terminate  both  this  lecture  and  what  I  have  to  say,  thus  generally,  of  the 
treatment  of  inflammatory  complaints. 

The  application  of  external  cold  will  aid  us  very  powerfully,  in  certain  serious 
cases  of  inflammation;  and  especially  in  cases  of  inflammation  within  the  cranium. 
It  is  really  wonderful  what  a  sedative  and  soothincr  efl^ect  this  expedient  frequently 
has  in  allaying  delirium,  the  result  of  active  inflammation  of  the  brain  and  its 
membranes.  Thin  folds  of  linen,  kept  constantly  moist  and  cold  by  cold  water,  are 
placed  upon  and  around  the  shaven  head.  We  often  apply  ice  in  the  same  way. 
But  I  need  not  go  at  present  into  any  detail  on  this  subject ;  I  will  only  observe, 
that  we  have  a  most  excellent  and  simple  guide  as  to  the  probable  usefulness  of  cold 
application  to  the  head,  in  the  sensations  of  our  patients.  It  is  very  lucky  that  it 
is  so.  As  long  as  the  cold  cloths,  or  the  bags  of  ice,  are  pleasant  and  grateful  to  the 
patient,  so  long  we  sedulously  continue  to  apply  and  renew  them ;  as  soon  as  the 
patient  dislikes  them,  they  had  better  be  intermitted. 

Cold  apphcations  to  the  chest,  and  to  the  belty,  in  active  inflammation  of  parts 
situated  within  those  cavities,  have  been  praised  by  some  practitioners  ;  but  I  believe 
are  veiy  seldom  emploj^ed.  I  have  no  personal  experience  either  of  their  utilitj'', 
or  of  their  hurtfulness.  I  confess  that  I  should  not  like  to  use  them.  I  should  think 
that  the  effect  of  the  cold,  in  driving  the  blood  from  the  cutaneous  vessels,  and  accu- 
mulating it  in  internal  parts,  would  be  hkely  to  be  injurious.  We  shall  see,  by  and 
by,  that  the  contents  of  the  skull  are  somewhat  differently  circumstanced,  in  this 
respect,  from  those  of  the  thorax  and  abdomen. 

The  totally  opposite  measure,  applying  7varmfh  to  the  surface,  is  of  very  great 
service  in  many  cases  of  internal  inflammation  ;  especially  in  inflammations  of  the 
abdominal  organs.  We  speak  of  cold  lotions,  and  of  hot  fomentations.  These 
last  are  managed  in  various  ways,  into  Avhich  I  do  not  at  present  enter.  They  seem 
to  do  good  by  determining  to  the  surface ;  they  promote  perspiration  ;  they  mitigate 
pain,  and  persuade  to  sleep. 

In  cases  of  external  inflammation,  sometimes  cold  applications  are  found  to  be  of 
use,  and  sometimes  warm.  In  this  matter,  also,  the  sensations  of  the  patient  afford 
the  best  criterion.  Both  of  them  tend,  in  different  circumstances,  to  promote  reso- 
lution. We  have  an  illustration  of  the  beneficial  agency  of  cold  applications  for 
this  purpose  in  the  treatment  of  recent  burns  and  scalds,  particularly  Avhen  the  injury 
is  superficial,  and  the  skin  has  not  been  destroyed.  Probably  there  is  scarcely  any 
one  present  who  has  not  experienced  the  rehef  given  to  the  pain  of  a  burned  finger, 
by  dipping  it  in  cold  water;  and  the  return  of  the  pain  upon  taking  the  finger  out 
again.  The  cold  may  be  so  constantly  applied  that  the  pain  will  cease  to  recur 
when  the  application  is  at  length  suspended.  Dr.  John  Thomson  relates  a  case  in 
which  a  burned  arm  was  kept  immersed  in  cold  water  for  two  days  and  two  nights 
incessantly  ;  and  inflammation  Avas  thereby  wholly  prevented.  I  have  known  this 
expedient  fail,  however.  A  nurse  in  the  Middlesex  Hospital  fell  as  she  was  car- 
rying a  pail  of  hot  water  upstairs,  and  in  her  fall  thrust  one  of  her  arms  into  the 
scalding  liquid.  Without  loss  of  time  she  plunged  the  same  arm  into  cold  nater; 
but  after  a  while  was  obliged  to  desist;  the  cold  immersion  bringing  on  severe 
ngor?. 

Tn  ei3'sipelas  I  am  persuaded  that  warm  fomentations  not  only  afford  more 
:omfort,  but  are  more  effectual  and  safer  than  cold  lotions. 

Independently  of  their  occasional  influence  in  promoting  resolution,  warm  appli- 
cations— warm  soft  poultices  for  instance — are  often  used  with  the  view  of  forward- 
mg  suppuration.  Hence  this  rule.  Whenever  resolution  of  the  inflammation  is 
possible — but  suppuration  is  likely  to  ensue — warm  applications  are  the  most  proper: 
because,  under  their  use,  we  have  an  equal  chance  of  obtaining  resolution,  with  less 
Ijfazard  of  retarding  or  rendering  untoward  the  process  of  suppuration,  in  case 
resolution  does  not  take  place. 

Coxinter-irritation,  by  means  of  blisters,  sinapisms,  irritating  ointments,  setonB 


HEMORRHAGE.  159 

issues,  or  moxas,  is  often  very  beneficial.  It  probably  operates  by  attracting  blood 
into  the  neighbouring  parts,  and  in  the  same  degree  diverting  it  from  the  inflamed 
part.  It  is  most  serviceable  in  chronic  inflammations,  and  towards  the  decline  of 
those  which  are  acute.  It  is  particularly  adapted  to  scrofulous  affections.  There 
is  an  objection  to  the  use  of  counter-irritation  during  the  height  of  the  inflammatory 
fever,  on  account  of  the  increase  of  general  irritation  which  it  would  then  occasion. 
Neither  in  local  inflammation  should  counter-irritation  be  applied  very  near  to  the 
inflamed  part.  Blisters  upon  the  head  or  neck,  are  not  proper,  therefore,  at  least 
in  the  early  stages  of  the  disease,  in  acute  inflammation  within  the  cranium ;  but 
they  are  sometimes  applied  in  such  cases,  with  advantage,  to  the  lower  extremities. 
To  the  chest,  however,  in  thoracic  inflammation,  and  to  the  belly  in  abdominal, 
bUsters  are  often  not  only  perfectly  safe,  but  of  the  greatest  use,  as  will,  I  trust,  be 
apparent  as  we  go  on. 


LECTURE  XV. 


Hemorrhage: — most  commonly  by  Exhalation.  Habitual  Hemorrhages.  Tlca- 
rioKS  Hemorrhages.  Idiopathic  Hemorrhages.  Active  and  Passive.  Symp- 
tomatic Hemorrhages.  Usual  Situations  of  Hemorrhage.  Symptoms  and 
Diagnosis.     Principles  of  Treatment: 

In  the  course  of  that  somewhat  cursory  account  which  I  have  been  endeavouring 
to  give  you  of  the  general  facts  and  doctrines  of  pathology,  as  a  preparation  for  the 
better  understanding  of  special  forms  of  disease,  we  reached,  some  lectures  back, 
the  subject  of  local  plethora  or  congestion.  From  that  point  our  road  branched  off" 
in  three  several  directions.  We  have  pursued  the  first  and  main  branch  to  its  ter- 
mination ;  that  which  led  to  the  discussion  of  inflammation.  We  must  now  go  back 
to  the  same  point  again,  and  follow  first  the  one  and  then  the  other  of  the  two 
remaining  branches,  w^hich  conduct  respectively  to  the  consideration  of  hemorrhage 
and  of  dropsy.  These  branches  are  shorter  than  that  along  which  we  were  last 
travelling ;  but  they  are  not  uninviting ;  they  will  open  to  us,  if  I  mistake  not,  some 
interesting  views  of  the  country  of  which,  we  purpose,  in  the  end,  to  make  a  more 
particular  survey. 

You  are  to  observe  that  I  treat  of  hemorrhage  only  so  far  as  it  falls  to  the  care  of 
the  physician.  The  subject  is  exceedingly  full  of  interest  in  its  relation  to  surgery  : 
and  it  will  receive  at  the  hands  of  my  colleague  all  the  attention  which  its  great 
importance,  as  a  surgical  accident,  demands. 

But  ive,  also,  as  physicians,  have  much  to  do  with  hemorrhagie ;  with  what,  for 
distinction's  sake,  I  may  call  medical  hemorrhage  ;  which  differs  in  kind,  in  cause, 
in  its  consequences,  and  in  the  treatment  it  requires,  from  that  which  surgery  con- 
templates. 

In  surgical  or  traumatic  bemorrhage  the  blood  flows  from  some  considerable 
vessel,  which  has  been  cut  or  torn,  or  somehow  ruptured.  You  would  greatly 
mistake,  if  you  inferred  from  that  circumstance  (as  you  naturally  might),  that  it  is 
Kstfally  so — the  only  difference  being  in  the  situation  of  the  vessel — in  medical 
hemorrhage  also. 

Yet  that  is  the  popular  notion.  When  blood  gushes  out  from  internal  parts, 
through  any  of  the  natural  apertures  of  the  body,  the  person  is  said  and  supposed 
to  have  broken  a  blood-vessel.  But  this  is  rarely,  though  it  is  sometimes,  the  case. 
In  nine  cases  out  of  ten,  if  there  be  any  rupture  at  all,  it  is  rupture  of  numerous 
capillaries  only :  but  even  of  this  there  is  often  no  evidence. 

Whence,  then,  and  how,  does  the  blood  escape  from  its  natural  channels?  Why, 
it  exudes  from  the  unbroken  surfaces  of  organs,  without  any  appreciable  lesion  of 
arteries,  veins,  or  capillaries ;  just  in  the  same  manner  as  sweat  oozes  from  the 
skin,  macus  from  the  inner  surface  of  the  bowels,  and  serum  or  synovia  from  th)i 


ICO  HEMORRHAGE. 

membranes  that  respectively  furnish  those  fluids ;  and  probably  by  the  very  same 
outlets. 

This  certainly  is  a  very  remarkable  circumstance,  if  it  be  true  ;  and  you  will  na- 
turally ask  what  proof  we  have  of  its  truth. 

Tlie  proof  is  simple,  and,  I  think,  conclusive.  "VVe  examine  the  surface  from 
which  the  blood  must  have  proceeded,  and  we  find  it  entire :  we  wash  and  even 
macerate  it:  we  employ  the  microscope  to  assist  our  powers  of  vision  :  yet  we  fail, 
after  this  careful  inspection,  to  discover  the  slightest  breach  of  substance,  or  any 
appearance  of  erosion. 

When,  for  example,  hemorrhage  has  occurred  so  profusely  from  the  stomach  oi 
bowels,  that  the  death  which  ensued  could  be  sufficiently  accoimted  for  by  the  mere 
loss  of  blood,  the  whole  tract  of  the  alimentary  canal  has  been  diligently  scrutinized, 
and  has  exhibited  no  ruptured  blood-vessel,  no  abrasion  even  of  its  surface,  nor  any 
perceptible  alteration  of  texture.  Sometimes  its  mucous  membrane  appears,  here 
and  there,  of  a  red  colour,  and,  as  it  were,  charged  Aviih  blood.  Sometimes  it  is  pale 
and  transparent,  while  the  vascular  net-work  visible  immediately  beneath  it  is  gorged 
and  turgid.  Sometimes  the  whole  is  colourless;  the  same  net-work  of  vessels  hav- 
ing been  completely  emptied  by  the  previous  hemorrhage ;  and  sometimes,  again 
(and  this  is  very  illustrative  of  the  mode  by  which  the  blood  has  issued),  vast  num- 
bers of  small  dark-coloured  masses,  like  grains  of  fine  sand,  can  be  made  to  start 
from  the  surface  of  the  membrane  by  slight  pressure.  There  can  be  no  doubt  that 
these  are  minute  portions  of  blood  which  had  remained  and  coagulated  in  the  vessels 
or  apertures  forming  the  ultimate  channels  of  the  hemorrhage. 

We  have  absolute  proof,  therefore,  that  hemorrhage  may  transude  through  an 
uninjured  surface  :  nay,  in  some  rare  cases,  the  process  has  been  actually  witnessed. 
There  are  well-authenticated  instances  on  record  of  cutaneous  hemorrhage ;  where 
a  dew  of  blood  has  appeared  upon  some  portion  of  the  skin,  has  been  wiped  away, 
and  has  reappeared  ;  and  that,  again  and  again,  without  any  perceptible  alteration  of 
the  affected  surface,  beyond  some  occasional  variation  in  its  colour.  So,  again,  the 
menstrual  discharge  has  been  seen  to  issue  guttuihn  from  the  healthy  surface  of  a 
living  but  inverted  uterus.  I  confess,  however,  that,  although  this  analogical  fact 
helps  our  conception  of  the  manner  in  which  blood  may  be  exhaled  from  an  un- 
broken membrane,  I  should  not  lay  much  stress  upon  it  for  any  other  purpose.  It  is 
not  exactly  a  case  in  point.  The  process  of  menstruation  cannot  be  looked  upon  as 
»i  morbid  process.  During  a  certain  portion  of  the  life  of  an  unpregnant  female,  it 
IS  not  only  consistent  with  perfect  health,  but  even  essential  to  it ;  and  the  fluid  poured 
out  is  not  strictly  blood. 

That  the  blood  proceeds  from  the  same  vessels  or  apertures,  Avhich,  in  health,  pour 
out  the  fluids  natural  to  the  part,  is  rendered  the  more  probable  by  this  fact : — that 
certain  hemorrhages  are  ushered  in  and  succeeded  by  an  increased  efflux  of  the  fluids 
which  belong  to  the  surface  concerned.  In  hemorrhages  from  the  mucous  mem- 
branes the  following  succession  of  events  is,  in  some  persons,  habitual.  First,  there 
is  an  augmented  flow  of  mucus  alone ;  then  of  mucus  tinged  with  blood ;  then  of 
pure  blood  :  and  the  hemorrhage  recedes  by  a  similar  but  inverse  gradation,  towards 
a  mucous  drain,  which  itself  at  length  decreases  or  disappears. 

When  blood  thus  exudes,  we  say  that  the  hemorrhage  takes  place  by  exhalation. 
It  is  a  convenient  word,  and  will  spare  circumlocution.  What  the  vessels  or  out- 
lets to  which  we  give  the  name  of  exhalants  really  are ;  whether  they  be  branches 
from  the  capillaries  not  large  enough  in  the  natural  state  to  admit  the  red  particles, 
or  whether  they  be  mere  pores  in  the  sides  of  the  capillaries  ;  these  are  points  con- 
cerning which  we  have  no  positive  knowledge.  We  know,  indeed,  that  such  chan- 
nels must  exist,  though  we  cannot  demonstrate  or  see  them  ;  and  we  know  that  wbik 
every  part  of  the  body  is  in  a  state  of  health  and  integrity,  they  do  not  aUow  the 
blood,  as  such,  to  pass  through  them. 

I  am  aware  that  my  learned  colleague  Dr.  Todd  objects  to  this  doctrine  of  hemor- 
rhage without  rupture,  even  of  capillary  vessels :  arguing  that,  if  the  red  corpus- 
cles of  the  blood,  which  measure  from  4  ocu  to  3  o'cu'-^  of  ^"^  i"^^  i"  diameter,  could 
pass  through  lateral  pores  in  those  vessels,  such  pores  must  be  large  enough  to  be- 


BY    EXHALATION.  161 

come  visible  under  the  microscope.  But  on  the  other  hand,  Mr.  Wharton  Jones, 
who  also  is  well  versed  in  the  use  of  that  instrument,  declares  that  the  red  corpuscles 
"can  readily  accommodate  themselves  to  vessels  of  a  diameter  less  than  their  own." 
However  this  may  be,  the  distinction  is  broad  enough  between  hemorrhage  from  a 
palpable  leak  in  a  large  vein  or  artery,  and  hemorrhage  from  innumerable  capillaries 
in  which  no  rent  can  be  demonstrated.  Treating,  then,  this  question  of  rupture 
according  to  the  old  maxim,  that  de  non  apparentibus  et  de  non  existendibus  eadem 
est  ratio,  1  shall  venture  to  adhere  to  the  term  exhalation. 

Now,  although  internal  hemorrhage  may  happen  in  other  ways  ;  as  from  the 
bursting  of  an  aneurism,  or  from  an  opening  made  in  a  large  vessel  by  progressive 
ulceration ;  yet  in  by  far  the  greater  number  of  cases  it  takes  place  by  exhala- 
tion.    Exhalation  is  the  rule — other  modes  of  hemorrhage  furnish  the  occasional 

o 

exception. 

I  must  exclude,  however,  from  this  general  statement  one  very  important  hemor- 
rhage. In  the  brain,  the  former  exception  becomes  the  rule.  In  almost  all  cases 
cerebral  hemorrhage  results  from  the  rupture  of  a  blood-vessel. 

There  are  various  kinds  of  hemorrhage  by  exhalation.  I  will  bring  them  before 
you,  in  succession,  as  clearly  and  concisely  as  I  can. 

In  the  first  place  there  are  hemorrhages  which,  although  they  do  not  belong  to  the 
state  of  health,  if  we  take  mankind  in  general,  yet  when  they  do  occur,  cannot  pro- 
perly be  called  diseases.  There  are  some  persons — I  believe  I  may  say  there  are 
many  persons — who  are  subject,  during  the  greater  part  of  their  fives,  to  discharges 
of  blood ;  which  happen  again  and  again,  commonly  at  regular  intervals,  without 
any  perceptible  detriment  to  the  general  health,  independently  of  any  obvious  ex- 
citing cause,  and  (as  it  would  seem)  from  some  inherent  property  or  necessity  of  the 
system. 

Hemorrhages  thus  occurring,  I  will  call  habitual  hemorrhages.  They  proceed 
more  commonly  from  the  rectum,  and  from  the  nares,  than  from  any  other  parts ; 
although  instances  are  recorded  of  their  taking  place  from  the  bladder,  and  from  the 
bronchi.  Appertaining  to  the  original  constitution  of  the  body,  this  disposition  to 
periodic  hemorrhage  has  been  sometimes  observed  to  be  hereditary. 

You  will  at  once  be  struck  with  the  analogy  which  obtains  between  these  habitual 
hemorrhages  occurring  in  either  sex,  and  the  monthly  discharge  which  is  pecufiar  to 
the  female.  The  analogy  is  even  closer  than  it  may  at  first  sight  appear:  but  it  is 
more  distinctly  marked  in  some  individuals,  liable  to  habitual  hemorrhage,  than  in 
others.  It  was  one  of  the  singular  notions  of  the  celebrated  phrenologist  M.  Grail, 
founded  upon  his  analogy,  that  there  is  such  a  thing  as  male  menstruation.  The 
points  of  resemblance  between  the  two  phenomena  will  be  manifest  in  the  following 
summary  of  the  characters  belonging  to  habitual  hemorrhage. 

Like  the  catamenia,  these  hemorrhages  do  not  ordinarily  prevail  throughout  the 
whole  course  of  life.  In  most  cases  they  do  not  commence  before  the  period  of 
adolescence  ;  and  they  cease  altogether,  or  recur  at  distant  intervals  only,  in  declin- 
ing age.  Their  first  eruption  is  sometimes  preceded  by  a  state  of  general  indisposition, 
more  rarely  by  slight  febrile  disturbance,  and  even  (according  to  some  observers)  by 
a  sort  of  chlorosis  similar  to  tnat  which  affects  young  girls  in  whom  the  menstrual 
evacuation  is  delayed  or  suspended.  The  hemorrhage  sometimes  recurs  at  precisely 
regular  intervals,  and  by  monthly  periods  more  commonly  than  any  other :  being 
announced,  on  each  occasion,  by  the  same  preludes,  proceeding  from  the  same  part, 
continuing  for  the  same  space  of  time,  and  furnishing  always  about  the  same  quan- 
tity of  blood.  Its  accidental  interruption  is  almost  uniformly  the  cause  or  the  conse 
quence  of  some  derangement  of  the  health :  and  when  it  becomes  excessive  i: 
becomes,  like  too  profuse  menstruation,  a  disease. 

It  forms  a  very  curious  part  of  the  general  history  of  hemorrhages  that  they  aie 
not  unfrequently  vicarious,  or  supplemental,  sometimes  of  each  other,  but  more  often 
of  the  monthly  discharge  from  the  uterus.  Females  are  hable  to  perverted  men 
struation  (so  to  call  it)  through  other  channels  than  the  natural  one :  and  here  agam 
the  analogy  between  the  catamenia  and  habitual  hemorrhage  comes  into  view.  The 
hemorrhages  which  belong  to  the  constitution  are  apt  to  wander  in  their  seal.  As 
11  o2 


IG2  HEMORRHAGE. 

bleeding  from  the  lungs,  stomach,  rectum,  or  skin,  sometimes  follows  upon  the  sus 
pension  of  the  menses,  so  bleeding  from  the  bladder,  from  the  mouth,  and  from  other 
parts,  has  been  occasionally  observed  to  succeed  the  suppression  of  habitual  hemor- 
rhois. 

These  hemorrhagic  deviations  take  place  commonly  by  the  same  organ  on  each 
occasion ;  more  seldom  by  different  organs  in  succession.  It  is  almost  always  in 
this  supplementary  manner  that  the  rarer  forms  of  hemorrhage  occur,  and  those  of 
the  skin  in  particular. 

This  singular  migration,  this  interchange  of  place  between  certain  hemorrhages, 
seems  calculated  to  throw  some  light  upon  the  obscure  doctrine  of  revidsion :  a 
doctrine  to  which  [  have  already  more  than  once  referred,  and  which,  though  it  is 
very  imperfectly  understood,  is  of  frequent  avail  in  the  practice  of  physic. 

Vicarious  hemorrhage  always  denotes  a  disordered  slate  of  the  general  health : 
and  must  be  considered,  in  itself,  as  a  malady. 

Again,  there  are  certain  forms  of  hemorrhage,  not  habitual,  which  may  be  deno- 
minated idiopathic :  inasmuch  as  they  are  apt  to  arise  without  any  perceptible  con- 
nection with  antecedent  local  disease. 

In  other  respects,  however,  they  differ  considerably,  and  require  to  be  further 
distinguished :  and  the  terms  active  and  passive,  which  are  in  common  use,  will 
sufficiently  express  the  two  forms  of  idiopathic  hemorrhage  that  I  wish  to  bring 
under  your  notice. 

Active  hemorrhage  is  preceded  by  active  congestion,  and  therefore  is  akin  to 
inflammation  ;  and  it  often  requires  the  treatment  of  inflammation. 

Passive  hemorrhage  often  occurs  without  any  apparent  previous  congestion  of  any 
kind.  Hemorrhage  of  this  passive  character  has  been  ascribed  to  some  change — 
different  from  that  which  we  conceive  to  be  produced  by  the  distension  of  plethora — 
in  the  vessels  or  apertures  through  which  the  healthy  exhalations  are  transmitted. 
The  change  is  considered  as  being  of  the  nature  of  morbid  debility  or  relaxation. 
That  such  a  state  may  sometimes  exist  is  not  impossible,  nor  even  unlikely :  but  as 
we  are  altogether  ignorant  of  the  natural  condition  of  these  outlets,  it  is  difficult  to 
reason  about  the  alterations  to  which  they  may  be  subject  in  disease.  This  hypo- 
thesis derives  its  chief  support  from  the  occasional  efficacy  of  astringent  substances 
(either  apphed  locally,  or  taken  into  the  system)  in  checking  the  effusion  of  blood, 
when  other  remedies  have  failed. 

A  more  probable  hypothesis  perhaps  is  that  which  supposes  some  alteration  in  the 
consistence  or  composition  of  the  blood  itself;  which  thus  becomes  attenuated,  and 
capable  of  passing  through  channels  or  orifices  that  healthy  blood,  under  ordinary 
circumstances,  cannot  penetrate.  In  support  of  this  supposition  are  adduced  the 
facts  that  hemorrhages  are  known  to  occur  where  the  blood  is  more  thin,  pale,  and 
serous  than  common  ;  and  still  more  remarkably  where  that  fluid  has  undergone  a 
demonstrable  change  in  its  chemical  nature,  or  is  even  visibly  altered  in  its  sensible 
quahlies  ;  as,  for  example,  in  certain  cases  of  purpura  and  sea-scurvy.  And  hemor- 
rhages of  this  kind  are  often  cured  by  measures  calculated  to  repair  the  blood ;  to 
restore  it  to  its  natural  condition  by  improvement  in  diet ;  or  by  food  of  a  pecuUar 
kind,  as  the  juice  of  lemons. 

AVhatever  may  be  the  true  explanation  of  the  differences  in  question,  there  can 
be  no  doubt  that  they  exist,  and  are  often  strongly  pronounced  in  case  of  hemorrhage, 
wliich,  inasmuch  as  they  cannot  be  traced  to  any  pre-existent  local  disease,  we  class 
together  as  idiopathic.  And  it  will  be  worth  while  to  run  over  the  distinctive  cha- 
racters of  active  and  passive  hemorrhage,  as  they  are  broadly  and  decidedly  visible, 
in  well-marked  cases. 

JJctive  hemorrhage  (which  is  preceded,  I  repeat,  by  active  congestion)  occurs 
principally  in  persons  who  are  young  and  robust,  who  live  fully,  and  lead  indolent 
lives,  and  are  subject  to  the  influence  of  those  causes  which  tend  to  generate  plethora. 
Occasionally  the  hemorrhage  can  be  traced  to  some  exciting  cause,  such  as  exposure 
to  heai,  strong  mental  emotion,  violent  exercise,  or  bodily  efforts.  More  frequently, 
perhaps,  no  exciting  cause  is  apparent.  It  is  sometimes  ushered  in  by  a  set  of 
avmptoras  expressive  of  what  has  been  called  the  molimen  hemorrhagicum.     The 


IDIOPATHIC.  163 

pafent  experiences  a  general  feeling  of  indisposition,  with  wandering  and  obscure 
pains  that  gradually  settle  in  the  part  from  which  the  blood  is  about  to  be  discharged. 
A  series  of  local  symptoms,  such  as  a  sensation  of  weight,  or  of  tension,  or  of  heal 
and  tingling,  sometimes  a  slight  degree  of  turgescence  and  redness,  and  a  visible 
fullness  of  the  larger  veins,  indicate  the  afflux  o^  blood  towards  the  labouring  organ, 
and  the  parts  in  its  vicinity :  while  chilliness,  paleness,  and  shrinking  of  distant 
parts,  and  especially  of  the  feet  and  hands,  denote  an  opposite  condition  of  the  cir- 
culation in  them.  And  to  this  state  of  things  there  often  succeeds  a  general  increase 
of  heat,  with  a  frequent  pulse, — a  pulse  which  is  so  characteristic  sometimes,  as  to 
have  acquired  a  name  ;  you  may  often  hear  or  read  of  a  hemorrhagic  pulse.  The 
blood,  when  at  length  it  breaks  forth,  commonly  escapes  with  rapidity ;  is  of  a  florid 
colour ;  proceeds  from  a  single  organ ;  and  readily  coagulates,  though  it  seldom 
separates  distinctly  into  serum  and  crassamentum.  While  it  is  flowing,  the  signs  of 
local  congestion  diminish  and  disappear;  warmth  returns  to  the  extremities,  and  the 
pulse  regains  its  natural  strength  and  frequency.  The  patient  becomes  conscious  of 
a  sensible  relief;  and  feels  stronger  and  more  lively  than  before.  This  kind  of 
hemorrhage  is,  in  some  sort,  its  own  remedy ;  it  ceases  in  virtue  of  the  discharge  of 
a  certain  quantity  of  blood,  and  it  is  followed  by  morbid  consequences  only  when 
that  quantity  has  been  excessive  ;  or  when  it  inflicts  some  mechanical  injury  upon 
the  parts  along  which  the  blood  passes. 

I  said  that  active  hemorrhage  is  preceded  by  active  congestion,  and  is  consequently 
akin  to  inflammation.  Perhaps  it  may  be  more  true  that  in  some  of  these  cases  we 
actually  have  the  initial  stage  of  mflammation,  of  which  the  hemorrhage  proves  the 
natural  cure  :  strangling  it  in  its  birth  ;  applying  that  remedy,  in  the  very  moment 
when  it  is  most  efiective,  which  I  told  you,  in  the  last  lecture,  was  the  most  potent 
of  all  the  remedies  of  inflammation :  namely,  loss  of  blood. 

Passive  hemorrhage  on  the  other  hand  is  characterized  by  circumstances  of  an 
exactly  contrary  nature.  It  occurs  in  those  who  are  naturally  feeble,  or  who  have 
been  debilitated  by  disease,  fatigue,  insufficient  nourishment,  great  evacuations,  or 
the  depressing  passions.  It  is  not,  in  general,  announced  by  any  precursory  symp- 
toms, nor  attended  by  any  re-action.  The  effused  blood  is  of  a  dark  colour,  serous, 
and  but  little  disposed  to  coagulate :  and  it  often  is  poured  forth  from  several  parts 
of  the  body  at  the  same  time.  If  the  quantity  lost  be  at  all  considerable,  the  natural 
debihty  of  the  patient  is  rapidly  augmented :  his  face  becomes  pale,  and  his  body 
loses  its  heat.  The  hemorrhage  leaves  him  in  a  worse  condition  than  that  in  which 
it  found  him.  The  flow  of  a  certain  quantity  of  blood  is  not,  as  in  the  cases  of  active 
hemorrhage,  suspensive  of  its  further  eff'usion ;  frequently,  indeed,  passive  hemor- 
rhage resists  the  means  opposed  to  it,  the  more,  in  proportion  as  it  has  continued 
lono-er,  or  been  more  profuse. 

Hemorrhages  of  the  kind  I  have  now  been  describing — that  is  to  say,  depending 
upon  no  palpable  disease  of  any  organ,  and,  therefore,  idiopathic — are  of  no  uncom- 
mon occurrence,  whether  we  regard  the  active  or  the  passive  form  in  which  they 
appear :  but  by  far  the  greater  number  of  hemorrhages  by  exhalation  are  sympto 
rnatic ;  that  is,  they  result  from  some  previous  disease,  either  in  the  organ  from 
which  the  blood  proceeds,  or  in  some  other  organ  connected  therewith  by  community 
or  dependence  of  function. 

These  secondary  or  symptomatic  hemorrhages  are  preceded  by  congestion,  but 
for  the  most  part  the  congestion  is  not  of  the  active,  but  of  the  mechanical  kind ;  and 
has  more  to  do  with  the  veins  of  the  part  than  with  the  arteries. 

Thus  we  have  hemorrhage  from  the  bronchial  membrane,  in  consequence  of  crude 
tubercular  matter  in  the  lungs,  filling  up  a  portion  of  the  pulmonary  tissue,  and 
obstructing  the  circulation  of  the  blood  through  it.  This  is  an  example  of  symp- 
tomatic hemorrhage  by  exhalation,  depending  upon  previous  disease  in  the  organ 
itself  from  which  the  blood  proceeds. 

In  some  of  these  cases  the  presence  of  pyrexia  renders  it  probable  that  the  hemoi 
rhage  is  the  consequence  and  the  relief  of  active  congestion,  provoked  by  tho 
irritation  of  tubercles ;  rather  than  the  result  of  a  mechanical  obstruction  of  tho 
circulation. 


164  HEMORRHAGE. 

Again,  we  have  hemorrhage  into  and  from  the  lungs,  as  a  consequence  of  -tuch 
disease  of  the  heart  as  mechanically  impedes  the  return  of  the  blood  from  the  lungs 
to  that  organ :  a  narrowing  of  the  mitral  orifice,  for  instance.  Here  the  blood  is 
barred  up,  as  it  were,  in  the  lungs,  till  at  length  the  capillaries,  incapable  of  further 
distention,  either  give  way,  or  become  so  dilated  as  to  allow  of  the  exit  of  the  blood 
through  their  exhalant  openings,  or  through  inorganic  pores  in  their  sides.  In  pre- 
cisely the  same  way  blood  is  poured  out  by  the  mucous  membrane  of  the  stomach 
and  bowels,  in  consequence  of  disease  in  the  liver,  obstructing  the  portal  circulation. 
These  are  examples  of  symptomatic  hemorrhage  by  exhalation,  depending  upon 
previous  disease,  not  of  the  organ  itself  from  which  the  blood  proceeds,  but  of  ano- 
ther organ  intimately  connected  with  the  former. 

When  I  say  that  hemorrhage  into  and  from  the  lungs  may  result  from  such  dis- 
ease of  the  heart  as  impHes  an  impediment  to  the  circulation,  you  must  not  suppose 
that  the  lungs  are  the  only  channel  through  which  the  mechanical  congestion  can  be 
relieved.  Disease  of  the  central  moving  organ  of  the  circulation  leads  often,  at 
length,  to  universal  venous  congestion  :  and  the  hemorrhage,  which  is  apt  to  be  the 
consequence  of  such  congestion,  may  burst  forth  from  any  part  where  th^  veins  are 
so  overloaded.  Hemorrhages  from  various  portions  of  the  mucous  membranes  are 
in  truth  very  common  effects  of  cardiac  disease. 

The  influence  of  mechanical  congestion  as  a  direct  cause  of  hemorrhage  is  some- 
times very  distinctly  seen  in  the  bodies  of  persons  who  have  been  hanged.  You 
know  that  when  suffocation  has  been  produced  by  suddenly  cutting  off  the  access 
of  air  to  the  lungs,  the  right  side  of  the  heart,  the  great  veins,  and  indeed  the  venous 
system  generally,  become  loaded  and  distended  with  dark  blood.  Dr.  Yelloly  exa- 
mined the  stomachs  of  five  men  who  had  been  executed  by  hanging:  he  found  them 
all  exceedingly  vascular ;  and  in  two  of  the  five  cases,  blood  was  actually  extra va- 
sated,  and  adhering  to  the  surface  of  the  membrane ;  there  had  been,  in  short,  une- 
quivocal hemorrhage. 

There  are  several  things,  worthy  of  notice,  in  respect  to  hemorrhage  by  exhala- 
tion, of  whatever  kind. 

In  the  first  place,  it  occurs  much  more  frequently  and  readily  from  some  tissues 
of  the  body  than  from  others :  and  most  especially  of  all,  from  mucous  surfaces. 
Thus  we  have  hemorrhage  from  the  mucous  membrane  lining  the  nasal  cavities ; 
from  the  pulmonary  mucous  membrane ;  from  the  stomach  and  bowels ;  from  the 
urinary  organs ;  and  from  the  uterus ;  constituting  distinct  forms  of  disease,  which 
we  are,  by  and  by,  to  investigate  more  particularly.  Epistaxis,  hfsmopfysis,  hscma- 
(emcsis,  melxna,  liscmorrhois,  hacviaturia,  mcnorrhagia,  are  names  descriptive  of 
hemorrhage,  as  it  is  apt  to  occur  from  different  parts  of  one  or  other  of  the  three 
tracts  of  mucous  membrane  met  with  in  the  body:  and  3'ou  will  find  that  these 
comprise  very  nearly  all  the  complaints  enumerated  by  nosological  writers  under  the 
head  of  hemorrhage. 

Now  this  is  a  very  remarkable  fact :  and  very  interesting  questions  arise  out  of 
it.  Has  it  any  relation  to  the  manner  in  which  these  membranes,  and  the  tissues 
subjacent  to  them,  are  supplied  with  a  capillar}'  circulation  ?  or  may  the  fact  be 
explained  by  the  laxity  of  their  attachment,  which  facilitates  and  favours  the  accu- 
mulation of  blood  in  the  vessels  of  the  submucous  tissue  ?  Or  has  the  density  or 
consistence  of  their  natural  exhalations  any  thing  to  do  with  this  disposition  to 
hemorrhage  in  the  mucous  membranes  ?  May  we  suppose  that  the  vessels  or  orifices 
appointed  to  exhale  mucus,  afford  a  more  easy  passage  to  the  blood  than  those  which 
give  egress  to  thinner  fluids ;  serum,  for  example,  or  the  cutaneous  perspiration  ? 
Whatever  answers  may  be  given  to  these  questions,  you  will  do  well  to  recollect  the 
fact  which  has  suggested  them. 

Hemorrhages  by  exhalation  are  not,  however,  exclusively  confined  to  mucous  sur 
faces.  They  are  fiable  to  occur,  but  much  more  rarely,  from  serous  membranes.  In 
the  majority  of  cases,  however,  in  which  blood  is  found  effused  into  any  of  the  serous 
sars,  it  has  either  been  an  event  of  inflammation,  or  the  blood  has  been  poured  out 
from  an  accidental  openmg  in  some  considerable  vessel.  Cutaneous  hemorrhage  is 
iLso  \-ery  rare;  probably  because  the  cuticle  opposes  a  barrier  to  the  exit  of  the 


USUAL    SYMPTOMS.  165 

blood :  for  the  little  red  spots  which  characterize  purpura  are  in  fact  hemorrhages, 
although  the  blood  has  not  penetrated  the  epidermis.  There  are  cases,  however,  as 
I  mentioned  before,  in  which  blood  has  transpired,  in  a  sort  of  dew,  from  the  exter 
nal  surface  of  the  body. 

Another  important  general  fact  in  respect  to  hemorrhages  by  exhalation  is,  that 
they  proceed  more  frequently  from  certain  parts  of  the  mucous  membranes  than 
others,  according  to  differences  of  age.  Thus  in  children  they  are  most  common 
from  the  membrane  that  lines  the  nasal  cavities :  in  youth  from  the  mucous  mem- 
brane of  the  lungs  and  bronchi ;  in  the  middle  years  of  hfe,  and  towards  its  decline, 
from  the  rectum,  uterus,  and  urinary  organs.  I  should  add  here,  from  the  blood- 
vessels of  the  brain,  in  old  age ;  except  that  this,  as  I  have  already  intimated,  is  not 
(speaking  generally)  hemorrhage  by  exhalation. 

Of  course  when  I  say  that,  in  the  instances  specified,  the  blood  is  commonly  poured 
out  by  exhalation,  you  will  understand  that  the  hemorrhage  sometimes  occurs  from 
the  laying  open  of  a  single  vessel  of  some  magnitude.  Thus  hemorrhage  from  the 
fauces  may  be  the  result  of  ulceration  there,  which  has  penetrated  the  coats 
of  a  vein  or  artery :  hcemoptysis  is  occasionally  produced  by  the  laceration  of  a 
blood-vessel  during  the  softening  and  expulsion  of  tubercles.  Haematemesis  some- 
times is  the  consequence  of  a  breach  made  in  a  considerable  blood-vessel  during  the 
progress  of  cancer  of  the  stomach,  or  by  the  extension  of  small  corroding  ulcers ; 
hemorrhage  from  the  bowels  is  no  uncommon  effect  of  ulceration,  such  as  happens 
in  fever,  of  the  mucous  follicles  of  the  small  intestine ;  calculous  matter  in  the  Idd- 
neys  will  often  lead  to  the  rupture  of  some  of  the  blood-vessels  there,  and  to  the 
discharge  of  blood  by  the  urethra.  Aneurisms  also  may  burst  into  almost  any  part 
of  the  body.  But  events  of  this  kind  are  unfrequent  when  compared  with  hemor* 
rhage  from  the  same  parts  in  the  way  of  exhalation. 

In  the  head,  however,  the  ratio  is  reversed.  Blood  does,  sometimes,  I  believe, 
exude  from  the  membranes  of  the  brain,  but  much  more  commonly  cerebral  hemor- 
rhage is  caused  by  the  giving  way  of  a  diseased  artery  in  the  brain. 

How,  in  ail  these  cases,  to  distinguish  whether  the  blood  has  oozed  out  by  many 
orifices  from  a  surface,  or  has  escaped  from  a  hole  in  the  sides  of  a  vein  or  artery, 
will  form  matter  for  future  inquiry.  Sometimes  we  can  make  the  distinction,  arid 
sometimes,  it  must  be  confessed,  we  cannot. 

You  will  readily  understand  that  hemorrhage  must  vary  greatly  in  respect  to  its 
importance,  and  to  the  danger  which  it  impUes,  according  to  the  part  from  which  it 
proceeds,  and  the  circumstances  under  which  the  blood  is  poured  out.  It  sometimes 
happens  that  death  ensues  from  the  mere  loss  of  blood  :  either  at  once,  by  one  pro- 
fuse bleeding,  or  more  slowly,  by  repeated  bleedings  which  we  are  unable  to  restrain : 
but  this  is  comparatively  rare,  and  when  it  does  happen,  the  blood  is  generally  found 
to  have  proceeded  from  one  considerable  vessel,  which  has  been  ruptured  or  eroded. 
The  case  approximates  to  traumatic  hemorrhage,  except  that  we  cannot  cut  down 
upon  and  tie  the  injured  vessel.  Much  more  commonly  danger  arises  from  the 
presence  and  pressure  of  the  extravasated  blood  in  and  upon  internal  parts ;  upon 
the  brain,  for  example,  in  cerebral  hemorrhage  ;  in  the  lungs,  in  pulmonary. 

The  symptoms,  also,  are  hable  to  much  variation  in  different  cases.  Even  the 
diagnosis  of  hemorrhage  is  not  always  equally  easy  or  certain.  When  the  part 
into  which  the  blood  is  directly  poured  communicates  with  the  exterior  of  the  body, 
the  expulsion  of  some  of  that  fluid  will,  generally,  sooner  or  later  demonstrate  tht 
case  to  be  one  of  hemorrhage.  I  say,  generally,  because  cases  have  been  known 
to  occur,  in  which  patients,  previously  in  a  state  of  great  weakness,  have  died  out- 
right, by  syncope,  from  the  mere  extravasation  of  the  blood,  and  before  any  of  it 
made  its  way  out  of  the  body.  The  stomach  and  bowels  have  been  found  full  o*" 
blood,  when  none  had  passed  either  by  vomiting  or  by  stool.  And  whun  the  blood 
does  make  its  appearance  outwardly,  it  is  sometimes  not  easy  to  determine  whethei 
it  has  come  from  a  certain  organ,  or  from  the  parts  that  lie  between  the  same  organ 
and  the  natural  outlet  by  which  it  ultimately  escapes.  For  instance,  it  is  sometimes 
a  matter  of  uncertainty  whether  the  blood,  in  hematuria,  proceeds  from  the  kidneys, 
or  the  bladder,  or  the  urethra. 


] G6  HEMORRHAGE. 

The  blood,  itself,  when  it  reaches  the  exterior,  will  generally  be  more  fluid,  and 
brighter,  in  proportion  as  it  is  effused  in  greater  quantity,  and  nearer  the  surface : 
more  in  clots,  and  darker  in  colour,  in  proportion  to  the  length  of  time  that  it  has 
remained  within  the  body  after  its  escape  from  its  proper  vessels ;  and  this  length 
of  time  may  depend  upon  the  smallness  of  the  quantity  of  blood  effused,  and  the 
consequent  tolerance  of  the  organs  through  which  it  may  have  passed ;  or  upon  the 
actual  space  traversed.  Respecting  the  colour,  however,  of  the  effused  blood,  1  shall 
have  some  curious  explanations  to  offer  you  when  I  come  to  speak  of  hematemesis 
as  a  disease.     It  would  be  superfluous  to  enter  upon  them  now. 

If  the  site  of  the  hemorrhage  does  not  communicate  with  the  external  air,  we  are 
without  that  certainty  which  results  from  the  actual  spectacle  of  the  blood.  But 
in  such  cases  we  are  much  assisted  by  local  disturbances  of  function,  springing  from 
the  pressure  upon,  or  the  laceration  or  distension  of,  the  suffering  organ,  or  the  parts 
contiguous  to  it.  And  we  may  derive  good  information  from  observing  the  indirect 
symptoms  which  declare  themselves  through  the  system  at  large ;  many  of  which 
indirect  symptoms  are  the  same  whether  the  blood  reach  the  exterior  or  not.  They 
principally  vary  according  to  the  quantity  of  blood  poured  out,  and  to  the  rapidity 
of  its  effusion  :  and  some  difference  will  occur  according  to  the  age  and  strength  of 
the  patient. 

Some  of  these  indirect  symptoms  have  not  always  been  imputed  to  their  true 
cause.  Paleness  of  the  face,  feebleness  of  the  pulse,  coldness  of  the  extremities,  and 
a  tendency  to  syncope — symptoms  which  are  apt  to  be  connected  with  hemorrhage 
— have  sometimes  been  ascribed  to  the  alarm  and  sense  of  danger  which  the  sight  of 
the  blood  is  calculated  to  produce  in  the  mind  of  the  patient.  This  may,  to  a  certain 
exlent,  be  sometimes  true ;  but  the  explanation  cannot  apply  to  those  cases  in  which 
the  hemorrhage  is  strictly  confined  to  the  interior  of  the  body,  yet  in  which  the 
symptoms  just  alluded  to  are  often  strongly  marked.  They  //len  depend — and 
probably  in  all  cases  they  chifjiy  depend — upon  the  actual  abstraction  of  the  blood 
from  the  circulation. 

The  management  of  individual  cases  of  hemorrhage  must  be  mainly  regulated  b}' 
the  particular  circumstances  under  which  they  occur.  The  few  observations  that  I 
have  at  present  to  make  respecting  their  treatment  cannot  be  otherwise  than  very 
general. 

But  a  preliminary  question,  of  some  importance,  presents  itself.  Is  it  in  all  cases 
of  hemorrhage  proper,  or  safe,  to  attempt  to  stop  the  bleeding  ? 

Without  going  into  detail,  it  may,  I  think,  be  laid  down  as  a  rule,  that  what  1 
have  called  habitual  hemorrhages  ought  not  to  be  interfered  with,  so  long  as  they 
have  no  perceptible  injurious  influence  upon  the  health,  and  so  long  as  they  proceed 
(as  they  mostly  do)  from  parts  of  which  the  structure  is  not  likely  to  be  spoiled,  nor 
the  function  impaired,  by  the  repeated  passages  of  the  blood.  The  most  common 
seat  of  these  habitual  hemorrhages  I  have  stated  to  be  the  rectum ;  to  which  the 
two  conditions  just  mentioned  are,  fortunately,  both  of  them  applicable.  Epista:xis 
supplies  a  less  frequent  example  of  the  same  kind.  When  they  deviate  from  their 
usual  channel,  and  are  transferred  (as  it  were)  to  some  more  important  organ,  it  will 
generally  be  right,  among  other  remedial  measures,  to  endeavour  to  recall  the 
original  hemorrhage.  It  is  very  seldom  that  the  metastasis  takes  place^br  the  better. 
— i.  e,,  from  a  part  where  the  bleeding  is  attended  with  danger,  to  one  where  it  is 
comparatively  harmless. 

However,  when  these  habitual  hemorrhages  happen,  as  they  often  do,  in  plethoric 
persons  ;  and  when  they  are  urged  and  kept  up,  as  they  frequently  are,  by  intem- 
perate and  luxurious  habits ;  we  ought  not  to  content  ourselves  with  merely  looking 
on.  Hemorrhois  often  performs  the  office  of  a  safety-valve  in  such  persons ;  and 
there  are  many  who  have  what  are  called  bleeding  piles,  and  Avho  would  rather 
continue  to  have  them,  than  to  submit  to  any  change  in  their  mode  of  hfe,  or  to  the 
employment  of  other  means  of  evacuation.  Certainly  these  are  cases  in  which 
nothing  should  be  done  to  stop  the  bleeding;  yet  such  patients  ought  to  be  told  that 
the  hemorrhoidal  discharge  is  but  a  precarious,  and  often  an  inadequate  relief  of  the 
plethora :  that  while  the  plethora  is  suffered  .0  exist  there  is  danger  of  a  cessation 


TREATx>IENT.  167 

of  the  piles,  and  of  the  supervention  of  serious  or  fatal  affections  6f  other  parts,  and 
especially  of  the  head.  Apoplexy,  or  cerebral  hemorrhage,  has  frequently  been 
known  to  follow  hard  upon  the  suspension  of  constitutional  hemorrhois.  The 
patient  should  be  admonished  also  that  the  discharge  of  blood  from  the  vessels  of  the 
rectum  may  become  excessive  ;  that  if  it  be  aggravated  by  exercise,  or  in  any  other 
way,  it  may  lead  to  inflammation  about  the  anus,  and  to  great  inconvenience ;  and 
that  there  are  safe  and  tolerably  sure  methods  of  getting  rid  of  the  plethora ;  (which 
IS  what  chiefly  constitutes  the  danger  of  such  cases),  if  they  will  submit  to  the  ob- 
servance of  them.  It  is  in  the  intervals  between  the  hemorrhages  that  the  danger 
of  which  they  are  in  some  sort  the  token,  may  best  be  met. 

Again,  it  will  seldom  be  proper  to  employ  direct  expedients  for  staunching  the 
flow  of  blood,  in  the  small  class  of  active  idiopathic  hemorrhages;  unless  the 
quantity  lost  is  so  great  as  to  endanger  the  safety  of  the  patient.  Such  hemor- 
rhages have  commonly  a  tendency  to  cure  themselves,  by  relieving  the  general 
plethora,  or  the  local  congestion,  on  which  they  depend.  For  these  hemorrhages, 
which  bear  so  strong  an  analogy  to  inflammation,  the  treatment  of  inflammation 
may  often  be  requisite,  as  an  indirect  mode  in  which  their  amount  may  be  mode- 
rated, and  their  recurrence  obviated. 

With  these  exceptions,  both  direct  and  indirect  measures  are  to  be  used,  for 
arresting  the  effusion  of  blood  as  speedily  as  may  be. 

To  this  end  the  patient  is  to  be  surrounded  as  much  as  possible  with  cool  fresh 
air,  and  kept  in  a  state  of  absolute  quiet.  All  motion  of  the  body,  and  emotion  of 
the  mind,  all  kinds  of  stimulating  food  and  drink,  every  thing,  in  short,  which  has 
a  tendency  to  hurry  the  circulation,  should  be  diligently  avoided  ;  and  that  position 
of  the  body  should  be  chosen  which  is  the  least  favourable  to  the  afflux  of  blood 
towards  the  part  affected.  The  horizontal  posture  will  be  proper  in  hemorrhage 
from  the  bowels,  the  uterus,  or  the  urinary  organs.  In  epistaxis,  and  in  cerebral 
hemorrhage,  the  head  should  be  raised. 

In  two  words,  the  antiphlogistic  regimen  should  be  strictly  enjoined  in  all  cases 
of  hemorrhage  sufficiently  severe  to  require  medical  assistance. 

Of  the  actual  remedies  used  for  checking  the  further  escape  of  the  blood,  one  of 
the  most  important  has  already  been  alluded  to — I  mean  venesection.  Herein  we 
are  guilty  of  homoeopathy ;  to  prevent  bleeding,  we  draw  blood.  After  what  was 
stated  respecting  the  use  of  blood-letting  in  inflammation,  I  need  not  dwell  upon  the 
objects  aimed  at  by  this  measure  :  they  are,  briefly,  to  abate  the  vigour  and  force  of 
the  heart's  contraction,  to  lessen  general  plethora  when  it  exists,  to  remove  local 
congestion,  and  to  divert  the  current  of  the  blood  from  the  suffering  organ.  The 
method,  and  the  amount,  and  the  repetition  of  the  blood-letting,  must  of  course  be 
regulated  by  the  circumstances  of  each  particular  case.  And  the  same  objects  may 
sometimes  be  efTected  by  other  modes  of  general  depletion,  especially  by  the  use  of 
purgative  medicines. 

Another  important  remedy  for  inward  bleedings  is  mercury.  Whatever  may  be 
the  modus  operandi  of  that  mineral,  the  fact  is  certain,  that  hemorrhage,  which  had 
resisted  other  modes  of  treatment,  has,  in  very  numerous  instances,  ceased  at  once 
upon  the  occurrence  of  a  moderate  degree  of  salivation. 

Next  to  blood-letting  and  mercury,  astringents  constitute  the  great  resource  against 
actually  existing  hemorrhage :  and  among  these,  cold  is  one  of  the  chief.  It  may  be 
placed  in  direct  contact  with  the  bleeding  surface:  as  when  ice  is  swallowed  to 
restrain  hematemesis ;  or  cold  water  injected  into  the  rectum  in  excessive  and 
exhausting  hemorrhois  ;  or  into  the  vagina,  in  flooding  from  the  uterus.  Or  it  may 
be  applied  to  the  surface  of  the  body,  as  near  as  possible  to  the  seat  of  the  hemor- 
rhage ;  as  to  the  nose  and  forehead  in  epistaxis ;  to  the  chest  in  hemoptysis  ;  to  the 
epigastrium  in  hemorrhage  from  the  stomach ;  to  the  lower  part  of  the  abdomen  or 
to  the  perineum  in  hemorrhage  from  the  intestines,  uterus,  or  urinary  organs.  But 
the  influence  of  coid  in  eonstringing  the  smaller  vessels  is  not  confined  to  the  part 
with  which  it  is  m  contact ;  it  wall  stop  hemorrhage  by  the  sympathetic  shrinking 
which  it  produces  in  distant  parts.  Epistaxis,  for  example,  has  often  been  arresteti 
by  the  sudden  apposition  of  cold  water  to  the  neck,  back,  or  genital  organs.     Tb«' 


168  DROPSV 

nursery  remedy  consists  in  slipping  a  cold  key  down  the  back  between  the  clothes 
and  the  skin. 

Of  the  mischievous  power  even  of  cold  in  this  way  we  have  continual  illustration 
in  the  suppression  of  the  catamenia  by  cold  and  wet  accidentally  apphed  to  the  feet. 

There  is  a  long  catalogue  of  medicinal  substances  which  are  esteemed  to  possess 
more  or  less  of  a  specific  virtue,  when  taken  internally,  in  checking  the  flow  of 
blood.  Most  of  these  are  of  an  astringent  nature,  and  some  of  them  are  eminently 
useful.  The  acetate  of  lead  enjoys,  in  this  country,  a  higher  character,  perhaps, 
than  any  other  of  these  substances. 

Many  vegetable  matters,  and  some  artificial  compounds,  frequently  employed  in 
internal  hemorrhage,  seem  to  owe  their  astringent  and  styptic  properties  to  the  gaUic 
acid  which  enters  into  their  composition.  Such  are  the  rhatany  root,  uva  ursi,  bistort, 
tormentil,  the  pomegranate,  kino,  catechu,  the  several  preparations  of  gall  nuts,  and 
the  nostrum  called  RuspinVs  styptic. 

The  power  of  arresting  internal  hemorrhage  has  also  been  confidently  ascribed, 
by  different  persons,  to  nitre  given  in  large  doses,  to  the  mineral  acids,  to  the  muriated 
tincture  of  iron,  to  alum,  to  the  oil  of  turpentine,  to  the  secale  cornutum  or  spurred 
rye,  and  to  various  other  substances,  a  more  particular  account  of  the  rules  and  indi- 
cations for  administering  which,  I  may  return  to,  when  I  have  to  speak  of  individual 
hemorrhaofes. 


LECTURE  XVI. 

Dropsy :  its  General  Pathology.  Passive  Dropsy  ;  Cardiac  and  Renal.  Active 
Acute,  or  Febrile  Dropsy.  Prognosis ;  and  General  Principles  of  Treattnent 
in  Dropsies. 

There  remains  now  only  one  subject,  of  the  patholog}'  of  which  it  will  be  con- 
venient and,  I  hope,  instructive,  to  take  a  short  general  view,  before  we  enter  upon 
the  consideration  of  special  diseases.  I  proceed  to  speak  of  dropsies :  by  which  I 
mean  collections  of  serous  liquid  in  one  or  more  of  the  shut  cavities  of  the  body,  or 
in  the  areolar  tissue,  or  in  both,  independent  of  inflammation. 

We  have  already  considered  serous  effusion  as  occurring  as  an  effect  or  event  of 
inflammation.  We  are  commonly  able  to  say  of  this,  that  it  has  originated  in  inflam- 
mation ;  either  from  its  being  mixed  with  some  of  the  less  equivocal  products  of  that 
disease,  such  as  coagulable  lymph  ;  or  from  its  having  taken  place  while  symptoms 
of  inflammation  existed.  But  there  are  numerous  examples  of  serous  accumulation, 
which  cannot  wiih  any  show  of  reason  be  regarded  as  events  of  inflammation.  It  is 
to  these  that  I  would  apply  the  simple  term  dropsy. 

It  has  been  said — and  said  with  much  truth — that  dropsy  is  rather  a  symptom  of 
disease,  than  a  disease  in  itself.  And  it  has  been  affirmed  that  it  Avould  be  more 
philosoj)hical  and  scientific  to  treat  of  the  original  malady  upon  which  the  effusion 
or  accumulation  depends ;  to  erase  dropsy  from  the  list  of  substantive  diseases,  and 
to  place  it  in  the  catalogue  of  mere  symptoms. 

But  this,  in  my  mind,  is  a  very  mistaken  view  of  the  matter.  For,  first,  it  is 
oftentimes  uncertain,  while  the  patient  is  yet  alive,  what  or  where  the  primary  dis- 
ease may  be  ;  and  even  after  death  we  sometimes  can  discover  no  organic  change 
that  would  satisfactorily  account  for  the  effusion.  Practically  speaking,  in  such 
cases  the  dropsy  is  the  disease,  and  the  sole  object  of  our  treatment. 

And,  secondly,  dropsy  is,  in  fact,  to  a  medical  eye,  in  all  cases,  something  more 
than  an  effect  or  symptom  of  disease.  The  imprisoned  liquid  is  often  a  cause  of 
various  other  symptoms ;  embarrassing,  by  its  pressure,  important  functions,  and 
even  extinguishing  fife.  The  removal  of  the  dropsy  (although  its  original  cause,  of 
which  it  was  a  symptom,  may  remain  behind,  untouched,  to  be  again  productive  of 
pffusion  under  circumstances  favourable  to  its  operation) — the  removal  of  the  dropsy 


DROPSY.  l()d 

will  often  restore  a  person  to  comparative  comfort ;  or  even  to  what,  so  far  as  his 
sensations,  and  powers,  and  belief  are  concerned,  is,  to  him,  for  the  time,  a  state  of 
health. 

You  see  then,  already,  that  in  a  dropsical  person,  whose  dropsy  depends  upon 
organic  disease,  there  are  two  sets  of  symptoms  to  be  distinguished :  viz.,  those 
which  depend  on  the  primary  disease ;  and  those  which  depend  on  the  collected 
fluid.  The  latter,  often  the  most  grievous,  are  often  to  be  got  rid  of:  the  former, 
frequently  permanent,  are  frequently  also  but  httle  complained  of  or  felt  by  the 
patient,  except  when  effusion  is  the  result. 

Some  persons,  I  fancy,  have  regarded  dropsy  as  a  less  attractive  subject  of  inves- 
tigation than  it  might  be  if  it  were  less  frequently,  in  its  nature,  incurable.  But  as 
far  as  the  dropsy  itself  is  concerned,  the  complaint  often  is  curable  ;  and  there  are 
some  forms  of  dropsy  that  are  curable  in  a  more  absolute  sense ;  that  is,  both  the 
effusion,  and  that  condition  which  was  the  physical  cause  of  the  effusion,  are  some- 
times remediable. 

Besides,  it  is  our  business  to  cure  when  we  can ;  but  whether  we  can  cure  or 
not,  to  relieve  and  palliate  human  suffering ;  and  this,  under  Providence,  we  are  able 
to  do,  in  many  or  most  cases  of  dropsy,  to  a  very  considerable  extent. 

Wherever  there  is  a  shut  sac,  or  wherever  there  is  loose  and  permeable  areolar 
tissue,  there  we  may  have  dropsy. 

Thus  there  may  be  dropsy  of  the  ventricles  of  the  brain,  or  of  the  meshes  of  the 
pia  mater,  leading  to  death  by  coma  ;  of  the  pleurse,  of  the  areolar  texture  of  the 
lungs,  or  of  the  submucous  areolar  tissue  of  the  glottis,  any  of  which  may  cause  death 
by  apnoea;  of  the  pericardium,  producing  death  by  syncope.  I  mention  these 
instances  in  particular,  to  show  that  almost  every  mode  of  dying  may  result  from 
dropsical  effusion ;  and  to  win  your  attention  to  a  disorder  so  full  of  peril. 

When  the  cerebral  ventricles  are  distended  with  water,  we  express  the  diseased 
condition  by  the  term  hydrocephalus.  When  serous  liquid  collects  in  the  pleurae, 
or  in  the  pericardium,  we  say  that  the  patient  has  hydrofhorax,  or  hydropericar- 
dium.  If  the  cavity  of  the  peritoneum  be  the  seat  of  the  effusion,  we  call  the  com- 
plaint ascites.  When  the  areolar  tissue  of  a  part  becomes  infiltered  with  serous 
fluid,  the  part  is  said  to  be  cedematous ;  and  anasarca  is  the  name  given  to  the 
more  or  less  general  accumulation  of  serum  into  the  areolar  tissue  throughout  the 
body,  and  especially  to  visible  subcutaneous  cedema  of  considerable  extent.  Finally, 
the  term  general  dropsy  signifies  the  combination  of  anasarca  with  dropsy  of  one 
or  more  of  the  large  serous  cavities. 

Other  local  dropsies  indeed  there  are,  but,  as  they  belong  entirely  to  surgery,  I 
need  not  emunerate  them. 

Now  what  reasonable  account  can  be  given  of  these  remarkable  conditions  ?  How 
is  it  that  the  hollows  and  interstices  of  the  Hving  body,  or  of  parts  of  the  body, 
become  thus  water-logged  ? 

To  solve  this  question,  we  must  carry  in  our  minds  some  physiological  recol- 
lections. 

The  closed  cavities,  or  the  interstitial  tissues,  within  which  the  fluid  of  dropsy  is 
confined,  are  kept  moist,  during  life  and  health,  by  a  continual  serous  secretion  from 
their  surfaces :  and  they  are  kept  merely  moist,  for  the  fluid  thus  constantly  secreted 
is  as  constantly  reabsorbed  into  the  circulation. 

When  these  tissues  or  cavities,  without  having  undergone  inflammation,  become 
filled  and  distended  with  the  serous  fluid  which  they  habitually  secrete,  one  of  three 
things  must  have  happened.  Either  the  quantity  of  fluid  exhaled  has  been  aug- 
mented, the  absorption  remaining  the  same ;  or  the  absorption  has  been  diminished, 
the  exhalation  continuing  the  same  ;  or  else  the  exhalation  has  been  increased, 
while  at  the  same  time  the  absorption  was  either  lessened  or  not  proportionallv 
increased. 

The  last  is  a  mixed  case  ;  and  we  need  only  consider  the  two  others. 

Now  the  balance  between  exhalation  and  absorption  is  often  deranged,  and  dropsie<s 
do  actually  arise,  in  each  and  all  of  these  ways. 

p 


170  DROPSY. 

It  will  best  suit  my  purpose  to  speak  first  of  those  dropsies  which  are  occasioned 
by  defective  absorption,  and  which  are  usually  called  chronic  or  passive  dropsies. 

The  direct  agency  of  the  blood-vessels  in  the  production,  as  well  as  in  the  removal 
of  dropsy,  although  indicated  by  many  common  and  obvious  facts,  has  not  been 
generally  recognized  till  a  comparatively  recent  period.  Perhaps  I  should  rather 
say  that  more  importance  used  to  be  assigned,  in  these  respects,  to  the  agency  of  the 
.ymphatic  absorbents,  than  they  are  really  entitled  to.  You  will  find  that  patho- 
logists, even  in  modern  times,  speak  of  a  want  of  tone,  of  deficient  energy,  in  the 
absorbents,  as  a  cause  of  dropsical  accumulations ;  the  superfluous  fluid  of  the  part 
is  not  adequately  taken  up  (they  say)  by  the  enfeebled  absorbents,  meaning  the  ab- 
sorbents strictly  and  anatomically  so  called.  And  this  view  of  the  matter,  connecting 
dropsy  always  with  debility  as  its  cause,  has  led  to  a  corresponding  plan  of  treat- 
ment :  the  object  aimed  at  being  the  stimulation  of  the  absorbents  to  more  energetic 
action. 

But  to  the  doctrine  that  dropsy  is  a  consequence  of  the  deficient  action  of  the  ab- 
sorbents, this  obvious  difficulty  presents  itself, — that  absorption  really  goes  on,  and 
goes  on  very  actively,  in  dropsical  patients  :  their  adipose  matter  disappears,  they 
become  wretchedly  thin.  There  is  no  complaint  in  which  wasting  and  emaciation 
go  to  a  greater  extent  than  in  dropsy.  You  will  find  also  that  persons  labouring 
under  anasarca  are  readily  enough  affected  by  mercury ;  which  must  of  course  be 
absorbed  before  it  can  produce  any  of  its  specific  effects. 

It^ust  be  confessed  that  our  knowledge  respecting  the  mechanism  of  absorption 
is  neither  complete  nor  certain ;  but  there  is  good  reason  for  supposing  that  the 
process  is  shared  among  the  lacteals,  the  lymphatics,  and  the  veins  ;  and  it  is  pro- 
bably distributed  between  these  sets  of  vessels  somewhat  in  this  manner; — that  the 
lacteals  absorb  the  chyle  from  the  surface  of  the  alimentary  canal,  and  convey  into 
the  blood  the  materials  of  its  renovation  ;  that  the  office  of  the  lymphatics  is  to  take 
up  and  carry  into  the  blood  those  old  and  effete  portions  of  the  solid  constituents  of 
the  bod}%  which  require  to  be  removed  to  make  way  for  a  fresh  deposit ;  while  the 
veins  imbibe  the  serous  fluid  exhaled  from  the  surfaces  of  serous  membranes,  and 
into  the  meshes  of  the  areolar  tissue,  as  well  as  poisons  and  other  substances  that  are 
soluble  and  dissolved  in  that  fluid. 

If  this  be  so,  the  difficulty  just  now  mentioned  vanishes.  Of  the  two  sets  of  ab- 
sorbing vessels,  the  lymphatics  and  the  veins,  one  set  may  continue  to  perform  its 
functions,  while  the  other  fails  to  do  so.  This  theory  is  quite  consistent  with  the 
actual  phenomena  of  dropsical  disease  ;  and  whether  it  be  altogether  true  or  not,  a 
part  of  it  is  certainly  true  ;  that,  namely,  which  assigns  to  the  veins  a  large  share  in 
the  whole  process  of  absorption.  The  experiments  of  Magendie  and  of  others  are 
quite  conclusive  upon  that  point. 

It  has  also  been  fully  established,  that  fluids  may  and  do  pass  into  or  out  of  the 
veins,  in  the  living  body,  not  by  any  vital  process,  but  by  mere  physical  imbibition 
and  transudation,  through  the  coats  of  those  vessels  ;  that  when  the  veins  are  dis- 
tended to  a  certain  degree  with  watery  fluid,  the  entrance  of  more  of  the  same  fluid 
through  their  sides,  is  impeded  or  prevented  ;  that,  when  the  distension  is  still  greater, 
the  aqueous  part  of  the  blood  may  even  pass  in  the  other  direction  out  of  the  vessel; 
and  that,  on  the  other  hand,  when  the  veins  are  comparatively  empty,  the  surround- 
ing serous  fluid  passes  readily  into  them,  or,  in  common  language,  is  absorbed. 
The  venous  absorption  is  explicable  therefore  upon  the  principles  of  endosmose  and 
exosmose,  as  laid  down  by  Dutrochet ;  or  I  woukl  rather  say,  according  to  the  more 
general  and  more  simple  laws  of  heterogeneous  attraction,  as  explained  by  Professor 
Danicll. 

Imbibition,  being  a  form  of  that  attraction,  belongs  in  various  degrees  to  all  the 
tissues  of  the  body.  Its  rapidity  —  and  even  its  direction  in  respect  to  the  elastic 
coats  of  a  vessel  surrounded  by  fluid,  and  also  carrying  fluid  of  a  certain  consistence 
—  will  vary  with  the  varying  distension  of  the  vessel.  When  the  vessel  is  mode- 
rately full,  the  exterior  fluid  passes  uninterruptedly  inwards,  and  is  conveyed  away 
hy  the  internal  current.  When,  on  the  other  hand,  the  vessel  is  kept  much  dis- 
iended  by  its  contents,  the  contained  fluid,  or  its  thinner  part,  passes  continually  out- 


PASSIVE   DROPSY.  171 

wards  ;  and  there  is  an  intermediate  degree  of  distension,  at  wnich  the  pressure  is 
just  sufficient  to  prevent  the  transit  of  fluid  in  either  direction,  Magendie  found, 
accordingly,  in  a  well-conducted  and  conclusive  series  of  experiments,  that  by  regu- 
lating the  conditions  of  comparative  emptiness  or  fullness  of  the  circulating  system, 
be  could  accelerate,  or  retard,  or  suspend  altogether,  the  operation  of  a  poison  dis- 
solved in  the  humours  of  the  body.  In  other  words,  he  could  thus  accelerate,  retard, 
or  prevent,  the  process  of  absorption  or  imbibition  through  the  blood-vessels. 

Bearing  these  physiological  truths  in  remembrance,  we  shall  have  no  difficulty  in 
showing  that  the  chronic  forms  of  dropsy  are  attributable  partly,  and  chiefly,  and  in 
many  instances  entirely,  to  undue  plenitude  of  the  veins  ;  and  that  this  venous  re- 
pletion is  produced,  almost  always,  by  some  impediment  to  the  free  return  of  the 
blood  towards  the  heart. 

When  the  areolar  tissue  of  a  limited  part  of  the  body  becomes  filled  and  distended 
by  serous  liquid,  we  call  the  swelling  oedema  ;  but  this  is  exactly  the  same,  in  its 
nature,  as  anasarca.  Now  oedema  is  often  the  consequence  of  some  mechanical  ob- 
struction to  the  venous  circulation.  We  can  produce  it  whenever  w^e  will.  Our 
countryman  Dr.  Lower,  170  years  ago,  tied  the  jugular  vein  of  a  hvingdog.  When 
a  [ew  hours  had  elapsed,  he  observed  that  all  the  parts  beyond  the  ligature,  reckoning 
from  the  heart,  were  much  swollen :  and  upon  dissecting  the  animal  after  death  he 
found  that  the  areolar  tissues  of  the  head  and  face  were  filled,  not  with  red  blood,  as 
he  had  expected  it  might  be,  but  with  clear  and  limpid  serum.  On  another  occasion 
he  placed  a  ligature  upon  the  vena  cava,  just  above  the  diaphragm :  death  soon 
ensued,  and  a  large  quantity  of  water  was  discovered  in  the  cavity  of  the  peritoneum, 
"  non  aliter  quam  si  ascite  diu  (canis)  laborasset." 

These  experiments  were  not  instituted  with  any  reference  to  the  pathology  of 
dropsy;  yet  that  Lower  perceived  their  bearing  upon  that  subject  is  plain  from  this 
sentence  :  "  Quantum  hsec  ad  ascitis  et  anasarcfe  causas  investigandas  conducant, 
ahis  judicandum  relinquo."  He  even  explains  the  extravasation  of  the  thinner  or 
serous  part  of  the  blood  as  taking  place  by  infiltration,  "  velt  in  filtro,"  through  the 
pores  of  the  vessels. 

Precisely  similar  phenomena  succeed  the  compression  or  obliteration  of  a  large 
vein  in  various  parts  of  the  body.  In  operating  for  popliteal  aneurism,  Mr.  Travers 
was  obliged  to  tie  the  femoral  vein  ;  the  areolar  tissue  of  the  hmb  was  speedily  infil- 
trated with  serous  fluid.  Long-abiding  oedema  of  one  foot  and  ankle  has  been  cured 
at  once  by  the  reduction  of  a  crural  hernia,  which  had  been  pressing  for  the  same 
length  of  time  upon  the  femoral  vessels.  You  have  heard,  most  probably,  of  the 
disease  called  phlegmasia  dolens ;  a  disease  that  is  very  common  in  women  soou 
after  childbirth,  although  it  is  not  pecuhar  to  them,  nor  to  the  female  sex.  The  foot, 
leg,  and  thigh,  become  enormously  (Edematous.  The  essence  of  this  disorder  is 
inflammation  of  the  femoral  vein  ;  blocking  up  that  vessel  near  the  groin,  and  retard- 
ing or  precluding  the  return  of  the  venous  blood  from  the  limb.  One  arm  often 
swells  in  the  same  way,  and  from  a  similar  cause,  in  women  who  are  afflicted  with 
cancer  of  the  breast.  In  pregnancy,  the  gravid  uterus  sometimes  presses  upon  the 
iliac  veins,  and  obstructs  the  current  of  blood  within  them :  the  consequence  is,  ana- 
sarca of  the  lower  extremities,  which  disappears  as  soon  as  the  pressure  is  removed 
by  the  dehvery  of  the  woman.  The  flow  of  blood  through  the  vena  portoe  is  fre- 
quently hindered,  by  disease  in  the  hver,  or  by  other  causes ;  and  serous  liquid 
accumulates  in  the  peritoneum,  constituting  ascites.  A  French  physician,  M.  Ton- 
nelle,  narrates  several  cases  in  which  serosity  was  found  in  the  cavity  of  the  arach- 
noid, in  conjunction  with  obhteration  of  the  venous  sinuses  of  the  dura  mater.  In 
all  these  instances  we  have  retardation  of  the  venous  current,  undue  plenitude  of  the 
veins,  and  dropsy  of  the  part  from  which  they  proceed.  The  natural  exhalation 
goes  on,  and  the  exhaled  fluid  collects  and  stagnates  because  the  channel  through 
which  it  ought  to  be  drained  away  is  choked  up.  The  larger  the  vein,  and  the 
nearer  we  approach  the  heart,  the  more  extensive  is  the  dropsical  accumulation  :  and 
if  we  could  plant  an  obstacle  at  the  very  termination  of  the  venous  stream,  we  should 
dam  up  the  blood  in  the  whole  system  of  veins,  and  produce  a  general  dropsy 

Such  an  obstacle  is  frequently  placed  there  by  disease.     The  returning  Hood  w 


172  DROPSY. 

checked  at  its  entrance  into  the  heart ;  at  the  confluence  of  all  the  veins  of  the  body, 
where  they  unite  to  empty  themselves  into  the  right  chambers  of  that  organ :  and 
then  anasarca  of  the  universal  areolar  tissue  comes  on,  and  water  collects  in  all  or 
most  of  the  great  serous  cavities. 

It  is  no  part  of  my  present  purpose  to  inquire  how  such  disease  of  the  heart  as  is 
productive  of  dropsy,  arises.  Commonly  we  find  the  right  auricle  and  ventricle 
enlarged  in  capacity,  the  opening  between  them  unnaturally  wide,  and  the  tricuspid 
valve  unequal  to  its  office  of  plosing  that  aperture.  Such  a  morbid  state  of  the  right 
heart  may  be  occasioned  by  any  cause  which  impedes  the  flow  of  blood  out  of  its 
cavities.  The  diseased  condition  of  those  cavities  may  be  primary  ;  but  it  is  oftener, 
perhaps,  consecutive  to  other  disease.  It  may  be  produced  by  disease  of  the  lungs, 
preventing  the  right  ventricle  from  freely  delivering  its  contents  into  the  pulmonary 
blood-vessels.  Or  the  retarding  cause  may  be  still  more  distant,  in  the  left  side  of 
the  heart,  keeping  the  pulmonary  blood-vessels  unduly  full,  and  thereby  hindering 
indirectly  the  escape  of  the  blood  from  the  right  ventricle.  The  dropsy  may  ulti- 
mately depend,  therefore,  upon  some  bar  to  the  circulation,  placed  even  at  the  mouth 
of  the  aorta.  Obstacles  situated  anywhere  in  the  circuit  fonned  by  the  right  heart, 
the  lungs,  and  the  left  heart,  have  the  effect  of  producing  secondary  changes  in  the 
parts  behind  them.  But  disease,  thus  propagated  in  a  direction  retrograde  to  the 
course  of  the  blood,  is  propagated  gradually,  and  sometimes  very  slowly.  These 
are  points  of  much  interest,  which  we  shall  investigate  together  by  and  by.  I  allude 
to  them  now,  that  you  may  not  be  perplexed  by  a  knowledge  of  the  fact,  that  dis- 
eases of  the  heart  often  exist  for  a  long  while  without  inducing  dropsy.  It  is  with 
disease  of  the  right  side  of  the  heart,  whether  primary  or  secondary,  that  passive 
dropsy  is  especially  associated. 

As  if  to  furnish  the  experhnentwn  crucis  in  respect  to  this  doctrine,  disease  does 
sometimes,  with  a  curious  precision,  dam  up  one  only  of  the  two  great  venous  trunks, 
at  the  junction  of  which  the  right  auricle  is  placed:  and  then  the  dropsy  is  as  curi- 
ously limited  to  that  half  of  the  body  in  which  the  tributary  veins  of  the  obstructed 
trunk  originate.  The  first  example  of  this  which  I  ever  saw  was  a  most  remarkable 
one.  The  patient  was  dropsical  in  his  upper  half  only.  His  arms  were  so  hugely 
anasarcous  that  he  could  not  bring  his  elbows  near  his  sides ;  his  neck  and  face 
were  hideously  bloated  and  exaggerated,  and  his  eyes  prominent  and  staring ;  while 
his  lower  limbs  were  of  their  natural  size,  and  appeared  preposterously  small  and 
out  of  proportion.  The  poor  man  looked  as  if  the  upper  part  of  his  body  had  been 
stuffed,  for  acting  some  ridiculous  part  upon  the  stage.  The  cause  of  this  strange 
and  distressful  state  was  found  to  be  the  obliteration  of  the  vena  cava  superior,  close 
to  the  auricle.  Its  sides  had  been  pressed  together  by  a  large  aneurism  of  the  aorta; 
and  a  portion  of  the  vein  was  fairly  sealed  up.    I  have  seen  two  similar  cases  since. 

Objections  have,  however,  been  taken  to  the  accuracy  of  the  conclusions  drawn 
from  such  cases  as  I  have  related ;  and  it  is  fit  that  you  should  be  aware  of  them. 
Thus  it  is  stated  that  veins  have  been  found  obliterated,  and  yet  there  was  no  dropsy. 
Now  to  this  objection  it  may  be  answered,  in  the  first. place,  that  it  is  not  every  vein, 
the  obliteration  of  which  would  cause  manifest  oedema.  It  must  be  the  principal 
venous  trunk  of  the  part  concerned.  When  some  of  the  secondary  and  smaller  veins 
alone  become  impervious,  the  blood  may  reach,  and  return  by,  the  primary  branches, 
with  sufficient  readiness  to  relieve  the  turgid  capillaries,  and  prevent  any  serous 
accumulation. 

But  (it  may  be  said)  the  principal  vein  itself  has  been  found  converted  into  a  solid 
cord,  and  still  there  was  no  dropsy.  Granted:  but  it  does  not  follow  that  there 
never  Iicid  been  dropsy.  You  know  that  when  a  large  artery  is  tied,  the  circulation 
is  carried  on  in  the  corresponding  limb,  by  means  of  collateral  arterial  branches : 
imperfecdy,  indeed,  at  first ;  but,  at  length,  as  the  supplemental  channels  become 
more  numerous  and  free,  the  supply  of  blood  to  the  hmb  is  as  copious  as  ever.  It 
is  precisely  the  same,  mutatis  mutandis,  with  the  veins  ;  only  that  the  anastomosing 
venous  tubes  are  not  (perhaps)  so  readily  developed  as  the  arterial.  Now  I  am  not 
aw^ire  of  any  instance  in  which  it  has  been  shown  that  the  principal  vein  was  oblite- 
rated, and  yet  there  neither  was,  nor  had  been,  any  oedema  of  the  limb.     The 


PASSIVE   DROPSY.  173 

recorded  cases  have  been  met  with  in  dissecting-rooms,  and  the  previous  history  of 
thf  subject  has  been  unknown  or  unregistered,  Mr.  Kiernan  has  told  me  that  he 
once  examined  the  body  of  a  woman  who  had  excited  much  curiosity  among  the 
medical  men  by  whom  she  had  been  seen  during  life,  on  account  of  a  remarkable 
and  enormous  dilatation  of  the  superficial  veins  of  the  abdomen.  She  was  not  drop- 
sical, and  the  cause  of  the  huge  varix  was  sought  for  with  great  interest  after  her 
death.  The  inferior  cava  was  obhterated.  Here  the  compensating  result  was  obvi- 
ous to  the  sight ;  the  new  channels  had  answered  their  purpose,  and  performed  the 
functions  of  the  original  channel.  The  history  of  this  case  was  incomplete :  it  was 
not  ascertained  whether  the  woman  had  always  been  free  from  dropsy. 

I  hold  this  objection  therefore  to  be  invahd,  until  some  authentic  instance  shall  be 
brought  forward  of  the  obliteration  of  a  large  venous  trunk,  without  a  corresponding 
accumulation  of  serous  fluid,  either  at  the  time  when  the  observation  is  made,  or  at 
some  previous  time  in  the  life  of  that  individual.  It  is,  besides,  possible  enough, 
that  the  obstruction  of  a  large  vein  may  be  effected  gradually,  by  the  slow  encroach- 
ment, for  instance,  of  a  growing  tumour ;  and  the  collateral  circulation  may  begin 
to  be  enlarged  with  the  first  impediment  in  the  vein,  and  may  keep  pace  with  and 
counterbalance  that  increasing  impediment,  till  the  closure  of  the  vessel  is  complete ; 
so  that,  from  first  to  last,  there  may  be  no  noticeable  dropsy. 

Again,  it  is  affirmed,  and  truly  affirmed,  that  anasarca  often  occurs,  without  any 
obhteration  of  veins,  and  independent  of  any  discoverable  organic  disease  in  the 
heart  or  anywhere  else.  We  see  this  every  day,  in  weak  chlorotic  girls,  with  blood- 
less cheeks,  and  pale  hps.  Some  of  you  saw  a  case  of  this  kind  which  was  lately 
under  my  care  in  the  hospital ;  besides  the  anasarca,  the  systolic  sound  of  the  heart 
was  accompanied  by  a  loud,  unmistakeable  bellows  sound.  This  girl  got  quite  well, 
and  left  the  hospital  without  bellows  sound,  or  any  other  trace  of  disease.  There 
could  not  then  hav  V?en  an  organic  change  :  in  fact  there  was  not.  Yet  was  there, 
virtually,  a  retardation  of  the  venous  circulation ;  not  by  any  mechanical  obstacle 
opposed  to  its  course,  but  in  consequence  of  the  debility  of  that  hollow  muscle,  the 
office  of  which  is  to  propel  onwards,  with  a  certain  degree  of  force,  the  blood  that 
reaches  it.  Girls  of  this  description  have  weak  and  flabby  voluntary  muscles ;  and 
it  is  reasonable  to  presume  that  the  involuntary  muscle,  the  heart,  partakes  of  the 
general  debility  of  the  muscular  system,  and  becomes  incapable  of  sending  the  blood 
forwards  with  the  requisite  energy.  Nay,  I  believe  that  a  heart  thus  feeble  may 
yield  a  little  and  dilate  under  the  resisting  pressure  of  the  blood  that  enters  its  cham- 
bers ;  and  that  so  an  occasional  but  temporary  bellows  sound  may  arise,  from  the 
altered  relation  between  the  cavities  of  the  heart  and  their  outlets.  Certainly  this 
view  of  the  matter  is  strengthened  by  the  juvantia  and  Icedentia.  If  you  are  tempted, 
by  the  pain  complained  of  by  your  patient,  or  by  the  violence  with  which  her  heart 
is  throbbing,  to  take  away  blood,  you  find  that  she  is  ultimately  made  worse  by  the 
depletion  ;  on  the  other  hand,  if  you  give  her  steel,  feed  her  well,  keep  her  bowels 
free,  and  place  her  every  morning  under  a  cold  shower-bath,  you  find  that  she  reco- 
vers her  lost  strength,  that  colour  returns  to  her  lips  and  cheeks,  that  her  palpitations 
cease,  and  her  dropsy  vanishes.  In  proportion  as  the  muscular  system  in  general 
receives  fresh  tone  and  vigour,  does  that  particular  muscle,  the  heart,  also  regain  the 
degree  of  power  necessary  for  the  effectual  discharge  of  its  proper  function,  which  is 
very  much  that  of  a  forcing-pump.  Such  is  the  way  in  which  I  should  explain  both 
the  cause  of  the  dropsy,  and  the  cause  of  its  cessation.  In  such  cases  our  patients 
do  not  simply  recoz)er ;  they  are  cured.  I  should  apply  a  similar  explanation  to 
some  other  forms  of  dropsy.  Andral  describes  a  certain  cachectic  disposition  of  the 
body  as  being  a  cause  of  dropsy ;  persons  may  be  bled  into  a  dropsy,  or  starved  or 
weakeried  into  a  dropsy.  These  are  genuine  instances  of  dropsy  from  debility, 
which  is  what  the  ancients  conceived  all  dropsies  to  proceed  from.  It  may  be  that 
the  thin  and  watery  quality  of  the  blood  induced  by  frequent  bleedings,  by  insufR 
cient  nourishment,  by  certain  poisons,  or  by  other  causes,  may  facilitate  its  passage 
through  the  coats  of  the  veins.  But  admitting  this  as  a  concurrent  cause,  I  am  dis- 
posed to  the  belief  that  all  passive  dropsies  occurring  under  the  circumstances  just 
auverttid  to,  and  without  any  apparent  organic  disease  or  change,  are  mamly  to  b«« 

p2 


174  DROPSY. 

ascribed  to  debility  of  the  heart :  and  viewed  in  this  way,  they  are  all  brought  under 
the  same  general  principle  ;  viz.,  the  retardation  of  the  blood  in  the  veins. 

A  large  class  then,  of  passive  dropsies,  depending  upon  mechanical  congestion, 
and  defective  absorption  by  the  veins,  are  traceable,  in  their  origin,  to  the  heart ;  ana 
we  call  them,  accordingly,  cardiac  dropsies.  But  another  class,  perhaps  numerous, 
are  connected  in  a  remarkable  manner  with  certain  diseased  conditions  of  the  kid- 
ne}'s ;  and  these,  for  the  sake  of  distinction,  we  style  renal  dropsies.  I  shall  say  a 
few  words  respecting  them,  after  I  have  briefly  considered  the  other  source  of  drop- 
sical swellings,  adverted  to  in  the  commencement  of  this  lecture  :  namely,  excessive 
exhalation  of  serous  liquid.  Dropsy  60  caused  comes  on  suddenly  and  tumultuously, 
and  is  spoken  of  as  being  acute  or  active.  It  borders  closely  upon  inflammation, 
and  sometimes  can  scarcely  be  discriminated  from  inflammation  with  serous  effusion. 
The  condition  of  the  capillary  circulation  is  supposed  to  be  intermediate  between 
that  in  which  the  ordinary  amount  of  secretion  is  maintained,  and  that  in  which 
inflammatory  efflision  takes  place.  The  excessive  increase  of  secretion  is  analogous 
to  what  we  observe  in  other  parts  and  predicaments  of  the  body ;  to  the  abundant 
perspirations,  for  example,  that  are  occasioned  by  violent  exercise ;  to  tlie  plentiful 
flow  of  tears  caused  by  any  irritation  of  the  eye,  or  by  the  passion  of  grief;  to  the 
augmented  watery  discharges  from  the  mucous  membrane  of  the  bowels  produced 
by  purgative  medicines ;  all  of  which  may  be  independent  of  inflammation,  but  all 
of  which  are  attended  with  congestion  that  might  readily  be  pushed  into  inflamma- 
tion. In  point  of  fact,  if  the  secretions  to  which  I  have  now  referred  were  poured 
into  close  cavities,  instead  of  proceeding  from  the  surfaces  that  are  situated  on  the 
exterior  of  the  body,  or  that  communicate  readily  with  the  exterior,  they  would  con- 
stitute dropsies. 

The  phenomena  of  active  dropsy  are  of  this  kind  :  a  labourer  is  engaged  in  some 
employment,  which,  while  it  requires  considerable  bodily  exertion,  and  causes  copious 
perspiration,  necessarily  exposes  him  also  to  the  influence  of  external  cold  and  mois- 
ture :  he  has  been  digging  (perhaps)  in  a  wet  ditch,  in  winter  time,  and  he  pauses 
to  take  his  meal ;  or  he  has  been  unloading  a  waggon,  and  rides  home,  some  miles 
in  a  heavy  rain  that  wets  him  to  the  skin ;  or  he  has  been  mowing,  in  the  heat  of 
summer,  and  lies  down  to  sleep  upon  the  damp  grass.  All  these  suppositions  are 
derived  from  actual  occurrences.  The  perspiration  is  suddenly  checked  ;  and  in  the 
course  of  a  few  hours  he  becomes  universally  anasarcous.  Again,  a  patient  recover- 
ing from  scarlet  fever  ventures  out  into  a  cold  atmosphere,  while  the  process  of  des- 
quamation is  yet  going  on ;  and  he  is  attacked  with  dropsy  of  the  areolar  tissue ; 
and,  it  may  be,  of  some  of  the  larger  cavities  also.  The  urine  at  the  same  time  is 
observed  to  be  scanty,  troubled,  mixed  with  blood. 

To  comprehend  this  rapid  change  from  a  state  of  health  to  a  state  of  dangerous 
disease,  we  must  again  have  recourse  to  the  findings  of  physiology. 

Besides  the  constant  exhalation  that  takes  place  from  the  inner  faces  of  the  shut 
serous  cavities,  a  large  amount  of  watery  fluid  is  continually  thrown  out  of  the  system, 
by  all  those  surfaces  that  communicate  with  the  air — by  the  skin,  the  lungs,  the 
bowels,  the  kidneys.  Now  it  is  well  ascertained  that  when  the  excretion  of  aqueous 
fluid  from  one  such  surface  is  checked,  the  exhalation  from  some  other  surface  becomes 
more  copious.  It  is  probable  that  the  aggregate  quantity  of  water  thus  expelled 
from  the  system  in  a  given  time,  cannot  vary  much,  in  either  direction,  without  de- 
ranging the  whole  economy.  But  we  are  sure  that  the  amount  furnished  by  any 
excreting  surface  may  vary  and  oscillate  within  certain  limits  consistent  with  health, 
provided  that  the  defect  or  excess  be  compensated  by  an  increase  or  diminution  of 
the  ordinary  expenditure  of  watery  liquid  through  some  other  channel.  Sound 
health  admits  and  requires  this  shifting  and  counterpoise  of  work  between  the  organs 
destined  to  remove  aqueous  fluid  from  the  body.  This  supplemental  or  compensating 
relation  is  more  conspicuous  in  regard  to  some  parts  than  to  others.  The  reciprocal 
but  inverse  accommodation  of  function  that  subsists  between  the  skin  and  the  kid- 
neys aflbrds  the  strongest  and  the  most  familiar  example.  In  the  warm  weather  of 
summer,  when  the  perspiration  is  abundant,  the  urine  is  proportionally  concentrated 
and  .scanty.     On  the  other  hand,  during  winter,  when  the  cutaneous  transpiration  is 


ACTIVE    DROPSY.  175 

thecked  by  the  agency  of  external  cold,  the  flow  of  dilute  water  from  the  kidneys  is 
strikingly  augmented.  All  this  is  well  known  to  be  compatible  with  the  maintenance 
of  the  most  perfect  health.  But  supposing  the  exhalation  from  one  of  these  surfaces 
to  be  much  diminished,  or  to  cease,  without  a  corresponding  increase  of  function  in 
the  related  organ,  or  in  any  excreting  organ  communicating  with  the  exterior,  then 
dropsy,  in  some  form  or  degree,  is  very  apt  to  arise.  The  aqueous  liquid  thus  de- 
tained in  the  blood-vessels,  seeks,  and  at  length  finds  some  unnatural  and  inward 
vent,  and  is  poured  forth  into  the  areolar  tissue,  or  into  the  cavities  bounded  by  the 
serous  membranes. 

Dropsy  of  one  part  sometimes  supervenes  suddenly  upon  the  rapid  disappearance 
of  a  watery  collection  from  another  part.  It  is  no  uncommon  thing  to  see  the  swollen 
unwieldy  legs  and  thighs  of  an  anasarcous  patient  qb>>kly  unload  themselves,  and 
resume  their  natural  bulk  and  symmetry.  His  friends  congratulate  him,  and  each 
other,  that  his  disease  is  leaving  him ;  but  as  his  legs  are  emptying,  he  becomes 
drowsy,  forgetful,  comatose,  apoplectic ;  and  after  his  death  we  find  the  ventricles  of 
the  brain  distended  with  serous  fluid. 

Or  the  dropsical  accumulation  may  be  transferred  from  its  place  through  a  safer 
channel.  The  best  instance  of  this  that  occurs  to  my  recollection  I  heard  related  by 
Dr.  Farre.  A  gouty  individual  had  hydrocele  ;  dropsy  of  the  tunica  vaginalis.  After 
the  disease  had  lasted  for  some  time  he  got  very  drunk  one  evening,  with  rack  punch, 
which  greatly  disordered  his  alimentary  canal,  and  brought  on  a  kind  of  cholera. 
He  had  profuse  vomiting  and  purging,  which  quite  exhausted  him :  and  at  length  he 
fell  asleep.  When  he  awoke  in  the  morning  he  found  that  his  hydrocele,  which 
had  been  a  large  one,  was  gone  :  and  it  never  returned.  Such  an  accidental  cure  is 
most  instructive. 

If  Avater  be  injected,  in  some  quantity,  into  the  blood-vessels  of  a  living  animal, 
the  animal  soon  perishes;  dying  generally  by  coma,  or  by  suffocation  :  and  when 
the  carcass  is  examined,  the  lungs  are  found  to  be  charged  with  serous  Hquid,  or 
water  is  discovered  in  the  areolar  tissue  of  some  other  part,  or  in  the  shut  serous 
membranes.  If,  however,  the  animal  be  first  bled,  and  then  a  quantity  of  water  be 
injected  equal  to  the  quantity  of  blood  abstracted,  the  injection  is  followed  by  no  seri- 
ous consequences. 

Facts  like  these  throw,  as  it  seems  to  me,  a  strong  light  upon  a  confessedly  obscure 
part  of  pathology.  It  appears  that  under  various  circumstances  the  blood-vessels 
may  receive  a  considerable  and  unwonted  accession  of  watery  fluid ;  and  that  they 
are  very  prone  to  get  rid  of  the  redundance.  When  they  empty  themselves  through 
some  free  surface,  their  preternatural  distension  is  relieved  by  a  flux.  If,  on  the 
other  hand,  the  surface  be  that  of  a  shut  sac,  in  discharging  their  superfluity  they 
cause  a  dropsy.  Why  sometimes  this  organ,  and  sometimes  that,  is  selected  as  the 
channel  by  which  the  superabundant  water  shall  be  thrown  out  of  the  vessels,  vve 
can  seldom  tell.  We  often  find  it  difficuk  to  determine  which  of  the  two  facts  in 
question  is  to  be  considered  the  antecedent,  and  which  the  consequent.  For  not  only 
is  it  true  that  when  the  blood-vessels  become  overloaded  with  serous  fluid,  they  rea- 
dily deposit  a  part  of  it :  but  also  that  M^hen  they  are  in  the  opposite  condition  of 
comparative  emptiness,  when  the}'^  contain  less  blood  than  is  natural,  they  are  equally 
ready  to  replenish  themselves  by  absorbing  fluids  from  any  source  to  which  they  car 
find  access.  In  the  case  of  the  man  who  was  cured  of  his  hydrocele  upon  the  oc 
currence  of  profuse  watery  discharges  from  the  stomach  and  bowels,  it  seems  cleai 
that  the  expenditure  of  serous  liquid  from  one  part  led  to  its  absorption  into  the  blood 
from  another.  When  anasarca  suddenly  leaves  the  extremities,  and  fatal  coma  fol- 
lows, it  appears  probable  that  the  absorption  is  the  first  of  the  changes,  and  the 
efliision  the  second  :  and  had  this  eflrision  been  determined  to  the  mucous  membrane 
of  the  intestines,  to  the  skin,  or  to  the  kidneys,  it  would  have  brought  relief  and 
safety  to  the  patient,  instead  of  causing  his  death. 

We  have  obtained,  then,  a  glimpse  of  one  or  two  most  important  principles  in 
respect  to  the  pathology  of  dropsy.  The  blood-vessels,  when  preternaturally  full  of 
aqueous  fluid,  have  a  strong  tendency  to  empty  themselves :  when  preternaturally 
prapty,  they  readily  drink  up  watery  fluid  wherever  they  come  in  contact  with  't 


176  DROPSY. 

From  the  discharge  of  their  superfluity  of  water  arises  a  dropsy  or  a  flux.  The 
cause  and  the  cure  of  many  dropsies  lie  in  these  propositions. 

The  apphcation  of  these  principles  to  the  supposed  case  of  active  dropsy  must  be 
obvious.  No  doubt,  in  some  such  cases,  actual  inflammation  takes  place ;  but  in 
many  of  them  there  is  merely  the  dropsical  effusion,  without  any  other  trace  or  evi- 
dence of  inflammatory  action.  The  two  facts  which  it  chiefly  concerns  us  to  remark 
fire  these — first,  that  the  aqueous  portion  of  the  blood  which  in  health  is  habitually 
carried  off  to  a  very  considerable  amount  by  the  skin,  is  suddenly  diverted  from  that 
tissue  ;  the  perspiration,  sensible  and  insensible,  is  suppressed :  and  secondly,  that 
the  areolar  tissue,  or  the  large  serous  bags,  or  both,  become  filled  with  serosity. 

It  is  not  by  any  necessity,  however,  that  the  vicarious  excretion  is  turned  upon  these 
serous  surfaces.  In  truth,  the  intercepted  perspiration  more  often  escapes,  or  labours 
to  escape,  from  some  free  surface ;  and  then  we  have,  not  a  dropsy,  but  a  flux. 
Diarrhoea,  for  example,  is  more  common,  under  the  supposed  circumstances,  than 
anasarca  or  ascites :  apparently  because  there  is  a  closer  analogy  of  structure,  and  a 
more  direct  consent  or  agreement  in  function,  and  a  stronger  reciprocal  influence,  be- 
tween the  skin  and  the  mucous  membrane  of  the  alimentary  canal,  than  between 
the  skin  and  the  serous  tissues. 

Brief  allusion  has  been  made  to  a  large  class  of  chronic  dropsies,  connected  with 
and  dependent  upon  a  peculiar  renal  disease.  This  important  species  of  dropsy  will 
require  a  detailed  examination  hereafter.  It  is  more  complex,  and  of  more  obscure 
pathology,  perhaps,  than  cardiac  dropsy.  It  certainly  has  a  more  direct  relation  also 
to  what  I  have  just  been  describing  as  active  dropsy :  of  which  it  may  almost  be 
regarded  as  the  chronic  form.  Sometimes  the  kidney  disease,  of  which  the  dropsy 
is  an  incidental  and  not  an  essential  symptom,  springs  up  silently  and  without  obvi- 
ous cause.  Sometimes  it  may  distinctly  be  traced  back  to  its  origin  in  an  attack  of 
acute  dropsy :  in  which  complaint  the  kidney  always  and  manifestly  labours,  its 
functions  being  violently  deranged,  and  the  urine  being  smaU  in  quantity,  and  mixed 
with  blood. 

In  this  chronic  and  renal  dropsy,  the  watery  accumulation  is  accounted  for  by  the 
deficient  excretion  through  the  customary  channels.  The  blood-vessels  deposit  that 
excretion  in  a  wrong  place.  The  urine,  in  the  outset  of  the  dropsy  at  least,  is 
scanty.  The  skin  is  almost  always  dry,  harsh,  and  unperspiring.  The  anasarca 
usually  increases  or  decreases,  as  the  quantity  of  urine  diminishes  or  augments 
Remarkable  alterations  take  place  also  in  the  qualities  and  composition  of  the  urine 
itself:  it  has  a  very  low  specific  gravity,  contains  albumen,  and  is  deficient  in  urea. 
The  blood  degenerates  too ;  and  other  organs  of  the  body,  and  especially  the  heart, 
are  apt  to  fall  into  disease.  The  suppression  of  perspiration,  and  the  appearance 
in  the  urine  of  blood  or  serum,  unchanged  by  the  secerning  power  of  the  kidney, 
form  striking  links  of  connection  between  acute  and  renal  dropsy. 

In  the  sketch  that  I  have  been  endeavouring  to  give  you  of  the  pathology  of 
dropsy,  I  have  taken  extreme  cases  to  elucidate  the  two  varieties  of  that  disease 
which  have  been  respectively  denominated  active  and  passive.  Let  me  once  more 
present  to  you,  in  a  summary  view,  the  points  of  resemblance,  and  the  points  of 
distinction  between  them. 

They  resemble  each  other  in  the  result ;  namely,  in  the  collection  of  serous  liquid 
m  the  circumscribed  cavities  and  vacuities  of  the  body.  They  differ  in  the  rate  at 
which  the  collection  augments. 

In  the  well-marked  acute  dropsies  the  liquid  is  rapidly  effused,  in  quantity  much 
beyond  the  natural  amou-nt  of  exhalation.  In  the  well-marked  passive  dropsies  the 
exhalation  goes  on  as  usual,  but  the  fluid  exhaled  is  not  taken  back  again  into  the 
circulating  vessels  with  sufficient  facility.  In  the  one  case  the  circulation  is  dis- 
•.urbed  and  tumukuous  ;  in  the  other,  it  remains  truhquil.  It  is  probable  that  in  tht 
more  acute  forms,  the  serum  transudes  through  the  coats  of  the  arteries,  or  of  the 
capillary  vessels  next  adjacent  to  the  arteries.  In  the  completely  chronic  and  cai- 
diac  forms,  there  is  a  defect  of  absorption  by  the  veins.      Active  dropsies  arc 


DROPSY.  177 

sometimes  spoken  of  as  belonging  to  the  left  side  of  the  heart ;  passive  dropsies  lo 
the  right. 

But  there  are  intermediate  degrees,  in  which  the  full  veins  are  not  only  unable  to 
admit  anj?-  addition  of  aqueous  Kquid,  but  also  to  retain  that  which  they  already  hold  ; 
and  serosity  gradually  exudes  through  their  parietes. 

What  connects  all  these  forms  of  dropsy  is  a  preternatural  fullness  in  some  part, 
or  the  whole  of  the  hydraulic  machine.  And  this  seems  to  be  the  grand  key  to  the 
entire  pathology,  as  well  as  to  the  remedial  management  of  the  disease. 

I  scarcely  need  point  out  to  you  the  fact,  that  the  water  of  dropsy  is  liable  to 
change  its  place,  in  obedience  to  the  force  of  gravity.  In  general  ansarca,  when 
the  serous  accumulation  slowly  augments,  it  first  becomes  visible  about  the  feet  and 
ankles.  There  are  two  causes  for  this :  the  one  occasional  in  its  operation,  the  other 
general.  The  veins  of  the  lower  extremities  are  apt,  when  the  patient  is  erect,  to 
be  more  turgid  than  other  veins ;  for  unless  the  action  of  their  valves  be  quite  per- 
fect, those  vessels  sustain  the  weight  of  a  large  superincumbent  column  of  blood, 
which  concurs  with  other  causes  to  retard  the  upward  current,  and  to  keep  the 
depending  capillaries  unduly  full.  Under  such  circumstances  the  effusion,  or  the 
arrest  of  absorption,  may  take  place  around  the  insteps  earlier  than  in  any  other  part. 
But  in  general  it  is  not  so.  In  most  cases,  the  truer  and  simpler  reason  of  the  ear- 
lier manifestation  of  dropsical  swelling  about  the  ankles,  is  merely  that  the  serous 
liquid  which  fails  to  be  removed  from  the  areolar  tissue  in  all  parts  of  the  body, 
gravitates  towards  the  lowest  part ;  and  being  thus  collected  into  a  comparatively 
small  space,  is  rendered  more  perceptible.  During  the  night,  when  the  horizontal 
posture  is  maintained  for  several  hours,  the  fcdema  of  the  ankles  disappears,  but  the 
neck  and  face,  perhaps,  become  bloated  and  puffy.  And  it  is  obvious  why,  in  these 
cases,  the  feet,  towards  evening,  swell  more  than  the  hands.  The  hands  receive  the 
serous  fluid  from  the  areolar  tissue  of  the  arms  alone ;  the  feet,  that  which  sinks 
down,  not  only  from  the  legs  and  thighs,  but  from  the  head  and  trunk  also.  The 
limbs  may  be  looked  upon  as  bags,  which  fill  up  in  proportion  to  the  quantity  of 
liquid  detained.  And  the  lungs  are  similarly  bags :  and  in  these  cases  we  com- 
monly may  hear  the  crepitation  of  pulmonary  cedema  in  their  lowermost  portions. 

I  mentioned  an  instance  in  which  one-half  only  of  the  body  was  anasarcous,  and 
that  the  upper  half.  The  descent  of  the  dropsical  fluid  was  prevented  by  the  dress 
of  the  patient ;  the  waistband  of  his  trowsers  having  compressed  the  areolar  tissue 
through  which  alone  the  gravitating  hquid  could  seek  a  passage.  So  sometimes,  it 
is  stopped  at  a  lower  point  of  its  descent  by  tight  garters,  and  the  thighs  swell  ear- 
lier than  the  insteps.  It  is  not  at  all  uncommon  to  see  persons  who,  in  the  daytimef 
at  least,  and  in  the  erect  posture,  are  anasarcous  in  the  lower  half  only  of  the  body. 
We  do  not  so  often  meet  with  anasarca  of  one  moiety  of  the  body,  the  division  being 
made  by  an  imaginary  plane  drawn  through  its  axis.  Yet  this  does  occasionally 
happen.  This  curious  phenomenon  is  usually  the  result  of  a  mere  accident,  the 
anasarcous  patient  being  unable  to  leave  his  bed,  or  to  lie  at  all,  except  on  one  side ; 
and  then  the  accumulating  liquid  gravitates  to  that  side.  I  have,  however,  seen  one 
case  to  which  this  explanation  would  not  apply.  I  believe  that  some  local  obstruc- 
tion to  a  large  vein  in  the  neighbourhood  of  the  shoulder  caused  oedema  there,  and 
(he  fluid  sank  down  and  filled  the  areolar  tissue  of  that  side  alone.  As  the  man 
recovered,  I  had  no  means  of  verifying  the  truth  of  this  conjecture. 

Cfeferis  paribus  those  parts  of  the  body  become  the  most  loaded  with  serous  fluid 
and  show  the  anasarca  the  plainest,  of  which  the  areolar  tissue  is  plentiful  and  loose  ; 
as  the  eyelids,  and  the  scrotum.  But  in  extreme  cases  the  liquid  pervades  the  same 
tissue,  where  it  is  much  more  dense  and  compact :  as  where,  for  example,  it  is  sub- 
jacent to  mucous  membranes.  In  the  examination  of  a  dropsical  corpse,  the  mucous 
coat  of  the  intestines  may  sometimes  be  seen  to  be  elevated  by  the  water  co-Uected 
beneath  it.  It  then  looks  hke  jelly,  and  the  valvulas  conniventes,  which  are  flat  and 
thin  in  their  ordinary  state,  become  round  and  convex.  Dropsy  of  the  submucou.s 
'issue  of  the  air-passages  is  frequently  a  cause  of  death. 

Many  persons  seem  disposed  to  ascribe   these  anasarcous  swellings,  espenallv 
12 


178  DROPSY. 

when  they  make  their  appearance  suddenly,  to  inflammation ;  and  much  is  said 
about  the  frequency  of  injjammalory  dropsy.  But  the  facts  we  have  just  been 
cjusidfring  sufficiently  refute  this  theory.  If  the  serous  liquid  be  the  product  of 
mflammation,  what  is  the  part  inflamed  ?  It  cannot  be,  as  some  appear  to  think,  the 
distended  areolar  tissue  itself;  for  if  so,  the  inflammation  must  shift  its  quarters  under 
the  influence  of  gravity.  The  term  inflammatory  dropsy  may  not,  perhaps,  be  inde- 
fensible when  applied  to  that  class  of  dropsical  affections  that  have  been  spoken  of 
under  the  head  of  active  dropsy.  I  am  far  from  denying-  the  frequent  agency  of 
inflammation  in  producing  changes  which,  in  their  turn,  lead  to  dropsy,  but  we  shall 
do  well  not  to  confound  those  collections  of  serum  mixed  with  blood  or  with  coagu- 
lable  lymph,  w'hich  are  distinctly  events  or  products  of  inflammation,  with  other 
collections  of  serum  which  resemble  the  former  in  that  respect  only,  but  differ 
entirely  from  them  in  everj^  other  particular.  To  the  class  denominated  active, 
which  occur  suddenly,  from  defect  of  some  one  or  more  of  the  usual  channels  of 
aqueous  excretion,  and  which  are  usually  attended  with  much  disturbance  of  the 
whole  system,  the  epithetyi'^nVe  Avould  not  be  inappropriate.  There  may  be  some 
few  cases  in  which  it  is  impossible  to  determine  whether  the  effusion  be  inflammatory 
in  its  origin  or  not.  If  the  serum  be  turbid,  if  we  can  discover  in  it  the  smallest  ad- 
mixture of  pus,  or  of  flakes  of  lymph,  or  if  the  disease  has  been  marked  by  the  ordi- 
nary signs  of  internal  inflammation,  we  need  not  hesitate  in  our  opinion.  One  of  the 
latest  systematic  writers  on  dropsy  in  this  country  holds  that  all  dropsies  are  more 
or  less  inflammatory.  We  can  see  one  reason  for  this  mistake  (for  a  mistake  it 
surely  is)  in  the  relief  and  amendment  which  often  ensue  upon  the  employment  of 
blood-letting  in  dropsy. 

The  oenexaX prognosis  in  this  disease  may  be  readily  gathered  from  what  I  have 
said  of  its  causes  and  conditions.  The  anasarca  which  occurs  in  chlorotic  young 
women  is  the  least  perilous,  and  the  most  curable.  Of  the  rest,  febrile  dropsies  are 
more  obedient  to  treatment,  and  oftcner  admit  of  complete  recovery,  than  the  passive 
or  chronic.  Local  dropsies  are  to  be  regarded  w^ith  hope,  in  proportion  as  the 
obstruction  on  which  they  depend  is  capable  of  being  removed,  or  compensated  by 
the  development  of  fresh  channels  for  the  delayed  blood.  As  far  as  the  mere  water 
is  concerned  in  the  chronic  forms  of  the  disease,  cardiac  dropsies  are  more  readily 
dispersed  for  a  time,  but  more  likely  also  to  return,  than  dropsies  which  are  compli- 
cated with  renal  disease.  It  is  obvious  also  that  the  immediate  danger  of  dropsical 
accumulations  will  depend  much  upon  the  place  the  liquid  may  occupy.  The  dif- 
ference in  this  respect  is  immense  between  the  tunica  vaginalis,  and  the  peiicar- 
dium;  between  the  areolar  tissue  of  a  limb,  and  that  which  lies  beneath  the  mucous 
membrane  of  the  glottis. 

It  remains  that  I  should  ofl^er  a  very  few  final  remarks  concerning  the  principles 
upon  which  dropsies  are  to  be  treated. 

The  first  object  is  to  get  rid  of  the  preternatural  accumulation  of  watery  fluid : 
the  second  is  to  prevent  its  collecting  again  ;  in  other  words,  to  remedy  the  diseased 
conditions  which  gave  rise  to  the  dropsy.  Indeed,  if  we  can  accomplish  this  second 
object  without  delay,  the  dropsy  will  generally  disappear  of  its  own  accord.  Now 
venesection  will  often  sensibly  reduce  the  dropsical  swelling.  In  what  has  been 
called  active  or  febrile  anasarca,  general  blood-letting  is  advantageous  in  several 
ways.  It  helps  to  relieve  the  congestion,  akin  to  inflammation,  upon  w'hich  the 
effusion  depends  :  it  tends  to  abate  the  undue  action  of  the  heart :  and  by  emptying 
the  blood-vessels,  it  facilitates  the  re-absorption  of  the  effused  liquid,  and  its  ultimate 
ejection  from  the  system. 

But  although  blood-letting  is  the  most  direct  and  certain  way  of  unburdening  the 
loaded  veins,  and  therefore,  in  many  instances,  the  most  efl^ectual  remedy  for  the 
dropsy,  it  is  by  no  means  adapted  to  all,  nor  even  to  many,  forms  of  the  malady.  It 
will  always,  indeed,  remove  a  portion  of  the  aqueous  ingredient  of  the  blood,  but  it 
expends  at  the  same  time  its  fibrin  and  its  red  particles.  It  impoverishes  the  circu- 
lating fluid,  and  thus  enleebles  the  patient  more  than  would  the  indirect  measures,  to 
be  mentioned  pre-^f'ntly,  for  evacuating  the  collected  liquid.  Perhaps,  by  rendering 
the  blood  more  watery,  venesection  may  indirectly  favour  the  transuding  of  its  serum 


TREATMENT.  179 

outwards  whenever  the  venous  current  happens  to  be  retarded.  It  certainly  weakens 
the  central  organ  of  the  circulation :  and  to  muscular  debility  of  the  heart  we  have 
already  seen  that  certain  forms  of  general  dropsy  may  owe  their  origin  ;  and  thus  it 
is  that  ill-timed  or  excessive  bleeding  may  be  the  cause  of  dropsy.  In  these  forms 
of  anasarca,  instead  of  robbing  the  veins  of  their  blood,  we  seek  to  repair  the  quality 
and  richness  of  that  fluid,  and  so  to  restore  the  deficient  tone  and  vigour  of  all  the 
muscles,  and  of  the  heart  among  the  rest. 

In  many  cases,  then,  it  is  inexpedient  to  let  blood  ;  and  we  endeavour  to  empty 
the  vessels  indirectly,  and  in  such  a  manner  as  to  withdraw  from  them  the  more 
watery  parts  only  of  their  contents.  In  other  words,  it  becomes  our  object  to  aucr- 
ment  the  discharge  of  watery  fluid  from  one  or  more  of  the  secreting  surfaces  of  the 
body :  but  it  must  not  be  the  inner  surface  of  a  shut  sac. 

I  noticed  before  the  close  analogy  that  obtains  between  dropsies  and  fluxes.  Dropsy 
is  a  flux  into  a  closed  cavity.  Fluxes  would  be  dropsies  if  the  fluid  poured  forth  did 
not  escape.  And^you  are  to  observe  that  we  frequently  try  to  cure  a  dropsy  by  pro- 
ducing a  flux. 

By  what  surface  or  channel  this  artificial  drain  shall  be  attempted,  is  often  a 
matter  of  gteat  nicety  and  importance.  In  some  cases  we  strive  to  promote  the 
discharge  of  the  superabundant  water  by  the  way  of  the  kidneys ;  in  others,  by  the 
mucous  hning  of  the  aUmentary  canal :  in  others,  by  the  external  skin.  The  cir- 
cumstances by  which  our  choice  must  be  determined  will  come  under  review  here- 
after. 

Passive  dropsies  are  much  more  difficult  of  cure  than  active,  and  will  often  baffle 
our  best  directed  efl!brts.  You  are  not,  however,  to  regard  those  passive  dropsies 
which  depend  upon  the  obliteration  of  a  large  vein  as  necessarily  incurable  ;  for  if  a 
collateral  venous  circulation  be  accomplished,  the  drops}?-  will  permanently  disap- 
pear. But  we  must  give  nature  the  credit  of  the  cure  in  such  cases.  Time  is  the 
best  remedy ;  and  all  that  we  can  sometimes  do  is  to  alleviate  in  the  meanwhile  the 
most  distressing  or  threatening  of  the  symptoms. 

I  mentioned,  in  the  outset  of  the  lecture,  that  the  presence  of  the  dropsical  fluid 
may  constitute  nearly  all  the  sufl^ering  of  the  patient,  as  well  as  much  of  his  danger. 
Now,  when  we  cannot  get  rid  of  the  water  by  bleeding,  or  by  internal  remedies 
which  excite  serous  discharges,  we  may  often  afford  great  present  comfort  to  our 
patient,  and  prolong  his  days,  by  letting  the  water  out  by  a  slight  mechanical  opera- 
tion. Paracentesis  is  the  scientific,  and  tapping  the  vulgar  name,  for  this  proceed- 
ing. It  has  been  performed  successfully,  by  means  of  a  small  trocar,  to  evacuate 
the  water  from  the  brain  in  chronic  hydrocephalus ;  it  is  often  resorted  to  for  the 
purpose  of  emptying  the  peritoneal  cavity,  and  the  tunica  vaginalis  testis ;  and  it  is 
not  seldom  practised  to  let  out  the  fluid  of  anasarca  ;  for  acupuncture  of  the  legs  and 
thighs  and  scrotum,  is  only  another  form  of  tapping. 

In  the  local  variety  of  dropsy  that  is  called  hydrocele,  the  re-accumulation  of  the 
liquid  is  sometimes  prevented  by  exciting  just  so  much  inflammation  of  the  mem- 
brane as  may  cause  its  opposite  surfaces  to  cohere ;  whereby  the  cavity  itself  being 
abolished,  any  return  of  the  disease  is  rendered  impossible. 

This  is  an  expedient  which  we  do  not  dare  to  employ  in  other  species  of  dropsy ; 
in  ascites,  for  example :  first,  because  the  inflammation  itself  would  place  the 
patient's  existence  in  imminent  peril ;  and  secondly,  because  if  it  could  be  safely 
conducted,  the  adhesion  and  obliteration  would  seriously  embarrass  and  impede  the 
functions  of  important  organs. 

The  circumstances  which  require  and  justify  this  mechanical  remedy ;  the  rule^j 
and  precautions  to  be  observed  in  its  performance ;  and  the  measures  to  be  adopted 
for  preventing  the  recurrence  of  the  accumulation,  by  the  removal  of  its  efficient 
cause,  will  all  be  considered  in  detail  when  we  come  to  treat  of  the  special  forms  of 
dropsy. 


180  DISEASES   OF   THE   EYE. 

LECTURE  XVII. 

Diseases  of  the  Eye.     Catarrhal  Ophthalmia.    Purulent  Ophthalmia  of  Adults. 

Having  brought  my  observations  on  general  patholog}'  to  a  close,  I  next  proceed 
to  the  consideration  of  individual  diseases ;  and  I  shall  take  them  up,  one  by  one,  in 
that  anatomical  order  to  which  I  adverted  in  the  introductory  lecture  of  this  course. 
That  is  to  say,  I  shair  go  a  capite  ad  calcem:  interpolating  those  disorders  which, 
although  they  have  a  name,  have  as  yet  no  ascertained  local  habitation,  wherever  it 
may  seem  most  convenient  to  introduce  them.  I  mentioned  before  one  advantage,  as 
it  seems  to  me,  of  bringing  together,  in  juxtaposition,  all  the  diseased  conditions  to 
which  the  same  part,  or  the  same  neighbourhood,  of  the  body  is  liable — namely,  the 
facility  thus  afforded  of  comparing  the  phenomena  by  which  they  are  characterized, 
and  of  discriminating  one  disorder  from  another.  .  In  taking  the  parts  in  succession 
from  the  head  downwards,  we  adopt  a  sort  of  order,  definite  enough  for  the  purpose 
of  aiding  tlie  memory,  and  yet  free  from  the  trammels  which  belong  to  all  attempts 
at  arranging  diseases  according  to  their  essential  nature  and  affinities. 

I  propose  then  to  speak,  in  the  first  place,  of  certain  diseases  of  the  organ  of 
vision.  Diseases  of  the  eye  occupy  a  sort  of  neutral  ground,  upon  which  the  sur- 
geon and  the  physician  may  both  lawfully  enter.  For  some  of  them  there  are  no 
means  of  relief  but  in  manual  operations  of  the  most  delicate  kind.  On  the  other 
hand,  many  of  the  internal  parts  of  the  eye  require,  when  diseased,  exactly  the  same 
species  of  general  treatment  which  the  physician  adopts  in  diseases  of  other  internal 
parts.  We  seek  to  change  the  condition  of  a  small  portion  of  the  body,  by  remedies 
which  act  upon  and  through  the  system  at  large.  My  real  and  only  motive,  however, 
for  beginning  with  a  few  of  the  numerous  morbid  states  to  which  this  little  part  is 
liable,  is  this : — that  we  find,  in  the  eye,  more  satisfactory  and  plain  illustrations  of 
the  general  facts  and  doctrines  of  pathology,  as  I  have  been  endeavouring  to  set 
them  before  you,  than  in  any  other  single  organ  of  the  body.  "  Here"  (to  use  the 
words  of  Dr.  Latham,  in  his  little  volume  on  Clinical  Medicine — a  book  which  I 
strongly  recommend  j-ou  to  study)  "  here  you  see  almost  all  diseases  in  miniature : 
and  from  the  peculiar  structure  of  the  eye,  you  see  them  as  through  a  glass ;  and 
you  learn  many  of  the  little  wonderful  details  in  the  nature  of  morbid  processes, 
which  but  for  the  observation  of  them  in  the  eye  would  not  have  been  known 
at  all." 

"Within  the  small  compass  of  the  visual  apparatus,"  says  Mr,  Lawrence,  "we 
meec  with  a  greater  variety  of  structures  than  in  any  other  part  of  the  body.  Indeed 
the  eye,  with  its  appendages,  exhibits  specimens  of  every  one  of  the  animal  tissues. 
We  find  in  it  bone,  cellular  and  adipose  substance,  and  blood-vessels;  mucous, 
fibrous,  and  serous  membranes  ;  the  conjunctiva  exemplifying  the  first ;  the  sclero- 
tica, the  sheath  of  the  optic  nerve,  and  the  lining  of  the  orbit,  the  second ;  the  sur- 
faces containing  the  aqueous  humour,  the  third :  muscular,  nervous  and  glandular 
parts  ;  common  integument  and  hairs.  Besides  these,  it  contains  several  tissues  of 
peculiar  nature,  to  which  there  is  nothing  strictly  analogous  in  other  parts." 

The  eye  itself,  taking  it  apart  from  its  appendages,  the  spheroidal  eyeball  itself,  is 
scarcely  an  inch  in  its  longest  diameter.  Yet  it  seldom  happens  that  disease,  of  any 
kind,  occupies  the  whole,  even  of  this  small  space,  at  once.  Inflammation,  for  exam- 
ple, is  often  confined  to  one  of  the  tunics  of  the  eye,  external  or  internal ;  and  wher 
it  affects  more,  it  is  usually  in  consequence  of  the  extension  of  the  inflammatory  pro- 
cess, from  some  one  texture  in  which  it  took  its  rise.  You  will  not  expect  me  tc 
treat  of  the  vast  number  of  disorders  to  which  the  several  parts  of  the  eye  are  liable. 
I  shall  bring,  I  repeat,  a  few  of  them  only  under  your  notice  ;  and  I  shall  select 
ihose  concerning  which  the  physician  is  most  frequently  consulted ;  Avhich  every 
one,  whatever  brancn  of  the  profession  he  may  follow,  ought  to  be  competent  tc 
treat;  and,  more  particularly,  which  are  calculated  to  elucidate  other  diseases,  and, 
above  all,  other  internal  diseases,  that  are  iipuedly  assigned  to  the  care  of  the  phy 


CATARRHAL    OPHTHALMIA.  164^ 

sician.     With  the  anatomy  and  physiology  of  the  organ,  I  may  take  for  granted  that 
you  are  already  acquainted. 

I  will  first  briefly  inquire  into  the  inflammatory  affections  of  what  may  be  consi- 
dered the  mucous  membrane  of  the  eye.  Like  other  mucous  membranes,  it  forms 
a  surface  communicating  with  the  external  air.  Some  of  these  affections  are  yery 
trifling :  some  are  very  severe. 

There  is  a  mild  form  of  inflammation  of  the  conjunctiva,  which  constitutes  the 
most  common  disease  of  the  eye  to  which  adults  are  subject.  It  results,  in  most 
cases,  from  vicissitudes  of  temperature  ;  or  from  certain  conditions,  or  sudden  varia- 
tions, of  the  atmosphere.  It  is  very  apt  to  be  excited  by  exposure  to  a  stream  or 
draft  of  air,  especially  in  the  night,  and  during  sleep.  It  has  a  strong  analogy — 
indeed  it  is  the  same  disease,  except  in  situation  —  with  that  moderate  degree  of 
inflammation,  produced  by  the  action  of  the  same  causes,  in  the  mucous  membrane 
of  the  nasal  cavities,  the  throat,  and  the  bronchi,  which  in  common  parlance  we 
style  a  cold  in  the  head,  or  in  the  chest,  as  the  case  may  be  :  and  accordingly  that 
inflammation  of  the  conjunctiva  of  which  I  speak  is  often  called  by  the  unlearned,  a 
cold  in  the  eye:  and  the  same  analogy  is  expressed  in  its  technical  appellation :  the 
cold  in  the  head  or  chest  is  termed  by  nosologists  a  catarrh;  and  the  cold  in  the  eye. 
of  the  vulgar,  is,  with  them,  catarrhal  ophthalmia.  The  suddenness  (sometimes)  of 
its  accession  has  procured  for  it  also  the  denomination  of  a  blight  in  the  eye. 

The  term  ophthalmia  is  at  present  used  to  denote  inflammation  of  the  eye  gene- 
rally;  it  conveniently  expresses  in  one  word  what  would  otherwise  require  more. 
Formerly,  when  the  diseases  of  the  eye  were  not  so  well  understood  in  this  country 
as  they  are  at  present,  almost  all  the  inflammatory  conditions  to  which  that  organ  is 
subject,  were  lumped  together  under  the  common  appellation  of  ophthalmia,  or  the 
ophthalmia.  That  word  now  requires  some  epithet  to  distinguish  the  seat  or  the 
kind  of  inflammation  that  is  meant. 

It  can  scarcely  be  otherwise  than  interesting  to  mark  the  phenomena  which  occur 
in  catarrhal  ophthalmia,  when  we  know  that  in  its  cause  and  nature,  it  is  the  same 
with  inflammation  of  a  similar  surface,  in  parts  which  we  cannot  so  well  inspect  as 
we  can  the  conjunctiva.  This  membrane,  as  you  know,  hues  the  eyehds,  and  covers 
about  a  third  part  of  the  globe  of  the  eye  anteriorly.  The  inflammation,  in  catarrhal 
ophthalmia,  is  confined  to  the  conjunctiva  and  the  meibomian  follicles.  Its  leading 
symptoms  are  redness  of  the  surface  of  the  ej^e ;  some  pain  and  uneasiness  there  ; 
an  increased  discharge  from  the  affected  membrane  and  the  follicles :  and  a  stick- 
ing together  of  the  eyelashes  and  lids. 

The  redness  is  worth  notice,  both  in  respect  to  its  tint,  and  to  the  arrangement  of 
the  vessels  in  which  it  appears.  It  is  superficial,  and  of  a  bright  scarlet  colour; 
and  usually  irregular,  or  diffliscd  in  patches,  some  fasciculi  of  vessels  being  more 
distended  than  others.  When,  however,  the  inflammation  is  more  intense,  the 
whole  surface,  except  that  of  the  cornea,  becomes  of  a  scarlet  red.  The  vessels  of 
the  conjunctiva,  thus  rendered  visible  by  inflammation,  anastomose  continually  with 
each  other,  and  form  a  network,  which  can  be  slipped  and  dragged  about  over  the 
subjacent  surface  by  moving  the  eyelids  with  the  finger.  Frequently  some  of  the 
meshes  of  this  network  are  filled  up  with  little  patches  of  extravasated  blood ;  the 
eye  is  what  is  called  blood-shot,  or,  to  speak  learnedly,  there  is  ecchymosis  ;  and 
sometimes  all  distinction  of  separate  vessels  is  nearly  lost.  In  the  commencement 
of  the  complaint  the  redness  is  confined  to  that  part  of  the  conjunctiva  which  lines 
the  lids ;  and  it  afterwards  advances  gradually,  from  the  angle  where  it  is  reflected 
over  the  eyeball,  towards  the  cornea. 

Now  all  these  particulars  are  of  consequence,  since  they  are  diagnostic  of  the  seat 
of  the  disease ;  and  to  show  this  I  must  mention,  by  anticipation,  the  appearance 
and  the  arrangement  of  vessels  that  are  observed  when  inflammation  affects  some  of 
the  textures  which  lie  deeper  than  the  conjunctiva,  and  especially  the  sclerotica 
The  sclerotic  redness  is  seen  through  the  conjunctiva.  It  is  of  quite  a  different  tint 
from  that  of  the  conjunctiva.  Instead  of  showing  a  blight  scarlet  colour,  it  is  pink, 
or  sometimes  of  a  slight  violet  hue.  The  vessels  are  much  smaller  and  finer  than 
those  belonging  to  the  conjunctiva,  like  hairs.    They  are  straight  also,  and  arranger? 

Q 


182  DISEASES    OF    THE    EYE. 

regularly,  after  the  manner  of  radii  in  a  circle.  They  lie  in  the  sclerotic,  round  the 
cornea,  like  what  is  called  by  painters  a  glor}%  or  like  a  halo,  or  zone  surrounding 
the  central  cornea;  and  they  cannot  be  made  to  shift  tlicir place  by  any  dragging 
of  the  lids.  These  are  very  important  distinctions.  They  are  such  as  are  easily 
recognized  when  two  eyes  are  examined  in  which  the  two  membranes  in  question 
are  separately  inflamed  and  vascular;  and  they  are  still  more  palpable,  perhaps, 
■when  both  membranes  are  simultaneously  inflamed,  as  they  often  are,  in  the  same 
eye.  Then,  unless  the  conjunctiva  is  so  universally  red  as  to  prevent  our  seeing  the 
sclerotica  through  it,  the  contrast  between  the  larger,  more  tortuous,  scarlet,  and 
reticular  vessels  of  the  conjunctiva,  and  the  fine,  straight,  rose-coloured,  radiating 
vessels  of  the  sclerotic,  is  exceedingly  striking ;  and  those  of  the  conjunctiva,  which 
lie  naked  on  the  loose  mucous  membrane,  admit  of  being  slipped  about  over  the 
fixed  zone  of  vascularity  which  is  presented  by  those  of  the  fibrous  tunic. 

The  pain  which  attends  catarrhal  ophthalmia  is  slight  and  trifling.  At  the  outset 
there  is  generally  some  uneasiness  when  the  eye  is  exposed  to  the  light ;  but  there 
is  no  intolerance  of  light  when  the  disease  is  fairly  developed.  The  patient  com- 
plains rather  of  a  sensation  of  stiffliess  and  dryness,  and  feels  as  though  there  were 
some  foreign  substance  in  the  eye,  between  the  globe  and  the  lids,  especially  when 
the  eye  is  moved  ;  a  grain  of  sand,  or  gravel,  or  a  little  fly.  So  exact  is  the  resem- 
blance of  this  feehng,  that  you  can  with  difficulty  persuade  the  patient  that  there  is 
nothing  of  that  sort  in  his  eye.  No  doubt  this  sensation  is  produced  by  the  ine- 
quality and  roughness  of  the  surface,  consequent  upon  the  irregular  distension  of  the 
vessels  of  the  inflamed  membrane  ;  irritating  the  organ  mechanically,  just  as  a  piece 
of  dust  would  irritate  it. 

Now  in  this  respect,  again,  there  is  a  m.arked  difference  between  conjunctivitis 
and  sclerotitis.  In  the  latter  disease,  the  pain  is  much  more  severe,  of  a  dull  aching 
character,  with  a  sense  of  tightness  :  the  part  inflamed  is  denser,  and  less  yielding 
than  the  conjunctiva.  The  pain  is  attended  also,  frequently,  by  throbbing,  and  is 
felt  in  the  surrounding  parts  more  severely  perhaps  than  in  the  eye  itself;  in  the 
brow,  temples,  and  head.  It  is  a  very  remarkable  circumstance,  too,  that  the  pain 
is  distinctly  aggravated  towards  night ;  increasing  in  violence  from  the  evening  till 
after  midnight,  abating  towards  morninc:,  and  ceasingf  in  a  great  measure  durincr  the 
day,  to  be  again  renewed  in  the  evening.  I  am  speaking  now  particularly  of  inflam- 
mation of  the  sclerotica  produced  by  the  same  causes  as  give  rise  to  catarrhal  oph- 
thalmia;  of  what  is  generally  called  rheumatic  ophthalmia. 

The  increased  discharge  that  takes  place  from  the  eye  in  catarrhal  ophthalmia  is 
not  a  discharge  of  tears.  In  the  beginning  of  the  complaint  there  is  sometimes  a 
slight  degree  of  lachrymation.  But  this  soon  ceases,  and  the  mucous  secretion  from 
the  surface  of  the  membrane  is  augmented  in  quantity,  and  changed  in  quality.  At 
first  it  is  somewhat  thin,  but  it  soon  becomes  thicker,  and  it  is  often  puriform  ;  i.  e., 
opaque  and  yellow :  sometimes  it  retains  more  exactly  the  characters  of  mucus,  is 
transparent  and  viscid  ;  so  that  the  eye  looks  moist  to  a  bystander,  while  to  the 
patient  it  feels  gummy.  The  puriform  secretion  is  not,  in  general,  in  any  great 
abundance.  You  may  see  it  lying  in  the  angle  between  the  eye  and  the  lower  lid, 
by  pulling  them  apart ;  or  it  makes  itself  visible  at  the  corner  of  the  eye,  or  between 
the  eye-lashes  along  the  edges  of  the  lids,  Avhich  it  glues  together  at  night.  Some- 
times, however,  the  discharge  is  more  copious,  so  as  to  approximate  to  what  is 
observed  in  the  less  severe  forms  of  another  disease  I  shall  presently  mention ;  viz., 
purulent  ophthalmia. 

There  is  seldom  much  sweUing  of  the  conjunctiva.  If  there  be  any,  it  results 
from  an  cflusion  of  serous  fluid  into  the  meshes  of  the  areolar  tissue  that  connects 
the  membrane  with  the  subjacent  sclerotica :  by  which  effusion  the  conjunctiva  is 
partially  raised  and  separated.  This  kind  of  eff'usion  often  goes  to  a  very  great 
extent  in  purulent  ophthalmia,  or  in  violent  inflammation  of  the  external  membranes, 
as  I  shall  show  you  by  and  by. 

So  much,  then,  for  the  symptoms  and  causes  of  catarrhal  ophthalmia.  It  is  neces- 
Kary  that  you  should  be  familiarly  acquainted  with  them ;  not  so  much  because  the 
complaint  is  very  serious  in  its  nature,  but  because  it  is  rnmmon  ;  because  you  are 


CATARRHAL  OPHTHALMIA.  -   183 

sure  to  be  again  and  again  consulted  about  it,  and  because  it  is  of  great  importance 
to  distinguish  it  from  other  forms  of  oplithahnia,  in  order  to  adopt  the  proper  treat- 
ment. A  mistake  of  diagnosis  might  lead  to  mischievous  activity  on  the  one  hand : 
or  to  still  more  pernicious  inertness  on  the  other. 

When  the  inflammation  does  not  extend  beyond  the  mucous  membrane,  it  will  run 
a  certain  course,  and  then,  under  favourable  circumstances,  subside.  But  if  it  be 
improperly  treated,  or  if  the  patient  cannot  guard  himself  against  a  repetition  of  its 
exciting  causes,  it  may  continue  for  weeks,  and  harass  him  a  good  deal,  and  even 
produce  such  a  change  in  the  inflamed  lids  as  may  prove  a  source  of  permanent 
irritation,  and  of  chronic  disease,  of  the  cornea  over  which  they  sweep. 

Remedies  of  an  active  kind,  such  as  influence  the  whole  economy,  are  scarcely 
ever  necessary.  The  patient  should  observe  the  main  particulars  of  the  antiphlo- 
gistic regimen,  and  avoid  exposure  to  drafts  or  currents  of  air,  and  to  cold  and  mois- 
ture generally.  When  the  external  weather  is  inclement,  he  should  remain  in  rooms 
of  a  uniform  temperature.  It  will  be  right  to  purge  him  in  the  outset  with  calomel  - 
and  jalap,  or  witli  calomel  followed  by  a  black  dose  finfusion  of  sennoe]. 

If  the  system  at  large  sympathize  with  the  local  disease,  it  may  become  necessary 
to  take  blood  from  the  arm,  or  to  apply  leeches ;  but  neither  of  these  measures  is 
requisite,  except  the  inflammation  is  unusually  severe,  or  the  disease  has  been  ne- 
glected or  mismanaged. 

After  the  bowels  have  been  thoroughly  cleared  by  an  active  purgative  or  two, 
remedies  which  encourage  moderate  perspiration  will  be  likely  to  forward  the  cure; 
such  as  warm  diluent  drinks ;  five  grains  of  Dover's  powder,  and  immersion  of  the 
feet  in  warm  water,  at  bed-time  ;  and  saline  draughts  containing  two  or  three  drachms 
of  the  liquor  amrnonix  acetatis,  taken  at  intervals  during  the  day. 

But  in  this  complaint  local  measures  are  of  greater  importance  than  those  which 
are  addressed  to  the  general  system:  stimulating  or  astringent  applications  to  the 
affected  membrane  itself.  Almost  all  modern  writers  on  diseases  of  the  eye  agree 
in  this.  Dr.  Mackenzie,  of  Glasgow,  states  it  as  the  result  of  his  observations  on 
Beer's  practice  in  Vienna,  and  of  his  own  subsequent  experience,  upon  an  extensive 
scale,  at  the  Glasgow  Eye  Infirmary,  that  "  general  remedies  in  this  disease  are  in- 
ferior to  local  ones  ;  that  violent  general  remedies  are  worse  than  useless  ;  and  that 
a  local  stimulant  treatment  may  almost  entirely  be  rehed  on."  Mr.  Melin,  in  a 
report  of  ocular  diseases  at  the  General  Hospital,  Fort  Pitt,  states  that  he  had  treated 
nearly  300  cases,  some  of  them  severe,  upon  the  same  principle,  without  either  local 
or  general  bleeding :  and  that  he  had  satisfied  himself  of  the  efficacy  of  this  plan 
of  management.  And  Mr.  Lawrence,  who  for  ten  years  was  one  of  the  surgeons 
to  the  Ophthalmic  Infirmary,  in  Moorfields,  and  who  during  that  period  had  ample 
opportunities  of  studying  this  disease  of  the  eye  as  well  as  others,  says  that  it  is  one 
to  which  the  use  of  powerful  astringents  is  more  particularly  applicable.  In  dis- 
orders which  manifest  a  strong  natural  tendency  to  terminate  in  recovery,  it  is  onlj- 
by  taking  advantage  of  the  conclusions  derived  from  extensive  observation  that  we 
can  be  quite  sure  of  our  ground  ;  and  when  the  same  result  is  reached  by  different 
and  independent  observers,  we  may  safely  place  confidence  in  their  concurrent 
testimony. 

Dr.  Mackenzie  and  Mr.  Melin  both  employ  and  recommend  the  same  application, 
viz.,  a  solution  of  the  nitrate  of  silver  in  distilled  water,  in  the  proportion  of  foijff 
grains  to  the  ounce.  A  large  drop  of  this  solution  is  to  be  applied  to  the  membrane 
once  or  twice,  or  three  times,  in  the  course  of  the  day.  If  the  patient  recline  his 
head  backwards,  and  the  drop  be  placed  in  the  hollow  formed  at  the  internal  angle, 
of  the  eye,  it  will  be  diffused  over  the  globe  upon  the  separation  and  subsequent 
winking  of  the  lids.  After  a  minute  or  two  this  causes  a  pricking  or  smarting  sen- 
sation, which  subsides  in  from  ten  to  twenty  minutes,  and  the  eye  then  feels  much 
easier  than  it  did  before  the  drop  was  applied.  Dr.  Mackenzie  says  that  the  feeling 
as  if  of  sand  in  the  eye,  is  uniformly  relieved,  and  the  inflammation  abated,  by  the 
use  of  this  solution,  which  he  speaks  of  as  a  remedy  of  sovereign  utility  in  the  puro- 
mucous  inflammations  of  the  conjunctiva.  The  eye  continues  easy,  after  its  appli- 
cation, for  five  or  six  hours  perhaps;  and  when  the  symptoms  return,  they  are  agaus 


184  DISEASES    OF    THE    EYE. 

to  be  met  by  the  introduction  of  another  drop.  As  the  disease  subsides  the  remedy 
gives  less  and  less  pain,  till  at  last  it  is  scarcely  felt.  He  tells  us  that  "  he  has  some- 
times alarmed  other  practitioners  by  proposintr  to  drop  upon  the  surface  of  an  eye 
highly  vascular,  affected  with  a  feeling  as  if  broken  pieces  of  glass  were  roiling  under 
the  eyelids,  and  evidently  secreting  puriform  matter,  a  solution  of  lunar  caustic ;  and 
that  he  has  been  not  a  httle  pleased  and  amused  at  their  surprise  when,  next  day, 
they  have  found  all  the  symptoms  much  abated  by  the  use  of  this  application."  He 
declares,  also,  that  the  acetate  of  lead,  and  the  sulphate  of  zinc,  substances  which 
are  much  used  in  what  are  called  colhjria  or  ei/e-ic ashes,  are  greatly  inferior,  as  local 
applications,  to  the  nitrate  of  silver,  in  this  disease. 

There  is  another  expedient  that  requires  to  be  attended  to  in  these  cases.  When 
the  eyelids  are  gummed  together  by  the  viscid  discharge,  much  hurtful  irritation  is 
often  produced  by  the  hasty  attempts  which  the  patient  makes  to  separate  them. 
Now  all  this  may  be  obviated  hy  smearing  their  tarsal  edges  at  bed-time  with  any 
mild  ointment ;  the  spermaceti  ointment,  or  a  bit  of  lard.  There  is  no  necessity, 
as  I  believe,  in  this  form  of  disease,  to  use  medicated  or  stimulating  salves :  the 
object  is  to  prevent  the  mutual  adhesion  of  the  lids  ;  and  this  is  accompanied  by 
simple  grease. 

Purulent  ophthalmia  is  another  disease  of  the  conjunctiva  ;  differing  from  catarrhal 
ophthalmia  in  degree,  in  the  severity  (3f  its  symptoms,  in  the  danger  which  it  imphes 
to  the  sense  of  vision,  and  in  its  exciting  causes.  It  takes  its  name  from  the  profuse 
discharge  of  pus,  or  of  altered  mucus  w'hich  cannot  be  distinguished  from  pus,  that 
pours  from  the  inflamed  surface.  There  are  three  remarkable  varieties  of  purulent 
ophthalmia,  called  respectively — 1,  purulent  ophthalmia  of  adults,  or  Egyptian 
ophthalmia,  or  contagious  ophthalmia;  2,  gonorrhceal  ophthalmia;  and  3,  purulent 
ophthalmia  of  ncAvly-born  children. 

The  symptoms  of  the  two  first-mentioned  varieties,  especially  in  their  severer 
forms,  are  so  much  the  same  that  it  would  involve  us  in  mere  repetition  if  I  did  not 
take  them  together.  In  truth  it  appears  to  me  much  the  simpler  and  better  mode  to 
look  upon  purulent  ophthalmia  as  one  disease  ;  and  then  to  specify,  as  we  go  on,  the 
differences  by  which  its  several  forms  are  characterized :  and  not  to  split  it  into  three 
different  diseases,  and  to  give  a  separate  description  of  each. 

Although  purulent  ophthalmia  is  inflammation  of  the  very  same  part  that  is  in- 
flamed in  catarrhal  ophthalmia,  from  which  it  differs  chiefly  in  degree,  it  is  a  hideous 
complaint,  either  to  suffer  or  to  treat :  on  account  of  the  rapid  progress  it  frequently 
makes,  and  its  destructive  tendency.  The  inflammation  is  greatly  more  intense  ; 
the  surface  becomes,  in  the  worst  cases,  highly  vascular  throughout.  A  copious 
discharge  of  thick,  yellow,  puriform  matter  is  speedily  established ;  this  flov/s  out 
from  between  the  swollen  lids,  and  runs  over  the  cheek  which  it  often  excoriates. 
At  the  same  time  considerable  effusion  takes  place  into  the  areolar  tissue  that  connects 
the  sclerotica  and  the  conjunctiva.  You  are  aware  that  the  conjunctiva  extends 
over  the  whole  anterior  face  of  the  globe  ;  adhering,  however,  so  much  more  closely 
to  the  cornea  than  to  the  sclerotica,  that  we  might  doubt  at  first  whether  it  did  not 
stop  at  its  margin.  This  close  and  firm  adhesion  over  the  cornea,  and  the  looser 
attachment  to  the  sclerotica,  give  rise  to  a  very  sintrular  phenomenon.  The  conjunc- 
tiva is  raised  to  some  distance  from  the  subjacent  sclerotica  by  the  effijsion  that  takes 
place  between  them ;  and  it  projects  around  the  cornea  in  the  shape  of  a  large  thick 
ring,  leaving  the  cornea  buried,  as  it  were,  in  a  pit ;  nay,  sometimes,  the  swollen  and 
prominent  membrane  will  lap  over,  so  as  nearly  to  exclude  the  cornea  from  our 
sight.  The  same  kind  of  effusion  takes  place,  also,  sometimes  very  rapidly,  into 
the  areolar  tissue  connecting  the  conjunctiva  with  the  palpebrre,  producing  great  ex- 
ternal tumefaction,  and  a  livid  red  appearance  of  the  eyelids,  which  project  forwards 
in  large  convex  masses,  and  often  prevent  our  seeing  the  globe  of  the  eye  at  all ; 
the  upper  lid  especially  becoming  hard  and  stiff,  and  completely  overhanging  the 
lower.  This  swelling  from  effusion  into  the  subconjunctival  tissue  is  of  a  pale  red 
fleshy  colour,  sometimes  marked  here  and  there  with  patches  of  extravasated  blood. 
The  appearance  is  called  chemosis  :  not  ecchymosis,  as  the  similarity  of  the  sound 


PURULENT   OPHTHALMIA.  185 

has  led  some  erroneously  to  suppose,  but  chemosis.  ExxviArtoai?,  from  sxxn^,  signifies 
an  effusion,  and  by  common  consent  among  medical  writers,  an  effusion  of  blood. 
Xriuaai;,  the  root  of  which  is  XW"-^  hiatus,  means  a  gap  or  hollow. 

Now  this  puriform  or  purulent  inflammation,  so  long  as  it  is  confined  to  that  part 
of  the  membrane  which  lines  the  eyelid,  is  not  of  any  serious  importance ;  but  it  is 
prone  to  extend  itself  to  the  cornea,  and  the  whole  anterior  surface  of  the  eye,  and 
to  produce  ulceration  or  sloughing  of  the  cornea,  either  in  consequence  of  the  actual 
inflammation  of  that  part,  or  in  consequence  of  the  pressure  made  upon  and  around 
it  by  the  swelling  of  chemosis.  Frequently,  when  the  cornea  remains  visible,  a 
furrow  or  trench  of  ulceration  may  be  seen  at  its  margin ;  sometimes  forming  a 
complete  circle,  sometimes  portions  of  a  circle,  sometimes  going  quite  through ;  and 
when  this  happens,  or  when  the  cornea  bursts,  from  the  effects  of  deeper-seated 
inflarrmiation,  the  aqueous  humour  is  evacuated,  and  the  iris  protrudes  through  the 
aperture.  Even  when  these  horrible  consequences  do  not  take  place,  the  eye  is  often 
as  effectually  spoiled  for  the  purposes  of  vision  by  an  interstitial  deposit  between  the 
laminre  of  the  cornea,  rendering  it  opaque,  and  permanently  precluding  the  passage 
of  light  towards  the  retina. 

And  when  neither  of  these  lamentable  effects  of  the  inflammation  is  produced,  it 
is  apt  to  leave  behind  it  a  chronic  and  very  troublesome  condition  of  the  membrane. 
The  conjunctiva  that  lines  the  hds  remains  thickened,  granular,  hard,  and  rough, 
instead  of  regaining  its  natural  smoothness,  softness,  and  polish.  One  consequence 
of  this  is  a  perpetual  irritation  of  the  surface  of  the  cornea,  by  the  mechanical  fric- 
tion of  the  rough  and  hard  lid  in  opening  and  closing  the  eye,  and  in  the  various 
motions  of  the  eyeball.  The  continuance  of  this  irritation  leads  at  length  to  hazi- 
ness or  opacity  of  the  cornea,  which  becomes  traversed  also  by  visible  red  vessels. 
Chronic  inflammation  of  its  investing  membrane  is  produced,  and  kept  up. 

The  most  severe  forms  of  this  disease  are  attended,  at  length,  with  a  good  deal  of 
pain  ;  doubtless  because  the  inflammation  penetrates  to  the  deeper-seated  textures  of 
the  organ.  The  pain  then  presents  those  characters  which  1  mentioned  before  as 
belonging  to  certain  inflammations  of  the  sclerotica :  i.  e.,  it  is  pulsative  ;  and  some- 
times sharp  and  lancinating,  sometimes  dull  and  aching ;  and  it  is  intermittent ;  or 
if  constant,  it  is  aggravated  by  paroxysms :  the  paroxysms  coming  on  at  night,  and 
abating  towards  morning:  and  it  is  not  confined  to  the  eye  itself,  but  extends  to  the 
parts  around  it.  This  circumorbilal  pain  is  characteristic  of  inflammation  of  the 
sclerotica  and  cornea,  and  of  the  internal  tunics,  the  choroid  and  iris.  When  the 
eye  is  not  visible,  from  the  swelling,  we  may  conclude  that  the  inflammation  is  as 
yet  confined  to  the  conjunctiva,  if  the  pain  be  only  scalding  or  "sandy;"  and  that 
it  has  extended  to  the  sclerotica  and  cornea  if  the  pain  be  severe,  throbbing,  and 
paroxysmal.  In  the  cases  in  which  the  latter  kind  of  pain  is  felt,  the  cornea  gene- 
rally gives  way.  Sometimes  this  event  brings  relief  to  the  pain,  and  sometimes  the 
pain  continues  to  return  after  the  bursting  of  the  cornea.  It  is  curious  that  with  all 
this,  there  is  seldom  much  intolerance  of  light. 

In  the  earlier  stages  of  this  malady,  it  is  entirely  local :  the  system  at  large  is 
scarcely  disturbed  at  all.  But  the  constitution^fbegins  to  sympathize  and  suffer  when 
the  local  symptoms  increase  in  severity  :  the  pulse  becomes  frequent,  and  the  tongue 
white,  but  there  is  seldom  much  thirst  or  fever;  and  when  blood  is  drawn  from  a 
vein,  it  does  not,  in  general,  exhibit  the  buffy  coat.  A  good  deal  of  variety  in  these 
respects  has  been  noticed,  however,  in  diferent  cases.  Children  manifest  more 
constitutional  disturbance  when  labouring  under  purulent  ophthalmia  than  adults.  If 
there  be  not  much  fever,  there  is  always  much  uneasiness  and  irritation,  and  the 
sleep  is  broken  by  the  nocturnal  accessions  of  pain. 

Such  being  the  general  features  and  course  of  the  disease,  at  least  as  it  occurs  in 
adults,  or  in  patients  beyond  the  period  of  infancy,  we  may  next  inquire  into  the 
circumstances  under  which  it  has  been  observed  to  arise. 

Purulent  ophthalmia  has  been  ascertained  to  be  a  common  disease  in  hot  cUmates  : 
m  India,  Persia,  and  Egypt.  It  was  brought  into  England,  from  the  latter  country, 
by  our  troops  in  the  beginning  of  the  present  century,  after  the  well-known  contest 
which  there  took  place  between  the  French  army  and  our  own  under  Sir  llal])b 

a2 


186  DISEASES    OF    THE    EYE. 

Abercromby.  In  this  way  it  got  the  name  of  the  Egyptian  ophthalmia.  It  naturally 
excited  very  great  attention  at  that  tinie,  and  it  does  not  appear  to  have  been  accu- 
rately described  before. 

To  give  you  some  notion  of  its  prevalence  in  certain  places  and  at  certain  periods, 
and  of  its  serious  nature,  I  may  state  that,  according  to  returns  made  from  the  military 
hospitals  at  Chelsea  and  Kilmainham,  there  were,  on  the  1st  of  December,  1810,  no 
fewer  than  2317  soldiers  a  burden  upon  the  public  from  blindness  in  consequence  of 
ophthalmia ;  and  in  this  number  those  soldiers  who  had  lost  the  sight  of  one  eye 
only  were  not  included. 

Again,  in  the  year  1804,  within  nine  months,  i.  e.,  from  April  to  December 
nearly  400  cases  of  purulent  ophthalmia  occurred  at  the  Royal  Military  Asylum; 
and  within  six  years  from  that  time,  without  including  relapses,  upwards  of  900 
cases  had  taken  place  in  the  same  establishment. 

You  Avill  find  these  statements  in  a  paper  in  the  third  volume  of  the  Transactions 
of  a  Society  for  the  improvement  of  Medical  and  Chiriirgical  Knowledge,  by  the 
late  Sir  Patrick  Macgregor.  Many  of  our  best  regiments  were  for  a  time  crippled 
and  rendered  unfit  for  service  by  this  disease ;  which  they  carried  from  Egypt  to 
other  foreign  stations  as  well  as  to  this  country,  especially  to  Sicily,  Malta,  and 
Gibraltar.  Nor  were  the  French  troops  less  extensively  affected  by  it.  Assalini, 
who  wrote  an  account  of  the  ophthalmia  of  Egypt,  states  that  two-thirds  of  the 
French  army  were  labouring  under  it  at  one  time.  It  occurs  also,  but  fortunately 
not  to  such  an  extent,  in  civil  life.  It  broke  out,  some  years  ago,  in  a  large  boys' 
school  in  Yorkshire  ;  and  Windness  of  one  or  both  eyes,  or  serious  injury  to  sight, 
from  opacity  of  the  cornea,  and  other  consequences,  took  place  in  nearly  twenty 
cases. 

You  perceive,  therefore,  that  this  formidable  complaint  has  been  ascertained,  within 
the  last  forty  years,  to  have  prevailed  as  an  epidemic  ;  attacking  great  numbers  of 
persons  living  under  the  same  circumstances,  and  having  constant  communication 
with  each  other.  And  one  of  the  first  questions  that  naturally  arises  in  one's  mind 
is,  whether  it  is  capable  of  beinj  propagated  from  one  person  to  another  by  conta- 
gion. Much  difference  of  opinion  has  existed  on  this  subject.  Fur  my  own  part  I 
cannot  imagine  how  any  one  can  doubt  its  contagious  properties. 

I  will  give  you  a  case  or  two,  as  related  by  Sir  Patrick  Macgregor,  proving  two 
very  im.}7i;rlant  facts :  first,  that  the  disease  is  capable  of  being  excited  in  the  eye  of 
a  person,  previously  healthy,  by  the  direct  application  of  the  puriform  discharge 
from  an  eye  affected  with  this  ophthalmia;  and  secondly,  the  very  rapid  operation 
of  the  poison  so  applied. 

One  of  the  nurses  employed  at  the  Mihtary  Asylum,  while  syringing  the  eye  of 
a  boy  who  had  much  purulent  discharge,  found  that  a  considerable  quantity  of  the 
matter  had  s^^urted  into  her  own  right  eye.  This  was  at  four  o'clock  in  the  after- 
noon. She  fek  little  or  no  smarting  at  the  time ;  but  towards  nine  o'clock  the  same 
evening  her  right  eye  became  red  and  somewhat  painful,  and  when  she  awoke  the 
next  morning,  the  eyelids  were  swelled,  there  was  purulent  discharge,  and  she  com- 
plained of  pain  in  the  eyeball.  The  usual  remedies  were  begun  in  the  morning, 
and  she  recovered  in  the  space  of  three  weeks  or  a  month.  The  left  eye,  into  which 
none  of  the  matter  had  gone,  remained  free  from  disease. 

On  another  occasion  a  precisely  similar  mischance  befell  another  of  the  nurses, 
« xcept  that  the  matter  spurted  into  her  Ifft  eye,  about  nine  in  the  morning.  Sir.  P. 
Macgregor  happened  to  be  in  the  hospital  at  the  time  when  the  accident  occurred. 
He  desired  the  nurse  to  bathe  her  eye  immediately  with  lukewarm  water,  and  she 
did  so  for  several  minutes ;  but  notwithstanding  this  early  precaution,  about  seven 
o'clock  in  the  evening  the  left  eye  began  to  itch  to  such  a  degree  that  she  could  not 
refrain  from  rubbing  it.  When  she  awoke  next  morning  the  eye  was  considerably 
inflamed,  tlit;  lids  were  swelled,  and  upon  moving  the  eyeball  she  had  a  sensation  as 
if  some  sand  were  lodged  beneath  it.  In  the  course  of  the  same  day,  purulent 
rtuid  issued  from  the  eye,  and  other  symptoms  followed,  which  were  similar  to  those 
of  the  children  under  her  care.  The  disease  subsided  under  the  usual  treatment,  in 
fourteen  days.     In  this  case  also  the  other  eye  remained  sound. 


PURULENT    OPHTHALMIA.  187 

A  third  nurse  in  the  same  institution  did  not  come  off  so  well.  She  wlis  spong- 
ing, with  warm  water,  the  eyes  of  a  boy  suffering  severely  from  purulent  ophthal- 
mia: and  she  inadvertently  applied  the  sponge  she  was  using  to  her  riglit  eye. 
This  happened  at  eight  o'clock  in  the  morning.  She  mentioned  the  circumstance  to 
the  other  nurses,  but  she  took  no  means  to  prevent  infection.  Between  three  and 
four  o'clock  of  the  afternoon  of  the  same  day,  itching  of  the  right  ^ye  came  on ;  and 
before  she  went  to  bed  it  was  considerably  inflamed.  Next  morning  her  eyelids 
were  swollen,  she  complained  of  pain  in  moving  them,  the  whole  anterior  surface  of 
the  eyeball  was  in  a  state  of  high  inflammation,  and  a  purulent  discharge  began  to 
trickle  down  the  cheek  from  the  inner  canthus.  The  symptoms  increased  in  severity 
in  spite  of  all  the  means  employed  to  check  them,  and  on  the  fourth  day  the  eyeball 
burst.  The  sight  of  the  eye  was  irrecoverably  lost,  and  the  inflammation  continued 
for  upwards  of  three  months.     The  left  eye  did  not  suffer. 

These  were  cases  in  which  the  poisonous  matter  was  acddenially  applied.  But 
a  similar  application  has  been  made  intentionallxj  and  by  the  way  of  experimenl,  and 
ivith  the  same  results.  Dr.  Guillie,  of  Paris,  introduced  the  puriforra  secretion  fur- 
nished by  some  children  affected  with  purulent  ophthalmia,  under  the  eyelids  of 
four  other  children  belonging  to  a  separate  institution  for  the  blind.  These  four 
children  were  amaurotic,  but  the  external  surface  of  their  eyes  was  healthy  and 
entire.  In  each  instance  a  regular  attack  of  purulent  ophthalmia  followed  the  intro- 
duction of-the  matter. 

Facts  of  this  kind  prove,  I  say,  beyond  the  possibility  of  question,  that  the  disease 
may  be  propagated  from  a  diseased  to  a  healthy  eye  by  actual  contact  of  the  puri- 
form  matter.  Here  we  have  not  one  case  (which  might  be  considered  as  an  acci- 
dental coincidence),  but  several:  the  morbid  secretion  is  applied  to  one  eye  only; 
the  symptoms  of  inflammation  commence,  and  the  regular  form  of  the  disease  is 
fully  developed  within  a  few  hours  after  the  first  application  of  the  pus;  and  that 
eye  only  is  affected.     It  is  impossible  to  get  over  evidence  of  this  kind. 

The  only  questions,  therefore,  that  can  be  raised  respecting  the  sources  of  the 
disease  are  these : — whether  the  malady  can  be  communicated  through  the  medium 
of  an  atmosphere  impregnated  with  the  efliuvia  that  proceed  from  the  diseased 
part,  without  any  actual  contact  of  the  pus  in  substance  ? — whether  the  disorder 
is  ever  produced  in  any  other  way  than  by  contagion  ? — and  if  so,  how  it  is  then 
excited  ? 

I  ought  to  observe,  that  independently  of  such  isolated  examples  of  the  direct 
communication  of  the  complaint,  by  contact  with  the  diseased  matter,  as  I  have  just 
laid  before  you,  the  history  and  progress  of  ophthalmia,  since  it  has  been  noticed  in 
Europe,  are  very  strongly  indicative  of  its  contagious  nature.  I  have  already  stated 
that  it  was  not  known  in  Europe  till  the  commencement  of  the  present  century — till 
after  the  Egyptian  campaign  in  fact.  It  is  not  alluded  to  by  any  of  the  authors  on 
disorders  of  the  eye  who  wrote  previously  to  that  period  ;  although  some  of  the 
Italian  physicians  and  surgeons,  and  many  of  the  Germans,  had  paid  great  attention 
to  ophthalmic  diseases.  It  spread  from  Egypt  both  to  France  and  to  this  country, 
and  to  other  places  in  which  detachments  of  the  Egyptian  force  were  subsequently 
stationed  :  in  Sicily  to  wit,  and  in  Gibraltar  and  Malta.  Whenever  it  has  prevailed 
among  our  troops  at  home,  this  circumstance  has  been  uniformly  observed :  that  it 
first  broke  out  in  soldiers  who  had  come  from  Egypt,  or  had  communicated  with  regi- 
ments which  had  been  in  Egypt.  In  aU  cases  its  origin  could  be  traced  to  the  intro- 
duction of  fresh  troops  into  the  regiment  or  the  barracks. 

Again,  the  manner  in  which  it  spreads  is  exceedingly  instructive  on  this  point.  It 
diffuses  itself  rapidly,  when  once  introduced,  in  places  where  a  considerable  number 
of  persons  are  collected  together ;  especially  under  circumstances  favourable  to  the 
propagation  of  contagious  maladies  ;  as  among  soldiers  assembled  in  barracks,  where 
many  of  the  men  live  in  the  same  apartments,  and  use  the  same  t9wels:  while  the 
officers,  who  live  in  larger  and  better  ventilated  rooms,  and  apart  from  each  other, 
generally  escape.  And  the  good  effect,  in  checking  the  further  extension  of  the 
disease,  of  separating  the  healthy  from  the  sick,  and  of  restricting  every  one  to  his 
own  washing  utensils,  and  clothes,  and  towels  and  sponges,  leads  to  the  same  cor» 


1S8  DISEASES    OF    THE    EYE. 

elusion.  Rust,  a  German  author,  mentions  this  striking  fact  in  corroboration  of  »^-hat 
I  have  just  been  saying.  The  disease  broke  out  in  the  town  of  Mayence.  This 
place  was  garrisoned  by  Prussian  and  Austrian  troops.  The  ophthalmia  began  and 
spread  extensively  among  the  Prussian  soldiery ;  while  the  Austrians,  who  were 
stationed  in  separate  barracks  from  the  Prussians,  in  another  quarter  of  the  town, 
remained  quite  free  from  it. 

Those  persons  who  deny,  or  who  doubt,  the  contagious  nature  of  purulent  oph- 
thalmia, rest  their  opinions  upon  some  such  considerations  as  these.  They  hold,  in 
the  first  place,  that  the  peculiarities  of  the  atmosphere,  in  Egypt,  where  the  disease 
has  been  found  so  common,  are  siffficient  in  themselves  to  account  for  it.  That  the 
inhabitants  of  that  country  never  dream  of  its  being  caused  by  contagion.  Assalini, 
who  saw  the  complaint  raging  in  the  Frencii  army,  professes  his  behef  that  it  did 
not  arise  or  spread  by  contagion.  He  remarks  that  the  atmospheric  conditions  which 
are  known  to  occasion  catarrhal  affections,  are  very  frequent  and  powerful  in  Egypt: 
the  days  are  very  hot,  the  nights  chilly,  and  attended  with  heavy  dews ;  and  men's 
eyes  are  perpetuall}'  exposed  in  the  day  time,  to  a  dazzling  glare  of  light  from  the 
white  and  arid  surface,  while  the  air  is  full  of  floating  particles  of  hot  sand,  which 
are  raised  from  the  ground  by  the  sHghtest  breeze.  His  opinion,  therefore,  and  the 
opinion  of  others  who  saw  the  disease  as  it  prevailed  in  that  country,  was,  that  it 
consisted  simply  of  acute  catarrhal  inflammation  of  the  conjunctiva  ;  and  that  it 
affected  those  persons  most  who  were  most  exposed  to  the  exciting  causes  of 
such  inflammation :  the  common  soldiers,  therefore,  more  frequently  than  the 
officers. 

Other  circumstances  adduced  by  the  disbelievers  or  sceptics,  in  respect  to  contagion, 
are  that  many  who  have  intercourse  with  the  sick  escape  the  disease  ;  and  that  when 
bodies  of  men,  among  whom  purulent  ophthalmia  has  been  prevailing  to  a  great 
extent,  are  broken  up  and  dispersed,  the  complaint  is  not  thereby  disseminated,  as 
they  say  it  ought  to  be,  supposing  it  to  be  communicable  from  one  person  to  another; 
that,  in  fact,  this  dispersion,  the  disbanding  of  troops,  for  instance,  and  sending  them 
to  their  friends  and  families  all  over  the  country,  is  the  surest  way  of  stopping  the 
disorder. 

Again,  man)'  inefTectual  attempts  have  been  made  to  inoculate  the  eyes  of  ani- 
mals with  the  matter  of  purulent  ophthalmia.  Miiller,  a  German,  with  that  pains- 
taking industry,  for  which  the  Germans  are  so  remarkable,  collected  on  a  camel's 
hair  pencil  matter  from  the  eyes  of  patients  labouring  under  purulent  ophthalmia, 
early  in  the  morning,  before  they  had  washed  them,  and  inserted  it  under  both  the 
lids  of  each  eye,  in  a  great  number  of  animals,  leaving  the  pencil  there  for  a  few 
seconds,  and  then  pressing  it  so  as  to  squeeze  the  matter  out.  He  also  smeared 
the  pus  copiously  and  repeatedly  along  the  edges  of  the  lids.  He  served  in  this 
way  five  cats,  ten  dogs,  two  rabbits,  two  squirrels,  two  blackbirds,  a  starling,  a 
yellow-hammer,  and  a  cock.  And  in  none  of  them  did  the  inoculation  produce  the 
slightest  effect. 

It  is  a  sufficient  answer  to  these  negative  experiments,  however,  that  other  persons 
were  more  successful  in  producing  the  disease  in  this  manner.  Vasani  and  Grafe 
have  both  excited  it  repeatedly  in  dogs  and  cats,  by  the  application  to  their  eyes  of 
matter  taken  from  human  patients.  And  I  have  already  informed  you  of  many  in- 
■lances  in  which  the  disease  was  generated  in  men  by  accidental,  and  even  by 
intentional  inoculation.  No  amount  of  negative  evidence  can  do  away  with  positive 
testimony  so  often  repeated. 

And  with  respect  to  the  other  objections,  and  especially  the  main  objection,  that 
persons  may  associate  and  hold  close  intercourse  with  individuals  labouring  under 
purulent  ophthalmia  without  contracting  the  disease,  I  would  have  you  remark  that 
this  is  no  more  than  what  continually  happens  in  regard  to  diseases  which  are 
ncknowledged  on  all  hands  to  be  contagious,  and  to  have  no  other  source  at  present, 
iiowever  they  might  have  originated  at  first,  hut  contagion ;  the  small-pox,  for 
example.  I  think  there  is  some  reason  for  believing,  from  the  facts  which  I  have 
been  relating,  that  purulent  ophthalmia,  like  the  small-pox,  is  capable  of  being  com 
tnunioated  from  one  person  to  another,  not  only  by  positive  contact,  but  by  trans- 


PURULENT   OPHTHALMIA.  189 

"nission  of  the  specific  poison  somehow  for  a  short  distance  through  the  air.  Bui 
many  persons  exposed  to  the  contagion  of  smull-pox  escape  it  altogether :  and  more 
persons  still,  perhaps,  fail  to  be  affected,  though  fully  exposed,  at  one  time,  and  yet 
readily  accept  the  disease  at  another  time,  even  when  the  exposure  may  seem  much 
more  slight  than  on  previous  occasions.  Now  what  is  true  of  the  small-pox  may 
be  presumed  to  be  likely,  although,  perhaps,  in  a  different  degree,  of  purulent 
ophthalmia. 

As  to  the  circumstance  that  the  disbanding  of  a  regiment  infected  Avith  the  disease 
prevents  instead  of  favouring  its  dissemination,  that  circumstance  is  really  no  ar- 
gument at  all  against  our  belief  in  its  contagious  nature.  We  shall  see  hereafter, 
that  when  fever  patients  are  collected  in  numbers  in  distinct  wards,  or  in  fever 
hospitals,  that  disease  is  very  apt  to  be  communicated  to  the  nurses  and  medical 
attendants  of  the  sick ;  whereas,  when  such  patients  are  distributed  here  and  there 
among  others,  in  a  general  hospital,  the  disease  is  scarcely  ever  known  to  spread. 
In  the  one  case  the  poison  is  concentrated  and  effeciive,  in  the  other  it  is  diluted 
and  harmless. 

Dr.  Mackenzie,  indeed,  has  come  to  the  conclusion,  from  what  he  has  himself 
observed,  that  the  discharge  in  catarrhal  ophthalmia,  especially  when  it  is  distinctly 
puriform,  if  conveyed  from  the  eyes  of  the  patient  to  those  of  others  by  the  fingers, 
or  by  towels,  and  so  forth,  is  capable  of  exciting  inflammation  of  the  conjunctiva, 
still  more  severe,  more  distinctly  puriform,  and  more  dangerous,  than  was  the  original 
ophthalmia.  And  with  respect  to  the  disease  which  1  have  been  speaking  of  as 
purulent  ophthalmia,  or  Egyptian  ophthalmia,  the  author  calls  it  contagious  oph- 
thalmia; he  holds  that  the  mflammation  of  the  conjunctiva,  whether  in  the  mild  or 
the  more  severe  form,  may  and  often  does  originate  from  common  atmospheric  in- 
fluences ;  but  that,  when  so  caused,  it  may  be  communicated  from  person  to  person, 
especially  when  it  is  attended  with  a  puriform  discharge. 

And  this  is  an  opinion  which,  I  think,  is  fully  warranted  by  the  facts  which  we 
are  in  possession  of  upon  this  subject.  There  is  a  strange  reluctance,  which  I  have 
never  been  able  to  account  for,  in  some  medical  men,  to  admit  of  the  operation  of 
contagion,  as  a  cause  of  disease.  Undoubtedly  there  are  some  difficulties  belonging 
to  the  doctrine  of  contagion,  and  I  hope  in  the  progress  of  the  course,  and  especially 
when  I  come  to  speak  of  fever,  to  give  that  subject  the  careful  attention  which  its 
great  importance  demands ;  and  to  enable  you  to  make  up  your  minds  respecting  it. 
At  present  I  will  only  remark,  that  there  is  nothing  absurd,  nor  unlikely  in  the  sup 
position,  that  diseases  may  first  arise  from  some  other  source,  and  then  become 
capable  of  spreading  by  contagion ;  and  that  in  all  cases,  even  when  the  contagious 
principle  is  most  manifest,  there  seems  to  be  something  else  required  besides  the 
presence  of  contagious  matter ;  there  must  be  a  readiness  to  receive  it,  a  suscep- 
tibility of  its  influence,  on  the  part  of  the  person  exposed  to  it :  a  predisposition  which 
is  less  common  in  regard  to  some  diseases  than  to  others  ;  but  without  which  there 
is  scarcely  any  complaint  that  can  be  so  propagated. 

At  any  rate  I  would  desire  to  impress  upon  you  the  expedience  and  propriety  of 
acting  whatever  your  doubts  or  your  belief  may  be,  'upon  the  safe  side.  We  are 
bound  to  proceed,  in  all  questionable  cases  of  this  kind,  upon  the  most  unfavourable 
supposition.  Very  great  discredit  and  loss  of  reputation  have  fallen  upon  practi- 
tioners who,  having  themselves  no  belief  that  a  given  complaint  was  contagious, 
have  neglected  those  precautions  which,  under  a  contrary  impression,  they  would 
have  thought  necessary.  Perhaps  they  may  have  sometimes  suffered  utijustly ;  but 
you  had  better  not  commit  yourselves,  especially  while  you  are  young  in  years  and 
in  experience,  by  strong  assertions  of  the  non-contagiousness  of  any  disease,  the 
mode  of  propagation  of  which  is  at  all  questionable.  And  as  for  the  disease  ;/iat  we 
are  now  concerned  with,  you  will  do  wefl  to  act  as  thougn  it  were  certainly  conta- 
gious ;  whether  you  meet  with  :t  as  a  sporadic  or  as  an  epidemic  complaint :  whether 
it  be  severe  in  its  symptoms,  or  mild.  You  should  forbid  the  use  of  your  patient's 
towels  and  washing  vessels  by  other  members  of  the  family ;  you  should  avoid  em- 
ploying the  same  instruments  or  sponges  to  any  sound  eye,  which  you  have  been 
using  for  one  that  is  affected  with  this  complaint ;  and  you  should  take  care  to  wash 


190  DISEASES    OF   THE    EYE. 

your  own  hands,  after  touching  a  diseased  eye,  before  you  apply  your  fingers  to 
another  that  is  yet,  in  this  respect,  healthy. 


LECTURE   XVIII, 


Purulent    Ophthalmia,    continued.      Gonorrhceal   Ophthalmia!     Purulent   Oplv- 
thalmia  of  Infants.     Strumous  Ophthalmia. 

When  we  last  met,  I  spoke  of  catarrhal  ophthalmia,  i.  e.,  a  mild  and  common 
form  of  inflammation  of  the  conjunctiva,  resulting  from  atmospheric  influences.  I 
described  its  characteristic  symptoms,  and  explained  the  treatment  that  has  been 
found  most  successful  for  its  cure  ;  consisting  chiefly  in  local  stimulating  or  astrin- 
gent applications. 

I  began  also  to  speak  of  the  severer  forms  of  inflammation  affecting  the  same  part, 
and  included  under  the  head  of  jmrulent  ophthalmia.  The  symptoms  and  course 
and  consequences  of  the  two  varieties  of  this  complaint,  as  it  occurs  in  adults,  are 
so  essentially  the  same,  that  one  description  of  its  phenomena  is  enough.  There  are 
certain  differences,  however,  that  require  to  be  noticed,  in  respect  to  its  exciting 
causes.  I  laid  before  you  the  reasons  Avhich  satisfy  me,  that  what  is  called  the 
Egyptian  ophthalmia  is  a  contagious  disease  ;  and  which  make  it  probable  that  the 
complaint  is  capable  of  being  propagated  from  person  to  person,  through  the  medium 
of  the  air,  without  the  necessity  for  any  substantial  application  of  the  morbid  secre- 
tion from  a  diseased  to  a  sound  eye.  These  reasons,  briefly  stated,  are  as  follows  : 
that  the  disease  was  unknown  in  Europe  till  after  the  war  in  Egypt ;  that,  arising 
among  our  own  and  the  French  troops  in  that  country,  it  was  conveyed  by  them 
to  various  places,  and  extended  itself  to  soldiers  who  had  intercourse  with  those 
troops ;  that  when  once  introduced  it  spreads  rapidly  wherever  men  are  crowded 
together  within  a  small  compass,  pay  insufficient  attention  to  cleanhness,  and  use 
the  same  towels  and  utensils ;  that  it  has  been  propagated  again  and  again  by  the 
direct  application  of  the  morbid  secretion ;  and  that  its  progress  is  checked  by 
measures  that  provide  against  such  accidental  apphcation,  and  by  separating  the 
diseased  from  the  healthy. 

On  the  other  hand,  it  has  been  contended  that  the  disease  is  nothing  more  than 
an  extreme  degree  of  catarrhal  ophthalmia ;  that  the  peculiar  conditions  of  the 
atmosphere  in  Egypt  and  other  hot  countries,  where  it  is  prevalent,  are  enough  to 
account  for  it ;  and  that  when  troops  are  disbanded,  they  do  not  give  the  disease  to 
their  friends  and  families  all  over  the  country,  but,  on  the  contrary,  the  dispersion  of 
the  sick  in  this  way  is  the  most  efl^ectual  mode  of  stopping  the  disease. 

To  these  arguments  the  proper  answer  is,  that  the  same  difficulties  meet  us  in. 
respect  to  some  other  diseases  which  are  confessed  by  all  persons  to  be  strictly  con 
tagious. 

My  own  creed  upon  the  matter  is  this — that  the  disease  may,  and  often  does  arise, 
independently  of  contagion,  from  the  agency  of  ordinary  causes  of  inflammation , 
and  that  having  so  originated,  it  acquires  contagious  properties,  which  develop  them- 
selves only  under  circumstances  that  favour  the  propagation  of  most  of  the  contagious 
rompiaints. 

I  shall  next  advert  to  purulent  ophthalmia  as  it  is  observed  to  occur,  in  the  adult, 
m  connection  with  gonorrhoea.  If  we  look  to  the  mere  phenomena  presented  by 
the  inflamed  eye,  we  find  nothing  to  distinguish  the  gonorrhceal  from  the  Egyptian 
ophthalmia.  Taking  the  average  of  a  large  number  of  cases,  the  gonorrhceal  is  the 
severer  form  of  the  two,  and  runs  the  more  rapid  course.  It  is  said,  also,  that  the 
inflamniation  usually  commences  on  the  lids  in  the  Egyptian  variety,  while  it  attacks 
the  whole  conjunctiva  at  once  in  the  gonorrhceal.  But  comparing  individual  in- 
stances, these  mere  differences,  and  slight  differences,  too,  in  degree  and  situation, 
•rill  not  help  our  diagnosis 


GONORRHCEAL  OPHTHALMIA.  191 

But  other  circumstances  may  guide  us.  If  a  patient  presents  himself  with 
severe  purulent  ophthalmia,  who  has  not  been  exposed  to  any  of  the  known  atmo- 
spheric causes  of  that  disease,  and  at  a  time  when  purulent  ophthalmia  is  not  pre- 
vailinjT  as  an  epidemic,  and  if  this  patient  have  a  clap,  we  may  conclude  that  we 
have  to  deal  with  a  case  of  gonorrlireol  ophthalmia  ;  and  this  conclusion  will  be  fur- 
ther strengthened  if  the  disease  affects  one  eye  only.  For  what,  through  the  lack 
of  any  better  nomenclature,  I  am  constrained  to  call  Egyptian  ophthalmia,  seldom 
restricts  itself  to  a  single  eye.  Dr.  Vetch  says,  "  there  is  but  one  case  in  a  thousand 
in  which  one  eye  only  becomes  affected."  Walther  observes  that  contagious  oph- 
thalmia almost  always  appears  in  both  eyes  together,  but  not  in  the  same  degree ; 
and  Eble  (another  German  author)  states  that  the  contagious  ophthalmia  has  not 
confined  itself  to  one  eye  in  any  instance.  These  round  assertions  require,  how- 
ever, some  qualification  ;  the  nurses,  whose  cases  I  quoted  in  the  last  lecture  from  Sir 
Patrick  Macgregor's  paper,  suffered  each  in  one  eye  only.  On  the  other  hand, 
gonorrhoea!  ophthalmia  mostly,  but  by  no  means  always,  is  hmited  to  one  eye.  In 
Mr.  Lawrence's  instructive  book  On  the  Venereal  Diseases  of  the  Eye,  he  mentions 
fourteen  cases  of  gonorrhoeal  ophthalmia.  In  nine  of  these,  one  eye  only  was 
inflamed. 

It  is  always  a  matter  of  some  interest  to  make  out  whether  the  disease  h^is  or  has 
not  any  connection  with  gonorrhcea ;  even  though  we  may  gain  nothing,  in  vespect 
to  the  treatment,  by  the  distinction. 

Purulent  ophthalmia  has  been  said  to  be  connected  with  gonorrhoea  in  three  seve- 
ral ways ;  1st,  by  direct  contact  of  the  gonorrhceal  discharge  from  the  urethra  with 
the  conjunctiva ;  2d,  by  metastasis  of  the  inflammation  from  the  urethra  to  the  eye, 
without  any  such  contact  of  matter;  and  8d,  independently  of  either  of  these  ways; 
i.  e.,  purulent  ophthalmia  has  been  supposed  to  occur  in  connection  with  clap,  just 
as  ulceration  of  the  throat  is  apt  to  occur  in  venereal  diseases. 

Now  the  last  two  of  these  three  modes  of  origin  are  more  or  less  questionable ; 
the  first  is  certain. 

Very  odd  speculative  opinions  are  apt  to  possess  themselves  of  the  minds  of  medi- 
cal as  well  as  of  other  philosophers.  Some  who  believe  that  the  disease  is  commu- 
nicable by  direct  contact  of  gonorrhoeal  matter  to  the  eye,  yet  hold  that  it  must  come 
from  the  urethra  of  another  person ;  that  the  Hudibrastic  aphorism  is  true,  "  No 
man  of  himself  doth  catch."  Dr.  Vetch  seems  to  have  fallen  into  this  opinion 
through  the  very  common  mistake  of  drawing  positive  conclusions  from  negative 
experiments.  He  had  known  a  hospital  assistant  who,  "  with  more  faith  than  pru- 
dence," conveyed  the  matter  of  gonorrhoea  from  his  urethra  to  his  eyes,  with  impu- 
nity. He  states  also  the  converse  experiment :  a  soldier  in  a  very  advanced  stage 
of  Egyptian  ophthalmia,  attempted  to  divert  the  disease  from  his  eyes  by  applying 
some  of  the  matter  they  were  discharging  to  the  orifice  of  his  urethra :  no  effect 
followed  this  trial.  But  in  another  case  the  matter  take>.  from  the  eye  of  one  man, 
labouring  under  purulent  ophthalmia,  was  applied  to  the  urethra  of  another  man ; 
and  inflammation  commenced  there  in  thirty-six  hours,  and  he  had  a  very  severe 
attack  of  gonorrhoea.  Some  persons,  judging  from  such  cases  as  this,  and  from  the 
similarity  of  the  discharge  in  the  two  diseases,  "  have  gone  the  length  of  concluding 
(according  to  Dr.  Mackenzie)  that  gonorrhoea  has  been  originally  an  inocula-tion  oi 
the  urethra  by  the  matter  derived  from  the  eye  in  the  Egyptian  ophthalmia ;  whilst 
others  are  of  opinion  that  this  last  disease  is  nothing  else  than  the  effect  of  an  inocu- 
lation of  the  conjunctiva  with  matter  from  the  urethra  in  gonorrhoea." 

To  satisfy  you  that  a  person  may  "catch"  the  complaint  from  himself,  or  from 
others,  it  is  right  that  I  should  bring  before  you  one  or  two  well-marked  cases. 

It  is  a  common  persuasion,  among  the  lower  classes,  that  to  bathe  the  eyes  in 
human  urine  is  good  for  the  sight.  This  piece  of  practice  has  cost  several  persons 
their  vision.  A  gentleman  belonging  to  the  class  mentioned  to  me  the  other  day  two 
cases  of  purulent  ophthalmia  so  produced,  which  he  had  seen  among  Mr.  Guthrie's 
patients  at  the  Ophthalmic  Hospital.  In  the  one,  a  young  woman,  not  so  healthy  as 
she  ought  to  have  been,  used  her  own  water :  in  the  other,  an  older  woman,  for 
what  reason  it  did  not  appear,  preferred  her  husband's  to  her  own.     Mr.  Lawrencu 


192  DISEASES    OF    THE    EYE. 

alludes  to  several  similar  cases.  He  details  an  instance  also,  in  which  partial  slough- 
ing of  one  cornea  occurred;  the  disease  having  been  caused  by  the  patient's  wiping 
his  e3'es  with  a  towel  soiled  with  the  gonorrha:;al  discharge  from  his  own  urethra. 
But  one  of  the  neatest  and  most  conclusive  examples  of  the  production  of  the  dis- 
ease in  this  way  has  been  furnished  by  Dr.  Mackenzie.  A  patient  was  brought  to 
him  from  the  country  with  his  left  eye  violently  inflamed  and  chemosed,  and  dis- 
charging a  large  quantity  of  purulent  fluid ;  the  lower  Hd  everted,  and  the  cornea 
totally  opaque.  Thirteen  days  before,  this  man,  who  had  then  a  profuse  gonorrhoea, 
but  whose  eyes  were  perfectly  well,  while  stooping  down  and  shaking  away  the  dis- 
charge from  his  penis,  flung  a  drop  of  it  fairly  into  his  left  eye.  Violent  inflamnia- 
mation  immediately  set  in,  was  confined  to  the  eye  that  was  thus  inoculated,  and 
produced  the  rcsuks  I  have  mentioned  :  the  gonorrhoea  going  on  just  as  before. 

Numerous  authentic  cases  have  been  recorded  of  gonorrhoeal  ophthalmia  produced 
by  the  application  to  the  eye  of  gonorrhoeal  matter  from  another  individual.  Mr. 
Wardrop  met  with  the  following  example.  An  old  lady  went  into  the  dressing-room 
of  her  son,  who  had  gonorrhoea,  and  washed  her  face  with  a  towel  which  he  had 
recently  heen  making  use  of.  Purulent  ophthalmia  quickly  supervened,  and  de- 
stroyed the  eye  in  a  few  days.  Delpech  mentions  the  instance  of  a  young  and 
healthy  woman,  who  bathed  her  eyes  with  goulard  water,  by  means  of  a  sponge 
which  had  been  used  by  a  young  man  who  had  a  clap :  violent  inflammation  soon 
arose,  and  the  sight  of  one  eye  was  lost.  Several  cases  of  purulent  ophthalmia 
have  been  observed  in  laundresses,  who  had  been  employed  in  washing  linen  fouJ 
with  the  discharge  of  gonorrhoea. 

Mr.  Lawrence  seems  to  be  of  opinion  that  purulent  ophthalmia  is  not  a  very  fre- 
quent consequence  of  the  application  of  the  urethral  discharge  to  the  eye  of  the 
same  person.  "  When  we  consider,"  he  says,  "  how  this  matter  is  diffused  over 
the  linen  of  patients,  both  male  and  female,  how  often  the  fingers  must  be  smeared 
Avith  it,  and  how  inattentive  to  cleanliness  the  lower  classes  are,  we  cannot  help 
concluding  that  the  gonorrhoeal  discharge  must  be  often  applied  to  the  eyes  of  the 
same  individual;  yet  gonorrhoeal  ophthalmia  is  comparatively  rare."  Dr.  Macken- 
zie, on  the  other  hand,  thinks  that  the  application  of  the  matter  to  the  eye  is  seldom 
made.  "The  instinctive  closure  of  the  eyelids,"  he  observes,  "  when  the  finger 
approaches  the  eye,  making  it  actually  difficult  for  a  person  to  touch  his  own  con- 
junctiva, unless  with  one  finger  he  draws  down  the  lower  lid,  and  intentionally 
applies  another  finger  to  the  eye,  will  serve  in  some  measure  to  explain  the  rarity  of 
this  kind  of  inoculation." 

It  has  been  noticed  that  women  are  much  less  frequently  the  subjects  of  gonor- 
rheal ophthalmia  than  men. 

Does  gonorrhoeal  ophthalmia  ever  occur  by  metastasis  ?  This  question  does  not 
admit  of  a  positive  answer.  Practical  men  are  divided  in  opinion  on  the  subject. 
In  the  majority  of  cases  of  gonorrhoeal  ophthalmia,  we  are  unable  to  trace  any  appli- 
cation of  the  urethral  discharge  to  the  eye,  either  from  the  same  or  from  another 
individual.  Yet  it  does  not  follow  that  no  such  application  took  place.  The  Ger- 
man and  Italian  writers  believe  in  metastasis.  "In  all  the  instances,"  says  Beer. 
"  which  I  have  seen,  this  ophthalmia  has  occurred  in  young,  plethoric,  robust,  and 
truly  athletic  men  ;  and  it  has  always  taken  place  in  a  very  short  time,  generally  in 
a  few  hours,  after  the  suppression  of  gonoirhceal  discharge  from  the  urethra."  Mr. 
Lawrence  never  knew  the  urethral  discharge  stop  upon  the  coming  on  of  the  oph- 
thalmia ;  it  has  generally  diminished,  but  in  some  instances  has  continued  as  copi- 
ous as  before.  He  seems  to  regard  the  occurrence  of  the  ophthalmia  as  analogous 
to  those  successive  attacks  of  distant  parts  that  are  common  in  gout  and  rheumatism. 
Dr.  Mackenzie  evidently  doubts  the  occurrence  of  metastasis  at  all  in  this  disease, 
and  IS  inclined  to  refer  all  the  cases  in  which  it  has  been  alleged,  to  inoculation,  or 
to  an  accidental  occurrence  of  purulent  ophthalmia  and  gonorrhoea  in  the  same 
person. 

The  supervention  of  purulent  ophthalmia  as  a  part  of  the  gonorrhoeal  malady, 
independently  of  inoculation  and  of  metastasis,  seems  to  me  extremely  problematical. 
The  eye  is  well  known  to  suffer,  as  well  as  other  organs,  in  the  secondary  forms  of 


GONORRHCEAL  OPHTHALMIA.  193 

syphilitic  disease,  but  the  conjunctiva  is  not  the  part  that  is  attacked.  I  have  never 
seen  nor  heard  of  any  satisfactory  example  of  purulent  ophthalmia  alternating  with 
gonorrhoea,  Avhere  the  possibility  of  inoculation  was  excluded.  And,  upon  the 
whole,  my  own  opinion  —  (you  will  take  it  for  whatever  it  may  seem  worth)  — is 
against  the  existence  of  this  alleged  form  of  purulent  ophthalmia.  Whether  it  exists 
or  not  is  of  very  little  consequence  in  regard  to  the  main  question ;  namely,  w^iat  is 
the  proper  mode  of  treating  the  purulent  ophthahnia  of  adults  i^ 

Now  the  two  chief  points  to  consider,  so  far  as  respects  the  treatment,  are — first, 
blood-letting;  and  secondly,  the  application  of  strong  astringents  to  the  inflamed 
membrane. 

Blood-letting  has  been  carried  to  a  very  great  extent  in  this  disease,  or  in  these 
diseases,  if  you  choose  to  consider  the  Egyptian  purulent  ophthalmia  and  the  gonor- 
rhoea! purulent  ophthalmia  as  two  different  inflammations.  Its  effects  have  not  been 
very  decisive  or  satisfactory  ;  indeed,  we  could  hardly  expect  that  they  would.  In 
the  first  place  the  inflammation  is  so  rapidly  destructive,  that,  in  many  of  the  worst 
cases,  irreparable  mischief  is  done  before  the  patient  applies  for  medical  assistance. 
In  forty-eight  hours,  or  a  little  more,  Mr.  Lawrence  tells  us,  the  affection  may  have 
proceeded  to  such  an  extent  as  to  be  beyond  our  control.  Of  course  this  reason  for 
the  want  of  success  is  equally  applicable  to  every  remedy  that  has  been,  or  could 
be,  proposed.  But  independently  of  this,  even  when  the  disease  is  seen  and  sub- 
mitted to  treatment  in  its  very  beginning,  we  should  have  the  less  confidence  in  the 
power  of  general  blood-letting  to  control  it,  for  these  two  reasons :  that  the  pari 
affected  is  a  mucous  membrane  ;  and  that  there  is  so  little  constitutional  sympathy 
with  the  local  inflammation.  Free  venesection  tells  most  upon  inflammation,  when 
it  is  attended  with  fever  and  a  hard  pulse,  i.  e.,  with  increased  action  of  the  heart : 
which  the  abstraction  of  blood  tends  to  abate.  It  is  also  a  matter  of  experience,  that 
general  bleeding  has  more  influence  over  the  inflammation  of  serous  and  fibrous 
raembranes  than  over  that  of  the  mucous  tissues.  Accordingly,  though  bleeding 
has  been  even  lavishly  employed  in  purulent  ophthalmia,  it  has  too  often  disap- 
pointed the  practitioner.  There  is  one  lesson,  however,  to  be  learned  from  copious 
blood-letting  in  this  disease,  even  when  it  fails  of  its  object.  It  clearly  demonstrates 
what  may  be  hoped  for,  by  having  recourse  to  that  measure  in  internal  inflamma- 
tions. "  You  see  a  person,"  says  Mr.  Lawrence,  who  has  both  had,  and  used 
freely,  very  numerous  opportunities  of  putting  this  remedy  to  the  test,  "  you  see  a 
person  with  his  eye  bright  red,  and  very  painful ;  he  cannot  face  the  light,  and  tears 
gush  out,  with  great  suffering,  if  he  attempts  to  do  so.  You  bleed  to  fainting,  and 
immediately  the  capillaries  are  emptied,  so  that  the  organ  resumes  its  natural  pale- 
ness ;  the  pain  is  gone,  the  eye  is  opened  without  difficulty,  and  the  full  influx  of 
hght  can  be  borne  without  an  uneasy  sensation.  For  the  time  the  part  has  passed 
from  violent  inflammation  to  a  nearly  natural  state.  With  the  restoration  of  the 
circulation  the  inflammation  will  recur  after  this  temporary  suspension  ;  but  its  vio 
lence  is  diminished,  and  it  often  gradually  abates."  Mr.  Lawrence  is  here  speaking 
of  acute  inflammation  affecting  the  textures  of  the  eye  generally,  and  not  of  purulent 
ophthalmia  in  particular;  but  I  am  desirous  that,  in  passing,  you  should  take  notice 
of  this  direct  effect  of  bleeding  to  syncope,  upon  the  capillaries  of  the  eye,  because' 
it  teaches  us  what  the  same  expedient  may  do  for  the  capillaries  of  any  other  inter- 
nat  part,  which  we  cannot  see-,  when  that  part  is  attacked  with  inflammation.  In 
purulent  ophthalmia,  however,  if  you  trusted  to  bleeding  alone,  you  would  often 
reduce  your  patient  to  a  very  dangerous  state  of  weakness,  and  after  all  fail  of  your 
mark.  Dr.  Vetch  bears  strong  testimony  to  the  usefulness  of  blood-letting  when 
freely  employed  in  the  early  stages  of  Egyptian  ophthalmia;  and  certainly  it  ought 
never  to  be  neglected.  In  the  very  onset  of  the  disease,  it  will  aid  the  local  expe- 
dients which  I  shall  presently  mention  ;  and  if  the  patient  be  not  seen  till  the  globe 
of  the  eye  is  invisible  for  the  swelling,  the  propriety  of  general  bleeding  will  be  still 
further  indicated  by  the  occurrence  of  throbbing  and  circumorbital  pain,  returning 
in  nncturnul  paroxysms ;  for  this  symptom  denotes  that  the  inflammation  has  de- 
scended deeper  than  the  conjunctiva.  The  bleeding  should  be  performed  in  the  way 
I  formerly  spoke  of  as  being  required  in  serous  inflammation:  the  patient  should  b'" 

V.\  R 


194  DISEASES    OF    THE    EYE. 

bled  from  the  ami  In  an  upright  position,  till  fainting  is  about  to  ensue,  or  the  pulse 
begins  to  falter.  You  will  do  more  towards  obtaining  safety  for  your  patient's  vision 
in  this  way,  and  at  less  expense  of  his  strength,  than  by  bleeding  him  manj'  times 
to  a  smaller  amount.  The  bleeding  ad  ddiqinum  may  require  to  be  once  or  twice 
repeated ;  and  when  the  patient  begins  to  rally  from  his  faintness,  from  twelve  to 
twenty-four  leeches  may  often  be  applied  with  advantage;  round  i\\e  eye  and  not 
ripoii  the  tumid  lids,  where  their  bites  are  apt  to  add  to  the  existing  irritation,  and  to 
fester.  You  had  better  bleed  your  patient  from  the  arm,  and  not  from  the  jugular 
vein,  or  the  temporal  artery,  for  reasons  which,  as  I  have  fully  stated  them  already, 
I  need  not  now  repeat. 

But  of  late  years,  more  reliance  has  been  placed  by  many  practitioners  upon  local 
stimulants,  for  checking  this  horrible  malady,  than  upon  general  or  topical  bleeding. 
Dr.  Vetch  strongly  recommended  the  insertion  o'i  imdihded  liquor  jdinnbi  accfalis  ; 
and  Mr.  Briggs,  in  his  translation  of  a  work  of  Scarpa  on  the  eye,  advised  the  intro- 
duction of  a  very  minute  quantity  of  the  oil  of  turpentine  between  the  eyelids.  But 
Mr.  Guthrie  has  the  merit  of  having  applied,  in  its  full  extent,  this  principle  of 
curing  conjunctival  inflammation,  even  in  its  severes-t  forms,  by  stimulant  and  astrin- 
gent substances.  I  told  you,  when  speaking  of  catarrhal  ophthalmia,  that  Mr.  Melin 
and  Dr.  Mackenzie  treat  that  complaint  with  a  wash,  made  by  dissolving  four  grains 
of  lunar  caustic  in  an  ounce  of  distilled  water.  I  might  have  added  other  authorities 
in  favour  of  the  same  kind  of  practice.  Now  Mr.  Guthrie  treats  purulent  ophthal- 
mia on  the  same  principle,  but  with  a  much  larger  dose  of  the  nitrate  of  silver.  The 
greater  intensity  of  the  disorder  is  met  by  increasing  the  strength  of  the  remedy.  He 
considers  it  to  be  a  local  disease  of  a  pecuhar  character ;  and,  acting  upon  the  aphor- 
ism of  John  Hunter  (an  aphorism,  however,  which  requires  som.e  quaUfication)  that 
two  diseases  or  actions  cannot  go  on  in  a  part  at  the  same  time,  he  proposes  to  set 
up  in  the  inflamed  conjunctiva  a  new  action,  which  shall  supersede  the  original  dis- 
ease, and  create  another  that  is  more  manageable.  In  this  point  of  view  Mr.  Guth- 
rie's ratio  mcdendi  agrees  with  that  of  Hahnemann,  about  which  there  has  been  so 
absurd  a  noise  made  of  late.  I  have  never  had  the  advantage  of  seeing  Mr.  Guth- 
rie's plan  tried,  but,  from  all  that  I  have  heard  of  it,  I  beheve  it  to  be  a  valuable  dis- 
covery. A  priori,  we  should  expect  that  the  caustic  application  would  add  to  the 
existing  mischief,  and  destroy  all  chance  of  saving  the  inflamed  ej'e.  But  it  is  not 
so.  Even  Mr.  Lawrence,  Avho  v/as,  I  have  reason  to  think,  formerly  very  sceptical 
on  this  point,  appears  to  be  so  no  longer.  In  his  treatise  On  the  J'enereal  Diseases 
of  the  Eye,  he  uses  this  cautious  language  : — "  Destructive  or  injurious  consequenres 
have  so  frequently  resulted  under  the  usual  management  of  this  disease"—  he  i^ 
speaking  of  gonorrhoea!  ophthalmia  —  "chat  I  should  certainly  employ  the  local 
astringent,  if  I  met  with  a  case  favourable  for  the  trial ;  i.  e.,  where  the  affection  had 
not  extended  beyond  the  conjunctiva.  Blood-letting  might  be  resorted  to  at  the  same 
time ;  in  moc^  cases,  however,  our  aid  is  not  sought  until  the  cornea  has  become 
affected,  and  it  is  therefore  too  late  for  the  astringent  plan."  But  he  subsequently 
added  a  note,  to  the  effect  that  after  the  statement  I  have  just  quoted  was  written,  he 
had  employed  the  caustic  solution  in  two  cases  of  conjunctival  inflammation  with  the 
best  result. 

Mr.  Guthrie's  plan,  therefore,  you  ought  to  be  acquainted  with.  After  many 
trials,  he  has  arrived  at  the  conclusion  that  the  best  appliance,  in  this  formidable 
complaint  is  an  ointment,  made  by  mixing  ten  grains  of  the  nitrate  of  silver,  reducec 
tu  an  impalpable  powder,  with  a  drachm  of  hog's  lard.  This  is  what  he  calls  his 
ten-grain  ointment. 

Before  applying  it  to  the  diseased  eye,  the  discharge  must  be  well  cleansed  away 
Dy  a  solution  of  alum  ;  then  the  ointment  having  been  inserted  beneath  the  lids,  they 
are  to  be  moved  freely  up  and  down,  so  that  the  whole  conjunctiva  may  get  its  due 
share  of  the  remedy  ;  and  that  it  has  done  so  is  shown  by  its  turning  white.  If  the 
surface  does  not  turn  white,  the  ointment  has  not  been  sufficiently  applied,  and  will 
iioi  answer  the  purpose.  If  we  wish  to  be  quite  sure,  he  says,  we  turn  out  the 
eyelids,  and  rub  the  ointment  on  them.  This  application  gives  pain,  which  lasts 
for  half  an  hour  or  an  hour,  or  more.     "  Warm  narcotic  fomentations  may  be  em- 


PURULENT   OPHTHALMIA.  195 

ployed  to  relieve  uneasiness,  and  opium  given  to  allay  pain,  and  to  obtain  sleep ; 
while  a  solution  of  alum,  in  the  proportion  of  a  drachm  to  a  pint  should  be  injected 
from  time  to  time  into  the  eye,  to  clear  it ;  but  should  the  patient  sleep,  he  must  not 
be  disturbed.  A  mild  ointment  may  be  applied  to  the  edges  of  the  lids  at  night,  to 
prevent  their  stickin'^  to^Tether.  The  next  morning  the  discharije  is  again  to  be  re- 
moved  and  the  ointment  to  be  reapphed ;  for  on  no  account  should  the  action  we  are 
desirous  of  exciting  be  allowed  to  cease."  Of  course  Mr.  Guthrie  means  it  is  not 
to  be  suffered  to  cease  prematurely.  This,  with  free  but  not  excessive  venesection, 
is  the  substance  of  his  peculiar  mode  of  treating  purulent  ophthalmia  ;  and  it  appears 
to  have  been  eminently  prosperous  in  his  hands.  I  have  been  informed,  by  one  of 
yourselves,  that  purulent  ophthalmia  has  been  successfully  treated,  on  a  large  scale, 
in  Manchester,  by  applying  the  nitrate  of  silver,  in  substance,  to  the  surface  of  the 
conjunctiva;  that  this  gives  less  pain  than  the  ten-grain  ointment,  though  perhaps  it 
may  require  to  be  oftener  repeated. 

I  say  I  have  never  seen  this  method  of  Mr.  Guthrie's  carried  into  effect ;  but  after 
what  I  have  myself  witnessed  of  the  intractable  and  destructive  nature  of  the  dis- 
ease, under  the  treatment  ordinarily  adopted  before  his  ointment  was  devised,  I  will 
say  also  that  were  I  so  unfortunate  as  to  be  attacked  v/ith  severe  purulent  ophthalmia, 
I  should  desire  to  have  the  caustic  applied  as  soon  as  possible,  and  to  be  freely  bled 
at  the  same  time. 

There  are  some  minor  points  in  the  treatment  that  require  a  cursory  notice 
only. 

Some  persons,  and  Mr.  Guthrie  among  the  rest,  recommend  the  exhibition  of 
mercury,  so  as  to  affect  the  gums.  Now  I  beheve  that  mercury  is  quite  useless  in 
this  complaint;  and  if  useless,  mischievous.  The  disease  is  too  rapid  to  be  over- 
taken by  the  mercury,  and  if  you  could  obtain  the  specific  influence  of  that  mineral 
in  time,  i.  c,  before  any  of  the  destructive  effects  of  the  inflammation  were  accom- 
plished, you  would  do  no  good  thereby.  This  is  not  the  kind  of  inflammation  over 
which  mercury  exercises  any  useful  control.  Mr.  Lawrence  tells  us  that  he  hag 
seen  both  the  ordinary  purulent,  and  gonorrhoea!  ophthalmia,  proceeding  apparently 
unchecked,  under  the  full  mercurial  action. 

Practical  men  are  not  agreed  about  the  propriety  of  scarifying  the  conjunctiva 
when  it  is  swelled  and  elevated  by  chemosis.  Mr.  Lawrence  objects  to  it,  as  likely 
to  increase  the  local  iritation ;  a  disadvantage  not  compensated  by  the  quantity  of 
blood  discharged  from  the  divided  vessels.  Dr.  Mackenzie  recommends  it,  stating 
that  the  incisions  will  bleed  copiously,  and  greatly  allay  the  symptoms.  Who  shall 
decide  in  this  puzzhng  discrepancy  of  opinion  ?  Mr.  Guthrie's  caustic  ointment 
would,  I  presume,  supersede  any  other  meddling  with  the  inflamed  surface.  But 
when  the  question  happens  to  lie  between  scarification  and  no  scarification,  I  should 
give  my  vote  for  scarifying:  not  because  I  think  any  useful  depletion  of  the  blood- 
vessels could  be  brought  about  by  that  measure,  but  because,  if  properly  performed, 
it  would  evacuate  the  serous  effusion  from  the  areolar  tissue  between  the  conjunc- 
tiva and  the  sclerotic,  which  effusion  constitutes  the  chemosis,  and  hastens,  if  it  does 
not  cause,  the  sloughing  of  the  cornea,  by  the  mechanical  pressure  that  it  exerts 
around  it. 

Are  blisters  of  any  use?  Hear  Dr.  Mackenzie.  "Counter-irritants  are  highly 
serviceable  in  this  disease,  and  ought  always  to  be  employed.  There  is  generally  a 
marked  change  in  the  quantity  and  appearance  of  the  discharge  from  the  eye,  as 
soon  as  a  counter-discharge  is  established  by  blisters  on  the  temples,  nape  of  the 
neck,  or  behind  the  ears."  But  listen  to  Mr.  Lawrence.  "Experience  does  not 
warrant  us  in  ascribing  much  efficacy  to  blisters^  Now  the  truth  is,  I  believe,  thai 
during  the  active  stage  of  the  disease,  blisters  are  not  of  any  use ;  but  that  in  the 
more  advanced  and  chronic  periods,  they  are.  Indeed,  Mr.  Lawrence  admits  thai 
they  may  be  regarded  as  auxiliary  measures,  and  resorted  to  after  antiphlogistic 
means. 

I  agree  with  the  same  gentleman  in  thinking  that  no  reliance  is  to  be  placea,  m 
gonorrhoea!  ophthalmia,  upon  any  attempts  to  reproduce  the  urethral  discharge  , ' 
indeed,  in  most  cases  it  is  not  suspended. 


196  DISEASES    OF   THE    EYE. 

Although  I  have  not  mentioned  purgatives,  you  will  conclude  that  they  form  a 
very  proper  and  necessary  part  of  the  treatment  during  the  activity  of  the  com- 
plaint. 

After  what  has  already  been  said  of  purulent  ophthalmia  in  the  adult,  and 
of  gonorrhceal  ophthalmia,  it  will  not  be  necessary  for  me  to  take  up  very  much 
of  your  time  in  speaking  of  purulent  ophthalmia  as  it  occurs  in  newly-born 
children. 

This  is  a  very  common  disease :  it  is  very  serious  when  neglected :  it  is  very 
eanly  managed  when  it  is  seen  and  treated  in  time.  These  are  all  reasons  why 
you  should  make  yourselves  familiar  with  the  complaint,  and  with  the  mode  of  curing 
it.  You  may  perhaps  never  have  occasion  to  treat  a  case  of  purulent  ophthalmia  in 
the  adult :  you  are  sure  to  be  consulted  about  the  purulent  eye  of  infants,  the  oph- 
thcdmia  neonatorum. 

The  importance  of  the  disorder  is  apt  to  be  overlooked  by  mothers  and  nurses ; 
they  say  the  baby  has  a  cold  in  the  eye,  which  will  go  off;  and  they  wash  it  perhaps 
with  a  little  of  the  mother's  milk,  or  some  such  insignificant  fluid.  Meanwhile  the 
eyelids  swell,  the  mischief  that  is  going  on  beneath  them  is  concealed  from  sight, 
and  when  at  last  a  medical  man  is  consulted,  he  too  often  finds  that  one  of  the  eyes 
has  perished,  or  both :  the  cornea  has  sloughed  or  become  opaque,  or  protrudes,  and 
constitutes  what  is  called  staphyloma ;  prolapse  of  the  iris  has  taken  place  ;  or  the 
coats  of  the  organ  have  shrunk  up. 

The  inflammation  usually  comes  on  about  three  days  after  the  child  is  born, 
although  it  may  commence  later.  It  is  confined,  at  first,  to  that  part  of  the  mem- 
brane which  fines  the  lids.  Their  edges  are  observed  to  stick  together  when  the 
infant  wakes  ;  there  is  more  intolerance  of  light,  apparently,  than  is  suffered  in  the 
analogous  disease  of  adults.  The  little  patients  cannot  indeed  tell  us  their  sensa 
tions  by  words,  but  they  express  them  significantly  enough  by  keeping  their  eyes 
shut,  by  knitting  their  small  brows,  and  by  turning  their  heads  away  from  the 
light.  At  length  the  inflammation  extends  to  the  conjunctiva  that  covers  the  eyeball, 
the  eyelids  swell,  sometimes  enormously :  and  an  astonishingly  copious  discharge  of 
pus  takes  place.  By  the  adhesion  of  the  edges  of  the  lids  the  puriform  matter  is 
sometimes  pent  up,  causing  them  to  protrude ;  and  when  they  are  separated  it 
escapes  in  a  profuse  hot  gush.  The  eyelids  are  sometimes  everted  during  the  cries 
and  struggling  of  the  little  sufferer,  and  their  mucous  surface  is  then  seen  to  be 
villous  and  shaggy,  and  of  as  bright  a  scarlet  as  you  ever  saw  the  injected  mucous 
membrane  of  a  foetal  stomach.  At  last  those  destructive  consequences  to  the  eye 
take  place  which  I  have  already  mentioned.  The  disease,  however,  may  continue 
for  eight  or  ten  days  without  any  affection  of  the  transparent  parts ;  and  so  long 
as  these  remain  uninjured,  the  eye  is  safe,  provided  that  proper  treatment  be 
adopted. 

This  disease  is  probably  much  the  most  fertile  source  of  blindness  with  which  we 
are  acquainted.  It  is  believed  to  originate  most  commonly,  if  not  always,  in  con- 
tajrion.  We  might,  perhaps,  expect  this  from  the  analogy  of  the  severe  inflamma- 
tion of  the  same  parts  in  adults.  And  it  is  a  matter  of  fact,  that  in  a  very  large 
number  of  cases  the  mother  has  been  affected,  at  the  time  of  her  confinement,  with 
some  kind  of  vaginal  discharge  —  leucorrhoea,  or  gonorrhoj^a ;  and  the  eyes  of  the 
children  are  exposed  to  these  morbid  secretions,  as  they  are  brought  into  the  world. 
The  circumstance  of  the  disease  commencing  so  regularly  on  the  third  day,  is 
greatly  in  favour  of  the  supposition  that  it  results  from  inoculation  of  the  eyes  by 
the  unhealthy  fluids  of  the  mother.  The  discharge  from  the  infant's  eyes  has  been 
ascertained  to  be  highly  contagious.  Dr.  Mackenzie  mentions  a  lamentable  illustra- 
tion of  this  fact,  which  fell  under  his  observation  at  the  Ej-e  Infirmary,  in  Glasgow. 
An  infant  and  its  grandfather  became  his  patients  there  at  the  same  time ;  the  latter 
having  been  inoculated  from  the  former.  Both  were  so  severely  affected  that  the 
infant  had  one  eye  left  in  a  state  of  total,  and  the  other  of  partial  staphyloma :  while 
m  each  eye  of  the  old  man,  the  greater  part  of  the  cornea  remained  opaqae,  and 
ndherent  to  the  iris. 

However,  the  disease  certainly  occurs  in  the  infants  of  mothers  who  seem  to  be 


PURULENT    OPHTHALMIA.  197 

nealthy,  and  who  deny  that  they  have  any  unnatural  discharge.  It  may  probably 
be  brought  on,  sometimes,  by  bad  management  on  the  part  of  the  nurse  :  bj''  expo- 
sure soon  after  birlii  to  draughts  of  cold  air,  or  to  the  injurious  influence  of  a  hot  and 
jright  fire  ;  or  by  the  introduction  of  soap  into  the  eye  in  the  primary  ablutions,  or 
vif  gin,  whereof  the  lower  classes,  in  some  absurd  persuasion  of  its  strengthening 
virtues,  are  wont  to  bathe  the  unlucky  infant's  head.  The  disorder  is  observed  to 
')e  mosc  common  in  damp  and  cold  weather ;  in  low  crowded  places ;  and  among 
Jfe  chiluren  of  the  poor. 

[The  reir.aiks  of  Dr.  Watson  on  the  causes  of  purulent  ophthalmia  in  children,  present  a 
brief  sumniaij"  of  all  that  is  positively  known  in  relation  to  the  subject  —  for  further  details, 
'>earing  more  t8^>f!cially  upon  the  question  of  the  production  of  the  disease  in  the  infant  by 
H.  morbid  vaginal  discharge  existing  in  the  mother  at  the  period  of  its  birth,  and  the  circum- 
stances generally,  under  which  the  affection  most  frequently  presents  itself,  the  reader  is 
leferred  to  the  Ed-vor's  Treatise  on  the  Diseases  of  Children.  We  have  not  met  with  a  single 
lact,  during  a  long  aud  somewhat  extensive  practice,  in  proof  of  the  communication  of  the 
i-urulent  ophthalmia  ciI  infants  by  contagion. — C] 

One  striking  difTere^TiCe  between  the  disease  as  it  exists  in  adults  and  in  newly- 
born  children  I  have  iilready  adverted  to;  viz.,  its  rapid  and  often  uncontrollable 
progress  in  the  former;  and  the  facihty  with  which  it  yields  to  suitable  and  timely 
treatment  in  the  latter.  If  a  child  is  brought  to  you  with  purulent  ophthalmia,  and 
you  are  able  to  separate  ihe  lids  sufficiently  to  obtain  a  glimpse  ^f  the  cornea,  and 
perceive  that  it  is  still  brilliant  and  uninjured,  you  may  confidently  tell  the  anxious 
mother  thai,  with  due  care  on  her  part,  her  child's  eye  is  safe.  If  the  cornea  has 
lost  its  transparency,  it  is  still  within  the  reach  of  recovery,  but  the  chances  are 
against  it :  if  you  cannot  get  a  sight  of  the  cornea  at  all,  you  will  do  wisely  to  give 
a  doubtful  prognosis,  or  even  an  unfavourable  prognosis  ;  for  such  is  the  ignorance 
of  the  vulgar  (and  I  include  both  rich  and  poor  under  this  phrase)  that  if  they  are 
not  forewarned  of  the  danger,  they  are  very  apt  to  attribute  the  blindness  that  ensues 
to  your  stuff,  as  they  call  it. 

In  the  severer  forms  and  stages  of  the  complaint,  if  the  lids  be  very  much  swelled 
and  red  externally,  and  especially  if  you  are  unable  to  obtain  any  satisfactory  view 
of  the  cornea  without  usinsr  a  deo-ree  of  violence  that  might  be  hurtful,  it  will  be 
right  to  apply  a  leech.  In  this  case  it  may  be  placed  upon  the  centre  of  the  tumid 
upper  lid ;  and  you  should,  whenever  that  is  possible,  stay  by  the  little  patient  until 
the  animal  drops  off,  and  the  bleeding  ceases ;  for  sometimes  the  bleeding  is  difficult 
to  stop,  and  must  not  be  trusted  to  the  care  of  the  nurse ;  and  the  loss  of  blood  occa- 
sioned by  the  bite  of  a  single  leech  will  often  blanch  the  infant's  skin,  and  make  you 
fear  that  the  depletion,  slight  as  it  is  in  actual  amount,  has  yet  been  too  much.  The 
child's  bowels  should  be  emptied  by  a  little  castor  oil;  and  a  lotion,  made  by  dis- 
solving two  grains  of  the  acetate  of  lead  in  an  ounce  of  water,  may  be  applied  to 
the  inflamed  organ. 

In  less  severe  cases,  and  I  believe  in  all  cases  in  which  you  can  see  the  uninjured 
cornea  gleaming  through  the  pus  that  bathes  it,  it  will  be  quite  sufficient  to  keep 
the  infant's  bowels  open  with  magnesia;  to  apply  a  little  lard  along  the  edges  of  the 
lids,  that  they  may  not  stick  together ;  and  to  inject  carefully  into  the  eye,  beneath 
and  between  the  lids,  a  solution  of  alum ;  in  the  ratio  of  four  grains  to  one  ounce  of 
water.  Such,  Mr.  Lawrence  tells  us,  was  the  treatment  in  forty-nine  cases  out  of 
fifty  at  the  London  Ophthalmic  Infirmary  when  he  was  surgeon  to  it:  no  other 
means  being  used  than  magnesia  internally,  and  the  solution  oi'  alum  locally :  and 
out  of  many  hundred  instances  he  scarcely  recollected  one  that  suffered  in  any 
respect,  if  the  cornea  were  clear  when  the  infant  was  first  seen.  I  had,  for  a  con- 
siderable period,  the  advantage  of  watching  Mr.  Lawrence's  patients  under  that 
treatment;  and  the  result  of  it  was  so  entirely  and  uniformly  satisfactory,  that  I 
should  never  think  of  employing  any  other.  U  the  eye  became  at  length  insensible 
to  the  stimulus  of  the  alum,  a  solution  of  the  nitrate  of  silver,  (from  one  to  four 
grains  in  the  ounce  of  water.)  was  substituted  with  advantage.  Mr.  Guthrie  Uie.s 
I  fancy,  his  cau.stic  ointment;  but  I  am  sure  that  the  simple  and  less  severe  plan  I 
have  been  describing  is  quite  sufficient. 

r2 


198  DISEASES    OF    THE    EYE. 

[A  very  excellent  application,  in  cases  of  the  purulent  ophthalmia  of  new-born  infants,  is 
a  strong  infusion  of  ccmmon  tea  —  when  this  cannot  be  introduced  between  the  lids  in  any 
other  manner,  it  may  be  carefully  injected  by  means  of  a  syringe. — C] 

There  is  just  one  more  disease  belonging  to  the  conjunctiva,  that  I  wish  to  brin-r 
before  you ;  and  then  I  have  done  with  the  morbid  affections  of  this  external  mem- 
brane of  the  eye.  It  has  received  several  names  ;  sometimes  it  is  called  pustular 
ophthalmia,  from  the  appearance  of  little  pustules  upon  the  surface  of  the  organ. 
Dr.  Mackenzie,  who  looks  upon  it  as  an  eruptive  disease,  aftecting  the  conjunctiva 
not  so  much  as  a  juucous  membrane,  but  rather  as  a  continuation  of  the  skin,  names 
it /7/?/i/r/o??//f/?- ophthalmia.  It  has  also  acquired  the  title  oi  .scrofulous  or  strumous 
ophthalmia,  from  its  continual  occurrence  in  children  of  a  scrofulous  habit,  and  its 
verv  frequent  association  with  scrofulous  disease  in  other  parts.  It  is  a  disorder  of 
childhood,  and  it  is  so  common  a  form  of  disorder,  that,  of  ten  cases  of  inflammation 
of  the  eves  in  young  persons,  nine  will  be  of  this  kind.  I  shall  call  it  strumous 
ophthalmia.  It  is  a  form  of  ophthalmia  that  differs  in  many  striking  points  from 
those  which  we  have  been  considering. 

In  the  first  place,  it  is  intimately  connected  with  the  scrofulous  constitution ;  the 
peculiarities  of  which  I  formerly  explained.  Akhough  a  disease  of  children,  it  is 
not  a  disease  of  infants  at  the  breast.  It  is  most  prevalent  from  the  time  of  wean- 
ing to  about  the  age  of  eight.  1  mentioned  to  you,  in  a  previous  lecture,  the  remark- 
able fact  —  showing  the  strong  influence  of  unsuitable  or  insufficient  nourishment  in 
developing  scrofulous  disease — that  when  asked  to  prescribe  for  children  having^  bad 
eyes,  you  will  find,  in  nineteen  cases  out  of  twenty,  that  you  have  to  deal  with  pu- 
rulent ophthalmia  if  the  child  be  still  at  the  breast,  and  with  strumous  ophthalmia 
if  it  have  been  weaned. 

The  leading  symptoms  of  this  disease  are,  slight  redness;  great  intolerance  of 
light;  the  formation  of  little  prominences  or  pustules  on  the  surface  of  the  conjunc- 
tiva ;  and  specks  which  are  the  resuk  of  these.  The  complaint  sometimes  occurs 
in  one  eye  alone,  oftener  in  both ;  but  then  one  eye  is  generally  worse  than  the 
other.  Mere  catarrhal  ophthalmia  is  apt  to  degenerate  into  this  affection  in  scrofulous 
children.  After  seeing  two  or  three  cases  of  strumous  ophthalmia,  you  cannot  fail 
to  recognize  it  whenever  you  meet  with  it  again. 

The  redness  has  this  peculiarity,  that  it  is  slight  and  partial.  Sometimes  it  is  alto- 
gether confined  to  that  part  of  the  membrane  which  lines  the  eyelids:  generally  a 
few  vessels,  collected  into  little  bundles,  are  seen  proceeding  from  some  point  of  the 
circumference — more  commonly  from  the  angles  of  the  eye  than  from  any  othei 
point — towards  the  cornea :  the  vessels  are  evidently  superficial,  often  prominent. 
These  scattered  bundles  of  vessels  (sometimes  there  is  but  one)  stop  when  they  reach 
the  cornea,  or  occasionally  encroach  a  little  upon  it ;  and  where  they  stop,  the  small 
elevations  of  the  membrane  may  be  observed,  which  are  called  pustules.  This  is 
the  most  common  situation  of  these  elevated  points,  just  at  the  line  of  junction  be- 
tween the  sclerotica  and  the  cornea,  or  near  that  line.  Sometimes,  however,  vou 
may  see  one  or  two  near  the  centre  of  the  cornea.  They  are  smaller  in  size  when 
th'  y  appear  on  the  cornea,  than  when  they  are  situated  near  its  edge. 

These  pimples  may  be  absorbed,  and  leave  behind  them  a  temporary  white  spot; 
morf  frequently  they  break  and  form  little  ulcers.  When  these  ulcers  are  beyond 
the  cornea  they  are  of  less  consequence :  when  they  are  situated  upon  it,  they  be- 
come sources  of  danger  in  two  ways  ;  they  may  penetrate  the  cornea,  and  let  out  the 
aqueous  humour,  and  cause  prolapsus  iridis  and  various  other  mischief;  or  they  may 
leave,  after  healing,  a  permanent  white  opaque  speck,  (called  leucoma,)  which, 
according  to  its  size  and  its  exact  place,  will  interfere  more  or  less  with  the  patient's 
vision. 

The  intolerance  of  light  is  a  very  prominent  symptom  of  this  disease,  and  some- 
'imes  it  really  is  the  only  sy^mptom  that  manifests  itself.  It  is  curious  that  this 
mabiiity  to  endure  a  bright  light  bears  no  regular  or  definite  proportion  to  the  inten 
sity  of  the  other  symptoms.  It  is  not  that  the  eye  is  painful  when  protected  from 
tKe  light ;  but  that  the  access  of  the  ordinary  light  of  day  occasions  extreme  -.ufTer 


STRUMOUS    OPHTHALMIA.  l90 

ing  ;  the  eyelids  being  spasmodically  closed  and  the  orbicular  muscle  in  such  strong, 
an^  appareruiy  involuntary  action,  as  effectually  to  resist  all  attempts  at  opening 
them.  Children  that  are  affected  with  this  disease,  carry  it  legibly  written  in  their 
physiognomy.  Although  you  cannot  tell  what  is  the  actual  condition  of  the  eye 
without  examining  it,  you  can  tell,  as  soon  as  you  look  at  the  patient,  what  is  the 
nature  of  the  inflammation  under  which  he  is  suffering.  The  child's  brow  is  knit 
and  contracted,  while  his  alae  nasi  and  his  upper  lip  are  drawn  upwards;  those 
muscles  of  the  face  (they  happen  to  be  also  muscles  of  expression)  are  instinctively 
put  in  action,  which  tend  to  exclude  the  light  without  shutting  out  the  perception  of 
external  objects;  producing  a  peculiar  and  distinctive  grin.  In  the  severer  cases 
the  child  will  skulk  all  day  in  dark  corners ;  or  if  in  bed,  will  lie  upon  his  face,  or 
under  the  clothes ;  and  while  the  hght  is  thus  kept  off,  he  does  not  appear  to  suffer. 
If  brought  towards  a  window,  he  holds  his  head  down,  and  presses  his  hands  or  arms 
over  his  eyes.  When  you  attempt  to  open  his  eye  to  examine  it,  a  profuse  discharge 
of  scalding  tears  takes  place :  these  pass  partly  into  the  nose,  and  excite  fits  of 
sneezing,  and  partly  over  the  skin,  which  they  sometimes  inflame  and  excoriate  ;  and 
then,  frequently,  pustules  arise,  and  produce  a  discharge  that  crusts  over  the  cheek 
and  extends  to  the  forehead  and  temples.  This  is  called  crusta  lactea,  and  is  very 
characteristic  of  the  scrofulous  habit;  it  occasionally  spreads  over  the  whole  body. 

You  might  suppose,  from  this  extreme  intolerance  of  light,  that  the  retina  was 
inflamed,  or  in  danger.  But  it  is  not  so.  The  affection  of  the  retina  is  purely  sym- 
])athetic,  and  need  not  of  itself  excite  any  fears  about  the  vision.  Towards  dusk, 
indeed,  in  the  twilight,  the  child  can  generallj^  open  his  eyes,  and  then  is  quite  as 
able  to  see  as  if  he  were  well.  Dr.  Mackenzie  endeavours  to  explain  the  connection 
of  intolerance  of  light,  spasmodic  contraction  of  the  lids,  and  lachrymation,  even 
when  there  is  but  little  visible  redness,  by  the  distribution  of  the  lachrymal  nerve; 
which,  after  supplying  the  lachrymal  gland,  goes  to  the  conjunctiva,  and  to  the  orbi- 
cularis palpebrarum.  We  have  the  same  set  of  symptoms  when  a  bit  of  dirt  gets 
into  the  eye,  and  fixes  itself  beneath  the  upper  lid.  When  little  or  no  redness  exists, 
this  extreme  intolerance  of  light  has  been  called  photophobia  scrofulosa. 

With  this  strumous  affection  of  the  eye  there  are  usually  present  other  evidences 
also  of  scrofulous  disease.  Swelling  and  redness  of  the  alee  nasi  and  upper  lip ; 
enlargement  of  the  absorbent  glands  about  the  neck ;  eruptions  upon  the  head  ;  sore 
ears  ;  a  large  and  hard  belly  ;  disordered  bowels  ;  offensive  breath  ;  grinding  of  the 
teeth  ;  and  general  debility.  And  the  ophthalmia  will  alternate  sometimes  in  seve- 
rity with  some  of  these  other  local  scrofulous  complaints  ;  getting  better  as  they  get 
worse,  and  vice  versa. 


LECTURE  XIX. 

Strumozis  Ophthalmia,  continued.  Recapittdation.  Treatm.ent  of  Strumous  Oph- 
thalmia. General  Remarks  on  Conjunctival  hijlammations.  Iritis:  its  Symp- 
toms and  Treatment.     Causes  of  Iritis. 

When  we  separated  yesterday,  I  was  about  to  describe  the  treatment  which  has 
been  found  by  experience  to  be  the  best  for  reheving  strumous  or  phlyctenular  oph- 
thalmia. Before  I  take  up  the  subject  where  it  was  then  dropped,  let  me  briefly 
remind  you  of  the  character  and  principal  symptoms  of  the  disorder.  It  is  a  form 
of  inflammation  of  the  conjunctiva,  to  which  scrofulous  children,  from  the  time  they 
are  weaned,  to  about  the  age  of  eight,  are  extremely  liable.  It  may  occur  consider- 
ably later.  Sometimes  it  is  the  first  and  only  token  of  the  existence  of  the  scrofulous 
diathesis  ;  generally  it  is  observed  in  children  who  bear  other  marks  of  the  strumous 
habit,  and  are  afflicted  with  other  forms  of  strumous  disease. 

Its  symptoms  are — first,  slight  vascularity  ;  the  redness  being  partial,  and  proceed- 
ing from  one  or  more  fasciculi  of  superficial  vessels,  which  advance  from  the  circum 
ference  of  the  visible  part  of  the  eye  towards  the  cornea,  where  they  usunllv  ston  ■ 


200  DISEASES   OF   THE    EYE. 

sometimes,  however,  they  pass  a  liltle  beyond  its  edge.  At  the  extremities  of  these 
fasciculi,  upon  or  near  the  line  of  separation  between  the  cornea  and  the  sclerotica, 
small  prominences  appear,  which  are  sometimes  absorbed,  sometimes  break  and  form 
ulcers.  Less  frequently  the  phlyctens  are  situate  towards  the  central  part  of  the 
cornea.  Secondly,  with  this  partial  vascularity  and  these  pimples,  and  sometimes 
even  without  them,  there  is  extreme  intolerance  of  light.  The  pain  produced  by 
exposing  the  eye  to  the  influence  of  light  imparts  a  characteristic  expression  to  the 
countenance  of  the  suffering  child.  Tears  flow  over  the  cheek,  and  inflame  it  often, 
and  give  rise  to  the  eruptive  appearance  termed  crusta  lactea:  or,  from  its  somethies 
covering  the  cheek  like  a  mask,  porrigo  larvalis. 

I  may  add  to  this  summary  of  what  was  stated  in  the  last  lecture,  that  sometimes 
the  vessels  which  pass  along  the  conjunctiva  and  over  the  cornea,  instead  of  leading 
to  pustules,  extend  laterally  :  so  that  several  bundles  of  vessels  unite  by  their  mutual 
ramifications ;  and  that  part  of  the  conjunctiva  which  covers  the  cornea  becomes 
ihick,  as  if  it  were  darned;  and  more  or  less  opaque.  Indeed,  the  greater  portion 
of  the  whole  of  the  corneal  covering  may  thus  be  rendered  patchy  and  vascular. 
The  appearance  presented  by  the  eye  under  these  circumstances  is  called  pannus. 

You  will  readily  believe,  from  what  has  been  said  of  this  complaint,  that  it  is  an 
obstinate  and  troublesome  one.  Even  when  it  has  been  cured  it  is  very  apt  to 
recur.  The  scrofulous  habit  on  which  it  depends  w-e  cannot  get  rid  of;  and  when 
ever  the  exciting  causes  of  scrofulous  diseases  come  into  action,  this  form  of  scrofula 
is  very  prone  to  declare  itself,  at  the  period  of  hfe  which  I  have  already  mentioned. 

More  good  is  to  be  done  bj^  general  treatment,  applied  to  the  system  at  large,  in 
this  form  of  ophthalmia,  than  in  those  we  were  occupied  with  before  ;  and  this  is  one 
strong  point  of  difference  between  them. 

In  the  first  place  we  must  endeavour  to  correct  that  unnatural  condition  of  the 
whole  system,  and  especially  of  the  digestive  organs,  which  is  commonly  so  striking 
a  concomitant  of  the  local  disease.  It  will  be  proper  to  clear  out  the  bowels  in  the 
outset,  and  occasionally,  by  a  mercurial  purge ;  and  to  regulate  them  at  other  times 
by  laxatives,  such  as  rhubarb,  or  the  confeclio  sennse,  or  castor  oil.  The  recovery 
will  be  greatly  promoted,  also,  by  those  measures  which  are  found  to  benefit  the 
general  health  in  such  constitutions ;  M-arm  clothing,  fi-equent  ablution  of  the  bodv, 
nourishing  though  plain  food,  the  respiration  of  a  pure  atmosphere,  change  of  air, 
and  regular  exercise. 

In  addition  to  these  measures,  tonic  medicines  should  be  administered ;  the  pre- 
parations of  iron,  for  example,  or  the  dilute  mineral  acids  :  but  the  best  remedy  of 
this  kind  is,  undoubtedly,  the  sulphate  of  quina.  This  may  be  given  to  a  child  in 
grain  doses,  three  times  a  day,  dissolved  in  water,  with  a  drop  of  the  dilute  sulphuric 
acid,  and  some  syrup  of  orange-peel.  Dr.  Mackenzie,  in  particular,  has  put  this 
medicine  fairly  to  the  test,  having  employed  it  in  a  very  large  number  of  cases  with 
the  happiest  results.  In  most  of  his  patients  he  declares  tliat  it  acted  like  a  charm, 
'•  abating,  commonly,  in  a  few  days,  the  excessive  intolerance  of  light  and  profuse 
epiphora;  promoting  the  absorption  of  phlyctenula?,  and  hastening  the  cicatrization 
of  ulcers  of  the  cornea."  And  Mr.  Lawrence  adds  his  testimony  to  the  same  effect ; 
and  his  experience  in  this  disease,  like  Dr.  Mackenzie's,  has  been  large  enough  to 
make  it  highly  valuable, 

A  few  words  will  suffice  to  explain  the  kind  of  local  treatment  that  has  been 
found  useful.  You  may  feel  tempted  to  apply  leeches  round  the  eye.  This  is  sel- 
dom requisite,  except  when  there  are  more  redness  and  pain  than  common,  rxnd  the 
tongue  becomes  white,  and  the  skin  hot.  Certainly  you  must  not  take  the  intole- 
rance of  light  as  a  fit  indication  for  the  use  of  leeches.  Abstraction  of  blood  rather 
uggravatoS  that  symptom  ;  apparently  by  increasing  the  irritability  of  the  retina. 
Warm  fomentations  are  generally  very  comfortable  to  the  patient's  feehngs. 

When  the  general  disorder  of  the  system  has  been  somewhat  rectified,  local  stimu- 
.unts  and  astringents  are  of  great  service.  The  vinum  opii  and  the  solution  oi  lunar 
caustic  are  the  best.  These  are  often  tedious  cases,  and  therefore  it  is  necessary 
nat  you  should  be  aware  of  one  great  objection  to  the  long-continued  em))loyment 
•  •'  the  nitrate  of  silver  wash,  wliich  objection  has  been  pointed  out  by  Dr.  Mac- 


STRUMOUS    OPHTHALMIA.  201 

kenzie.  It  is  apt  (but  only  when  frequently  repeated  for  a  long  time  together)  to 
stain  the  conjunctiva  of  an  indelible  olive  colour.  For  this  reason  the  vinum  opii  is 
to  he  preferred  in  slow  cases,  and  in  cases  where  frequent  relapses  happen.  The 
good  effects  of  either  of  those  preparations  are  very  striking ;  they  diminish  the 
irritabihty  of  the  eye,  and  promote  the  healing  of  the  ulcers.  The  red  precipitate 
ointment,  and  the  citrine  ointment  of  the  Pharmacopeia,  diluted,  are  also  found 
beneficial. 

[According  to  Dr.  Glover  (Pathol,  and  Treat,  of  Scrofula),  there  appears  to  be  little  doubt 
of  the  success  of  an  infusion  or  decoction  of  walnut  leaves  in  scrofulous  ophthalmia. — C] 

Counter-irritation  is  another  local  measure,  which  is  of  undoubted  utility  in  this 
complaint.  A  great  change  for  the  better  in  the  state  of  the  organ  often  occurs, 
almost  suddenly,  upon  the  rising  of  a  blister  placed  behind  the  ear,  or  at  the  back 
of  the  neck.  And  issues  in  the  arms  are  not  only  serviceable  in  promoting  the 
cure,  but  have  a  marked  effect  in  many  children,  in  preventing  relapses.  Mr.  Wel- 
bank,  in  his  notes  to  Frick's  Treatise  on  Diseases  of  the  Eye,  states  that  he  has 
seen  chronic  strumous  ophthalmia,  of  seven  years'  duration,  quickly  and  effectually 
relieved  by  an  issue  in  the  arm.  "  Having  once  (says  he),  in  the  case  of  a  boy  in 
Christ's  Hospital,  directed  the  healing  of  an  issue  whicn  had  been  made  above 
twelve  months,  I  found  the  immediate  consequence  to  be  a  relapse  of  strumous 
inflammation  and  ulceration  of  the  cornea,  resisting  every  measure  but  the  renewal 
of  the  issue. 

He  suggests,  also,  (what  parents  are  sometimes  more  willing  to  assent  to,)  the 
advantage  of  making  counter-irritation  by  piercing  the  lobe  of  the  ear,  and  inserting 
a  ring  or  silk ;  and  "  a  very  convenient  form  of  vesication  will  be  found  in  the 
application  of  a  strong  thread,  smeared  with  the  emplastrum  cantharidis,  and  firmly- 
tied  behind  the  ear  at  the  angle  of  its  reflection." 

When  ulceration  is  going  on  in  the  cornea,  and  threatening  to  penetrate  it,  the 
progress  of  the  ulcer  may  be  checked  by  touching  its  surface  once  in  two  or  three 
days  with  a  pencil  of  lunar  caustic  which  has  been  scraped  to  a  fine  point. 

When  the  more  urgent  symptoms  have  abated,  and  the  discharge  of  hot  and 
irritating  tears  has  ceased,  the  crusla  lactea  may  very  easily  be  got  rid  of.  The 
crusts  are  to  be  removed  by  a  light  poultice,  or  by  warm  water;  and  then  the  part 
must  be  bathed  from  time  to  time  with  a  lotion  made  by  mixing  the  oxide  of  zinc 
with  water;  a  drachm  to  four  ounces  is  the  proportion  I  am  in  the  habit  of  prescrib- 
ing. If  rose-water  be  used  instead  of  common  pump-water,  the  prescription  will  be 
thought  the  more  elegant.  This  lotion  will  speedily  dry  up  the  discharge,  and  in  a 
short  time  no  vestige  of  the  ugly-looking  crust  will  remain.  Parents  are  highly 
delighted  and  very  thankful  when  you  thus  accomplish  the  removal  of  a  large  dis- 
figuring and  disgusting  scab,  which  they  naturally  enough  felt  apprehensive  might 
leave  behind  it  a  corresponding  scar.     But  it  is  quite  superficial. 

I  have  now  done  with  the  exterior  membrane  of  the  fore  part  of  the  eye — with  its 
mucous  membrane.  In  examining  some  of  its  diseases,  we  have  had  the  oppor- 
tunity of  noticing  several  things  which  illustrate  the  pathology  of  the  mucous  tissues 
generally,  and  which  exemplify  the  influence  of  other  circumstances  also,  as  well  as 
of  peculiarities  of  tissue,  upon  the  morbid  processes  to  which  these  membranes  are 
obnoxious. 

We  have  seen  that  the  mucous  surface  of  the  eye  readily  enough  takes  on  inflam- 
mation, under  vicissitudes  of  external  temperature,  and  from  the  agency  of  other 
atmospheric  conditions ;  that  the  inflammation  is  apt  to  spread,  often  rapidly,  over 
the  whole  surface  of  the  membrane ;  and  that,  in  some  cases,  it  may  be  strictly 
limited  for  a  long  time  together,  or  entirely,  to  the  mucous  tissue  in  which  it  began; 
but  that  when  intense,  or  under  special  circumstances,  it  may  dip  through  and 
extend  to  the  subjacent  textures :  that,  on  the  other  hand,  the  inflammation  some- 
times occupies  separate  specks  only  of  the  membrane,  and  then  is  more  likely  to 
penetrate  to  the  deeper  seated  tunics:  that  although  the  membrane  is  folded  upon 
itself,  so  that  different  portions  of  it  are  mutually  in  apposition  and  contact,  these 
opposing  surfaces  do  not  become  adherent  to  each  other  under  inflammation  :  on  the 


202  DISEASES    OF    THE    EYE. 

contrary,  that  they  readily  pour  forth  pus.  This  tendency  to  the  formation  of  pus  I 
formerly  showed  you  to  be  commonly  observable,  whenever  the  air  finds  free  access 
to  the  inflamed  part.  The  pus  thus  poured  out  possesses  the  remarkable  property 
of  exciting  the  same  kind  of  inflammation  when  placed  in  contact  with  any  healthy 
mucous  membrane  of  the  same  or  of  another  individual :  whether  it  be  the  conjunc- 
tiva of  the  eye,  or  the  internal  hning  of  the  urethra.  The  pus,  in  short,  acts  locally, 
upon  certain  parts  at  least,  as  a  poison.  And  we  perceive,  in  this  fact,  how  a  disor- 
>der  that  originates  in  common  and  accidental  causes  may  become  capable  of  propa- 
gating itself  indefinitely — may  become,  in  one  word,  contagious.  We  have  seen 
also  that  the  most  intense  inflammation  may  occur  in  this  membrane,  without  exciting 
much  or  any  constitutional  disturbance ;  an  illustration  of  the  fact  that  the  inflamma- 
tion of  mucous  membranes  is  not  so  prone  to  light  up  fever,  is  not  in  general  attended 
with  so  much  pyrexia,  as  inflammation  of  some  other  tissues,  and  especially  of  the 
serous  and  fibrous  tissues:  and  in  proportion  as  this  constitutional  sympathy  with  the 
local  disease  is  small  or  absent,  so  the  influence  of  general  bleeding  upon  the  inflamed 
part  is  slight  or  ineffectual.  The  effect  of  a  new  and  strong  local  irritation,  in  alter- 
ing or  superseding-  the  original  inflammation  in  some  cases,  has  been  illustrated  in 
the  treatment  of  purulent  ophthalmia  as  it  occurs  in  the  adult  subject.  The  influence 
of  age  in  modifying  the  phenomena,  and  in  qualifying  the  plan  of  treatment,  has 
been  made  perceptible  in  the  differences  noticed  in  these  respects  between  purulent 
ophthalmia  in  infants  and  in  grown-up  persons.  We  have  witnessed,  too,  the 
remarkable  characters  impressed  upon  inflammation  of  the  very  same  part,  by  the 
presence  of  the  scrofulous  diathesis.  We  shall  hereafter  meet  with  numerous 
examples  of  chronic  inflammation,  and  the  deposition  of  tubercular  matter,  and  the 
formation  of  ulcers  in  consequence  of  the  elimination  of  that  matter,  in  other  mucous 
membranes.  AVhether  the  phlyctena^,  or  pustules,  which  appear  upon  the  surface 
of  the  eye  in  strumous  ophthalmia,  result  from  a  similar  separation  of  tubercular 
matter  from  the  blood-vessels,  near  the  extremities  of  which  these  prominences  are 
placed,  has  not  been  clearly  ascertained.  One  other  lesson  we  have  learned  from 
this  review  of  conjunctival  inflammation,  viz.,  that  general  bleeding,  carried  so  far  as 
to  produce  syncope,  will  sometimes  completely  empty  the  capillaries  of  an  inflamed 
part  of  the  red  blood  wherewith  they  were,  just  before,  so  turgid. 

I  shall  next  request  your  attention  to  a  part  of  the  organ  which  is  strictly  internal 
— to  the  iris  :  that  thin  curtain,  with  a  circular  aperture  nearly  in  its  centre,  which 
hangs  between  the  cornea  and  the  crystalline  lens,  and  is  bathed  on  both  sides  by 
the  aqueous  humour.  This  little  part,  the  office  of  which  is  to  regulate  the  quantity 
of  light  admitted  to  the  retina,  is  of  exceeding  interest  in  respect  to  its  morbid  as 
well  as  its  healthy  conditions.  It  is  frequently  the  seat  of  inflammation :  and,  small 
as  it  is,  the  inflammation  seems  to  be  entirely  confined  to  it,  or  to  the  surfaces  im- 
mediately before  and  behind  it.  No  doubt,  with  inflammation  of  the  iris,  there  is  in 
many  cases  inflammation  of  the  choroid  and  retina  also,  and  of  the  sclerotica.  But 
the  inflammation  seems  to  make  the  iris  its  point  of  departure,  and  there  it  works  its 
most  striking  changes.  We  cannot  see  so  well  Avhat  is  the  actual  condition  of  the 
choroid  and  retina ;  but  we  have  this  proof,  either  that  thej'^  do  not  always  partici- 
pate in  the  disease,  or  that  they  often  suffer  less  than  the  iris ;  viz.,  that  when  the 
natural  pupil  has  been  closed  up  by  lymph,  and  a  new  or  artificial  one  is  formed, 
vision  is  frequently  restored. 

The  little  cavity  across  which  the  iris  is  vertically  stretched,  is  lined  by  a  smooth 
membrane,  the  source  of  the  watery  fluid  always  contained  in  the  cavity.  This 
membrane  is  analogous  in  its  smoothness,  in  its  forming  a  shut  sac,  and  in  the  nature 
of  its  secretion,  to  the  serous  membranes  met  with  in  other  parts  of  the  body ;  it  is 
analogous  also  to  the  serous  membranes,  in  its  behaviour  under  inflammation.  It  is, 
in  fact,  the  serous  membrane  of  the  eye.  Now  we  have  the  means  of  inspecting  a 
portion  at  least  of  several  of  the  mncoits  surfaces  of  the  body  ;  but  this  serous  cavity, 
constituting  the  anterior  chambers  of  the  eye,  is  the  only  serous  cavity  into  vvhich 
we  have  the  privilege  of  looking,  and  of  noting  what  is  going  on,  when  the  mem- 
hrane  that  forms  its  boundary  is  inflamed ;  and  this  it  is  that  makes  iritis,  to  me,  one 


IRITIS.  203 

of  the  most  interesting  of  all  diseases.  There  is  no  aingie  part  of  the  body  from 
which  vou  can  derive  so  much  instruction  concerning  some  of  the  minuter  processes 
of  inflammation,  and  concerning  ♦he  power  of  certain  medicines  over  those  pro- 
cesses, as  you  may  by  watching  a  few  examples  of  inflammation  of  the  iris. 

All  the  changes  which  occur  in  iritis  depend  upon  the  circumstance  that  the 
inflammation,  like  that  of  the  serous  membranes  generally,  is  of  the  adhesive  kind  ; 
i.  e.,  is  attended  with  the  eflusion  of  coagulable  lymph.  By  means  of  this  lymph 
the  form  and  the  colour  of  the  part  are  changed;  the  size  and  figure  of  the  pupil 
undergo  alterations,  or  that  aperture  is  completely  closed  up ;  the  motions  of  the 
iris  are  limited,  or  entirely  put  an  end  to. 

The  symptoms  which  characterize  inflammation  of  the  iris  are  very  obvious.  To 
be  perceived  and  understood,  they  require  only  to  be  looked  at.  Yet  they  long 
escaped  notice,  and  even  now  are  not  always  so  carefully  studied  as  they  deserve  to 
be.  Not  a  great  while  ago  I  had  to  convince  a  surgeon  of  some  pretensions,  that  he 
did  not  know  this  disease  when  he  saw  it.  And  English  surgeons  and  physicians 
were  all  of  them  ignorant  even  of  its  existence  as  a  distinct  disease,  until  a  most 
excellent  account  of  it  was  published  by  a  German,  Schmidt,  in  the  first  year  of  the 
present  century. 

What  are  these  plain  and  obvious  symptoms  that  were  so  long  overlooked,  or  that 
were  not  understood  when  seen?  They  are  the  following.  I  will  first  enumerate 
them,  and  then  speak  of  each  rather  more  particularly.  Redness  of  the  sclerotica  ; 
a  change  in  the  colour  of  the  iris  itself,  and  in  its  general  appearance ;  irregularity 
of  the  pupil,  produced  by  adhesion  of  the  iris  to  the  neighbouring  parts;  immobility 
sometimes  of  the  pupil  from  such  adhesion  ;  a  visible  deposition  of  coagulable  lymph. 
All  these  changes  are  apparent  and  conspicuous.  Scientific  wn'iters  term  them  ob- 
jecfive  symptoms.  Then  there  are  also  the  subjective  symptoms,  of  which  the 
patient  alone  is  conscious — impaired  sight ;  pain  in  the  eye,  and  round  it. 

The  redness  is  such  as  I  formerly  described  as  resulting  from  the  vascularity  of 
the  sclerotic.  The  cornea  is  surrounded  by  a  zone  of  fine  straight  converging  pink 
lines,  very  different  in  appearance  from  the  tortuous,  anastomosing,  scarlet  blood- 
vessels of  the  inflamed  conjunctiva.  These  hair-like  converging  hues  slop  abruptly 
at  the  edge,  or  just  before  they  reach  the  edge  of  the  cornea;  they  dip  through  the 
sclerotic,  in  fact,  to  go  to  the  iris.  The  vascular  zone,  therefore,  is  well  defined  in 
front,  while  it  becomes  fainter  from  before  backwards,  and  is  gradually  shaded  ofl"; 
the  posterior  portion  of  the  sclerotic  being  generally  pale.  As  the  disease  advances, 
and  in  violent  cases,  the  more  superficial  conjunctival  vessels  also  sometimes  enlarge, 
and  mingle  their  tint  of  redness  with  that  of  the  sclerotic,  and  more  or  less  confuse 
or  conceal  it.  Now  this  red  zone  or  halo  continues  as  long  as  the  inflammation  of 
the  iris  continues,  and  disappears  when  that  ceases.  It  is  an  important  symptom 
therefore. 

The  change  in  the  colonr  of  the  iris  itself  is  also  a  remarkable  circumstance. 
You  know  that  what  is  called  the  colour  of  the  eye  is  simply  the  colour  of  the  iris. 
When  the  lymph  begins  to  bo  effused  into  the  texture  of  this  coloured  part,  it  deep- 
ens, and  at  the  same  time  alters,  its  tint.  A  gray  or  blue  eye  is  thus  rendered  yel- 
lowish or  greenish.  A  dark  eye  presents  a  reddish  tinge.  The  change  is  such  as 
would  be  produced  by  a  mixture  of  the  colour  of  the  lymph  with  that  which  is  natu- 
ral to  the  iris.  But  besides  a  variation  of  colour,  the  peculiar  brilliancy  of  the  sur- 
face is  spoiled.  It  becomes  dull  and  tarnished,  as  it  were,  and  the  fibrous  arrange- 
ment, Avhich  is  usually  so  evident,  is  confused  or  gone.  The  change  commences 
at  the  inner  or  pupillary  margin  of  the  iris,  and  extends  gradually  towards  the  outer 
or  ciliary  edge.  This  is  a  symptom  which  you  can  scarcely  overlook.  It  is  ren- 
dered certain  and  unequivocal  by  comparing  the  sound  eye  with  that  which  is 
inflamed. 

The  change  of  colour  which  I  have  been  describing  is  occasioned  by  the  effusion 
of  lymph.  But  the  same  event  of  inflammation  leads  to  various  other  changes  not 
less  strikincr  and  more  important,  in  so  far  as  the  functions  of  the  organ  are  con- 
cerned. The  lymph  becomes  visible  upon  the  surface  of  the  iris.  Its  precise  ap- 
pearance varies  considerably  in  different  cases.     Sometimes  it  presents  htllc  spou> 


204  DISEASES    OF    THE    EYE. 

bke  freclcles,  or  specks  of  rust :  or  a  thin  stratum  of  the  same  colour  is  deposited. 
Sometimes  it  exhibits  the  appeai-ance  of  drops,  or  (as  the}^  have  improperly  been 
called)  tubercles,  embossing  the  surface,  and  projecting  from  its  pupillary  edge. 
These  are  commonly  of  a  yellowish  or  reddish-brown  colour,  and  they  vary  in  mag- 
nitude from  the  size  of  a  small  pin's  head  to  that  of  a  large  shot.  There  are  seldom 
more  than  two  or  three  of  these  masses.  The  lymph  thus  effused  upon,  or  thrusting 
forward  the  surface,  is  confined  almost  always  to  that  part  of  the  iris  which  is  near- 
est to  the  pupil,  to  the  annulus  minor;  while  its  ciliary  portion,  or  annulus  major, 
is  dull  and  clouded.  Sometimes,  when  the  inflammation  is  very  violent,  or  the  dis- 
ease has  been  neglected,  actual  suppuration  takes  place.  A  reddish-yellow  promi- 
nence arises  from  the  surface  of  the  iris,  and  at  length  breaks,  and  discharges  matter 
which  sinks  down  to  the  bottom  of  the  anterior  chamber,  and  presents  the  appear- 
ance that  has  been  called  hypopyon.  All  these  changes,  I  say,  become  perceptible 
near  the  margin  of  the  iris ;  its  free  edge  which,  in  the  natural  state,  is  clear  and 
sharp,  becomes  rounded  and  blunt :  and  at  the  same  time  the  pupil  often  begins  to 
lose  its  jet-black  colour. 

Another  very  common  consequence  of  the  effusion  of  lymph  from  and  upon  the 
surface  of  the  iris  (from  its  hinder  surface,  that  is,  which  is  called  the  uvea,  or  from 
its  pupillary  edge),  is  its  adhesion  to  the  capsule  of  the  crystalhne  lens,  which  lies, 
you  know,  behind  the  iris  and  very  near  it.  And  the  pupil  itself  is  apt  to  become 
blocked  up  by  lymph. 

The  motions  of  the  iris  are  seriously  impeded  by  the  mere  effusion  of  lymph  into 
its  texture.  At  first  it  moves  sluggishly  under  variations  of  the  hght ;  gradually  the 
pupil  contracts,  and  becomes  fixed  and  motionless.  The  adhesion  of  the  iris  to  the 
capsule  of  the  lens  still  more  decidedly  restrains  the  action  of  the  part.  When  it 
adheres  at  one  or  more  points  of  the  margin,  and  remains  free  elsewhere,  the  pupil 
is  deformed ;  loses  its  circular  shape;  becomes  angular ;  and  this  deformity  is  the 
most  marked  when  the  eye  is  examined  either  under  a  weak  light,  which  allows  the 
pupil  to  dilate,  except  at  the  points  where  the  iris  is  tied  down  to  the  lens ;  or  under 
a  very  strong  light,  which  forces  the  free  portions  of  the  margin,  and  those  onl}'',  to 
approach  the  centre.  Still  more  palpable  does  the  alteration  of  figure  become  when 
the  pupil  is  artificially  dilated. 

Vision  is  always  impaired  in  this  complaint :  partly  because  the  posterior  tunics 
of  the  eye  are  liable  to  be  implicated  in  the  inflammatory  process  ;  partly  by  the 
detriment  done  to  the  proper  function  of  the  iris,  which  should  duly  measure  the 
quantity  of  light  admitted  to  the  retina;  partly  by  the  presence  of  more  or  less 
lymph,  filling  up  the  pupil ;  and  partly  by  a  change,  not  yet  mentioned,  which  is 
apt  to  take  place,  especially  in  severe  cases,  in  the  cornea,  and  perhaps  in  the  aqueous 
humour.  The  cornea  becomes  hazy  and  dull,  and  loses  its  bright  polish.  It  looks 
like  a  piece  of  glass  that  has  just  been  breathed  upon.  It  has  been  thought  (on  the 
ground  of  analogy  chiefly)  that  the  aqueous  humour  grows  turbid  under  the  inflam- 
mation of  the  membrane  that  secretes  it ;  just  as  serous  effusion  into  the  pleura  is 
often  found  to  be  troubled  and  thick.  But  there  is  no  sure  evidence  that  this  is  the 
case.  While  the  cornea  remains  transparent,  the  aqueous  humour  is  seen  to  be 
clear ;  when  the  cornea  is  dim  and  semi-opaque,  we  cannot  distinguish  the  stair  of 
the  aqueous  humour. 

Acute  iritis  is  attended  with  pain  and  intolerance  of  light.  To  the  latter  circum- 
stance is  probably  owing  the  contraction  of  the  pupil  during  the  progress  of  the 
inflammation  :  and  then  the  lymph  fixes  the  pupil  in  that  slate  of  smallness  and 
contraction.  There  is  pain  in  the  eyeball  itself,  and  in  the  parts  about  the  eye,  the 
brow  and  temple,  most  severe  at  night.  There  is  much  variety,  however,  in  regard 
to  the  pain.  Sometimes  it  is  constant  and  severe,  but  still  more  agaravated  in  noc- 
turnal ])aroxysms.  Sometimes,  even  when  the  quantity  of  mischief  that  is  visible 
IS  very  great,  scarcely  any  pain  at  all  has  been  experienced. 

The  same  remark  applies  to  the  constitutional  symptoms.  In  some  instances  these 
are  but  slightly  pronounced ;  but  in  most  cases,  particularly  in  acute  cases  (for  iritis, 
as  I  have  hinted  before,  is  sometimes  a  chronic  disease)  there  is  a  good  deal  of  fever 
and  headache,  tne  pulse  is  full  and  hard,  and  the  tongue  white,  and  the  sleep  is  broken. 


IRITIS.  205 

If  the  progress  of  the  inflammation  be  not  checked,  it  extends  itself  beyond  its 
origmal  seat.  It  creeps  from  the  pupillary  margin  to  the  cihary ;  and  thence  it 
passes  on  to  the  ciliary  body,  to  the  choroid  coat,  and  to  the  retina ;  and  as  this  takes 
place,  the  pain  and  the  pyrexia  increase,  and  blindness  is  usually  the  result.  The 
deUcate  texture  of  the  retina  is  spoiled  for  ever. 

I  have  thus  described  the  phenomena  of  iritis  generally  :  and  I  will  next  consider, 
in  the  same  manner,  the  treatment  which  it  requires.  It  will  afterwards  be  neces- 
sary for  me  to  mention  certain  modifications  of  the  disease,  in  respect  to  its  rate  of 
progress,  its  causes,  and  the  circumstances  under  which  it  occurs.  I  say  it  will  be 
necessary  to  mention  these  modifications,  because  they  require  a  corresponding 
adjustment  of  the  plan  of  treatment. 

When  we  have  to  deal  \vith  iritis  alone — that  is,  when  the  inflammation  and  the 
changes  to  which  it  may  have  led,  are  confined  to  the  iris — the  disease  is  always,  I 
believe,  manageable ;  and  affords  a  beautiful  instance  of  the  power  of  well-directed 
remedial  measures.  We  cannot  always  tell  whether  the  inflammation  has  been 
restricted  to  the  iris  or  not. 

We  have  three  powerful  weapons  wherewith  to  combat  iritis;  blood-letting; 
mercury ;  and  a  remedy  that  hitherto  has  not  been  mentioned  in  these  lectures, 
belladonna. 

If  I  were  restricted  to  the  use  of  one  of  these  means,  I  should  choose  mercury ; 
if  to  two,  mercury  and  belladonna ;  but  the  combined  employment  of  the  three  has 
the  most  powerful  effect  in  curing  the  disease  ;  and  cases  that  have  seemed  almost 
desperate,  have  been  retrieved  and  rescued  by  these  remedies. 

With  respect  to  blood-letting.,  I  shall  not  run  the  risk  of  fatiguing  you  by  dwelling 
at  any  length  upon  the  mode  in  which  it  should  be  employed,  or  the  indications  for 
its  adoption.  I  shall  content  myself  with  saying  that  the  intensity  of  the  local  symp- 
toms, especially  of  the  pain, — and  the  degree  in  which  the  general  symptoms,  the 
fever,  and  the  hardness  of  pulse,  are  present, — offer  the  best  measure,  both  of  the 
necessity  for  bleeding,  and  the  amount  to  which  it  ought  to  be  carried.  Both  will 
depend  somewhat  also  upon  the  strength  and  constitution  of  the  patient.  Bleeding 
from  the  arm  till  some  decided  impression  is  made  upon  the  circulation;  cupping 
from  the  temples ;  or  both  these  modes  of  taking  blood,  together  or  in  succession, 
will  often  be  required.  At  the  same  time  active  purgatives  should  be  exhibited; 
and  the  whole  of  the  antiphlogistic  regimen  strictly  enforced. 

But  bleeding,  assisted  by  purgatives  and  the  antiphlogistic  regimen,  will  not  cure 
the  disease  ;  or  it  will  not  cure  one  case  in  a  hundred.  It  will  stop  the  inflamma- 
tion probably,  but  not  till  the  organ  has  been  spoiled.  Such  a  termination  cannot 
with  any  propriety  be  called  a  cure.  We  want  not  only  to  put  an  end  to  the  inflam- 
matory process,  but  to  repair  the  mischief  which  may  already  have  been  done. 

Yet  bleeding  is  not  to  be  despised  or  neglected  because  it  is  unequal  to  the  cure 
of  iritis.  It  is  productive  of  direct  benefit  by  abating  the  force  of  the  circulation,  and 
by  checking  the  progress  of  the  local  inflammation :  and  it  is  productive  of  great 
indirect  benefit  by  preparing  the  system  to  submit  itself  more  readily  and  rapidly 
than  it  otherwise  would,  to  the  specific  influence  of  mercury.  Mercury  is  our  sheet- 
anchor  in  this  disease. 

After  free  blood-letting,  then,  or  after  such  abstraction  of  blood  from  the  system, 
or  from  the  part,  as  the  circumstances  of  the  case  may  dictate,  you  must  administer 
inercurij  in  the  manner  that  I  formerly  recommended.  The  object  is,  in  acute  cases, 
to  affect  the  gums  as  speedily  as  possible  ;  the  soreness  of  the  gums,  and  the  peculiar 
fcEtorof  the  breath,  being  the  tokens  that  the  whole  capillary  system  feels  the  specific 
influence  of  the  remedy.  Calomel  with  opium  is,  in  most  cases,  the  best  form  in 
which  mercury  can  be  introduced  into  the  system ;  the  purpose  of  the  opium  being 
to  prevent  the  calomel  from  running  off  by  the  bowels.  Two,  three,  or  four  grains 
of  calomel,  with  one-fourth,  one-third,  or  one-half  of  a  grain  of  opium,  should  be 
given  every  four,  or  six,  or  eight  hours.     Equal  doses  at  equal  intervals. 

Some  persons  prefer  giving  the  calomel  still  more  frequently ;  one  grain,  for 
instance,  with  one-tenth,  or  one-eighth  of  a  grain  of  opium,  every  hour.  If  the 
gums  do  not  rise  in  the  course  of  thirty-six  or  forty-eight  hours,  and  a  speedy  eflTect 


206  DISEASES    OF   THE    EYE. 

is  desirable,  inunction  of  ihe  mercurial  ointment  should  be  added.  And  in  some 
cases  mercurial  frictions  alone  may  be  sufficient,  and  tiie  most  expedient.  Or  tiie 
hydnirgyruin  cum  creta,  in  five  or  ten  grain  doses. 

You  may  liave  bled  your  patient  freely,  and  purged  him  well,  and  yet,  on  lookinor 
into  his  eye,  you  perceiv^e  the  mischief  to  be  still  going  on,  and  the  deposition  of 
lymph  increasing.  But  the  instant  that  his  gums  and  breath  acknowledge  the  spe- 
cific agency  of  mercury  upon  his  system,  a  welcome  change  becomes  visible;  the 
red  zone  surrounding  the  cornea  begins  to  fade  ;  the  drops  of  lymph  to  lessen ;  the 
iris  to  resume  its  proper  tint;  and  the  puckered  and  irregular  pupil  once  more  to 
approach  to  the  perfect  circle ;  till,  at  length,  the  eye  is  restored  to  its  original  in- 
tegrit}',  and  beauty,  and  usefulness. 

I  speak  now  of  favourable  cases.  The  changes  for  the  better  that  I  have  been 
describing  are  sometimes  rapidly  accomphshed,  sometimes  slowly.  If  the  disorder 
has  been  long  neglected,  irreparable  damage  may  have  been  done ;  the  elTused 
lymph  may  have'  become  organized ;  or  firm  adhesions  may  have  been  already 
contracted  between  the  iris  and  the  lens.  But  even  in  cases  of  some  standing, 
when  the  inflammatory  action  has  in  a  measure  subsided,  the  use  of  mercury 
will  sometimes  greatly  improve,  sometimes  altogether  restore,  the  impaired  vision. 

With  the  mercury,  both  before  and  while  its  specific  influence  is  manifested,  we 
combine  the  use  o{  beJludonna. 

Doubtless  you  are  all  aware  of  the  singular  effect  of  this  vegetable  poison  upon 
the  iris.  It  dilates  the  pupil.  Now  it  is  of  great  importance  in  iritis  to  prevent  that 
tendency  to  contraction  which  the  pupil  manifests.  If  we  can  artificially  dilate  the 
pupil,  we  may  prevent  the  iris  from  forming  adhesions  with  the  capsule  of  the  crys- 
wlline  lens ;  and  if  it  has  recently  contracted  such  adhesions,  we  may,  while  the 
.ymph  is  yet  soft,  stretch  or  break  them.  And  this  power  of  artificially  dilating  the 
pupil  we  possess  in  the  agency  of  belladonna,  and  of  certain  other  narcotic  vegetables. 
This  remarkable  efTect  of  the  belladonna  was  first  discovered,  accidentally,  by  our 
countryman,  the  celebrated  Ray.  He  tells  us  that  a  noble  lady  of  his  acquaintance 
applied  a  leaf  of  the  plant  to  a  small  ulcer,  suspected  to  be  cancerous,  just  below 
one  of  her  eyes.  The  pupil  of  that  eye  became  greatly  dilated,  and  the  membrane 
remained  motionless  under  the  strongest  light.  This  effect  gradually  subsided  when 
the  leaf  was  removed.  But  it  took  place  on  three  several  occasions,  and  was  wit- 
nessed by  Ray  himself.  Other  vegetables  have  the  same  property  :  henbane,  for 
exampk-",  stramonium,  and  the  cherry  laurel.  And  there  are  others  which  have  it 
not,  although  we  might  have  expected  that  they  would  possess  it,  from  the  analogy 
they  bear  to  the  former  in  other  respects.  It  has  been  ascertained  that  neither  hem- 
lock, nor  aconite,  nor  foxglove,  nor  opium,  has  any  such  power. 

Preparations  of  belladonna  are  chiefly,  if  not  exclusively,  employed  in  ophthal- 
mic disorders  in  this  country.  It  is  used  in  two  ways.  The  extract  is  rendered 
soft  and  semifluid  by  admixture  with  distilled  water,  and  then  is  smeared  freely 
arouad  the  eye,  upon  the  lids,  and  brow,  and  forehead.  It  is  washed  ofT  after 
remaining  an  hour:  generally  it  produces  a  marked  effect  upon  the  pupil. 

A  more  efficacious  and  speedy  mode  of  dilating  the  pupil,  is  to  drop  a  solution 
of  the  extract  into  the  eye  itself.  The  solution  is  to  be  made  by  rubbing  down  a 
scruple  of  the  extract  in  an  ounce  of  distilled  water,  and  filtering  the  fluid  through 
linen.  Two  or  three  drops  of  this  solution  are  to  be  introduced  between  the 
ej'elids. 

Some  very  interesting  experiments  have  been  made  in  Germany  by  Dr.  Rei- 
singer  upon  this  property  of  belladonna  and  hyoscyamus,  of  contracting  the  iris — 
in  other  words,  of  dilating  the  pupil.  The  result  of  these  experiments  is  given  in 
the  24th  volume  of  the  Edinburgh  Medical  and  Surgical  Journal.  Dr.  Reisinger 
procured  atropine  and  hijoscyamine,  the  active  principles  of  the  two  plants,  and 
made  comparative  experiments  with  these  principles,  and  with  the  coarser  extracts ; 
and  he  concludes  that  the  former  are  much  to  be  preferred  to  the  latter.  Thus,  he 
dissolved  a  grain  of  hyoscyamine  in  ten  minims  of  water,  and  introduced  a  small 
drop  of  the  solution  into  the  eyes  of  several  dogs  and  cats.  No  irritation  whatever 
uf  the  eye  was  produced  in  any  instance,  but  the  pupil  was  so  much  widened  by 


IRITIS.  207 

the  application,  that  in  an  hour's  time  onl\'  a  small  ring  of  the  iris  could  be  seen 
beyond  the  edge  of  the  cornea;  and  after  three  hours,  the  pupil  seemed  as  large  as 
the  cornea  itself.  The  dilatation  did  not  begin  to  diminish  till  after  three  days ;  and 
the  pupil  did  not  recover  its  natural  dimensions  until  the  sixth  day.  Then  he  ap- 
plied a  solution  of  the  extract  of  hyoscyamus,  made  by  mixing  five  grains  with  ten 
minims  of  water.  This  evidently  caused  irritation  of  the  organ,  which  lasted  from 
five  to  eight  minutes,  and  was  evinced  by  a  discharge  of  tears,  by  the  animal's  shut- 
ting its  eyes,  and  rubbing  its  eyebrows  with  its  paws.  Much  less  dilatation  of  the 
pupil  followed,  and  continued  not  more  than  six  or  eight  hours  in  dogs,  and  about 
twenty-four  hours  in  cats.  As  soon  as  Dr.  Reisinger  had  satisfied  himself  that  the 
hyoscyamine  had  no  injurious  influence  either  upon  the  conjunctiva,  or  upon  the 
deeper-seated  textures  of  the  organ,  he  applied  it  to  the  human  eye.  He  dissolved 
a  grain  of  hyoscj'^amine  in  a  drachm  of  distilled  water,  and  inserted  a  drop  of  the 
solution  into  the  eye  of  an  old  lady  of  seventj^-one,  who  had  cataract.  So  great  was 
the  consequent  dilatation  of  the  pupil,  that  only  a  narrow  ring  of  the  iris  remained 
visible.  No  irritation  whatever  of  any  part  of  the  eye  was  produced  ;  and  the  dila- 
tation continued  for  seven  days. 

As  chemistry  is  now  furnishing  us  every  day,  in  greater  abundance,  and  with 
more  ease,  the  active  principles  of  various  of  our  medicinal  vegetable  substances, 
we  shall  soon,  in  all  probabilitj'',  adopt  hyoscyamine  or  atropine,  for  artificially 
dilating  the  pupil,  instead  cf  the  preparations  now  in  use.  Till  that  time  arrives, 
you  had  better  smear  the  surrounding  skin  with  the  moistened  extract  of  bella- 
donna whenever  the  eye  is  painful  or  much  inflamed.  But  under  other  circum- 
stances, the  solution  dropped  into  the  eye  is  to  be  preferred  for  its  readier  action, 
and  its  greater  power.  The  use  of  this  curious  virtue  possessed  by  certain  plants  is 
not  confined  to  the  cure  of  iritis :  it  enables  the  surgeon  to  introduce  instruments 
through  the  pupil  with  greater  facihty  and  safety;  it  affords  us  also  the  means  of 
examining  the  deeper-seated  textures  of  the  eye  ;  and  it  is  of  great  service  to  many 
persons  who  are  partially  blind  ;  to  such,  for  example,  as  have  central  specks  on 
the  cornea,  or  central  opacities  of  the  crystalline  lens ;  it  enables  such  persons  to 
enlarge  the  window  of  the  eye;  to  admit  more  light;  and  to  have  painted  upon 
the  retina,  and  represented  to  the  mind,  the  images  of  objects  which,  but  for  the 
mysterious  agency  of  these  poisonous  vegetables,  they  could  never  hope  to  see 
at  all.  It  is  a  very  fortunate  circumstance  that  the  power  of  belladonna  over  the 
iris  does  not  diminish  by  repetition.  Mr.  Lawrence  mentions  two  patients  of  his, 
(Hie  of  whom  had  used  it  habitually  for  four  or  five  years,  and  the  other  for  four- 
teen or  fifteen ;  and  it  dilated  the  pupil  just  as  well  at  the  end  of  these  periods  as 
at  the  beginning.  By  carefully  examining  an  eye  in  which  lymph  has  recently 
been  effused,  you  may  distinctly  see  the  good  effects  of  the  artificial  dilatation  of 
the  pupil ;  little  strings  of  adhesion  are  often  visible,  connecting  the  edjie  of  the 
iris  with  the  surface  of  the  lens ;  and  these  are  stretched,  and  not  un frequently 
broken  under  the  influence  of  the  belladonna :  and  minute  black  spots  may  some- 
times be  seen  upon  the  capsule,  marking  the  points  where  the  uvea  had  stuck,  and 
where  it  left  behind  it,  when  it  was  detached  by  the  belladonna,  a  portion  of  its 
peculiar  pigment.  These  black  points  are  indelible.  There  is  one  case  recorded 
in  which  the  pupil,  after  being  dilated  by  belladonna,  became  fixed  in  that  con- 
dition ;  probably  by  lymph  subsequently  efflised  into  its  texture,  and  binding 
together  its  fibres.  Even  this  is  better  than  that  the  pupil  should  be  contracted  and 
fixed. 

These  three  remedies,  then — ^bleeding,  mercury,  and  belladonna — are  the  means 
by  which  we  are  to  subdue  inflammation  of  the  iris,  and  repair  the  ravages  it  has 
occasioned.  With  respect  to  the  most  important  of  the  three,  mercury,  there  are 
some  points  that  require  to  be  further  noticed. 

You  may  ask  to  what  extent  the  mercury  should  be  pushed,  and  how  long  it 
should  be  continued? 

Why  we  have,  in  iritis,  an  illustration  of  what  I  have  more  than  once  mentioned 
before,  viz.,  that  the  rapidity  of  a  disease  will  require  a  corresponding  haste  m  tne 
use  of  its  remedy.     In  acute  and  violent  cases,  the  mouth  should  be  made  decidedly 


208  DISEASES    OF   THE    EYE. 

sore,  as  quickly  as  possible  ;  and  when  that  has  been  done,  the  further  administration 
of  the  mercury  may  be  suspended.  "  Full  sahvation,"  says  Mr.  Lawrence,  "  quickly 
produced,  cuts  short  recent  disease,  as  if  by  a  charm."  In  cases  of  longer  stand  in  (t, 
or  of  slower  progress,  we  must  be  slower  in  the  introduction  of  the  remedy :  it  will 
DC  enough  to  obtain  any,  the  smallest  certain  evidence  of  its  action,  in  the  gums  and 
breath  ;  and  we  must  keep  up  that  moderate  influence  for  some  time.  For  what 
precise  time  it  is  impossible  to  say  ;  but  till  the  redness  has  gone,  and  the  natural 
colour  of  the  iris  returns,  and  all  the  visible  lymph  has  disappeared,  and  the  sight  is 
perfectly  restored ;  and  this  may  require  a  month  or  two. 

^Vhen  you  look  from  day  to  day  into  the  aqueous  chamber  of  an  eye  in  which 
iritis  has  recently  produced  its  peculiar  changes,  and  after  the  due  effect  of  mercury 
upon  the  gums  has  been  achieved,  you.  will  be  surprised  as  well  as  delighted  to  see 
large  masses  of  lymph  rapidly  disappear,  melt  away,  as  it  were,  from  the  surface  of 
the  iris,  while  that  which  had  been  deposited  in  its  intimate  texture,  rendering  it 
confused  and  discoloured,  as  quickly  clears  ofT.  And  you  will  be  inchned  to  beheve, 
as  many  have  done,  that  mercury  has  a  vast  influence  in  promoting  and  accelerating 
absorption.  It  may  have  such  a  power  :  I  am  not  disposed  to  deny  it :  but  that  it 
really  has  so  we  cannot  safely  infer  from  such  circumstances.  It  clearly  has  the 
power  of  arresting  the  deposition  of  lymph  ;  of  putting  an  end  to  the  adhesive  in- 
flammation. Whether  it  does  any  thing  more  towards  completing  the  cure,  we  have 
these  reasons  for  doubting.  When  blood  happens  to  be  effused  into  the  anterior 
chamber ;  or  pus ;  or  when,  as  frequently  happens,  pieces  of  a  cataract  that  has 
been  broken  up  pass  through  the  pupil,  and  show  themselves  between  the  iris  and 
cornea ;  they  (the  blood,  the  pus,  the  fragments  of  the  lens)  disappear,  i.  e.,  are 
absorbed,  just  as  rapidly  as  the  lymph  in  iritis,  not  a  particle  of  mercury  is  taken 
Mr.  Lawrence  even  gives  a  case  of  syphilitic  iritis,  which  got  well  without  any 
affection  of  the  gums  by  mercury,  and  which  had  been  marked  by  the  deposition  of 
a  large  mass  of  Ij-mph  on  the  iris  ;  and  he  says  that  the  lymph  was  immediately 
absorbed,  as  soon  as  the  inflammation  ceased  ;  and  that  he  never  saw  it  disappeai 
more  quickly  under  any  circumstances. 

There  is  one  local  use  of  mercury  which  I  must  not  omit  to  mention,  because 
though  it  probably  has  no  share  in  curing  the  complaint,  it  is  productive  of  great 
comfort  and  relief  to  the  sufferings  of  the  patient.  It  is  adapted  to  those  cases  in 
which  severe  pain  is  felt  round  and  over  the  orbit  of  the  eye  at  night.  Ten  grains 
of  the  strong  mercurial  ointment,  intimately  mixed  with  two  grains  of  finely  powdered 
opium,  and  well  rubbed  into  the  temple  a  little  while  before  the  nocturnal  pain  is 
accustomed  to  recur,  will  in  many  cases  completely  prevent  it.  We  owe  this  piece 
of  practice  to  the  Germans. 

Iritis  is  apt  to  occur  from  different  causes,  and  in  connection  with  different  diseased 
states  of  the  system.  It  is  no  uncommon  accident  from  surgical  operations  performed 
upon  the  eye,  the  iris  suffering  mechanical  injury.  The  inflammation  thus  excited 
IS  usually  violent  and  acute,  and  requires  that  the  whole  plan  of  treatment  that  I  have 
been  sketching  out  should  be  actively  prosecuted. 

But  inflammation  of  the  iris  sometimes  arises  slowly  and  insidiously,  without  vas- 
cularity enough  to  call  attention  to  the  eye,  and  without  pain.  This  generally 
happens  when  the  eye  has  been  strained  by  over-use  ;  in  women  who  occupy  them- 
selves Avith  fine  needle-work ;  in  engravers,  and  such  as  are  accustomed  to  look  at 
minute  objects,  or  at  bright  objects.  A  more  common  effect  of  continued  exertion 
of  the  eyes  in  this  way,  is  a  diseased  state  of  the  retina;  but  (however  the  fact  may 
be  explained)  the  iris  is  sometimes  the  part  that  suffers.  In  this  form  of  the  disease 
mercury  will  often  be  found  a  successful  remedy ;  but  its  influence  must  be  gra- 
dually brought  about;  and  it  is  not  so  certainly  productive  of  benefit  as  when  it  is 
employed  in  acute  iritis : — probably  because  the  chronic  inflammation  has  involved 
the  posterior  tunics  also. 

But  most  frequendy  iritis  is  met  with  in  combination  with  syphilitic,  or  with  rheu- 
matic disease,  which  manifests  itself  at  the  same  time  in  other  parts  of  the  body. 
Syphilitic  iritis  is  more  common  than  any  other.  It  is  one  of  the  secondary  symptoms 
.-;t  syphilis  ;  and  accordingly  it  is  commonly  associated  with  other  secondary  symp- 


IRITIS.  209 

toms ;  with  syphilitic  eruptions,  nodes,  pains  in  the  limbs,  and  ulceration  of  the 
thioat.  It  IS  also  one  of  the  earlier  of  these  secondary  affections,  and  therefore  is 
sometimes  the  only  one  to  be  seen;  and  occasionally  it  declares  itself  before  the 
primary  disease  is  well.  The  pain  that  attends  this  species  of  iritis  is  chiefly  felt 
at  night,  but  at  that  time  it  is  apt  to  be  very  severe  and  distressing,  so  as  entirely  to 
prevent  sleep  until  it  takes  its  departure  in  the  morning.  We  cannot,  I  believe,  dis- 
cinguish  syphihtic  iritis  with  any  certainty  from  other  acute  varieties  of  the  same 
complaint,  by  mere  inspection  of  the  eye.  However,  there  are  some  points  worth 
remembering  in  respect  of  the  local  phenomena  which  it  most  commonly  presents. 
Syphilitic  iritis  is  never  attended  (according  to  Mr.  Lawrence)  with  abscess  of 
the  iris,  and  hypopyon ;  the  lymph  is  usually  deposited  in  distinct  masses;  and  the 
pupil  becomes  angular,  and  is  not  unfrequently  displaced  towards  the  root  of  the 
nose,  by  the  adhesions  which  the  iris  has  contracted  with  the  parts  behind  it.  In 
another  variety  of  inflammation  of  the  iris  (which  I  shall  mention  to-morrow,  arthri- 
tic iritis)  lymph  is  equally  effused  from  the  margin  of  the  iris,  but  it  is  not  usually 
deposited  in  a  distinct  drop-like  form.  We  ascertain  the  variety  of  iritis  with  which 
we  have  to  do  by  these  peculiarities  ;  by  the  co-existence  of  other  tokens  of  syphilis  ; 
by  the  periodical  character  of  the  nightly  pain  ;  by  taking  into  our  account  the  a^e, 
the  constitutional  habit,  and  the  probable  state  of  morals  of  our  patient.  Syphilis, 
you  know,  is  not  uncommon  in  children  ;  it  is  sometimes  even  congenital :  but  it 
very  Sfldom  afft-cts  the  iris  at  that  early  period  of  life.  Among  a  large  number  of 
syphilitic  children  brought  to  Mr.  Lawrence,  he  never  witnessed  iritis  but  once. 

It  was  in  syphilitic  iritis  that  the  curative  power  of  mercury  over  adhesive  inflam- 
mation was  first  distinctly  recognized.  But  you  must  not  fall  into  the  error  of  sup- 
posing that  the  success  of  the  remedy  depended  upon  the  specific  character  of  the 
disorder  ;  upon  its  connection,  I  mean,  with  the  venereal  virus.  Mercury  is  fully  as 
serviceable  and  as  sure  in  common  acute  inflammation  of  the  iris.  Upon  this  point 
ail  men  of  experience  are  agreed.  "  Its  influence  (says  Mr.  Lawrence)  is  not  con- 
fined to  the  syphilitic  form  of  the  disease,  but  extends  equally  to  the  idiopathic." 
And  Dr.  Farre  bears  testimony  to  the  same  effect. 


LECTURE  XX. 

Iritis  concluded.     Rheumatic  Ophthalmia.     Amaurosis. 

The  principal  theme  of  the  last  lecture  was  that  most  interesting  disease,  inflam- 
mation of  the  iris. 

The  symptoms  of  iritis  are  these  :  a  radiating  zone  of  vascular  redness  situated  in 
the  sclerotica,  and  surrounding  the  cornea ;  a  change  in  the  colour  of  the  iris,  from 
gray  or  blue  to  a  yellow  or  greenish  tint,  from  brown  or  hazel  to  a  dusky  reddish 
hue  ;  a  visible  deposit  of  lymph  upon  the  anterior  and  innermost  portion  of  the  iris  ; 
a  thickening  of  its  free  edge  ;  contraction,  irregularity,  and  immobility  of  the  pupil ; 
closure  of  the  pupil  by  lymph  ;  adhesion  of  the  uvea  to  the  membrane  of  the  chrys- 
talline  lens.  All  these  we  can  see  aqd  ascertain  for  ourselves.  We  can  ascertaiu 
also  the  presence  of  fever,  which  attends  the  acute  forms  of  the  disease.  And  wj 
learn  from  the  testimony  of  our  patient  that  his  sight  is  impaired ;  that  the  influx  o. 
hghl  into  the  eye  hurls  him ;  and  that  he  experiences  pain  in  and  around  the  organ 
especially  at  night. 

The  grand  remedies  in  iritis  are  three. 

1.  Blood-letting :  of  which  the  objects  are  to  abate  the  force  of  the  heart's  action, 
to  moderate  the  febrile  disturbance ;  and  to  facilitate  the  operation  of  the  second 
remedy  :  which  is — 

2.  Mercury.  This  is  to  be  given  so  as  to  produce  soreness  of  the  gums,  and  the 
peculiar  fostor  of  the  breath  :  and  these  effects  are  to  be  sought  for  rapidly  or  gradu- 
ally, according  as  the  inflammation  of  t"".e  iris  is  recent  and  acute,  or  moderaTe  and 

14  s3 


210  DISEASES    OF    THE    EYE. 

chronic.  The  object  of  this  remedy  is  to  arrest  the  efTusion  of  coagulable  Ij^mph  : 
to  put  a  stop  to  the  adhesive  inflammation. 

S.  The  appHcation  of  the  extract  of  belladonna  to  the  conjunctiva,  or  to  the  skin 
around  the  eye,  so  as  to  dilate  the  pupil.  The  objects  of  this  measure  are  to  pre- 
vent the  adhesion  of  the  iris  to  the  parts  in  its  neighbourhood  ;  to  detach  it  from  ih^ 
lens  when  it  has  already  been  glued  thereto  by  soft  lymph ;  and  to  stretch  and 
elongate  the  bands  of  adhesion  when  they  cannot  be  broken  :  and  thus  to  obviat?; 
any  impairment  of  the  free  movements  of  the  iris,  and  any  deformity  of  the  pupil, 
after  the  inflammation  shall  have  ceased. 

I  began  to  speak  of  the  causes  of  iritis. 

I  say  it  may  be  occasioned  by  mechanical  injury ;  as  during  the  operation  for  the 
extraction  of  a  cataract.  A  clean  cut,  however,  is  frequently  followed  by  no  bad 
consequences ;  a  portion  of  the  iris  has  been  shaved  oft'  by  the  knife  in  making  the 
section  of  the  cornea,  without  any  injurious  result.  When  iritis  is  excited  by  mecha- 
nical violence,  it  is  acute. 

2dlv.  A  chronic  form  of  iritis  is  sometimes  brought  on  by  excessive  er./loyment 
of  the  eye,  in  looki.ig  at  minute  or  bright  objects. 

'3dly.  The  most  common  species  of  iritis  is  that  which  arises  in  connection  with 
syphiltic  disease.  It  is  one  of  the  early  secondary  symptoms  of  syphilis.  l!  is 
marked  by  the  co-existence  of  other  secondary  consequences  of  the  introduction  inio 
the  system  of  the  syphilitic  poison,  and  by  the  periodical  character  of  the  nightly 
pain :  it  is  never  attended  with  abscess  of  the  iris  and  hypopyon ;  the  lymph  that 
is  effused  is  deposited  in  separate  masses  ;  and  the  pupil  is  often  displaced  towards 
the  root  of  the  nose,  as  well  as  rendered  irregular,  by  the  adhesion  of  the  iris  to  the 
capsule  behind  it. 

4thly.  It  is  curious  enough  that  iritis  has  actually  been  ascribed  to  mercury,  as  a 
cause.  This  notion  can  only  have  arisen  from  that  loose  kind  of  logic,  and  hasty 
generalization,  for  which,  I  am  sorry  to  say,  medical  reasoners  are  too  often  distin- 
guished. Mercury  is  perpetually  exhibited  for  the  cure  of  syphiUs ;  and  people 
who  have  been  treated  for  syphilis  are  very  hable  to  iritis.  This  seems  to  be  the 
only  foundation  for  the  opinion  in  question.  When  we  come  to  appeal  to  i:;cts.  we 
find  no  ground  for  believing  that  this  mineral  is  thus  both  bane  and  antidote.  If  it 
were  so,  Benvolio's  advice  to  the  slighted  Romeo  might  be  very  pertinently  otTered 
to  the  pal  lent  in  such  a  case  : 

"  Take  thou  some  new  infection  to  thiue  eye, 
And  the  rank  poison  of  the  old  will  die." 

Mr.  Lawrence  has  seen  no  instance  of  iritis,  of  whatever  kind,  in  which  there  - 
ha?  appeared  to  him  any  reason  for  attributing  the  occurrence  of  the  complaint  to 
this  cause.  I  have  never  heard  it  alleged  that  persons  who  have  taken  large  quan- 
tities of  mercury  for  other  diseases,  as  for  affections  of  the  liver  in  India,  are  parti- 
cularly subject  to  inflammation  of  the  iris.  On  the  other  hand,  iritis  has  come  on, 
in  hundreds  of  cases,  in  connection  with  syphihs,  though  not  a  particle  of  mercury 
had  been  sAvallowed  by  the  patients. 

Lastly,  there  is  a  pecuhar  form  or  variety  of  iritis,  called  tne  arthritic  or  rheii- 
mafic. 

This  affection  is  characterized  by  the  Vdowing  general  features.  It  occurs  in 
persons  who  are  subject  to  gout  or  rheumatism,  and  often  forms  a  part  of  the  attack  ' 
of  the  one  or  the  other  of  those  diseases.  Like  them  it  is  liable  to  return  again  and 
again  ;  and  this  circumstance  it  is  which  makes  arthritic  iritis  a  serious  disorder.  It 
is  seldom  that  much  or  permanent  damage  to  vision  is  effected  by  a  single  attack  ; 
bu*  -^''hesions  readily  form  under  it,  and  lymph  is  effused  :  and  in  each  successive 
Attack  fresh  efliision  takes  place :  the  pupil  becomes  more  and  more  contracted  ;  and 
p  may  be  filled  up,  at  last,  by  an  opaque  plug  of  lymph.  Some  patients,  howevjr, 
>vill  suffer  ten  or  a  dozen  recurrences  of  the  disease,  and  recover  almost  completely, 
and  enjoy  perfect  vision  in  the  intervals,  before  the  vision  becomes  much  impaired.  . 

.Some  of  the  local  appearances  are  more  or  less  characteristic  of  this  variety  of 
iritis.     It  is  seldomer  attended  than  the  syphihtic  variety  by  a  deposition  of  lymph 


RHEUMATIC   OPHTHALMIA.  211 

in  distinct  masses ;  .the  contracted  pupil  keeps  its  central  position,  and  is  not  dis- 
placed towards  the  root  of  the  nose,  as  it  is  apt  to  be  in  syphihtic  iritis.  The  adhe- 
sions that  bind  the  iris  to  the  neighbouring  parts  are  said  to  be  whiter  in  this  variety 
of  iritis  than  in  others..  It  is  also  a  very  remarkable  circumstance  that  the  zone  of 
red  vessels  encircling,  the  conjunctiva  does  net  approach  so  close  to  the  cornea  as  in 
other  species  of  iritis  ;  but  a  white  ring  is  left  between  the  cornea  and  the  anterior 
margin  of  the  zone.  Sometimes  the  circular  white  stripe  is  partial,  being  most 
marked  towards  the  angles  of  the  eye  ;  sometimes,  on  the  other  hand,  it  is  as  perfect 
as  if  it  had  been  described  with  a  pair  of  compasses.  I  believe,  with  Mr.  Welbank, 
that  the  appearance  of  this  bluish  ring  depends  upon  the  less  intense  degree  of  the 
sclerotic  inflammation.  He  says  that  he  has  noticed  its  coming  on,  when  syphilitic 
inflammation  of  the  iris  was  beginning  to  yield  to  the  action  of  mercury ;  although 
there  had  been  no  such  interval  during  the  height  of  the  inflammation.  Again,  the 
colour  of  the  zone  is  not  so  bright  as  in  other  forms  of  iritis ;  it  is  of  a  somewhat 
livid,  or  slightly  purplish  tint :  and  the  larger  vessels  at  the  back  part  of  the  eye, 
belonging  to  the  conjunctiva,  are  apt  to  become  tortuous  and  varicose. 

Rheumatic  iritis  is  often  met  with  in  combination  with  what  is  called  rheumatic 
ophthalmia:  a  disease  which.  I  have  not  before  mentioned.  But  each  may  exist 
alone.  And  as  rheumatic  iritis,  though  frequently  an  independent  disease,  does  also 
in  many  instances  grow  (as  it  were)  out  of  rheumatic  ophthalmia,  I  will  take  this 
opportunity  of  shortly  describing  the  latter  complaint. 

AVhat  is  called  rheumatic  ophthalmia,  then,  is'  inflammation  aff'ecting  the  fibrous 
coat  of  the  eye,  the  sclerotica.  We. know  that  the  fibrous  tissues  throughout  the 
body  are  frequently  the  seat  of  rheumatic  inflammation.  Some  persons  are  more 
liable  to  rheumatism  than  others  — are  more  readily  affected  by  its  external  exciting 
causes,  which  are  vicissitudes  of  temperature,  and  exposure  to  cold  and  wet.  In 
such  persons  there  ^eems  a  tendency  to  take  on  inflammatory  action  in  all  the  struc- 
tures of  the  sams  kind  ;  and  most  particularly  in  the  fibrous  membranes,  and  tei  - 
dons,  lha.t  help  to  form  the  various  joints ;  and  as  the  sclerotica  partakes  of  this 
fibrous  texture,  so  it  is  apt  to  suffer,  in  its  turn,  from  rheumatic  inflammation.  The 
connection  of  the  movable  eyeball  with  the  head  may  be  considered  as  a  sort  of 
joint.  The  local  symptoms  are  not  in  general  of  a  violent  kind  ;  and,  as  in  other 
parts,  the  rhematism  seldom  leadis  to  any  permanent  alteration  of  structure  ;  seldom, 
at  least,  when  che  ophthalmia  is  confined,  as  it  often  is,  to  the  sclerotica  alone.  Pcr- 
naps  the  best  way  to  put  you  in  possession  of  the  features  that  belong  to  rheumatic 
ophthalmia  will  be  to  describe  an  actual  instance  of  it.  1  will  take  a  well-marked 
example,  related  by  Mr.  Lawrence..  He  was  sent  for  to  see  a  gentleman  who  was 
suffering  from  whaf  is  commonly  called  rheumatic  gout :  swehing,  some  redness, 
and  severe  pain  of  oni?  foot  and  knee,  and  one  hand;  aching  of  the  back;  and 
great  constitutional  excitement.  He  got  Avell  under  the  treatment  adopted.  After 
a  short  interval,  lipon  Mr.  Lawrence's  calling  to  inquire  how  he  was,  he  said  there 
was  something  the  matter  with  his  .eyes;  and  asked  to  have  them  examined.  "I 
looked,  at  them  hastily,"  says  Mr.  Lawrence:  "the  room  was  dark,  and  the  day 
dull ;  and  I  saw  no  appearance  of  disease.  When  I  called  again,  after  a  few  days, 
as -the  complaint  was  repeated,  1  examined  more  attentively.  On  bringing  him 
towards  the  window,  he  obviously  felt  the  light  troublesome;  he  drew  down  ihe 
eyebrows,  and  half  closed  the  hds,  to  avoid  it.  The  conjunctiva  was  natural;  but 
the  whole  of  the. sclerotica  had  a  livid  red,  and  mottled  appearance,  which  might 
have  been  called  dull,  or  almost  dirty,  in  comparison  with  the  red  colour  of  common 
active  iriflammation.  The  sclerotic  vessels  were  partially  distended  ;  the  redness 
terminated  short  of  the  cornea,  so  that  there  was  a  distinct  white  rim  round  the  latter. 
Vision  was  perfect;  there  was  no  pain  so  long  as  the  eye  remained  at  rest ;  but 
exertion  of  the  organ,  particularly  under  strong  light,  brought  on  uneasiness.  The 
nature  of  this  gentleman's  occupation,  and  of  his  tastes,  which  were  literary,  pre- 
vented him  from  giving  his  eye  the  necessary  repose ;  and  the  condition  of  the  scle- 
rotica just  descrih.ed  lasted  for  three  or  four  months;"  so  that  Mr.  Lawrence  was 
apprehensive  that  some  serious  mischief  would  ensue  to  the  organ.  The  afTeotion 
remained  confined,  however,  to  its  original  seat,  evincing  only  that  obstinate  chafac 


212  DISEASES   OF   THE   EYE. 

tor  which  belongs  to  disorders  of  such  structures ;  and  at  last  it  disappeared  com 
pletely,  leaving  the  eyes  with  their  organization  and  powers  unimpaired. 

The  treatment  that  appears  to  answer  best  in  simple  rheumatic  ophthalmia  of  this 
kind,  consists  in  moderate  topical  bleedings,  and  counter-irritation :  with  such  other 
measures  as  conduce  to  improre  the  general  health ;  and  among  these,  change  of 
air  and  scene  have  sometimes  a  decided  effect.  Those  remedies  also  are  to  be  given 
which  have  been  found  by  experience  to  be  beneficial  in  rheumatic  inflammation, 
although  we  cannot  always  depend  upon  finding  them  useful :  colchicum,  I  mean  ; 
bark  ;  sarsaparilla  ;  the  iodide  of  potassium.  In  these  abiding  or  frequently  recur- 
ring forms  of  disease,  you  will  often  be  obliged  to  try  the  so-called  specific  remedies 
one  after  the  other. 

Now  when  the  rheumatic  inflammation  is  not  confined  to  the  sclerotic,  but  creeps 
inward,  as  by  their  vascular  connections  it  easil}^  may,  to  the  iris  also,  we  name  the 
disease  according  to  the  most  important  part  that  it  occupies — arthritic  iritis.  On 
the  other  hand,  when,  Avith  that  affection  of  the  sclerotic  which  I  have  been  de- 
scribing, there  is  combined  a  moderate  degree  of  inflammation  of  the  conjunctiva, 
this  complex  disorder  receives  a  compound  denomination ;  it  is  called  catarrho* 
rheumatic  ophthcdmia. 

Dr.  iVlackenzie  states  it  as  the  result  of  his  experience,  that  arthritic  iritis  seldom 
occurs  in  connection  with  the  earlier  appearance  of  gout,  while  the  patients  stil 
retain  strong  powers  of  digestion,  and  have  the  means  of  indulging  their  appetites; 
but  rather  with  the  asthenic  and  irregular  forms  of  gout  and  rheumatism;  when 
repeated  attacks  have  been  followed  by  mental  depression,  indigestion,  flatulence 
and  languor.  He  has  generally  met  with  the  disease  in  subjects  beyond  the  age 
of  fift)-,  very  frequently  in  tobacco-smokers,  and  whiskey-drinkers,  who  have  often 
suffered  rheumatic  affections,  who  are  teased  by  headaches,  acidity  of  stomach,  bad 
gums  and  teeth,  and  lowness  of  spirits  :■  in  persons,  that  is,  whose  health  has  heen 
impaired  and  broken  by  intemperate  habits.  I  believe  you  will  find  this  to  be  a  very 
correct  statement;  although  arthritic  iritis  may  ■Q.ho  take  place  in  those  who  are 
more  robust. 

After  what  has  now  been  stated  you  will  be  prepared  to  believe  that  arthritic  iritis 
neither  requires  nor  bears  those  free  emissions  of  blood,  and  that  liberal  use  of  mer- 
cury, which  are  necessary  for  the  cure  of  other  varieties  of  the  complaint.  Mercury, 
pushed  to  salivation,  is  sometimes  found  to  do  more  harm  to  the  system  than  good 
to  the  eye  ;  and  in  a  disease  which  is  so  apt  to  recur,  we  must  not  be  continually 
salivating  our  patient.  I  can  only  say  that  the  treatment  must  be  conducted  on  the 
principles  already  laid  down,  and  adapted  to  circumstances.  If  there  be  an}^  fever, 
and  a  hard  pulse,  and  a  white  tongue,  you  should  bleed  and  purge  your  patient,  and 
afterwards  give  him  from  twenty  minims  to  half  a  drachm  of  the  wine  of  colchicum 
two  or  three  times  a  day.  When  the  symptoms  are  less  active,  you  must  be  less 
active  too:  strive  to  set  the  disordered  dijjestive  organs  ri2"ht,  and  to  correct  the  bad 
habits  of  the  patient:  give  small  doses  of  mercurj'  (such  as  five  grains  of  Plummcr's 
pill)  three  or  four  times  a  week  ;  excite  counter-irritation  bj'  blisters,  or  by  the  tartar- 
emetic  ointment.  After  the  use  of  bleeding  or  leeches,  and  the  regulation  of  the 
bowels,  preparations  of  iron,  the  sulphate  of  quina  —  tonics,  in  short,  —  have  been 
found,  in  not  a  few  cases,  extremely  beneficial. 

I  should  have  mentioned  another  remedy,  which  of  late  years  has  been  recom- 
mended in  iritis,  and  especially  in  syphilitic  iritis,  by  Mr.  Carmichael,  of  Dublm : 
not  as  being  a  better  remedj'  in  itself  than  mercury,  or  so  good,  but  as  having  con- 
siderable, power  over  the  disease,  and  as  affording,  therefore,  a  valuable  resource 
when  from  any  cause  the  exhibitkin  of  mercury  is  forbidden.  This  remedy  is  the 
oil  of  turpentine.  He  gives  it  in  drachm  doses,  three  times  a  day.  He  relates 
cases  of  syphilitic  iritis  in  which  the  pain,  redness  and  other  symptoms,  were  quickly 
xemoved,  and  effiised  lymph  was  absorbed,  and  vision  restored,  under  the  use  of  this 
medicine.  It  is  necessary  to  its  beneficial  action  that  the  bowels  should  nqj  be  con- 
nned.  In  other  instances  of  the  same  disease,  Mr.  Carmichael  was  not  so  success- 
ful. Mr.  Guthrie,  who  has  also  tried  this  remedy,  reports  of  it  that  "  in  some  cases 
t  succeeded  admirably,  m  others  it  has  been  of  litde  service,  and  in  some  unequal 


AMAUROSIS..  213 

to  the  cure  of  the  complaint."     I  do  not  know  that  it  has  been  fairly  put  to  the  test 
in  arthritic  iritis. 

I  proceed  next  to  quite  a  different  kind  of  ophthalmic  disease  from  any  that  we 
have  yet  considered.  I  have  spoken  of  inflammation  of  the  exterior  membrane  of 
the  eye  occurring  separately;  and  of  inflammation  of  certain  internal  parts,  and  par- 
ticularly of  the  iris,  occurring  separately.  Between  these  exterior  and  interior  tunics, 
the  sclerotica  forms  a  sort  of  natural  barrier  or  shield,  the  chief  point  of  connection 
Detween  them  being  near  the  edge  of  the  cornea,  where  the  sclerotic  vessels  dive 
through  to  reach  the  iris.  Inflammation  of  the  sclerotica  itself  has  also  been  de- 
scribed. When  vision  is  impaired  or  destroyed  in  consequence  of  any  of  the  com- 
plaints which  have  hitherto  engaged  our  attention,  that  effect  results  from  the  partial 
or  total  exclusion  of  light  from  the  retina.  The  cornea  is  left  opaque,  or  it  bursts  ; 
the  pupil,  or  aperture  in  the  iris,  is  shut  up  by  a  web  of  lymph  ;  or  the  capsule  of 
the  lens  to  which  the  iris  adheres  has  undergone  a  change,  and  lost  its  transparency. 
In  each  case  the  retina  suffers  an  eclipse. 

But  light  may  be  freely  admitted,  and  yet  no  vision  ensue.  The  transparent  parts 
of  the  eye,  the  several  media,  so  skilfully  and  exquisitely  adjusted  for  the  due  refrac- 
tion and  collection  of  the  rays  of  light  into  an  image  of  the  object  from  which  they 
flow,  may  all  be  perfect  and  in  order;  but  the  beautiful  apparatus  is  useless;  the 
patient  cannot  see  Vv'ith  it.  The  fault  is:  in  the  nervous  matter  that  should  receive 
and  transmit  the  impression,  and  render  it  an  object  of  perception  to  the  mind. 

Now  persons  in  this  condition  are  said  to  have  amaurosifi.  The  term  is  derived 
from  the  Greek  word  a,uarpoj,  which  signifies  obscure  or  dark.  It  expresses  various 
degrees  of  imperfect  vision,  from  defective  nervous  function.  The  words  gutta 
serena  are  applied  to  that  form  of  amaurosis  in  which  vision  is  totally  lost.  It  was 
formerly  supposed  that  this  'sort  of  blindness  was  caused  by  the  effusion  of  some 
humour  or  fluid  behind  the  pupil:  and  this  was  held  to  be  a  clear  fluid,  because  the 
natural  blackness  of  the  pupil  is  sometimes  not  troubled  in  arnaurosis.  Milton  has 
literally  translated  this  term  when,  speaking  of  his  own  eyes,  he  says : 

■  "  So  thick  a  drop  serene  hath  quenched  their  orbs."        • 

Amaurosis  is  a  very  obscure  disease.  It  is  capable  of  being  caused  by  various 
changes,  the  exact  seat  and  nature  of  which  we  often  have  no  means  of  determining 
during  life;  and  which  frequently  leave  no  traces  behind  them  in -the  dead  body. 
It  would  take  a  much  larger  space  than  I  can  possibly  devote  to  it  in  these  lectures, 
thoroughly  to  discuss  this  difficult  but  interesting  subject.  I  shall  endeavour  to  give 
you  such  a  sketch  of  it  as  you  may  fill  up  and  complete  by  future  observation  and 
reading  for  yourselves.  Ii  will  be  something  to  learn  the  direction  and  objects  of 
our  inquiries  into  what  is  yet  unknown  in  the  pathology  of  this  affection. 

There  is  one  division  of  the  disorder  which  immediately  suggests  itself.  The 
cause  of  defect  may  exist  in  the  brain,  at  or  beyond  the  origin  of  the  optic  nerve; 
or  it  may  be  situated  in  any  part  of  the  course  of  that  nerve,  from  its  commencement 
at  the  base  of  the  brain  to  its  termination  in  theretina;  or  it  may  be  confined  to  the 
retina  itself. 

There  is  reason  to  believe  that  the  functions  of  the  retina  may  be  impaired  or  sus- 
pended, by  deviations  from  the  natural  quantity  of  blood  sent  to  it;  by  disturbances 
of  its  circulation.  Various  degrees  of  amaurosis  aje  common  among  persons  who 
employ  the  sense  of  vision  overmuch,  and  strain  the  eye.  This  over-use  is  likely 
to  produce  congestion,  or  chronic  inflammation,' in  the  vessels  of  the  retina  ;  and  very 
slight  changes  of  that  kind  may  seriously  affect  the  function  of  a  part  so  delicate  and 
tender.  I  say  we  frequently  meet  with  amaurosis  among  those  whose  occupations 
oblige  them  to  look  attentively  at  small  or  bright  objects  during  many  hours  of  the 
day;  or  what  is  still  more  pernicious,  during  many  hours  of  lamp  or  candle  lighi ; 
so  as  habitually  to  fatigue  the  eye.  Engravers,  printers,  watchmakers,  tailors  and 
milliners,  mathematical  in.^trument  makers,  persons  who  gain  their  oread  by  writing, 
miniature  painters,  cooks  who  are  exposed  to  the  heat  and  glare  of  large  fires,  men 
who  have  the  charge  of  forges  or  furnaces,  and  so  on.     Here  a  continual  stimulua 


£14  DISEASES    OF    THE    EYE. 

Jcads  to  a  chronic  disorder,  which,  increasing  in  intensitj',  may  terminate  in  total 
blindness.  We  call  these  cases  of  amuuroais,  but  they  may  be  justly-considered  to 
be  instances  o^  chronic  wjlammution  of  the  retina;  we  cannot  see  the  suffering  part 
indeed. during  life ;  and  the  complaint  is  not  a  fatal  one,  and,  therefore,  we  have  few 
opportunities,  or  none,  of  examining  after  death  the  condition  of  the  retina  while  the 
amaurosis  is  yet  recent.  But  judging  from  the  nature  of  the  causes  that  precede 
the  defect  of  vision,  and' from  the  nature  of  the  remedies  that  are  often  found  to  re- 
move it,  we  are  ^yarranted  in  regarding  the  essence  of  the  disease  to-be  retinitis^ 
The  same  condition,  apparently,  may  be  suddenly  produced  b}'  the  transient  opera- 
tion of  some  more  powerful  cause  of  congestion:  such  as  intense  light.  1  will 
illustrate  this  form  of  amaurosis — amaurosis,  that  is,  dependent  upon  congestionj 
which,  perhaps,  amounts  to  inflamniation,  sometimes  slowly  established,  and  some- 
times very  suddenly — by  the  narration- of  a  few  cases.  I  may  as  well  premise, 
however,  that  the  treatment  which'  promises  niost,  or  I  should  rather  say,  which  has 
performed  most,  in  this  form  and  kind  of  amaurosis,  is  very  nearly  the  same  (except- 
ing the  use  of  belladonna)  that  I  have  already  recommended  for  chronic  and  acute 
iritis.  Blood-letting,  general  or  topical,  according  as  there  are  more  or  less  pain  and 
fever,  and  fullness  of  the  system,  and  according  as  the  amaurosis  is  more  or  less 
recent ;  and  above  all  mercury,  so  administered  as  to  affect  the  gums,  and  rapidly 
introduced  into  the  system  in  the  acuter  cases:  more  slowly  in  proportion  as  the 
disease  has  crept  on  more  gradually  and  lasted  longer.  This  treatment  is  very  often 
quite  successful :  the  mercury  is  the  most  important  part  of  it ;  and  we  have  in 
this  facta  strong  corroboration  of  the  inference  drawn  from  the  nature  of  the  exciting 
causes,  viz.,  that  the  complaint  is  essentially  inflammatory.  And  again,  supposing 
it  inflammatory,  we  need  not  be  surprised  that  a  remedy,  the  curative  effect  of  which 
we  can  see  in  inflammation  of  the  iris,  should  be  equally  serviceable  when  the  same 
diseased  process  is  set  up  in  the  retina,  which  we  cannot  see.  Purgatives,  counter- 
irritation,  and  perfect  repose  of  the  eye,  are  necessary  parts  of  the  treatment  in  both 
forms  of  disease. 

Mr.  Allan  gives  the  following  account  of  the  master  of  a  printing-office,  who  be- 
came blind.  He  had  corrected  the  press,  and  Avas  otherwise  engaged  in  reading,  for 
eighteen  hours  daily  out  of  the  twenty-four.  He  continued  this  practice  for  twelve 
months,  notwithstanding  an  evident  failure  of  his  sight..  At  the  end  of  that  time  the 
amaurosis  was  so  complete  that  he  could  not  distinguish  one  object  from  anothu-r, 
but  was  merely  capable  of  just  perceiving  the  light,  so  as  to  grope  his  way  along 
the  streets.  He  continued  in  this  state  for  several  years,  but  ultimately  recovered 
his  vision. 

The  next  instance  that  I  shall  cite  is  recorded,  in  these  words,  by  Mr.  Lawrence. 
"A  young  woman,  of  florid  complexion  and  full  habit,  came  to  the  London  Ophthal- 
mic Infirmary,  complaining  that  she  had  lost  the  sight  of  one  eye.  She  was  a  cook, 
in  a  family,  and  occupied  for  several  hours  daily  before  large  fires,  supporting  he' 
strength  by  free  living.  The  pupil  was  slightly  dilated  ;  the  iris  motionless.  A 
faint  and  scarcely  perceptible  pink  tint  was  observed  in  the  sclerotica  near  the  cornea. 
Vision  was  dim,  and  had  been  so  for  three  days.  There  were  headache,  flushed 
countenance,  heat  of  skin,  whitish  tongue,  and  thirst.  1  considered  the  case  to  be 
pure  retinitis  ;  and  to  afford  a  favourable  opportunity  for  slwwing  whether  the  affec- 
tion could  be  arrested  by  antiphlogistic  treatment.  At  that  time  (now  many  years 
ago)  I  did  not  possess  the  knowledge  of  the  power  of  mercury  in  inflammation  of 
the  retina,  which  subsequent  experience  has  given  me.  I  directed  a  fuU  bleeding 
from  the  arm,  free  purging,  low  difet,  repose  of  the  organ,  and  general  rest.  At  the 
end  of  two  days  the  sight  was  worse  :  cupping  and  a  bhster  were  now  ordered  ;  but 
there  was  no  improvement  at  the  end  of  two  daj's.more.  I  now  determined  on  try- 
mg  mercury,  and  ordered  two  grains  of  calomel  every  four  hours.  Before  the 
remedy  had  affected  the  system,  vision  was  quite  lost,  or  at  least  reduced  to  the  mere 
power  of  distinguishing  light  from  darkness.  FuU  salivation,  which  took  place  in 
about  a  week  from  the  first  application  of  this  patient  at  the  infirmary,  suspended 
all  the  symptoms ;  the  sight  immediately  improved,  and  was  soon  completely 
restored." 


AMAUROSIS.  215 

A  soldier,  unacquainted  with  the  proper  method  of  observing  an  ecHpse  of  the 
sun,  employed  fur  that  purpose  a  piece  of  opaque  glass,  with  a  transparent  point  in 
its  centre.  Notwithstanding  the  vivid  and  painful  impression  he  experienced  from 
the  rays  that  passed  through  the  lucid  part  of  the  glass,  he  continued  to  look  at  the 
sun  till  the  eclipse  was  over,  using  his  right  eye.  He  vi^as  soon  after  seized  with 
vertigo,  and  pain  in  the  right  side  of  the  head,  and  found  himself  almost  entirely 
deprived  of  the  sight  of  the  right  eye.  Some  weeks  afterwards,  the  pain  in  the 
head  continuing,  he  came  under  the  care  of  Baron  Larrey,  who  observed  that  the 
vessels  of  the  eye  were  injected,  the  pupil  somewhat  smaller  than  that  of  the  other 
eye,  retaining,  however,  its  natural  freedom  of  motion  ;  the  vision  very  obscure  or 
almost  gone.  This  man  recovered  his  sight  completely  after  two  bleedings,  one 
from  the  temporal  artery,  the  other  from  the  jugular  vein ;  blisters  to  the  temple  and 
nape  of  the  neck ;  ice  to  the  head,  and  moxas. — [Mackenzie  from  the  Mtmoires 
de  Chirurgie.) 

In  the  year  1833,  a  young  man  standing  in  a  door-way,  by  a  lamp-iron,  in  a 
thunder-storm,  was  struck  by  the  lightning,  fell  backwards,  and  was  convulsed.  He 
t^aid  afterwards  that  the  lightning  appeared  to  enter  his  eye  with  a  scorchino-  sensa- 
tion. During  the  night,  vision  was  quite  lost.  The  next  morning  there  was  no  red- 
ness, nor  any  unusual  appearance  of  the  eye.  The  iris  was  motionless,  however, 
and  the  patient  could  not  see  even  the  sun.  He  was  treated  with  calomel,  and  his 
sight  returned ;  but  the  retina  remained  extremely  irritable,  and  unable  to  bear  the 
light.  A  month  afterwards,  when  this  account  was  written,  he  could  see  distinctly 
t-nough,  but  he  could  not  use  his  eyes  without  the  protection  of  blue  glasses. — 
{Lawrence.) 

In  these  cases  the  nervous  apparatus  that  ministers  to  vision  is  not,  I  believe,  in 
general,  the  only  part  of  the  nervous  system  that  is  injured.  In  August,  1839, 
Phoebe  Judge,  a  delicate-looking  girl,  eleven  years  old,  became  my  patient  in  the 
Middlesex  Hospital.  She  had  lost,  in  a  great  degree,  the  power  of  using  her  legs : 
when  she  attempted  to  stand  they  separated,  and  she  sank  down.  She  had  not  per- 
fect control  over  her  bladder.  The  desire  to  make  water  was  frequent,  and  if  not 
immediately  attended  to,  the  urine  escaped  in  spite  of  her  efforts  to  retain  it.  The 
same  urgency,  and  inability  to  wait,  occurred  whenever  her  bowels  were  about  to  act. 
Sensibihty  in  the  legs  and  thighs  Avas  impaired,  but  not  extinct. 

Her  parents  informed  me  that  some  time  previously,  while  stooping  to  raise  up  a 
sister  in  a  room  at  Hampstead,  she  had  been  struck  by  lightning,  fell  backwards, 
became  blind,  and  remained  so  for  ten  days.  She  did  not  lose  her  consciousness, 
but  complained  immediately  that  the  lightning  had  hurt  her  eyes.  They  presented 
no  visible  irijury  or  defect,  but  the  upper  lids  fell,  and  she  was  unable  to  raise  them. 
It  was  soon  found,  however,  that  when  pressure  was  made  on  the  right  eyelid  she 
could  open  the  other  eye.  The  palsy  of  her  limbs  commenced,  by  degrees,  two 
or  three  days  afterwards.  The  power  of  vision  returned  suddenly,  and  at  the  same 
moment  the  power  of  moving  her  limbs  was  restored  ;  but  it  gradually  went  again. 
When  she  lay  down,  her  limbs  were  still;  but  they  began  to  femble,  and  to  be 
agitated  as  soon  as  she  sat  up.  Even  when  lying  in  bed,  she  had  occasionally  a 
sensation  and  dread,  as  if  she  were  falling  down.  She  had  been  in  this  state  nearly 
three  weeks. 

She  was  put  upon  steel,  and  a  tonic  plan  of  treatment,  and  in  ten  days  she  could 
walk,  dragging  her  left  leg  a  little  afier  her.  In  ten  days  more  she  was  dismissed 
quite  well,  and  able  to  run  from  one  end  of  a  long  ward  to  the  other. 

The  greater  number  of  the  cases  of  amaurosis  depending  upon  a  morbid  condition 
of  the  retina  itself,  belong  to  the  class  that  I  have  now  been  mentioning:  there 
is  congestion  of  the  vessels  of  the  retina ;  or  inflammation,  chronic  or  acute.  In  a 
few  instances  a  totally  opposite  condition  of  the  blood-vessels  is  presumed  to  exisi. 
I  say  presumed  to  exist,  because  our  judgment  of  this  matter  is  founded,  as  before, 
upon  the  nature  of  the  circumstances  that  have  caused  the  affection,  and  upon  the 
nature  of  the  treatment  that  removes  it.  On  these  grounds  some  cases  of  amaurosis 
(few  in  number,  speaking  comparatively)  may  fairly  be  ascribed  to  a  deficient  supply 
of  blood  to  the  vessels  of  the  retina.    We  know  that  a  temporary  defect  of  sight  may 


216  DISEASES    OF    THE    EYE. 

be  produced  by  a  diminished  circulation  through  the  retina,  as  in  approaching  syn- 
cope under  hemorrhage ;  and  we  can  therefore  the  more  readily  believe  that  more 
permanent  amaurosis  may  be  occasioned  by  causes  that  gradually  lessen  the  quantity 
of  blood  circulating  in  the  body,  and  debilitate  the  whole  system.  "  It  is  well  known 
(writes  the  late  Dr.  Gooch)  that  large  losses  of  blood  enfeeble  vision.  I  saw  a 
striking  instance  of  this  in  a  lady  who  was  flooded  to  death.  When  I  entered  the 
chamber  she  had  no  pulse,  and  she  was  tossing  about  in  that  restless  state  which  is 
so  fatal  a  sign  in  these  terrific  cases.  She  could  still  speak ;  asked  whether  I  was 
come  ?  (she  knew  I  had  been  sent  for),  and  said,  '  Am  I  in  any  danger  ? — How  dark 
the  room  is !  I  can't  see.'  The  shutters  were  open,  the  blind  up,  and  the  light 
from  the  window  facing  the  bed  fell  strong  on  her  face.  I  had  the  curiosity  to  lift 
the  hd,  and  to  observe  the  state  of  the  eye.  The  pupil  was  completely  dilated,  and 
perfectly  motionless,  though  the  light  fell  full  upon  it.  Who  can  doubt  that  here 
the  insensibility  of  the  retina  depended  on  the  deficiency  of  its  circulation?" 

One  might  ask,  also,  who  can  doubt  that  the  retina  may  become  insensible  from  a 
similar  state  of  the  circulation  in  it,  brought  on  by  some  long-continued  drain  upon 
the  system  ?  Amaurosis  of  this  kind,  proceeding  from  too  profuse  and  protracted  a 
secretion  (which  may  be  considered  a  sort  of  hemorrhage),  is  sometimes  noticed  in 
nurses.  Mr.  Lawrence  describes  the  case  of  a  3'oung  mother  of  slender  make,  who 
suckled  her  first  child,  which  was  strong,  and  look  the  breast  very  often  ;  her  milk 
was  abundant.  After  two  or  three  months  she  began  to  feel  very  weak,  could  not 
lift  a  weight,  and  cried  frequently,  without  having  any  moral  reason  for  grief.  She 
became  totally  blind,  and  was  led  to  his  house  by  a  friend.  He  found  her  pallid, 
with  a  small  feeble  pulse.  The  pupils  were  of  middle  size,  and  the  irides  moved 
slightly.  The  retina  Avas  completely  insensible.  She  could  not  discern  the  situation 
of  the  window,  nor  see  a  lighted  candle  held  close  to  her.  After  weaning  the  child, 
and  using  generous  diet,  she  got  perfectly  well.  Some  counter-irritation  was  em- 
ployed in  this  instance,  but  I  question  whether  it  had  any  thing  to  do  with  the 
recovery.  Such  cases  are  not  unconmion,  and  their  well-known  occurrence  has 
probably  tended  to  encourage  the  notion  —  too  prevalent  among  both  patients  and 
practitioners — that  amaurosis  is  always  essentially  a  disease  of  debility,  and  requires 
tonic  and  stimulant  remedies  ;  bark,  and  high  feeding,  and  strychnia,  and  electricity. 
"Our  eyes  are  iveak,^''  say  they,  "and  we  require  strengthening  medicines."  You 
must  perceive  from  what  has  already  been  said,  how  necessary  it  is  to  discriminate 
in  such  cases  :  to  look  closely  into  all  the  circumstances  under  which  the  disease  has 
occurred. 

W'hen  amaurosis  is  the  resuU  of  pressure  or  of  disease,  in  the  course  of  the  optic 
nerve,  or  in  the  sensorium,  the  complaint  is  generally  less  within  the  power  of  reme- 
dial measures.  We  cannot  say,  indeed,  in  many  instances,  where  the  cause  of  defect 
lies :  and  in  obscure  cases,  I  should  always  advise  a  trial  of  the  mercurial  plan.  I 
have  again  and  again  seen  slight  palsy  of  some  of  the  voluntary  muscles,  evidently 
depending  upon  some  morbid  condition  of  the  brain,  clear  away  rapidly  upon  the 
affection  of  the  gums  by  mercury ;  and  the  lost  power  of  the  retina  will  sometimes 
return  under  similar  treatment. 

There  is  something  very  peculiar  in  the  expression  of  countenance,  and  in  the 
gait,  of  an  amaurotic  person,  by  attending  to  which  alone,  you  may  almost  recognize 
his  disease.  He  comes  into  a  room  with  an  air  of  uncertainty  in  his  movements  ; 
the  eyes  are  not  directed  towards  the  surrounding  objects ;  the  eyelids  are  wide 
open  ;  to  use  a  strange  but  common  and  intelligible  phrase,  the  patient  seems  gazing 
upon  vacancy — has  an  unmeaning  stare ;  and  there  is  a  want  of  that  harmony  of 
•noveuu'iit  and  ex[)ression  which  results  in  a  great  measure  from  the  information 
Obtained  by  the  exercise  of  vision.  This  seeming  stare  at  nothing  at  all,  is  not 
observed  in  patients  who  are  blind  in  consequence  of  opacity  of  the  crystalline  lens 
or  its  capsule,  i.  c,  in  consequence  of  cataract.  They,  on  the  contrary,  while  they 
:^nnot  see,  still  seem  to  look  about  them,  as  if  they  were  conscious  that  the  power 
of  sight  remained  to  the  retina,  although  light  was  shut  out  from  it. 

When  the  amaurosis  is  incomplete,  the  motions  of  the  iris  are  sluggish,  and  the 
[>upil  is  largfer  than  ordinary.     When  the  bhndness  is  total,  the  commonest  condition 


AMAUROSIS.  217 

of  the  eye  is  that  of  great  dilatation  of  the  pupil,  with  complete  immobility  of  the 
iris.  A  mere  ring  of  iris  is  all  that  is  visible,  and  no  change  takes  place  in  the 
diameter  of  the  pupil,  under  the  greatest  variation  of  the  Hght  that  falls  upon  it. 

Sometimes,  on  the  other  hand,  though  the  amaurosis  be  total,  the  iris  is  as  active 
as  ever;  and  this  is  a  very  interesting  circumstance,  and  may  help  us,  in  some 
degree,  to  conjecture  the  actual  seat  of  the  malady.  When  the  amaurosis  is  con- 
fined to  one  eye,  this  may  happen.  You  examine  the  diseased  eye,  and  you  find 
that  the  pupil  enlarges,  or  contracts,  as  you  diminish  or  increase  the  hght.  But  the 
other  eye  is  open.  Shut  the  sound  eye,  and  try  the  amaurotic  eye  again,  and  you 
find  the  pupil  fixed,  although  you  vary  the  light.  The  motion  you  formerly  noticed 
was  sympathetic  of  the  motion  of  the  iris  in  the  healthy  eye.  We  express  this 
otherwise  by  saying  that  the  associated  movements  of  the  iris  were  natural  and 
iiveljr,  but  its  independent  movements  were-  lost.  But  sometimes  the  independent 
movement  is  unaffected :  nay,  the  motions  of  both  irides  may  be  perfect,  although 
both  eyes  are  completely  amaurotic.  I  may  state,  by  the  way,  that  cseteris  paribus, 
when  both  eyes  are  affected,  that  is  a  ground  for  supposing  the  cause  of  the  disease 
to  be  situate  within  the  cranium.  And  I  should  come  to  the  same  conclusion  if,  in 
the  case  where  one  eye  alone  was  amaurotic,  I  found  the  independent  motion  of  the 
iris  of  that  eye  unimpaired.  AVe  know  that  in  the  healthy  condition  of  the  parts, 
the  brightness  of  the  light  admitted  to  the  retina  determines  the  size  of  the  pupil ; 
but  the  motions  of  the  iris  do  not  depend  solely  or  directly  upon  the  retina.  It  has 
been  ascertained,  by  experiments  made  upon  animals,  that  the  pupil  may  be  made  to 
contract  either  by  mechanical  irritation  of  the  optic  nerve  within  the  cranium,  or  by 
irritation  of  the  third  nerve  ;  a  motor  nerve  which  sends  filaments  to  the  ophthalmic 
ganglion,  whence  the  ciliary  nerves,  passing  to  the  iris,  are  derived.  Now  the  optic 
and  the  third  nerves  have  some  link  of  connection  within  the  brain;  and  if  the 
morbid  condition  upon  which  the  amaurosis  depends  is  situate  deeper  than  the  point 
of  connection,  we  may  understand,  I  think,  how  disease  so  placed  may  destroy  the 
power  of  vision,  and  yet  leave  the  connection  between  the  retina  and  the  third  pair 
unafl^ected :  and  then  the  influence  of  light  falling  on  the  retina,  though  it  fails  to 
create  a  perception  in  the  mind,  will  be  reflected  back  upon  the  third  pair  of  nerves, 
and  so  continue  to  govern  the  motions  of  the  pupil.  In  conformity  with  these  views, 
jM.  Andral  relates  cases  in  which  amaurosis  connected  with  disease  in  the  cerebellum 
was  attended  with  brisk  movements  of  the  iris. 

There  are  other  causes  of  amaurosis  besides  those  that  I  have  already  adverted  to. 
It  is  sometimes  produced  by  the  presence  of  worms  in  the  alimentary  canal. 

[That  amaurosis  is  frequently  dependent  upon  irritations  seated  within  the  stomach  and 
bowels,  and  upon  derangements  of  the  digestive  organs  generally,  there  can  be  little  doubt. 
We  liave  met  with  many  cases  of  this  kind,  and  they  are  repeatedly  referred  to,  more  espe- 
cially by  the  German  writers  on  the  disease.  Children  confined  in  ill-ventilated  and  ill 
lighted  apartments,  and  supplied  with  coarse  and  indigestible  food,  are  often  affected  with  a 
certain  degree  of  amaurotic  blindness,  which  is  readily  removed  by  a  proper  hygienic  treat- 
ment, and  such  remedies  as  are  adapted  to  restore  the  regular  functions  of  the  stomach  and 
alimentary  canal.  We  have  observed  the  disease,  also,  in  children  who  have  been  at  too 
early  an  age,  confined  in  crowded  school  rooms  for  many  hours  of  the  day,  while  their  minds 
were  compelled  to  the  performance  of  tasks  beyond  their  powers.  Complete  blindness,  we 
have  known  suddenly  to  occur  in  consequence  of  the  jiresence  of  indigestible  food  in  the 
stomach,  and  to  be  as  quickly,  removed  upon  its  expulsion.  For  further  information  on  this 
subject,  the  reader  is  referred  to  the  chapter  on  amaurosis  by  Ur.  Taylor,  in  the  2d  volume 
of  Tweedie's  Library,  Philadelphia  edition,  page  515,  and  to  the  very  able  paper  of  Dr.  Jaoob 
on  the  same  subject  in'  the  Cyclopa;dia  of  Practical  Medicine,  Philadelphia  edition,  vol.  i. 
page  78.— C] 

It  has  some  obscure  connection  with  teething,  probably  through  irritation  of  the 
facial  branches  of  the  fifth  pair.  A  physician  of  my  acquaintance,  residing  in  Lon- 
don, has  a  young  son,  who  on  two  or  three  occasions  has  caused  him  great  uneasi- 
ness, by  becoming  blind  in  one  eye  without  any  obvious  cause,  and  with  no  visible 
change  in  the  organ;  but  the  blindness  on  each  occasion  has  gone  off  again,  appa- 
rently in  consequence  of  the  extraction  of  some  teeth  which  had  grown  irregularly. 
I  am  assured  by  Dr.  Ashburner  that  such  cases  are  common.  Mr.  Lawrence  relarie* 

T 


£18  DISEASES    OF    THE    EYE. 

a  very  singular  instance  of  denfal  irritation  giving  rise  to  amaunsis.  A,  man,  thirty 
years  old,  was  suddenly  attacked  with  violent  pain  in  the  left  temple  near  the  eye, 
and  in  that  side  of  the  face  generally.  The  pain  continued  to  recur  from  time  to 
time,  and  at  length  he  discovered  that  he  was  blind  in  the  left  eye.  By  and  by  the 
cheek  swelled,  and  some  spoonfuls  of  bloody  matter  were  discharged  by  a  spontaneous 
opening  in  the  lower  eyelid,  and  then  the  pain  subsided  ;  but  after  some  months  it 
returned  with  great  severity.  The  patient  then  went  to  Wilna,  with  the  intention 
of  having  his  eye  extirpated,  and  consulted  Professor  Galenzowski,  who  found  the 
left  eye  totally  insensible  to  light,  with  the  pupil  dilated,  and  no  other  visible  altera- 
tion. He  ascertained,  however,  that  the  first  molar  tooth  on  that  side  was  carious: 
it  had  never  caused  the  patient  much  uneasiness ;  and  the  toothache  which  he  had 
occasionally  suffered  had  not  been  coincident,  in  point  of  time,  with  the  pains  in  the 
head  and  eye.  ,  Dr.  Galenzowski  thought  fit  to  extract  this  tooth,  and  was  greatly 
surprised  at  seeing  a  small  substance  protruding  from  the  extremity  of  its  fang.  This 
proved  to  be  a  little  splinter  of  wood  about  three  lines  in  length,  which  had  perforated 
the  Centre  of  the  tooth,  and  had  probably  been  introduced  in  using  a  wooden  tooth- 
pick. A  probe  passed  from  the  socket  into  the  antrum,  from  which  a  few  drops  of 
a  thin  purulent  fluid  escaped.  The  pain  ceased  almost  entirely,  and  on  the  same 
evening  the  eye  began  to  be  sensible  to  light.  The  vision  gradually  improved,  and 
on  the  ninth  day  from  that  time,  after  thirteen  months'  blindness  in  that  eye,  he  was 
able  to  see  with  it  as  perfectly  as  with  the  other.  M.  Galenzowski  has  since  been 
in  England,  and  he  showed  Mr.  Lawrence  the  tooth,  and  the  splinter  of  wood. 
Doubtless  he  felt  some  pride  in  exhibiting  these  trophies  of  his  exploit. 

Amaurosis  is  said  also  to  occur  as  an  hysterical  affection :  and  t  am  certain  that  I 
have  seen  this  myself.  An  unmarried  lady,  of  a  very  nervous  and  susceptible  habit, 
came  to  town  in  great  apprehension  about  her  eyes,  the  sight  of  one  of  them  being 
quite  gone.  I  could  perceive  no  defect  in  the  eye  itself.  I  saw  her  in  consultation 
with  Mr.  Tra vers,  who  took  an  unfavourable  view  of  the  case,  and  thought  the 
chance  of  recovery  was  very  slender.  I  had  one  reason  for  hoping  a  better  result, 
in  the  knowledge  of  some  facts  which  Mr,  Travers  was  not  aware  of  till  I  mentioned 
them  to  him.  I  had  been  acquainted  with  this  lady  for  some  years,  and  during  that 
period  she  had  several  times  almost  entirely  lost,  and  again  recovered,  the  use  of  her 
lower  extremities.  On  two  occasions  she  had  been  affected  with  aphonia,  and  unablfe 
to  speak,  except  in  a  whisper,  for  months  together ;  and  then,  on  a  sudden,  without 
any  apparent  cause,  her  voice  returned.  I  trusted,  therefore,  that  this  suspension  of 
the  power  of  vision  in  one  eye  might  be  a  similar  freak ;  and  so  it  turned  out.  After 
a  {e\v  weeks  the  sight  returned,  she  knew  not  how;  and  she  has  since  lost  it  a 
second  time,  and  a  second  time  regained  it. 

Certain  ])oisons  will  produce  temporary  amaurosis;  and  the  suppression  of  certain 
natural  evacuations,  as  of  the  perspiration,  of  the  rhenstrual  fluid,  and  of  the  bleeding 
from  piles,  and  the  repulsion  of  certain  eruptions,  have  been  charged,  by  authors, 
with- producing  tlie  same  complaint. 

In  those  cases  in  which  amaurosis  creeps  on  slowly  and  insidiously,  as  it  is  apt  to 
do  fi-on>  various  causes :  and  more  particularly  when  it  depends  upon  a  low  and. 
chronic  inflammation,  engrafted  upon  habitual  congestion  of  the  vessels  of  the  inter- 
nal tunics  of  the  eye;,  its  approach  is  marked  by  sundry  curious  affections  of  the 
vision.  The  rye  feels  full  or  stiff,  and  sometimes  there  is  pain  of  the  head  in  its 
neighbouihood;  the  patient  complains  that  he  sees  things  through  a  fog  or  mist,  or 
as  if  a  thick  piece  of  gauze  were  interposed  between  his  eye  and  the  object  he  is 
looking  at.  In  the  daylight,  the  gauze  or  fog  seems  dulf  and  murky,  but  in  the 
dark  it  often  appears  shining,  reddish  and  fiery  :  the  flame  of  a  candle  is  seen  ^ur• 
founded  with  a  halo  of  prismatic  colours.  That  amaurosis  of  this  kind  is  often  really 
dependent  upon  local  congestion  we  are  taught  by  the  hcdenlio,  by  the  circumstances 
that  aggravate  it:  thus  slrainins;  of  any  kind,  M'liich  augments  for  the  time  the  fiill- 
ness  of  the  vessels  about  the  head,  will  make  the  mist  appear  more  dense  :  the  same 
effect  may  be  produced  by  tj'eingthe  neckcloth  tight;  or  even  by  stooping.  Boerhaave 
lelates  the  case  of  a  man  who,  whenever  he  was  intoxicated,  laboured  under  com- 
plete amaurosis :  it  came  on  by  degrees,  increasing  according  to  the  quantity  of 


AMAUROSIS.  219 

vi'ine  he  drank;  and  after  the  drunkenness  went  off,  his  vision  returned.  Surely 
the^e  phenomena  are  very  illustrative  of  the  way  in  which  nervous  disorders  may 
arise,  or  be  made  worse,  from  mere  local  plethora,  in  almost  any  part  of  the  body. 

Sometimes  the  perfect  amaurosis  is  preceded  by  a  remarkable  diminution  of  the 
apparent  size  of  the  objects  looked  at.  A  patient  told  Dr.  Farre  that  a  carriage, 
which  happened  to  pass  the  window,  seemed  to  him  as  small  as  a  wheelbarrow,  and 
the  horses  no  bigger  than  dogs.  More  commonly  ocular  spectra  become  visible : 
that. is,  parts  of  the  rej.ina  lose  their  power,  or  perhaps  are  eclipsed  by  turgid  vessels  : 
the  patient  sees  flies  in  the  air,  muscse  volltantes,  particles  of  soot,  blacks,  as  we, 
who  live  in  London,  call  them,  which  always  float  before  his  eyes,  and  seeiii  to  fol-' 
low  their. motions ;  and  which  are  especially  plain  and  troublesome  when  he  is  look- 
ing upon  a  white  surface.     They  multiply  in  number  till  the  whole  becomes  dark. 

Do  not,  however,  suppose  that  the  appearance  of  these  muscoe  volitantes,  even 
Vvhen  they  are  permanent,  necessarily  implies  "(he  approach  of  amaurosis.  I  should 
oe  sorry  if  it  were  so,  for  I  see  two  of  them  every  morning,  when' my  eyes  are 
directed  towards  a  white  basin,  while  I  arti  washing  my'face.  I  can  find  them  at 
other  times  if  I  look  for  them  ;  else  I  am  not  sensible  of  their  presence.  They  bode 
no  further  evil,  if  they  are  associated  with  no  other  defect,  in  function  or  in  appear- 
ance, of  the  instrument  of  vision. 

It  is  obvious  that  no  particular  rules,  no  rules,  that  is,  which  will  fit  all  cases,  can 
be  laid  down  for  the  treatment  of  so  multiform  a  complaint  as  amaurosis.  When  it 
manifestly  results  from  disease  of  the  brain,  as  when  it  accompanies  hydrocephalus, 
or  remains  after  a  stroke  of  apoplexy,  our  attention  must  be  directed  to  the  disease 
from  which  it  has  sprung.  When  there  is  any  reason  to  suppose  that  congestion  or 
chronic  inflammation  of  the  internal  tunics  of  the  eye  itself  is  concerned  in  the  pro- 
duction of  the  amaurosis,  we  must  adopt  the  measures  that  I  have  already  described, 
as  the  most  likely  to  remove  the  congestion;  and  especially  the  mercurial  plan. 
When  there  is  ground  for  suspecting  that  the  blindness  takes  its  rise  in  vascular 
exhaustion,  or  nervous  debility,  we  must  have  recourse  to  tonics ;  bark,  preparation? 
of  iron,  nourishing  diet,  the  cold' bath. 

After  all,  you  will  find  too  many  cases  which  will  baffle  your  best-directed  attempts, 
and  in  which  you  will  be  required  and  warranted  to  try  other  expedients.  When 
what  I  may  call  rational  measures  have  been  expended  in  vain,  you  may  have 
recourse  to  such  as  are  empirical  and  tentative.  There  are  various  stimulants  which 
have  occasionally  been  found  serviceable ;  but  most  of  them,  I  believe,  fail  much 
oftener  than  they  succeed.  Electricity  is  one  of  these  :  it  is  applied  by  taking  small 
sparks  from  the  eyelids,  and  from  the  integuments,  round  the  orbit.  The  object  of 
this  is  to  rouse  the  dormant  energies  of  the  impassive  nerve :  and  it  appears  some- 
tiniesHo  do  this  for  the  retina,  as  well  as  for  the  nerves  supplying  voluntary  mus- 
cles. Mr.  Ware  tells  us  that  electricity  is  most  beneficial  in  those  cases  in  which 
amaurosis  has  succeeded  a  stroke  of  lightning.  You  must  take  great  care  .not  to 
employ  this  remedy  when  there  is  any  inflammatory  action  at  the  bottom  of  the 
complaint :  it  should  seldom  be  tried  therefore  when  the  affection  is  recent. 

S'lrycluiia  has,  of  late  years,  been  used  for  the  cure  of  amaurosis.  I  shall  here- 
after take  an  opportunity  of  telling  you  the  ordinary  effects  of  that  substance  upon 
the  body,  when  given  in  a  certain  dose — what  is  its  poisonous  operation,  and  what 
may  sometimes  be  hoped  from  it  as  a  remedy.  In  amaurosis  it  does  good,  when  it 
is  useful  at  all,  by  stimiilating  the  exhausted  or  atonic  nerve  into  action.  With 
respect  to  this  remedy  also  I  may  say — first  endeavour  to  ascertain  that  it  is  not 
Jik(  ly  to  do  harm  ;  as  it  will  be  if  the  blindness  depend  upon  any  condition  akin  to 
inflammation.  Mr.  Middlemore,  of  Birmingham,  has  probably  given  this  remedy 
an  ampler  trial  than  any  other  person,  and  he  speaks  very  favourably  of  its  effects 
in  certain  cases :  in  others  he  found  it  to  produce  so  much  pain,  and  spasm,  and  dis- 
tre.ss,  that  he  was  obliged  to  discontinue  its  use.  It  is  not  given,  in  these  cases,  by 
the  mouth,  but  applied  locally  ;  and  Mr.  Middlemore  considers  that  it  is  most  efficient 
when  placed  over  the  supra-orbitary  nerve.  He  puts  a  narrow  blister  above  the 
eyebrow.;  when  it  has  risen  he  cuts  off  the  cuticle,  and  applies  a  piece  of  linen,  for 
half  an  hour,  to  absorb  the  serum  that  continues  to  ooze  forth ;  then  he  spnnkles  fJJB 


220  DISEASES    OF    THE    BRAIN 

Strychnia,  finely  powdered,  upon  the  raw  part,  and  covers  it  with  linen  smeared  with 
the  iinguentum  cefacei.  He  repeats  this  every  twenty-four  hours,  cautiously  increas- 
ing the  dose  till  the  vision  improves,  or  some  sensible  evidence  of  ihe  agency  of  the 
strychnia  becomes  apparent.     He  commences  with  the  sixth  part  of  a  grain. 

I  must  here  leave  the  subject  of  diseases  of  the  eye. 

In  addition  to  the  lessons  which  I  pointed  out  before  as  capable  of  being  learned 
by  attending  to  the  disorders  of  this  small  organ,  I  may  now  mention  a  few  "others, 
of  no  little  moment,  since  we  shall  meet  with  their  application  again  and  again,  as 
^ye  proceed  to  investigate  the  morbid  conditions  of  other  parts.  We  have  seen 
enough  to  convince  us  that  mercury,  properly  administered,  has  the  invaluable 
power  of  stopping  adhesive  inflammation ;  of  arresting  the  effusion  of  coagulable 
lymph  from  the  blood-vessels :  that  inflammation  of  a  given  part  may  be  sensibly 
modified  by  the  simuUaneous  agency  of  some  specific  poison  upon  the  system,  as 
that  of  syphilis  ;  or  by  the  presence  of  constitutional  tendencies  to  disease,  such  as 
•ire  observable  in  gouty  and  rheumatic  people.  And  we  have  seen  that  the  func- 
tions of  a  nerve  may  be  perverted;  suspended,  or  abolished,  in  various  ways :  by 
pressure  made  upon  it;  by  a  plethoric  state  of  its  blood-vessels,  or  by  an  empty 
state  of  them;  by  injiammation  of  its  texture,  chronic  or  acute :  and  even,  in  some 
mysterious,  or  hitherto  unexplained  manner,  by  mere  irritation  of  a  distant  part;  by 
Avorms,  for  example,  in  the  alimentary  canal ;  by  poisorious  substances  introduced 
into  the  stomach:  and  by  what,  in  oiir  ignorance,. we  denominate  the  freaks  and 
caprices  of  hysterical  disorder.  All  these  lessons  we  shall  find  repeated,  as  the 
course  advances. 


LECTURE  XXI. 

Diseases  of  the  Brain  and  Nervous  System.  Difficulties  of  the  subject.  Short 
Revieiv  of  some  points  in  the  Physiology  of  the  Brain  and  Nerves.  Peculiarity 
of  the  Cerebral  Circulation.     Pressure. 

Having  considered  some  of  the  most  important  disorders  of  the  ej-e,  because  they 
afforded  me  the  means  of  illustrating  many  of  the  doctrines  and  principles,  which  I 
had  previously  endeavoured  to  lay  before  you,  o^  general  pathology,  I  go  next  to  the 
diseases  of  that  portion  of  the  body,  which,  though  it  includes  many  distinct  parts, 
is  called,  collectively,  the  head.  I  pass  over  the  maladies  to  which  the  integuments 
of  the  head  are  liable,  because  they  will  fall  more  naturally  and  conveniently  into 
the  class  of  cutaneous  disorders ;  and  I  come  at  once  upon  one  of  the  most  interest- 
ing, and  at  the  same  time  most  difficult  and  obscure  subjects  of  special  pathology — ■ 
that  which  embraces  the  'diseases  of  the  brain  and  nerves.  Though  it  will  be  a 
slight  departure  from  the  plan  I  have  proposed  of  taking  diseases  as  they  affect  dif- 
ferent parts  of  the  body  from  the  head  downwards  in  succession,  I  shall  speak  of 
diseases  of  the  spinal  cord,  and  of  the  nervous  system  generally,  in  connection  with 
'Jiose  of  the  brain.     To  disunite  them  would  neither  be  easy  nor  useful. 

The  study  of  the  maladies  and  disordered  conditions  of  the  brain  and  nervous  sys- 
tem, h  surrounded  with  peculiar  difficukies :  and,  accordingly,  our  knowledge  of 
these  diseases  is  less- precise  than  of  the  diseases  of  most  other  parts  of  the  body. 

1.  One  source  of  difficulty  lies  in  the  circumstance,  that  the  structure  of  the  ner- 
vous system  has  no  perceptible  or  understood  subservience  to  its  functions.  We  do 
not  discover  in  the  mechanism  of  this  system  that  adaptation  of  means  to  an  end 
which  is  so  conspicuous  in  many  other  parts  of  the  body  :  and  consequently,  though 
such  adaptation  doubtless  exists,  we  are  not  able  to  trace  the  reason  or  the  manner 
tjf  its  interruption.  We  find  in  the  lungs  an  apparatus  of  tubes  and  cells  fitted  fo) 
che  reception  of  air,  upon  the  expansion  of  the  chest  by  the  contraction  of  certain 
muscles  ;  of  which  muscles  also  we  can  see  and  understand  the  action.  If  we  meet, 
vilh  any  obstruction  of  these  tubes,  or  any  obvious  impediment  to  the  play  of  thosi 


AND  NERVOUS  SYSTEM.  221 

muscles,  we  perceivt  at  once  how  and  why  the  function  of  respiration  is  deranged. 
But  no  alterations  that  becgnoe  visible,  after  death,  in  the  brain  or  spinal  marrow, 
afford  us  any  explanation  of  the  interruption  of  their  proper  functions;  which  are, 
in^hree  words,  sensation,  thought,  and  motion.  An  apoplectic  cell  has  no  relation, 
direct  or  inverse,  that  we  are  capable  of  appreciating,  with  a  sentiment ;  nor  a  dis- 
tended lateral  ventricle  with  the  exercise  of  the  will.  The  morbid  anatomy  does  not 
in  any  degree  elucidate  the  disorder,  simply  because  the  natural  structure  throws  no 
light  upon  the  healthy  office  of  the  parts  concerned. 

2.  It  is  a  further  source  of  difficulty,  that  physiologists  have  not  yet  been  able  to 
determine,  with  any  thing  like  precision  or  certainty,  what  share  the  several  parts 
of  the  brain  and  spinal  cord  have  in  regulating,  respectively,  the  functions  which  all 
physiologists  acknowledge  to  belong  to  the  nervous  system  in  the  aggregate..  There 
are  many  and  convincing  reasons,  for  believing  that  the  brain  is  a  complex  organ  ; 
but  we.  can  seldom  put  our  finger  upon  this  or  that  portion  of  the  nervous  m.atter 
which  composes  it,  and  say,  here  resides  the  influence  that  governs  this  or  that  par- 
ticular function. 

3.  Again,  the  brain  and  cranio-spinal  axis  are  so  encased  by  their  bony  coverings, 
that,  in  the  living  body,  we  are  unable  to  ascertain  their  physical  conditions  by 
jneans  of  any  of  our  senses.  Of  many  parts  of  the  frame  we  ascertain  the  state  by 
the  sense  of  sight ;  and  of  many  parts  that  we  cannot  see,  we  still  may  recognize  the 
changes  by  the  faculty  of  touch,  or  by  the  ear.  The  brain  and  spinal  cord  we  can 
neither  see,  nor  hear,  nor  handle. 

4.  Besides  these  obstacles  to  the  acquisition  of  information  by.  the  exercise  of  our 
Own  senses,  concerning  the  organs  affected,  the  very  disturbance  of  the  functions  of 
the  brain  cuts  us  off,  in  many  cases,  from  that  kind  of  information  which  we  might 
otherwise  derive  from  the  statements  of  the  patient  himself. 

5.  There  is  a  still  greater  cause  of  perplexity,  with  which  we  have  to  contend. 
The  very  same  symptoms  accompany  alterations  of  the  brain  apparently  of  a  very 
different,  nay  of  the  most  opposite  kind  ;  and  on  the  other  hand,  changes  of  struc- 
ture, which,  as  far  as  we  can  perceive,  are  absolutely  identical  in  their  nature,  are 
associated,  in  different  cases,  with  totally  different  symptoms;  and  more  frequently 
than  not,  nervous  diseases  are  attended  with  no  alterations  of  structure,  appreciable 
by  our  senses, 

6.  And  lastly,  we  are  perpetually  asking  ourselves,  when  we  find  the  proper  func- 
tions of  the  nervous  system  disordered, — is  this  disorder  the  result  of  disease  in  the 
nervous  matter  itself?  or  is  it  merely  sympathetic  of  disease  in  other  parts?  for  there 
are  few  diseases  of  any  kind  which  do  not,  in  some  degree,  modify  or  disturb  the 
due  exercise  of  the  offices  of  the  brain  and  nerves:  and  it  is  very  difficult  often, 
and.  sometimes  it  is  impossible,  to  determine  whether,  and  how  far,  the  disturbance 
is  primary  or' secondary. 

With  all  its  difficulties,  however,  the  pathology  of  the  brain  and  nerves  is  always 
full  of  interest.  How  can  it  be  otherwise,  when  we  reflect  that  the  nervous  system 
is  the  medium  through  which  we  hold  comnmnion  with  the  world  around  us;  the 
stage  upon  which  all  the  phenomena  of  animal  life  are  transacted :  the  instrument 
of  the  mind  ? 

And  '.vith  all  its  difficulties,  there  is  also  a  good  deal  in  the  pathology  of  tJie  brani 
and  n<'rves  that  is  fairly  made  out  and  well  understood  ;  and  we  are  at  present  in  the 
right  way  for  advancing  our  knowledge  of  this  intricate  and  mysterious  subject,  by 
that  careful  collection  of  facts,  and  rigid  induction  of  particulars,  that  will  lead,  at 
length,  to  a  safe  and  useful  generalization. 

I  shall  endeavour  to  point  out  to  you  what  is  known  of  the  morbid  conditions  of 
the  nervous  system ;  I  shall  also  state  the  conjectures  and  probabilities  by  which  our 
judgment  and  practice  must  be  guided,' when  absolute  certainty  is  unattainable. 
With  mere  speculative  questions,  that  have  no  practical  beanng,  I  sna.l  meddle  aa 
little  as  I  can. 

Our  knowledge,  I  say,  of  the  exact  functions  of  the  different  parts  of  the  nervous 
apparatus,  is  scanty  and  imperfect.     Some  certainties,  however,  we  possess ;  an 'I 

t2 


222  DISEASES    OF   THE   BRAIN 

some  strong  probabilities  which  almost  amount  to  certainties.  Without  first  ex- 
pounding mj'  creed  upon  these  matters,  it  Avould  be  inipossible  for  me  to  explain,  as 
it  would  be  for  3'ou  to  understand,  the  notions  I  entertain  respecting /many  of  the 
diseases  of  the  brain  and  nerves. 

Omitting  the  sympathetic  nerve  and  its  ramifications  (for  we  know  but  little  of 
its  office,  and  still  less  of  its  disorders),  the  nervous  system  is  made  up  of  certain 
rnasses  of  nervous  matter,  called  the  nervous  centres;  and  of  ?je?T'e^  therewith  con- 
nected. 

The  nervous  centres  consist  of  the  cerebrum  and  cerebellum,  the  medulla  ob 
longata  and  the  medulla  spinalis.  I  shall  include  the  cerebral  hemispheres,  and  the 
lobes  of  the  cerebellum,  under  the  common  term,  the  brain.  So  I  shall  speak  of 
the  oblong  and  of  the  spinal-marrow,  in  the  single  phrase,  the  spinal  cord,  or. the 
craniospinal  axis  ;  their  endowments  appearing  to  differ  more  in  relation  and  de- 
gree, than  in  kind. 

I  adopt  the  belief  that  the  gray  (which  are  much  the  more  vascular  portions  of 
these  nervous  centres,  form  the  part  in  which  their  peculiar  powers  reside,  or  are 
generated ;  and  that  their  white  or  fibrous  portions  are,  like  the  white  and  fibrous 
nerves,  mere  conductors  of  the  nervous  influence. 

I  incline,  also,  to  the  opinion  (recollect,  if  you  please,  that  I  do  not  press  these 
opinions  of  mine  upon  you  as  being  necessarily  correct)  that  the  influence  which 
originates  in  the  gray  matter,  and  is  transmitted  by  the  white,  will  at  last  be  found 
to  consist  in,  or  to  be  closely  connected  with,  some  modification  of  electricity;  We 
know  that  some  of  the  effects  of  this  influence  may  be  very  exactly  imitated,  in  ani- 
mals recently  dead,  by  galvanism. 

The  functions  of  the  brain  and  nerves  are  sensation,  thought,  volition,  and  the 
power  of  originating  motion.  Other  functions  indeed  there  are  ;  but  these  four  are 
all  that  we  need,  at  present,  concern  ourselves  with. 

Now,  it  is  a  part  of  my  creed,  that  the  faculties  of  sensation,  of  thought,  and  of 
the  will,  belong  to  the  brain  :  in  all  probability  to  the  cerebrum  alone.  The  precise 
office  of  the  cerebellum  is  involved  in  much  obscurity  and  dispute.  Some  of  the 
opinions  that  have  been  formed  respecting  it,  I  shall  notice  hereafter.  , 

The  chief  grounds  for  beheving  that  the  brain  proper  is,  exclusively,  the- instru- 
ment of  the  mind,  are  these  : — 

1.  Because  this  portion  of  the  nervous  centres  is  superadded  to  the  cranio-spinal 
axis,  in  the  greatest  bulk  and  most  comphcated  form,  in  man  :  and  after  him,  in  those 
of .  the  inferior  animals  which  show  the  largest  share  of  reason.  r 

.  ■2.  Because,  in  inferior  animals  which  evince  a  certain  amount  of  mental  endow- 
ment, all  manifestation  of  intellect  ceases  upon  the  gentle  and  gradual  removal  of 
the  cerebrum  and  cerebellum  :  the  animals  continuing  to  live,  for  a  long  time,  not* 
withstanding  this  mutilation. 

,  Again,  it  forms  part  of  my  creed  on  these  subjects  that  the  motive  power  resides 
m  the  spinal  cord. 

The  muscles  furnish  the  instruments  of  motion. 

Now  there  is  a  certain  class  of  muscles  which  contract  without  our  willing  theii 
contraction :  and  generally  without  our  being  conscious  that  they  are  contracting, 
Such  are  the  heart,  the  njuscular  fibres  of  the  alimentary  canal,  and  of  the  bladder. 
These  are,  therefore,  called  involuntary  muscles. 

There  is  another  large  class  of  muscles  which  obey  the  bidding  of  the  will,  and 
.serve  the  purposes  of  prehension,  locomotion,  and  bodily  effort.  These  are  consi- 
dered and  called  voluntary  muscles. 

There  is  still  another  distinct  set  of  muscles,  of  which  the  habitual  action  is  invo- 
luntary, yet  which  submit  also  to  the  interposing  control  of  the  will.  You  will 
'all  to  mind  at  once  the  muscles  of  respiration,  which  act  while  we  are  asleep,  or 
otherwise  unconscious  ;  and  the  sphincters,  which  regulate  the  entrances  and  outlets 
of  th')  body.  Here,  I  say,  the  habit  is  involuntary,  but  the  occasional  action  is 
prompted  and  governed  by  volition.  But  sometimes  the  involuntary  action  rebels 
njjainst  thp  willed  action,  and  overcomes  it.  The  muscle  contracts  in  spite  of  tho 
ATii: 


AND  NERVOUS  SYSTEM.  223 

Nay,  those  muscles  which,  ordinarily,  move  only  in  obedience  to  voliiion,  do 
sometimes,  under  the  influence  of  strong  emotion,  or  of  disease,  contract  independ- 
ently of  any  effort  of  the  will,  and  even  in  opposition  to,  and  defiance  of,  the  volun- 
tary power. 

Under  certain  circumstances  the  limbs  move  with  much  briskness  and  force  in 
decapitated  animals,  in  Avhich  sensation  and  volition  are  extinct.  Some  physiologists 
hold,  indeed,  that  sensation  and  volition  are  properties  of  the  spinal  cord ;  and  they 
would  object  to  these  cases,  that  no  one  is  warranted  in  afiirming  the  movements  in 
question  to  be  independent  of  the  will.  The  animal  has  no  means  of  informing  us 
whether  it  feels  or  not,  any  more  than  the  human  head  that  has  been  severed  by  the 
axe  or  the  guillotine. 

This  point,  however,  has  been  settled  by  certain  phenomena  which  are  observed 
to  occur,  in  the  human  body,  under  disease.  Limbs  completely  palsied  as  to  volun- 
tary motion,  and  quite  dead  as  to  sensation,  do  yet,  under  certain  conditions,  contract 
and  move  when  the  integuments  are  pinched ;  the  rational  patient  not  feehng  the 
pinch,  and  not  being  conscious  of  the  movement. 

Whence  does  the  impulse  that  leads  to  motion  in  these  cases  proceed — how  is  the 
motive  power  awrkened  ? 

The  answer  to  this  physiological  question  has  a  most  important  bearing  upon  the 
pathology  of  the  nervous  system. 

It  is  no  part  of  my  purpose  to  enter  into  any  history  of  the  steps  by  which  this 
curious  problem  has  been  worked  out.  Its  solution  is  an  achievement  of  our  own 
time ;  and  I  may  add,  of  our  own  country.  I  profess  no  more  than  to  sketch,  in 
mere  outline,  the  leading  facts  that  have  been  ascertained  ;  yet  I  must,  in  passing, 
pay  the  tribute  due  to  one  indefatigable  labourer  in  this  department  of  science, 
whose  sagacity  has  enabled  him  to  seize  the  clue,  and  in  a  greiat  measure  to  unfold 
the  mazes  of  the  labyrinth  in  which  this  part  of  the  physiology  of  the  nervous  system 
was  so  long  entangled.  Dim  and  uncertain  glimmerings  of  the  truth  appear  in  the 
writings  of  bygone  authors,  but  it  was  never  clearly  discerned,  and  plainly  stated, 
and  successfully  applied  to  the  elucidation  of  a  large  class  of  disorders,  until  the 
publication,  in  183*^  or  1833,  of  Dr.  Marshall  Hall's  ingenious  and  most  interesting 
researches  into  "  the  functions  of  the  medulla  oblongata  and  spinal  cord."  Similar 
views  appear  to  have  suggested  themselves,  about  the  same  time,  to  Professor  MuUer 
of  Berlin.  I  must  recommend  you  to  study  the  works  of  these  authors;  and  Imay 
also  point  out,  as  fit  writings  for  your  perusal  (since  the  doctrines  I  am  now  speaking 
of  are  comparatively  new),  Dr.  Grainger's  Observations  on  the  Structure  and 
Functions  of  the  Spinal  cord;  Dr.  Carpenter's  two  works.  Principles  of  General 
and  Comparative  Physiology,  and  Principles  of  Human  Physiology :  and  a  very 
able  paper  on  the  Pathology  of  l^he  Spinal  Cord,  by  Dr.  William  Budd,  in  the  22(1 
volume  of  the  Medico-Chirur gical  Transactions. 

If,  on  the  other  hand,  you  wish  to  see  how  nearly  the  idea,  which  has  been  so 
happily  simphfied  into  an  intelligible  principle  by  Dr.  Hall,  was  reached  by  earher 
observers,  you  may  consult  the  writings  of  Dr.  Whytt,  upon  nervous  diseases. 

What,  then,  respecting  this  intricate  subject,  are  the  main  facts  and  doctrines 
which  modern  research  has  made  clearer  ? 

It  seems  ascertained,  that  the  movements  of  those  muscles  which  acknowledge  the 
empire  of  the  will,  depend  essentially  upon  some  momentary  change  in  the  condi- 
tion of  the  spinal  cord.  This  change  (whatever  may  be  its  nature)  is  capable  of 
being  effected  in  three  several  ways. 

First,  volition,  or  emotion,  originating  in  the  brain,  may  send  down  an  influence 
which  travels  with  electrical  rapidity  to  the  spinal  cord  :  whence,  the  renuisite  change 
having  been  instantly  produced,  the  motive  influence  passes,  with  proportional  speed, 
along  the  nerves  which  connect  the  cord  with  the  muscles  to  be  moved. 

Secondly,  the  change  productive  of  motion  may  be  wrought  in  the  cord,  whethei 
the  brain  be  attached  to  it  or  not,  by  mechanical,  chemical,  or  electrical  agencies, 
operating  directly  upon  the  cord  itself. 

Thirdly,  the  change  productive  of  motion  may  be  wrought  in  the  cord,  bv  an 


2'M  DISEASES    OF    THE    BRAIN 

influrncc  carried  to  the  cord,  not  from  the  brain,  but  from  the  extremiiies  of  nerves 
distributed  upon  the  internal  and  external  surfaces  of  the  body, 

The  action  of  this  nervous  circle,  whereby,  I  say,  an  influence  is  first  carried  from 
the  surfaces  of  the  body,  along  nerves  to  the  spinal  cord — whence  again  an  influence 
is  transmitted,  or  reflected,  as  it  were,  to  certain  muscles  along  certain  other  nerves— ^ 
has  been  called  by  Dr.  Hall  the  reflex  function  of  the  spinal  cord.  The  apparatus 
subservient  to  this  function  is  named  by  him  the  excito-motory  system;  the  nerves 
which  carry  the  impression  to  the  cord  are  incident  or  cxcitor  nerves;  those  which 
convey  the  motive  imj)ulse  froin  the  cord,  reflex  or  motor  nerves.  Dr.  Carpenter's 
terms  (which  I  like  better,  except  for  their  similarity  in  sound)  are  querent  and 
efferent  nerves. 

Mr.  C4rainger  believes  that  physiology  indicates,  and  anatomy  can  exhibit,  four 
sets  of  fibres  belonging  to  the  nerves  and  the  nervous  centres.  Sensiferous,  S-wA 
volition  nerves,  connected  with  the  gray  substance  of  the  cerebrum  and  subordinate 
to  the  exercise  of  feeling  and  of  the  will ;  awA  incident  and  reflex  nerves,  connected 
with  the  gray  matter  of  the  cord,  and  belonging  to  the  excito-motory  system. 

Whether  this  be  the  true  state  of  the  case,  or  whether  the  efiexent  fibres  be  the 
game,  while  the  afll;rent  fibres  are  difl^erent ;  the  latter  coming  to  the  spinal  marrow 
both  from  the  brain  and  from  the  various  surfaces,  just  as  two  trains  may  arrive  at 
Euston  Square  ultimately  by  the  same  rail,  although  tlie  one  starts  at.  Derby  and  the 
other  at  Birmingham;  or  (which-  is  perhaps  the  better  illustration)  just  as,  in  some 
houses,  the  same  bell  is  made  to  ring  in  the  servants'  hall  by  pulling,  indifferently, 
the  dining-room  or  the  drawing-room  rope  : — which  of  these  two  hypotheses  is  the 
more  correct,  I  am  not  competent  to  determine. 

This  reflex  action,  independent  of  the  will,  and  although  attended  often  by  con- 
sciousness and  sensation,  yet  often  also  exercised  when  there  is  neither,  governs  the 
orifice  by  which  air  and  food  are  introduced,  and  excrements  are  voided.  The 
infant  breathes  and  sucks  by  it;  the  adult  uses  his  will  for  bringing  nutriment  into 
his  mouth ;  in  both,  the  act  of  deglutition,  after  the  food  has  reached  a  certain  point, 
is  involuntary.  The  expulsion  of  the  feces,  the  urine,  the  semen,  and  the  foetus,  is 
regulated  by  the  same  function.  Nevertheless,  most  of  these,  muscular  acts  are 
capable  of  being  moderated  and  directed  by  volition.  The  reflex  power,  on  the 
other  hand,  extends,  both  in  health  and  in  disease,  to  the  entire  system  of  the  strictly 
voluntary  muscles ;  during  health  it  is  manifested  only  in  the  maintenance  of  what 
is  called  their  tone,  their  natural  tension  and  firmness :  in  disease,  as  we  shall  here- 
after see,  it  sometimes  acts  upon  them  with  terrific  energy. 

Some  of  the  difficulties  which  I  enumerated  in  the  beginning  of  the  lecture,  as 
impeding  our  researches  into  the  diseases  of  the  nervous  centres,  are  insurmount- 
able.   One  or  two  of  them,  however,  appear  to  call  for  a  more  attentive  consideration. 

I  say  we  often  fail  to  discover  any  deviation  from  the  natural  condition  of  these 
nervous  centres,  or  of  their  appendages;  even  when  the  disorder  of  their  functions 
has  been  broadly  displayed.  ' 

We  tire  not  to  infer,  from  this,  that  no  change  has  taken  place  in  these  parts. 
The  only  legitimate  conclusion  is,  that  the  nervous  functions  are  liable  to  be  deranged, 
impaired,  or  suspended,  by  altered  conditions,  not  traceable  by  our  senses,  or  at  least 
not  yet  discovered  by  us,  of  the  organs  which  minister  to  those  functions. 

There  may  be  only  one  such  undiscovered  disturbing  cause,  variable  in  degree  in 
difll'rent  cases ;  or  (what  is  more  probable)  there  may  be  several  such  conditions 
differing  in  kind.  A  blow  or  fall,  which  jctrs  the  brain  ;  a  sudden  mental  emotion ; 
an  electric  shock ;  a  teaspoonful  of  prussic  acid  ;  any  one  of  these  causes  may  de- 
stroy life,  yet  leave  no  vestige  of  its  action  in  the  nervous  substance  upon  which  it 
operates.     It  is  probable  that  the  fatal  condition  is  not,  in  each  case,  the  same. 

We  may  even  form  a  reasonable  conjecture  of  the  manner  in  which  the  invisible 
changes  are  sometimes  brought  about.  We  can  conceive,  for  example,  that  undue 
pressure  upon  the  nervous  pulp  on  one  hand,  or  insufficient  pressure  on  the  other, 
may  constitute  conditions  of  the  kind  we  are  in  search  of;  and  I  shall  be  able,  I 
think,  to  convince  you  that  such  is  sometimes  the  case.     Again,  we  can  conceive 


AND  NERVOUS  SYSTEM.  225 

that  such  conditions  may  be  furnished  by  the  varying  state  of  the  cerebral  circulation. 
In  point  of  fact,  we  kno7V  of  some  changes  m  the  circulation  through  the  brain 
which  have  the  effect,  invariably,  first  of  modifying,  and  at  length,  if  they  are  con- 
tinued, of  arresting,  the  cerebral"  functions.  If  no  blood  be  sent  through  the  arteries 
of  the  brain,  death°in  the  way  of  syncope  ensues  ;  if  venous  blood  circulates  in  those 
vessels,  it  leads  to  death  by  coma. 

But  whatever  may  be  the  nature  of  the  unknown,  and  perhaps  fugitive,  physical 
conditions  of  the  nervous  centres,  thus  capable  of  disturbing  or  abolishing  their  func- 
tions, it  is  useful  to  keep  in  our  minds  a  distinct  and  clear  conception  of  the  fact  that 
there  must  be  some  such  physical  conditions.  By  steadily  retaining  this  idea  of 
their  real  existence,  we  may  hope,  at  length,  to  get  some  insight  into  their  nature ; 
which  we  are  the  less  likely  to  obtain,  if  we  dwell  only  on  the  obvious  and  visible 
injuries  effected  in  the  nervous  substance  ;  associated,  as  they  are  apt  to  be,  with  so 
perplexing  a  diversity  of  symptoms.  Indeed,  by  the  help  of  this  distinct  conception, 
we  are  at  once  enabled  to  reconcile  some  of  the  seeming  anomalies  and  inconsisten- 
cies to  Avhich  I  before  adverted.  The  same  symptoms,  I  repeat,  have  been  found  to 
accompany  phj'sical  lesions  of  die  nervous  centres,  apparently  different  in  kind, 
place,  and  degree:  and,  on  the  contrary,  physical  lesions,  apparently  identical  in 
their  nature,  extent,  and  situation,  are  attended  by  different  and  contradictory  symp- 
toms. We  must  not  attribute  the  symptoms,  in  such  cases,  to  the  visible  physical 
lesions,  but  to  some  unperceived  condition  of  the  nervous  centres,  concomitant  with 
those  lesions.  The  proximate  cause  of  the  symptoms  escapes  our  notice.  The 
obvious  physical  changes  may  be  remoter  causes  of  the  symptoms — causes  of  this 
proximate  cause  :  but  they  may  also  be  merely  cotemporaneous  effects  of  some  other 
remote  agency. 

I  have  adverted  to  deviations  from  the  natural  and  healthy  circulation  of  the  blood 
through  the  brain,  as  being  capable  of  modifying  the  nervous  functions.  Of  such 
deviation,  one  mode  which  is  conceivable,  and  which  has  been  assigned  as  a  pre- 
sumed cause  of  morbid  phenomena,  is  a  variation  in  the  relative  quantity  of  blood 
contained  respectively  in  the  arteries  and  veins  that  He  within  the  cranium.  And  it 
seems  probable  enough  that  a  healthy  condition  of  the  cerebral  circulation  may  imply 
and  require  a  certain  balancing  and  adjustment  of  the  amount  of  blood  carried  in 
hese  two  sets  of  vessels.  But  with  this  theory — that  disturbance  of  the  functions 
of  the  brain  may  result  from  an  altered  ratio  of  the  arterial  and  venous  blood  therein 
— has  been  associated  another;  namely,  that  although  the  blood  may,  at  different 
times,  be  variously  distributed  between  the  cerebral  veins  and  arteries,  yet  that  the 
absolute  quantity  of  blood  circulating  within  the  cranium  is  always  and  necessarily 
the  same,  or  nearly  so. 

This  notion,  broached  by  the  second  Monro  of  Edinburgh,  and  upheld  (as  it  then 
seemed)  by  experiments  performed  upon  animals  by  Dr.  Kellie,  received  at  a  later 
period  the  sanction  and  approval  of  Dr.  Abercrombie.  And,  resting  upon  such 
authority,  I  have  been  in  the  habit  of  delivering  the  same  theory,  not,  however,  with- 
out some  misgiving  as  to  its  soundness,  in  these  lectures.  It  has  been  completely 
overthrown,  of  late,  by  Dr.  George  Burrows. 

The  doctrine  was  this.  The  brain  is  closely  shut  up  in  an  unyielding  case  o\ 
bone.  Its  surfiice  must  therefore  be  exempt  from  the  influence  of  atmospheric 
pressure.  Hence,  supposing  its  substance  to  be  unaltered  and  incompressible,  it 
would  seem  impossible  to  empty  the  blood-vessels  of  the  brain.  The  cavity  being 
completely  full,  the  blood  which  circulates  in  those  vessels  can  neither  be  materially 
increased,  unless  something  is  displaced  or  compressed  to  make  room  for  tho  addi- 
tion ;  nor  materially  diminished,  without  the  entrance  of  something  to  supply  the 
place  of  the  blood  substracted. 

Dr.  Kellie  noticed  that  while,  in  animals  bled  to  death,  the  other  ^Jrganb  of  the 
body  were  emptied  of  their  blood,  and  blanched — the  brain  presented  its  ordinary 
appearance,  and  even  seemed  to  contain  more  blood  in  its  superficial  vessels  than 
usual.  Having  satisfied  himself  upon  this  point,  he  varied  his  experiment.  He  first 
made  a  small  opening  in  the  skull,  by  means  of  the  trephining  instrument,  takmy 
15 


226  DISEASES    OF    THE    BRAIN 

away  a  little  circular  piece  of  bone,  and  then  he  bled  the  animals  until  they  died : 
and  in  these  cases  he  found  that  the  brain  was  as  completely  drained  of  red  blood  as 
the  rest  of  the  body.  He  did  that  with  respect  to  the  cranium  which  housekeepers 
do  when  they  tap  a  barrel  of  beer.  You  know  that  if  the  barrel  be  quite  full,  you 
may  introduce  a  fawcet  at  its  lower  orifice,  but  no  beer  will  run  out  through  it.  The 
pressure  of  the  atmosphere  operates  upon  that  portion  only  of  the  fluid  which  is  now 
exposed  to  the  air,  and  its  effect  is  to  keep  the  beer  in.  But  if  j'ou  bore  a  small  hole 
with  a  gimlet  through  the  top  of  the  cask,  and  so  admit  air  to  the  upper  surface  of 
the  beer,  it  will  then  flow  readily  through  the  lower  outlet.  Dr.  Kellie  imitated  this 
process  of  making  a  vent-hole,  when  he  trepanned  the  skulls  of  sheep,  and  admitted 
air  to  the  yielding  membranes  of  the  brain. 

He  availed  himself,  also,  in  these  researches,  of  what  he  considered  the  converse 
experiment.  He  desired  to  ascertain  whether,  under  circumstances  calculated  to 
gorge  the  vessels  of  the  head,  those  of  the  brain  were  or  were  not  made  really  more 
full  than  usual.  With  this  object  he  examined  the  brains  of  two  men  who  had 
been  hanged.  When  the  scalp  in  these  cases  was  divided,  a  great  quantity  of  blood 
escaped  ;  marking  plainly  enough  the  congestioniBf  the  vessels  exterior  to  the  era- 
niinn,  but  there  was  no  such  congestion  observable  tvifhin.  "  The  sinuses  contained 
blood,  but  in  no  extraordinary  quantity ;  the  larger  vessels  on  the  surface  and  be- 
tween the  convolutions  were  but  moderately  filled  ;  and  the  pia  mater  was,  upon  the 
whole,  paler,  and  less  vascular  than  we  often  find  it  in  ordinary  cases."  Similar 
appearances  have  been  noticed  by  myself.  I  paid  particular  attention  to  the  condi- 
tion of  the  head  during  the  examination,  below-stairs,  of  the  body  of  Bishop,  the 
murderer  of  the  Italian  boy.  When  the  corpse  was  brought  hither  after  the  execu- 
tion, the  eyes  were  blood-shotten,  and  the  lips  and  countenance  turgid  and  hvid.  The 
inner  surface  of  the  scalp,  when  it  was  turned  back,  and  the  exposed  surface  of  the 
skull,  were  very  red  and  bloody ;  and  in  one  part,  on  the  right  side  of  the  head, 
there  was  some  blood  exfravasated.  But  when  the  bone  had  been  sawn  through, 
and  the  skull-cap  removed,  the  large  veins  of  the  brain  did  7iot  appear  unnaturally 
full. 

In  the  year  1826  I  was  present  in  St.  Bartholomew's  Hospital,  at  the  opening  of 
the  head  of  a  woman  who  had  been  hanged  the  day  before,  for  murder.  I  find  the 
following  statement  in  a  note  which  I  made  at  the  time.  "  The  scalp  was  bloody, 
but  the  brain  w^as  of  very  natural  texture  and  appearance,  and  not  more  than  com- 
monly full  of  blood." 

Among  the  propositions  deduced  by  Dr.  Kellie  from  his  observations  and  experi- 
ments were  the  following : — 

1.  That  in  the  brains  of  animals  that  hr.ve  died  of  hemorrhage,  there  is  no  lack 
of  blood,  but,  on  the  contrary,  very  often  a  state  of  venous  congestion. 

2.  That  congestion  of  the  cerebral  vessels  is  not  met  with  in  those  cases  in  which 
we  should  most  expect  to  find  it ;  in  persons,  for  example,  who  die  strangled. 

8.  That  the  quantity  of  blood  in  the  cerebral  vessels  is  not  afl"ected  by  gravitation: 
in  other  words,  that  it  remains  the  same,  whatever  may  be  the  posture  of  the  body, 
and  the  position  of  the  head. 

Dr.  Burrows,  distrusting  the  whole  theory,  and  unsatisfied  with  the  experiments 
by  which  it  was  fortified,  determined  to  repeat  them,  taking  care  as  much  as  was 
possible,  to  exclude  every  conceivable  source  of  fallacy  :  and  he  has  shown,  most 
convincingly,  that  Dr.  Kellie's  conclusions  were  erroneous. 

First,  he  demonstrated  that  hemorrhage  has  a  most  decided  effect  in  depleting  the 
cerebral  blood-vessels,  and  in  reducmg  the  quantity  of  blood  within,  as  well  as  upon 
the  outside  of  the  cranium.  Two  well-grown  rabbits  were  killed  :  the  one  (A)  by 
opening  the  jugular  vein  and  carotid  artery  on  one  side  of  the  throat ;  the  other  (B) 
by  strangulation.  Round  the  throat  of  the  first,  as  soon  as  it  was  dead,  a  ligature 
was  tightly  drawn,  to  prevent  any  further  escape  of  blood  from  the  -essels  of  the 
head. 

"  The  contrast  between  the  two  brains  in  point  of  vascularity,  both  on  the  surface 
and  m  the  interior,  was  most  striking.  In  the  one,  scarcely  the  trace  of  a  blood- 
vessel could  be  seen  ;  in  the  other,  every  vessel  was  turgid  with  blood." 


AND  NERVOUS  SYSTEM.  227 

He  next  investigated  the  effect  of  posture  upon  the  condition  of  the  intercranial 
ressels. 

•'Two  full-grown  rabbits  were  killed  by  prussic  acid;  and  while  their  hearts 
were  still  pulsating,  the  one  (C)  was  suspended  by  the  ears,  the  other  (D)  hy  the 
hind  legs.  They  were  left  suspended  for  twenty-four  hours ;  and  before  they  were 
taken  down  for  examination,  a  hght  hgature  was  placed  round  the  throat  of  each 
rabbit,  to  prevent,  as  effectually  as  was  possible,  any  further  flow  of  blood  to  or  from 
the  head,  after  they  were  removed  from  their  respective  positions. 

"  In  the  rabbit  (C)  the  whole  of  the  external  parts  of  the  head,  the  ears,  the  eye- 
balls, &c.,  were  pallid  and  flaccid ;  the  muscles  of  the  scalp  and  bones  of  the  cra- 
nium were  also  remarkably  exsanguine.  Upon  opening  the  cranium,  the  membranes 
and  substance  of  the  brain  were  pallid,  the  sinuses  and  other  vessels  were  exsanguine 
— ancemic  beyond  my  expectation. 

"  In  the  rabbit  (D),  the  external  parts  of  the  head,  the  ears,  eyeballs,  &c.,  were 
turgid,  livid,  and  congested.  The  muscles  and  bones  of  the  cranium  were  of  a  dark 
hue,  and  gorged  with  blood,  which  at  some  parts  appeared  extravasated.  Upon 
opening  the  cranium,  the  membranes  and  vessels  were  dark,  and  turgid  with  liquid 
blood ;  the  superficial  veins  were  proininent,  the  longitudinal  and  lateral  sinuses 
were  gorged  with  dark  blood,  and  there  was  straining  of  the  tissues,  if  not  extrava- 
sation of  blood  into  the  membranes.  The  substance  of  the  brain  was  uniformly 
dark,  and  congested  to  a  remarkable  extent." 

From  these  experiments.  Dr.  Burrows  draws  the  logical  inference,  that  "  the 
principle  of  the  subsidence  of  fluids  after  death  operates  on  the  parts  contained 
Within  the  cranium,  as  well  as  upon  those  situated  in  the  thorax  or  abdomen." 

And  of  that  absence  of  vascularity  sometimes  observed  within  the  skulls  of 
persons  who  have  died  of  strangulation,  he  offers  a  very  satisfactory  explanation. 

In  the  first  place,  the  cerebral  vessels  are,  in  some  instances,  highly  congested. 
Something  will  depend  upon  the  position  of  the  rope;  which  may  press  unequally 
upon  the  jugular  veins  on  the  opposite  sides  of  the  neck,  leaving  one  of  them  more 
or  less  pervious. 

"  But  there  is  another  still  more  efficient  cause  of  the  occasional  absence  of  con- 
gestion of  the  cerebral  vessels  after  death  by  hanging.  It  is  the  subsidence  of  the 
Jlidd  blood  after  death,  while  the  body  is  yet  suspended,  through  the  cervical 
vessels  which  are  not  completely  obliterated  by  the  pressure  of  the  cord.  And,  it 
should  be  recollected,  there  are  some  channels  which  are  scarcely,  if  at  all,  affected 
by  the  compression  of  the  rope.  These  other  channels  are  the  vertebral  sinuses, 
and  special  plexus  of  veins,  so  ably  dehneated  by  M.  Breschet." 

Moreover,  the  manner  in  which  the  corpse  is  generally  examined,  proves  an  ad- 
ditional source  of  fallacy.  All  the  great  vessels  of  the  neck  are  usually  cut  across, 
and  the  viscera  of  the  thorax  removed  from  the  body,  before  the  skull  is  opened. 
Then,  while  the  head  is  elevated,  during  the  operation  of  taking  off  the  calvarium, 
and  examining  the  brain,  the  blood,  still  fluid  (as  it  almost  always  remains,  after 
sudden  death  of  any  kind,)  "gravitates  from  the  cranium,  and  pours  from  the 
divided  cervical  vessels  into  the  chest." 

By  this  refutation  of  a  prevalent  error,  not  unlikely  to  warp  or  mislead  our 
practice  in  some  cerebral  disorders.  Dr.  Burrows  has  done  the  science  of  medicine 
an  essential  service. 

The  theory  which  he  has  demolished  involved  probably  more  than  one  erroneoiu 
assumption.  Dr.  Burrows  thinks  that  the  anatomical  structure  of  the  human  cra- 
nium does  not  warrant  the  opinion  that  its  contents  are  withdrawn  from  the  pressure 
of  the  atmosphere.  "  The  numerous  fissures,  and  foramina,  for  the  transmission  of 
vessels  and  nerves  through  the  bones  of  the  cranium,  appear  to  me  (he  says)  to  do 
away  with  the  idea  of  the  cranium  being  a  perfect  sphere,  like  a  glass  globe,  to 
which  it  has  been  compared  by  some  writers.  If  there  were  not  always  an  equi 
hbrium  of  pressure  on  the  parts  within  and  without  the  cranium,  very  serious 
consequences  would  arise  at  the  various  foramina  of  the  skuU." 

We  fall  back,  therefore,  upon  another  principle,  whereby  some  of  the  difficulty 
and  obscureness  which  attend  certain  affections  of  the  brain  and  nerves  may  \^ 


228  DISEASES   OF   THE   BRAIN. 

explained.  1  mean  the  principle  of  varying  jrressure  upon  the  nervous  substance 
Physiologists  say  that  the  cerebral  matter  is  incompressible.  This  is  another  of  the 
questionable  assumptions  implied  in  the  foregoing  theory.  Upon  what  grounds  the 
opinion  may  rest,  I  am  ignorant :  but  whether  the  brain  be  compressible  or  not, 
whether,  that  is,  it  be  or  be  not  reducible  by  pressure  into  a  smaller  compass,  it  is 
clearly  capable  of  having  different  degrees  of  pressure  applied  to  it,  and  of  being 
pressed  out  of  its  ordinary  form.  We  shall  see,  hereafter,  that  by  pressure  exercised 
from  within,  by  the  distension  of  what  are  called  the  ventricles  of  the  brain,  the 
convolutions  on  its  surface  are  sometimes  flattened,  and  the  natural  furrows  between 
them  nearly  effaced.  Pressure  there  certainly  is  in  what  I  shall  have  to  describe 
to  you  as  hypertrophy  of  the  brain.  There  must  be  considerable  pressure  on  the 
nervous  pulp  when  blood  is  poured  out  within  it  from  a  ruptured  artery  in  cerebral 
hemorrhage.  But  the  phenomena  noticeable  when  a  portion  of  the  skull  has  been 
removed  by  the  trephine,  show  very  clearly  that  the  encephalon  sustains  pressure 
from  the  varying  states  of  the  circulation  during  perfect  health.  The  surface  of  the 
brain,  seen  through  the  circular  opening  in  the  bone,  is  observed  to  pulsate  ;  and  to 
pulsate  with  a  twofold  motion.  With  every  systole  of  the  heart,  the  surface  pro- 
trudes a  little ;  and  it  again  subsides  with  the  succeeding  diastole.  This  shows 
that  the  tension  of  the  arteries,  produced  by  every  contraction  of  the  ventricles  of  the 
heart,  exerts  a  degree  of  pressure  upon  the  contents  of  the  cranium.  But  the  brain 
has  an  alternate  movement  also,  corresponding  with  the  movements  of  the  the  rax  in 
breathing  ;  rising  with  every  act  of  expiration,  and  sinking  with  every  act  of  inspi- 
ration. Now,  during  expiration,  the  blood  escapes  less  freely  from  the  head  through 
the  veins ;  and  thus  again  vascular  fulness  is  found  connected  with  evidence  of  pres- 
sure on  the  parts  within  the  head.  In  further  proof  of  this,  if  any  were  needed,  I 
may  again  refer  to  Dr.  Kellie's  experiments.  He  removed  a  portion  of  the  cranium 
of  a  dog  by  the  trephine.  The  brain  was  observed  to  rise  and  fall  alternately,  but  so 
as  always  to  fill  the  cranium;  the  rise  being  marked  by  a  sort  of  protrusion  through 
the  hole  that  had  been  made.  One  of  the  carotid  arteries  was  now  opened,  and  in  a 
minute  or  two  afterwards  there  was  an  evident  gradual  sinking  and  receding  of  the 
brain  from  the  margin  of  the  bone.  So,  likewise,  when  the  blood  was  flowing  from 
the  rabbit  (A)  in  Dr.  Burrows'  experiment,  "the  conjunctiva  was  observed  to 
become  pallid,  and  the  eyeballs  to  shrink  within  the  sockets.^^ 

It  is  certain  then  that,  whether  the  cerebral  pulp  yields  to  it  or  not,  there  is  a 
constant  alternation  of  a  greater  and  a  less  compressing  force,  exerted  upon  it,  during 
life.  It  is  not  improbable  that  this  continual  variation  of  the  compressing  force  may 
be  essential  to  the  performance  of  the  cerebral  functions.  May  not  the  brain 
be  thus  incessantly  charged,  if  indeed  it  be  (as  has  been  suggested  by  no  less  a 
philosopher  than  Sir  John  Herschel)  "an  electric  pile,  constantly  in  action,"  dis- 
charging itself  by  the  nerves,  at  brief  intervals,  "  when  the  tension  of  the  electricity 
developed  reaches  a  certain  point?"  However  this  may  be,  it  is  equally  certain  that 
the  compressing  force  may  transgress  its  natural  limits,  in  either  direction  ;  may  be 
too  great  or  too  little.  The  functions  of  the  nervous  centres  may  be  perverted,  or 
lost,  when  the  pressure  becomes  excessive  :  or,  on  the  other  hand,  when  the  pressure 
is  insufficient. 

It  IS  plain  that  excess  of  pressure  may  cause  fatal  coma,  or  defect  of  pressure  fatal 
syncope,  and  yet  no  evidence  of  the  operation  of  these  causes  be  left  in  the  dead 
brain.  And  we  may  explain,  by  the  help  of  this  same  theory  of  pressure,  a  very 
singular  phenomenon  observed  in  certain  forms  of  cerebral  disease ;  I  mean  the 
occasional  recurrence  only  of  the  symptoms,  although  the  organic  disease  itself  be 
permanent.  For  example,  we  see  continually  persons  who  are  epileptic:  that  is, 
they  have  fits  of  convulsion  and  stupor  noio  and  then,  and  appear  perfectly  well  in 
the  intervals.  After  the  death  of  such  patients  we  sometimes  find  organic  disease  of 
the  brain ;  a  piece  of  bone  perhaps  projecting  from  the  cranium,  or  a  tumour,  or  a 
cyst :  and  this  we  are  apt  to  consider  as  a  sufficient  explanation  of  the  preceding 
disease;  but  we  are  always  pressed  with  this  difficulty;  if  the  tumour  or  piece  of 
bone  was  the  cause  of  the  paroxysms,  why  had  the  paroxysms  any  cessation  ? 

It  seems  probable,  or  not  improbable,  that  in  such  cases  as  these,  and  in  manj 


SYMPTOMS   OF   CEREBRAL   DISEASES.  229 

Others,  the  permanent  morbid  condition  is  a  predisposing  cause  only  of  the  occa 
sional  symptoms ;  rendering  the  diseased  organ  more  sensible  to  variations  in  the 
circulation;  to  accidental  circumstances  which  determine  an  undue  amount  of  conf- 
pressing  force,  or  a  deficient  amount ;  and  I  think  Dr.  Abercrombie  has  gone  too 
far  when  he  says  "we  may  safely  assert  that  the  brain  is  not  compressible  by  any 
such  force  as  can  be  conveyed  to  it  from  the  heart  through  the  carotid  and  vertebral 
arteries." 

Dr.  Kellie  narrates  the  following  curious  circumstance : — "Mr.  G.,  with  a  nume- 
rous train  of  distressing  symptoms,  which  too  well  marked  the  existence  of  enlarge- 
ment of  the  heart,  and  the  violent  propulsive  energy  of  that  viscus,  had  only  one 
characteristic  of  any  disturbance  within  the  head.  On  looking  upwards  to  the 
whitened  ceiling  of  a  room,  he  saw  a  darkened  spectrum,  which  vanished  ari  reap- 
peared with  great  regularity.  It  was  soon  discovered  that  the  appearance  of  this 
umbra  was  synchronous  with  the  systole  of  the  heart,  so  that  he  used  often,  in  my 
presence,  to  count  his  pulse  with  the  utmost  precision,  by  keeping  his  eye  fixed  on 
the  ceiling,  and  numbering  every  appearance  of  the  spectrum."  In  this  case  it  is- 
presumable  that  b)'"  each  contraction  of  the  left  ventricle  of  the  heart,  plethora  of  the 
cerebral  blood-vessels  was  produced,  and  therefore  an  excess  of  pressure  upon  the 
cerebral  substance.  In  that  which  I  am  about  to  quote  it  seems,  on  the  other  hand, 
probable  that  comparative  emptiness  of  the  vessels  of  the  brain,  and  a  consequent 
defect  of  the  requisite  degree  of  pressure,  occasioned  the  morbid  phenomenon. 

A  gentleman,  thirty  years  old,  was  reduced  to  a  state  of  extreme  weakness  and 
emaciation  by  some  complaint  of  his  stomach.  As  the  debihty  advanced  he  became 
very  deaf;  and  this  symptom  varied  in  the  following  instructive  manner.  He  was 
very  deaf  while  sitting  erect,  or  standing;  but  when  he  lay  horizontally,  with  his 
head  quite  low,  he  could  hear  very  well.  If,  when  standing,  he  stooped  forwards, 
so  as  to  produce  flushing  of  the  face,  his  hearing  was  perfect ;  and  upon  raising 
himself  again  into  the  erect  posture,  he  continued  to  hear  distinctly  as  long  as  the 
flushing  continued  :  as  this  went  off  the  deafness  returned. — (Abercrombie.)  An 
old  clergj'man,  who  is  sometimes  my  patient,  is  troubled  by  two  grievances :  deaf- 
ness and  an  intermitting  pulse.     They  are  both  always  benefited  by  quina. 

Objections,  I  should  tell  you,  have  been  raised  against  this  theory  of  pressure 
affecting  the  functions  of  the  nervous  centres ;  but  I  think  the  objections  are  sus- 
ceptible of  a  satisfactory  answer.  I  must  content  myself,  however,  for  the  present, 
with  having  pointed  out  the  main  grounds  upon  which  the  theory  rests.  The  diffi- 
culties that  attend  it,  and  the  considerations  which  diminish  the  force  of  those  diffi- 
culties, \vill  come  necessarily  before  us  on  a  future  occasion. 


LECTURE  XXII. 

Symptoms  of  Cerebral  Diseases.  —  Inflammation  of  the  Dura  Mater  and  Arach- 
noid, from  external  injury  ;  from  Disease  of  the  Bones  of  the  Ear,  and  of  the 
Nose. — Inflammation  of  the  Pia  Mater. 

The  functions  of  the  brain,  summarily  expressed,  being  sensation,  thought,  and 
voluntary  motion,  we  naturally  look  for  disturbances  of  those  functions  whenever 
the  organ  suffers  disorder  or  disease.  And  experience  has  made  us  familiar  witn 
various  forms  of  disturbance  to  which  these  same  cerebral  functions  are  liable.  Let 
us  pass  them  shortly  in  review. 

1.  The  faculty  of  sensation  may  be  morbidly  keen,  or  morbidly  ooiuse  ;  or  it  may 
be  perverted  :  in  other  words,  it  may  deviate  in  degree,  or  in  kind,  from  the  healthy 
standard. 

The  sensations  referred  to  the  several  surfaces  and  structures  of  the  body,  and  to 
the  organs  of  sense,  may  (without  any  fault  in  those  parts  and  organs)  be  preternatu- 
ra.ly  acute.     Tenderness  ascribed  to  different  parts,  their  ratural  sensations  being 

u 


230  DISEASES    OF    THE    BRAIN. 

heightened  into  pain ;  a  general  state  of  irritability ;  intolerance  of  Hght,  and  of 
noise  ;  are  so  many  instances  of  this  over-sensitiveness  of  the  percipient  organ. 
•Under  the  head  of  diminished  or  defective  sensation  may  be  ranked,  numbness  in 
all  its  degrees,  up  to  total  loss  of  sensibility  or  ansesthesia  ;  dullness  of  hearing,  deaf- 
ness ;  dimness  of  sight,  blindness ;  failure,  or  absolute  extinction  of  the  senses  ot 
taste  and  of  smell. 

Perverted  sensations,  sensations  unnatural  in  kind,  are  very  numerous.  To  men- 
tion a  iew :  giddiness ;  nausea ;  ringing  in  the  ears ;  ocular  spectra ;  ill  smells  in 
the  nostrils  ;  false  tastes  on  the  palate  ;  itching ;  and  sundry  uneasy  feehngs,  many 
of  which  are  indescribable.  Various  kinds  of  pain  belong  to  this  class  ;  spirits  vio- 
lently high  ;  causeless  depression,  anxiety,  and  dread. 

2.  Innumerable  degrees  and  varieties  of  disturbance  of  the  faculty  of  tJwvght  are 
met  with.  Dehrium  in  all  its  shades  ;  dullness  and  confusion  of  intellect ;  sundry 
defects  of  memory  ;  incapacity  of  judgment ;  and  every  degree  of  stupor  up  to  com- 
plete coma. 

3.  Of  the  function  of  voluntary  motion  there  are  also  various  kinds  and  grada- 
tions of  derangement :  twitchings  of  the  muscles ;  tremors  of  the  limbs ;  rigidity 
from  spasm ;  irregular  and  involuntary  jactitation  ;  convulsions  ;  muscular  debihty ; 
palsy. 

Now,  as  I  stated  before,  there  is,  and  there  can  be,  no  ph3'^sical  exploration  of  the 
living  brain.  We  are  limited,  therefore,  in  studying  its  diseases,  to  the  rational 
symptoms.  It  becomes  our  task  to  interpret  the  import  of  the  multiform  disturbances 
of  function  just  enumerated,  in  every  case  in  which  more  or  fewer  of  them  appear; 
and  when  you  are  told  that  these  sj^mptoms  are  apt  to  present  themselves  in  almost 
every  conceivable  order  and  combination,  and,  moreover,  that  many  of  them  may  be 
S3'mpathetic  of  diseases  of  other  parts  than  the  brain,  you  will  scarcely  need  to  be 
further  informed,  that  the  language  thej^  speak  is  often  very  hard  to  construe ;  that 
we  frequently  fail  to  reach  and  discover,  by  these  outAvard  signals,  the  inward  things 
they  denote. 

I  am  about  to  consider,  in  the  first  place,  some  of  the  inflammatory  affections  of 
the  brain,  and  some  which  may  easily  be  mistaken  for  inflammatory  affections ;  and 
I  warn  you  beforehand,  that,  in  respect  to  exactness  of  diagnosis,  we  are  sadly  bar- 
ren of  certainties  in  these  matters.  Hints,  sketches,  approxinnations,  are  nearly  all 
that  I  can  promise  concerning  not  a  few  of  the  many  diseased  conditions  to  which 
the  brain  and  its  appendages  are  obnoxious. 

In  the  brain,  as  in  other  composite  organs,  inflammation  may  be  general  or  par- 
tial. It  may  attack  certain  tissues  only :  it  may  be  seated  in  the  substance  of  the 
cerebral  mass ;  or  in  the  membranes  that  envelop  it. 

I  need  not  tell  any  of  you  that  the  membranes  which  invest  the  brain  are  three  in 
number;  the  fibrous  dura  mater,  the  serous  arachnoid,  and  the  pia  mater,  which  ie 
composed  of  blood-vessels  held  together  by  a  web  or  areolar  tissue. 

Speaking  generally,  inflammation  of  the  cerebral  substance  alone,  is  perhaps  more 
common  than  inflammation  of  the  investing  membranes  alone.  The  central  parts  of 
the  nervous  mass  may  and  do  suffer  inflammation,  while  the  membranes  escape. 
But  it  seems  to  me  scarcely  possible  that  inflammation  of  the  pia  mater  should  take 
place  without  imphcating  also  the  surface  of  the  convolutions  with  which  it  has  so 
close  a  relation,  and  so  intimate  a  vascular  connection. 

Agam,  with  respect  to  the  membranes  themselves,  the  dura  mater  my  be  inflamed 
while  the  pia  mater  remains  unaffected.  I  befieve  also  that  the  arachnoid  may  suflTer 
inflammation,  and  leave  the  subjacent  pia  mater  untouched.  Whether  the  arachnoid 
ever  escapes  participating  in  the  inflammation  of  the  dura  mater  on  the  one  side,  or 
of  the  pia  mater  on  the  other,  is  to  be  doubted. 

Cin  we  separate  and  distinguish  these  several  inflammations  by  assigning  to  each 
Its  proper  external  phenomena  1  Seldom ;  scarcely  ever.  Doubtless  each  has  its 
peculiar  symptoms ;  and  if  inflammation  were  often  strictly  limited  to  the  one  mem- 
brane or  the  other,  and  if  the  course  and  events  of  the  inflammation  did  not  modify 
the  condition  of  the  brain  itself,  by  pressure,  or  by  affecting  the  circulation  of  blood 
mrough  it,  then  we  might  expect  greater  uniformity,  and  might  hope  by  careful  ami 


DURA  MATER  AND  ARACHNOID.  231 

repeated  observation  to  seize  upon  the  desired  distinctions.  But  this  simplicity  is 
not  exhibited  by  the  inflammatory  affections  of  the  parts  v/ithin  the  cranium.  Inflam- 
mation commencing  in  one  membrane  is  apt  to  spread  readily  and  rapidly  to  the 
rest,  and  to  the  cerebral  substance;  and  the  compHcation  of  diseased  conditions 
coexisting  within  the  skull  at  the  same  time,  throws  confusion  over  the  whole  sub- 
ject. This  unceriainty  of  exact  diagnosis  is  however  of  the  less  consequence,  inas- 
much as  when  we  have  learned  that  inflammation  is  going  on  in  any  part  of  the 
encephalon,  we  have  learned  enough  to  direct  us  as  to  the  geileral  plan  of  treatment 
to  be  adopted. 

After  all,  certain  symptoms  do  present  themselves  more  frequently  when  one  part 
is  inflamed,  and  certain  other  symptoms  more  frequently  when  another  part  is 
inflamed ;  and  it  will  be  proper  and  convenient  to  contemplate  certain  forms  of 
meningeal  inflammation  separately. 

Let  us,  first,  then,  consider  inflammation  as  it  is  confined,  occasionally,  to  the  dura 
mater — or  to  the  dura  mater  and  arachnoid. 

This  very  rarely  happens  as  an  idiopathic  or  spontaneous  disease ;  but  it  is  not  at 
all  uncommon  as  a  result  of  external  injury.  And  we  may  advantageously  trace  its 
ordinary  phenomena  and  consequences,  by  attending  to  these  instances  of  traumatic 
inflammation  of  the  dura  mater.  They  were  excellently  well  described  many  years 
ago,  by  Mr.  Pott.  A  man  receives  a  blow  on  the  head ;  the  blow  stuns  him  per- 
haps at  the  time,  but  he  presently  recovers  himself,  and  remains,  for  a  certain  period, 
apparently  in  perfect  health.  But  after  some  days  he  begins  to  complain ;  he  has 
pain  of  the  head,  is  restless,  cannot  sleep,  has  a  frequent  and  hard  pulse,  a  hot  and 
dry  skin,  his  countenance  becomes  flushed,  his  eyes  are  red  and  ferrety ;  rigours, 
nausea,  and  vomiting  supervene  ;  and,  towards  the  end,  deHrium,  convulsions,  or 
coma.  Meanwhile  the  part  which  was  struck  becomes  puffy,  tumid,  and  somewhat 
lender ;  and  if  this  tumid  portion  of  the  scalp  be  cut  through,  the  pericranium  beneath 
it  is  found  to  be  separated  from  the  bone ;  moreover,  the  bone  itself  is  observed  to  be 
altered  in  colour,  whiter  and  drier  than  the  healthy  bone ;  and  if  a  piece  of  this  bone 
be  reiuuved,  it  is  also  seen  that  the  dura  mater  on  the  other  side  of  it  is  detached 
from  the  cranium,  and  sometimes  smeared  with  lymph  or  puriform  matter.  This  is 
a  form  of  disease  very  often  met  with  by  the  surgeon.  I  have  watched,  with  much 
interest,  several  such  cases  under  the  care  of  my  hospital  colleagues.  One  or  two 
of  them  I  will  briefly  describe. 

In  the  year  1833,  during  Christmas  time,  the  coachman  of  a  lady  living  in  my 
neighbourhood  fell,  being  intoxicated,  into  a  cellar  or  area,  struck  in  his  fall  one  side 
of  his  head,  and  tore  up  the  scalp  over  a  considerable  space.  He  was  carried  to  the 
hospital,  where  the  loose  flap  of  integuments  was  cleansed  and  replaced.  After 
some  days  erysipelas  came  on,  and  then  a  much  larger  portion  of  the  scalp  sloughed 
away,  so  that  the  bone  was  laid  bare  to  a  frightful  extent,  and  looked,  at  a  little  dis- 
tance, as  he  sat  up  in  bed,  like  the  tonsure  of  a  monk.  Nevertheless  the  man  seemed 
wonderfully  free  from  suffering  or  distress :  his  pulse,  indeed,  v.-as  frequent,  but  it 
was  said  to  be  so  during  health.  His  intellect  was  clear,  and  he  had  no  head  symp- 
toms ;  or  rather,  no  brain  symptoms. 

In  the  early  part  of  February,  1834,  he  had  a  shivering  fit,  which  was  followed 
by  convulsions  of  the  right  side  of  the  body,  and  subsequently  by  paralysis  of  the 
right  arm  and  leg,  and  by  stupor,  from  which  he  could  easily  be  roused.  He  would 
put  out  his  tongue  when  desired  to  do  so;  but  to  every  question  he  answered  "yes." 
A  portion  of  the  left  parietal  bone  was  evidently  dead  :  here  the  trephine  was 
applied;  and  a  piece  of  bone  being  removed,  the  dura  mater  was  exposed.  It 
looked  as  if  it  had  lost  its  vitality.  Some  pus  lay  upon  it.  No  relief  followed  the 
operation. 

On  the  lOtli  of  February  fluctuation  was  detected  beneath  the  dura  mater  which 
was  then  slit  open.  About  three  drachms  of  puriform  fluid  escaped.  The  patient 
died  soon  afterwards,  having  had  no  active  delirium  throughout. 

The  surface  of  the  dura  mater  was  found  to  be  nearly  of  its  natural  appearance, 
except  where  the  trepanning  had  been  performed.     At  that  spot  it  was  dry  and 


232  DISEASES   OF   THE   BRAIN. 

sloughy.  Over  the  whole  of  the  anterior  and  lateral  surface  of  the  left  hemisphere 
there  lay,  upon  the  arachnoid,  a  thick  coating  of  coagulable  lymph,  smeared  with 
pus :  this  extended  down  the  posterior  part  of  the  hemisphere  also,  nearly  to  its 
base.  There  was  no  other  morbid  appearance  ;  no  fluid  in  the  pia  mater,  nor  in  the 
ventricles.  The  substance  of  the  brain  was  everywhere  perfectly  sound  and  healthy : 
it  was  divided  in  all  directions  in  search  of  an  abscess,  but  nothing  unnatural  could 
be  delected. 

Another  man  came  to  the  hospital  to  have  a  small  incised  wound  of  the  scalp 
looked  at.  The  injury  appeared  to  be  trivial ;  the  cut  was  dressed,  and  the  man 
made  an  out-patient.  A  few  days  afterwards  he  came  again,  incompletely  paralytic 
on  one  side  of  his  body.  I  saw  this  man's  skull  trepanned ;  he  was  perfectly  calm 
and  collected :  that  part  of  the  dura  mater  which  corresponded  to  the  wound  was 
found  to  be  inflamed  ;  and  there  was  pus  diffiised  over  the  arachnoid  covering  the 
cerebral  convolutions  on  the  same  side.  He  sank  quietly  into  a  state  of  coma,  and 
so  died.  Not  the  slightest  incoherence  or  dehrium  had  been  manifested:  there 
had  been  no  convulsions,  nor  was  there  any  other  morbid  appearance  within  the 
cranium. 

I  mention  these  cases  to  show  you  the  grounds  of  my  own  opinion,  that  inflam- 
mation, beginning  in  the  fibrous  membrane,  may  affect  the  arachnoid,  without  neces- 
sarily extending  to  the  pia  mater;  just  as  inflammation  ??ift^  overspread  the  pleura, 
or  the  pericardium,  without  touching  the  lung  or  heart  which  those  serous  mem- 
branes respectively  clothe.  Here  no  sensible  traces  of  inflammation  were  discovered 
deeper  than  the  free  surface  of  the  arachnoid ;  and  there  had  been  no  disturbance, 
t]*ll  towards  the  end,  of  the  proper  functions  of  the  brain.  I  conclude  that  the  disease 
did  not  pass  beyond  the  serous  membrane ;  for  I  can  scarcely  conceive  inflammation 
of  the  pia  mater  to  exist  without  involving,  in  some  degree,  the  surface  of  the  brain; 
nor  inflammation  of  the  surface  of  the  brain  to  exist  without  some  manifest  derange- 
ment of  the  cerebral  functions.  In  the  instances  that  I  have  been  relating,  the  final 
stupor  and  palsy  may  reasonably  be  ascribed  to  pressure  resulting  from  the  events 
of  the  inflammation  of  the  arachnoid  :  from  the  effused  pus  and  lymph. 

Inflammation  of  the  dura  mater  is  very  rare  as  a  simple  and  idiopathic  affection. 
Dr.  Abercrombie  relates  one  instance  of  it,  as  the  only  one  he  had  seen  ;  and  even 
that  was  not  a  pure  case  of  inflammation  of  the  dura  mater.  There  was  pus  upon 
that  membrane,  which  adhered  to  the  cranium  over  a  space  as  big  as  a  crown-piece, 
and  at  that  spot  was  ulcerated.  But  there  was  also  found  an  adventitious  membrane 
beneath  the  arachnoid  where  it  covers  the  brain. 

Speaking  generally,  this  complaint  is  marked  by  pain  of  the  head,  by  fever,  and 
by  rigors  which  intermit ;  and  so  regular  sometimes  are  the  intermissions,  that  the 
practitioner  may  be  tempted  to  beHeve  that  he  has  got  an  aguish  patient,  and  to 
administer  bark.  The  intellectual  faculties,  especially  at  the  outset  of  the  disease, 
are  but  little  affected  ;  which  is  just  what  we  might  expect.  The  dura  mater  and 
the  arachnoid  lying  apart  from  the  sensorium,  their  inflammation  can  have  no  other 
than  an  indirect  influence  upon  its  functions. 

Although  inflammation  of  the  dura  mater  is  very  uncommon  as  an  idiopathic  or 
primary  disorder,  we  very  frequently  meet  with  it  as  a  secondary  afll'Ction ;  and 
then  there  are  few  diseases  more  surely  fatal  or  less  within  the  reach  of  remedies. 
It  is  as  a  consequence  of  what  is  called  otitis,  that  physicians  are  chiefly  accustomed 
to  encounter  inflammation  of  the  dura  mater.  It  results  from  disease  of  the  internal 
ear,  and  of  the  petrous  portion  of  the  temporal  bone.  Sometimes  acute  inflammation 
arises  within  the  tympanum,  when  there  has  been  no  previous  disease  :  the  patient 
has  severe  headache  ;  at  length  a  gush  of  matter  comes  from  the  external  meatus, 
but  the  pain  does  not,  as  it  usually  does  in  such  cases,  cease ;  it  continues,  or  even 
increases  in  intensity  :  the  patient  begins  to  shiver;  he  becomes  dull  and  drowsy  ; 
slight  dehrium,  perhaps,  occurs ;  and  by  degrees  he  sinks  into  stupor.  In  some 
instances  no  pus  issues  externally.  More  commonl)*  symptoms  of  the  same  kind 
•supervene  upon  a  chronic  discharge  of  purulent  matter  from  the  ear.  It  is  scarcely 
possible  to  sketch  an  accurate  general  picture  of  this  insidious  but  most  dangerous 
r-innplamt.    Next  to  seeing  and  watching  actual  cases  of  it,  the  best  way  of  becoming 


DURA  MATER  AND  ARACHNOID.  233 

acquainted  with  its  phenomena  is  by  attending  to  recorded  instances.  I  will  bring 
before  you,  therefore,  some  examples  of  inflammation  of  the  dura  mater,  occurring 
in  connection  with  disease  of  the  interior  of  the  organ  of  hearing. 

A  youth,  sixteen  years  old,  applied  to  the  late  Dr.  Powell  (who  has  related  the 
case  in  the  fifth  volume  of  the  Transactions  of  the  College  of  Physicians)  on  account 
of  an  eruption,  with  an  acrid  discharge  behind  the  right  ear.  He  had  become  deaf 
five  years  before,  after  scarlet  fever,  but  no  discharge  took  place  at  that  time  from 
the  ear.  In  the  following  year,  however,  he  had  the  measles,  and  then  an  absces.<5 
formed  in  the  right  ear  ;  and  after  giving  him  much  pain,  it  burst.  He  had  again 
suffered,  three  days  before  Dr.  Powell  first  saw  him,  a  sudden  attack  of  very  severe 
pain  in  the  same  ear.  The  pain  quite  deprived  him  of  rest ;  but  he  had  no  fever, 
nor  delirium,  nor  soma.  He  slept,  indeed,  a  great  deal,  but  that  was  the  effect  of 
opiates,  which  he  took  to  relieve  the  pain.  This  symptom  was  quieted  by  the  opium ; 
but  it  always  returned  with  severity  if  the  medicine  was  suspended.  A  foetid  dis- 
charge came  from  the  ear.  On  the  tenth  day  of  this  attack,  after  a  most  violent 
paroxysm  of  pain,  his  strength  rapidly  declined,  and  he  died. 

"When  the  head  was  examined, *the  structure  of  the  dura  mater  was  healthy  and 
natural,  but  beneath  this  membrane  the  whole  superior  surface  of  the  right  hemi- 
sphere was  covered  with  a  layer  of  coagulable  lymph  and  pus.  The  vessels  of  the 
substance  of  the  brain  were  not  more  numerous  or  loaded  than  usual,  and  the  brain 
itself  was  healthy  in  every  part.  In  the  base  of  the  skull  the  dura  mater  adhered 
to  the  bone,  except  at  one  part,  of  about  half  an  inch  diameter,  just  over  the  petrous 
portion  of  the  temporal  bone,  where  it  was  black  and  sloughy.  The  subjacent 
portion  of  the  bone  itself  was  carious,  black,  and  crumbling ;  and  contained  foetid 
pus." 

In  this  case,  you  will  observe,  there  was  no  symptom  to  mark  the  extensive  mis- 
chief within  the  head,  except  the  pain  :  the  pulse  never  exceeded  72 ;  the  skin 
was  warm  and  moist ;  there  was  neither  fever,  nor  delirium,  nor  convulsion,  nor 
coma. 

A  girl,  aged  nine,  (I  take  this  case  from  Dr.  Abercrombie,  whose  volume  on  the 
diseases  of  the  brain  is  full  of  practically  instructive  examples,)  had  been  liable  to 
attacks  of  suppuration  of  the  ear,  which  were  usually  preceded  by  severe  pain,  and 
some  fever.  She  suffered  one  of  these  attacks  in  the  left  ear,  in  July,  1810.  Upon 
the  discharge  of  matter  from  the  ear  she  did  not  obtain  ease,  as  she  had  done  on 
former  occasions ;  but  continued  to  be  affected  with  pain,  which  extended  over  the 
forehead.  When  Dr.  Abercrombie  saw  her,  he  found  that,  besides  the  pain,  she 
had  some  vomiting,  and  impatience  of  light.  Her  look  was  oppressed ;  the  pulse 
84.  Blood-letting,  purging,  blistering,  and  mercury,  were  employed  without  relief. 
Two  days  afterwards  there  was  slight  and  transient  delirium,  a  degree  of  stupor,  and 
slight  convulsions.  She  lay  constantly  with  both  her  hands  pressed  upon  her  fore- 
head, and  moaning  from  pain,  of  which  there  had  not  been  the  least  alleviation.  On 
the  fifth  day  from  the  commencement  of  the  discharge,  she  continued  sensible,  and 
died  suddenly  in  the  afternoon,  without  either  squinting,  blindness,  or  C0K\a,  the  pulse 
having  been  always  under  90.  A.  considerable  quantity  of  colourless  fluid  Avas 
found  in  the  ventricles  of  the  brain,  which,  in  other  respects,  was  healthy.  In  the 
left  lobe  of  the  cerebellum  there  was  an  abscess  of  considerable  extent,  containing 
purulent  matter  of  intolerable  foetor.  The  dura  mater,  where  it  covered  this  part  of 
the  cerebellum,  was  thickened  and  spongy,  and  the  bone  corresponding  to  this  portion 
was  soft,  and  slightly  carious  on  its  inner  surface ;  but  there  was  no  communication 
with  the  cavity  of  the  ear. 

Here  again  the  pain  was  the  most  prominent  symptom,  and  probably  resulted  from 
the  partial  inflammation  of  the  dura  mater.  It  is  interesting  to  mark  these  two 
points  :  —  that  the  disease  in  the  bone  imparted  disease  to  the  dura  mater,  although 
no  passage  was  opened  from  the  tympanum ;  and  that  this  inflammatory  state  of 
the  external  membrane  of  the  brain  led  (apparently^  to  deep-seated  sujfpuration 
in  the  cerebellum;  the  parts  lying  between  the  aoscess  and  the  dura  matei 
escaping. 

This  last,  and  somewhat  singular  circumstance,  might  have  been  owing,  (so  at 

u2 


234  DISEASES    OF   THE   BRAIN. 

least  I  conjecture),  to  the  extension  of  the  inflammation  from  the  suppuratinir  ear  to 
some  of  the  veins  of  the  skull ;  and  the  consequent  formation  in  the  cerebellum  of 
one  of  those  secondary  abscesses  so  commonly  noticed  in  uncircumscribed  phlebitis. 
Two  very  remarkable  instances  of  diffused  inflammation  of  veins,  and  of  its  terrible 
effects,  occurring  in  connection  with  purulent  otorrhosa,  have  fallen  under  my  own 
observation ;  one  of  them  in  private  practice,  the  other  in  the  hospital.  As  I  am  not 
aware  that  such  consequences  as  supervened  in  these  cases  upon  otitis,  have  received 
much  attention,  I  will  briefly  describe  them. 

The  first  of  these  two  patients  was  a  boy,  eleven  years  old,  whom  I  attended  with 
Dr.  Maclntyre  and  Mr.  Arnott.  He  had  had  a  discharge  of  offensive  purulent 
matter  from  his  ear  since  the  time  when,  four  years  before,  he  had  gone  through 
scarlet  fever.  In  August,  1833,  he  went,  for  a  walk,  into  Kensington  Gardens,  and 
there  lay  down,  and  slept  upon  the  damp  grass.  The  next  day  he  was  attacked 
with  headache,  shivering,  and  fever.  Strong  rigors,  followed  by  heat  and  perspi- 
ration, occurred  very  regularly  for  two  or  three  days  in  succession  ;  suggesting  the 
suspicion  that  his  complaint  might  be  ague :  but  then  pain  and  swelling  of  some  of 
the  joints  came  on,  and  were,  at  first,  considered'rheumatic.  However,  the  true  and 
alarming  nature  of  the  case  soon  became  apparent.  Abscesses  formed  in  and  about 
the  affected  joints  ;  and  one  of  these  fluctuating  swellings  was  opened,  and  a  consi- 
derable quantity  of  foul,  grumous,  dark-coloured  matter  let  out.  After  about  a  fort- 
night the  child  sunk  under  the  continued  irritation  of  the  disease.  The  hip-joint 
presented  a  frightful  specimen  of  disorganization ;  it  was  full  of  unhealthy  sanious 
pus,  the  ligamentum  teres  was  destroyed,  the  articular  cartilages  were  gone,  and 
matter  had  burrowed  extensively  among  the  surrounding  muscles.  The  knee  and 
ankle  joints  of  the  same  limb  were  in  a  similar  state.  It  is  curious  that  the  destruc- 
tive disease  of  the  joints  was  limited  to  those  of  the  right  lower  extremity,  while  the 
primary  suppuration  was  in  the  left  ear.  Unfortunately  the  head  was  not  examined ; 
but  that  the  fatal  disorder  had  penetrated  from  the  ear  to  the  dura  mater,  I  entertain 
no  doubt :  in  all  probabihty  the  inflammation  had  involved  the  veins  or  sinuses  of 
the  head. 

The  second  case  had  many  points  of  similarity  with  this. 

William  Marriott,  aged  19,  was  admitted  under  my  care  into  the  Middlesex  Hos- 
pital, on  the  18th  of  October,  1834,  having  pain  and  tumefaction  of  the  right  shoulder, 
wrist,  and  foot,  with  redness  of  the  latter.  He  complained  also  of  headache,  vertigo, 
drowsiness,  and  of  an  occasional  feeling  of  stupor.  His  skin  was  hot  and  dry,  his 
face  flushed,  his  tongue  furred,  his  pulse  frequent  (112),  and  his  bowels  were  re- 
laxed.    A  puriform  discharge  came  from  his  right  ear. 

He  had  been  suddenly  seized,  a  week  before,  with  sharp  pain  in  that  ear,  which 
lasted  twenty-four  hours,  when  the  discharge  commenced,  and  the  pain  was  relieved. 
He  then  began  also  to  have  headache,  which  had  never  left  him,  and  to  be  sometimes 
dizzy.  Three  days  previously  to  his  admission  the  rheumatism  (as  he  supposed  it 
to  be)  commenced  in  the  foot.  When  this  part  was  examined,  the  redness  was 
found  to  be  circumscribed,  somewhat  livid,  and  limited  to  the  great  toe.  It  had  much 
the  appearance  of  gout. 

He  soon  began  to  be  troubled  with  shivering  fits,  which  recurred  regularly  every 
morning  about  the  same  hour,  and  were  followed  by  burning  heat  of  the  skin,  but 
no  sweating.  An  abscess  formed  near  the  toe,  and  was  opened  by  Mr.  Mayo,  and 
some  healthy-looking  pus  evacuated.  Next  a  large  fluctuating  tumour  near  the 
bhoulder  was  punctured,  and  three  ounces  of  pus,  mixed  with  blood,  came  out. 
After  this  incision  the  rigors  ceased ;  but  the  abscesses  continued  open,  and  the  dis- 
charge had  an  offensive  smell.  On  the  14th  of  November  it  was  discovered  that 
matter  had  collected  in  the  left  hip :  this  also  was  emptied  by  puncture.  On  the  1st 
of  December,  a  very  large  quantity,  not  less  than  three  pints,  of  unhealthy  and 
grumous  pus,  was  let  out  from  a  vast  abscess  which  had  formed  in  the  loins :  and 
pus  was 'noticed  in  his  stools.  The  discharge  from  the  shoulder  came  at  last  to 
resemble  the  lees  of  port  wine. 

During  all  this  while  the  patient  remained  feverish,  with  a  dry  parched  tongue, 
ajid  a  rapid  and  feeble  pulse.     The  diarrhoea  continued,  more  or  less,  throughour 


DURA   MATER   AND   ARACHNOID.  23S 

I  For  some  titno  oefore  his  death,  which  happened  about  the  middle  of  the  month  of 
I  December,  the  left  leg  and  thigh  had  been  much  enlarged  by  osdema. 

I  was  not  able  to  be  present  at  the  inspection  of  the  body ;  and  I  have  to  regret 
that  in  the  report  which  I  received  of  it,  the  condition  of  the  brain,  of  its  membranes, 
and  of  its  veins,  was  not  noted. 

The  right  shoulder-joint  was  extensively  diseased  ;  the  cartilages  Avere  destroyed 
by  ulceration  over  a  considerable  space.  Those  of  the  left  hip  were  entire,  but  the 
synovial  cavity  was  full  of  foul  matter.  The  joint  of  the  great  toe  was  implicated 
also  in  the  abscess  wliich  had  formed  there.  The  femoral  vein,  on  the  left  side,  was 
plugged  up,  throughout  its  whole  extent,  by  a  coagulum,  which  was  firm  and  of  a 
reddish  brown  colour  at  the  upper  part  of  the  vessel,  loose  and  darker  towards  the 
ham.     The  saphena  was  pervious  :  the  iliac  was  free  from  disease. 

The  lungs  had  undergone  partial  disorganization.  Several  distinct  portions  of  the 
pulmonary  tissue  were  nearly  solid,  while  the  tissue  immediately  around  them  was 
crepitant  and  healthy.  From  these  small  solidified  portions,  puiulent  riiatter  could 
be  made  to  ooze  by  gentle  pressure. 

The  mastoid  cells  of  the  right  temporal  bone  were  filled  with  pus,  and  there  was 
a  sht-like  opening  in  the  membrana  tympani.  The  small  bones  of  the  ear  were 
sound. 

I  much  lament  that  in  these  instances,  the  direct  link  of  connection  between  the 
disease  of  the  ear  and  the  dis'organization  of  the  joints  was  not  demonstrated :  for 
seeing  (they  say)  is  believing.  Yet  the  pain  of  the  ear,  the  discharge  of  pus  from 
the  external  meatus,  the  subsequent  pain  of  the  head,  coming  on  with  fevers  and 
rigors,  and  followed  after  a  short  interval  by  destructive  suppuration  in  several  dis- 
tant parts,  and,  in  the  last  case,  the  actual  femoral  phlebitis:  these  circumstances 
form  a  chain  of  presumptive  evidence,  amounting,  in  my  judgment,  to  moral  cer- 
tainty, that  the  fatal  mischief,  in  each  case,  found  entrance  through  "  the  porches  or 
the  ear;''  and  that  the  dura  mater  underwent  inflammation.  The  same  evidence  is 
scarcely  less  affirmative  of  the  complication  of  cerebral  phlebitis.  Perhaps  the  veins 
of  the  diploe,  which  in  the  cranial  bones  are  of  considerable  magnitude,  were 
involved  in  the  inflammatory  mischief ;  perhaps  the  large  sinuses  of  the  brain.  The 
close  vicinity  of  the  lateral  sinus  to  the  diseased  bone,  and  its  formation  by  a  dupli- 
cature  of  the  dura  mater,  would  seem  to  render  such  a  complication  highly  probable. 

These  views,  which  were  brought  forward  in  my  first  course  of  lectures  here,  in 
183G,  have  been  confirmed  by  the  publication,  very  recently  (1841)  in  the  Medical 
Gazette,  by  Dr.  Bruce  of  Liverpool,  of  two  cases  witnessed  by  himself,  of  "Phle- 
bitis of  the  cerebral  sinuses  as  a  result  of  purulent  otorrhcea."  He  refers  to  several 
other  instances  of  the  same  kind  recorded  by  diflerent  authors.  This  combination 
of  disease  is  doubtless  more  common  than  had  been  heretofore  supposed :  and  the 
important  pathological  considerations  connected  with  it  will  probably  receive  further 
illustration,  now  that  the  attention  of  the  profession  has  been  called  to  the  subject  by 
Dr.  Bruce's  paper. 

Dr.  Griffin  has  pubhshed,  in  the  DuhUn  Journal  of  Science,  two  examples  of 
otitis  attended  with  symptoms  exactly  resembling  those  of  intermittent  fever.  One 
of  them  is  as  follows  : — A  young  man,  previously  healthy,  was  attacked  with  fits  of 
shivering,  accompanied  by  pain  in  the  left  side  of  the  head.  At  first  the  paroxysms 
were  rather  irregular,  but  they  soon  assumed  the  form  of  tertian  ague ^  coming  on 
every  other  day,  at  about  the  same  hour;  the  cold  fit  commencing  at  noon,  and 
lasting  about  half  an  hour,  followed  by  a  hot  stage  of  somewhat  longer  duration, 
and  then  a  profuse  sweat.  In  the  intermissions  the  pain  in  the  head  was  triflino-: 
there  was  no  thirst  nor  heat  of  skin,  but  he  did  not  sleep.  A  tumour  formed  over 
the  mastoid  process  of  the  left  side,  and  was  opened,  and  a  quantity  of  extremely 
ofll'nsive  brownish  pus  sprang  out  with  great  force.  This  gave  much  relief.  The 
bone  was  carious  over  a  space  as  big  as  a  shilling.  After  about  ten  days,  the  pam 
in  the  head  and  in  the  mastoid  process  became  very  severe ;  the  patient  had  violent 
shivering  fits  many  times  in  the  day,  great  thirst,  heat  of  skin,  vomiting,  and  dei.- 
riuin :  his  face  was  flushed,  and  his  pulse  hard ;  and  he  died  within  a  few  hours 
after  the  acci?ssion  of  these  last  symptoms. 


236  DISEASES   OF   THE   BRAIN. 

The  most  remarkable  features  in  this  case  were  the  similarity  of  the  fits  of  shiver 
ing  to  the  paroxysms  of  ague,  their  regular  recurrence  at  periods  of  forty-eight  hours, 
and  the  circumstance  that  they  seemed  to  be  checked,  for  some  time,  by  the  treat- 
ment proper  in  ague  ;  namely,  the  exhibition  of  bark.  The  occurrence  of  quotidian 
paroxysms  of  the  same  kind  has  been  noticed  in  relating  some  of  the  previous  cases. 

I  have  related  them  to  show  you  what  different  symptoms  may  result  from  inflam- 
mation of  the  dura  mater ;  and  to  put  you  upon  your  guard  against  overlooking  the 
cause  from  which  such  inflammation  does  frequently  originate.  The  suppuration  of 
the  tympanum,  and  consequent  disease  of  the  bone,  are  more  common  in  scrofulous 
persons  than  in  others ;  and  they  are  more  apt  to  occur  as  a  sequel  of  scarlet  fever 
than  in  any  other  way.  I  conceive  that  the  inflammation  of  the  throat,  belonging  to 
that  disorder,  and  often  constituting  all  its  danger,  creeps  along  the  Eustachian  tube 
into  the  interior  of  the  ear.  In  strumous  subjects  the  fire  thus  hghted  smoulders  on, 
or  if  it  ever  goes  out,  is  readily  rekindled  :  that  part  of  the  temporal  bone,  in  which 
the  organ  of  hearing  is  principally  lodged,  becomes  carious  :  the  membrana  tympani 
is  perforated  :  the  little  bones  of  the  ear  come  away :  more  or  less  deafness  ensues ; 
and  from  time  to  time,  or  habitually  it  may  be,  there  is  a  discharge  of  pus  from  the 
external  orifice.  At  length  the  inner  surface  of  the  bone  participates  in  the  disease  ; 
and  then  the  inflammation  is  apt  to  be  propagated  to  the  dura  mater,  in  the  manner 
of  which  I  have  given  you  some  instances.  It  is  in  the  first  onset  of  the  inflamma- 
tion in  the  ear  that  remedies  are  most  likely  to  be  efficient  in  preventing  this  catas- 
trophe. Leeches  applied  early  and  repeatedly  to  the  mastoid  process,  especially 
when  that  part  becomes  tender,  as  it  often  does  in  such  cases,  and  counter-irritation 
afterwards,  are  the  best  means  in  our  possession. 

[The  frequency  with  which  inflammation  of  the  dura  mater  supervenes  upon  otitis,  espe- 
cially in  children,  should  be  kept  constantly  in  mind ;  for  it  is  only  by  a  prompt,  active,  and 
judicious  treatment,  whilst  the  disease  is  confined  to  the  internal  ear,  that  we  can  have  any 
hopes  of  saving  the  patient — when  inflammation  has  extended  to  the  dura  mater,  the  termi- 
nation is  very  generally  fatal. — C] 

If  symptoms  of  acute  inflammation  within  the  head  supervene,  the  complaint 
requires  more  vigorous  treatment,  which  I  shall  describe  when  I  have  spoken  of  in- 
flammation of  the  other  membranes  of  the  brain.  After  what  has  been  said,  it  is 
unnecessary  to  point  out  to  you  that  the  prognosis  in  these  cases  is  very  unfavour- 
able. But  we  are  not  to  abandon  them  in  despair.  That  inflammation  of  the  dura 
mater  may  be  recovered  from,  we  know,  by  what  happens  in  certain  injuries  of  the 
head :  and  the  following  would  seem  to  be  an  instance  of  recovery  when  the  source 
of  the  mischief  was  situated  in  the  ear.  A  young  lady,  after  the  usual  symptoms 
in  the  head,  lay  for  three  or  four  days  in  a  state  of  perfect  coma,  and  her  condition 
was  thought  utterly  hopeless.  Her  medical  attendants  continued  to  visit  her  as  a 
matter  of  form ;  and  one  day  they  were  agreeably  surprised  to  find  her  sitting  up, 
and  free  from  complaint :  a  copious  discharge  of  matter  had  taken  place  from  the 
ear,  with  immediate  relief:  and  she  continued  in  good  health. — (Abercrombie.) 
We  cannot  be  sure  in  such  a  case  that  the  matter  came  from  the  brain ;  but  the 
symptom  made  that  supposition  exceedingly  probable.  The  case  shows  clearly  one 
of  two  things ;  either  that  pus  may  thus  escape  from  the  skull,  and  the  patient  get 
well;  or  that  pus  shut  up  in  the  cavity  of  the  tympanum  may  produce  the  urgent 
symptoms  that  are  known  to  result  from  cerebral  pres-sure. 

Cases  are  recorded  of  analogous  disease  communicated  from  the  carious  cethmoid 
bone  to  the  dura  mater;  the  patients  having  had  pain  in  the  forehead  and  purulent 
discharge  from  the  nose,  and  becoming  at  last  forgetful  and  delirious,  and  dying  in 
a  state  of  coma.  I  have  never  met  with  an  instance  of  this  kind  ;  nor  of  inflamma- 
tion spreading  inwards  from  the  socket  of  the  eye  ;  but  I  make  no  doubt  that  each 
may  occasionally  happen. 

These  three,  then  —  j(/jo/jo//a'c  inflammation  of  the  dura  mater — very  rare  ;  in- 
flammation of  the  dura  mater  by  extension  of  disease  from  the  sethmoid  bone,  or 
from  the  orbit  —  also  infrequent;  and  inflammation  of  the  dura  mater  by  extension 
of  disease  from  the  petrous  portion  of  the  temporal  bone — very  common :  constitute 
those  forms  of  inflammation  of  the  outermost  tunic  of  the  brain,  which  the  physician 


PIA   MATER.  237 

may  be  called  upon  to  treat.  The  inflammation  is  not  always  —  nay,  perhaps  it  is 
Iseldom,  if  ever — restricted  to  that  tunic ;  but  it  begins  there ;  and  the  essence  of  the 
Idisease  is  inflammation  of  the  dura  mater. 

Acute  aracJmitis — by  which  I  mean  active  and  uncombined  inflammation  of  the 
arachnoid  membrane  —  is,  I  apprehend,  a  very  uncommon  disorder ;  although  that 
term  is  of  frequent  occurrence  in  medical  writings.  I  have  shown  you  already  that 
inflammation  may  pass  from  the  fibrous  dura  mater  to  the  serous  membrane  reflected 
over  it ;  and  thence  (by  what  is  sometimes  called  contiguous  sympathy)  to  the  oppo- 
site portion  of  the  same  membrane  spread  over  the  surface  of  the  brain.  So,  hke- 
wise,  inflammation  may  extend  from  the  pia  mater  to  the  arachnoid.  If  simple 
arachnitis,  of  an  acute  kind,  ever .  happens,  it  has  not  been  my  fortune  to  see  or  to 
recognize  it ;  and  I  can  tell  you  nothing  about  it.  In  truth,  the  authors  who  use  the 
word  arachnitis  do  not  intend  thereby  to  express  unmixed  inflammation  of  the  arach- 
noid ;  but  include  under  that  term  inflammation  of  the  pia  mater  also.  Some  apply 
the  name  meningitis  to  that  compound  affection ;  and  the  only  objection  to  this 
nomenclature  is,  that  the  dura  mater  is  as  much  one  of  the  meninges  of  the  brain  as 
either  of  the  two  others. 

In  the  few  remarks  which  I  have  to  make  upon  inflammation  of  the  pia  mater 
(or,  if  you  will,  of  the  pia  mater  and  arachnoid  at  once),  I  shall  chiefly  follow  Dr. 
Abercrombie :  because  his  observations  are  comparatively  recent,  and  carefully 
made ;  because  his  veracity,  and  sobriety  of  judgment,  and  philosophical  turn  of 
mind,  are  well  known ;  and  because  his  cases  (as  regards  this  particular  affection) 
are  quite  to  the  point,  and  his  descriptions  clear  and  concise. 

But  I  must  premise  a  word  or  two  respecting  the  anatomical  characters  of  the 
disease. 

When  the  upper  part  of  the  skull,  and  the  dura  mater,  have  been  removed,  you 
may  frequently  see,  on  the  surface  of  the  exposed  brain,  what  seems  to  be  a  thin 
layer  of  a  clear  gelatinous  substance  :  but  this  appearance  is  fallacious.  Puncture 
here  and  there  the  transparent  arachnoid,  and  a  limpid  fluid,  like  water,  trickles  out ; 
and  the  jelly-hke  investment  of  the  convolutions  is  gone.  Now  this  thin  serous 
liquid,  thus  collected  in  the  meshes  of  the  pia  mater,  may  be  the  event  of  inflamma- 
tion of  that  membrane :  but  it  may  also  be  produced,  and  it  very  often  indeed  is 
produced,  by  simple  congestion  and  remora  in  the  cerebral  veins.  Nay,  a  certain 
amount  of  serosity,  in  this  situation,  belongs  to  the  condition  of  health.  We  cannot, 
therefore,  with  any  certainty,  infer,  merely  from  seeing  this  serous  effusion,  that 
there  has  been  inflammation :  we  judge  of  its  import,  by  noting  the  co-existence,  or 
the  absence,  of  other  traces  of  inflammation ;  and  by  the  character  of  the  symptoms 
that  preceded  death. 

On  the  other  hand,  we  may  be  sure  that  there  has  been  inflammation  of  one  or 
both  of  these  tunics  of  the  brain  when  we  find  false  membranes  between  them ; 
layers,  i.  e,,  of  coagulable  lymph.  In  the  effusion  of  this  substance  I  conclude  that 
the  vessels  of  the  pia  mater  play  the  main  part ;  both  because  it  is  always,  in  such 
cases,  excessively  vascular,  while  the  arachnoid  is  seldom  found  to  be  so  in  any 
remarkable  degree,  if  at  all:  and  also,  because  the  false  membrane  commonly,  though 
not  always,  sends  down  layers  between  those  duplicatures  of  the  pia  mater  which 
descend  into  the  sulci  formed  by  the  convolutions  ;  where,  as  you  know,  the  arach- 
noid does  not  go.  In  fact,  considering  the  arachnoid  as  the  serous  membrane  of  the 
brain,  we  should  expect  that,  when  inflamed,  it  would  present  the  events  or  products 
of  inflammation  on  its  free  surface  ;  and  we  sometimes  find  them  there  ;  but  this  is 
very  rare  ;  and  for  my  own  part,  I  look  upon  those  effusions  which  he  beneath  the 
arachnoid,  between  it  and  the  pia  mater,  as  being  furnished  exclusively  by  the  ves- 
sels of  which  the  latter  membrane  is  mainly  composed. 

Now  the  inflammation  of  these  membranes  (taking  them  together)  commences, 
and  declares  itself,  by  no  fixed  or  uniform  symptoms.  The  most  common  and 
striking  phenomena  is  a  sudden  and  long-continued  paroxysm  of  general  convul- 
sions. Sometimes  this  is  the  first  thinsj  noticed.  Sometimes  it  comes  on  after  a 
few  day»  of  discomfort,  shght  headache,  and  vomiting.    The  convulsions  recur,  and 


'SS8  DISEASES    OF    THE    BRAIN. 

at  length  end  in  coma.  Sometimes,  again,  the  first  attack  of  convulsions  is  preceded 
by  violent  pain  in  the  head,  setting  in  quite  suddenly,  and  attended  with  screaming 
Considering,  on  the  one  hand,  the  intimate  connection  between  the  pia  mater  and 
the  gray  matter  of  the  convolutions,  and,  on  the  other,  the  presumed  functions  of 
that  gray  matter,  we  might  expect  that  inflammation  of  the  pia  mater  would  soon  be 
attended  with  some  manifest  derangement  of  the  mental  faculties.  Accordingly, 
delirium,  often  violent  and  continued,  is  stated  by  most  authors  to  accompany  and 
denote  inflammation  of  the  membranes ;  and  especially  of  the  membranes  where 
the}^  invest  the  upper  surface  of  the  cerebral  hemispheres.  Yet  I  do  not  find  that 
symptom  mentioned  in  any  of  the  various  examples  of  meningitis  recorded  by  Dr. 
Abercrombie.  He  does  give  cases,  indeed,  in  which  there  was  much  delirium; 
but  they  were  not  cases  of  meningitis  of  any  kind.  He  relates  them  as  instances 
"  of  a  very  dangerous  modification  of  the  disease,  which  shows  only  increased  vas- 
cularity." I  venture  with  great  hurftility  to  question  or  criticise  any  opinion  of  Dr. 
Abercrombie's  ;  but  I  entertain  no  doubt  about  the  nature  of  the  cases  which  he  so 
describes ;  and  I  hope  to  convince  you  by-and-by  that  they  are  not  examples  of 
inflammation  at  all :  they  neither  show  the  anatomical  characters  of  inflammation, 
nor  yield  to  the  remedies  of  inflammation.  Excluding  these  cases,  I  do  not  find 
dchrium  specified  as  a  symptom  of  uncombined  meningitis.  I  shall  abridge  one  or 
two  of  the  well-marked  examples  of  the  disease. 

A  girl,  aged  nine,  woke  suddenly  in  the  middle  of  the  night,  screaming  from  vio- 
lent headache,  and  exclaiming  that  some  person  had  given  her  a  blow  on  the  head. 
For  the  next  two  days  she  complained  of  some,  but  not  much  pain  in  her  forehead, 
and  did  not  even  remain  constantly  in  bed  :  no  alarm  was  felt  about  her.  On  the 
third  day  she  was  seized  with  violent  and  long-continued  convulsions,  and  imme- 
diately after  the  convulsions  she  fell  into  a  state  of  deep  coma ;  she  remained  in  this 
state,  with  a  natural  pulse,  till  she  died,  on  the  sixth  day  of  the  disease. 

When  the  dura  mater  had  been  removed,  the  other  membranes  appeared  highly 
vascular,  except  where  this  appearance  was  concealed  by  a  layer  of  yellow  adven- 
titious membrane,  spread  out  betwixt  the  arachnoid  and  the  pia  mater.  This  was 
distributed  in  irregular  patches  over  various  parts  of  the  surface  of  the  brain,  but 
was  most  abundant  on  the  upper  part  of  the  right  hemisphere.  It  was  as  thick  as 
a  wafer,  and  in  some  places  dipped  down  between  the  convolutions.  A  considera- 
ble quantity  of  it  extended  over  the  surface  of  the  cerebellum  also. 

A  child  two  years  old  was  suddenly  attacked  one  morning  with  severe  and  long- 
continued  convulsions.  The  convulsions  recurred  many  times  ;  in  the  intervals  she 
■was  dull  and  torpid,  in  a  state  of  partial  coma,  with  occasional  starting,  and  a  frequent 
and  feeble  pulse.     On  the  fourth  day  she  sank. 

The  surface  of  the  brain,  when  the  dura  mater  was  removed,  was  covered  in  many 
places,  betwixt  the  arachnoid  and  pia  mater,  by  an  adventitious  membrane.  It 
was  chiefly  found  above  the  openings  between  the  convolutions,  and  in  some  places 
appeared  to  descend  a  little  way  between  them.  The  arachnoid  when  detached 
seemed  to  be  healthy ;  but  the  pia  mater  was  in  the  highest  state  of  vascularity 
throughout ;  and  when  the  brain  was  cut  vertically,  the  spaces  between  the  convolu- 
tions were  most  strikingly  marked  by  a  bright  fine  of  vivid  redness,  produced  by 
the  inflamed  membrane.  There  was  no  eflusion  in  the  ventricles,  and  no  other 
morbid  appearance. 

In  another  example,  the  whole  surface  of  the  brain  was  'covered  by  a  continued 
stratum  of  yellow  false  membrane,  lying  between  the  arachnoid  and  pia  mater,  and 
in  some  parts  following  the  course  of  the  pia  mater  through  the  whole  depth  of  the 
convolutions :  the  pia  mater  and  arachnoid  adhered  together  everywhere,  very 
firmly,  by  means  of  it:  not  a  trace  of  it  could  be  found  either  on  the  outer  surface 
of  the  arachnoid,  or  the  inner  surface  of  the  pia  mater :  the  arachnoid  itself,  when 
separated,  presented  no  unusual  appearance,  but  the  pia  mater  was  everywhere  ex- 
cessively vascular.  There  was  no  serous  effusion,  and  the  brain  and  cerebellum  were 
perfectly  healthy. 

Now  in  this  dissection  there  was  unequivocal  evidence  of  acute  and  extensive 
inflammation  of  these  membranes,  or  I  should  say,  of  the  pia  mater ;  yet  the  symp- 


PIA   MATER.  239 

toms  had  been  very  obscure.  The  child  in  whom  the  disease  occurred  was  conva- 
lescent from  a  mild  attack  of  scarlet  fever.  One  evening  he  became  very  feverish, 
and  complained  of  his  belly.  Three  days  afterwards  he  had  frequent  vomiting, 
followed  by  stupor,  and  some  convulsive  movements  of  his  face  and  arms,  and  death 
took  place  four  days  and  a  half  after  the  feverishness  began.  We  learn  from  this 
case,  that  general  and  severe  inflammation  of  the  innermost  membrane  maj^  exist, 
and  prove  fatal,  without  giving  rise  to  any  violent  symptoms  at  all. 

I  must  trouble  you  with  one  more  history,  because  it  atibrds  another  examjile  of 
what  I  have  mentioned  as  being  rare;  viz.,  the  effusion  of  the  products  of  inflam- 
matory action  upon  the  outer  surface  of  the  arachnoid,- — marking  therefore  very 
distinctly  the  inflammation  of  that  membrane.  It  was  evidently  combined,  however, 
with  inflammation  of  the  pia  mater  also.  A  child,  eight  months  old,  died  after  more 
than  three  weeks'  illness ;  which  began  with  fever,  restlessness,  and  quick  breathing; 
afterwards  there  were  frequent  convulsive  affections,  with  much  oppression ;  and  at 
last  severe  convulsions,  squinting,  and  coma.  At  an  early  period  of  the  complaint, 
a  remarkable  prominence  of  the  anterior  fontanelle  was  noticed  ;  in  the  second  week 
this  increased  considerably ;  and  in  the  third  week,  it  was  elevated  into  a  distinct 
circumscribed  tumour,  which  was  soft  and  fluctuating,  and  pressure  upon  it  occa- 
sioned convulsions.  It  was  opened  by  a  small  puncture,  and  discharged  at  first  some 
purulent  matter,  afterwards  bloody  serum.  No  change  took  place  in  the  symptoms, 
and  the  child  died  four  days  after. 

A  deposit  of  thick  flocculent  matter  mixed  with  pus  was  found  covering  the  sur- 
face of  the  brain  to  a  considerable  extent,  and  lying  upon  the  free  surface  of  the 
arachnoid.  There  was  a  similar  deposition  also  between  the  arachnoid  and  ftie  pia 
mater,  and  considerable  effusion  into  the  ventricles. 

If  the  sketches  I  have  been  giving  you  afford  a  true  outline  of  the  phenomena 
which  attend  acute  inflammation  of  the  pia  mater,  or  of  the  pia  mater  and  arachnoid 
jointly,  what,  you  may  naturally  ask,  is  the  nature  of  those  cases  in  which  there  is 
high  excitement,  and  much  fever,  and  great  delirium,  and  which  are  sometimes 
spoken  of  as  phrenitis,  or  as  brain-fever  ?  Why  these  are  instances  of  acute  inflam- 
mation of,  the  whole  contents  of  the  cranium ;  of  the  brain  and  its  membranes : 
of  the  encephalon  in  short ;  and,  therefore,  the  disease  has,  not  improperly,  been 
called  encephalitis.  Of  this  formidable  malady  I  shall  give  you  some  account 
to-morrow. 


LECTURE  XXIII. 

Acute  and  general  inflammation  of  the  Encephalon.  Period  of  Excitement.  Modes 
inivhich  the  disease  may  commence.  Period  of  Collapse.  Treatment.  Deli 
rium  tremens. 

Acute  inflammation  does  sometimes  appear  to  invade  at  once  the  whole  of  the 
parts  that  are  lodged  within  the  skull ;  or,  beginning  in  one  part,  it  extends  rapidly 
to  all  the  rest.  As  the  contents  of  the  cranium  are  called,  collectively,  the  encephalon, 
so  the  disorder  which  I  am  about  to  consider  has  been  named  encephalitis.  It  is  an 
uncouth  appellation,  but  it  will  serve  its  purpose.  Cullen,  and  many  others,  apply 
the  term  phrenitis  to  the  same  disease.  You  may  choose  between  these  names, 
taking  care  to  remember  what  they  signify.  The  malady  is  sometimes  described  as 
inflammation  of  the  membranes  of  the  brain.  I  believe  "this  to  have  arisen  from  the 
circumstance  that  the  effects  of  the  inflammation,  which  become  visible  after  death, 
are  otten  more  striking  and  obvious  on  the  surface  of  the  brain,  or  in  its  ventricles, 
than  in  the  cerebral  substance  itself.  An  abscess  in  the  nervous  mass  can  scarcely 
be  overlooked :  a  softening  of  the  cerebral  pulp  may  escape  the  notice  of  a  hasty 
or  inexpert  observer  :  and  those  changes  of  colour,  which  sometimes  denote  increased 


240  DISEASES   OF   THE   BRAIN. 

vascularity  of  the  same  part,  may  very  easily  be  passed  over  without  attracting 
much  attention. 

Phreniiis,  or  encephalitis,  or  acute  and  general  inflammation  of  the  brain  and  its 
membranes,  as  it  occurs  in  adults,  presents  two  periods,  which  are  marked  by  differ- 
ent symptoms,  and  in  most  instances  are  very  distinctly  observable.  In  the  first 
period  what  are  called  symptoms  of  excitement  predominate  ;  the  functions  of  the 
organ  are  exaggerated  as  well  as  disordered  :  in  the  second  period  those  symptoms 
appear  which  are  comprised  under  the  term  collapse.  Sometimes  these  two  sets  of 
symptoms,  instead  of  ibllowing  each  other,  are  more  or  less  mixed  and  confounded 
together.     But  the  distinction  is  real,  and  requires  to  be  attended  to. 

The  symptoms  that  characterize  the  period  of  excitement,  are  pain  of  the  head, 
often  intense  and  deeply  seated,  or  extending  over  a  large  part  of  it ;  a  sense  of  con- 
striction across  the  forehead  ;  throbbing  of  the  temporal  arteries,  flushing  of  the  face; 
injection  of  the  eyes,  which  have  a  wild  and  briUiant  look  ;  contraction  of  the  pupils  ; 
preternatural  sensibility  to  external  impressions,  amounting  frequently  to  impatience 
of  light,  and  of  sound ;  violent  delirium ;  want  of  sleep ;  paroxysms  of  general 
convulsion  ;  a  parched  and  dry  skin  ;  a  frequent  and  hard  pulse  ;  a  white  tongue ; 
thirst ;  nausea  and  vomiting  ;  constipation  of  the  bowels. 

You  are  not  to  look  for  all  these  symptoms  in  every  case,  nor  to  conclude  that 
your  patient  has  not  inflammation  of  the  brain  because  the  phenomena  I  have  been 
enumerating  do  not  all  present  themselves,  or  do  not  take  place  in  any  regular  order 
of  succession. 

In  fact,  we  find,  in  actual  practice,  that  encephalitis  is  apt  to  come  on,  to  commence 
I  mean,  as  far  as  symptoms  are  concerned,  in  three  or  four  different  ways. 

Sometimes  there  is  a  sudden  alteration  of  manner,  and  the  patient,  complaining 
probably  of  his  head,  becomes  all  at  once  and  furiously  delirious  ;  and  fever  is 
lighted  up.  These  are  symptoms  which  cannot  pass  unnoticed,  and  which  imme- 
diately direct  one's  attention  to  the  head.  They  may,  however,  be  fallacious,  as  we 
shall  see  by-and-by. 

In  other  cases  the  first  thing  remarked  is  nausea  and  vomiting :  and  those  symp- 
toms may  soon  cease ;  or  they  may  continue  several  days,  and  even  sometimes 
throughout  the  whole  course  of  the  disease.  Bitter  fluids  are  brought  up,  yellow  or 
green,  and  evidently  containing  a  good  deal  of  bile  ;  and  whatever  is  introduced  into 
the  stomach,  even  a  small  quantity  of  the  most  simple  drink,  is  immediately  rejected. 
With  this  state  of  matters  there  is  generally  much  constipation,  and  the  bowels  refuse 
to  act  except  under  the  stimulus  of  strong  purgatives. 

It  is  important  to  attend  to  these  symptoms  ;  for,  occurring,  as  they  usually  do, 
with  headache,  they  may  easily  deceive  a  person  who  is  not  previously  aware  of 
what  they  may  portend.  If  the  patient  has  not  been  previously  subject  to  sick 
headaches,  and  if  the  epigastrium  and  abdomen  be  natural,  not  tender,  nor  distended, 
as  they  are  apt  to  be  when  the  stomach  itself  is  in  fault,  we  have  the  more  reason  to 
look  narrowly  into  the  case,  and  to  suspect  that  some  serious  mischief  of  which  the 
nausea  is  a  token,  may  be  going  on  in  the  brain.  I  would  observe,  by  the  way, 
that  where  there  is  much  vomiting  of  bile,  persons  are  apt,  both  patients  and  their 
doctors,  to  blame  the  liver,  to  set  down  the  disorder  as  bilious ;  but  you  ought  to  be 
aware,  that  whenever  vomiting  is  often  repeated,  or  long  continued,  bile  is  to  be 
expected  in  the  matters  brought  up :  the  action  of  the  duodenum,  as  well  as  that  of 
the  stomach,  is  inverted  ;  and  the  bile  passes  in  the  wrong  direction.  If  you  have 
ever  suffered  from  sea-sickness,  you  must  know  that  after  the  puking  has  gone  on 
for  a  little  while,  bile  is  constantly  voided. 

Again,  some  cases  of  acute  inflammation  of  the  brain  set  in  neither  with  sudden 
and  great  disturbance  of  the  intellectual  functions,  nor  with  sickness  and  vomiting, 
but  with  a  paroxysm  of  general  convulsion,  such  as  often  ushers  in  an  attack  of  me- 
ningitis. This  symptom,  according  to  Andral,  is  a  much  more  certain  sign  of  cere- 
l)ral  inflammation,  than  the  occurrence  of  active  delirium ;  and  I  quite  agree  with 
him  in  so  thinking. 

It  is  probable  (but  I  speak  conjecturally  only)  that  this  diversity  of  symptoms, 
marking  the  onset  of  encephahtis,  may  depend  upon  the  part  in  which  the  m- 


1 


ENCEPHALITIS.  241 

flammation  begins ;  and  that  it  is  soon  propagated  from  that  part  to  the  whole  of  the 
organ.  I  should  suppose  that  when  nausea  and  vonriiting  are  the  earliest  symptoms, 
the  inflammation  has  taken  its  point  of  departure  in  the  cerebral  pulp ;  in  the  sub- 
stance of  the  brain  ;  and  that  when  the  attack  comes  on  with  a  sudden  fit  of  convul- 
sion, the  inflammation  has  commenced  in  the  pia  mater  or  arachnoid.  This  is  con- 
sonant with  what  we  know  of  inflammation  of  those  parts  when  they  are  separately 
afl^ected.  Again,  it  seems  to  me  presumable  that  the  cases  which  are  characterized 
by  early  and  fierce  delirium  are  cases  in  which  the  inflammatory  action  has  invaded 
the  whole  of  the  encephalon,  substance  and  membranes,  simultaneously.  I  say  I 
offer  these  as  conjectures  of  my  own :  what  it  is  of  importance  for  you  to  remember 
is,  that  inflammation  of  the  brain  does  commence  in  the  three  several  ways  that  I 
have  been  describing. 

There  are  some  cases,  however,  that  cannot  be  brought  within  even  this  general 
rule.  They  begin  in  some  irregular  or  obscure  manner,  or  with  some  unusual  phe- 
nomenon. Andral  states  that  he  has  seen  a  few  striking  instances  of  inflammation 
of  the  brain,  of  w^hich  the  flrst  sign  was  a  sudden  loss  of  the  power  of  speech ;  and 
Dr.  Abercrombie  relates  a  very  remarkable  case  in  which  the  same  thing  happened. 
I  call  it  very  remarkable  both  on  account  of  the  singular  manner  in  which  the  dis- 
ease first  showed  itself,  and  because  it  furnishes  an  example  of  encephalitis  produced 
by  direct  exposure  to  intense  heat  of  the  sun — insolation  ;  an  event  very  uncommon 
in  our  chmate.     It  occurred  in  the  practice  of  a  surgeon  at  Selkirk,  in  Scotland  : — 

"A  young  man,  aged  16,  bathed  twice,  on  the  5th  of  June,  1818,  in  the  river 
Tweed.  After  coming  out  the  second  time  he  lay  down  on  the  bank  and  fell 
asleep,  without  his  hat,  and  with  his  head  exposed  to  the  direct  beams  of  a  hot  sun. 
On  awaking,  he  was  speechless ;  but  walked  home,  and  seemed  to  be  otherwise  in 
good  health.  He  was  bled  and  purged,  and  the  next  day  recovered  his  speech,  but 
lost  it  again  at  intervals  several  times  during  the  three  or  four  following  days.  He 
was  forgetful,  and  his  look  was  dull  and  heavy  :  he  made  little  complaint,  but  when 
closely  questioned  said  he  had  a  dull  uneasiness  at  the  back  of  his  head.  In  a  few 
days  more  he  had  squinting  and  double  vision,  and  a  very  obstinate  state  of  bowels, 
and  his  pulse  was  GO.  After  further  bleeding  the  pulse  rose  to  86 ;  but  he  sank 
gradually  into  coma,  and  died  on  the  30th. 

The  substance  of  the  brain  in  general  was  found  highly  vascular,  and  a  very  con- 
siderable extent  of  it  was  in  a  state  of  softening  mixed  with  suppuration.  The  ven- 
tricles were  distended  with  fluid,  and  the  membranes  in  many  places  were  much 
thickened.  One  very  curious  circumstance  (affording  perhaps  some  explanation  of 
the  readiness  with  which  the  inflammation  was  produced)  was,  that  the  cranium  was 
of  very  unequal  thickness  at  its  upper  part ;  in  one  spot,  as  big  as  a  sixpence,  it  was 
as  thin  as  writing-paper,  and  transparent. 

However,  the  phenomena  which  I  mentioned  at  first  constitute  the  common  and 
ordinary  symptoms  of  acute  inflammation  of  the  brain  and  its  membranes.  They 
continue  for  a  variable  period  ;  from  twelve  hours  to  two  days,  or  more  ;  and  then 
they  are  succeeded  by  others,  which  characterize  the  second  stage  of  the  complaint, 
or  the  period  of  collapse,  as  it  is  called.  These  result,  I  apprehend,  from  the  events 
and  products  of  the  inflammatory  action ;  the  violence  of  which  is  over  or  abated. 
The  patient  ceases  to  complain  of  headache  ;  instead  of  being  excited  or  wildly  deli 
rious,  he  mutters  indistinctly,  and  falls  into  a  state  of  stupor,  from  which  it  is  difficult. 
and  at  length  impossible,  to  rouse  him.  His  vision  and  hearing  are  no  longer  pain- 
fully acute,  but  dull,  or  perverted ;  strabismus  and  double  vision  are  not  uncom 
mon  ;  and  the  pupil,  from  being  contracted  to  the  size  of  a  pin's  head,  becomes  first 
oscillating,  then  widely  dilated,  and  ultimately  motionless.  The  patient  is  not  shalcen, 
at  this  period,  with  violent  convulsions ;  but  twitchings  of  his  muscles,  and  startings 
of  their  tendons  come  on,  and  some  of  his  limbs  are  agitated  with  tremors,  or  become 
powerless  and  palsied  ;  the  countenance  is  ghastly  and  cadaverous ;  cold  sweats 
break  out ;  the  sphincters  relax :  at  length  the  coma  becomes  profound,  and  life 
ceases. 

The  disease,  when  it  proves  fatal,  as  it  too  often  does,  mostly  runs  a  rapid  course. 
It  may  kill  in  as  short  a  time  as  twenty-four  or  even  twelve  ^ours  •  «^r  the  natietu 
16 


242  DISEASES    OF    THE    BRAIN 

may  struggle  on  for  two  or  three  weeks.  The  morbid  appearances  met  with  in  the 
dead  body  are  very  various.  Serous  or  puriform  effusion  into  the  ventricles,  and 
into  the  meshes  of  the  pia  mater ;  layers  of  coagulable  lymph  between  that  mem- 
brane and  the  arachnoid ;  softening  of  the  cerebral  substance,  Avith  pus  infiliered 
into  the  softened  parts;  or  great  vascularity,  shown  by  a  pink  or  purplish  molding 
of  its  cut  surface,  giving  it  a  stained  appearance. 

Let  us  next  consider  the  treatment  required  for  this  frightful  disorder. 

It  is  quite  plain  that  in  an  organ  so  essential  to  life,  and  of  such  dehcate  organiza- 
tion as  the  brain,  and  in  which  changes  so  irreparable  in  their  nature  as  many  of 
those  I  have  just  enumerated,  so  readily  take  place  under  acute  inflammation,  we 
cannot  hope  to  be  of  much  service  unless  we  see  and  treat  the  case  at  an  early 
period.  On  this  account  it  becomes  exceedingly  important  to  recognize  the  nature 
of  the  disease,  at  its  very  commencement ;  and,  therefore,  I  have  taken  pains  to 
point  out  to  you  the  various  forms  which  it  may  assume,  while  it  is  yet  within  the 
reach  of  remedial  measures. 

The  principal  of  those  measures  are  blood-letting,  purging,  and  the  application 
of  cold  to  the  head.  All  the  particulars  of  the  antiphlogistic  regimen  are  to  be 
rigidl}^  observed  ;  the  patient  should  be  kept  as  much  as  possible  in  silence,  and 
darkness,  with  his  head  high,  and  on  a  firm  pillow.  And  the  antiphlogistic  reme- 
dies are  to  be  employed  with  decision  and  energy. 

With  respect  to  bleeding  I  can  only  repeat  what  I  have  said  before :  the  blood 
should  be  drawn  in  a  full  stream,  and  suffered  to  flow  till  some  decided  impression 
is  made  upon  the  pulse ;  or  until  syncope  occurs,  or  is  evidently  at  hand.  After 
the  patient  has  rallied  a  little,  blood  should  be  taken  hy  cupping  or  leeches  from  the 
back  of  the  neck,  or  the  temples,  or  the  mastoid  processes ;  and  these  depletory 
measures  must  be  repeated  according  to  the  violence  or  continuance  of  the  symp- 
toms which  first  demanded  them. 

The  application  of  cold  to  the  head  is  a  remedy  of  great  importance  in  this  disease. 
The  head  must  be  first  shaved,  and  the  mere  removal  of  the  hair  is  sometimes  fol- 
lowed by  a  manifest  abatement  of  some  of  the  most  urgent  symptoms ;  of  the  pain, 
for  example,  and  of  the  delirium.  In  cases  such  as  I  am  now  supposing,  it  will  not 
be  enough  to  apply  wetted  cloths  to  the  head :  the  application  must  be  colder  than 
the  ordinary  temperature  of  the  cold  water ;  and  it  may  be  made  colder  by  ice ;  and 
the  best  way  to  ensure  a  permanent  depression  of  the  superficial  heat  is  to  put  some 
pounded  ice  with  a  little  water  into  a  thin  and  flexible  bladder,  and  to  lay  it  on  the 
patient's  head :  there  should  not  be  too  much  ice,  or  its  weight  may  be  injurious. 
This  is  generally  very  grateful  and  pleasant  to  the  feelings  of  the  patient ;  and  we 
often  have  the  satisfaction  of  perceiving  that,  wnth  the  reduction  of  the  external  heat 
of  the  head,  there  is  also  an  evident  mitigation  of  the  violent  symptoms ;  the  agi- 
tation and  delirium  are  calmed,  and  the  patient  sleeps,  or  recovers  his  senses. 

Another  excellent  and  most  powerful  method  of  applying  cold,  is  by  pouring  cold 
water  in  a  slender  stream  upon  the  vertex  of  the  head,  until  it  produces  some  marked 
effect.  Of  course  this  as  well  as  all  other  strong  measures,  must  be  adopted  with 
great  caution,  and  its  influence  closely  watched :  I  mean  it  is  not  to  be  left  to  the 
discretion,  or  indiscretion,  of  domestics  and  nurses.  Dr.  Abercrombie  tells  us  that 
he  has  sfen  a  strong  rnan,  submitted  to  the  operation  of  this  cold  douche,  "thrown 
in  a  very  few  mmutes  into  a  state  approaching  to  asphyxia,  Avho  immediately  before 
had  been  in  the  highest  state  of  maniacal  excitement,  with  morbid  increase  oi 
strength,  defeating  every  attempt  of  four  or  five  men  to  restrain  him."  Of  the 
efTect  of  this  measure  in  a  somewhat  diffl'rent  morbid  condition,  he  gives  an 
instance,  which  I  will  quote,  because  it  shows,  in  the  first  place,  the  striking  power 
of  the  remedy  ;  and,  secondly,  the  simple  mode  of  applying  it.  A  strong  plethoric 
:hild,  five  years  old,  after  being  for  one  day  feverish,  oppressed,  and  restless,  fell 
rather  suddenly  into  a  state  of  perfect  coma.  She  had  been  in  that  state  about  an 
hour  when  Dr.  Abercrombie  saw  her.  She  lay  stretched  on  her  back  motionless, 
nnd  completely  insensible;  her  face  flushed  and  turgid.  She  was  raised  into  a 
Filling  posture  and  a  basin  being  held  under  her  chin,  a  stream  of  cold  water  was 


ENCEPHALITIS.  243 

directed  against  the  crown  of  her  head.  In  a  few  minutes,  or  rather  seconds,  shp. 
was  completely  recovered  ;  and  the  next  day  was  in  her  usual  health. 

This  measure  also  is  to  be  repeated,  according  to  the  circumstances  of  the  case. 

Some  persons  recommend  that  a  constant  dripping  of  cold  water  upon  the  patient's 
shaven  head  should  be  kept  up.  This  may  easily  enough  be  managed  by  means  of 
a  sponge  and  funnel  placed  a  little  above  the  head.  Andral  mentions  his  attending 
with  another  physician  (M.  Recamier)  a  young  man  who  laboured  under  all  the 
symptoms  of  acute  inflammation  of  the  brain.  Cold  water  was  made  to  drop  slowly 
upon  his  head,  and  complete  recovery  took  place,  although  no  other  active  treatment 
of  any  kind  was  adopted. 

In  strongly  recommending  this  efficient  remedy  to  your  notice,  you  will  not  un- 
derstand me  to  advise  that  it  should  supersede  the  use  of  copious  blood-letting  ;  i* 
is  to  be  employed  as  an  auxiliary  to  the  lancet ;  not  as  a  substitute  for  it. 

The  third  remedy  which  I  named,  that  is  to  say,  purging,  is  also  of  great  im- 
portance and  efficacy.  But  it  must  be  hard  purging.  There  is  a  great  tendency 
to  obstinate  constipation  in  most  cases ;  and  this  must  be  overcome,  and  free  and 
frequent  evacuations  from  the  bowels  obtained ;  five  grains  of  calomel  and  fifteen 
of  jalap  should  be  followed  in  three  or  four  hours  by  a  strong  black  dose  ;  and 
after  that  I  should  give,  in  such  cases,  three  or  four  grains  of  calomel  every  four 
hours,  and  repeat  the  black  dose  at  least  every  morning,  until  the  symptoms  gave 
way.  If  the  mercury  thus  exhibited  affect  the  gums,  so  much  the  better ;  bat 
we  must  not,  in  this  disease,  combine  it  with  opium,  to  prevent  its  passing  ofTby  the 
boAvels. 

Dr.  Abercrombie  uses  this  strong  language  in  reference  to  the  value  of  purga- 
tive medicines  in  acute  inflammation  of  the  brain: — "In  all  the  forms  of  the  dis- 
ease, active  purging  appears  to  be  the  remedy  from  which  we  find  the  most 
satisfactory  results ;  and  although  blood-letting  is  never  to  be  neglected  in  the  earlier 
stages  of  the  disease,  my  own  experience  is  that  more  recoveries  from  head  affec- 
tions of  the  most  alarming  aspect  take  place  under  the  use  of  very  strong  purging 
than  under  any  other  mode  of  treatment.  In  most  of  these  cases,  indeed,  full  and 
repeated  bleeding  had  been  previously  employed,  but  without  any  apparent  effect  in 
arresting  the  symptoms."  He  has  found  the  croton  oil  the  most  convenient  medi- 
cine for  this  purpose. 

Dr.  Abercrombie  is  disposed  to  regard  mercury  as  being  useful  in  affections  of 
the  brain,  chiefly  in  virtue  of  its  purgative  operation:  and  the  opinions  of  a  phy- 
sician of  his  large  experience,  and  observing  mind,  must  and  ought  to  have  great 
weight.  But  I  must  not  conceal  from  you  my  own  persuasion  that,  in  the  early 
periods  of  acute  inflammation  of  the  encephalon  (and  it  is  of  the  early  periods 
that  I  have  hitherto  been  speaking),  if  the  mercury  comes  in  a  short  time  to  produce 
its  specific  influence  upon  the  gums,  a  great  change  for  the  better  will  often  be  per- 
ceived. Such  is  the  result  of  my  own  observation.  Recollect,  however,  that  you 
are  not  to  give  calomel  with  the  direct  object  of  affecting  the  gums,  but  as  part  of 
the  purgative  plan,  and  j^ou  take  the  chance  of  its  specific  effect.  You  must  not 
combine  opium  with  it,  for  two  reasons ;  first,  you  would  thereby  shut  up  the 
bowels,  and  deprive  yourself  of  the  use  of  one  of  your  best  weapons  ;  and,  secondly, 
you  would  incur  the  risk  of  augmenting  and  perplexing  your  patient's  head  symp- 
toms, and  of  puzzling  yourself;  since  you  would  not  be  able  to  determine  how  much 
of  the  coma  that  ensued  was  owing  to  the  progress  of  the  disease,  how  much  to  your 
remedy 

When  the  second  order  of  symptoms  have  arrived,  those  which  are  included 
under  the  general  phrase  of  collapse,  and  which  commonly  result,  I  fancy,  rather 
from  the  products  of  the  inflammation  than  from  the  inflammation  itself;  from 
softening,  that  is,  and  from  pressure  exerted  by  efflised  serum,  or  lymph ;  when  this 
order  of  symptoms  make  their  appearance,  I  believe  the  time  for  doing  much  good 
bv  active  bleeding  has  gone  by.  If,  however,  blood-letting  has  not  yet  been  em- 
ployed, and  especially  if  the  pulse  continue  hard,  whether  blood  has  been  already 
abstracted  or  not,  it  will  be  right  to  give  the  patient  the  chance  of  that  remedy.  Of 
the  propriety  of  doing  so,  take  the  following  illustration : — "  A  girl,  aged  eleven,  nnd 


244  DISEASES   OF   THE   BRAIN. 

violent  headache  and  vomiting,  with  great  obstinacy  of  the  bowels ;  and  these  symp- 
toms were  followed  by  dilated  pupils,  and  a  degree  of  stupor  bordering  upon  perfect 
coma;  pulse  130.  She  had  been  ill  five  or  six  days;  purgatives,  blistering,  and 
mercury  to  saHvation,  had  been  employed  without  benefit.  One  bleeding  from  the 
arm  gave  an  immediate  turn  to  this  case,  the  headache  was  relieved,  the  pulse  came 
down,  the  vomiting  ceased,  the  bowels  were  freely  acted  upon  by  the  medicines 
which  they  had  formerly  resisted,  and  in  a  few  days  she  was  quite  well."  (Aber- 
CROMBiE.)  I  must  recite  one  other  case — from  among  many  which  go  to  the  same 
effect — to  show  the  occasional  influence  of  hard  purging.  "  A  young  man  who 
had  had  cough  and  dyspnoea,  and  been  bled  for  those  symptoms,  appeared  conva- 
lescent. One  evening  he  became  affected  with  headache,  and  some  vomiting. 
About  midnight,  having  got  out  of  bed  to  go  to  stool,  he  fell  down  in  a  state  of  vio- 
lent and  general  convulsion.  The  convulsion  returned  during  the  night  six  or  seven 
times  with  such  violence  that  one  of  the  paroxysms  continued  without  intermission 
for  an  hour.  The  pulse  during  the  night,  varied  from  60  to  120."  (I  should  have 
mentioned  before  this  great  and  rapid  fluctuation  of  the  pulse  in  respect  to  its  fre- 
quency, as  being  a  very  common  circumstance  and  sign,  in  inflammatory  affections  of 
the  brain.)  "  At  first  it  was  found  impossible  to  bleed  him,  on  account  of  the  vio- 
lence of  the  convulsions ;  but  about  seven  in  the  morning  a  full  bleeding  was  ob- 
tained, after  which  the  convulsions  ceased,  except  some  slighter  attacks  during  the  day^ 
which  appeared  to  be  arrested  by  pouring  cold  water  over  his  head.  The  next  day  he 
was  oppressed  ;  with  occasional  tremors  of  the  limbs,  and  some  vomiting,  and  he  had 
one  or  two  threatenings  of  convulsion.  He  took  repeated  doses  of  active  purga- 
tives with  little  effect ;  and  on  the  following  morning  he  appeared  to  be  sinking  into 
a  state  of  perfect  coma,  with  a  pulse  at  50.  Croton  oil  was  now  given,  which 
operated  powerfully  seven  or  eight  times.  He  passed  a  good  night ;  and  the  day 
afterwards  was  free  from  complaint." 

Having  this  evidence  of  the  separate  efficacy  of  the  three  remedies — blood-letting 
strong  purgatives,  and  the  local  apphcation  of  cold  to  the  head  —  we  have  much  en- 
couragement to  put  them  into  combined  operation  in  these  very  serious  cases,  espe- 
cially when  Ave  have  the  opportunity  of  using  them  at  an  early  period.  ShoiiJd  the 
disorder  happily  yield  to  these  measures,  great  care  will  long  be  required  on  your 
part,  and  great  prudence  on  the  part  of  the  patient  and  his  friends,  lest  the  recent 
mischief  should  rekindle.  A  relapse  is  even  more  perilous  than  the  first  assault  of 
the  disease.  Such  prudence  and  care  will  consist  chiefly  in  the  avoidance  anc 
denial  of  all  that  might  excite  and  disturb  the  brain;  whether  it  be  a  premature 
return  to  animal  food  ;  or  indiscreet  and  fatiguing  interviews  and  conversations ;  or 
the  too  early  resumption  of  the  cares  and  concerns  of  business. 

Are  we  to  employ  blisters  in  this  disease  ?  Not  in  the  outset,  during  the  period 
of  excitement.  They  only  add  to  the  irritation,  and  make  matters  worse.  And 
especially  you  should  avoid  putting  them,  as  many  are  apt  to  do,  upon  the  head 
itsell",  at  that  stage  of  the  disease.  We  should  not  suppose,  a  priori,  that  they  could 
then,  and  in  that  place,  have  any  beneficial  effect.  They  cannot  divert  the  blood 
from  the  inflamed  part ;  but  they  may  attract  it  towards  the  encephalon.  If  they 
could  be  expected  to  do  any  good  at  all,  it  would  be  when  they  are  placed  upon  the 
feet  or  legs.  But  this  kind  of  revulsion  is  better  accomplished  by  means  of  mustard 
poultices,  or  fomentations  with  hot  water,  which  are  often  of  much  apparent  service, 
in  addition  to  the  measures  already  spoken  of.  Experience  confirms  what  reason 
teaches  us  to  look  for  in  this  matter. 

When,  however,  the  patient  had  sunk  into  a  state  of  coma,  he  has  sometimes,  in 
my  experience,  emerged  from  that  condition  after  a  cap  of  bhstering  plaster  has 
been  put  upon  his  head.  It  is  only  when  the  violent  symptoms  of  excitement  have 
abated  that  I  can  venture  to  advise  you  to  employ  blisters:  they  may  then  be  applied 
to  the  nape  of  the  neck,  or  behind  the  ears,  or  to  the  head  itself. 

The  symptoms  which  I  enumerated  as  marking  the  period  of  collapse  or  sinking, 
are  fearful  symptoms ;  but  the  conditions  on  which  they  depend  are  not,  necessarily, 
hopeless  conditions.  These  symptoms  do  not  always  procped  from  fatal  disorganiza- 
L'cn  of  the  bram,  but  sometimes  (there  is  reason  to  beUeve)  from  simple  exhaustion 


ENCEPHALITIS.  245 

of  the  nervous  power.  And  this  is  a  point  of  critical  importance.  Patients  appa- 
rently moribund  are  occasionally  saved  by  the  judicious  administration  of  stimu- 
lants and  restoratives;  of  ammonia,  Hoffman's  anodyne,  beef-tea,  wine,  and,  it  may 
be,  of  well-timed  opiates.  This  plan  of  treatment  you  must  therefore  cautiously  try, 
when  an  extreme  degree  of  collapse  occurs.  If  the  structure  of  the  brain  be  already 
seriously  injured,  and  the  disease  irretrievably  mortal,  no  harm  can  be  done ;  while 
in  doubtful  cases,  and  when  the  symptoms  resuh  from  mere  depression  of  the  vital 
powers,  the  patient  may  be  rescued ;  and  this  chance  in  his  disease  must  not  be 
thrown  away. 

Do  you  ask  whether  there  be  any  mode  of  discriminating  these  opposite  condi- 
tions, one  of  which  is  within,  and  the  other  beyond,  the  range  of  possible  recovery  ? 
I  believe  there  is.  If  the  tendency  to  death  by  coma  be  strong,  the  prospect  is  very 
discouraging :  if,  on  the  other  hand,  the  symptoms  that  mark  the  mode  of  dying  by 
asthenia  predominate,  you  may  hope  to  push  the  patient  through.  But  to  succeed, 
you  must  watch  him  hour  by  hour.  Pallor,  a  feeble  and  flying  pulse,  extreme  de- 
bility and  tremors,  coldness  of  the  extremities,  a  want  of  power  to  respond  to  exter- 
nal impressions ;  these  are  alarming,  but  not  absolutely  desperate  symptoms,  espe- 
cially if  the  mental  faculties  remain.  Whereas  profound  stupor,  partial  palsy, 
profuse  sweats,  are  of  the  worst  omen ;  yet  even  these  do  not  preclude  the  trial, 
together  with  blistering  the  head,  of  internal  stimuli ;  and  no  other  plan  affords  even 
a  gleam  of  hope. 

There  is  just  one  caution  that  1  wish  to  mention  before  I  leave  the  subject  of  acute 
encephahtis  ;  and  it  apphes  to  all  cases  of  coma  and  insensibility,  and  especially  when 
there  is  any  paralysis  mixed  with  the  coma :  it  is,  that  you  should  daily  ascertain 
that  the  bladder  is  emptied.  Always  make  the  attendants  show  you  the  urine  that 
has  been  passed ;  and  lay  your  hand  upon  the  hypogastric  region,  and  try  whether 
there  is  any  undue  hardness  or  prominence  there,  produced  by  the  distended  blad- 
der. I  shall  revert  to  this  matter  more  particularly  at  some  future  time ;  and  I  con- 
tent myself  with  merely  suggesting  its  importance  to  you  now,  in  all  cases  of  head 
affection.  If  the  patient  does  not  or  cannot  empty  his  bladder,  of  course  it  must  be 
emptied  for  him,  by  means  of  a  catheter. 

It  would  seem  perhaps  the  most  natural  arrangement  if  I  next  proceeded  to  speak 
of  cerebral  inflammations  which  are  chronic,  or  partial.  These  forms  of  disease  are 
more  common,  in  adults,  than  acute  and  general  encephahtis.  I  shall  be  obliged  also 
to  treat,  separately,  of  inflammation  of  the  brain  as  it  is  modified  by  its  occurrence 
in  young  children, — of  what  is  called  acute  hydrocephalus.  But  before  I  touch  upon 
any  of  these,  I  am  desirous  to  bring  under  your  notice  at  once  a  very  singular  and 
extremely  interesting  complaint,  which  is  not,  I  am  persuaded,  in  its  essential  nature, 
inflammatory,  but  which  may  easily  be  mistaken,  and  has  over  and  over  again  been 
mistaken,  for  acute  inflammation  of  the  brain  and  its  membranes,  with  the  consider- 
ation of  which  we  have  just  been  occupied.  The  mistake  is  the  more  serious, 
because  the  remedies  I  have  been  recommending  for  encephalitis,  and  especially 
blood-letting,  not  only  are  not  required,  but  are  in  most  cases  positively  injurious,  in 
the  disorder  of  which  I  am  now  about  to  speak :  and  which  is  best  known  under  the 
appellation  of  delirium  tremens.  Nay,  this  affection  of  the  nervous  system  may 
actually  be  brought  on,  in  a  predisposed  subject,  by  the  abstraction  of  blood.  I  go 
apparently  out  of  my  way  in  taking  notice  of  this  complaint  now,  but  I  do  so  that 
I  may  have  the  opportunity  of  contrasting  it  with  encephalitis,  while  the  phenomena 
of  the  latter  disease  are  fresh  in  your  memory.  It  certainly  resembles  it  also  in 
many  respects :  and  it  has  been  regarded  as  an  inflammatory  disorder  by  some 
excellent  pathologists. 

The  symptoms  which  mark  a  decided  attack  of  delirium  tremens,  and  which 
have  sometimes  been  found  so  equivocal,  are  very  striking.  You  will  be  sum- 
moned to  a  man  who  is  supposed  to  be  mad,  or  to  have  brain  fever.  You  find  him 
with  a  red  face,  perhaps,  and  injected  eyes,  talking  wildly  and  incessantly,  fidgetinj/ 
with  his  hands,  affected  often  with  tremors  of  the  limbs,  havincr  a  rapid  pulse,  and 
oathed  in  sweat.    Now  it  is  very  natural  that  a  person  not  on  his  guard  should  look 

v3 


S4$  DISEASES    OF    THE    BRAIN. 

upon  these  symptoms  as  indicatino^  inflammation  within  the  head.  But  if  you  look 
closely  into  the  matter,  you  will  find  in  the  state  of  the  patient,  and  in  his  history, 
some  things  very  peculiar.  The  deHrium  you  will  generally  find  to  be,  not  a  fierce 
or  mischievous  delirium,  but  a  bu>iy  delirium :  he  does  whatever  you  desire  him  to 
do,  but  he  does  it  in  a  hurried  manner,  with  a  sort  of  anxiety  to  perform  it  properly. 
During  the  approach  of  the  malady,  while  he  is  yet  able  to  go  about,  he  manifests 
great  impatience  of  any  interference,  or  advice,  or  assistance,  in  his  ordinary  duties, 
which  he  sets  about  in  a  bustling  and  blundering  manner.  His  loquacity  is  extreme, 
and  he  refers  to  matters  that  are  not  present  before  him :  he  is  not  altogether  inattentive 
to  the  objects  and  proceedings  that  are  going  on  around  him,  but  his  mind  wanders 
away  to  other  subjects.  There  is  an  odd  mixture  of  the  real  and  the  ideal  in  his 
thoughts  and  language.  Sometimes  he  is  ver}^  suspicious  that  those  who  are  about 
him  intend  him  some  injury ;  or  that  he  is  surrounded  by  enemies.  You  will  find 
also  that  he  does  not  sleep ;  that  he  has  not  slept  perhaps  for  several  nights,  but 
been  restless  and  rambhng ;  and  you  will  generally  learn  that  he  has  been  habitually 
intemperate,  or  subject  to  some  great  source  of  care,  or  anxiety,  or  excitement :  and 
in  many  cases  he  has  recently  been  somehow  or  other  debarred  from  his  customary 
stfmulus.  In  addition  to  these  points  in  his  history,  you  will  frequently  be  told  that 
having  been  unwell,  first  he  has  been  kept  upon  low  diet,  and  then,  as  the  delirium 
came  on,  he  has  been  freely  bled  ;  and  that  he  has  been  none  the  better,  but  com- 
monly the  worse  for  the  bleeding.  When  you  gather  such  particulars  as  these 
from  his  friends  (for  upon  his  own  statements  you  cannot  place  any  reliance),  and 
when  you  find  the  delirium  to  have  the  characters  I  have  been  attempting  to  do- 
Bcribe,  and  especially  when  there  has  been  obstinate  watchfulness,  and  the  tongue 
is  moist,  and  the  skin  is  sweating,  you  may  be  pretty  certain  that  j'our  patient  is 
afTected,  not  with  inflammation  of  the  brain,  but  with  dehrium  tremens ;  and  that  if 
you  bleed  him  further,  you  will  make  him  worse. 

But  what  are  you  to  do  under  such  a  fearful  state  of  things?  Why  the  great  indi- 
cation is  to  procure  sleep ;  and  the  remedy  which,  in  nine  instances  out  of  ten,  you 
will  find  successful,  is  opium.  The  beneficial  effects  of  this  drug,  in  tolerably 
favourable  cases  of  delirium  tremens,  are  really  surprising.  I  will  give  you  an 
example  or  two,  which  will  be  more  instructive  than  any  abstract  description. 

In  the  year  1831  I  was  requested,  by  a  most  respectable  practitioner  in  this  town, 
to  visit  a  patient  of  his  whom  he  reported  to  have  had  phrenitis,  for  which  he  had 
been  freely  bled,  cupped  from  the  back  of  the  neck  and  purged  ;  and  Avho,  he 
believed,  was  now  rapidly  sinking,  and  not  likely  to  survive  many  hours.  I  found 
the  patient,  a  middle-aged  man,  with  a  red  face,  ferrety  eyes,  a  frequent  pulse, 
bathed  in  perspiration,  busy  with  his  hands,  which  trembled  a  htlle,  and  talking 
much  and  incoherently.  He  was  particular!}'  anxious  that  his  lecfs  should  not  be 
scarified,  told  me  he  was  willing  to  do  any  thing  I  pleased,  if  I  would  not  scarify  his 
legs,  nor  let  any  one  else  scarify  them.  There  was  nothing  the  matter  with  his  legs, 
nor  had  it  entered  any  body's  head  but  his  own,  that  they  wanted  scarifying.  He 
had  not  slept  for  several  nights.  He  had  been  intemperate,  especially  of  late,  drink- 
ing a  good  deal ;  and  somewhat  anxious  about  his  aflairs  :  he  was  a  builder. 

His  former  historj'^  was  not  very  promising.  He  had  brought  up  a  good  deal  of 
blood  a  few  months  before,  and  some  years  previously  he  had  had  jaundice ;  latterly 
he  had  been  troubled  with  indigestion. 

I  saw  him  in  the  afternoon,  and  prescribed  one-third  of  a  grain  of  morphia  :  in  the 
evening  he  was  just  in  the  same  state.  I  then  directed  half  a  drachm  of  laudanum 
to  be  given  immediately,  and  twenty  drops  every  two  hours  afterwards,  till  he  slept. 
I  said  to  the  gentleman  who  had  called  me  to  the  case,  that  I  thought  it  very  likely 
our  patient  might  be  well  the  next  day ;  he  smiled  and  shook  his  head.  I  was 
obliged  to  leave  London,  early  the  next  morning,  for  two  or  three  days ;  on  my 
return,  I  learned  from  the  medical  man  that  the  patient  took  five  doses  of  the  laud- 
anum, after  which  he  fell  asleep,  and  slept  soundly,  and  for  a  long  time,  and  then 
awoke  (to  his  attendant's  extreme  surprise  and  satisfaction)  sane,  and  well. 

I  was  asked  by  the  apothecary  of  the  Middlesex  Hospital  to  see  a  publican  in 
inat  neighbourhood.     I  found  a  large  strong  man  between  30  and  40  years  of  age 


DELIRIUM   TREMENS.  247 

He  had  been  Avithout  sleep  for  several  nights,  somewhat  incoherent,  and  (what  is 
not  usual  in  such  cases)  violent,  threatening  and  striking  those  about  him  because 
they  refused  him  access  to  strong  drink.  He  was  joint  proprietor  with  another  in  a 
gin-shop,  and  for  some  time  previously  he  had  been  a  sot,  and  daily  muddled  with 
drink.  He  told  me  he  was  quite  well;  there  was  not  much  tremor.  I  found  that 
the  object  of  his  partner  and  relations  in  sending  for  me  was  that  I  might  sanction 
his  removal  to  St.  Luke's,  for  his  strength  made  him  altogether  unmanageable,  and 
his  insane  and  extraordinary  conduct  was  hurting  the  business  of  the  house.  I 
declined  to  take  any  part  in  consigning  him  to  a  mad-house,  and  recommended 
morphia.  After  one  full  dose  he  soon  slept ;  and  the  next  day  he  was  quite  rational, 
and  comparatively  well. 

These  are  the  broad  outhnes  of  dehrium  tremens  ;  there  are  many  other  features 
wanted  to  complete  the  portrait  of  the  disease,  which  I  shall  endeavour  to  paint  at 
our  next  meeting. 


LECTURE  XXIV. 

Delinum  Tremens,  concluded.     Chronic  Inflammation  of  the  Brain.     Softening, 
Suppuration,  Mscess,  Induration,  Tumours  in  the  Brain. 

I  DREAV  a  rude  outline,  yesterday,  of  that  singular  and  interesting  malady  usually 
denominated  delirium  tremens.  The  disease  is  very  common  in  this  country ;  for 
its  causes  are  in  common  and  powerful  operation.  You  will  meet  with  it  in  every 
walk  of  life :  and  you  will  be  almost  sure  to  witness  several  examples  of  it  during 
the  course  of  every  year,  in  any  of  our  metropolitan  hospitals.  It  is  not  a  chronic 
or  vague  complaint,  likely  to  be  treated  with  placebos,  or  by  waiting  upon  nature. 
Active  measures  are  pretty  certain  to  be  adopted ;  and,  in  many  cases,  one  plan  of 
treatment,  vigorously  pursued,  will  hurry  the  patient  to  his  grave ;  another  plan 
will  restore  him  to  health  with  an  almost  magical  celerity.  It  certainly  bears  a 
strong  resemblance  to  that  most  formidable  disease,  inflammation  of  the  brain  and  its 
membranes ;  but  the  great  remedy  for  encephalitis  acts  like  a  poison  in  pure  deli- 
rium tremens  ;  and  the  drug,  by  the  timely  and  careful  administration  of  which  we 
can  often  promise  a  speedy  cure  in  dehrium  tremens,  is  one  which  we  must  care- 
fully avoid,  in  the  earlier  treatment,  at  least,  of  encephalitis.  Accuracy  of  diagnosis, 
therefore,  between  these  different  disorders,  with  similar  outward  signals,  becomes 
of  the  very  highest  importance. 

Delirium — tremens. — There  is  delirium  always  ;  and  there  is  generally,  but  not 
always,  tremor.  The  name  is  a  good  enough  name,  in  my  humble  opinion ;  yet  it 
has  been  found  fault  with,  because  the  trembling  is  not  in  all  cases  present;  and 
some  have,  therefore,  christened  it  delirium  e  potu,  or  delirium  ebriositatis :  but 
these  terms  are  open  to  just  the  same  objection  as  the  other;  for  though  the  disorder 
is  most  commonly  connected  with  intemperate  habits,  that  is  not  always  the  case. 
One  very  curious  fault  has  been  discovered  in  the  name :  it  is  said  that  the  delirium 
cannot  tremble ;  and,  therefore,  that  it  is  better  to  say,  delirium  cum  tremore,  or 
tremcfaciens :  and  you  would  hardly  suppose  it,  but  there  has  been  a  sort  of  conten- 
tion for  the  honour  of  thus  mending  the  nomenclature  of  this  disease.  But  they  w^ho 
do  object  to  delirium  tremens  appear  to  see  no  harm  in  delirium  ferox  ;  whereas  it 
is  just  as  incorrect  to  say  delirium  is  fierce,  as  to  say  that  it  trembles:  it  is  the 
patient  who  is  furious,  even  as  it  is  the  patient  who  trembles  ;  and  all  this  dispute 
about  a  name  is  mere  trifling.  It  matters  not  what  we  call  a  disease,  so  that  the 
name  conveys  no  erroneous  theory  as  to  its  nature  or  treatment.  No  such  source 
of  error  attaches  itself  to  the  term  dehrium  trenjens :  and,  therefore,  if  it  be  only  ic 
avoid  the  inconvenience  of  change,  we  will  adhere  to  that  term. 

Recollect  that  the  strong  features  of  the  complaint  are  sleeplessness ;  a  busy,  but 
not  angry  or  violent  delirium ;  constant  chattering ;  trembling  of  the  hands,  and  an 


248  DELIRIUM   TREMENS. 

eager  and  fidgety  employment  of  them.  To  these  are  added  other  symptoms  which, 
though  they  are  not  so  calculated  to  strike  a  looker-on,  are  of  not  less  importance, 
masmuch  as  they  help  to  establish  the  diagnosis.  The  tongue  is  moist  and  creamy ; 
ihe  pulse,  though  frequent,  is  soft;  the  skin  is  perspiring,  and  most  commonly  the 
patient  is  drenched  in  sweat.  The  sweat  is  usually  described  as  having  an  offensive 
or  a  peculiar  smell :  I  cannot  say  that  I  have  observed  it  to  be  so.  The  face  also  is 
said  to  be  pale ;  but  that,  I  know,  is  not  always  the  case,  and  therefore  this  point 
cannot  be  rehed  upon  as  a  distinguishing  circumstance.  In  one  of  the  instances 
which  I  related  in  the  last  lecture,  the  face  was  flushed,  and  the  eyes  red  and  ferrety. 

Let  me  remind  you,  in  a  few  words,  of  the  peculiar  characters  of  the  delirium. 
If  you  question  the  patient  about  his  disease,  he  answers  quite  to  the  purpose  ;  de- 
scribes, in  an  agitated  manner,  his  feelings,  puts  out  his  tongue,  and  does  whatever 
you  bid  him :  but  immediately  afterwards  he  is  Avandering  from  the  scene  around 
him  to  some  other  that  exists  only  in  his  imagination.  Generall}'-  his  thoughts  appear 
to  be  distressful  and  anxious  ;  he  is  giving  orders  that  relate  to  his  business  to  per- 
sons who  are  absent ;  or  he  is  devising  plans  to  escape  from  some  imaginary  enemy : 
he  fancies  that  rats,  mice,  or  other  reptiles,  are  running  over  his  bed,  or  that  strangers 
are  in  his  room.  He  looks  suspiciously  behind  the  curtain,  or  under  his  pillow,  and 
he  is  perpetually  wanting  to  get  out  of  bed ;  but  he  is  readily  induced  to  lie  down 
again.  It  is  very  seldom  that  he  meditates  harm,  either  to  himself  or  to  others  ;  there 
is  rather  a  mixture  of  cowardice  and  dread  with  the  delirium. 

All  the  points  that  I  have  been  mentioning  require  to  be  investigated  in  every  case 
of  this  nature  :  and  an  inquiry  into  the  previous  history  of  the  patient,  into  what  the 
French  call  the  commemorative  symptoms,  is  equally  important.  In  a  large  majority 
of  instances  you  w^ill  find  that  he  has  been  an  habitual  drunkard  ;  and  very  frequently 
that  from  some  reason  or  other  this  habitual  stimulus  has  been  diminished  or  taken 
away.  Some  accidental  illness  has  befallen  him,  and  he  has  been  restricted  to  low 
diet,  and,  as  a  sailor  would  say,  "his  grog  has  been  stopped."  When,  with  symp- 
toms such  as  I  described  just  now,  you  hear  a  history  of  this  kind,  you  may  be 
satisfied  that  the  disease  is  not  inflammation  of  the  brain,  but  dehrium  tremens.  I 
beUeve  that  habitual  intoxication  of  any  sort  may  lead  to  this  disorder;  but  distilled 
spirits  more  surely  than  wine  ;  wine  more  than  beer.  I  make  no  doubt  either,  that 
what  is  alleged  of  the  habitual  use  of  opium,  in  preparing  a  person  to  suffer  in  the 
same  way  upon  its  being  withheld,  is  quite  true,  although  I  have  had  but  few  oppor- 
tunities of  noticing  such  cases. 

But  the  disease  is  not  confined  to  drunkards,  although  it  is  so  commonly  connected 
w'ith  that  pitiable  vice,  as  to  have  been  called  mania  e  potu.  You  meet  with  it  occa- 
sionally in  men  who  have  overstained  their  nervous  system  by  other  modes  of  strong 
excitement.  Long-continued  mental  anxiety,  that  state  of  mind  in  which  gamblers 
and  great  speculators  (who  are  indeed  gamblers)  are  accustomed  to  live,  may  cause 
it ;  any  thing  by  which  the  mind  is  over-wrought.  A  well-informed  medical  man, 
of  temperate  habits,  told  me  a  few  days  ago  that  he  was  on  the  brink  of  delirium 
tremens  in  the  year  1825.  He  had  foolishly  entangled  himself  in  some  of  the  specu- 
lations which  prevailed  here  like  an  epidemic  at  that  period,  and  his  mind  was  on 
the  tenter-hooks  of  suspense  and  apprehension  for  some  time.  He  could  not  sleep, 
and  he  found  himself  everlastingly  chattering.  It  comes  on  in  the  course  of  certain 
diseases ;  as  sometimes,  for  example,  in  apoplexy  :  and  it  is  a  very  common  result 
of  bodily  injuries  and  accidents,  and  of  surgical  operations ;  or,  I  should  rather  say, 
that  it  often  follows  such  diseases  and  casualties ;  for  it  is,  even  then,  the  conse 
quencc  of  the  treatment  and  regimen  to  which  the  patients  are  subjected,  rather  than 
of  the  surgical  or  medical  complaint.  And  it  is  certainly  more  apt  to  occur,  under 
these  circumstances,  in  old  people  ;  and  in  those  who,  being  younger,  are  known  to 
have  been  intemperate.  So  frequently  does  the  delirium  manifest  itself  upon  the 
".essation  of  the  accustomed  spur,  that  the  continually  recurring  stimulus  has  been 
regarded  as  the  predisposing,  and  the  privation  of  that  stimulus  the  exciting  cause 
of  the  affection.  Sometimes,  however,  it  comes  on  in  men  who  are  perpetually 
fuddled,  even  although  they  have  not  intermitted  their  usual  indulgence  in  drink. 
VVe  had  a  porter  (an  old  soldier  he  had  been)  at  the  Middlesex  Hospital,  who  was  of 


DELIRIUM   TREMENS. 


249 


great  use  to  us  as  a  subject  to  practice  upon,  and  to  show  to  the  pupils.  I  never  saw 
him  so  drunk  as  to  be  unable  to  perform  his  duly  :  but  I  cannot  conscientiously  say 
that  I  ever  saw  him  sober.  Every  three  or  four  months  we  were  sure  to  have 
him  in  the  wards  with  delirium  tremens.  Sometimes  he  fell  into  the  hands  of  one 
physician,  and  sometimes  of  another;  but  in  one  of  his  attacks  he  slipped  through 
our  fingers.  I  am  not  certain  that  he  was  not  nominally  my  patient  on  the  last  and 
fatal  occasion :  but  assuredly  he  was  never  an  example  of  the  disease  coming  on 
from  the  adoption  of  more  temperate  habits.  We  often  find  that  the  malady  shows 
itself  immediately  after  an  unusually  severe  debauch,  which  has  disturbed  the 
stomach  and  bowels,  and  left  behind  it  a  proportional  degree  of  exhaustion  and 
languor. 

Without  knowing  why  it  should  be  so,  my  own  experience  would  lead  me  to  the 
belief  that  delirium  tremens  is  very  uncommon  among  women.  The  number  of  beds 
for  females  in  the  physicians'  wards  of  the  Middlesex  Hospital  is  somewhat  greater 
than  for  males.  On  the  men's  side  of  the  house  cases  of  dehrium  tremens  are  very 
frequent:  whereas  I  scarcely  remember  any  on  the  women's.  Yet  each  sex  is 
obnoxious  to  its  main  causes.  The  gin-shops  of  this  town  are  said  to  draw  a  fearful 
crowd  of  votaresses.  And  we  might  expect  that  the  more  sensitive  character  of  the 
female  constitution  would  render  them  especially  liable  to  this  peculiar  consequence 
of  the  abuse  of  alcohol.  My  experience,  however,  is  such  as  I  tell  yon.  On  the 
other  hand,  Dr.  Roots  thinks  that  he  has  seen  quite  as  many  instances  of  delirium 
tremens  attacking  females  as  males.  The  result  of  M.  Rayer's  observations  is  more 
in  accordance  with  my  own.  Of  176  patients  seen  by  him,  seven  only  (not  one  in 
twenty-five)  were  women.  A  still  smaller  ratio  is  recorded  by  Bang,  ten  in  456 : 
less  than  one  in  forty-five.  The  disorder  appears  to  be  more  common  in  the  summer 
than  in  the  winter  months. 

The  pecuhar  nature  of  the  complaint,  and  the  proper  method  of  treating  it,  were 
first  brought  into  general  notice  in  1813  by  a  little  work  of  Dr.  Sutton's,  of  Green- 
wich. He  saw  a  good  deal  of  the  diseases  of  the  smugglers,  and  of  the  customers 
of  the  smugglers,  who  frequent  the  coast  of  Kent ;  and  he  was  struck  by  the  different 
event  of  this  disorder  in  the  hands  of  different  practitioners,  according  as  bleeding  or 
narcotics  were  adopted.  It  is  the  same  disease  which  Dr.  Abercrombie  speaks  of  as 
"  a  dangerous  modification  of  meningitis,  which  shows  oniy  increased  vascularity." 
Dr.  Bright  also  includes  it  among  his  cases  of  "  Arachnitis."  Both  these  eminent 
physicians  had  learned,  however,  that  the  complaint  requires  a  particular  method  of 
treamient.  Of  late  years  many  essays  and  papers  on  the  same  malady  have  ap- 
peared in  this  country,  in  France,  and  in  the  United  States,  where  the  disorder  is 
common.  But  even  now  it  is  not  so  well  understood,  throughout  the  profession,  as 
it  ought  to  be. 

You  may  ask  me,  what  is  the  essential  nature  of  the  disease :  and  I  can  only- 
state  in  reply  that  it  consists  in  nervous  irritation.  Some  persons  hold  that  this  is 
tantamount  to  no  answer  at  all ;  but  I  do  not  agree  with  them.  They  seem  to  think 
that  if  you  assign  a  state  of  the  brain  or  nervous  system  which  is  not  visible  or  tangi- 
ble, you  lose  yourself  in  mere  hypothesis.  But  we  see  a  number  of  striking  phe- 
nomena in  this  and  in  many  other  forms  of  disease,  for  which  phenomena  we  can 
trace  by  our  senses,  in  the  organ  affected,  no  physical  cause  ;  yet  we  are  sure  that 
they  have  a  cause ;  and  we  call  that  cause  irritation  :  if  we  had  given  it  some  Chi 
nese  name,  it  would  have  been  all  the  same.  From  certain  symptoms  we  infer  irri 
tation ;  just  as  from  certain  phenomena  we  infer  gravitation.  I  do  not  mean  to  put 
the  two  upon  an  equal  footing ;  or  to  pretend  to  say  that  the  laws  of  irritatipn  are 
established  wiih  any  thing  like  the  certainty  which  belongs  to  the  ascertained  laws 
of  gravity :  but  we  pursue  the  investigation  of  these  laws  in  the  same  Avay  in  the 
one  case  as  in  the  other:  and  it  is  quite  idle  to  object  to  an  arbitrary  term,  like  irri- 
tation, because  it  is  meant  to  represent  something  which  makes  itself  known  to  us 
only  by  its  efl^ects. 

Now  I  apprehend  that  we  are  borne  out,  by  authentic  facts,  in  believing  that  cer- 
tain changes  in  the  blood-vessels  will  lead  t5  irritation,  and  at  length  to  inflammation, 
of  a  part.     But  there  are  other  sourcs  of  irritation;  and  irritation  in  its  turn  wiJl 


250  DELIRIUM   TREMENS 

lead  to  changes  in  the  blood-vessels.  In  the  one  case  we  bring  oacK  the  blood-vessels 
to  their  healthy  condition,  and  the  symptoms  of  irritation  cease.  In  the  other  we 
calm  the  irritation,  and  the  previous  effect  of  it  upon  the  blood-vessels  stops.  In 
other  words,  deviations  from  the  natural  and  healthy  state  of  the  nervous  system  are 
sometimes  the  cause,  and  sometimes  the  consequence,  of  disturbances  in  the  sangui- 
ferous system.  Whether  this  be  good  philosophy,  or  whether  it  seem  to  you  rational 
and  intelligible,  I  do  not  know ;  but  it  is  the  best  explanation  that  I  can  offer  you  ■• 
upon  this  subject. 

I  apprized  you,  in  the  last  lecture,  that  the  great  remedy  in  delirium  tremens  is 
sleep  ;  and  that  our  most  powerful  means  of  inducing  sleep  are  to  be  found  in  opium. 
The  opium  must  be  given  in  full  doses  ;  and  it  must  be  fearlessly  repeated  if  its 
desired  effect  does  not  follow.  If  the  patients  pass  many  nights  without  sleep,  they 
will  die.  I  have  tried  various  forms  of  opium ;  and  I  am  quite  satisfied  with 
morphia.  Some  persons,  however,  have  not  found  it  so  successful  as  solid  opium, 
or  as  the  common  tincture,  laudanum.  You  may  try  the  one  or  the  other,  or  the 
one  after  the  other,  if  you  please.  No  particular  rules  can  be  laid  down  that  will 
suit  all  cases.  After  clearing  out  the  bowels  by  a  moderate  purgative,  you  may 
give  three  grains  of  solid  opium ;  and  if  the  patient  show  no  inclination  to  sleep 
after  two  or  three  hours  have  elapsed,  you  may  begin  to  give  one  grain  every  hour 
till  he  does  sleep.  Or  you  may  prescribe  corresponding  quantities  of  the  acetate  or 
muriate  of  morphia  :  or  of  laudanum :  or  of  the  black  drop  :  or  of  Battley's  sedative 
liquor.  His  room,  meanwhile,  should  be  kept  dark  and  quiet.  If  he  sleeps  for  some 
time  he  will  awake  calmer  and  more  sensible  ;  perhaps  perfectly  so :  and  you  must 
withhold  the  remedy,  or  continue  it  in  smaller  or  less  frequent  doses,  according  to 
the  circumstances  of  the  case. 

Dupuytren  found  opiate  enemata  of  great  efficacy  in  the  cases  of  traumatic  deli- 
rium which  came  under  his  care.  That  mode  of  administering  the  narcotic  may 
properly  be  adopted,  if  there  be  any  impediment  to  its  reception  or  retention  by  the 
stomach. 

Now  sometimes  this  opiate  treatment  alone  is  quite  enough  :  sometimes  it  is  not. 
You  will  meet  with  patients  who  resist  very  large  doses  of  the  drug ;  but  who  prc- 
senth'-  sleep,  or  become  composed,  if  j'ou  give  some  of  their  accustomed  stimulus 
with  it:  "a  hair  (as  the  vulgar  saying  goes)  of  the  dog  that  bit  them  :"  if  you  put 
their  opiate  dose  into  a  glass  of  gin,  or  a  pint  of  porter.  Nervous  exhaustion  goes 
along  with  and  augments  the  nervous  irritability.  This  I  have  continually  expe- 
rienced with  hospital  patients.  And  I  rather  think  that  you  may  get  some  clue  to 
the  particular  cases  which  require  this  treatment,  by  examining  into  the  slate  of  the 
digestive  functions.  If  you  learn  that,  notwithstanding  the  intemperate  habits  of 
the  patient,  his  appetite  for  food  has  continued  unimpaired,  and  his  digestion  sound, 
you  will,  I  believe,  generally  find  that  good  nourishing  diet,  strong  broths  for 
example,  and  the  opium,  will  suffice  for  the  cure.  But  if  the  powers  and  natural 
sensations  of  the  stomach  have  been  injured  and  perverted,  as  is  too  often  the  fact, 
then  a  temporary  recurrence  to  the  habitual  stimulus  Avill  frequently  be  necessary : 
and  it  is  well  to  ascertain,  in  such  cases,  what  the  stimulus  has  been,  whether  spirits, 
or  beer,  or  wine,  and  to  order  it  accordingly.  Of  course  this  is  not  to  be  continued 
after  the  patient  has  recovered  from  his  delirium  ;  but  the  stimulus  under  these  cir- 
cumstances must  be  cautiously  witWrawn.  When  the  stomach  retains  its  power 
of  digestion,  the  bad  habit  of  drinking  ought  to  be  broken  off  at  once  :  and  if,  after 
sleep,  you  can  get  the  patient  to  eat  heartily  of  a  beef-steak,  or  mutton-chop,  I  should 
always  advise  it. 

There  are  some  things  which  I  find  it  necessary  to  mention,  for  the  sake  of  dis- 
commending them.  I  know  persons  who  in  treating  these  cases  combine  calomel 
with  the  opium.  And  they  say  that  they  cure  their  patients  so  ;  and  I  make  no 
doubt  that  they  do;  neither  can  I  doubt  that  the  same  success  would  have  followed 
the  same  quantity  of  opium  without  the  calomel.  In  pure  cases  of  delirium  tremens 
I  advise  you  not  to  give  calomel.  I  know  no  possible  good  it  can  answer  :  it  is 
itself  a  source  of  great  irritation  to  the  nervous  system  in  many  persons :  and  if  it 
romes  to  affect  the  mouth,  you  inflict  upon  j-our  patient  a  superfluous  discomfort; 


DELIRIUM   TREMENS.  251 

and,  I  believe,  in  many  cases,  a  downright  injury.  You  will  be  told  also  of  digitalis, 
as  a  specific  remedy  for  the  disease ;  or  you  may  read  of  it :  but  do  not  be  led  away 
from  the  standard  remedies  which  reason  recommends,  and  large  experience  has 
sanctioned.  Knowing  what  we  do  of  the  power  of  opium  generally,  and  of  its 
efficacy  in  this  complaint  in  particular,  I  should  consider  myself  guilty  of  a  criminal 
trifling  with  human  life  if  I  made  experiments  with  digitalis,  upon  the  loose  reports 
of  some  one  or  two  persons,  of  whose  credit  or  information  I  knew  nothing ;  and 
whose  dicta  had  been  transferred  perhaps  from  some  foreign  journal  to  fill  a  vacant 
corner  in  one  of  our  own.  Of  the  combination  of  opium  and  antimony,  which  has 
been  much  praised  by  good  and  competent  judges,  I  am  unable  to  tell  you  any  thing 
from  my  own  experience. 

In  hospital  practice  it  sometimes  becomes  necessary  to  confine  the  patient  to  his 
bed  by  straps,  or  to  muffle  his  limbs  in  a  strait  waist-coat :  but  this  is  a  most  unfor- 
tunate necessity.  Physical  coercion,  whether  manual  or  mechanical,  should  never 
be  resorted  to  in  delirium  tremens,  when  by  any  means  it  can  be  avoided.  The 
angry  feeling  and  mental  fret  which  it  produces,  and  the  exhausting  bodily  struggles 
to  escape  or  resist  the  thraldom,  are  always  highly  injurious  and  full  of  danger  to  the 
patient.  A  couple  of  strong  and  good-tempered  attendants  will  not  have  much  diffi- 
culty in  persuading  and  managing  the  sick  man,  who  is  seldom  either  boisterous  or 
obstinate  :  and  if  he  be  intractable  by  soft  words,  he  will  yield  more  patiently  to 
their  gentle  restraint  than  to  the  force  of  manacles  ;  while  the  appearance  of  coercion 
need  not  be  continued  a  moment  after  his  acquiescence. 

I  have  drawn  the  line  between  encephalitis  and  delirium  tremens  with  sufficient 
clearness,  because  I  have  taken  well-marked  forms  of  each.  But  I  am  sorry  to  add 
that  there  are  mixed  cases,  which  are  very  puzzling  when  they  occur,  and  exceed- 
ingl}?^  difficult  to  treat;  and  which  require  opiates  on  the  one  hand,  and  moderate 
depletion  on  the  other.  When  the  indications  are  uncertain,  or  equivocal,  we  must 
carefully  weigh  the  different  symptoms,  and  we  must  cautiously  try  the  remedies. 
The  circumstances  that  most  distinguish  the  one  form  of  the  disease  from  the  other 
are  to  be  found  in  the  pulse  ;  which  is  hard  and  resisting  in  the  earlier  stages  of  in- 
flammation of  the  encephalon,  soft  and  compressible  in  delirium  tremens :  in  the 
tongue  ;  which  is  mostly  parched  and  rough  in  the  former,  moist  and  creamy  in  the 
latter  :  in  the  skin  ;  which  is  hot  and  dry  in  the  one  case,  covered  with  sweat  in  the 
other :  in  the  countenance  ;  Avhich  is  flushed  in  inflammation,  and  mostly  (though 
not  always)  pale  in  delirium  tremens  :  in  the  tremors  ;  which  are  not  common  in 
the  primary  periods  of  inflammation  of  the  brain :  in  the  usual  absence  of  headache 
in  delirium  tremens  :  and  in  the  peculiar  characters,  which  I  need  not  recount,  of 
the  delirium  in  the  two  cases.  If  these  symptoms  contradict  each  other,  as  they 
sometimes  will,  you  had  better  act  on  the  worst  supposition,  and  presume  that  there 
is  inflammation,  and  employ  antiphlogistic  remedies  :  but  you  must  not  do  so  with 
a  strong  hand ;  you  must  use  them  cautiously,  and  watch  their  effects,  and  guide 
thereby  your  subsequent  treatment.  Take  a  moderate  quantity  of  blood  from  the 
arm :  observe  Avhether  it  has  the  huffy  coat :  and  note  the  condition  of  the  patient 
afterwards.  In  mixed  or  ambiguous  cases  it  will  be  proper  to  combine  calomel  with 
the  opium.  You  will  sometimes  find  a  state  resembling  delirium  tremens  left  after 
the  subsidence  of  acute  inflammation  of  the  parts  within  the  cranium,  and  requiring 
the  treatment  of  dehrium  tremens. 

I  do  not  know  that  there  is  much  good  to  be  expected  from  counter-irritation  in  this 
disease.  But  after  the  more  decided  symptoms  were  gone  by,  I  have  sometimes 
thought  that  the  recovery  has  been  accelerated  by  the  application  of  a  blistec  to  the 
nape  of  the  neck. 

Inflammation  of  the  brain,  and  delirium  tremens,  are  distinct  diseases.  Hence,  in 
the  mixed  cases,  of  which  I  just  now  spoke,  we  may  expect  after  death  to  find,  and 
we  often  do  find,  unquestionable  traces  of  inflammatory  action  within  the  skull.  But 
pure  delirium  tremens  frequently  leaves  behind  it  no  morbid  appearance  whatever 
m  the  brain  or  its  membranes.  In  other  cases  there  is  serous  liquid  collected  in  tho 
mterstices  of  the  pia  mater,  or  in  the  cerebral  ventricles  ;  and  I  have  on  several 
occasions  seen   the   arachnoid  thicker  and  less  transparent  than   i^  naiuinl,  and 


252  DELIRIUM    TREMENS. 

sprinkled  over  with  little  spots  or  streaks  of  a  milk-white  colour.  Changes  of  this 
kind  we  believe  to  be  owing  to  chronic  inflammation  of  the  membrane.  But,  even 
in  these  cases,  I  see  no  reason  for  thinking  that  the  fatal  disorder  had  any  connection 
with  the  morbid  state  of  the  arachnoid.  We  meet  continually  with  like  appearances 
when  there  has  been  no  delirium  tremens ;  and  we  have  delirium  tremens  without 
any  such  appearances.  The  habitual  abuse  of  ardent  spirits  leads  to  chronic  inflam- 
mation in  various  parts  and  tissues  of  the  body :  in  the  blood-vessels,  in  the  liver,  in 
the  kidneys,  and  in  the  arachnoid.  We  need  not  be  surprised  at  finding  that  mem- 
brane thickened  and  partially  opaque  in  the  victims  of  delirium  tremens  ;  since  they 
are  chiefly  men  who  have  run  a  long  course  of  intemperance.  I  believe  that  disease 
to  bear  the  same  relation,  and  no  other,  to  the  chronic  arachnitis  in  such  persons,  as 
to  the  chronic  hepatitis  to  which  they  are  equally  subject.  There  is  but  one  morbid 
condition  which,  since  my  attention  was  first  directed  to  it,  I  have  found  constant  in 
persons  dead  of  delirium  tremens,  and  that  is,  a  remarkably  soft,  pale,  and  flabby 
state  of  the  muscular  tissue  of  the  heart. 

The  chemist  may  be  more  Hkely  to  detect  altered  conditions  in  the  brain,  in  these 
cases,  than  the  anatomist.  Very  lately  Dr.  Percy  has  obtained  alcohol  from  the 
brain  of  a  person  who  died  from  excessive  drinking  ;  and  from  those  of  various  ani- 
mals which  had  been  killed  by  that  poison.  These  facts  are  interesting,  but  they  do 
not  help  us  much  in  our  attempts  to  explain  the  phenomena  of  the  disorder. 

Cases,  such  as  I  related  in  the  last  lecture,  where  violent  symptoms  are  calmed  at 
once,  and  the  patient  is  rescued  in  a  few  hours  from  great  apparent  peril,  make  a 
strong  impression  upon  those  who  witness  them  ;  and  the  practitioner  gains  amazing 
credit,  and  is  spoken  of  to  all  their  acquaintances  as  a  wonderfully  clever  man.  It 
is  unfortunate  that  we  are  obliged  to  set  off,  against  this  advantage,  a  corresponding 
danger,  when  the  disease  ends  ill,  of  being  blamed  without  our  deserving  it.  When 
these  patients  die  (and  they  usually  persist  in  their  evil  habits  and  die  at  last  in  one 
of  the  attacks  of  the  disease),  when  they  so  die,  they  are  apt  to  die  much  in  the 
same  way  as  patients  who  are  poisoned  by  opium ;  and  if  their  friends  are  aware 
that  we  have  been  giving  large  and  repeated  doses  of  that  drug,  they  sometimes 
have  the  charity  to  lay  the  death  at  our  door:  and  you  ought  to  be  prepared  for 
this ;  and  I  will  conclude  what  I  have  to  say  upon  the  subject  of  delirium  tremens 
by  relating  a  case,  in  which  I  have  no  doubt  that  I  suffered  (though  quite  unjustly) 
under  that  kind  of  imputation. 

Several  years  ago  I  was  asked,  one  morning,  by  a  general  practitioner  at  the  west 
end  of  the  town,  to  see  a  patient  with  him  :  of  whom  he  gave  me  this  account.  The 
man  was  about  forty  years  old.  He  had  been  attacked  some  daj's  before  with  sore 
throat,  common  cynanche  tonsillaris.  The  tonsils  and  fauces  were  so  much  swelled 
that  his  deglutition  was  greatly  impeded,  and  for  four  or  five  days  he  had  not  been 
able  to  swallow^  any  thing.  The  night  before  I  saw  him  he  had  become  dehrious, 
and  then  had  been  largely  bled,  and  he  was  worse  in  the  morning.  His  bowels  had 
also  been  very  much  purged. 

I  found  him  propped  up  in  his  bed,  whh  a  coronet  of  leeches  round  his  head.  He 
was  pale ;  there  was  no  headache,  nor  affection  of  his  breathing;  his  pulse  was  not 
very  frequent,  and  it  was  quite  soft  and  compressible.  He  was  sweating  profusely. 
He  answered  the  few  questions  I  put  to  him  readily  and  pertinently,  and  then  went 
talking  on  in  a  rambling  way  about  his  business.  He  was  a  hackney-man  or  stable- 
keeper,  in  a  large  way.  He  said  (I  remember)  that  the  boys  were  all  ready  to 
start,  that  there  were  two  pair  of  horses  going  down  the  road,  and  that  he  must  go 
and  see  after  them ;  and  much  more  on  the  same  subject.  His  mind  was  busy 
about  the  execution  of  imaginary  orders.     He  had  not  slept  at  all  for  some  nights. 

Upon  my  inquiring  into  his  previous  condition,  his  wife  told  me  that  without  any 
turn  lor  dissipation  he  had  for  some  time  been  an  habitual  hard  drinker;  that  he  had 
!«equent  dealings  with  the  coachmen  to  the  various  families  which  he  furnished  with 
horses  ;  and  that  he  was  obliged  to  drink  something  with  each  of  them  ;  so  that  every 
aav  he  had  many  glasses  of  spirits,  and  a  good  deal  of  porter.  She  told  me,  also 
th::t  his  mind  had  been  anxious  and  uneasy;  that  the  business  was  a  large  and 


DELIRILM   TREMENS  253 

narassing  one  ;  that  he  had  embarked  a  considerable  sum  of  money  in  it ;  and  that 
it  had  not  turned  out  so  prosperously  as  he  had  expected. 

Putting  all  these  things  together,  there  could  be  no  doubt,  either  as  to  the  charac- 
ter of  the  complaint,  or  as  to  the  treatment  proper  to  be  adopted.  Here  was  a  man 
who  had  been  living  a  life  of  continued  mental  and  physical  excitement.  Suddenly 
the  stimulus  to  which  he  had  been  accustomed,  was  taken  away ;  he  could  not  swal- 
low even  such  nourishment  as  his  case  required  or  admitted  :  then  came  on  delirium 
—  a  symptom  not  belonging  to  the  disease  in  his  throat  —  and  protracted  watchful- 
ness. He  is  largely  bled,  and  profusely  purged,  and  he  gets  worse  instead  of  better 
under  these  remedies.  At  the  same  time  his  skin  is  moist  and  perspiring,  and  there 
is  no  hardness  in  his  pulse. 

I  recommended  that  the  leeches' should  be  removed  from  his  head;  that  he  should 
take  immediately  (for  he  could  swallow  now)  two  grains  of  opium,  and  afterwards 
twenty  drops  of  laudanum  every  two  or  three  hours  till  he  fell  asleep. 

Somewhat  unluckily,  his  wife's  brother — a  very  young  man — was  the  apprentice 
or  assistant  of  a  surgeon  in  the  neighbourhood  of  town,  and  he  came  in  to  see  his 
relative.  After  hearing  what  I  had  said,  he  went  home,  and  probably  consulted  his 
books,  and  then  came  back  again  with  doubts  whether  the  complaint  really  was 
delirium  tremens  after  all.  Whether  in  consequence  of  these  doubts  I  cannot  tell, 
but  for  some  reason  or  other  only  one  or  two  doses  of  the  medicine  were  taken.  I 
Jiad  offered  to  see  the  patient  again  in  the  evening,  but  his  friends  said  they  would 
send  for  me  if  he  did  not  get  better.  They  did  not  send.  The  patient  did  not  sleep. 
At  night,  therefore,  at  ten  o'clock,  three  grains  of  opium  were  administered.  The 
result  of  this  was,  that  he  passed  a  quiet  but  a  sleepless  night.  Perhaps  (but  I  can- 
not be  sure  of  that)  if  the  opium  had  been  persisted  with,  the  case  might  have  termi- 
nated otherwise.  About  eight  o'clock  the  next  morning  I  was  summoned  to  him  in 
a  great  hurry ;  when  I  got  there  he  was  dying,  perfectly  comatose,  breathing  sterto- 
rously,  with  blue  lips  and  contracted  pupils.  He  had  appeared  so  much  better  at 
seven,  that  he  was,  for  the  first  time,  left  alone  for  a  quarter  of  an  hour ;  and  when 
they  went  back  to  him,  he  was  changed  in  the  manner  I  have  described. 

The  general  practitioner  with  whom  I  had  first  seen  the  patient — a  very  sensible 
man — was  much  concerned  at  this  issue  of  the  case,  and  observed  to  me  that  doubt- 
less our  patient  had  been  poisoned  by  the  three  grains  of  opium.  I  was  able,  how- 
ever, to  relieve  his  mind  from  this  notion :  and  I  have  mentioned  the  case  chiefly 
for  the  sake  of  guarding  you  against  similar  misgivings,  under  similar  circumstances. 
The  manner  of  dying  was  just  such  as  opium  will  produce;  but,  then,  death  by 
coma  is  also  frequently  the  termination  of  delirium  tremens.  Effusion  at  length  is 
apt  to  take  place  into  the  ventricles,  or  into  the  meshes  of  the  pia  mater,  and  stupor 
comes  on,  and  the  patient  sinks.  But  in  this  instance  I  was  certain  that  his  death 
had  nothing  to  do  with  the  opium  he  had  taken,  for  this  reason  :  that  so  long  a  space 
of  time  had  elapsed — nine  hours — between  his  taking  the  opium  and  the  coming  on 
of  the  comatose  symptoms.  Dr.  Christison,  in  his  elaborate  and  valuable  work  on 
Toxicology,  states  it  as  the  result  of  extensive  inquiry  into  this  subject,  that  when 
opium  has  been  swallowed  in  a  poisonous  dose,  it  almost  always  begins  to  act  as  a 
poison  within  an  hour;  that  very  rarely  indeed  has  its  specific  operation  been  post- 
poned much  beyond  the  hour,  except,  occasionally,  when  the  person  taking  it  was 
intoxicated  at  the  time.  In  one  remarkable  instance  a  drunken  man  took  two  ounces 
of  laudanum,  and  no  material  stupor  followed  for  five  hours.  I  guess  that  I  incurred 
the  reproach  of  recommending  a  fatal  plan  of  treatment  in  the  particular  case  I  have 
now  related ;  but  I  am  quite  satisfied  that  the  opium  was  innocent  of  the  patient's 
death,  and  I  even  think  that  his  chance  might  have  been  much  mended  if  the  opi- 
ate, m  smaller  doses  perhaps,  had  been  steadily  continued. 

We  may  be  content  to  bear  occasionally,  these  unfounded  imputations  when  we 
consider  the  other  side  of  the  account,  and  call  to  mind  the  far  greater  number  of 
instances  in  which  spontaneous  recoveries  are  credited  to  us  as  cures ;  and  the  Doc- 
tor, like  Belinda's  Betty,  is  "praised  for  labours  not  his  own." 

[The  account  given  by  the  author,  of  the  character,  phenomena,  causes,  and  treatme?nt 
of  delirium  tremens,  is,  upon  the  whole,  so  very  judicious,  that  it  would  scarcely  appear  to 

w 


254  DISEASES   OF   THE   BRAIN. 

demand  any  other  comment,  than  one  of  general  approval.  But  as  there  exists  a  very  decided 
difference  of  opinion  among  American  practioners  in  regard  to  the  proper  management  ot 
the  disease,  a  few  words  upon  this  point  may  not  be  improper. 

Four  different  plans  of  treatment  have  been  recommended,  and  the  results  of  their  exten- 
sive employment  for  a  series  of  years,  have  been  adduced,  by  their  respective  advocates,  in 
evidence  of  the  superior  efBcacy  of  each.  One  practioner  cures  all  or  nearly  all  his  cases  by 
repeated  emetics,  another,  by  the  free  exhibition  of  alcoholic  drinks,  and  a  third,  by  opiates 
n  free  doses,  continued  at  short  intervals,  until  sleep  is  procured — while  a  fourth  considers 
diat  neither  excitants  proper  nor  opiates  are  necessary,  but  simply  a  state  of  tranquillity  in  a 
quiet  and  darkened  chamber — with  perhaps  an  emetic  to  unload  tlie  stomach  in  the  com- 
mencement of  the  attack,  and  some  gentle  cathartic  to  keej?  the  bowels  open — and  when  the 
stomach  will  retain  it,  a  light,  nutritious,  and  easily  digested  diet. 

The  opiate  practice  is  the  one,  in  favour  of  the  superior  efficacy  of  which  we  have  the 
most  imposing  weight  of  evidence — and  it  is  unquestionably  the  one  that  will,  in  the  majo- 
rity  of  cases,  when  judiciouslyand  cautiously  managed,  the  most  promptly  and  effectually  remove 
/he  symptoms  of  the  disease.  That  the  opiate  practice  has  been  abused,  we  are  perfectly 
aware.  Under  the  supposition  that  opiimi  to  any  extent  that  may  be  requisite  to  induce 
speedy  sleep  can  be  administered  in  delirium  tremens  with  perfect  safety,  we  have  cause 
to  fear  that  a  state  of  coma  has  in  more  than  one  instance  been  induced  from  which  the 
patient  has  never  awoke.  We  have  never  been  in  the  habit  of  administering  large  doses  of 
opium,  and  have  usually  combined  each  dose  with  an  equal  quantity  of  camphor,  and  about 
half  a  grain  of  ipecacuanha.  In  young,  robust,  and  plethoric  subjects,  we  believe  that  the 
application  of  cups  to  the  temples  and  nape  of  the  neck,  or  even  a  moderate  bleeding  from 
the  arm,  is  an  important  measure  in  the  commencement  of  the  attack,  which  should  not  be 
lost  sight  of. 

That  there  are  many  cases  of  delirium  tremens  in  which  a  perfect  recovery  maybe  effected 
without  the  administration  of  opium  or  of  any  stimulant  is  very  certain — but  our  experience 
has  taught  us,  that  when  the  disease  occurs  in  confirmed  inebriates,  with  a  broken  down 
constitution,  and  in  whom  there  is  almost  complete  destruction  of  the  proper  functions  of  the 
digestive  organs,  almost  the  only  means  by  which  it  can  be  certainly  and  promptly  arrested 
is  opium  administered  in  moderate  doses  at  short  intervals. 

The  treatment  of  delirium  tremens  by  alcoholic  drinks,  while  we  can  have  no  doubt  of  its 
very  general  efficacy, — is  attended  with  an  evil  of  too  serious  a  character,  to  permit  us  to 
give  to  it,  under  any  circumstances,  our  sanction.  It  cannot  fail,  we  are  persuaded,  to  con- 
firm  tlie  patient  in  his  intemperate  habits — and  thus  render  him  liable  to  a  renewal  of  the 
disease  after  a  short  interval.  That  it  is  not  the  only  successful  treatment  we  are  convinced 
from  ample  experience.  In  the  practice  of  our  preceptor  as  well  as  in  our  own,  which  has 
extended  now  beyond  a  qtiarter  of  a  century,  we  have  had  sufficient  opportunities  for  testing 
the  value  of  the  opiate  practice  in  this  disease,  and  have  seldom  been  disappointed  in  its 
effects.  We  do  not  say  that  the  patient  will  invariably  recover  under  it.  There  are  cases, 
in  which,  from  the  condition  of  the  patient's  system — the  complication  of  the  temulent  deli- 
rium with  serious  disease  of  the  brain  or  other  important  organs,  death  is  inevitable  under 
any  plan  of  treatment :  we  believe,  however,  that  in  the  general  run  of  cases,  the  success  of 
a  properly  conducted  opiate  treatment  will  equal  that  of  any  other  ;  while  in  the  old,  broken 
doM'n  drunkard,  it,  or  the  stimulant  practice,  is  the  only  one  upon  which  any  dependence 
can  be  placed.  Of  the  emetic  treatment,  as  recommended  by  Dr.  Klapp,  we  cannot,  it  is 
true,  speak  from  experience;  in  the  very  few  cases  in  which  we  have'tried  it,  we  were  dis- 
appointed in  its  effects. 

On  the  subject  of  the  proper  treatment  of  delirium  tiemens,  the  reader  may  consult  with 
profit  Dunglison"s  Practice  of  Medicine,  2d  edition,  vol.  ii.,  page  274,  and  the  able  note  by 
Dr.  Gerhard  in  Tweedie's  Library,  American  Edition,  vol.  ii.,  page  237. — C] 

I  should  next  wish  to  put  you  in  possession  of  what  has  been  ascertained  in 
respect  to  partial  and  to  chronic  inflammation  of  the  brain,  as  these  are  met  with  in 
adults  ;  for  I  must  speak  of  the  head  affections  of  children  separately.  But  I  really 
do  not  know  how  to  bring  this  part  of  the  subject  before  you  in  a  practical  manner. 
If  I  were  first  to  describe  symptoms,  and  then  to  state  what  organic  changes  had 
been  discovered  after  death  preceded  by  them,  I  should  have  to  tell  you  of  different 
bymptoms  with  the  same  morbid  conditions,  and  of  the  same  symptoms  with  different 
morbid  conditions,  in  various  individuals.  I  believe  the  best  method,  upon  the  whole, 
will  be  to  describe  the  several  morbid  appearances  which  the  brain  is  found  to  pre- 
sent ;  and  then  to  mention  the  symptoms  that  have  most  commonly  been  observed 
to  occur  in  association  with  such  morbid  conditions.  I  must  premise,  however,  that 
the  whole  subject  is  full  of  uncertainty  and  apparent  irregularity.  Doubtless  there 
w  some  constant  and  uniform  connection  of  cause  and  effect  between  the  ?Jterea 


RAMOLLI 3SEMENT.  255 

physical  states  of  the  brain  and  the  altered  manifestation  of  its  functions :  but  we 
nave  not  yet  been  successful  in  our  search  after  those  settled  relations ;  or  we  have 
but  partial  and  imperfect  ghmpses  of  them. 

One  very  remarkable  condition  of  the  brain  has  been  several  times  mentioned  m 
these  lectures ;  viz.,  softening — ramollissement.  A  great  deal  of  attention  has  been 
paid  to  this  condition  of  late  years,  both  in  France  and  in  this  country :  and  some 
points  in  its  pathology  have  been  fairly  made  out.  I  will  bring  them  together  as 
concisely  as  i  can.  In  the  first  place,  the  softening  varies  greatly  in  degree,  from 
the  consistence  which  naturally  belongs  to  the  cerebral  substance,  to  that  of  thin 
cream.  In  its  minor  degrees  it  may  be  easily  overlooked  ;  and  is  more  perceptible 
by  the  touch  than  by  the  eye.  The  cerebral  matter  is  less  coherent,  but  it  is  not  yet 
discontinuous  or  broken  down.  It  may  be  washed  away,  however,  by  letting  a 
slender  stream  of  water  fall  upon  it ;  and  the  softened  parts  are  thus  easily  distin- 
guishable from  those  Avhich  retain  their  natural  consistence.  In  the  next  stage  of 
softening  we  recognize  the  complaint  at  once,  for  the  softened  parts  undergo  a  change 
of  form  by  their  own  weight :  parts  that  are  prominent  in  the  healthy  state,  as  the 
optic  thalami,  corpora  striata,  and  convolutions,  sink  down,  as  it  were,  and  are  more 
or  less  flattened.  If  you  make  a  horizontal  section  through  a  part  thus  diseased,  a 
portion  of  the  softened  brain  adheres  to  the  knife,  and  is  removed  by  it,  and  a  de- 
pression is  left.  In  a  still  more  advanced  degree,  the  natural  texture  of  the  organ  in 
the  softened  part  is  entirely  destroyed  and  confused  by  the  change,  diffluent :  3^ou 
may  pour  the  softened  matter  out. 

The  colour  of  the  softened  portions  varies  also  considerably.  Sometimes  they  are 
unchanged  in  colour  :  sometimes  they  are  quite  white,  and  present  a  strong  contrast 
with  the  tint  of  the  neighbouring  parts  :  sometimes  they  are  marked  with  various 
shades  of  redness,  from  a  rosy  pink  to  an  orange,  or  deep  red,  or  even  a  mahogany 
brown.  Often  there  are  red  spots  mixed  irregularly  with  the  softened  cerebral  pulp, 
and  giving  it  very  much  the  appearance  of  a  mixture  of  raspberries  and  cream. 
In  other  cases  we  find  the  softened  mass  of  a  pale  yellow,  or  straw  colour,  infiltered, 
as  it  were,  with  purulent  matter :  and  sometimes  it  is  mixed  with  serous  fluid. 

Softening  of  the  brain  is  usually  partial.  It  may  occupy  any  part ;  but  it  is  said 
to  be  more  frequently  met  with  in  the  gray  than  in  the  white  matter  ;  and  more  often 
in  the  gray  matter  of  the  convolutions  than  of  the  more  central  parts  of  the  brain. 

You  will  find  softening  of  the  septum  lucidum,  and  of  the  fornix,  occurring 
very  frequently  in  connection  with  an  accumulation  of  serous  fluid  in  the  lateral 
ventricles. 

Now  it  is  well  established  that  softening  of  the  brain  is  a  common  result  of  two 
very  different  morbid  conditions.  It  is  often  caused  by  inflammation  of  the  softened 
part :  it  is  often  caused,  also,  if  I  may  say  so,  by  its  starvation ;  by  the  diminished 
supply  of  arterial  blood,  in  consequence  of  diseased  blood-vessels. 

Can  we  distinguish  these  two  forms  of  softening  from  each  other  by  their  phy- 
sical characters  ?  Why,  sometimes,  we  can  :  and  sometimes,  it  must  be  confessed, 
we  cannot. 

The  same  parts  that  are  most  liable  to  have  their  consistence  diminished  through 
an  inflammatory  process,  are  also  most  liable  to  be  softened  from  defect  of  nutrition. 
The  most  vascular  parts  of  the  brain,  in  short :  the  gray  matter  of  the  convolutions, 
and  the  gray  matter  of  the  thalami,  and  corpora  striata. 

It  is  stated,  however,  that  softening  of  the  corpus  callosum,  septum  lucidum,  and 
fornix,  from  obliteration  of  the  arteries,  is  extremely  rare. 

If  there  be  pus  mixed  with  the  softened  brain,  we  know  that  there  has  been  pre 
ceding  inflammation.  Again,  if  we  find  the  arteries  impervious,  we  conclude  that 
the  softening  has  not  been  inflammatory.  Dr.  Carswell  states  that  the  obliterated 
arteries  may  occupy  the  softened  cerebral  substance,  and  often  be  seen  ramifying 
through  it ;  and  that  when  this  substance  is  removed  by  pouring  water  upon  it,  the 
solidified  vessels  retain  their  situation,  and  feel  sometimes  as  hard  as  fine  wires.  But 
Xve  come  to  the  same  conclusion  if  we  find  the  larger  vessels,  the  carotid  or  vertebral 
arteries,  obstructed  by  ossification  ;  and  a  large  portion  of  the  brain  unnaturally  soft. 

We  have  no  certain  test  of  the  nature  of  the  softening  in  its  being  red.    The  red 


256  DISEASES    OF   THE   BRAIN. 

ness  may  be  the  result  of  inflammatory  congestion ;  but  cerebral  hemorrhage  may 
occasion  softening ;  and,  on  the  other  hand,  softening  may  give  rise  to  cerebral 
hemorrhage.  This  may  be  said,  however ;  that  the  redness  is  seldom  condderable 
when  the  softening  proceeds  from  obliteration  of  the  arteries.  When  the  softening 
extends  much  beyond  the  redness,  or  the  effused  blood  ;  or  when  the  redness  occu- 
pies several  small  portions  only  of  the  softened  pulp;  we  may  presume  that  the 
blood  was  extravasated  subsequently  to,  and  in  consequence  of,  the  softening.  On 
the  other  hand,  when  redness  and  vascularity  can  be  traced  into  the  brain,  some 
way  beyond  the  softened  part,  we  may  regard  the  softening  as  the  consequence  of 
inflammation.  And  we  adopt  the  same  belief,  with  still  greater  confidence,  when 
around  the  softened  and  disorganized  pulp  we  find  the  cerebral  substance  hardened, 
and  of  a  uniform  reddish  colour. 

In  attempting  to  make  the  diagnosis  between  these  two  forms  of  softening,  we  get 
some  assistance  by  noticing  the  age  of  the  patient.  The  ossification,  which  gives 
rise  to  the  obliteration  of  the  arteries,  is  almost  pecuhar  to  the  advanced  periods  of 
life  ;  whereas  inflammatory  softening  may  occur  at  any  age ;  in  children,  in  adults, 
or  in  old  persons. 

Some  of  the  French  pathologists  have  laid  down  this  rule,  as  the  result  of  their 
experience  in  regard  to  softening  of  the  brain — that  it  is  attended,  during  the  earlier 
part  of  its  progress,  with  a  permanently  contracted  state  of  the  flexor  muscles  of  one 
or  more  of  the  limbs.  "  In  some  cases  the  contraction  of  these  muscles  amounts 
only  to  a  slight  degree  of  stiffness ;  in  others  it  reaches  such  an  extent,  that  if  the 
arm  be  the  part  affected,  the  hand  is  clenched,  and  remains  pressed  against  the 
shoulder ;  or,  if  the  leg,  the  heel  is  carried  up  to  the  hip."  Sometimes  this  tonic 
spasm  is  so  strong  that  you  cannot  extend  the  limb ;  and  the  attempt  to  do  so  gives 
the  patient  pain.  After  a  certain  time  the  rigidity  is  succeeded  by  complete  relaxa- 
tion ;  the  contracted  limb  has  become  utterly  palsied. 

I  beheve  that  this  is  a  valuable  diagnostic  symptom  of  softening,  and  especially  of 
inflammatory  softening — when  it  occurs.  But  it  is  often  wanting.  I  vinsh  I  could 
tell  you  something  more  certain  and  constant  in  respect  to  the  symptoms  of  this 
interesting  change  ;  but  the  facts  which  I  have  myself  observed,  and  which  have 
been  recorded  by  others,  will  not  permit  me  to  do  so.  Dr.  Abercrombie  even  goes 
so  far  as  to  say,  that  judging  from  the  cases  that  have  fallen  under  his  own  notice, 
there  is  no  foundation  for  the  statement  that  ramollissement  is  distinguished  by  tonic 
contraction  of  one  or  more  limbs :  that  the  same  thing  is  met  with  in  connection 
with  affections  of  the  membranes,  without  any  disease  of  the  cerebral  substance; 
and  with  the  encysted  abscess  of  the  brain ;  and  that  it  is  frequently  observed  in 
cases  of  typhus  fever  where  there  is  much  cerebral  disturbance,  but  which  terminate 
favourably.  I  will  give  you  the  general  resuh  of  his  experience  in  this  matter  as 
being  untinctured  with  any  wish  to  reduce  his  facts  into  conformity  with  a  precon- 
ceived opinion,  or  hasty  generalization.  He  states  that  "  the  cases  which  terminate 
by  ramollissement  seem  in  general  to  be  characterized  by  convulsion,  more  or  less 
extensive,  followed  by  paralysis  and  coma ;  the  convulsion  ceasing  for  some  time 
before  death,  and  being  succeeded  by  the  coma."  But  he  saw  one  case  in  which 
"the  convulsion  continued  with  the  utmost  violence  till  the  very  time  of  death."  In 
another  instance  "there  was  no  convulsion  at  all,  but  a  sudden  attack  of  palsy, 
exactly  resembling  the  ordinary  attack  of  hemiplegia  from  other  causes."  In  two 
cases  he  found  "  ramollissement  of  very  limited  extent,  in  connection  with  symptoms 
of  long  standing,  both  cases  being  at  last  rapidly  fatal  by  a  sudden  attack  of  convul- 
sion." In  other  cases  "there  was  extensive  destruction  of  the  cerebral  substaiK.e, 
without  either  paralysis  or  convulsion,  and  even  without  coma." 

When  you  find  the  softened  substance  infiltered  with  purulent  matter,  you  may  call 
the  case  one  of  suppuration  of  the  brain.  But  suppuration  also  occurs  in  another  form ; 
viz..,  in  the  form  of  abscess.  The  pus  is  contained  in  a  regular  well-defined  cavUy, 
surrounded  by  cerebral  matter  in  a  healthy  or  in  a  hardened  state.  Now  in  suppt  ja- 
tion  occurring  in  the  brain,  there  is  the  same  puzzling  diversity  of  symptoms  as  in  C3«es 
of  simple  softening.  Still,  in  the  main,  there  seems  an  approach  to  the  same  order  of 
srymptoms :  convulsions  in  the  earher  period  constituting  the  most  prominent  featvire 


RAMOLLISSEMENT.  257 

of  the  disease  ;  paralysis  in  the  latter.  I  will  take  one  of  Dr.  Abercrombie's  cases 
in  illustration  of  the  formation  of  encysted  abscess  in  the  brain. 

A  girl,  aged  eleven,  thin  and  delicate,  after  having  complained  for  some  days  of 
headache,  was  seized  on  the  11th  of  January,  with  convulsions,  which  continued 
about  half  an  hour:  paralysis  of  the  right  arm  followed  the  attack  of  convulsion. 
She  was  bled  from  the  arm,  and  purged,  and  cold  was  applied  to  her  head ;  and  she 
was  much  benefited  by  this  treatment.  On  the  13lh  the  headache  was  much  abated, 
and  she  had  recovered  a  considerable  degree  of  motion  of  the  arm.  On  the  15th  the 
headache  increased  again,  and  the  arm  became  more  paralytic,  and  she  was  agam 
bled:  and  on  the  16th  and  17th  the  power  of  moving  the  arm  was  greatly  improved. 
On  the  18th,  after  being  affected  with  increase  of  headache,  and  some  vomiting,  she 
became  convulsed,  the  convulsion  being  confined  entirely  to  the  head,  and  to  the 
right  arm ;  the  head  was  drawn  towards  the  right  side,  with  a  rolling  movement  of 
the  eyes ;  the  arm  was  in  constant  and  violent  motion.  She  was  sensible,  and  com- 
plained of  headache.  Being  bled  to  eight  ounces,  the  convulsion  ceased  instantly, 
and  the  headache  was  relieved;  but  the  right  arm  remained  in  a  state  of  complete 
paralysis.  Her  pulse,  during  the  five  following  days,  fell  from  100  to  GO ;  some 
headache  continued;  she  had  occasional  vomiting:  and  the  convulsive  attacks 
returned  several  times ;  they  were  entirely  confined  to  the  right  arm,  which  after 
the  2-M,  was  left  in  a  state  of  permanent  palsy.  Hitherto  no  other  parts  of  the  Dody 
had  been  affected  by  the  convulsion ;  but  on  the  24th  it  attacked  the  right  thigh  and 
leg,  and  left  them  powerless.  The  former  remedies  were  repeated  without  any 
effect.  The  thigh  and  leg  went  through  a  course  precisely  similar  to  that  described 
in  regard  to  the  arm,  and  on  the  29th  were  permanently  incapable  of  motion. 

She  was  now,  therefore,  paralytic  of  the  whole  right  side ;  she  had  no  return  of 
convulsion,  was  perfectly  sensible,  and  made  little  complaint.  Gradually  she  became 
dull  and  oppressed,  and  at  length  fell  into  a  state  of  perfect  coma,  and  died  on  the 
14th  of  February,  a  litile  more  than  a  month  after  the  commencement  of  her  illness. 

In  the  upper  part  of  the  left  hemisphere  of  the  brain  there  were  two  distinctly 
defined  abscesses,  containing  together  from  six  to  eight  ounces  of  very  foetid  pus. 
They  were  lined  by  a  firm  white  membrane ;  and  a  thin  septum  of  firm  white  matter 
separated  them  from  each  other.  The  one  was  in  the  anterior  part  of  the  hemi- 
sphere, very  near  the  surface  ;  and  the  other  immediately  behind  it.  In  the  poste- 
rior part  of  the  right  hemisphere  there  was  a  small  abscess  containing  about  half  an 
ounce  of  pus.  There  was  no  serous  effiision  in  any  part  of  the  brain,  and  no  other 
morbid  appearance. 

In  this  very  interesting  case  it  is  worth  remarking  how  the  convulsion  preceded 
the  paralysis,  and  how  the  palsy  was  more  than  once  diminished  by  antiphlogistic 
measures. 

It  is  remarkable  to  conclude — it  can  hardly  be  called  a  conjecture — that  in  such 
cases  of  partial  disease  of  the  brain  as  I  have  hitherto  mentioned,  the  occurrence  of 
convulsion,  or  of  rigidity,  marks  the  inflammatory  stage  ;  and  the  supervention  of 
permanent  paralysis  denotes  the  period  of  softening  or  suppuration,  of  complete  dis- 
organization, that  is,  of  the  texture  of  the  brain  in  that  part. 

Partial  inflammation  of  the  brain,  especially  when  it  is  chronic,  sometimes  pro- 
duces a  totally  different  change  from  any  that  have  yet  been  described.  Instead  of 
becoming  softer,  or  being  converted  into  pus,  the  inflamed  part  is  indurated ;  cornea 
to  resemble  in  consistence  portions  of  brain  that  have  been  for  a  short  time  immersed 
in  weak  nitric  acid.  In  this  state  it  is  often  unusually  vascular  and  injected.  When 
the  induration  is  greater  in  degree,  the  hardened  part  assumes  the  appearance  of 
wax,  or  of  boiled  white  of  egg,  or  (as  Andral  says)  of  Gruyere  cheese,  ind  contains 
but  litile  blood,  but  is,  on  the  contrary,  distinguished  by  its  pearly  whitt.iess.  That 
these  changes  are  the  result  of  slow  inflammatory  action  is  the  more  probable,  be- 
cause they  are  sometimes  found  to  exist  around  an  old  apoplectic  clot  or  cell ;  the 
blood  effused  having  acted  as  a  cause  of  inflammation  of  the  neighbouring  part,  just 
as  any  foreign  substance  might  do.  In  the  progress  of  cases  in  which  partia'  indu- 
ration is  effected,  convulsive  movements  are  common,  but  paralysis  does  not  appear 
to  be  so  frequently  present.  The  symptoms  may  go  on  for  months,  and  often  rerr.iu 
17  w2 


253  DISEASES    OF    THE    BRAIN.      ' 

and  are  ap'ain  aggravated  by  paroxj'sms.  These  cases  are  the  more  interesting', 
because  they  ofler  a  greater  probability  of  cure  than  those  that  are  attended  with 
an  opposite  condition  of  the  cerebral  mass. 

Besides  these  varieties  of  inflammation,  and  their  consequences,  the  brain  is  often 
infested  with  fiimoKrs,  which  also  jxive  rise  to  a  great  diversity  of  symptoms.  There 
are  fibrous  tumours  which  grow  rather  around  the  nervous  matter  than  within  it, 
and  ai'e  connected  with  the  dura  mater.  They  have  been  found  at  almost  all  parts 
of  the  surface  of  the  brain  ;  at  its  base,  at  its  sides,  and  towards  its  summit.  Scro- 
fulous tubercles  are  also  not  uncommon  :  these  are  embedded  in  the  nervous  sub- 
stance, and  assume  a  round  form,  for  the  reason  I  formerly  mentioned,  viz.,  because 
the  tubercular  matter  that  is  separated  from  the  blood  is  not  cast  into  any  particular 
mould  (as  it  is  when  it  is  effused  into  the  small  bronchial  tubes),  but  poured  forth 
into  the  homogeneous  pulp,  which  exerts  an  equal  degree  of  pressure  upon  it  on  all 
sides.  These  scrofulous  tubercles  of  the  brain  are  infinitely  more  frequent  in  chil- 
dren than  in  adults ;  and  they  are  more  commonly  met  with  in  the  cerebral  hemi- 
spheres than  in  any  other  part  of  the  brain,  occupying  the  cortical  and  medullary 
substance  indifferently.  They  sometimes  appear  to  originate  in  the  pia  mater. 
They  differ  from  pulmonary  tubercles  in  this  respect,  that  they  are  seldom  numerous 
in  the  same  brain.  Sometimes  one  only  is  found.  They  vary  in  magnitude  from 
the  size  of  a  large  pin's  head  to  that  of  a  hen's  Q%g\  and  they  are  sometimes  even 
bigger  than  that.  The  substance  of  the  brain  immediately  surrounding  these  tuber- 
cles may  be  unchanged,  in  which  case  it  is  probable  that  the  tubercles  themselves 
give  rise  to  no  particular  symptoms,  the  cerebral  matter  of  the  spots  they  occupy 
having  been  gradually  absorbed  to  make  room  for  them ;  but  at  length  important 
alterations  take  place  in  the  neighbouring  texture ;  congestions  of  blood,  or  soften- 
ing, or  suppuration  ;  and  then  the  ordinarjr  consequences  of  these  changes  declare 
themselves  outwardly. 

Cancerous  tumours  occur  also  in  the  substance  of  the  brain.  They  usually 
occujiy  a  large  portion  of  it  before  they  extinguish  life.  Hydatids  are  sometimes 
found  there. 

Now  of  the  occurrence  of  these  various  local  maladies  of  the  brain  it  is  necessary 
that  you  should  be  aware,  for  you  may  expect  to  meet  with  them  frequently  in  prac- 
tice. And  it  is  right  also  that  you  should  be  aware  that  they  do  not  disclose  their 
precise  nature  by  any  peculiar  symptoms,  or  succession  of  symptoms.  They  all, 
sooner  or  later,  disturb  the  functions  of  the  organ  in  which  they  are  situated ;  and 
they  may  all  disturb  them  exactly  after  the  same  fashion.  We  may  judge,  some- 
times, y>'0/;?  other  circumstances,  that  the  disease  is  of  this  or  of  that  character.  If 
we  see  scrofulous  or  cancerous  disease  in  other  parts  of  the  body,  we  infer  that  the 
symptorns  which  denote  disease  of  the  brain  are  caused  by  scrofulous  or  cancerous 
tumours  there  situated  ;  but  from  the  symptoms  themselves,  we  can  only  learn  that 
there  is  some  morbid  condition  of  the  brain. 

I  attended,  recently,  with  Dr.  Latham,  a  youth,  whose  symptoms  led  us  to  believe 
that  he  had  tubercular  disease  of  the  ])eritoneum ;  a  very  formidable  complaint, 
which  I  shall  m.ore  particular!}''  describe  hereafter.  We  thought  it  probable,  also, 
although  there  were  no  physical  signs  of  pulmonary  disease,  that  his  lungs  con- 
tained crude  tubercles.  After  some  time,  he  went  down  to  the  coast ;  and  was 
there  attacked  with  a  fit  of  general  convulsions.  Up  to  that  period  he  had  shown 
no  sj^mptoms  whatever  indicative  of  organic  disease  Avithin  the  head.  On  being 
apprized  of  this  seizure,  we  expressed  in  a  letter  to  the  physician  then  attending 
him,  our  opinion  that  it  had  resulted  from  the  presence  of  scrofulous  tumours  in  the 
patient's  brain.  The  convulsions  returned  a  k\v  days  afterwards  with  great  violence, 
and  he  died.  It  was  as  we  had  conjectured.  The  peritoneum  vv'as  found  studded 
with  innumerable  miliary  tubercles  :  there  were  a  few  crude  tubercles,  of  some  size, 
nround  the  roots  of  the  lungs ;  and  two  large  masses  of  the  same  sort  in  the  brain. 
Here,  you  see,  we  were  directed  to  a  correct  special  diagnosis  of  the  cerebral  dis- 
ease, simpl}'  by  the  evidence  which  had  satisfied  us  that  scrofulous  tubercles  existed 
in  other  parts  of  the  body. 

[For  a  more  full  account  of  the  present  state  of  our  kno'wledge  in  regard  to  tubercles  of 
"'\c  brain,  see  the  Editor's  Treatise  on  Diseases  of  Children,  page  57'2. — C.J 


HYPERTROPHY.  259 

In  the  case  of  specific  tumours  there  is  really  nothing  to  be  done  by  way  of  cure 
We  must  then  treat  the  symptoms,  and  seek  to  alleviate  them  as  they  arise.  When 
it  appears  hkely,  or  not  unlikely,  that  the  cerebral  symptoms  may  be  the  result  of 
cerebral  inflammation,  we  must  give  the  patient  the  chance  of  being  benefited  by 
some  of  the  remedies  of  inflammation  :  we  must  treat  the  case  in  this  instance  upon 
the  most  favourable  supposition.  The  class  of  remedies  from  which  most  may  be 
hoped  in  equivocal  cases,  are  local  bleeding,  counter-irritation,  and  especially  the 
cautious  and  regulated  employment  of  mercury.  I  have  stated  to  you  before,  that 
I  have  known  several  obscure  but  threatening  symptoms  of  brain  disease  clear 
entirely  away,  when  the  gums  were  made  sore  by  mercury,  and  kept  slightly  tender 
for  some  little  time.  It  is  possible  that  we  may  sometimes  do  our  patients  harm  by 
this  mercurial  treatment.  We  may,  now  and  then,  accelerate  the  arrival  of  death 
in  persons  whom  nothing  could  save  ;  but  we  must  not  be  deterred  from  giving  them 
this  chance  of  being  rescued  from  a  disorder  which  may  be  susceptible  of  cure,  but 
which,  if  unchecked,  will  be  inevitably  fatal. 


LECTURE   XXV. 

Hypertrophy  of  the  Brain :  Atrophy.  Acute  Hydrocephalus ;  Premonitory 
Signs  ;  Different  Modes  of  Attack  ;  Stages  of  the  Disease  ;  Anatomical  Cha- 
racters ;  Causes. 

There  is  a  very  curious  morbid  condition  of  the  brain,  to  which  I  shall  advert 
before  I  take  up  the  consideration  of  certain  cerebral  diseases  as  they  occur  in  chil- 
dren. The  condition  of  which  I  am  about  to  speak  I  was  totally  ignorant  of  till  I 
had  been  for  some  years  in  practice.  In  the  spring  of  1833  I  admitted  a  young 
woman,  19  years  old,  into  the  Middlesex  Hospital.  Her  countenance  was  sallow, 
and  her  lips  pale.  She  complained  of  pain  in  her  chest  and  limbs ;  of  great  and 
increasing  debility,  and  wasting ;  and  of  nightly  perspirations.  She  had  some 
cough,  and  a  frequent  pulse  ;  and  although  no  morbid  sounds  were  audible  in  her 
lungs,  I  suspected  that  they  might  contain  small  or  scattered  tubercles.  She  had 
been  in  the  hospital  scarcely  a  week,  when  she  had  a  violent  fit  of  epilepsy ;  and 
when  she  was  somewhat  recovered,  she  told  us,  for  the  first  time,  that  she  was  sub- 
ject to  such  attacks.  The  convulsions  recurred  on  the  same  day,  and  she  became 
insensible,  and  remained  so  during  the  whole  of  the  next  day,  and  till  the  evening 
of  the  day  after,  when  she  died.  During  this  period  of  insensibility  she  had  many 
convulsive  fits ;  the  pupils  were  dilated,  the  pulse  100,  small  and  feeble.  Leeches 
were  applied  to  the  temples,  a  blister  to  the  neck,  and  afterwards  to  the  shaven  head, 
and  other  measures  were  used,  but  in  vain. 

When  the  surface  of  the  brain  was  exposed  by  the  removal  of  the  skull-cap,  and 
of  the  dura  mater,  it  was  observed  that  the  convolutions  were  remarkably  flattened, 
so  that  the  little  furrows  between  them  were  nearly  efl'aced ;  and  the  surface  of  the 
arachnoid  membrane  was  perfectly  dry.  These  are  not  very  unusual,  though  they 
are^  unnatural  appearances.  I  had  often  seen  such  before  :  and  I  ventured  to  sa3r 
that  we  should  find  some  cause  of  strong  pressure  in  the  central  part  of  the  brain ; 
efTusion  of  serum  into  the  ventricles,  or  a  large  extravasation  of  blood.  But  to  my 
great  surprise,  and  much  to  the  discredit  of  my  prophecy,  we  found  nothing  of  the 
kind.  The  ventricles  were  even  smaller  than  natural,  and  contained  scarcely  any 
moisture.  The  skull-cap  was  afterwards  examined,  and  the  bone  was  found  to  be 
uncommonly  thick,  dense,  and  heavy  ;  and  its  inner  surface,  without  being  rough, 
was  very  irregular.  I  regret  that,  in  tliis  examination,  the  state  of  the  blood-vesseis 
of  the  brain,  and  the  consistence  of  the  cerebral  matter  itself,  were  not  particularly 
noticed.  In  the  record  made  at  the  time  by  my  clinical  assistant,  it  is  merely  stated 
that  the  brain  was  otherwise  healthy.     There  was  no  disease  in  the  lungs. 

This  dissection  interested  me  much,  for  I  had  never  seen  nor  heard  of  any  thing 


260         I  DISEASES   OF   THE   BRAIN. 

like  it  before.  But  upon  looking  into  some  modern  authors,  I  discovered  that  the 
same  phenomena  had  been  noticed  by  two  or  three  observers,  who  had  very  properly 
(as  it  seems  to  me)  considered  them  as  the  result  of  hyi:)ertroj)hy  of  the  brain.  There 
is  a  very  good  memoir  upon  the  snbject,  by  M.  Dance,  pubhshed  in  the  fifth  volume 
of  Breschet's  Repertoire  (T Jlnatomie :  and  Andral  gives  an  account  of  the  disease 
in  his  Pathology.  It  appears  that  Morgagni  had  not  overlooked  it,  for  he  speaks  of 
instances  in  which  the  brain  seemed  too  big  for  its  bony  enclosure.  When,  in  these 
cases,  the  skull  is  sawn  through,  the  upper  loose  portion  of  bone  starts  up,  as  if 
moved  by  a  spring,  and  the  edges  of  the  bone  remain  widely  apart.  Laennec,  also, 
in  Corvisart's  Journal,  states  that  upon  opening  the  bodies  of  persons  whom  he  had 
thought  affected  ^vith  hydrocephalus,  he  had  been  surprised  at  finding  a  very  smali 
quantity  only  of  fluid  in  the  ventricles,  while  the  convolutions  on  the  surface  of  the 
brain  were  strangely  flattened  ;  proving  that  the  cerebral  mass  had  undergone  strong 
compression,  which  could  only  have  arisen  from  its  preternatural  volume,  and  undue 
nutrition. 

Besides  the  characters  I  have  mentioned,  the  hypertrophied  and  compressed  brain 
is  firmer  and  tougher  than  natural ;  it  contains  but  httle  red  blood ;  and  sections  of 
it  are  seen  to  be  unusually  dry  and  pale. 

In  several  of  the  cases  of  hj-pertrophy  of  the  brain  recorded  by  authors,  the  pa- 
tients had  suffered  epileptic  fits,  or  rather  paroxysms  of  convulsion ;  and  in  some  of 
them  the  convulsions  terminated  in  paralysis.  Andral  states  that  the  intellectual 
faculties  have  been  observed,  in  some  instances,  to  become  dull  and  obtuse.  Many 
of  the  patients  were  subject  to  severe  headaches.  All  these  symptoms  are  common 
to  various  cerebral  complaints.  The  diagnosis  of  this  rare  disorder  can  be  no  better 
than  conjectural ;  and  its  treatment  we  have  still  to  seek. 

Andral  remarks,  what  is  very  true,  that  hypertrophy  of  the  brain,  i.  e.,  an  undue 
and  disproportionate  development  of  that  organ,  may,  and  does  happen,  without 
giving  rise  to  any  morbid  phenomena  at  all.  But,  in  such  instances,  the  brain-case 
is  equally  enlarged  in  capacity ;  so  that  no  pressure  upon  the  cerebral  mass  results 
from  its  own  preternatural  growth.  It  is  only  when  the  brain  increases  faster  than 
the  bony  sphere  which  contains  it,  that  the  hypertrophy  becomes  a  disease.  In  my 
patient  there  was  also,  in  one  sense,  hypertrophy  of  the  skull ;  the  bone  was  consi- 
derably thicker,  and  more  compact  and  heavy,  than  is  usual ;  but  the  capacity  of 
the  cavity  had  not  undergone  a  proportional  augmentation ;  nay  it  might,  for  any 
thing  I  know,  be  diminished  in  consequence  of  the  increased  thickness  of  the  bone ; 
the  case  may  have  been  one  of  concentric  hypertrophy  of  the  bone,  without  any 
fault  of  the  brain  itself;  but  what  makes  this  the  less  probable  is,  that  in  other  cases, 
the  skull  has  been  found  of  the  ordinary  thickness  and  density  ;  but  too  small  for  its 
contents. 

It  is  of  some  importance  for  you  to  be  aware  that  the  brain,  and  its  case,  may  bp 
extravagantly  developed  without  there  being  any  disease,  or  any  symptoms  of  dif> 
ease.  M.  Scoutetten  gives  an  instance  of  this  which  he  observed  in  a  child  fiv3 
years  old.  Its  head  was  as  large  as  that  of  a  well-grown  adult  person.  The  skull 
was  from  a  line  and  a  half  to  two  Hnes  in  thickness.  The  dura  mater  adhered  firmly 
to  the  bone,  and  the  cerebral  mass  exactly  filled  up  the  cranial  cavity.  The  superior 
and  posterior  part  of  the  brain  was  developed  beyond  measure,  so  that  to  reach  the 
ventricles  it  was  necessary  to  make  an  incision  nearly  three  inches  in  depth.  There 
was  nothing  unusual  to  be  remarked  in  any  of  the  cerebral  functions  of  this  child ; 
It  was  just  like  other  children  of  the  same  age  in  respect  of  intellect.  It  died  of 
acute  inflammation  of  the  bowels. 

The  late  Dr.  Sweatman  met  with  just  such  another  child  a  few  years  ago  :  and  I 
refer  to  his  description  of  it  the  rather,  because  cases  that  occur  near  home  are 
always  more  interesting,  and  satisfactory,  than  those  which  we  merely  read  of  in 
foreign  authors.  Dr.  Sweatman  had  never  read  of  any  thing  of  the  kind :  but  in 
August,  1834,  a  httle  boy,  two  years  old,  was  brought  to  him  on  account  of  the  size 
of  his  head  It  had  been  gradually  increasing  from  the  age  of  six  months,  till  it  had 
become  so  large  as  by  its  weight  to  prevent  the  child  from  continuing  long  in  the 
upright  posture.     The  boy  was  active  and  lively,  though  thin.     He  never  had  any 


HYPERTROPHY.  261 

fit  or  convulsion ;  but  occasionally  seemed  uneasy,  and  then  would  relieve  himself 
by  laying  his  head  upon  a  chair.  He  had  never  squinted  nor  was  he  subject  to 
drowsiness,  or  starlings  during  sleep ;  and  his  pupils  contracted  naturally.  His 
appetite  was  good,  and  all  the  animal  functions  were  properly  performed.  Dr. 
Sweatman  got  Mr,  Mayo  to  see  the  child  with  him :  they  both  set  it  down  as  a  case 
of  hydrocephalus,  but  agreed  in  thinking  that  in  the  absence  of  symptoms  it  would 
be  wrong  to  risk  disturbing  his  digestive  organs  by  active  medicines.  In  the  early 
part  of  1835  the  child  died  of  inflammation  of  the  chest,  and  Dr.  Sweatman  and  Mr. 
Mayo  examined  the  head.  I  here  show  you  a  cast  of  it.  It  measured  from  ear  to 
ear,  over  the  vertex,  twelve  inches ;  from  the  superciliary  ridges  to  the  occipital, 
thirteen  inches  ;  and  in  circumference  twenty-one  inches.  The  anterior  fontanelle, 
which  was  quite  flat,  measured  across  its  opposite  angles  two  inches  and  a  quarter 
by  one  and  a  half;  the  posterior  fontanelle  was  completely  closed,  as  was  the  frontal 
suture.  There  was  no  absorption  of  bone  at  any  part ;  on  the  contrary  it  was 
becoming  thicker.  The  dura  mater  adhered  with  great  firmness  to  the  skull ;  and 
a  layer  of  false  membrane,  as  big  as  a  crown-piece,  was  found  upon  its  upper  and. 
anterior  part.  Beneath  the  arachnoid  at  that  part  there  was  slight  jelly-like  effusion. 
In  all  other  respects  the  organ  was  sound.  The  convolutions  were  perfectly  distinct, 
and  retained  their  proper  rounded  shape.  All  the  ventricles  were  found  empty, 
and  not  dilated.  The  surfaces,  however,  of  the  medullary  matter,  exposed  by  differ- 
ent sections,  presented  very  unusual  vascularity. 

The  lesson  we  learn  from  cases  of  this  kind  is,  that  we  are  not  to  regard  every 
child  that  has  a  very  large  head  as  a  hydrocephalic  child ;  and  especially  that  we 
are  not  to  inflict  upon  such  a  child  a  course  of  mercury,  or  other  active  remedies, 
unless  some  morbid  symptoms  appear.  The  nimia  cura  medici  may  in  these,  as  in 
many  other  cases,  destroy  health ;  produce  disease  where  none  existed  before. 

[The  subject  of  Hypertrophy  of  the  Brain  would  appear  to  demand  a  more  extended  notice 
than  has  been  given  in  the  text.  There  is  reason  to  believe  that  the  disease  is  of  more  fre- 
quent occurrence  than  is  generally  suspected,  and  that  to  it  are  to  be  ascribed  n  any  cases  of 
convulsions,  epileptic  attacks,  inflammation  and  softening  of  the  brain,  and  even  of  idiocy,  in 
which  the  connection  has  heretofore  been  entirely  overlooked  ;  we  know  that  hypertrophy 
of  the  brain  has,  in  more  than  one  instance,  been  mistaken  for  chronic  hydrocephalus,  and 
that  even  the  operation  of  tapping  the  brain  has  under  such  circumstances  been  proposed, 
nay,  probably  performed. 

Hypertrophy  of  the  brain,  or  at  least  a  condition  of  that  organ  predisposing  it  to  undue 
and  more  or  less  rapid  augmentation  in  bulk,  is  often  congenital.  Thus  children  are  not 
unfrequently  born  with  heads  of  dimensions  far  exceeding  the  usual  standard — ■while,  in 
other  instances,  the  head  soon  after  birth  is  found  to  augment  rapidly  in  bulk,  disproportion- 
ately to  the  growth  of  the  rest  of  the  body,  and  within  a  short  period  to  attain  an  enormous 
magnitude. 

When  the  cranium  is  developed  in  the  same  ratio  with  the  brain,  at  first  no  morbid  symp- 
toms arc  produced,  or  only  slight  ones.  In  almost  every  case,  however,  we  have  observed 
more  or  less  apathy,  dullness,  and  drowsiness,  to  accompany  these  cases  of  undue  develop- 
ment of  the  brain,  from  a  very  early  period. 

After,  however,  the  disease  has  existed  for  some  time,  and  particularly  when  there  is  a 
disproportion  between  the  morbid  development  of  the  brain,  and  the  expansion  of  tlie 
cranium,  the  patient  becomes  affected  with  apathy  to  external  objects,  a  disposition  to  som- 
nolency—  great  irritability  of  temper,  giddiness,  habitual  headache,  attended  with  sevm-e 
exacerbations  at  irregular  intervals,  and  inordinate  appetite.  The  intellect  becomes  more 
and  more  obtuse,  verging  occasionally  upon  complete  idiocy.  There  is,  usually,  a  debility  of 
the  muscles  of  the  extremities,  particularly  of  the  inferior,  which  constantly  increases,  until, 
finally,  complete  paralysis  results. 

The  bowels  are  usually  torpid,  and  the  pulse  remarkably  slow.  In  many  cases,  the 
muscles  are  affected  with  convulsive  twitchings,  at  first  slight,  and  occurring  at  long  irre- 
gular intervals,  but  gradually  becoming  more  severe  and  frequent,  until  regular  convul- 
sive paroxysms  ensue.  The  convulsions,  not  unfrequently,  assume  all  tlie  characteristics  of 
epilepsy. 

In  some  cases  there  suddenly  ensues  a  considerable  reduction,  and,  occasionally,  an  entire 
abolition  of  sensibility.  In  other  instances,  the  patient  is  suddenly  attacked  with  acute  deli- 
rium, quickly  followed  by  complete  coma  and  death.  J^'aniawas  observed  byAndral  in  one 
case.  In  the  majority  of  cases  that  have  fallen  under  our  notice,  the  patients  have  been 
mc lined  to  fat. 


262  DISEASES  OF  IHE  BRAIN. 

The  disease  is  divided  by  Andral  into  two  stages: — 1st.  The  chronic,  marked  Ly  few 
symptoms,  or  simply  by  slight  obtuseness  of  intellect — more  or  less  headache,  either  perma- 
nent or  intermittent — vertigo,  apathy,  drowsiness,  broken  at  irregular  intervals  by  convulsive 
paroxysms.  All  of  the  foregoing  symptoms  may  occur,  simultaneously  or  successively,  in 
the  same  case,  or  only  one  or  a  part  of  them  may  be  present.  2d.  The  acute  stage,  marked 
by  sudden  attacks  of  violent  convulsions,  idiocy,  epileptic  paroxysms,  deep  coma,  or  the 
ordinary  symptoms  of  acute  hydrocephalus. 

The  prognosis  in  cases  of  hypertrophy  of  the  brain  is  not  necessarily  unfavourable.  As  Dr. 
Lees  correctly  remarks,  the  affection  of  the  brain  is  rather  an  error  of  development  than  an 
actual  disease,  and  the  excess  of  nutrition  will  often  cease,  and  the  brain  may  even  leturn  to 
its  normal  state.  Many  patients  who  have  laboured  under  cerebral  hypertrophy  have  entirely 
recovered,  others  will  arrive  at  puberty,  or  even  a  more  advanced  age,  with  but  little  suffer- 
ing or  inconvenience,  while  others  again  die  at  an  early  age  from  the  accidental  occurrence 
of  hyperEemia  of  the  brain,  convulsions,  or  meningeal  inflammation.  In  some  instances  death 
occurs  suddenly  during  an  attack  of  convulsions — or,  the  patient  becoming  more  and  more 
comatose,  death  finally  ensues  without  a  struggle.  The  chief  danger  arises  from  the  very 
great  susceptibility  of  the  hypertrophied  brain  to  disease,  especially  upon  the  occurrence  of 
any  accidental  affection  of  one  of  the  other  organs,  or  of  either  of  the  affections  incident  to 
childhood. 

Upon  dissection,  the  brain  is  found  to  be  enlarged  in  size,  the  convolutions  being  flattened — ■ 
the  blood-vessels  containing  a  diminished  amount  of  blood,  the  cortical  substance  exhibiting 
iu  consequence  a  morbid  paleness,  with  but  little  or  no  serum  within  the  ventricles  or  be- 
neath the  membranes.  The  substance  of  the  brain  is  in  many  cases  increased  in  density. 
Sometimes,  according  to  Sims,  the  hyjiertrophy  is  confined  to  one  lobe,  or  to  the  corpora  striata 
or  thalami;  in  all  cases,  the  hypertrophy  is  chiefly  confined  to  the  cerebrum,  the  cerebellum 
being  seldom  much,  if  at  all  atfected.  Instances  occasionally  occur  in  which  the  vessels  of 
the  brain  are  injected  with  blood ;  others  where  a  slight  amount  of  reddish  serum  is  found 
at  the  base  of  the  brain, — and  others  again  with  a  clot  of  blood  within  the  substance  of  the 
brain,  and  rupture  of  the  fibres  of  its  medullary  portion ;  in  all  these  cases,  it  will  be  found, 
upon  an  inquiry  into  their  history,  that  death  was  preceded  by  symptoms  of  cerebral  disease, 
in  addition  to  those  which  properly  belong  to  simple  hypertrophy  of  the  brain. 

It  is  important  to  distinguish  the  hypertrophied  state  of  the  brain  from  chronic  hydroce- 
phalus, to  which,  particularly  in  its  advanced  stages,  its  phenoiuena  bear  a  strong  resem- 
blance, so  much  so  as  to  have  caused  the  two  to  be  not  unfrequently  confounded.  Drs.  Lees 
and  Muncmeyer  point  to  a  particular  and  very  striking  projection  of  the  parietal  protube- 
rances, in  hypertrophy  of  the  brain,  as  a  valuable  guide  in  our  diagnosis,  while  Dr.  Henms 
Green  suggests  the  difference  in  the  sensation  communicated  to  the  fingers  when  pressed  upon 
the  fontanelles  in  children  aflected  with  the  two  diseases,  as  a  diagnostic  sign.  The  sensation 
being  that  of  a  tense  membrane  filled  with  water  in  cases  of  hydrocejohalus,  and  of  a  firm 
solid  substance  in  cases  of  hypertrophy.  Dr.  Mauthner,  in  his  work  on  Diseases  of  the  Brain 
(Viciuia,  1S44),  lays  down  the  following  diagnosis  between  these  two  affections : — In  hyper- 
trophy, it  is  the  posterior  part  of  the  skull  which  is  first  observed  to  become  abnormally 
prominent,  the  projection  of  the  forehead  occurring  subsequently;  whereas,  in  chronic  hydro- 
cephalus, the  enlargement  of  the  forehead  is  one  of  its  first  results.  The  latter  affection  is 
usually  associated  with  a  general  emaciated  condition  of  the  body;  the  former  with  a  leuco- 
phlegmatic  habit,  and  an  increased  deposition  of  fat.  The  constitutional  symptoms  likewise 
differ  in  the  two  aflections — restlessness,  convulsions,  and  sopor,  mark  the  early  stages  of 
chronic  hydrocephalus,  while  spasmodic  aflections  of  the  respiratory  organs  are  among  the 
earliest  indications  of  hypertrophy  of  the  brain,  but  seldom  occur  until  the  advanced  stage 
of  hydrocephalus.      (See  Condie  on  Diseases  of  Children,  2d  edition.) — C] 

Having  told  you  what  I  know  of  hypertrophy  of  the  brain,  it  is  proper  that  I 
should  say  a  word  or  two  respecting  the  opposite  condition  ;  of  atrophy  of  the  cere- 
bral mass.  There  are  two  forms  of  this  affection  :  one  is  congenital,  and  results  from 
imperfect  development,  or  an  arrest  of  development,  of  the  brain  in  its  foetal  state.  In 
the  other  the  change  appears  to  take  place  in  consequence  of  disease,  either  in  the 
membranes  of  the  brain,  or  perhaps  in  its  arteries ;  though  the  effect  of  disease  in 
'.he  arteries  is  usually  softening,  which  is  a  species  of  atrophy.  But  in  the  atrophy 
to  which  I  am  now  alluding,  the  volume  of  the  atrophied  part  is  diminished,  not  its 
consistence.  And  the  diminution  of  size  may  extend  only  to  a  few  convolutions :  or 
it  may  be  most  manifest  in  the  interior  of  the  organ  ;  in  the  optic  thalami  and  corpcra 
.striata  for  example.  There  is  still  another  alteration  to  which  some  have  applied  the 
term  atrophy,  though  improperly,  I  think :  I  allude  to  those  cases,  which  I  shall 
speak  of  more  particularly  soon,  in  which  the  form  and  disposition  of  the  cerebral 
substance  is  altered,  the  convolutions  being  unfolded,  and  the  nervous  matter  spread 


i 


ACUTE    HYDROCEPHALUS.  263 

■9Ut  by  a  large  collection  of  fluid  in  the  interior  cavities  of  the  brain,  constituting  the 
disease  called  chronic  /lydroccphahis.  I  hav^e  not  much  to  say  upon  what  may  be 
styled  atrophy  proper  of  the  brain  :  that  it  will  give  rise  to  symptoms  we  cannot 
doubt,  but  that  it  shows  itself  by  any  pecuhar  or  characteristic  symptoms  is  what  I 
have  not  discovered. 

I  shall  content  myself,  on  this  subject,  with  showing  you  Cruveilhier's  representa- 
tion of  a  strongly  pronounced  example  of  atrophy  of  the  entire  cerebrum  on  one 
side.  The  drawing  from  which  this  engraving  was  made,  was  painted  from  the 
body  of  a  patient  who  died  in  the  Hotel-Dieu,  dropsical,  in  consequence  of  disease 
of  the  heart.  He  was  forty-two  years  old.  When  you  look  at  the  engraving  you 
will  perceive  that  the  left  side  of  the  cerebrum  is  diminutive  compared  with  the 
right.  It  filled  up,  however,  a  larger  space  than  it  appears  to  do  in  the  plate ;  for 
the  lateral  ventricle  on  that  side  was  distended  by  a  quantity  of  serous  fluid,  which 
ran  out  when  the  ventricle  was  punctured ;  and  then  the  surface  of  that  side  of  the 
brain  sank  down,  and  collapsed.  Still  the  convolutions  on  that  side,  and  all  the 
dimensions,  are  remarkably  less  than  on  the  other.  The  anterior  lobe  projected  half 
an  inch  further  on  the  right  than  on  the  left  side.  The  frontal  bone,  you  will  observe, 
is  much  thicker;  twice  as  thick  on  the  atrophied  as  on  the  natural  side;  and  the 
frontal  sinus  very  wide  and  open.  The  internal  parts  of  the  brain  are  all  diminished 
in  proportion.  There  was  a  large  quantity  of  serous  liquid  filling  and  distending 
the  subarachnoid  areolar  tissue.  The  nervous  matter  was  whiter  and  harder  on  the 
atrophied  side.  One  very  curious  thing  is,  that  the  left  lobe  of  the  cerebe/liwi  was 
the  bigger  of  the  two;  but  there  was  no  such  marked  difference  between  them  as 
between  the  two  sides  of  the  cerebrum. 

Now,  the  patient,  in  whom  this  singular  disproportion  between  the  two  sides  of  his 
brain  was  met  with,  had  been  incompletely  hemiplegic,  as  long  as  he  could  recollect, 
on  the  right  side ;  and  the  imperfectly  palsied  limbs  were  shrunk  and  withered,  and 
the  fingers  of  the  hand  contracted.  Yet  he  had  managed  to  walk  about  with  the 
help  of  a  stick  ;  and  there  was  nothing  remarkable,  one  way  or  the  other,  in  the  state 
of  his  intellectual  faculties. 

The  same  condition  has  been  seen  on  both  sides  of  the  brain :  the  organ  itself 
existing  in  miniature,  as  it  were,  and  lying  at  the  lower  part  of  the  vaulted  cavity 
of  the  cranium  :  the  intermediate  space  being  filled  up  with  water.  Tn  long-standing 
cases  of  this  description  you  hiust  not  suppose  that  the  nervous  matter  has  been 
compressed  into  a  smaller  compass  by  the  effused  fluid  ;  but  that  the  fluid  has  been 
poured  out  to  fill  that  part  of  the  skull  which  is  empty  of  brain,  and  which  must 
be  filled  with  something.    This  condition  of  the  cerebrum  is  accompanied  by  idiotcy. 

I  proceed  in  the  next  place  to  the  consideration  of  that  disease  to  which  the  name 
of  acufe  hydrocephalus  has  been  given.  By  that  term  1  desire  to  signify  wjfumma- 
tion  of  the  brain,  as  it  frequently  occurs  in  children,  and  especially  in  scrofulous 
children.  The  inflammatory  character  of  the  disorder,  though  not  always  very 
clearly  expressed  in  its  symptoms,  is  sufficiently  attested,  in  many  of  the  fatal  cases, 
by  the  changes  discovered  within  the  cranium. 

I  made  some  observations,  in  the  last  lecture,  respecting  the  nomenclature  of 
diseases,  and  said  something  in  defence  of  the  name  delirium  tremens.  Now  it  must 
be  confessed  that  the  complaint  we  are  about  to  consider  was  unfortunately  named, 
when  it  was  called  hydrocephalus.  I  repeat  that  it  matters  not  at  all  how  we  deno- 
minate a  disease,  provided  that  its  title  does  not  involve  any  erroneous  notion  of  its 
nature.  I  think  hydrocephalus  a  bad  name,  because  it  reminds  us  of  one  circumstance 
only  of  the  malady,  viz.,  the  serous  effusion,  which  so  far  from  being  the  caicse,  or 
the  essence,  is  only  a  frequent  effect  of  the  disease ;  nay,  it  is  no  uncommon  effect 
of  other  morbid  conditions  also,  besides  inflammation.  But  hydrocephalus,  or  water 
in  the  head,  is  an  appellation  so  established,  both  among  ourselves  and  with  the 
public,  that  I  cannot  venture  to  propose  any  change. 

After  what  I  have  already  stated  in  respect  to  inflammation  of  the  brain  in  adults, 
you  will  be  prepared  to  hear  that  acute  hydrocephalus  (remember,  I  restrict  that 
term  to  the  same  inflammatory  malady  as  it  occurs  in  strumous  children) — I  say  vow 


264  DISEASES   OF   THE   BRAIN. 

will  not  be  surprised  to  learn  that  acute  hydrocephalus  furnished  a  great  variety  of 
symptoms  ;  and  many  variations  in  the  mode  of  their  coming  on,  and  in  their  combi- 
nation, and  succession. 

It  is  of  the  greatest  importance  to  recognize  acute  hydrocephalus  in  its  earliest 
stages  ;  and  even  to  look  out  for  indications  of  its  approach.  I  shall,  therefore,  de- 
scribe those  changes  in  the  state  of  the  young  patient,  which  have  been  found  to  be, 
in  many  cases,  premonitory  that  the  disease  was  impending.  But  such  symptoms 
Hre  by  no  means  always  followed  by  acute  hydrocephalus ;  nor  is  acute  hydroce- 
phalus always  preceded  by  such  symptoms.  Still,  when  they  do  occur,  they  should 
put  us  upon  our  guard. 

The  precursory  symptoms  to  which  I  allude  consist  chiefly  in  a  morbid  state  of 
the  nutritive  functions.  The  child  loses  his  appetite  ;  or  his  appetite  becomes  capri- 
cious :  he  sometimes  appears  to  dislike  his  food,  and  sometimes  devours  it  voraciously: 
his  tongue  is  foul,  his  breath  offensive,  his  belly  enlarges,  and  sometimes  is  tender ; 
his  bowels  are  torpid,  and  the  evacuations  from  them  unnatural ;  the  stools  are  pale 
and  contain  but  little  bile ;  or  they  are  dark,  with  vitiated  bile,  foetid,  sour-smelhnaf, 
shni}',  or  scybalous  ;  and  the  child  loses  his  former  healthy  aspect,  becomes  paler, 
and  thinner.  Even  already  there  are  obscurer  indications  of  derangement  in  the 
cerebral  functions  ;  the  child  is  heavy,  languid,  and  dejected  ;  his  customary  spirit 
and  activity  are  gone ;  he  gets  fretful  and  irritable,  and  is  manifestly  uneasy ;  and 
sometimes  he  shows  a  little  unsteadiness  and  tottering  in  his  gait. 

In  very  young  children,  when  the  disorder  is  at  hand  or  incipient,  an  unnatural 
wakefulness  is  often  observable.  A  frequent  sudden  cry  or  scream,  a  clenching  of 
the  little  fists,  and  a  turning  in  of  the  thumb  towards  the  palm  of  the  hand,  givt 
warning  also  of  the  approaching  malady. 

Now  when  this  sort  of  alteration  is  observed  in  a  child  who  has  anj'-  hereditary 
title  to  scrofula,  or  bears  the  marks  of  the  strumous  diathesis,  or  is  even  a  precocious 
and  particularly  clever  child,  and  still  more  if  he  present  any  other  indications  of 
strumous  disease,  there  will  be  much  reason  to  apprehend  that  mischief  is  brewing 
within  his  head.  I  advert  to  these  tokens  of  scrolula,  because  the  inflammation,  in 
a  majority  of  cases,  if  not  in  all,  is  of  a  scrofulous  character.  But  there  is  this 
peculiarity  in  it,  which  distinguishes  it  from  scrofulous  inflammation  in  most  other 
parts,  viz.,  that  it  occurs  in  an  organ  of  a  very  delicate  structure,  and  one  which  is 
essential  to  life,  its  progress  is  more  rapid,  and  it  is  more  necessary  to  treat  the 
disease  promptly. 

It  has  been  made  a  question  whether  the  derangement  of  the  digestive  organs  that 
has  just  been  described  is  or  is  not  the  cause  of  the  affection  of  the  brain  ;  or  whether 
both  the  abdominal  and  cerebral  disorder  are  not  common  and  concurrent  effects  of 
the  same  cause.  It  is  said  that  the  stomach  and  bowels  are  more  in  the  way  of  being 
acted  upon  by  injurious  influences  than  the  brain,  and  that,  therefore,  the  complaint 
may  be  supposed  often  to  originate  in  their  derangement ;  and  great  good,  it  is  alleged, 
is  done,  the  disease  of  the  brain  is  often  prevented,  by  remedying  the  disordered 
condition  of  the  stomach  and  bowels.  On  the  other  hand,  it  may  be  stated  that  a 
similar  derangement  of  the  digestive  organs  often  comes  on  and  lasts  long  in  children, 
without  leading  to  hydrocephalus ;  and  hydrocephalus  often  attacks  a  child  in  whom 
no  such  symptoms  of  abdominal  disease  have  appeared.  We  can  never  be  certain, 
therefore,  that  hydrocephalus  has  been  prevented,  in  any  given  case,  by  remedies 
addressed  to  the  digestive  organs.  I  cannot  think  the  question  is  one  of  much  prac- 
tical imi^ortance.  Whether  the  disturbances  of  the  nutritive  functions  cause  the 
brain  disease,  or  merely  indicate  it,  they  are  equally  valuable  in  directing  our  atten- 
tion to  ihe  head. 

In  these  little  patients  any  source  of  irritation  seems  to  act  as  an  exciting  cause : 
aurgical  operations,  which  are  sometimes  necessary  at  that  tender  age — falls  or  in- 
juries of  any  kind — painful  dentition. 

There  arc,  at  least,  three  several  ways  in  which  tliis  disease  may  make  its  attacks  ; 
and  with  these  it  is  proper  that  you  sfiould  be  acquainted. 

In  the  first  place,  it  may  come  on  gradually  ;  after  such  symptoms  as  have  already 
bf!en  s[)ouen  of  as  being  premonitory.     Probably  this  is  the  way  in  which  it  most 


ACUTE   HYDROCEPHALUS.  265 

frequently  commences.  After  a  period,  of  uncertain  duration,  in  which  the  child  has 
complained  of  occasional  pains  in  the  belly  and  head,  and  signs  of  derangement  of 
the  stomach  and  bowels  have  been  present,  the  pain  in  the  head  begins  to  be  more 
severe  and  to  recur  more  frequently.  It  is  not  mere  headache,  but  generally  a  sharp 
shooting  pain,  recurring  at  intervals ;  sometimes  it  affects  one  side  of  the  head  more 
than  the  other ;  the  little  patients  wake  and  shriek  out  with  the  pain,  and  this  in 
children  is  a  very  characteristic  symptom.  As  coma  comes  on,  this  shrieking  gives 
place  to  an  habitual  moaning,  which  is  scarcely  less  characteristic.  Very  often  ic 
the  beginning  of  the  disease  there  are  pain  and  stiffness  at  the  back  of  the  neck ; 
sometimes  there  is  much  pain  of  the  limbs  in  the  early  periods,  and  in  some  chil- 
dren extreme  tenderness  of  the  scalp,  so  that  they  cannot  endure  to  have  the  head 
shaved.  The  pain  of  the  head  becomes  complicated  with  vomiting,  and  both  these 
symptoms  are  aggravated  by  motion.  Very  often  nausea  is  excited  by  the  erect  pos- 
ture, and  the  patient  begs  to  lie  down.  The  child  sighs  frequently,  and  looks  grave 
or  sad  ;  his  eyes  are  pained  by  a  strong  light,  so  that  he  knits  his  brows.  The  pulse 
becomes  rapid,  and  the  disturbance  and  irregularity  in  the  abdominal  functions 
increase.  This  stage  of  the  complaint  may  last  tea  days  or  a  fortnight,  the  child 
becoming  daily  more  weak,  and  more  peevish,  and  looking  more  and  more  ill. 

In  the  second  form  of  attack  there  are  no  premonitory  symptoms  ;  or  they  occur 
for  a  very  short  while  only  before  the  disease  sets  in  suddenly  and  violently,  with 
acute  pain  in  the  head  and  high  fever ;  or  with  convulsion  :  the  face  is  flushed,  the 
eyes  are  brilliant ;  there  is  intolerance  of  light  and  of  sound,  and  there  are  pain  and 
tenderness  of  the  abdomen.  In  short,  the  disease,  when  it  commences  in  this  man- 
ner, is  very  like  an  attack  of  continued  fever.  You  may  find  these  varieties  described 
in  Dr.  Cheyne's  excellent  treatise  on  this  disorder.  "We  are  led  to  suspect,"  he 
says,  "  some  deeply-seated  evil  from  the  frantic  screams  and  complaints  of  the  head 
and  belly,  alternating  with  stupor,  or  rather  lowness,  and  unwilhngness  to  be  roused ; 
and  we  are  struck  with  the  great  irritability  of  the  stomach,  which  exists  in  a  degree 
beyond  what  we  generally  find  it  in  the  fevers  of  this  country ;  retching  and  vomit- 
ing being  brought  on  by  a  change  of  posture,  and  certainly  by  every  attempt  to  sit 
up  in  bed ;  and  the  disordered  state  of  the  bowels,  which  attends  this  irritability  of 
the  stomach,  is  also  remarkable :  and  when  at  any  time  the  child  has  a  little  respite 
from  the  violence  of  these  symptoms,  we  find  our  suspicions  confirmed  by  his  looks  ; 
for  when  the  features  do  not  express  pain  or  terror,  there  is  not  unfrequently  a  vacancy 
of  look,  the  eyes  being  set,  with  an  expression  of  dejection  which  is  peculiar  to  cer- 
tain diseases  of  the  brain."  The  mode  of  attack  which  has  now  been  described, 
although  the  most  regular  in  its  progress,  is  not  so  common  as  the  first,  nor  as  the 
third,  which  I  have  yet  to  mention.  The  third  way  in  which  the  disease  makes  its 
advances  is  very  insidious :  the  head  symptoms  supervene  upon  the  subsidence  of 
some  other  malady  :  presently  after  the  disappearance  of  an  eruption  from  the  scalp  ; 
during  the  dechne  of  scarlet  fever,  small-pox,  hooping-cough,  or  any  inflammatory 
or  febrile  complaint;  and  even  after  painful  dentition.  In  these  cases  the  early 
symptoms  are  often  but  slightly  marked,  or  do  not  take  place  at  all ;  the  sudden 
occurrence  of  convulsions  or  paralysis  affording  the  first  evidence  that  the  brain  is 
implicated.  This  is  the  most  dangerous  form  of  hydrocephalus.  It  has  received  the 
expressive  title  of  water-stroke. 

In  whatever  way  the  disease  makes  its  invasion,  it  is  apt  to  be  attended  with  many 
and  variable  symptoms;  and  different  observers,  with  a  view  of  facilitating  their 
description  of  the  disease,  and  of  making  it  more  intelligible  and  more  easily  remem- 
bered, have  divided  the  symptoms  into  groups,  and  considered  each  group  as  charac- 
teristic of  a  particular  stage  of  the  malady.  But  they  have  not  all  done  this  in  the 
same  way.  It  may  be  of  use,  however,  to  inform  you  of  the  different  classifications 
which  have  thus  been  proposed.  Dr.  Whytt,  who  was  a  most  the  first  person  in 
this  country  who  wrote  upon  this  disease  (I  believe  Dr.  Paisley  of  Glasgow  was  the 
first :  you  may  see  his  paper  in  the  third  volume  of  the  Edinburgh  Medical  Es- 
says), Dr.  Whytt,  I  say,  whose  description  is  an  extremely  good  one,  took  the  pulse — 
which  undergoes  very  remarkable  variations  in  the  course  of  the  disease — as  th» 
ground  of  his  division.     He  makes  three  stages  of  it  therefore ;  the  first,  in  which 


^i 


26G  DISEASES    OF   THE   BRAIN. 

the  pulse  is  frequent;  the  second,  in  which  it  is  slow  and  irregular  ;  and  the  thiio, 
in  which  it  again  becomes  frequent  and  feeble.  These  successive  fluctuations  in 
the  pulse  are  to  be  noticed  in  very  many  cases.  Dr.  Golis,  again,  an  eminent  Ger- 
man writer  on  hydrocephalus,  whose  little  work  was  translated  by  the  late  Dr. 
Gooch,  as  being  the  best  book  on  the  subject  that  he  was  acquainted  with,  makes 
four  stages,  according  to  what  he  believes  to  be  the  condition  of  the  brain  in  each. 
First,  he  has  the  period  oi  tiirgescence,  which  corresponds  with  that  period  in  which 
the  premonitory  symptoms  occur;  secondly,  the  TpexioA  oi  infiaimnation ;  thirdly, 
the  period  of  ejfusion  ;  fourthly,  the  period  of  palsy.  The  two  last  would  appear 
to  be  almost  identically  the  same.  Dr.  Cheyne  makes  three  stages ;  which  he  finds 
marked,  not  like  Dr.  Whytt,  by  the  state  of  the  circulation,  but  by  the  state  of  the 
nervous  system.  Thus  he  calls  the  first  the  period  of  increased  sensibilily,  when 
every  stimulus  produces  an  impression  more  than  proportioned  to  its  common  effects. 
In  the  second  stage,  that  of  diminished  sensibility,  the  child  is  not  easily  roused,  his 
pupil  is  dilated,  and  his  pulse  slow ;  he  is  lethargic,  with  obstinately  costive  bowels. 
The  third  stage  with  him  is  that  of  palsy  and  convulsions,  in  which  there  is  squint- 
ing, rolling  of  the  head,  stupor,  convulsions,  with  a  rapid  thready  pulse. 

Cases  often  occur,  however,  that  baffle  all  these  attempts  at  classification.  Con- 
vulsions, instead  of  being  among  the  last,  are  not  seldom  among  the  very  Jirst  symp- 
toms. The  pulse  is  sometimes  remarkably  slow  at  the  outset ;  sometimes  frequent 
through  the  whole  disease  ;  and  sometimes  petfectly  natural. 

I  do  not  make  these  statements  to  magnify  the  difficulty  of  distinguishing  the  dis- 
ease ;  for  the  diagnosis  is  really  not  so  difficult  as  it  has  sometimes  been  represented  ; 
but  to  show  you  that  you  must  not  trust  to  any  succession  of  symptoms,  still  les^s  to 
any  one  symptom,  as  being  pathognomonic. 

The  symptoms  that  occur  during  the  first  stage  are  very  variable,  as  you  may 
suppose  from  what  I  have  said  of  the  different  modes  in  which  the  disease  is  apt  to 
set  in.  Those  that  are  most  constant  are,  pain  of  the  head,  severe  shooting  pain,  I 
say,  it  seems  to  be,  for  the  child  puts  its  hand  there,  and  cries  out  frequently,  "  Oh ! 
my  head  ;"  restlessness  ;  inability  to  sit  up  ;  very  disturbed  sleep,  with  grinding  of 
the  teeth,  and  from  this  sleep  the  child  often  starts  apparently  in  terror,  and  with  a 
scream.  The  head  is  hot  externally  ;  the  little  patient  is  annoyed  by  light  and  by 
noise ;  the  pupils  are  contracted  most  commonly  during  this  stage ;  the  child  is  un- 
wilHng  to  be  disturbed,  and,  therefore,  does  not  reply  readily  to  questions;  but  the 
replies,  when  made,  are  correct  and  rational.  This  stage  is  marked,  also,  by  vomit- 
ing, a  total  loss  of  appetite,  a  white  tongue,  offensive  breath,  costive  bowels,  unna- 
tural stools,  green  often,  or  black,  like  tar,  scanty  and  high-coloured  urine.  Dr. 
Golis  says  that  the  abdomen,  which  has  been  tumid  and  tender,  perhaps,  sinks  down 
and  becomes  flat,  without  any  increased  excretion  by  stool ;  and  that  this  is  a  very 
characteristic  symptom.  The  pulse  in  this  stage  is  frequent  and  sharp.  In  short, 
the  symptoms  are  such  (in  general)  as  indicate  very  plainly  that  inflannnatory  action 
is  going  on  within  the  head.  Now  the  symptoms  that  characterize  this  first  stage  of 
the  complaint  sometimes  rapidly  pass  into  those  which  belong  to  the  second.  They 
may  not  be  present  for  more  than  a  few  hours;  or  they  may  last  a  day  or  two,  or 
several  days ;  it  is  very  seldom,  I  believe,  that  they  continue  longer  than  a  week. 
The  period  answers,  in  the  general  character  of  the  symptoms,  to  the  period  of 
excitement  in  encephalitis,  w^hich  I  repeat  is  very  much  the  same  disease,  modified 
by  its  occurrence  in  the  adult  and  otherwise  healthy  subject. 

So,  also,  the  second  stage  of  acuie  hydrocephalus  corresponds,  in  its  general 
features,  with  the  period  of  collapse  in  encephalitis.  The  pulse  becomes  irregular, 
extremely  variable  and  fluctuating,  and  often  slow :  it  is  easily  accelerated,  however, 
by  the  smallest  exertion — by  taking  the  child  out  of  bed,  or  even  raising  him  into  a 
sitting  posture.  With  this  slowness  of  the  pulse  come  on  a  diminution  of  sensibility, 
and  general  heaviness  and  stupor;  the  pupils  dilate,  the  light  is  no  longer  trouble- 
some, the  vision  is  imperfect,  often  it  is  doubtful  whether  the  child  sees  at  all.  If 
the  eye  be  closely  examined  and  watched,  the  degree  of  light  remaining  the  same, 
the  size  of  the  pupil  will  frequently  be  seen  to  fluctuate  or  oscillate,  till  at  last  it  is 
wide  open  and  immovable.     While  this  goes  on  squinting  takes  place,  and  double 


ACUTE    HYDROCEPHALUS.  267 

Vision  when  the  child  can  yet  see  any  thing.  One  or  both  eyes  are  turned  in,  or 
more  rarely  outwards.  Noises  do  not  now  disturb  or  irritate  the  child — who  hes  on 
his  back,  with  the  eyes  half  closed,  in  a  state  of  drowsiness  or  stupor,  which  is  oc- 
casionally interrupted  by  some  cry  or  exclamation  expressive  of  pain.  Convulsions 
frequently  occur,  but  not  uniformly;  slight  and  partial  spasmodic  twitchings;  or 
general  and  long-continued  convulsions ;  paralysis ;  sometimes  hemiplegia.  The 
urine  and  stools  are  passed  unconsciously.  Sometimes  the  shild,  with  feeble  and 
tremulous  hands,  is  incessantly  picking  his  lips,  or  boring  his  fingers  into  his  ears 
or  nostrils. 

This  stage  may  last  a  week  or  two.  And  what  is  remarkable,  it  is  often  attended 
with  remissions,  sometimes  sudden  and  sometimes  gradual — deceitful  appearances 
of  amendment,  and  even  of  convalescence.  The  child  regains  the  use  of  its  senses  ; 
recognizes  those  about  him  again  ;  appears  to  its  anxious  parents  to  be  recovering ; 
but  in  a  day  or  two  it  relapses  into  a  state  of  deeper  coma  than  before.  And  these 
fallacious  symptoms  of  improvement  may  occur  more  than  once. 

The  third  stage  does  not  differ  materially  in  the  character  of  the  symptoms  that 
accompany  it,  from  the  second,  except  that  the  pulse  again  becomes  frequent,  nay, 
uncommonly  rapid  :  beating  sometimes  200  strokes  in  the  minute,  so  that  you  can 
scarcely  count  it.  Dr.  Whytt,  in  one  instance,  reckoned  more  than  210  pulsations. 
The  child  rolls  its  head  perpetually  from  side  to  side  ;  moans  continually ;  waves  its 
hands  in  the  air,  or  one  hand,  the  other  frequently  being  palsied  ;  sometimes  there  is 
paralysis  of  one  side,  and  conv^ulsive  twitchings  of  the  other.  The  circulation  is 
very  unequal ;  one  part  of  the  body  will  be  found  hot  and  dry,  and  another  covered 
with  a  cold  sweat :  the  cheeks  are  alternately  pale  and  flushed  ;  the  child  is  raving, 
or  insensible  ;  the  rapid  pulse  gets  more  and  more  weak ;  and  at  length  the  patient 
expires.  In  many  instances  death  takes  place  in  the  midst  of  a  strong  convulsion. 
This  last  period  is  of  very  uncertain  duration ;  it  may  be  over  in  a  few  hours,  or  it 
may  last  a  fortnight. 

For  my  own  part,  I  conceive  that  for  all  practical  purposes  it  would  be  quite 
enough  to  make  two  stages  only  of  this  disease.  In  the  first  the  symptoms  are  those 
of  inflammation  of  the  parts  within  the  cranium,  or  of  some  of  those  parts ;  in  the 
second,  we  have  the  symptoms  that  result  from  the  consequences  and  products  of  the 
inflammation,  from  softening,  and  from  the  effusion  of  serum.  And  frequently  these 
sets  of  symptoms  are,  in  some  respects,  common  to  both  these  causes ;  and  more 
frequently  still  they  are  mixed  up  together,  effusion  taking  place,  yet  the  inflamma- 
tion going  on.  And  we  may  understand  how  the  whole  collection  of  symptoms  may 
vary  and  fluctuate,  and  assume  an  uncertain  character,  according  as  the  inflamma- 
tory process  has  ceased,  or  is  still  in  progress ;  according  as  it  exists  alone,  or  is 
mingled  with  the  further  source  of  cerebral  disturbance  that  is  furnished  by  its  own 
events ;  and  according  as  the  inflammation  may  have  come  to  an  end,  while  its 
events  remain  behind,  and  declare  their  presence  by  appropriate  signs  in  proportion 
to  their  place  and  extent,  and  their  various  kinds  and  combinations. 

What  are  these  events  ?  In  other  words,  what  are  the  morbid  appearances  pre- 
sented after  death  in  acute  hydrocephalus  ? 

In  some  cases  we  find  traces  of  inflammation  of  the  membranes  of  the  brain ;  a 
firm  attachment  of  the  skull-cap  to  the  dura  mater :  occasionally  some  adhesion  of 
the  opposite  surfaces  of  the  arachnoid  membrane  to  each  other.  Very  commonly 
there  is  an  effusion  of  serous  fluid  beneath  the  arachnoid  in  the  meshes  of  the  pia 
mater,  and  especially  in  the  depressions  between  the  convolutions.  You  would 
suppose,  upon  looking  at  this  collected  fluid  through  the  arachnoid,  that  it  had  the 
consistence  of  jelly,  but  it  is  not  so  ;  if  you  divide  the  arachnoid  by  means  of  a  sharp 
scalpel,  a  perfectly  limpid  fluid  makes  its  escape.  Not  unfrequently  there  are  layers 
of  coagulable  lymph  interposed  between  the  arachnoid  and  pia  mater ;  this  is  a  most 
unequivocal  evidence  of  foregone  inflammation ;  and  it  is  more  frequently  met  with 
in  the  strongly  marked  cases.  When  portions  of  the  cerebral  mass  are  removed  by 
shcing  it,  a  great  number  of  red  points  are  often  observed,  speckling  its  cut  surface  ; 
I  mention  this  appearance  just  to  say,  that,  to  the  best  of  my  belief,  it  does  not  war- 
rant any  conclusion  in  repect  to  the  state  of  the  brain  before  death.     We  find  th.ef.» 


268  DISEASES    OF    THE    BRAIN. 

red  spots  numerous  in  many  cases,  where  there  had  been  no  cerebral  affection  rnani 
fested  during  hfe  ;  and  they  are  not  always  to  be  seen  when  we  are  certain  that  there 
was  inflammation. 

[The  gray  substance  of  the  convolutions,  in  cases  in  which  the  sub-arachnoid  tissue  is 
strongly  injected,  is  usually  of  a  pale  rose,  or  bright  red  colour.  The  lining  membrane  of 
the  ventricles  is  occasionally  injected,  opaque,  or  covered  with  a  pseudo-membranous  exuda- 
tion, or  with  numerous  white  flocculi,  which  become  very  apparent  when  the  membrane  is 
immersed  in  water.  It  is  often  easily  separated  from  the  cerebral  substance.  The  plexus 
choroides  is  very  often  injected,  and  thickened ;  sometimes,  however,  it  is  pale  and  dis- 
coloured, and  lined  with  small  hydatiform  cysts :  this  latter  appearance  has,  also,  been  found 
in  the  cellular  texture  of  the  pituitary  gland. — C] 

With  respect  to  the  nervous  matter  itself  it  is  said  to  be  sometimes  softer  than 
natural,  and  occasionally  it  has  been  found  infiltered,  as  it  were,  with  serous  fluid ; 
wet,  and  so  rendered  soft,  Gohs  describes  an  instance  of  this  kind,  in  which, 
he  says,  the  fluid  could  be  expressed  from  the  cerebral  substance  as  from  a 
sponge. 

[In  some  cases  the  substance  of  the  brain  has  been  found  of  a  firmer  consistence  than 
natural,  and  to  a  certain  extent  hypertrophied.  A  case  is  related  by  Golis,  in  which,  upon 
opening  the  skull,  tlie  whole  brain  expanded,  so  that  it  could  not  again  be  replaced  within  the 
cranium.  The  convolutions  are  sometimes  flattened,  apparently  from  pressure  against  the 
ckulL— C] 

But  the  most  common  and  characteristic  change  is  softening  of  the  central  parts 
of  the  brain,  tvith  an  elusion  of  serous  fluid  iiito  the  ventricles.  Generally  the 
effiised  fluid  is  thin  and  watery  ;  serosity  rather  than  serum.  It  contains  less  animal 
matter,  perhaps,  than  any  other  animal  production.  Dr.  Bostock  found  that  of  103 
parts,  98.6  consisted  of  water,  1  part  of  salt,  and  .4  only  of  animal  matter.  It  is  not, 
therefore,  in  common,  coagulable  by  heat.  The  quantity  effiised  is  uncertain ; 
speaking  generally,  it  varies  from  two  to  six  ounces. 

[In  many  cases  the  amount  of  effused  fluid  is  very  trifling ;  in  some  scarcely  a  trace  is  to 
be  discovered.  The  efibsion  may  take  place  in  the  arachnoid  or  sub-arachnoid  tissues,  or  in 
the  ventricles,  or  in  all  these  parts  at  the  same  time.  The  greatest  amount  is  generally  met 
with  in  the  lateral  ventricle — occasionally  the  quantity  is  so  great  as  to  enlarge  the  posterior 
cornea,  elevate  the  fornix,  rupture  the  septum  lucidum,  and  thus  establish  a  free  communi- 
cation between  all  the  ventricles.  The  cellular  tissue  of  the  choroid  plexus  may  also  be 
distended  with  serum.  When  the  serous  efi'usion  in  the  brain  is  considerable,  it  is  often 
found  also  in  the  spinal  canal. — C] 

But  the  effused  fluid  is  not  always  clear  and  limpid  ;  sometimes  it  is  turbid,  like 
whey,  or  even  puriform,  with  flocculent  shreds  floating  in  it.  These  have  been  con- 
sidered as  flakes  of  coagulable  lymph  ;  but  I  question  whether,  in  many  cases,  they 
are  not  merely  fragments  of  the  softened  and  broken-down  materials  in  the  neigh- 
bourhood ;  for  the  septum  lucidum,  the  fornix,  and  other  parts  forming  the  walls  of 
the  ventricles,  are  very  commonly  found  soft,  and  pulpy,  or  entirely  disorganized.* 
The  septum  lucidum  is  perforated  perhaps  by  a  ragged  irregular  opening,  the 
softened  portion  having  fallen  out ;  the  fornix  has  lost  its  consistence,  and  often  its 
flgure,  or  falls  asunder  when  the  most  gentle  attempt  is  made  to  raise  it,  Dr,  Aber- 
crombie  holds  not  only  that  this  softness  is  the  result  of  inflammation,  which  I  think 
cannot  reasonably  be  doubted,  but  that  the  inflammation  of  these  central  white  pans 
constitutes  the  essence  of  the  disease,  in  very  many  cases  of  acute  hydrocephalus  ; 
and  what  bears  him  out  in  this  opinion  is  the  interesting  fact,  that  this  softened  con- 
dition of  the  septum  lucidum,  fornix,  and  corpus  callosum,  may  be  fatal  without  any 
effusion  of  serum,  and  without  any  other  morbid  appearance,  although  with  all  the 
symptoms  which  are  usually  considered  to  indicate  acute  hydrocephalus.  He 
rt4ates  two  striking  examples  of  this  kind;  one  of  them  was  as  follows, — A  woman 
became  affected  with  violent  pain  in  her  head,  shooting  from  temple  to  temple. 
She  was  extremclv  restless,  tossing  from  one  side  of  the  bed  to  the  other ;  her  eyes 
were  slighil}  suffuspd,  and  impatient  of  the  light;  pupils  contracted  ;  the  pulse  tiO, 
soft  and  rather  weak.     She  was  repeatedly  bled,  both  generally  and  topically,  and 

[•   This  is  the  opinion  of  Barthez  and  Rilliet.] 


ACUTE   HYDROCEPHALUS.  269 

used  purgatives,  cold  applications  to  the  head,  blistering,  &c.  For  three  days  she 
was  nnuch  relieved  by  these  measures :  the  violent  pain  was  removed,  and  she  com- 
plained of  pain  only  when  she  moved  her  head.  She  was  quite  sensible,  but 
oppressed,  and  inchned  to  lie  without  being  disturbed.  At  the  end  of  four  days  her 
speech  became  affected,  of  which  she  was  aware,  for  she  said  she  felt  a  difficulty  in 
getting  out  her  words.  Then  came  stupor,  and  at  times  incoherence,  and  double 
vision,  and  at  last  coma,  and  dilated  pupil.  She  died  on  the  eighth  or  ninth  day  of 
the  disease. 

The  fornix  and  septum  lucidum  were  found  broken  down  into  a  soft  white  pulpy 
mass  ;  there  was  no  effusion  in  the  ventricles,  and  no  other  disease  in  any  part  of 
the  brain. 

[In  the  cells  of  the  arachnoid  membrane  there  is  often  deposited  a  concrete  yellowish 
matter,  either  soft  and  inelastic,  or  somewhat  firm,  elastic,  and  of  a  shining  appearance.  It  is 
deposited  either  in  patches,  or  in  lines  bordering  the  blood-vessels;  and,  as  is  the  case  with 
all  the  indications  of  inflammation  in  this  disease,  it  is  more  commonly  met  with  at  the  base 
than  at  the  summit  of  the  brain.  Granulations  and  miliary  tubercles  are  often  interspersed 
in  its  midst.  The  whole  base  of  the  brain  is  often  covered  with  a  continuous  layer  of  the 
yellowish  gelatinous  deposit  alluded  to.  This  deposit  differs  from  the  matter  effused  in  in- 
flammation occurring  in  persons  unaffected  with  tuberculous  disease  ;  the  difference  is  thus 
traced  by  Barthez  and  Rilliet  (^Malad.  des  Enfants,  tom.  iii).  The  former  is  almost  always 
solid,  the  latter  almost  always  fluid ;  the  former  occurs  more  especially  at  the  base  of  the 
brain,  the  latter  upon  its  convex  surface ;  the  former  is  of  limited  extent,  particularly  when 
upon  the  surface  of  the  hemispheres,  the  latter  may  spread  over  the  greater  portion  of  the 
surface  of  the  brain  ;  finally,  the  former  is  almost  invariably  found  in  the  cells  of  the  pia 
mater,  while  the  latter  occurs  habitually  in  the  great  cavity  of  the  arachnoid. — C] 

Not  unfrequently  scrofulous  tubercles  are  discovered  in  the  substance  of  the  brain ; 
and  it  is  probable  that  these  would  have  been  more  frequently  met  with  if  they  had 
always  been  carefully  looked  for.  They  consist  almost  universally  of  a  cheesy  kind 
of  matter,  hke  that  of  large  tubercles  in  the  lungs. 

[Tubercles,  varying  in  size  from  that  of  a  pin's  head  to  that  of  a  pea,  are  very  generally 
found  scattered  irregularly  over  the  surface  of  the  pia  mater,  following  it  between  the  con- 
volutions ;  occasionally,  however,  they  occur  in  distinct  patches  of  an  inch  or  more  in  extent. 
They  are  commonly  hard,  and  semi-transparent,  sometimes  opaque  and  of  a  whitish,  grayish  or 
yellowish  colour.  They  are  found  upon  all  parts  of  tlie  surface,  the  convex  and  lateral  portions 
as  well  as  the  base,  in  the  infractuosities  of  the  convolutions,  and  in  the  fissures.  According  to 
Rilliet  and  Barthez,  they  are  more  frequent  upon  the  convex  surface  of  the  hemispheres  than 
at  the  base.  Dr.  Hamernjh  (^Schmidt's  Jahrbucher,  1845)  fo;md  them  more  frequently  at  or 
near  the  base  of  the  brain.  They  are  much  more  abundant  upon  the  brain  tlian  the  cere- 
bellum. They  are  met  with,  also,  imbedded  in  the  gray  matter  of  the  brain,  and  are  her* 
often  surrounded  by  a  halo  of  redness,  usually  connected  with  an  enlarged  vessel,  ramifying 
from  the  pia  mater.  More  rarely,  tubercles  are  detected  in  the  medullary  portion  of  the 
brain,  where  they  are  often  overlooked  in  consequence  of  their  pale,  semi-transparent,  yellow- 
ish tint.  The  plexus  choroides,  is,  also,  often  covered  with  tubercles.  They  are  very  com- 
monly met  with,  likewise,  on  tbe  serous  membranes  of  the  thorax  and  abdomen,  in  the  lungs, 
and  occasionally  in  the  substance  of  the  liver.  In  twenty-seven  ovtt  of  thirty-three  cases  of 
hydrocephalus,  Barthez  and  Rilliet  found  tubercles  or  granulations,  associated  with  inflam- 
mation of  the  pia  mater;  in  four  cases  the  meningitis  was  unattended  by  any  trace  of  tuber- 
cular deposition  in  the  encephalon ;  and  in  two  cases,  the  granulations  or  meningeal  tubercles 
were  unattended  with  any  traces  of  inflammation.  In  all  the  thirty-three  cases  the  symptoms 
were  nearly  identical. — C] 

You  will  find  a  good  deal  said  by  writers  on  this  disease,  of  morbid  appearances 
found  in  other  parts  besides  the  brain,  and  especially  in  the  abdominal  organs,  — 
enlargement  of  the  liver,  inflammation  of  its  peritoneal  covering,  a  preternatural 
development  of  Peyer's  glands,  tuberculous  matter  in  the  glands  of  the  mesentery. 
One  remarkable  change  is  very  often  seen,  viz.,  intussusception  of  the  small  intes- 
tines. This  probably  takes  place  a  short  time  only  before  death,  and  appears  to  be 
the  result  of  spasmodic  or  irregular  movements  of  the  bowels,  analogous  to  those 
which  are  observed  in  the  voluntary  muscles.  The  intussuscepted  portions  arc 
easily  pulled  out,  and  show  no  marks  of  inflammation. 

There  have  been  endless  discussions  respecting  the  true  pathology  of  acute  hydro- 
cephalus, and  it  may  be  proper  that  I  should  offer  you  a  few  remarks  upon  thi* 
point,  before  I  proceed  to  the  treatment  of  the  disease 

x2 


270  DISEASES    OF    THE   BRAIN. 

I  need  not,  I  conceive,  take  any  further  pains  to  convince  you  that  the  disease  is 
essentially  inflammatory.  We  are  inevitably  led  to  that  conclusion  by  the  symptoms, 
which  nearly  resemble  those  that  occur  when  undoubted  inflammation  has  arisen 
from  injuries  of  the  head  :  by  the  appearances  on  dissection,  which  are  always  such 
as  inflammation  may  have  produced,  as  softening  and  effusion  of  serum ;  and 
frequently  such  as  nothing  but  inflammation  could  have  produced,  as  suppuration, 
and  the  formation  of  adventitious  membranes  :  and  lastly,  by  the  unequivocal  relief 
given  by  blood-letting,  and  other  evacuations,  the  blood  drawn  being  sometimes  also 
sizy. 

Many  persons,  as  I  have  already  hinted,  lay  great  stress,  when  discussing  the 
pathology  of  acute  hydrocephalus,  upon  the  previous  unhealthy  state  of  the  nutri- 
tive apparatus.  They  hold  that  the  primary  disease — the /o;is  et  origo  mali — lies 
in  the  stomach,  or  bowels,  or  hver  ;  and  that  the  brain  affection  is  secondary,  and 
caused  by  sympathy  with  these  distant  parts :  and  this  opinion  they  fortify  by  refer- 
,  ring  to  the  frequency  of  organic  disease,  met  with  after  death,  in  the  abdominal 
viscera.  In  accordance  with  these  views  of  its  origin,  they  propose  to  cure,  or  to 
prevent,  hydrocephalus,  by  redressing  the  fauhy  condition  of  the  digestive  organs. 

Now  this,  in  my  judgment,  is  not  only  an  erroneous,  but  an  unsafe  doctrine  :  for 
it  tends  to  divert  our  attention  from  the  head,  and  to  suggest  a  feeble  and  inadequate 
plan  of  treatment.  The  grand  predisposing  cause  of  acute  hydrocephalus  is  cer- 
tainly the  scrofulous  diathesis,  and  this  is  why  we  see  the  complaint  run  so  often  in 
families  :  so  that  one  child  having  died  of  that  disorder  afl^ords  much  ground  for 
apprehending  that  others,  belonging  to  the  same  family,  will  become  victims  to  it. 
The  constitutional  tendency  is  hereditary,  and  children  born  with  it  are  liable  and 
likely  to  have  strumous  disease  set  up  in  various  organs  at  once,  or  perhaps  in  suc- 
cession ;  not,  however,  a  succession  of  cause  and  effect,  but  of  common  relation  to 
one  pervading  disposition.  We  need  not  be  surprised  that  scrofulous  inflammation 
should  affect  the  brain  and  abdomen  at  the  same  time.  When  we  find  obvious 
organic  disease  of  the  brain,  scrofulous  tubercles  for  instance,  which  must  have  been 
antecedent  to  the  hydrocephalus,  it  would  be  just  as  absurd  to  look  to  the  abdomen 
for  the  cause  of  the  hydrocephalus,  as  it  would  be  to  seek  in  the  brain  for  an  expla- 
nation of  the  cause  of  jaundice  or  of  dysentery,  when  the  liver  or  the  colon  w'as 
known  to  be  diseased. 

I  do  not  mean  to  assert  that  the  morbid  conditions  of  the  brain  and  of  the  abdomen 
are  perfectly  independent  each  of  the  other.  The  vomiting  that  is  so  constant  a 
feature  of  acute  hydrocephalus,  the  constipation  that  is  so  common  a  consequence  of 
head  affections,  affords  familiar  evidence  of  the  influence  which  cerebral  disorders 
may  exercise  upon  the  abdominal  functions.  Conversely,  any  disease  in  other  ptyts 
of  the  body  may  react  injuriously  upon  the  brain,  and  may  sometimes  be  regarded 
as  an  exciting  cause  of  disease  in  that  organ. 

The  period  of  life  is  also  a  strong  predisposing  circumstance  ;  acute  hydrocephalus 
being  very  much  more  frequent  during  infancy  and  childhood  than  at  any  subsequent 
time.  It  is  said  that  fifty  children  are  attacked  by  it  in  the  first  five  months  of  life, 
for  one  child  that  has  it  afterwards.  But  it  may  occur  at  any  age  up  to  the  twelfth 
or  fourteenth  year.     After  that  period  it  is  comparatively  rare. 

Whatever  tends  to  deepen  and  aggravate  the  scrofulous  diathesis  —  improper  or 
msufficient  nutriment,  exposure  to  cold,  inadequate  clothing,  impure  air  —  may  be 
regarded  as  Vi  predisposing  cause  of  acute  hydrocephalus.  And  whatever  tends  to 
call  scrofulous  disease  into  action,  may  be  reckoned  among  the  possible  exciting 
causes  of  acute  hydrocephalus.  Any  general  irritation  may  bring  it  on.  It  some- 
times supervenes  upon  the  drying  up  or  repression  of  eruptions,  as  tinea  capitis,  or 
sores  behind  the  ears.  Such  eruptions,  therefore,  occurring  in  strumous  children, 
we  must  not  attempt  to  cure  suddenly  ;  and  free  purging  should  be  employed  when 
they  begm  to  disappear.  The  irritation  produced  by  difficult  and  painful  dentition 
IS  a  very  frequent  exciting  cause  ;  and  this  is  a  source  of  danger  which,  in  many 
cases,  may  be  obviated  by  timely  and  judicious  management.  Violent  heating 
exercise  has  sometimes,  apparently,  kindled  the  cerebral  inflammation.  Among  the 
4'xciting  causes  we  may  place  all  physical  injuries  which,  jar  and  stun  the  brain. 


ACUTE    HYDROCEPHALUS.  271 

blows  on  the  head,  falls  from  a  height,  although  the  head  may  not  be  the  part  struck  i 
and  all  moral  agencies  which  shock  or  strongly  disturb  the  nervous  system  ;  severe 
bodily  pain,  violent  fits  of  anger,  sudden  fright.  Golis  goes  even  so  far  as  to  say 
that  great  terror  and  distress  of  mind  in  the  mother  during  the  latter  months  of  preg- 
nancy may  lead  to  the  occurrence  of  acute  hydrocephalus  in  the  child  ;  and  he  brings 
forward  this  curious  fact  in  support  of  his  opinion  : — A  large  proportion  of  the  chil- 
dren that  were  born  in  Vienna  soon  after  the  bombardment  of  that  place  by  the 
French,  in  1809,  were  seized  with  convulsions  within  a  month  after  their  birth,  and 
died  of  inflammation  within  the  cranium ;  effusion  of  coagulable  lymph  between  the 
membranes,  and  of  serum  in  the  ventricles,  being  discovered  on  dissection.        ^ 


LECTURE  XXVI. 

^citfe  Hydrocephalus,  continued.  Prognosis  and  Mortality  tf  the  Disease. 
Treatment ;  Blood-letting ;  Purgatives ;  Cold ;  Mercury ;  Blisters.  Pro- 
phylaxis. Spurious  Hydrocephalus.  Chronic  Hydrocephalus,  or  Dropsy  of 
the  Brain.  Shape  of  the  Head  and  Face.  Anatomical  Conditions.  Symp- 
toms. 

The  disease,  of  which  I  described  the  symptoms  in  the  last  lecture,  acute  hydro- 
cephalus, is  a  very  dangerous  disease :  and,  when  once  it  is  fairly  established,  many 
more  die  of  it  than  recover.  Our  chance  of  saving  the  patient's  life,  by  appropriate 
treatment,  is  always  greater  in  proportion  as  the  complaint,  or  the  tendency  to  the 
complaint,  is  detected  ear/?/;  and  for  that  reason  the  precursory  symptoms  possess 
so  high  an  importance. 

When  our  treatment  commences  while  the  symptoms  are  as  yet  rather  those  of 
the  ppecursory  state,  than  of  the  confirmed  disease,  it  is  impossible  to  say  how  many 
of  those  cases  which,  under  such  treatment,  terminate  favourably,  would  otherwise 
have  ripened  into  well-marked  hydrocephalus;  and  we  must  be  content  to  have  it 
said,  VN-ithout  its  being  possible  for  us  to  refute  the  assertion,  that  not  all  of  the  dis- 
orders which  we  treat  as  acute  hydrocephalus  are  really  instances  of  that  complaint. 
We  must  act  upon  the  worst  supposition,  and  not  wait  until  the  nature  of  the  symp- 
toms demonstrates  that  the  malady  is  present,  while  it  demonstrates  also,  at  the  same 
time,  that  it  is  well  nigh  hopeless.  These  are  cases  which  peculiarly  demand  de- 
cision on  the  part  of  the  medical  man ;  and  we  are  bound  to  act,  in  some  instances 
upon  very  shght  indications ;  as  when,  for  example,  we  perceive  what  Ave  thinV 
threatenings  of  acute  hydrocephalus  in  a  scrofulous  child,  or  in  a  child  belonging 
to  a  family  in  which  others  have  already  been  cut  off  by  that  disorder. 

It  has  been  supposed,  by  some,  that  the  case  is  hopeless  after  effusion  has  taken 
place,  but  we  cannot  be  sure  of  that ;  nay  more,  there  are  no  symptoms  by  which 
we  can  ever  ieWfor  certain  that  effusion  has  taken  place, 

I  remember  to  have  heard  it  gravely  maintained,  in  the  debating  societies  which 
I  sometimes  attended  when  a  student,  that  there  are  no  such  things  as  absorbents, 
and  no  absorption,  in  the  brain ;  and  therefore  that  perfect  recovery  from  serous 
effusion  in  that  organ  is  impossible.  [There  is  no  evidence  that  the  effusion  within 
the  cranium  is  the  cause  of  danger,  or  even  of  the  symptoms  which  mark  the  latter 
stage  of  the  disease. — C]  But  this  notion  is  refuted  by  plain  and  well-known  facts. 
We  shall  see  hereafter,  that  blood  poured  forth  within  the  nervous  pulp  is  capable 
of  being  removed  by  absorption.  How  an  opinion  so  palpably  erroneous  could 
ever  have  found  credit,  except  with  that  class  of  men  who  can  or  will  believe  nothing 
which  they  cannot  see,  I  am  at  a  loss  to  guess. 

The  prognosis,  always  doubtful  or  bad,  is  a  little  better  when  the  disease  is  vio- 
lent, and  occurs  in  tolerably  healthy  subjects,  than  when  it  creeps  on  slowly  and 
insidiously,  and  in  weakly,  scrofulous  patients.  In  the  former  case  there  is  more 
room  for  the  adoption  of  active  measures ;  and  the  diseaso  is  more  hkely  to  be  ame- 


272  DISEASES    OF    THE    BRAIN. 

nable  lo  remedies,  and  less  likely  to  be  obstinate ;  it  is  also  less  likely  to  depend 
upon  a  permanent  cause,  such  as  "the  existence  of  a  scrofulous  tumour  in  the  brain. 

The  probable  issue  of  the  disease  is  often  judged  of  by  the  state  of  the  pulse. 
The  quick  pulse  belonging  to  the  earh^  stages  of  the  disease  will  become  slow ;  but 
it  may  become  slow  in  two  very  different  ways :  it  may  diminish  in  frequency  in  a 
gradual  and  moderate  manner,  and  then  we  may  hope  that  the  alteration  proceeds 
from  the  progressive  declension  of  the  fever  ;  or  it  may  drop  suddenly,  which  would 
be  a  reason  for  our  fearing  that  the  second  stage  of  the  disease  was  about  to  estab- 
lish itself.  We  must  take  care,  under  the  former  circumstances,  not  prematurely  to 
assert  that  the  disorder  is  on  the  decline,  and  the  patient  safe.  On  the  other  hand, 
if  the  pulse  has  been  morbidly  slow,  a  gradual  and  slight  increase  in  its  frequency 
must  be  considered  as  a  favourable  omen  ;  while  its  rapid  and  great  acceleration 
would  show  that  the  disease  was  passing  into  its  worst  and  final  stage. 

I  have  already  cautioned  you  against  being  misled  by  that  deceitful  truce,  and  ap- 
parent improvement,  which  is  apt  to  take  place  in  the  course  of  the  disease.  If  the 
signs  of  amendment  continue,  or  make  progress,  during  two  or  three  entire  days,  we 
may  venture  to  admit  a  little  more  hope.  But  the  patient  can  never  be  considered 
secure  while  any  approach  to  what  are  thought  symptoms  of  effusion  remains ; 
while  the  pupil  continues  dilated,  for  example ;  or  even  so  long  as  it  does  not  con- 
tract briskly  under  a  strong  light. 

The  prognosis  is  especially  bad  when  acute  hydrocephalus  supervenes  upon  othei 
disease ;  or  when  it  is  engrafted  (as  it  sometimes  is)  upon  the  chronic  form  of  the 
disorder.     It  is  very  seldom  that  the  acute  form  subsides  into  the  chronic. 

To  show  you  that  Ave  are  warranted  in  the  expectation  of  sometimes  carrying  our 
patient  through  this  most  perilous  malady,  1  will  mention  a  few  statistical  facts  that 
have  been  recorded  in  respect  to  its  mortality.  Dr.  Odier,  of  Geneva,  states  that, 
upon  an  average,  eighteen  cases  of  acute  hydrocephalus  occur  every  year  in  that 
place  ;  and  of  these  six  get  well ;  i.e.,  the  recoveries  are  to  the  deaths  as  one  to  two. 
Dr.  Golis,  to  whose  work  I  referred  in  the  last  lecture,  and  who  had  the  charge  of  a 
large  institution  for  children  in  Vienna,  gives  an  account  of  thirty-seven  cases,  out 
of  which  five  recov^ered.  He  had  seen,  upon  the  whole,  forty-one  instances  of  reco- 
very from  acute  hydrocephalus.  Dr.  Mills,  who  has  also  written  on  the  disease,  has 
narrated  twenty-eight  cases,  all  of  which  died  but  seven ;  and  JMr.  Brichetau  lost 
four  out  of  eleven.  Adding  these  together,  and  taking  the  average,  we  have  seventy- 
six  instances  of  the  disease,  and  nineteen  recoveries;  exactly  one  in  four.  The 
cases  in  which  recovery  took  place  were  mostly  those  in  which  antiphlogistic  mea- 
sures were  adopted  earh). 

The  treatment  of  acute  hydrocephalus  is  difficult  to  conduct ;  and  scarcely  less 
difficult  to  describe  and  teach.  The  disease  being  essentially  an  inflammation, 
requires,  in  its  earlier  periods  at  least,  the  remedies  of  inflammation.  But  we  must 
ever  bear  in  mind  that  our  patients  are  children ;  and,  for  the  most  part,  weakly  and 
scrofulous  children.  Their  time  of  fife,  and  the  presence  of  the  strumous  diathesis,  both 
forbid  that  strenuous  appliance  of  antiphlogistic  remedies  which  might  be  proper  and 
necessary  in  adults  of  strong  and  healthy  frame.  We  take  our  weapons,  however,  in 
either  case,  from  the  same  armoury. 

The  only  event  of  the  inflammatory  process  compatible  with  the  safety  of  the 
patient  is  resolution.  To  this  end,  therefore,  must  our  efforts  be  earnestly  directed. 
If  the  child  be  feverish,  the  pulse  sharp,  the  head  hot,  the  cheek  flushed,  the  pain 
severe,  and  if,  moreover,  the  case  be  seen  early,  there  need  be  no  doubt  about  the 
propriety  of  abstracting  blood.  It  is  a  matter  of  obvious  importance  to  ascertain  how 
far  we  may  safely  and  beneficially  carry  this  measure,  in  the  diseases  of  infants. 
Dr.  John  Clarke,  a  physician  of  large  experience  (the  elder  brother  of  the  present 
Sir  Charles  Clarke),  found  that  very  young  children  would  very  well  bear  the  lo^s 
of  blood,  even  to  fainting,  once  or  twice :  but  that  their  vital  powers  were  apt  to 
a'iirk  if  the  bleeding,  to  that  extent,  was  oftener  repeated.  It  is  better,  in  my  opinion, 
to  apply  leeches  to  the  temples,  or  to  the  mastoid  processes,  of  these  little  patients, 
than  to  cut  one  of  their  veins.  Recollect  that,  upon  very  young  children,  leeches 
produce  an  effect  tantamount  to  that  of  venesection.     Their  bites  bleed  more  freely 


•ACUTE    HYDROCEPHALUS.  273 

than  in  grown  persons,  on  account  of  the  greater  activity  of  the  capillary  circulation 
in  children.  No  general  rule  can  be  prescribed  in  respect  to  the  number  of  leeches 
to  be  used ;  three  will  take  as  much  blood  in  one  case  as  half  a  dozen  in  another ; 
but  assuming  that  one  leech  will,  on  an  average,  cause  the  discharge  of  one  ounce 
of  blood,  we  may  apply  three  of  them  to  a  strong  infant  of  six  months,  when  the 
symptoms  are  violent.  Of  course  the  further  efiiux  of  blood  must  be  stopped  if  syn- 
cope occurs.  In  older  children  the  quantity  of  blood  requisite  to  be  taken  will  be 
somewhat  larger:  six  ounces  drawn  from  a  vein  is  a  full  bleeding,  I  should  say,  for 
a  child  five  or  six  years  old.  I  mention  these  quantities  as  mere  approximations,  as 
guides  to  what  you  may  expect  to  find  practically  needful :  the  true  measure  and 
test  of  salutary  blood-letting  being  in  this,  as  well  as  in  other  inflammations,  the 
effect  it  has  at  the  time.  The  first  bleeding,  in  what  manner  soever  the  blood  is 
taken,  should  be  a  sufficient  one ;  should  produce  some  decided  and  manifest  im- 
pression. By  attending  to  this  rule  you  will  break  the  force  of  the  early  disease 
more  surely,  and  more  safely  too,  than  by  drawing  blood  in  frequent  driblets  ;  a  mode 
of  using  the  remedy  calculated  to  subdue  the  patient  rather  than  to  overcome  his 
.nalady.  You  must  afterwards  go  on  with  the  leeches  to  the  head,  or  you  must  with- 
.-old  them,  according  to  the  exigency  of  the  particular  case  ;  according  to  the  state 
of  the  pulse,  the  continuance  or  the  cessation  of  the  pain,  the  increase  or  diminu- 
tion of  the  fever,  the  previous  strength  and  condition  of  the  child,  and  so  forth.  And 
let  me  once  more  admonish  you  that,  as  you  have  to  deal,  in  general,  with  scrofulous 
children,  any  superfluous  removal  of  blood,  the  abstraction  of  more  than  is  required 
for  extinguishing  the  inflammation  within  the  head,  will  be  likely  to  prove  injurious 
to  the  general  system  ;  and  even  dangerously  to  depress  the  vital  power.  After  the 
full  formation  of  the  comatose  state,  a  further  prosecution  of  the  bleeding  has  some- 
times been  rapidly  followed  by  death. 

The  next  in  rank  and  importance  to  bleeding  come  purgatives.  They  are  to  be 
exhibited  with  the  threefold  view  of  correcting  depraved  secretions,  of  clearing  the 
ahmentary  canal  of  its  irritating  contents,  and  above  all,  of  deriving,  as  the  phrase 
is,  from  the  head ;  producing  a  discharge  of  the  watery  parts  of  the  blood,  and 
taking  ofT  the  stress  from  the  cerebral  arteries.  The  best  forms  of  purgative  medi- 
cine to  be  used  for  these  purposes  with  children,  consist  of  calomel  and  jalap,  or 
calomel  and  scatnmony ;  and  if  these  do  not  act  freely,  senna  and  salts  must  be 
given  in  aid  of  them.  I  have  already  made  you  acquainted  with  Dr.  Abercrombie's 
high  estimate  of  the  efficacy  of  purgatives  in  inflammation  of  the  brain,  whether  in 
the  child  or  in  the  adult.  Dr.  Whytt,  again,  states  that  he  never  saw  even  tempo- 
rary relief  of  the  symptoms  produced  by  any  other  means  than  those  which  increased 
the  evacuations.  Purgatives  are  to  be  administered,  therefore,  at  an  early  period. 
But  sometimes  the  stomach  is  so  irritable  that  it  rejects  them.  A  previous  bleeding 
will  often  correct  this ;  and  it  is  no  small  part  of  the  benefit  derived  from  the  ab- 
straction of  blood,  that  it  prepares  the  way  for  the  more  efleclual  operation  of  aperi- 
ents and  of  mercury.  A  large  clyster  will  often  be  of  service,  both  in  seltlmg  the 
stomach,  and  in  procuring  stools,  when  there  is  much  vomiting,  and  a  continual 
rejection  of  medicine  given  by  the  mouth.  Dr.  Cheyne  mentions  a  form  of  medi- 
cine by- which  he  sometimes  succeeded  in  quieting  the  irritable  stomach,  and  pro- 
curing evacuations;  he  would  give  a  drachm  or  two  of  magnesia,  saturated  with 
lemon  juice,  every  two  or  three  hours.  You  may  sometimes  get  calomel  and  scam- 
mony,  however,  to  remain  on  the  stomach,  when  almost  every  other  medicine  is 
rejected.     The  purgative  plan  should  be  steadily  persisted  in  for  several  days. 

To  show  you  how  torpid  the  bowels  are  apt  to  be  in  this  disease,  and  how  diffi- 
cult It  sometimes  is  to  procure  evacuations  from  them,  I  may  mention  the  following 
circumstances  which  I  heard  Dr.  Alison  relate  as  having  occurred  in  the  practice  of 
his  uncle,  the  late  Dr.  Gregory,  of  Edinburgh.  He  had  one  patient  who  took  \AS) 
grains  of  calomel  in  the  course  of  five  days ;  yet  his  bowels  were  not  relieved  till  he 
had  also  taken  two  doses  of  jalap,  the  first  of  30,  and  the  second  of  35  grains.  In 
another  case,  a  child  of  twenty-eight  months  took  in  nine  days  3.30  grains  of  calo 
mei  (nearly  40  grains  a  day) ;  and  in  six  of  these  days  136  grains  of  jalap  (more 
than  20  grains  a  day)  :  the  effects  were  a  gentle  purging  from  the  jalap,  none  fro/n 
18 


274  DISEASES    OF   THE    BRAIN. 

the  previous  calomel,  and  but  slight  salivation.  The  child  recovered  after  having 
been  nearly  in  a  comatose  state.  Of  course  large  doses  of  this  kind  are  never  to  be 
given,  uulil  tiie  inefficiency  of  smaller  ones  has  been  ascertained. 

Cold  applied  to  the  head  :  —  I  have  before  given  you  examples  of  its  power.  It 
is  especially  useful  in  the  early  periods  of  the  disease,  when  there  is  rnucb  heat, 
and  when  evacuations  have  been  obtained.  I  am  doubtful  about  the  propriety  of 
keeping  ice  in  contact  with  the  surface  of  the  head  in  very  young  children.  It  will 
in  many  cases  be  sufficient  to  lay  a  linen  rag  wet  with  cold  water  (or  spirit  and 
water,  to  promote  evaporaiion),  upon  the  child's  head,  taking  care  to  renew  it  fre- 
quently, not  merely  as  often  as  it  gets  dry,  but  as  often  as  it  gets  hot ;  or  water  may 
be  poured  from  a  pitcher  upon  the  head,  a  basin  being  held  under  the  chin.  Dr. 
Darwall  states  that  he  has  known  cases,  which  seemed  utterly  hopeless,  retrieved 
by  letting  water  fall  in  a  small  succession  of  drops  upon  the  scalp,  and  coniinuing 
it  until  the  head  no  longer  recovered  its  high  temperature  upon  intermitting  the 
dropping.  I  need  scarcely  say  that  under  all  circumstances  it  is  expedient  to  keep 
the  head  somewhat  elevated.  The  influence  of  this  mode  of  applying  cold  to  the 
head  is  increased,  and  perhaps  rendered  safer,  by  immersing  the  lower  extremities 
of  the  patient  at  the  same  time  in  warm  water. 

Different  opinions  have  been  held  in  respect  to  the  value  of  mercury  in  this  dis- 
ease. Knowing  how  powerful  an  influence  it  has  in  controlling  inflammatory  action, 
and  that  the  inflammation  in  acute  hydrocephalus  often  leaves  behind  it  traces  show- 
ing that  it  was  of  the  adhesive  kind,  I  should  not  omit  giving  mercury ;  but  (as  1 
stated  when  upon  the  subject  of  encephalitis)  I  should  not  give  it  with  the  direct 
object  of  affecting  the  gums,  of  producing  ptyalism.  I  believe  the  evidence  respect- 
ing the  efficacy  of  mercury  carried  to  salivation  in  acute  hydrocephalus  is  this  :  — ■ 
that  some  few  very  desperate  cases  have  got  well,  the  improvement  commencing  at 
the  time  when  the  mercurial  influence  on  the  system  was  becoming  apparent ;  and 
that  in  other  cases,  the  occurrence  of  salivation  has  been  followed  by  no  alleviation 
of  the  symptoms,  but  the  disease  has  run  on,  unchecked,  to  its  fatal  terminaiion.  In 
truth  it  is  a  very  difficult  matter  to  salivate  a  child;  there  is  a  great  reluctance  in 
the  system,  at  the  earlier  periods  of  hfe,  to  take  on  the  specific  mercurial  action  ;  and 
the  disinclination  seems  peculiarly  strong  during  the  presence  of  this  disease  ;  and 
the  younger  the  child,  the  more  difficult  is  it  to  affect  the  gums.  Perhaps  this  may 
be  couL-idered  fortunate ;  for  when  salivation  does  take  place  in  these  little  patients, 
it  sometimes  proceeds  to  an  alarming  extent.  Dr.  John  Clarke,  who  employed 
calomel  largely  in  a  variety  of  diseases,  never  saw  more  than  three  instances  in 
which  salivation  was  produced  in  children  under  three  years  of  age. 

If  you  are  desirous  of  taking  the  chance  of  the  specific  influence  of  mercury 
doing  good,  you  had  better  give  calomel  as  a  part  of  the  purgative  plan,  and  rub  in 
some  of  the  mercurial  ointment;  you  had  better  do  this  than  lock  up  the  child's 
bowels  by  combining  opium  with  the  calomel ;  not  to  mention  the  injurious  effects 
of  opium  upon  young  children  in  general,  and  in  the  early  period  of  head  affections 
in  parUfcuIar.  The  calomel  should  be  given  steadily,  in  equal  doses,  at  equal  in- 
tervals. Green  evacuations  from  the  bowels,  resembling  wet  tea-leaves  or  chopped 
spinach,  usually  follow  its  continued  administration ;  and  this  appearance  (like 
the  rising  of  the  gums  in  adults)  is  generally  regarded  as  a  proof  that  the  influ- 
ence of  the  mineral  is  felt  by  the  system,  and  that  it  is  doing  all  the  gQod  of  which 
it  is  capable. 

Upon  the  whole,  I  believe  it  will  be  found  that  they  who  have  had  the  most  ample 
experience  of  this  perilous  disease,  have  ended  with  the  conviction,  that  moderate 
local  dep''etion,  and  the  regulated  exhibition  of  mercury  in  small  quantities,  afford, 
generally,  a  better  chance  of  success  than  the  large  bleedings,  and  the  full  and  fre- 
quent doses  of  calomel,  which  have  sometimes  been  recommended. 

Of  blisters  I  may  repeat  the  substance  of  what  I  stated  when  we  were  considering 
encephalitis.  I  sliould  abstain  from  them  at  the  commencement  of  the  disease. 
Even  when  applied  at  a  distance  from  the  head,  they  are  apt  to  prove  a  source  of 
hurtful  irritation  in  these  young  and  susceptible  subjects.  But  in  the  second  stage 
ttf  the  malady,  I  believe  blisters  are  often  of  good  service.     They  may  be  applied 


ACUTE    HYDROCErHALUS  275 

to  the  nape  of  the  neck,  or  to  the  head :  and  several  may  be  applied  in  succession ; 
or  the  ulcerated  surface  may  be  kept  open  by  the  help  of  irritating  ointment,  such 
as  the  unguentLim  cantharidis,  or  the  ceratum  sabins. 

These  are  the  main  remedies  to  which  we  trust  in  the  treatment  of  acute  hydro- 
cephalus :  bleeding,  purgatives,  cold,  in  the  outset ;  mercury  and  blisters,  of  more 
equivocal  efficacy  than  the  former,  in  the  more  advanced  stages  of  the  disease. 
When  there  is  much  irritability  towards  the  decline  of  the  disorder,  or  in  its  latest 
period,  opiates  may  cautiously  be  tried ;  they  sometimes  have  appeared  to  be  ex- 
tremely beneficial :  two  or  three  grains  of  Dover's  powder  furnish  a  very  eligible 
form  of  opiate  in  such  cases. 

[Dr.  Wood  (Prac.  of  Med.  vol.  2,  page  636)  remarks :  "  One  additional  remedy  should  be 
employed  in  this  form  of  meninsritis,  from  its  supposed  influence  over  the  scrofulous  habit 
of  body,  and  in  the  hope,  that  if  it  do  not  promote  the  absorption  of  the  tuberculous  matter, 
it  may  possibly  prevent  its  deposition.  I  allude  to  iodine.  I  would  commence  with  it  in 
such  doses  as  the  stomach  of  the  child  could  bear,  and  continue  it  throughout  the  treatment. 
The  iodide  of  potassium,  or  the  compound  solution  of  iodine  (U.  S.  Ph.)  should  be  einployed. 
The  iodide  of  mercury  might  widi  great  propriety,  be  substituted  for  the  calomel  at  the  stage 
at  which  it  is  desirable  to  aim  at  the  mercurial  impression;  and,  in  this  case,  the  other 
preparations  of  iodine  should  be  abandoned." — C] 

I  do  not  feel  called  upon  to  say  any  thing,  in  addition  to  what  I  stated  m  a  former 
lecture,  about  other  remedies  that  have  been  proposed  in  acute  hydrocephalus ; 
digitalis,  colchicum,  squills,  antimony.  These  may  be  useful,  when  they  act  as 
diuretics :  but  they  have  no  specific  virtue.  I  have  told  you  the  remedies  which  I 
beheve  to  be  the  best ;  and  which  will  save  the  patient,  when  judiciously  used,  if 
the  case  be  within  the  compass  of  our  cure  :  and  you  will  do  well  to  learn  how  to 
manage  these  powerful  means.  I  am  confident  you  will  find  that  more  to  your  pur- 
pose than  trying  now  this  and  now  the  other  remedy,  because  it  is  new,  or  because 
some  persons  tell  you  they  have  been  wonderfully  successful  with  it. 

[When  the  disease  has  reached  the  paralytic  stage,  its  fatal  termination  is  usually  supposed 
to  be  inevitable ;  but  Dr.  Christie,  of  Scotland,  and  Dr.  Woniger.  of  Hamburg,  have  each  re- 
cently reported  a  case,  in  which  a  cure  was  effected  after  paralysis  had  occurred,  by  the 
administration  of  iodine.  Dr.  Christie  employed  a  solution,  containing  sixteen  grains  of  iodide 
of  potassium,  and  four  grains  of  iodine  to  one  ounce  of  water,  given  in  the  dose  of  a  tea- 
spoonful  every  four  hours,  at  the  same  time  diat  a  weak  ointment  of  the  biniodide  of  mer- 
cury was  rubbed  ujjon  the  child's  scalp.  Dr.  Woniger  gave  a  solution  of  one  drachm  of 
iodide  of  potassiu!!!,  dissolved  in  half  an  ounce  of  water,  in  the  dose,  at  first,  of  forty,  and 
subsequently  of  fifty  drops  every  two  hours.  In  the  case  of  Dr.  Christie,  the  first  indication 
of  improvement  occurred  in  thirty-six  hours  after  the  employment  of  the  iodine  was  com- 
menced with,  but  in  Dr.  Woniger's  case,  not  until  after  the  end  of  seventy-two  hours.  In 
bjth  the  recovery  is  said  to  have  been  complete  and  permanent. — C] 

Let  me  say  a  word  in  reference  to  the  prevention  of  this  disease :  concerning 
which  your  advice  will  be  sure  to  be  asked  again  and  again.  In  families,  in  which 
acute  hydrocephalus  has  occurred,  or  wliich  show  decided  marks  of  the  scrofulous 
diathesis,  the  earliest  attention  should  be  paid  to  any  deviation  from  the  healthy  con- 
dition of  any  of  the  functions.  W^eaned  children  in  such  families  should  be  kept 
upon  a  nourishing  but  light  and  unstimulating  diet ;  consisting  of  well-dressed  vege- 
tables, farinaceous  substances,  and  a  moderate  proportion  of  animal  food.  Particular 
care  should  be  taken  to  keep  the  bowels  regular ;  not  that  weakening  purges  should 
be  given,  but  the  bowels  should  be  fairly  relieved  at  least  once  every  day.  Any 
disturbance  of  the  digestive  organs  should  be  immediately  corrected ;  by  antacids, 
laxatives,  change  of  diet,  and  sometimes  by  mercurials,  as  the  hydrargyrum  cum 
creta.  Such  children  should  also,  if  possible,  be  brought  up  in  the  country,  and  bo 
freely  exposed  to  mild  and  dry  air;  and  in  winter  great  care  should  be  taken  to  have 
ihem  sufficiently  clothed.  During  the  hazardous  period  of  dentition,  the  state 
of  the  teeth  and  gums  must  be  sedulously  attended  to.  There  is  good  reason  foi 
believing  that  a  seton  or  an  issue  in  the  neck  or  arm  has  been  very  serviceable  in 
warding  off  and  preventing  attacks  of  the  disease.  Dr.  Cheyne  mentions  some 
striking  instances  of  the  good  effect  of  establishing  an  artificial  irritation  at  some 
distance  from  the  brain,  when  there  has  been  a  disposition  to  disease  in  thai  organ. 


276  DISEASES    OF    THE    BRAIN. 

There  is  another  caution,  too,  which  you  will  often  find  reason  for  suggesting : 
and  that  is,  not  to  press  or  encourage  the  development  of  the  mental  faculties  m 
children  who  are  quick  and  intelligent  beyond  their  years.  Parents  are  apt  to  be 
proud  of  the  early  acquirements  of  their  little  ones :  they  are  not  aware  that  such 
precocity  of  the  mind  implies  danger  to  the  health  of  the  body ;  and  they  provide 
them  with  instructors,  and  to  a  certain  extent  abridge  their  hours  of  exercise  and 
amusement,  that  they  may  do  justice  to  their  cleverness.  But  it  is  our  duty  to 
admonish  them  of  the  risks  they  are  thus  running:  to  advise  them  to  think  only, 
for  the  present,  of  corroborating  the  corporeal  strength  of  the  child ;  and  to  avoid 
over-cultivation  of  his  intellect  until  this  dangerous  period  of  his  existence  is  got 
over. 

There  is  still  one  point  remaining,  and  one  of  the  utmost  importance,  in  relation 
to  the  acute  hydrocephalus  of  children.  I  told  you  in  the  last  lecture  that,  in  general, 
the  diagnosis  was  not  very  difficult.  But  there  is  a  form  of  disorder  very  apt  to  be 
mistaken  and  treated  for  acute  hydrocephalus,  by  those  who  are  not  forewarned  ;  and 
one  which  may  be  rendered  fatal,  if  the  remedies  of  acute  hydrocephalus  be  di- 
rected against  it.  Encephahtis,  whether  it  occur  in  the  child  or  in  the  adult,  has  its 
spurious  double.  As,  in  morals,  every  virtue  has  its  corresponding  vice,  which  apes 
its  actions  and  assumes  its  garb,  so  is  it  also  with  many  opposite  bodily  disorders : 
and  it  is  of  great  moment  that  we  should  be  capable  of  discerning  the  essential  dif- 
ference of  character  that  lurks  beneath  external  similarity  of  feature.  It  is  a  most 
curious,  but  unquestionable  fact,  that  anxtnia  of  the  brain,  a  diminution  of  its  natural 
supply  of  red  blood,  and  exhaustion  of  the  nervous  power,  will  produce  symptoms 
very  much  resembhng  those  which  result  from  the  diametrically  opposite  condition. 
To  excess  of  pressure  on  the  one  hand,  and  to  defect  of  pressure  or  support  on  the 
other,  there  are  many  phenomena  in  common.  If  you  pay  no  regard  to  the  state  of 
the  general  circulation,  as  indicated  by  the  temperature  and  b}'  the  pulse,  you  will 
find  the  actual  symptoms  of  syncope,  and  of  apoplectic  fullness,  to  be  identically  the 
same.  When  a  human  being  bleeds  to  death — as  many  do  from  wounds,  from  ute- 
rine hemorrhage  and  so  on — what  do  we  see  ?  Why  the  patients  may  have  nervous 
delirium,  become  convulsed,  and  then  insensible,  with  a  wide  and  fixed  pupil.  The 
outward  visible  signs  of  concussion  and  of  compression  of  the  brain  are  very  much 
alike.  The  vulgar  always  confound  them,  and  are  clamorous  that  a  vein  should  be 
opened ;  a  measure  which  would  be  proper  and  useful  in  the  one  case,  but  mur. 
derous  in  the  other.  It  is  the  same  with  the  functions  of  other  parts :  we  have  pal- 
pitation of  the  heart  when  that  organ  is  insufficiently  supplied  with  blood ; 
palpitation  when  it  is  over-loaded ;  dispnoca,  or  hurried  breathing,  when  the  lungs 
are  congested  ;  hurried  breathing  when  blood  does  not  arrive  in  them  plentifully 
enough.  You  must  see  that  the  importance  of  distinguishing  between  the  causes 
of  these  analogous  phenomena  is  immense.  Several  authors  in  modern  times  have 
noticed  the  condition  of  the  brain  to  which  I  now  wish  you  to  attend,  and  -which 
may  be  called  spurious  hydrocephalus.  Dr.  Marshall  Hall,  Dr.  Abercrombie,  and 
the  late  Dr.  Gooch — each  of  these  three  physicians  appears  to  have  discriminated 
ibr  himself  the  spurious  from  the  genuine  disease;  but  their  several  accounts  of  it 
were  made  public  in  the  order  of  time  in  which  I  have  here  mentioned  their  names. 
Dr.  Gooch's  Essay  is  entitled — "  Of  some  Sijmptoms  in  Children  erroneously  attri- 
buted to  Congestion  of  the  Brain."  His  description  of  the  disorder  in  question  is 
very  graphic.  It  is  chiefly  indicated,  he  says,  by  heaviness  of  head  and  drowsiness. 
The  age  of  the  little  patients  whom  he  had  seen  so  affected  was  from  a  few  months 
to  two  or  three  years ;  they  were  generally  small  of  their  age  and  of  delicate  health, 
or  had  been  exposed  to  debilitating  causes.  The  ph3'sician  finds  the  child  lying  on 
its  nurse's  lap,  unable  or  unwilling  to  raise  its  head  ;  half  asleep;  one  moment  open- 
ing it?  eyes,  and  the  next  closing  them  again,  with  a  remarkable  expression  of 
languor.  The  tongue  is  slightly  white,  the  skin  is  not  hot,  at  times  the  nurse  re- 
marks that  it  is  colder  than  natural ;  in  some  instances  there  is  now  and  then  a  slight 
and  transient  flush.  In  all  the  cases  that  Dr.  Gooch  saw,  the  bowels  had  been 
already  disturbed  by  purgatives ;  the  symptoms  had  invariably  been  attributed  to 
t't)ngr3tion  of  the  brain  ;  and  the  remedies  employed  had  been  leeches  and  cold  lotions 


SPURIOUS   HYDROCEPHALUS.  ,  277 

to  the  head,  and  purgalives-^especially  calomel.  Under  this  treatment  the  patients 
had  gradually  got  worse,  the  languor  had  increased,  the  pulse  become  quicker  and 
weaker,  and  at  the  end  of  a  certain  number  of  days  the  children  had  died.  In  two 
instances  he  had  known  coma  to  come  on  during  the  last  few  hours ;  stertorous 
breathing,  and  dilated  and  motionless  pupils. 

Dr.  Hall  describes  a  very  similar  set  of  symptoms :  the  face  pale,  the  cheeks  cool 
or  cold,  the  eyelids  half  closed,  the  eyes  unattracted  by  any  object  put  before  them, 
the  pupils  unmoved  on  the  approach  of  Hght,  the  breathing  irregular  and  suspirious, 
the  voice  husky.  These  symptoms  are  sometimes  preceded  by  irritabihty,  and  a 
feeble  attempt  at  reaction  ;  in  which  case  the  diagnosis  requires  extreme  care  and 
circumspection.  He  attributes  the  disorder,  which  he  calls  the  "  hydrocepha/ozJ 
disease,"  principally  to  exhaustion.  In  early  infancy  the  exhaustion  has  its  origin 
chiefly  in  diarrhoea,  or  catharsis ;  in  the  latter  periods  of  infancy,  in  the  loss  of  blood, 
with  or  without  a  relaxed  condition  of  the  bowels.  The  diarhoea  is  often  produced 
by  improper  food,  and  frequently  succeeds  weaning;  or  it  results  from  the  ill-timed 
administration  of  purgative  medicine.  The  exhaustion  from  loss  of  blood  generally 
follows  the  application  uf  leeches,  for  some  previous  complaint — or  for  this  very  com- 
plaint itself,  when  incipient,  and  misunderstood. 

I  will  take  one  of  Dr.  Gooch's  cases  in  illustration,  and  give  it  you  in  his  own 
words.  "I  was  going  out  of  town  (he  says)  one  afternoon,  when  a  gentleman  drove 
up  to  my  door  in  a  coach,  and  entreated  me  to  go  and  see  his  child,  which  he  said 
had  something  the  matter  with  its  head,  and  that  the  medical  attendant  of  the  family 
was  in  the  house,  and  was  just  going  to  apply  leeches.  I  went  with  him  immedi- 
ately, and  when  I  entered  the  nursery  I  found  a  child  ten  months  old,  lying  in  its 
nurse's  lap,  exactly  in  the  state  which  I  have  already  described  ;  the  same  unwilling- 
ness to  hold  its  head  up,  the  same  drowsiness,  languor,  absence  of  heat  and  all 
symptoms  of  fever.  The  child  was  not  small  of  its  age,  and  had  not  been  weak ; 
but  it  had  been  tvcaned  about  two  months,  since  which  it  had  never  thriven.  The 
leeches  had  not  been  put  on.  I  took  the  medical  gentleman  into  another  room,  related 
the  foregoing  case  (z.  e.,  a  case  in  which  a  child  had  been  leeched  out  of  its  life), 
and  several  similar  to  it,  which  had  been  treated  in  the  same  way,  and  had  died  in 
the  same  way.  Then  I  related  to  him  a  similar  case  which  I  had  seen  in  the  neigh- 
bouring square,  which  had  been  treated  with  ammonia  and  decoction  of  bark,  and 
good  diet,  and  which  had  recovered ;  not  slowly,  so  as  to  make  it  doubtful  whether 
the  treatment  was  the  cause  of  the  recovery,  but  so  speedily  that  at  a  third  visit  I 
took  my  leave.  He  consented  to  postpone  the  leeches,  and  to  pursue  the  plan  which 
I  recommended.  We  directed  the  gruel  diet  to  be  left  olT,  and  no  other  to  be  given 
than  ass's  milk,  of  which  the  child  was  to  take  at  least  a  pint  and  a  half,  and  at 
most  a  quart,  in  the  twenty-four  hours.  Its  medicine  was  ten  minims  of  the  aro- 
matic spirit  of  ammonia  in  a  small  draught  every  four  hours.  When  we  met  the 
next  day  the  appearance  of  the  child  proved  that  our  measures  had  been  right;  the 
nurse  was  walking  about  the  nursery  with  it  upright  in  her  arms.  It  looked  happy 
and  laughing.  The  same  plan  was  continued  another  day ;  the  next  day  it  was  so 
well  that  I  took  my  leave,  merely  directing  the  ammonia  to  be  given  at  longer  inter 
vals,  and  thus  gradually  withdrawn ;  the  ass's  milk  to  be  continued,  which  kept  the 
bowels  sufficiently  open  without  aperient  medicine."  This  case  contains  both  a  pic- 
ture of  the  morbid  state  and  a  summary  account  of  the  treatment  it  requires.  Instead 
of  the  sal  volatile,  you  may  occasionally  substitute  with  advantage  from  five  to  ten 
drops  of  brandy  m^ixed  with  arrow-root.  You  are  to  restrain  diarrhoea  if  it  exists ; 
give  the  child  plain  nourishing  diet — there  is  none  so  good  for  it  as  that  furnished 
from  a  mother's  breast ;  caution  the  nurse  or  mother  against  raising  it  into  the  upright 
position  ;  keep  its  extremities  warm  with  flannel ;  and  if  the  season  permit,  let  a 
current  of  mild  fresh  air  blow  freely  over  it. 

Bear  in  mind,  then,  the  distinctive  characters  of  this  spurious  hydrocephalus — the 
pale,  cool  cheek  ;  the  half-shut,  regardless  eye  ;  the  insensible  pupil ;  the  interrupted 
sighing  respiration  :  and  when  the  mere  symptoms  are  more  ambiguous,  your  judg- 
ment concerning  the  true  nature  of  the  case  will  be  much  aided  by  tracing  the  man 
Her  m  which  they  came  on,  and  the  causes  to  which  they  seem  to  be  attribuiah!c 

y 


278  DISEASES    OF    THE    BRAIN. 

In  very  young  children — in  respect  to  whom  the  question  is  most  likely  lo  arise — ■ 
you  may  often  determine  between  contjestion  and  exhaustion,  between  fullness  and 
emptiness,  between  too  much  and  too  little  pressure,  by  a  very  simple  and  easy  test, 
which  is  not  adverted  to,  so  far  as  I  remember,  by  any  of  the  three  writers  whom  I 
have  mentioned.  I  mean,  by  taking  notice  of  the  slate  of  the  unclosed  fontanelle. 
If  the  symptoms  proceed  from  plethora,  or  inflammation,  or  an  approach  to  inflam- 
mation, you  will  find  the  surface  of  the  fontanelle  convex  and  prominent,  and  you 
may  safely  employ,  and  expect  benefit  from,  depletion.  If,  on  the  other  hand,  the 
symptoms  originate  in  emptiness  and  want  of  support,  the  surface  of  the  fontanelle 
will  be  concave  and  depressed  ;  and  in  that  case  leeches,  or  other  evacuants,  will  do 
harm,  and  you  must  prescribe  better  diet,  ammonia,  and  so  forth. 

All  that  has  hitherto  been  said  has  reference  to  acjde  hydrocephalus,  which  is  an 
injiammatlon.  I  have  next  to  speak  of  chronic  hydrocepbalus,  which  is  a  dropsy. 
From  some  cause,  not  well  understood,  a  watery  fluid  collects  within  the  skull,  most 
commonly  in  the  ventricles  of  the  brain  ;  and  this  occurring  at  the  earlier  periods 
of  life,  before  the  whole  of  the  brain-case  has  become  solid,  the  containing  parts  j'ield 
to  the  increasing  pressure,  and  the  size  of  the  head  is  augmented  in  various  degrees; 
at  the  same  time  the  cerebral  functions  are  more  or  less  deranged.  This  droj^sy  of 
the  cranial  cavity  often  commences  before  the  period  of  intra-uterine  life  is  com- 
pleted, and  the  head  of  the  foetus  becomes  so  large,  that  it  cannot  pass  with  safety 
into  the'  world.  Accordingly,  many  of  these  infants  perish  at  the  moment  when 
their  separate  existence  commences ; — nar.centcs  moriunlur.  The  pressure  of  the 
maternal  pelvis  is  fatal  to  them  ;  or  the  diseased  head  bursts  ;  or  it  is  crushed  by  the 
accoucheur,  to  preserve  the  life  of  tbe  mother.  The  skull  is  emptied  of  its  contents, 
and  the  shell,  if  I  may  so  call  it,  collapsing,  passes  through  the  natural  outlets. 

In  many  cases,  however,  the  dropsical  skull  is  expelled  entire  and  unhurt,  and  the 
infant  lives  for  a  shorter  or  longer  period.  Sometimes  the  fluid  does  not  begin  to 
accumulate  till  after  birth :  in  a  few  days,  however,  or  after  some  weeks,  or  some 
months  even,  the  head  is  perceived  to  enlarge  with  a  rapidity  quite  disproportionate 
to  the  growth  of  the  other  parts  of  the  body ;  and  enlarging,  it  becomes  misshapen 
also.  The  intervention  of  the  membranous  partitions  called  fontanelles  and  oj.'en 
sutures,  between  the  ununited  bones,  allows  the  centrifugal  pressure  of  the  gradually 
accumulating  water  to  modify  the  shape  of  the  head.  These  membranous  inter- 
spaces are  unnaturally  wide,  and  more  numerous  than  in  healthy  children.  Never- 
theless the  process  of  ossification  goes  on,  but  the  bones  are  extremely  thin.  We 
see  little  islands  of  bone  in  seas  (as  it  were)  of  membrane.  By  degrees,  if  the  child 
survives,  the  proportion  of  membrane  to  bone  becomes  less  and  less,  and  at  length 
the  whole  brain-case  is  hard,  and  firmly  closed  up,  its  surface  exhibiting  an  unusual 
number  of  joinings  ;  there  are  man}'-  ossa  triqueira. 

In  the  mean  time  the  direction  and  relations  of  the  loose  and  yielding  bones  are 
altered.  The  os  frontis  is  tilted  forwards,  so  that  the  forehead,  instead  of  slanting  a 
little  back,  rises  perpendicularly,  or  even  juts  out  at  its  upper  part,  and  overhangs 
the  brow.  The  parietal  bones  bulge  above  towards  the  sides;  the  occiput  is  pushed 
back ;  and  the  head  becomes  long,  broad  and  deep,  but  flattened  on  the  top.  This, 
at  least,  is  the  most  ordinary  result.  In  some  instances,  however,  the  skull  rises  up 
in  a  conical  form,  like  a  sugar-loaf.  Not  unfrequently  the  whole  head  is  irregularly 
deformed,  the  two  sides  being  unsymmetrical.  Some  of  these  rarer  varieties  of  form 
are  fixed  and  connate ;  others  are  owing,  probably,  to  the  kind  of  external  pressure 
to  which  the  head  has  been  subjected. 

While  the  skull  may  be  rapidly  enlarging,  the  bones  of  the  face  grow  no  faster 
than  usuil,  perhaps  not  even  so  fast ;  and  the  disproportion  that  resuhs  gives  an  odd 
and  pecuhar  physiognomy  to  the  unhappy  beings  who  are  the  subjects  of  this 
calamity.  They  have  not  the  usual  round  or  oval  face  of  childhood.  The  forehead 
?s  broad,  and  the  outline  of  the  features  tapers  towards  the  chin.  The  visage  is 
triangular.  The  great  disproportion  of  size  between  the  head  and  the  face  is  diag- 
nostic of  the  disease,  and  would  serve  to  distinguish  the  skull  of  a  hydrocephalic 
ohild  from  that  of  a  giant.     Heartless  parents  sometimes  make  a  wTetched  profit  of 


CHRONIC    HYDROCEPHALUS.  279 

the  deformity.  A  penny  show  of  that  kind  existed  very  recently  in  the  immediate 
vicinity  of  this  college. 

When,  after  deaih,  we  explore  the  physical  causes  of  these  singular  deviations 
from  the  natural  figure  and  bulk  of  the  cranium,  we  find  that  they  proceed  from  the 
pressure  of  accumuiaied  water:  the  complaint  is  manifestly  a  dropsy.  But  the 
situation  of  the  water,  and  the  condition  of  the  brain  itself,  are  subject  to  some  curious 
varieties. 

In  a  certain  number  of  cases  the  brain  is  incompletely  formed ;  deficient  in  some 
of  its  parts,  or  even  altogether  wanting.  That  portion  of  the  cranial  caviiy  which 
should  contain  the  nervous  pulp  is  filled  up  by  a  thin  pellucid  fluid.  From  some 
unknown  cau^e,  operating  during  the  period  of  intra-uterine  life,  the  progressive 
formaiion  of  the  brain  has  been  arrested.  Marks  of  imperfect  development  are  often 
visible  in  other  parts  of  the  same  infants  ;  they  have  a  hare-lip,  a  bifid  spine,  or  a 
fissured  palate.  It  is  in  cases  of  this  kind  generally  that  the  skull,  unnaturally  small 
})erhaps,  is  pinched  up  into  a  conical  peak,  and  has  considerable  thickness.  They 
are  obviously  hopeless  cases.  To  the  physiologist  they  are  subjects  of  much  inte- 
.  est ;  for  the  practical  physician  they  have  none. 

But  in  the  majority  of  instances,  when  the  infants  survive  their  birth,  the  liquid 
:3  contained  in  the  central  cavities  or  ventricles  of  the  brain,  which  are  expanded  into 
'  ne.  The  convolutions  are  unfolded,  and  the  cerebral  matter  is  spread  out  into  a 
iiollow  sphere;  the  irregularities  of  the  surface  have  disappeared;  the  whole  of  the 
brain  is  smoothly  extended  in  a  thin  layer,  immediately  beneath  the  bones  and  the 
membranes  that  connect  them,  and  surrounds  the  inclosed  liquid  like  a  bag.  Less 
frequently  a  different  state  of  matters  is  seen.  The  liquid,  instead  of  being  included 
within  the  cerebral  substance,  lies  in  contact  with  the  dura  mater;  while  the  brain, 
perfect  in  all  its  essential  parts,  is  at  the  bottom  of  the  cavity.  The  difference,  how- 
ever, is  more  apparent  than  real ;  the  two  conditions  are  substantially  the  same,  only 
that,  in  the  one  case,  the  solid  parts  that  lie  around  the  ventricles  gradually  expand 
as  the  fluid  slowly  collects,  much  as  an  air-balloon  dilates  in  proportion  as  gas  is  in- 
troduced within  it ;  while  in  the  other  case  the  seams,  or  connnissures  (as  they  are 
technically  called),  that  unite  the  hemispheres  of  the  brain,  give  way,  or  are  deficient, 
so  that  the  ventricles,  and  the  general  sac  of  the  arachnoid  form  together  one  huge 
cavity  ;  the  hemispheres  are  turned  aside,  or  folded  back  ;  the  surfaces  that  naturally 
have  a  central  aspect  look  upwards,  and  seem  to  constitute  the  summit  of  the  cere- 
brum. This  was  the  state  of  the  parts  within  the  immense  skull  from  which  the 
largest  of  the  casts  before  you  was  taken.  It  belonged  to  a  man  named  Cardinal, 
who  died  in  Guy's  Hospital,  in  1825,  and  of  whom  Dr.  Bright  has  given  a  very 
.mteresting  account. 

Now  some  of  the  consequences  of  this  distension  of  the  brain  and  skull  with 
watery  fluid  are  simply  mechanical.  The  child  is  top-heavy.  His  large  unwieldy 
head  is  too  much  for  the  muscles  of  his  neck  to  sustain  without  faligue ;  or  even, 
when  they  are  unassisted,  to  sustain  at  all.  He  walks  gertly  and  carefully,  like  a 
person  balancing  a  heavy  load  upon  his  head ;  or  he  holds  and  partly  carries  his 
liead  with  his  hands,  as  a  milkmaid  steadies  and  supports  her  pail ;  or  he  reclines  the 
weight  of  his  burden  upon  the  chair,  or  table,  as  he  sits. 

But  far  more  important  effl'cts  of  the  disease  are  those  which  relate  to  the  three 
great  functions  of  the  brain.  The  child  is  soon  found  to  be  deaf  or  blind  ;  or  palsied 
in  one  or  more  of  its  limbs ;  or  idiotic ;  or  all  these.  In  other  words,  the  special 
senses,  the  power  of  voluntary  motion,  and  the  mental  faculties,  are  apt  to  be  defec- 
tive or  perverted.  Instances,  however,  do  occur,  in  which  these  functions  are,  for 
some  time,  but  little  deranged.  The  greater  number  of  those  who  are  afflicted  with 
dropsy  of  the  brain  either  recover  or  die  during  their  infancy.  Still,  a  few  survive, 
bearing  their  complaint  to  the  adult  period,  and  even  to  old  age ;  and  in  some  of 
these  individuals  who,  with  excessively  large  heads,  have  yet  numbered  many  years 
of  existence,  the  intellect  and  the  senses,  if  not  entii-e  and  perfect,  have  been  suffi- 
ciently effective  to  answer  the  common  wants  and  purposes  of  social  life :  the  moral 
emotions  strong,  the  feelings  lively  and  correct,  the  memory  tolerably  retentive,  the 
reasoning  powers  respectable.    Dr.  David  Monro  relates  the  case  cf  a  hydrocephalic 


280  ^  DISEASES    OF    THE    BRAIN. 

girl,  SIX  years  old,  whose  head  measured  two  feet  four  inches  in  circumference.  She 
is  described  by  him  as  being  "as  hveiy  and  sensible  as  most  of  her  age,"  and  as 
"  having  a  strong  memory."  Dr.  Brighl's  patient,  Cardinal,  was  nearly  thirty  years 
of  age  when  he  died.  He  was  born  in  1795.  At  the  time  of  his  birth,  his  head 
was  only  a  little  larger  than  natural ;  but  it  had  a  pulpy  feel,  as  if  it  were  almost 
destitute  of  bony  matter.  A  fortnight  afterwards,  it  began  to  increase  rapidly;  and 
when  he  was  five  years  old,  it  was  but  little  less,  according  to  his  mother's  account, 
than  when  he  died.  He  could  not  walk  alone  till  he  was  nearly  six,  and  then  only 
on  level  ground.  If  he  attempted  to  run,  or  to  stoop,  he  fell  down.  He  was  sent  to 
school  when  he  was  about  six,  and  soon  learned  to  read  well  and  to  write  tolerably ; 
but  writing  he  soon  gave  up,  because,  as  he  was  near-sighted,  it  obliged  him  to  stoop, 
which  he  could  not  conveniently  do.  When  a  candle  was  held  behind  his  head,  or 
when  his  head  happened  to  be  between  a  spectator  and  the  sun,  the  cranium  ap- 
peared semi-transparent ;  and  this  was  more  or  less  the  case  till  he  was  fourteen 
years  old.  About  the  age  of  twenty-three,  epileptic  fits  began  to  occur ;  and  after 
that  his  health,  which  previously  had  been  very  good,  failed  somewhat.  The  ossifi- 
cation of  the  skull  was  not  complete  till  two  j^ears  before  his  death,  the  anterior 
fontanelle  being  the  last  part  that  closed.  It  has  been  mentioned  that  he  was  near- 
sighted ;  but  he  was  very  quick  of  hearing,  his  taste  was  perfect,  and  his  digestior? 
good.  Dr.  Bright  states  that  his  mental  facukies  were  very  fair,  and  his  memory 
tolerable  ;  but  it  was  not  retentive  of  dates.  It  was  said  that  he  was  never  known 
to  dream.  There  was  something  childish  and  irritable  in  his  manner,  and  he  was 
easily  provoked.  He  died,  at  last,  of  fever  and  diarrhoea.  There  were  seven  or 
eight  pints  of  fluid  within  the  cranium,  in  contact  with  the  dura  mater.  On  the  base 
or  floor  of  the  skull  lay  the  brain,  with  its  hemispheres  opened  outwards,  like  the 
leaves  of  a  book. 

How  comes  it  that  the  cerebral  functions  are  thus  sometimes  fulfilled,  or  ^o  on  so 
well,  when  the  machinery  through  which  the  mental  powers  are  manifested — the 
instrument  whereon  and  whereby  the  immaterial  principle  mysteriously  operates — 
is  so  palpably  and  greatly  deranged  ?  How  comes  it  that  life,  and  especially  the  life 
of  the  mind,  subsists  at  all  ?  These  questions  open  very  interesting  considerations. 
It  would  appear,  from  such  cases  as  I  have  been  referring  to,  that  the  curious 
arrangement  and  collocation  of  the  several  parts  of  the  brain  are  rather  a  matter  of 
convenient  package  than  of  necessary  relation.  The  pulp  which  furnishes  the 
medium  of  sense  and  thought,  and  volition,  is  there,  but  it  is  disposed  in  an  unusual 
shape.  In  neither  of  the  two  varieties  of  the  malady  that  have  been  described  as 
being  compatible  with  prolonged  existence,  is  there  any  necessary  diminution  of  the 
cerebral  mass.  The  brain  itself,  which  forms  a  bag  in  the  one  case,  and  is  split  in 
halves  in  the  other,  has  been  found  to  weigh  quite  as  much  as  a  healthy  brain  at  the 
same  period  of  life.  There  has  been  no  loss,  therefore,  of  substance  ;  the  pressure 
iias  been  gradual,  and  it  has  not  been  made  to  act  injuriously  by  counter-pressure ; 
no  effectual  resistance  has  been  afforded  by  the  rigidity  of  the  brain-case ;  and  thus 
the  unopposed  distending  force  neither  causes  absorption  of  the  cerebral  pulp  on  ;he 
one  hand,  nor,  on  the  other,  induces  coma,  or  convulsions,  or  idioc}-,  by  its  com- 
pression. 

Most  commonly,  however,  the  mental  and  voluntary  functions  are  maimed  or  per- 
verted ;  and  these  serious  calamities  make  parents  look  at  a  large  head  in  a  young 
child  with  anxious  solicitude.  But  you  are  aware,  after  what  I  stated  on  this  sub- 
ject in  the  last  lecture,  that  the  head  may  be  extravagantly  large  Avithout  dropsy  of 
the  brain  and  without  disease. 

.We  have  just  seen  that,  while  the  brain  itself  is  gradually  unfolded,  or  its  hemi- 
spheres are  parted  and  turned  aside,  bj' the  liquid  accumulating  within  the  cranium, 
the  I  unctions  of  the  organ  ma}'  suffer  but  little,  so  long  as  the  yielding  brain-case 
permits  the  expansion  or  separation  of  the  nervous  substance,  without  inordinate 
pressure.  But  as  soon  as  undue  pressure  begins  to  be  exercised,  then  morbid  symp- 
'oms  arise,  or  the  defects  that  have  previout^h^  shown  themselves  are  aggravated. 
Hence  that  period  of  life  becomes  a  perilous  period,  at  which  the  skull,  by  the 
rlosure  of  its  fonianelles  and  sutures,  loses  its  capability  of  further  expansion.     In 


CHRONIC   HYDROCEPHALUS.  281 

some  raie  cases,  the  closed  sutures  re-open  under  the  augmenting  pressure,  and  a 
respite  it>  thus  obtained.  Dr.  Baiilie  has  recorded  an  instance  in  which  this  hap- 
pened in  a  boy  seven  years  old.  A  similar  case  is  mentioned  in  Dr.  Yeat's  work 
on  hydrocephalus.  The  patient  was  a  boy  nine  years  of  age.  The  sutures  of  his 
skull  separated  agaui  after  having  been  united  ;  and  it  was  remarked  that  the  teeth 
in  the  jagged  edges,  whereby  the  bones  interlock  with  each  other,  were  much  fewer 
•han  is  usual,  ll  this  be  always  so  when  the  sutures  give  way,  it  will  serve  to  faci- 
litate our  understandmg  how  such  a  separation  can  take  place.  The  skull  may, 
however,  go  on  expanding,  although  the  sutures  are  permanently  closed ;  there  still 
being  left  intervals  between  the  several  points  of  ossification,  which  intervals  are 
covered  by  membrane  oniy.  The  beautiful  preparation  on  the  table,  showing  this 
remarkable  state  of  the  cranium,  I  have  borrowed  for  your  inspection  from  Dr.  Sweat- 
man's  museum. 

Indeed,  although  I  have  spoken  of  this  complaint  as  being  especially  a  disease  of 
childhood,  it  does  occasionally  commence  long  after  the  skull  has  become  a  complete 
case  of  bone.  Enlargement  of  the  head,  in  these  cases,  is  impossible  ;  but  this  cir- 
cumstance, and  the  symptoms  it  is  apt  mechanically  to  produce,  form  the  only  differ- 
<mces  between  the  disorder  as  it  affects  the  child  and  the  adult.  In  both  cases  dis- 
•iirbance  of  t-he  cerebral  functions  arises,  and  at  length  convulsions  or  coma  closes 
fhe  scene.  In  both,  a  dropsical  state  of  the  ventricles  of  the  brain  constitutes,  often, 
•he  only  morbid  change  presented  after  death.  A  young  and  distinguished  lawyer 
of  my  acquaintance  had  one  or  two  attacks  of  rather  sudden  loss  of  consciousness 
while  engaged  in  the  Court  of  Chancery ;  by  degrees  he  became  dull,  stupid,  for- 
getful, and,  at  length,  insensible.  In  this  condition  he  died.  A  large  quantity  of 
serous  liquid  was  found  distending  the  ventricles  of  his  brain.  No  other  alteration 
could  be  detected. 

Dr.  Baiilie  describes  a  case  of  chronic  hydrocephalus  that  occurred  in  a  man  fifty 
years  old.  Six  ounces  of  fluid  were  contained  in  the  lateral  ventricles.  He  had 
been  paralytic  on  the  right  side  of  the  body ;  and  for  eleven  months  before  his  death 
had  lost  the  recollection  of  his  own  language,  with  the  exception  of  four  or  five 
words,  which  he  employed,  with  different  intonations,  to  express  his  various  wants. 

The  celebrated  Dean  of  St.  Patrick's  afforded  another  instance  of  the  same  dis- 
ease, attended  with  a  similar  interruption  of  the  power  of  discoursing.  The  case,  as 
related  in  Sir  Waller  Scott's  Life  of  Dr.  Swift,  is  curious,  and  contains  an  early 
suggestion  of  a  piece  of  practice  which,  in  our  own  time,  has  met  with  more  flxvour. 
'^  A  few  days  afterwards  he  sunk  into  a  state  of  total  insensibility,  slept  much,  and 
could  not,  without  great  difficulty,  be  prevailed  on  to  walk  across  the  room.  This 
was  the  effect  of  another  bodily  disease  :  his  brain  being  loaded  with  water.  Mr. 
Stevens,  an  ingenious  clergyman  of  his  chapter,  pronounced  this  to  be  the  case 
during  his  illness,  and  upon  opening  his  head  it  appeared  that  he  was  not  mistaken  ; 
but  though  he  often  entreated  the  Dean's  friends  and  physicians  thai  his  skull  might 
be  trepanned,  and  the  water  discharged,  no  regard  was  paid  to  his  opinion  or 
advice." 

He  remained  from  October  1742,  to  October  174.5,  in  a  state  of  silence,  with  few 
and  slight  exceptions  ;  and  died  in  the  7f^th  year  of  his  age. 

Gohs  also  mentions  three  instances  in  which  this  disease  began  in  advanced  life  ; 
two  of  the  patients  were  above  seventy  years  old  ;  the  third,  who  was  a  {)hysician 
at  Vienna,  likewise  died  in  the  decline  of  life,  having  sufliired  under  the  disorder  for 
ten  years. 

Now,  what  can  we  do  in  these  wretched  cases?  Seldom  much  good,  I  am  afraid 
Yet  something  we  must  try,  for  parents  will  flatter  themselves  with  hopes  of  a  cure  : 
and  to  say  the  truth,  there  have  been,  under  judicious  management,  a  sufficient  num- 
ber of  recoveries  to  forbid  our  despairing  in  any  case,  and  to  make  it  incumbent 
upon  us  to  employ  carefully  all  those  measures  which  have  occasionally  brought  the 
disease  to  a  favourable  termination.  Golis  even  afflrms,  that  of  the  cases  which 
began  after  birth,  and  which  he  saw  and  treated  early,  he  was  frj-tnnate  enough  to 
save  the  majority. 

y2 


282  DISEASES    Of    THE    BRAIN. 


LECTURE  XXVII. 

7\eatme.nt  of  Chrome  Hydrocephalus;  Irdcnuil  Remedies:  Mechanical  Expedi- 
ents; Bandages,  Tapping.  Symptoms  of  Spinal  Disease.  Inflammatory  co)\r 
ditions  of  the  Spinal  Marrow. 

The  cure  of  chronic  hydrocephalus  maybe  attempted  by  internal  remedies,  or  by 
external  mechanical  expedients,  or  by  both. 

The  internal  remedies  by  which  most  good  appears  to  have  been  affected,  and 
from  which,  therefore,  most  is  to  be  hoped,  are  diuretics,  purgatives,  and  above  all, 
mercury,  which  is  believed  by  many  to  have  a  special  and  powerful  influence  -in 
promoting  absorption.  Conjointly  with  these,  the  abstraction  of  small  quantities  of 
blood  from  the  head,  by  means  of  leeches,  has  been  found  beneficial. 

Golis  advises  that  calomel  should  be  given  in  half-grain  doses,  twice  a  day ;  or 
if  that  quantity  should  purge  too  much,  in  doses  containing  only  one-fourth  of  a 
grain.  At  the  same  time  he  would  rub  a  scruple  or  two  of  mercurial  ointment, 
mixed  with  ointment  of  juniper  berries,  upon' the  scalp,  every  night.  He  recom- 
mends that  the  head  should  be  kept  constantly  covered  also  by  a  woollen  cap.  In- 
fants require,  he  says,  no  other  nutriment  than  good  breast  milk  ;  while  older  patients 
should  take  a  moderate  quantity  of  meat.  In  mild  weather  they  should  be  as  much 
as  possible  in  the  open  air.  Under  this  plan  of  treatment  he  affirms  that  he  has 
known  the  circumference  of  the  head  decrease  by  half  an  inch  or  an  inch,  in  a  period 
of  six  weeks  or  three  months;  and  that  perseverance  in  this  method  has  frequently, 
in  his  experience,  been  followed  by  perfect  recovery,  both  of  the  mental  and  of  the 
bodily  powers.  If  no  improvement  should  be  perceptible  in  two  months,  he  advises 
that  diuretics  should  be  given,  ivith  the  former  remedies :  the  acetate  of  potash,  or 
squills,  or  both  :  that  an  issue  should  be  made  in  the  neck,  or  in  each  arm,  and 
be  kept  discharging  for  several  months.  And  he  thinks  that  when  convalescence 
has  once  begun,  it  may  often  be  much  accelerated  by  minute  doses  of  quina ;  the 
fourth  of  a  grain,  for  example,  thrice  daily. 

In  a  disease  so  unpromising  as  chronic  hydrocephalus,  we  are  warranted  in  trying 
any  plan  that  has  been  found,  or  supposed,  to  be  useful.  An  apothecary  of  consi- 
derable experience  —  now  dead  —  once  took  the  pains  to  write  out  and  send  me  the 
particulars  of  two  cases  in  which  he  had  seen  a  peculiar  mode  of  administering 
mercury  successful.     I  will  give  you  them  nearly  in  his  own  words. 

In  the  year  1817,  he  had  under  his  care  a  .ad,  named  Scott,  labouring  under 
chronic  hydrocephalus.  He  had  been  ill  tw:  or  three  years,  was  nearly  blind,  had 
very  little  use  of  his  lower  extremities,  f.id  could  not  walk  across  the  room  without 
support.  He  suffered  violent  pains  \ii  his  head,  and  was  unable  to  bear  the  least 
pressure  on  his  scalp.  His  bowels  were  constipated,  and  his  pulse  "  oppressed." 
Cupping  and  blistering,  the  bh^e  pill,  drastic  purgatives,  and  ordinary  diuretics,  tried 
in  combination  and  succession,  gave  him  temporary  relief;  but  no  |)ermanent  benefit 
was  obtained.  Dr.  Go'.ver  then  suggested  a  plan  which  he  had  himself  found  suc- 
cessful in  such  caset;,  and  which  had  first  been  used  by  Dr.  Carmichael  Smith,  who 
had  recorded  ten  cases  of  recovery  under  its  adoption.  Dr.  Gower's  plan  was  to 
rub  down  ton  grains  of  crude  mercury  with  about  a  scruple  of  manna,  and  five 
grains  o( fresh  squills;  this  was  to  be  one  dose:  and  it  was  to  be  repeated  every 
eight  hours. 

My  informant  rubbed  the  quicksilver  down  with  conserve  of  roses,  and  then  added 
♦.he  fresh  squills,  making  the  whole  into  the  consistence  proper  for  pills  with  liquo- 
-ice  powder.  The  patient  took  this  dose  three  times  a  day,  for  nearly  three  weeks, 
without  any  ptyalism  being  jiroduced.  Its  eflects  were  great  prostration  of  strength 
and  loss  of  flesh,  with  gradual  relief  of  all  the  boy's  sufferintis.  It  operated  profusely 
by  the  kidneys.  The  medicine  was  continued  twice  a  day,  and  at  length  once,  for 
another  fortnight ;  when  all  the  symptoms  of  the  disease  had  disappeared.  The  boy 
was  greatly  emaciated.     He  was  then  oraered   an  ounce  and  a  half  of  Griffith's 


CHRONIC    HYDROCEPHALUS.  283 

mixture  thrice  daily  ;  "tnd  soon  regained  his  health  and  strengt]'  tki  got  quite  well. 
He  remained  well  eight  years  afterwards. 

The  success  obtained  in  this  case  led  to  the  pursuance  of  a  similar  course  in  that 
of  the  son  of  a  well-known  fishmonger  in  Old  Bond  Street.  He  was  about  twelve 
vears  old,  and  afflicted  in  nearly  the  same  manner  as  Scott,  except  that  the  pain  in 
his  head  was  more  acute,  and  caused  violent  screaming:  reliff  had  been  repeatedly 
given  for  a  time,  b}^  cupping.  The  physician  in  attendance  was  unwilling  to  try 
the  plan,  when  it  was  proposed  to  him,  but  said  that  he  would  give  what  was  equi- 
valent— small  doses  of  blue  pill,  with  squills  in  powder.  The  result  was  salivation 
in  a  few  days,  without  any  amendment.  In  about  three  weeks,  the  local  elfects  of 
the  mercury  having  subsided,  and  the  patient  then  suffering  extreme  pain  in  the 
head,  loss  of  sight,  and  want  of  power  over  the  lower  extremities,  my  informant  was 
desired  to  adopt  any  measures  he  thought  fitting.  The  medicine  was  given  as  in 
the  former  case,  and  with  the  same  happy  consequence.  It  acted,  as  before,  without 
producing  ptyalism,  but  with  a  great  reduction  of  strength  and  flesh.  Health  was 
restored  by  steel,  after  the  symptoms  of  hydrocephalus  had  disappeared.  This  cure 
also  was  permanent. 

I  think  you  will  give  me  credit  for  not  being  over-fond  of  recommending  Avhat 
may  be  called  conundrums,  instead  of  well-tried  and  approved  means  of  cure  ;  but  I 
say  that  in  such  a  complaint  as  chronic  hydrocephalus,  we  have  generally  the  oppor- 
tunity of  testing  the  virtues  of  many  reputed  remedies,  one  after  another ;  and  we 
are  not  to  despise  or  neglect  any  measures  that  have  been  found  beneficial,  merely 
because  they  are  out  of  the  way,  or  because  we  cannot  see  in  what  manner  they  can 
excel  the  more  common  formuloe. 

You  will  observe  that  these  were  cases  in  which  the  disease  came  on  some  time 
after  the  sutures  of  the  skull  had  closed. 

{Dr.  Hannay  relates  a  case  of  chronic  hydrocephalus,  in  the  Eflinburgh  Med.  and  Surg. 
Journal,  in  which  he  attributes  the  recovery  of  the  patient  mainly  to  the  application  to  the 
scalp  of  a  liniment,  composed  of  powdered  ipecacuanha  and  olive  oil,  each  two  drachms, 
and  half  an  ounce  of  suec.  Dr.  Hannay  remarks,  that  the  application  of  this  liniment,  three 
or  four  times  a  day,  is  followed  in  about  thirty-six  liours,  by  a  papular  and  vesicular  eruption  ; 
and  he  is  of  the  opiniwi,  that  as  chronic  hydrocephalus  often  succeeds  to  the  suppression  of 
eruptions  on  the  scalp,  the  use  of  this  counter-irritant  ^vill  prove  in  many  cases  extremely 
useful  —  its  effects  are  much  more  manageable  than  those  of  the  tartar  emetic  ointment, 
which,  in  this  disease,  has  been  found  advantageous. — C] 

The  mechanical  remedies  of  chronic  hydrocephalus  are  two  :  and  they  have  a 
totally  opposite  mode  of  action.  By  the  one,  the  brain  is  compressed  ;  by  the  other, 
it  is  lightened  of  its  pressure  :  yet  both  of  them  have  proved  successful.  What  does 
this  show  ?  what,  but  a  confirmation  of  the  doctrine  that  there  are  different  states  of 
the  eneephalon,  very  dissimilar  in  their  e.'^sential  character,  yet  having  some  S3'mp- 
toms  in  common  ;  and  those  the  most  likely  of  all  to  catch  our  attention.  Such 
common  symptoms  resemble  an  algebraical  symbol,  which  derives  its  value  from  the 
plus  or  minus  sign  prefixed.  Surely  it  is  of  vital  importance  to  study,  and  if  we  can, 
to  settle,  the  differences  wheivby  these  inverse  condiiions,  requiring  contrary  reme- 
dies, may  be  discriminated. 

Bamluging  the  head  is  one  of  these  two  expedients  ;  punctnrlas:;  it  the  other. 
Neither  of  them  is  practically  applicable  after  the  bones  of  the  skull  have  united. 

Bandages  appear  to  have  been  suggested  by  the  notion  that  the  increase  of  the 
fluid  within  the  head,  and  probably  some  of  the  symptoms  too,  might  depend,  more 
or  less,  upon  the  want  of  firmness  and  proper  resistance  in  the  outer  containing 
parts;  in  the  feeble  and  half  solid  skull.  A  certain  amount  of  support  and  pressure 
is  requisite  for  the  due  exercise  of  the  cerebral  functions.  Beyond  this  amount  all 
mcrease  of  pressure  is  hurtful.  The  middle  point  of  safety  it  may  be  hard  to  hiu 
It  is  certain  that  the  easy  yielding  of  the  bony  walls  of  the  head,  by  reason  of  the 
membranous  interspaces  that  exist  in  the  early  periods  of  life,  proves  oftentimes  ilu 
safety  of  these  patients.  If  the  skull  did  not  expand  as  the  water  gathered,  morbid 
symptoms  would  ensue.  Great  nicety  must  therefore  be  requisite  in  the  use  of  this 
remedy.     While  the  head  is  palpably  enlarging,  compression  b}'  means  of  plasters 


284  DISEASES    OF    THE    BRAIN. 

or  bandages  would  probably  be  mischievous.  When  the  disease  is  stationary,  and 
the  unconnected  bones  of  the  skull  are  loose  and  fluctuating,  and  the  child  is  pale 
and  languid,  much  benefit  may  be  expected  from  moderate  and  well-regulated  sup- 
port. The  late  Sir  Gilbert  Blane  was  the  first,  I  believe,  to  suggest  this  mode  of 
treatment ;  but  its  safety  and  efficacy  have  been  more  recently  demonstrated  by  Mr. 
Barnard,  who  has  related  several  examples  of  complete  success  from  the  employment 
of  bandages.  In  these  cases  the  children  were  pale,  bloated  and  feeble,  with  flabby 
muscles :  the  bones  of  their  heads  were  movable  and  floating,  and  the  functions  of 
the  brain  more  or  less  impaired.  Mr.  Barnard  applied  strips  of  adhesive  plaster, 
about  three-quarters  of  an  inch  wide,  completely  round  the  heads  from  before  back- 
Avards :  covering  the  forehead  from  the  eyebrows  to  the  hair  of  the  head,  as  low 
down  on  the  sides  as  the  ear  will  permit,  and  lapping  over  each  other  behind.  Then, 
cross-strips  are  carried  from  one  side  of  the  head  to  the  other  over  the  crown ;  and 
lastly,  one  long  slip,  reaching  from  the  forehead,  within  half  an  inch  of  the  root  of 
the  nose,  over  the  vertex  to  the  nape  of  the  neck.  In  his  first  trial  of  this  plan,  but 
never  afterwards,  Mr.  Barnard  laid  pieces  of  linen,  wetted  with  cold  water,  over  the 
plasters.  The  only  internal  medicine  given  was  castor  oil,  to  regulate  the  bowels. 
The  effects,  in  all  this  gentleman's  cases,  were  these :  a  gradual  diminution  of  the 
size  of  the  head  ;  mitigation,  and  ultimate  disappearance,  of  all  head  symptoms,  such 
as  strabismus,  rolling  of  the  eyes,  starting  of  the  muscles,  and  convulsions  :  and  at 
the  same  time,  increased  tone  of  the  muscular  system,  with  an  improved  appearance 
of  the  skin  and  of  the  secretions  from  the  bowels.  These  are  striking  results.  They 
show  that,  in  certain  conditions  of  chronic  hydrocephalus,  a  part  of  the  danger  arises 
from  a  lack  of  due  support  and  confinement  of  the  brain  ;  and  they  prove  that  com- 
pression alone  may  be  equal  to  the  cure.  To  such  cases.  Dr.  Arnott's  air-press 
would  seem,  from  the  facility  with  which  its  equable  compressing  force  may  be  regu- 
lated, to  be  especially  adapted. 

But  in  children  who  are  not  of  this  pale  anxl  feeble  habit,  and  in  whom  ossification 
of  the  skull  goes  on,  the  period  when  the  walls  cease  to  j'ield  is  the  period  of 
danger.  The  water  continuing  to  accumulate,  inordinate  pressure  begins  to  take 
place.  Under  these  circumstances,  the  application  of  bandages  or  plasters  must,  if 
nothing  else  be  done,  be  insufficient  or  unsafe.  The  brain-case  being  no  longer 
capable  of  expansion,  there  remains  to  be  attempted  a  reduction  of  the  quantityof 
the  liquid  which  it  contains. 

Now,  any  considerable  diminution  of  the  accumulated  fluid,  through  the  agency 
of  mere  absorption,  is  scarcely  to  be  expected  ;  even  although  we  endeavour  to  aid 
that  process  by  applying  leeches  and  cold  to  the  head,  and  by  purgatives,  or  diuretics, 
or  diaphoretics.  Some  mode,  more  certain  and  elTectual,  of  emptying  the  distended 
cavity,  has  therefore  been  earnestly  sought  after;  and  the  second  mechanical  expe- 
dient of  which  I  have  spoken  oflxn-s  a  very  sure  method  of  attaining  this  object.  He 
must  have  been  a  bold  pliysician  who  first  proposed  to  decant  the  water  from  the 
brain,  by  means  of  a  perforation,  made  with  a  trocar,  through  the  membrane  of  the 
fontanelle,  through  the  membranes  of  the  brain,  and  through  even  the  expanded 
cerebral  substance  itself.  But  the  success  of  the  project  has  amply  vindicated  his 
happy  audacity.  It  is  not  a  very  new  suggestion,  but  it  has  received  particular 
attention  in  this  country  of  late  years:  and  though  tapping  the  bruin  in  chronic  hy- 
drocephalus has  been  denounced  as  useless  and  cruel  by  some  high  continental  autho- 
rities, by  Golis  and  Richter  especially,  it  furnishes  one  of  the  best  of  the  few  chances 
of  safety  to  the  patient.  Of  course  I  mean  ultimate  safely,  for  the  operation  itself 
;s  attended  with  the  present  risk  of  accelerating  the  patient's  death.  Other  means, 
however,  faihng,  we  are  justified  in  advising  that  hazard.  We  have  to  consider  that 
by  performing  the  operation  we  incur  the  danger  of  abbreviating  the  existence  of  a 
being,  whoso  life,  without  it,  could  scarcely  be  long  continued,  or  capable  of  enjoy- 
ment :  but  then  we  afford  some  chance  of  a  perfect  cure.  A  speedy  death,  or  an 
uncertain  life  of  mental  and  bodily  imbecility,  or  complete  restoration:  these  are  the 
three  events  to  be  looked  at.  Of  the  three,  the  second  is,  in  my  judgment,  incom- 
parably the  worst ;  and  if  the  case  were  my  own,  if  I  had  to  decide  the  painful 


CHRONIC    HYDROCEPHALUS.  285 

question  in  reference  to  one  of  my  own  children,  I  would  accept  the  alternative  of 
probable  speedy  death  on  the  one  hand ;  possible  complete  recovery  on  the  other. 

To  say  the  truth,  the  immediate  danger  is  not  so  very  great  as  you  might  suppose ; 
provided  that  the  operation  be  skilfully  and  cautiously  performed,  and  only  a  mode- 
rate quantity  of  water  drawn  off  at  a  time.  That  even  a  very  rough  operation  is 
not  necessarily  fatal  we  learn  from  a  singular  case  related  by  Mr.  Greatwood.  A 
child,  fifteen  months  old,  afflicted  with  chronic  hydrocephalus,  fell  down,  and  struck 
the  back  part  of  its  head  against  a  nail,  which  penetrated  the  skull.  Above  three 
pints  of  water  gradtially  flowed  out  at  the  orifice  thus  made,  and  the  child  was 
cured. 

I  will  mention  a  few  instances  in  which  tapping  the  brain  has  been  performed ; 
for  I  know  no  better  mode  of  showing  you  the  manner  in  which  the  operation 
should  be  done,  the  cautions  to  be  attended  to  in  doing  it,  and  what  kind  of  success 
it  has  had. 

There  is  an  account  of  the  performance  of  this  operation  by  Lecat,  in  the  Philo- 
sophical Transactions  for  the  year  1751.  This  date  is  subsequent  to  the  period 
when  the  Rev.  Mr.  Stevens  suggested  the  propriety  of  trepanning  Dean  Swift's  cra- 
nium. In  1778,  Dr.  Remmet,  of  Plymouth,  punctured  the  head  of  a  hydrocephalic 
child  on  five  several  occasions,  with  a  lancet,  and  took  away,  in  all,  no  less  than 
eighty  ounces  of  fluid  ;  five  pints,  as  pints  were  measured  in  that  day.  The  child 
died  seventeen  days  after  the  last  tapping.  A  very  interesting  case  of  the  same  kind 
is  related  by  Dr.  Vose,  of  Liverpool.  His  patient  was  an  infant  seven  months  old. 
Its  head  was  more  than  twice  the  ordinary  size.  Three  operations  were  performed  ; 
the  first  with  ^  couching  needle.  Upwards  of  three  ounces  were  on  that  occasion 
evacuated  ;  and  it  was  estimated  that  about  the  same  quantity  dribbled  away  after- 
wards. The  child  thereupon  became  very  weak,  but  was  presently  revived  by  some 
cordial  medicine.  About  six  weeks  afterwards,  the  liquid  having  collected  again,  an 
opening  was  made  with  a  bistoury,  and  eight  ounces  were  removed  ;  and  nine  days 
after  that,  twelve  ounces  more,  without  any  bad  consequences.  The  head  dimin- 
ished in  size,  the  patient  got  apparently  well,  and  the  case  was  published  as  a  suc- 
cessful one.  Unfortunately,  however,  the  complaint  afterwards  returned,  and  the 
child  died  of  it. 

Mr.  Lizars,  of  Edinburgh,  operated  upon  a  little  patient  of  his  twenty  times  in 
the  course  of  three  months ;  using  a  small  trocar.  Dilatation  of  the  pupils,  and 
squinting,  which  had  previously  existed,  ceased  immediately  upon  the  escape  of  the 
water.  The  child  recovered.  Another  very  striking  and  instructive  instance  is 
recorded  by  Mr.  Russell,  of  Edinburgh.  The  patient  was  an  infant  three  months 
old,  with  an  enormous  head  ;  twenty-three  inches  in  circumference,  and  fifteen 
inches  and  a  half  from  one  ear  to  the  other.  The  child  was  afltcted  with  strabis- 
mus, and  a  perpetual  rolling  of  the  eyes.  The  usual  routine  measures,  compression 
among  the  rest,  had  been  employed  without  any  success.  By  four  operations  per- 
formed at  intervals  of  about  ten  days,  the  size  of  the  head  was  considerably  reduced: 
but,  the  fluid  continuing  to  collect,  calomel  was  given  in  small  and  frequent  doses, 
and  the  gums  became  sore,  and  the  child  got  well.  At  eight  months  old  the  dimen- 
sions of  the  head  were  less,  by  four  inches  in  circumference,  and  by  two  inches  and 
a  half  across  the  vertex,  than  they  had  been  before  the  first  tapping  ;  and  the  sutures 
had  entirely  closed. 

But  Dr.  Conquest,  of  Finsbury  Square,  has,  more  than  any  other  person,  given 
authority  to  these  operations.  In  a  paper  published  in  the  Medical  Gazette  in  March, 
1838,  he  tells  us  that  he  had  then  tapped  the  heads  of  nineteen  children  for  this  com- 
plaint, and  in  ten  of  the  nineteen  cases  the  children  survived.  Ho  introduces  a  small 
trocar  through  the  coronal  suture  below  the  anterior  fontanelle,  and  cautiously  makes 
pressure  upon  the  head  afterwards  by  means  of  strips  of  adhesive  plaster;  and  he 
closes  the  wound  in  the  integuments  carefully  after  each  time  of  punciuring.  The 
greatest  quantity  of  liquid  withdrawn  by  him  at  any  one  time,  has  been  twenty 
ounces  and  a  half;  and  the  greatest  number  of  operations  on  any  one  child  has  been 
five,  performed  at  intervals  of  from  two  to  six  weeks.  The  largest  tota)  quantity  of 
water  removed  was  fifiy-seven  or  fifty-eight  ounces  by  five  successive  tappings. 


280  DISEASES    OF    THE    BRAIN. 

This  expedient,  therefore,  though  doubtless  hazardous,  is  really  a  valuable  one. 
The  rules  relating  to  its  performance  may  be  brieflj"-  summed  up.  The  operation 
should  scarcely  be  had  recourse  to  until  other  means  have  failed.  The  trocar  should 
be  small,  and  it  should  be  introduced  perpendicularly  to  the  surface,  at  the  edge  of 
the  anterior  fontanelle ;  so  as  to  be  as  much  as  possible  out  of  the  way  of  the  longi- 
tudinal sinus,  and  of  the  great  veins  that  empty  themselves  therein.  The  fluid 
should  be  allowed  to  issue  very  slowly;  and  a  part  of  it  only  should  be  evacuated 
at  once.  The  instant  that  the  pulse  becomes  w'eak,  or  the  dilated  pupil  contracts,  or 
the  expression  of  the  child's  countenance  manifestly  alters,  the  canula  should  be 
withdrawn,  and  the  aperture  in  the  skull  closed.  Gende  compression  should  be 
carefully  made  to  compensate,  in  some  degree  at  least,  the  pressure  that  has  been 
removed  with  the  fluid.  Should  the  infant  become  pale  and  faint,  it  must  be  placed 
m  the  horizontal  posture ;  and  a  few  drops  of  sal  volatile,  or  of  brandy,  mixed  with 
water,  may  be  given.  Sometimes  slight  inflammatory  action  comes  on  in  the  course 
of  a  day  or  two  after  the  tapping.  When  this  happens,  we  must  apply  cold  lotions, 
and  leeches,  and  use  the  other  remedies  which  I  mentioned  before,  as  proper  to  sub- 
due such  inflammation. 

I  once  got  a  surgeon  to  perform  the  operation  upon  the  infant  of  a  poor  woman, 
after  I  had  tried  in  vain  all  the  other  measures  I  have  spoken  of.  To  our  horror, 
when  the  trocar  was  withdrawn  from  the  canula,  instead  of  clear  serosity,  a  fine 
stream  of  purple  blood  spouted  forth.  The  opening  was  at  a  considerable  distance  from 
the  longitudinal  sinus ;  but  the  trocar  was  not  so  delicate  as  it  might  have  been,  and 
I  presume  that  one  of  the  larger  superficial  veins  had  been  pierced.  I  do  not  think, 
either,  that  the  instrument  was  introduced  in  a  sufficiently  perpendicular  direction. 
Of  course  the  risk  of  hitting  a  vein  is  increased  when  the  trocar  is  carried  obliquely 
inwards  :  and  a  larger  portion  of  the  cerebral  mass  is  also  wounded.  We  naturally 
thought  it  was  all  over  with  the  child,  which  presently  became  deadly  pale  and  faint. 
A  verdict  of  infantidde  by  misadvenliire  stared  us  in  the  face.  But  under  the  use 
of  stimulants  the  infant  revived  again;  no  hemorrhage  went  on  internally,  as  we 
apprehended  it  would  ;  but  the  child,  after  a  day  or  two,  seemed  very  much  the 
better  for  the  loss  of  blood.  This  amendment,  however,  did  not  last;  and  the 
mother,  who  had  been  terrified  by  the  immediate  consequences  of  the  operation, 
feared  to  come  near  me,  lest  I  should  w'ish  to  have  it  repealed  ;  and  at  length  our 
patient  died,  I  was  very  desirous  to  examine  the  interior  of  the  head  ;  but  this  was 
not  permitted. 

On  one  subsequent  occasion  I  have  witnessed  the  operation.  The  subject  of  it 
was  an  infant  about  eight  months  old.  Four  months  after  its  birth,  its  head  was 
observed  to  grow  inordinately  large.  At  the  time  of  the  operation  the  fontanelles 
were  exceedingly  tense ;  the  child  screamed  frequently,  occasionally  vomited,  and 
was  slightly  convulsed ;  the  features  were  pinched,  and  the  eyeballs  distorted  down- 
wards ;  but  the  pupils  were  not  dilated.  Four  ounces  of  transparent  liquid  were  let 
out  by  puncturing  the  anterior  fontanelle.  A  few  hours  afterwards  the  child  was 
tranquil,  and  much  improved  in  aspect;  the  distortion  of  the  eyeballs  had  disap- 
peared. Three  ounces  more  were  taken  away  the  next  day.  For  two  days  there- 
after all  the  symptoms  appeared  to  be  mitigated ;  but  the  skull  was  flaccid  ;  yield- 
ing, like  a  broken  egg,  to  the  gentlest  pressure.  On  the  evening  of  the  fourth  day 
after  the  first  tapping,  the  respiration  became  hurried,  the  child  grew  dull,  and,  befSre 
nr'dnight,  expired.  In  this  case  it  appeared  to  me  that  the  chance  of  success  was 
baulked  by  the  want  of  external  support  subsequently  to  the  tapping. 

You  will  not  expect  me  to  draw^  any  comparison  between  the  merits  of  compres- 
sion and  paracentesis,  as  substantive  remedies.  They  are  opposite  measures,  and 
adapted  to  different  and  opposite  conditions  of  the  brain.  The  one  repairs  defect  of 
pressure ;  the  other  relieves  its  excess.  To  hold  the  balance  even  requires  much 
care,  a  steady  and  gentle  hand,  an  accurate  judgment,  and  incessant  vigilance. 
Either  expedient  may  suffice,  alone.  Both  may  be  (and  have  been)  profitably  em- 
ployed in  the  same  case,  in  succession,  according  to  its  varying  circumstances.  If 
.he  \^lls  of  the  head  be  tight  and  firm,  the  trocar  should  precede  the  bandage  ;  if 


CHRONIC   HYDROCEPHALUS.  287 

jax  and  movable,  compression  should  be  cautiously  tried,  and  followed,  if  need  be. 
by  the  puncture. 

'  [Dr.  Whitney  relates,  in  the  Edinburgh  Med.  and  Surg.  Journal,  an  instance  of  the  success- 
ful puncture  of  the  brain  in  a  case  of  chronic  hydroceiThalus.  By  the  first  operation,  nine 
ounces  of  fluid  were  drawn  off,  and  in  three  weeks  subsequently,  by  a  second  operation,  five 
ounces  more.  Neither  operation  was  succeeded  by  any  bad  symptom,  and  the  recovery  of 
tlie  child  appears  to  have  been  complete.  Two  eases  are  related  by  Professor  Wutzer,  and 
Dr.  Butcher,  in  the  Austrian  IMedical  Journal,  in  which  the  puncture  of  the  brain  was  unsuc- 
cessfully employed.  In  the  first,  a  child  seven  months  old,  death  occurred  in  six  days  ?  '°' 
the  first  operation;  in  the  second  case,  of  a  child  sixteen  months  old.  the  operation  \."<«f 
repeated,  after  an  interval  of  four  weeks,  anil  seven  weeks  after  the  second  puncture,  tht, 
child  died  in  convulsions.  Dr.  West  (^Report  for  1844-45)  states  that  oi  sixty  recorded  cases 
in  which  puncture  of  the  brain  was  performed,  seventeen,  or  one  in  85,  had  a  favourable  te 
mination  ;  or,_in  other  words,  the  recoveries  have  been  to  the  deaths  in  the  proportion  of  28 
per  cent. — C] 

I  have  now  done  with  the  inflammatory  affections  of  the  brain :  in  conjunction 
with  which  I  have  also  considered  some  other  morbid  conditions,  that  are  either  con- 
nected with  inflammation  of  the  contents  of  the  cranium,  or  resemble  it  in  some  of 
their  phenomena.  Thus,  I  have  spoken  of  delirium  tremens,  which  is  apt  to  be 
mistaken  for  inflammation  of  the  brain :  of  soflening  from  disease  of  the  cerebral 
arteries,  which  is  liable  to  be  confounded  with  inflammatory  softening:  of  tumours 
of  different  kinds,  which  tend  to  produce  inflammation,  or  symptoms  like  those 
belonging  to  inflammation :  and  of  chronic  hydrocephalus,  which  sometimes  is  the 
sequel,  sometimes  the  precursor,  of  acute  hydrocephalus ;  and  has  other  points  of 
analogy  with  that  disease,  the  encephalitis  of  children.    • 

\_Me'ningitis  encephalica. — Under  this  name.  Dr.  Brockman  has  recently  described  a  peculiar 
form  ol'  cerebral  disease  incidental  to  childiiood,  in  which  the  membranes  of  the  medulla 
oblongata  and  pons  varolii  are  chiefly  affected. 

Dr.  B.  has  met  with  fourteen  cases  of  this  affection.  It  was,  at  first,  observed  by  him  as  a 
sequel  of  scarlatina,  but  subsequently,  he  has  seen  it  to  occur  most  I'equently  as  an  idio- 
pathic affection. 

It  is  sometimes  associated  with  general  disease  of  the  brain ;  at  others,  it  is  uncomplicatecL 
Notwithstanding,  in  its  earlier  stages,  it  is  unattended  by  any  serious  symptoms,  it  is  an  affec- 
tion fully  as  dangerous  as  cerebral  meningitis.  The  first  stage,  or  that  of  simple  hypertemiaj 
generally  continues  for  one  or  two  days.  The  child  is  dull  and  heavy,  and  the  occiput  is 
often  hot;  the  bowels,  however,  are  regular;  there  is  no  vomiting,  no  intolerance  of  light, 
nor  any  disturbance  of  sleep.  The  general  dullness  of  the  patient,  and  vague  complaints  of 
some  uneasy  sensation  in  the  head,  increase  as  the  inflammatory  stage  sets  in  ;  the  heat  of 
tlie  occiput  is  augmented ;  the  head  becomes  retracted,  as  in  the  ordinary  cases  of  acute  hy- 
drocephalus; and  convulsive  twitchings  of  the  limbs  occur,  similar  to  the  eflects  of  light  elec- 
tric shocks,  which  recur  every  iew  minutes  while  the  patient  is  awake,  but  cease  during 
sleep.  The  general  febrile  symptoms  continue  during  the  third  stage  ;  the  pulse,  however, 
diminishes  in  frequency  and  fullness,  but  does  not  become  either  irregular  or  intermittent. 
The  general  disquietude  of  the  child  subsides,  by  degrees,  into  a  comatose  condition,  in  which 
the  head  becomes  still  more  retracted,  but  unattended  with  strabismus,  or  any  morbid  con- 
dition of  the  pupil;  the  peculiar  air  of  stupidity  that  characterizes  hydrocephalic  patients  is 
■wanting.  Two  pathognomonic  symptoms,  however,  indicate  the  occurrence  of  the  stage  of 
eflusion.  One  of  these  is  deafness  ;  the  other  difficult  articulation,  and  dhncidty  in  moving 
the  tongue  —  both  of  which  occur  at  the  same  time,  probably  from  paralysis  of  the  motor 
nerves  of  the  tongue.  The  deafness  and  affection  of  the  tongue  usually  occur  suddenly; 
sometimes  they  are  first  observed  upon  the  child  awaking  from  a  quiet  sleep.  They  are, 
according  to  Dr.  Brockman,  tlie  earliest  and  most  certain  indications  of  the  occurrence  of 
effusion.  This  stage  continues,  sometimes,  for  three,  and  sometimes  for  fourteen,  days.  Its 
termination  is  in  fatal  paralysis,  the  occurrence  of  which  is  often  preceded  by  various  singt*- 
lar  nervous  phenomena — as  sudden  pauses  in  the  respiration,  or  equally  suddan  syncope.  In 
some  cases,  however,  the  paralysis  does  not  follow,  but  the  anomalous  symptoms  subside, 
and  die  jiatients  gradually  recover;  until,  indeed,  the  paralytic  stage  is  fully  established,  tho 
recovery  of  die  patient  is  still  possible. 

In  the  uncomplicated  cases  of  the  disease,  upon  examination  after  death,  the  cerebrum  m 
general,  presents  an  extremely  pallid  and  ana'mic  condition,  in  striking  contrast  with  the 
cerebellum,  the  vessels  of  which  are  turgid  with  blood,  while  its  substance,  also,  is  often  i^ 
a  state  of  marked  hyperaemia.  The  hyperamia  increases  in  intensity  towards  tlie  centr-ij 
portions  of  the  encephalon ;  and  the  membranes  covering  the  pons  varolii  and  medulla  ob^ 
'•ngata  are   found  in  a  most  decided  stale  of  inflammation  ;  the  portion  of  inflanieil  .iistu 


288  DISEASES    OF   THE   BRAIN 

brane  is  perfectly  isolated,  and  not  more,  usually,  than  a  square  inch  in  extent  —  the  mem 
brane  of  the  cerebellum  being  entirely  free  from  any  indications  of  inflammation.  There  is 
ordinarily  an  effusion  of  a  serous  fluid  into  the  sub-arachnoidal  tissue;  sometimes  to  the 
extent  of  several  ounces ;  occasionally  a  gelatinous  matter  is  effused,  and,  in  some  cases^  the 
efi'usion  is  of  a  purulent  character. 

This  form  of  the  disease  is  most  frequently  observed  in  children  from  three  to  ten  years 
of  age.  and  who  had  previously  enjoyed  good  health. 

The  treatment  recommended  by  Dr.  Broclcman,  in  its  first  two  stages,  is  depletion,  by 
leeches  to  the  posterior  part  of  the  head,  cold  applications  to  the  scalp,  and  the  free  adminis- 
tration of  calomel,  which  latter  may  be  continued  during  the  stage  of  effusion.  Here,  how- 
ever, it  becomes  necessary  to  support  the  strength  of  the  patient ;  for  this  purpose  ammonia 
is  directed  by  Dr.  B.,  but  he  remarks  that,  in  some  cases,  the  administration  of  wine  may  be 
required.  According  to  his  experience,  powerful  counter-irritants,  as  a  large  blister,  or  the 
actual  cautery,  prove,  also,  sometimes  beneficial. — C] 

Before  I  take  up  the  subject  of  apoplexy,  and  of  cerebral  hemorrhage,  I  wish  to 
direct  your  attention  to  the  inflammatory  conditions  of  the  spinal  cord. 

The  whole  pathology  of  this  portion  of  the  nervous  system  is  extremely  interest- 
mg ;  but  it  has  not  yet  been  so  thoroughly  made  out  as  to  enable  any  one  to  give  a 
very  systematic  or  satisfactory  account  of  it.  In  addition  to  those  numerous  difficul- 
ties with  which  I  showed  you  in  a  former  lecture  that  the  entire  subject  of  the  dis- 
eases of  the  nervous  apparatus  is  beset,  there  is  this  further  obstacle  to  our  studying 
diligently  the  structural  changes  of  the  spinal  marrow — that  much  labour  and  ex- 
pense cf  time  are  required  for  exposing  the  interior  of  the  vertebral  canal;  which  is, 
therefore,  too  often  neglected  in  examining  the  dead  body. 

There  are  certain  points  in  the  anatomy  and  physiology  of  the  spinal  cord  which 
it  is  necessary  that  you  should  bear  in  mind,  if  you  would  have  any  clear  notions 
even  of  what  has  been  learned  in  respect  to  its  pathology. 

1.  In  the  first  place  the  spinal  cord  (including  the  medulla  oblongata)  is  the  seat 
and  centre  of  that  remarkable  property,  the  reflex  function ;  by  which  so  many  of 
the  automatic  movements  of  the  body  are  regulated. 

2.  In  order  that  we  may  feel,  or  be  conscious  of,  what  occurs  in  any  part  of  the 
trunk  or  limbs,  and  in  order  that  our  will  to  move  any  such  part  should  be  obeyed, 
it  is  necessary  that  there  should  be  a  continuity  of  nervous  matter  between  the  part 
in  question  and  the  brain.  If  the  cord  be  cut  across  at  any  point,  or  so  crushed  as 
to  be  thoroughly  disorganized  at  that  point,  a  complete  abolition  of  sensation  and  of 
vohmlary  motion  ensues  in  all  those  parts  of  the  bod}^  that  receive  their  sentient  and 
motor  nerves  from  that  portion  of  the  cord  which  lies  beyond  the  place  of  the  injury, 
reckoning  from  the  brain.  What  is  true  in  this  respect  of  the  mechanical  division 
of  the  cord,  is  equally  true  of  such  disease  as  pervades  and  spoils  the  nervous  matter 
composing  it. 

Now  it  follows  from  this,  that  the  effects  of  disorganizing  forms  of  disease  —  as 
well  as  the  effects  of  injury  —  must  Tary  greatly  according  to  the  part  of  the  cord 
they  occupy. 

Thus  any  injury  or  disease  affecting  the  whole  thickness  of  that  portion  of  the 
spinal  marrow  which  is  contained  within  the  upper  cervical  vertebrae,  is  inevitably 
fatal  at  once ;  producing  suffocation  by  paralyzing  those  muscles  through  the  play 
of  which  the  motions  of  respiration  are  performed.  You  know  that  the  intercostal 
muscles  and  the  diaphragm  have  at  all  times  the  main  share  in  carrying  on  the  me- 
chanical actions  of  respiration  ;  and  probably  they  execute  the  whole  action  in  every 
case  of  ordinary  breathing.  Now  the  miercostal  muscles  are  furnished  with  motor 
nerves  frorifi  the  spinal  cord,  all  along  the  dorsal  vertebrae ;  and  the  diaphragm  is 
principally  supplied  by  the  phrenic  nerves,  which  are  chiefly  derived  from  the  third 
and  fourth  cervical  nerves.  These  muscles  obey  the  will;  but  they  act  also  inde- 
pendently of  the  will.  The  pneumogastric  and  trifacial  nerves,  with  respect  to  them, 
are  excito-motor^^  nerves,  and  call  into  play  a  reflex  power  which  is  transmitted  from 
the  n.edulla  oblongata.  Hence  any  profound  injury  of  the  spinal  cord,  above  the 
origin  of  the  phrenic  nerves,  stops  both  the  voluntary  and  the  involuntary  movements 
of  the  respiratory  muscles,  and  the  individual  perishes  by  apnoea,  in  as  strict  a  sense 


AND    SPINAL    CORD.  289 

as  though  the  access  of  air  to  the  lungs  had  been  suddenly  prevented  by  a  hgaiure 
drawn  tightly  round  his  windpipe. 

Again,  when  a  segment  of  the  cord,  however  small,  is  disorganized  in  its  cervical 
part,  between  the  origin  of  the  phrenic  and  the  origin  of  the  upper  intercostal  nerves, 
the  breathing  is  not  instantly  suspended  ;  but  is  performed  entirely  by  means  of  the 
diaphragm,  the  intercostal  muscles  having  no  share  in  it.  The  ribs  cease  to  rise  and 
fail;  and  the  abdomen  is  alternately  protruded,  and  sinks  back  again.  In  each  case 
I  suppose  the  disease  of  the  cord  to  be  such  as  suffices  to  paralyze  the  parts  supplied 
with  nerves  from  it,  beyond  the  seat  of  the  disease.  If  disease  of  this  kind  occur 
below  the  giving  out  of  the  intercostal  nerves,  the  breathing  is  not  affected ;  we  have 
paraplegia  only,  palsy  and  loss  of  feehng  in  the  lower  extremities,  and,  perhaps,  in 
the  hips,  or  even  higher.  Now  a  person  in  this  condition  may  live  a  long  time. 
When  the  disease  is  situated  between  the  origin  of  the  intercostal  nerves  and  the 
origin  of  the  phrenic,  he  may  live  a  few  days,  but  he  seldom  lives  a  week,  and 
never  survives  a  month :  and  when  the  disease  is  higher  still,  in  the  very  upper  part 
of  the  cord,  above  the  origin  of  the  cervical  nerves,  he  perishes  outright.  The  kind 
and  degree  of  disease,  therefore,  being  the  same,  the  character  of  the  symptoms,  and 
the  amount  of  danger,  differ  remarkably  according  to  the  seat  of  the  disease. 

3.  Although  sense  and  voluntary  motion  cease  upon  the  disruption  of  the  commu- 
nication with  the  brain,  the  excito-molory  functions  of  the  separated  portion  of  the 
cord  are  not  necessarily  suspended.  On  the  contrary,  they  seem  to  acquire  increased 
activity.  The  automatic  power  is  apt  to  run  riot,  as  it  were,  when  the  controlling 
influence  of  the  sensorium  is  withdrawn.  All  of  you  have  probably  seen  the  hmbs 
of  a  recently  decapitated  frog  thrown  into  violent  action  by  the  stimulus  of  galvanism. 
I  have  witnessed  the  same  thing  in  the  human  body  after  death  by  hanging.  What 
is  still  more  curious,  you  may  have  unequivocal  manifestations  of  similar  phenomena 
in  the  living  body.  I  have  lately  been  informed,  by  Dr.  William  Budd,  of  a  case 
in  which  a  man  was  afflicted  with  paraplegia,  in  consequence  of  disease  of  the  ver- 
tebral column.  He  was  totally  deprived  of  the  power  of  moving  his  lower  extremi- 
ties. Sensation  in  them  was  almost,  yet  not  entirely  extinct.  A  sharp  pinch,  or  the 
prick  of  a  pin,  he  could  feel;  but  slight  friction  he  was  quite  unconscious  of:  yet 
(as  he  himself  said)  his  limbs  were  not;  for  when  the  inner  edge  of  the  foot  was 
brushed  or  tickled  by  the  hand  of  another  person,  the  corresponding  leg,  over  which 
he  had  no  voluntary  control,  would  start  up,  and  be  briskly  convulsed.  The  same 
thing  took  place,  in  both  limbs,  whenever  he  passed  his  urine  or  feces;  so  that  he 
was  obliged  to  have  an  apparatus  of  straps  and  ligatures  to  keep  the  legs  down  on 
such  occasions.     I  have  seen  something  like  this  myself.* 

4.  Distinct  and  different  filaments  of  the  spinal  cord  connect  themselves  with,  or 
help  to  form,  different  nerves  which  emerge  from  the  cranio-spinal  axis.  A  know 
ledge  of  this  fact  enables  us  to  understand  how  it  happens  (as  it  sometimes  does 
happen,)  that  the  upper  extremities  are  bereft  of  sensibility,  or  of  voluntary  motion, 
or  of  both,  by  disease  of  the  cord,  while  the  same  functions  remain  perfect  in  the 
lower  and  more  distant  limbs.  Here  the  disease  must  have  spared  those  strands  or 
filaments  of  the  cords  which  pass  down  to  connect  themselves  with  the  nerves  given 
off  at  the  lower  part  of  the  spine  ;  while  it  has  affected  those  strands  or  filaments 
only  which  belong  to  certain  nerves  from  the  upper  part. 

•S.  Under  the  sagacious  researches  of  Dr.  Marshall  Hall,  the  physiology,  and  witri 
it  the  whole  pathology,  of  the  spinal  cord  is  undergoing,  at  this  very  time,  a  com 
plete  reformation.  I  know  of  no  modern  discovery  so  fruitful  of  important  practical 
consequences,  or  so  likely  to  improve  our  remedial  management  of  nervous  disor- 
ders, as  the  singularly  interesting  truths  which  he  is  even  now  engaged  in  demon 
strating  and  enforcing.  I  do  not  profess  to  teach  you  this  new  physiology.  I  touch 
only,  as  I  pass  along,  upon  some  of  its  cardinal  points,  to  which  1  may  have  occasion 
to  refer  in  future.  We  are  considering  how  the  signs  of  spinal  disease  may  vai y 
according  to  the  particular  location  of  that  disease;  and  I  would  have  you  remark, 

*  This  very  interesting  case  has  since  been  published,  in  detail,  with  several  otLera  * 
Bcmbling  it,  in  the  22d  volume  of  the  Medico-Chirurgical  Transactions. 

19  z 


290  DISEASES    OF    THE 

here,  that  inasmuch  as  all  the  acts  of  ingestion  and  expulsion,  all  the  inlets  and  out- 
lets of  iho  bod}',  are  governed  by  the  spinal  marrow,  with  its  corresponding  apparatus 
of  incident  and  motor  nerves — it  is  to  be  expected  that  disease  in  the  upper  part  of 
the  true  spinal  system  should  affect  the  orifices  which  answer  to  that  part,  and  which 
are  principally  inlets — the  larynx,  the  gullet,  the  cardia:  while  disease  in  its  lower 
portion  will  be  lik'ely  to  disturb  the  natural  functions  of  the  lower  orifices  —  the 
rectum  and  anus,  the  bladder  and  urethra,  the  os  uteri — which  are  chiefly  outlets. 

G.  You  must  bear  in  mind  also  the  grand  discovery  of  Sir  Charles  Bell,  that  the 
two  roots  by  which  each  spinal  nerve  arises  have  distinct  and  different  functions ; 
the  anterior  roots  being  composed  of  motor  fibrils,  the  posterior  of  sensiferous. 

It  is  not  so  clear,  although  that  opinion  is,  I  believe,  a  prevalent  one,  that  the 
anterior  columns  of  the  spinal  cord  are  subservient  to  the  purposes  of  motion,  and 
the  posterior  to  the  faculty  of  sensation.  This  has  been  inferred,  too  hastily  perhaps, 
from  the  ascertained  endowments  of  the  anterior  and  posterior  roots  of  the  nerves: 
and  cases  are  cited  which  appear  to  favour  such  a  notion  :  but  then  other  cases  go 
completely  to  contradict  it.  Thus  Mr.  Stanley  has  recently  published  an  account  of 
a  patient  who  died  in  St.  Bartholomew's  Hospital.  For  some  time  before  his  death 
he  had  been  completely  unable  to  move  his  lower  limbs,  throughout  their  entire  ex- 
tent ;  while  there  was  no  discoverable  impairment  of  sensation  in  any  part  of  either 
limb.  The  spinal  cord  was  the  only  organ  found  diseased :  and  the  disease  was 
strictly  limited  to  its  posterior  half  or  columns.  This  portion  of  the  cord,  in  its 
whole  length,  from  the  pons  to  its  lower  end,  was  of  a  dark-brown  colour,  and  ex- 
tremely soft  and  tenacious.  The  anterior  half,  in  its  entire  length,  exhibited  its 
natural  whiteness  and  firm  consistence.  The  roots  of  the  spinal  herves  were  un- 
altered. 

It  was  remarkable,  and  illustrative  of  the  difficulty  of  these  subjects,  that  with 
the  change  of  structure  which  the  cervical  portion  of  the  cord  had  undergone  in 
this  instance,  there  was  no  defect  either  of  motion  or  of  sensation  in  the  upper 
limbs. 

7.  We  must  not  forget  that  the  brain,  and  the  spinal  cord,  which  are  distinct  from 
but  yet  continuous  with  each  other,  sympathize  largely  and  mutually  under  disease. 
This  circumstance  throws  an  additional  obscurity  over  the  study  of  their  morbid 
conditions.  It  is  one,  however,  which  we  cannot  avoid,  but  which  we  must  estimate 
and  allow  for,  in  our  observation  of  diseases,  as  we  best  may. 

8.  There  are  a  few  remarks  made  by  Dr.  Abercrombie  in  relation  to  some  of 
the  anatomical  dispositions  of  the  cord  and  its  investing  membranes,  which  may 
help  us  to  comprehend  better  some  of  their  morbid  contingencies.  Thus,  with 
respect  to  the  dura  mater  of  the  cord,  it  is  practically  of  importance  to  recollect 
"  that  it  adheres  very  slightly  to  the  canal  of  the  vertebrae  by  a  very  loose  cellular 
texture;  and  that  it  adheres  very  intimately  to  the  margin  of  the  foramen  magnum. 
In  this  manner  a  cavity  is  produced  betwixt  the  membrane  and  the  inner  surface  of 
the  spinal  canal  (external,  i.  €.,  to  the  membrane),  which  cavity  may  be  the  seat  of 
effusion,  and  which  has  no  communication  with  the  cavity  of  the  cranium.  On  the 
other  hand,  the  space  between  the  dura  mater  and  the  pia  mater  (or  membrane  im- 
mediately covering  the  cord),  communicates  freely  with  the  cavity  of  the  cranium; 
so  that  fluid  may  pass  easily  from  one  to  the  other,  according  to  the  position  of  the 
body." 

1  shall  pursue  the  same  order,  in  speaking  of  the  inflammatory  affections  of  the 
^pinal  cord,  as  I  followed  in  respect  to  the  analogous  conditions  of  the  encephalon. 
And,  first,  let  us  inquire  vvhat  has  been  noticed  of  inflammation  of  the  membranes 
of  the  cord.  They  may  undergo  inflammation,  independently  of  the  substance  of 
the  cord,  and  independently  of  the  brain:  but  this  is  not  very  common.  Usually, 
when  we  have  meningitis  of  the  cord,  we  have  the  same  disease  also  within  the  era 
nium ;  usually,  also,  with  meningitis  of  the  cord,  we  have  more  or  less  inflam 
■nation  of  the  nervous  matter  composing  it.  The  commonest  symptoms  of  in- 
riammation  of  the  meninges  of  the  cord  (for  I  do  not  pretend  to  speak  of  the  several 
membranes  separately),  appear  to  be  pains,  often  intense,  extending  along  the  spine. 


SPINAL    CORD.  291 

and  stretching  into  the  Hmbs,  and  aggravated  usually  by  motion,  and  simulating 
therefore  rheumatic  pains :  rigidity  or  tetanic  contraction,  and  sometimes  violent 
spasms,  of  the  muscles  of  the  back  and  neck,  amounting  in  some  instances  to 
perfect  opisthotonos  :  a  similar  affection  of  other  muscles,  also,  as  those  of  the  upper 
or  lower  extremities :  a  sense  of  constriction  in  various  parts,  in  the  neck,  hack, 
and  abdomen,  as  if  those  parts  were  girt  by  a  tight  string :  feelings  of  sufToca 
tion :  retention  of  urine  :  obstinate  constipation :  and  with  these  symptoms,  rigois 
often. 

You  are  not  to  expect  all  the  symptoms  which  I  have  been  enumerating  in 
every  case ;  they  will  vary  according  to  the  seat  and  extent  of  the  inflammation. 
We  need  not  wonder  at  the  spasmodic  symptoms,  when  we  recollect  that  the 
nerves  which  issue  from  the  body  of  the  cord  receive  a  covering  from  its  pia 
mater.  The  pain  felt  along  the  course  of  the  spine  itself  is  said  to  be  aggravated 
by  percussion  of  the  spine,  but  not  by  simple  pressure ;  and  this  seems  very 
likely. 

I  know  of  no  way  in  which  I  can  so  well  hope  to  awaken  an  interest  in  you 
about  these  diseases,  or  to  offer  you  instruction  respecting  them,  as  by  instances. 
The  following  I  take,  abridging  it  somewhat,  from  Dr.  Abercrombie.  A  man, 
twenty-six  years  old,  had  for  several  years  been  subject  to  suppuration  of  the  left 
ear,  suffering  ocasional  attacks  of  pain  on  that  side  of  the  head,  which  were  fol- 
lowed by  a  more  copious  discharge  from  the  ear.  In  the  first  week  of  April  he 
became  ill,  with  pain  of  the  forehead  and  occiput,  disturbed  sleep,  and  loss  of  appe- 
tite, but  no  fever.  At  the  end  of  the  week  he  complained  of  pain  extending  along 
the  neck.  This  pain  gradually  passed  downwards  in  the  course  of  the  spine,  and 
deserted  the  head;  and,  at  last,  after  many  days,  it  fixed  itself  with  intense  severity 
at  the  lower  part  of  the  spine,  shooting  thence  around  the  body  towards  the  crest  of 
the  ilia.  He  became  affected,  also  with  great  uneasiness  over  the  whole  of  the  ab- 
domen, and  had  much  pain  and  difficulty  in  passing  his  urine.  About  the  end  of 
the  second  week  in  April  his  suffl^rings  had  become  extreme.  He  could  not  lie  in 
bed  for  five  minutes  at  a  time,  but  was  generally  walking  about  the  house  in  a  state 
of  great  agitation,  grasping  the  lower  part  of  his  back  with  both  his  hands,  and 
gnashing  his  teeth  with  the  intensity  of  the  pain.  He  had  no  interval  of  ease,  and 
was  sometimes  incoherent  and  unmanageable.  On  the  I6th,  he  went  to  take  a  warm 
bath,  walking  down  three  stairs,  and  into  an  adjoining  street,  with  little  assistance. 
His  speech  afterwards  became  somewhat  affected :  there  were  convulsive  twitches 
of  his  face,  and  difficulty  of  swallowing.  Some  transient  squinting  also  was  ob- 
served. The  pulse  was  now  very  frequent.  On  the  18th,  while  sitting  in  a  chair, 
he  suddenly  threw  his  head  backwards  with  great  violence,  fell  immediately  into  a 
state  of  coma,  in  \vhich  he  remained  for  two  hours,  and  then  died.  During  the 
whole  disease  there  had  been  no  paralysis,  except  the  slight  affection  of  his  speech ; 
no  difficulty  of  breathing ;  no  vomiting  ;  and  no  convulsion  except  the  twitching  of 
his  face  the  day  before  his  death.  The  pulse  was  small  and  irregular.  The  bowels 
were  easily  kept  open,  but  the  pain  in  his  back  was  much  increased  by  going  to 
stool.  Two  days  before  his  death  he  had  several  attacks  of  shivering;  and  much 
purulent  matter  was  discharged  from  his  left  ear  during  his  illness. 

Upon  a  very  careful  examination  of  his  body,  every  part  of  the  brain  was  found 
to  be  in  a  most  healthy  state.  Some  gelatinous  deposit  was  found  under  the  ?7ic- 
dulla  oblongata ;  and  purulent  matter  flowed,  in  considerable  quantity,  out  of  the 
spinal  canal.  The  spine  being  entirely  laid  open,  the  cord  was  seen  covered  with 
a  coating  of  purulent  matter,  which  lay  betwixt  it  and  its  membranes.  The  matter 
was  most  abundant  at  three  places  ;  at  the  upper  part,  near  the  foramen  magnum — 
about  the  middle  of  the  dorsal  region — and  at  the  top  of  the  sacrum :  but  it  was 
also  distributed  over  the  other  parts  with  much  uniformity.  The  substance  of  the 
cord  was  soft,  and  separated  in  some  places  into  filaments.  All  the  other  viscera 
were  healthy. 

You  may  find  several  interesting  examples  of  this  form  of  disease  in  Ollivier  a 
Treatise  on  the  Spinal  Marrow.  The  prominent  symptom  was  generally  pam, 
referred  to  some  part  of  the  spine,  and  increased  by  motion;  and  what  is  curious. 


292  DISEASES   OF   THE 

sometimes  little  complained  of  except  upon  motion.  In  general,  also,  it  extended 
along  some  of  the  limbs,  and  was  accompanied  by  muscular  rigidity  or  tetanic 
spasms.  Palsy  occurred  in  one  case ;  but  this  seemed  to  have  been  owing  to  soft- 
ening of  the  cord  itself.  Constantly  there  was  increased  sensibility ;  a  circum- 
stance which  OUivier  thinks  calculated  to  distinguish  inflammation  of  the  membranes 
from  inflammation  of  the  substance  of  the  cord ;  the  latter  being  usually  attended 
with  diminished  sensibility.  In  the  case  that  I  have  quoted  from  Dr.  Abercrom- 
bie,  the  intense  pain  underwent  no  remission  or  abatement.  In  one  of  Ollivier's 
examples,  there  was  at  the  commencement  of  the  disease,  a  striking  inlermittence  of 
the  pain ;  it  came  on  with  intense  severity  at  ten  at  night,  and  lasted  till  three  in  the 
morning. 

The  causes  of  spinal  meningitis  are  not  always  to  be  discovered.  It  sometimes 
extends  from  within  the  cranium.  It  may  be  excited  by  external  violence  to  the 
spine,  of  which  a  good  specimen  has  been  recorded  by  Sir  Charles  Bell. — A 
Avagoner  sitting  on  the  shafts  of  his  cart,  was  thrown  off  by  a  sudden  jerk,  and 
pitched  upon  the  back  of  his  neck  and  shoulders.  He  was  taken  to  the  Middlesex 
Hospital,  where  he  lay  for  a  week,  without  complaining  of  any  thing  except  stiff 
ness  of  the  back  part  of  the  neck.  He  could  move  all  his  limbs  with  freedom.  On 
the  eighth  day  after  his  admission  he  was  seized  with  general  convulsions  and  locked 
jaw.  He  then  became  affected  with  a  singular  convulsive  motion  of  the  jaw,  which 
continued  in  violent  and  incessant  movement  for  about  five  minutes.  This  was  fol- 
lowed by  maniacal  delirium.  He  then  sank  into  a  state  resembling  typhus  fever; 
and  after  four  days  was  found  to  be  palsied  and  insensible  in  his  lower  extremities. 
The  day  before  his  death  he  recovered  sensation  in  his  legs. 

On  dissection,  a  great  quantity  of  purulent  matter  was  found  within  the  spinal 
canal.  It  appeared  to  have  formed  about  the  last  cervical  and  the  first  dorsal  ver- 
tebras, and  to  have  dropped  down,  by  its  own  gravity,  to  the  lower  part  of  the  canal; 
where  it  produced  palsy  and  anaesthesia  of  the  inferior  limbs  by  the  pressure  it 
occasioned. 

[Cerebho-Spixal  Mexingitis  has  attracted  considerable  attention  recently  from  tlie  cir- 
cumstance of  its  having  occurred  as  an  epidemic  in  different  parts  of  France  and  Ireland. 
In  1844  the  disease  prevailed  extensively  among  the  civil  population  of  Gibraltar.  Accord- 
ing to  M.  Rollet,  who  describes  the  disease  as  it  occurred  at  Nancy,  {Bulletin  de  I'Acad.  Roy. 
de  Med.  viii.  43,)  cerebro-spinal  meningitis  occurs  in  two  forms  j  in  the  one,  there  are  no 
signs  of  lesion  of  \^  nervous  centres  themselves,  no  affection  of  sensation  or  motion,  though 
tliere  are  all  the  symptoms  of  inflammation  of  the  membranes;  at  first,  rigors,  then  maliase, 
tinnitus  aurinm,  vertigo,  violent  pain  in  the  head,  extending  along  the  vertebral  column,  agi- 
tation or  restlessness,  slight  delirium,  and  moderate  fever,  or  absence  of  fever.  In  the  second 
form  there  is  affection  of  the  intellectual  faculties,  and  also  of  the  functions  of  sensation  and 
motion,  and  more  or  less  complete  abolition  of  all  the  senses.  In  this  latter  form  the  appear- 
ances upon  dissection  were,  great  vascularity  of  the  cerebral  arachnoid  ;  a  layer  of  plastio 
purulent  matter  covering  the  whole  inner  surface  of  the  pia  mater  and  the  brain,  and  a  con- 
siderable collection  of  the  same  matter  at  the  base  of  the  brain,  about  the  pons  varolii  and 
medulla  oblongata.  The  cerebrum  was  slightly  punctated,  but  not  softened.  The  choroid 
plexus  was  injected;  the  cerebellum  softened;  and  the  arbor  vitae  of  a  blood-red  colour. 
Beneath  the  spinal  arachnoid  there  was  the  same  kind  of  purulent  matter  as  beneath  the 
cerebral  arachnoid  ;  and  opposite  the  third  dorsal  vertebra,  a  consitlerable  collection  of  pus, 
as  well  as  opposite  the  last  dorsal  vertebra.  The  substance  of  the  spinal  cord  appeared 
healthy.  The  lesions  here  described  exactly  correspond  with  those  described  by  MM.  Fanre- 
Villar,  Chauffard,  and  Forget,  by  whom  accounts  of  the  disease  have  been  given  as  it  pre- 
vailed in  Versailles.  Avignon,  and  Strasburg. 

Morbid  changes  from  inflammation  have  also  been  noticed  in  the  alimentary  canal,  but 
these  M.  Rollet  regards  as  merely  accidental  coincidences.  M.  Forget,  however,  attaches 
great  importance  to  them. 

]\I.  Rollet  remarks,  that,  in  those  cases  in  which  the  substance  of  the  brain  is  affected, 
mere  is  an  almost  continual  tendency  to  intermission,  or,  at  least,  remission,  which  alternates 
about  every  three  hours  with  an  exacerbation ;  this  he  regards  as  merely  characteristic  of  tho 
enoephalo-meningitis,  and  not  as  an  evidence  of  tlie  disease  partaking  of  the  nature  of  remit- 
tent fever,  which  is  the  view  taken  by  M.  Gassaud. 

According  to  Dr.  Mayne,  by  whom  an  interesting  account  is  given  of  the  disease  as  it 
occurred  m  Ireland  during  the  year  1846,  (Dublin  Quarterly  Journal  of  Medical  Sciences,  for 
August,  1846,)  its  general  pathological  characters  were  nearly  vLniformly  the  samf   where.'ei 


SPINAL    CORD.  293 

examined.  The  serous  membrane  covering  the  brain  and  spinal  marrow  was  invariably 
found  to  be  the  seat  of  extensive  inflammation,  and  unlike  the  more  ordinary  forms  of  arach 
nitis,  tlie  spinal  arachnoid  always  sullered  much  more  severely  than  the  cerebral,  in  the 
post-mortem  examinations  made  by  Dr.  Mayne,  the  scalp  and  dura  mater  exhibited  but  little 
undue  vasciUarity ;  the  pia  mater  covering  the  hemispheres  of  the  brain  was  congested,  and 
the  large  veins  in  their  way  to  the  several  sinuses  appeared  remarkably  turgid.  The  free 
surface  of  the  cranial  arachnoid  felt  dry  and  clammy,  and  had  lost  its  transparency  in  many 
places,  particularly  at  the  base  of  the  brain,  but  there  was  no  lymph  or  other  inflammatory 
eflusion  in  the  sac  of  the  arachnoid.  Lymph  of  a  yellowish  or  greenish  hue  appeared  on  the 
surface  of  the  encephalon,  beneath  the  serous  tunic:  this  occurred  sparingly  on  the  upper  sur- 
face of  the  hemispheres,  and  there  only  along  the  sulci ;  but  at  the  base  of  the  brain  it  was 
found  in  greater  quantities,  especially  in  the  sub-arachnoid  space  corresponding  to  the  circle 
of  Willis,  where  many  of  the  cerebral  nerves  at  their  origin  were  fairly  imbedded  in  it.  Li 
the  spinal  canal,  a  similar  exudation  filled  the  sub-arachnoidal  space ;  it  there  existed  in 
sufficient  abundance  to  envelope  the  cord  completely;  it  also  extended  down  to  the  lowest 
extremity  of  the  cauda  equina,  investing  each  of  the  spinal  nerves  at  its  source  ;  but  in  the 
vertebral  canal,  as  in  the  cranium,  the  cavity  of  the  arachnoid  contained  none  of  this  morbid 
secretion.  The  substance  of  the  brain  and  spinal  marrow  appeared  remarkably  free  from 
lesion,  there  was  no  unusual  vascularity,  induration,  or  softening  apparent,  nor  did  the  ven- 
tricles betray  any  evidence  of  inflammation. 

Li  many  of  the  cases  rejDorted,  however,  the  brain  and  spinal  marrow  are  stated  to  have 
been  occasionally  implicated  ;  in  some,  the  ventricles  of  the  brain  contained  inflammatory 
efliisions,  and  the  choroid  plexus  appeared  unusually  vascular ;  in  others,  more  or  less  of 
the  substance  of  the  brain  and  spinal  marrow  was  found  in  a  state  of  softening  ;  in  a  certain 
number,  sero-purulent  eifusion  was  detected  at  the  base  of  the  brain,  and  in  the  theca  verte- 
bralis ;  but  in  every  instance  the  serous  membrane  was  the  part  essentially  engaged,  whilst 
tlie  nervous  material  seldom  suffered,  and  when  affected  it  was  only  accidentally  involved. 
the  disease  having  been,  in  such  cases,  evidently  propagated  to  the  substance  of  the  cerebro- 
spinal axis  from  its  membranous  investments. 

A  remarkable  feature  of  this  malady  is  the  class  of  persons  on  whom  it  has  seized.  Li 
Ireland,  so  far  as  has  been  ascertained,  boys  under  twelve  years  of  age  have  been,  with  few 
exceptions,  its  only  victims ;  the  seven  cases  reported  by  Dr.  Darby  were  all  boys,  and  only 
one  of  them  had  passed  his  twelfth  year;  in  Belfast  ten  cases  of  the  disease  were  noted,  all 
occurring  in  boys  from  seven  to  twelve  years  of  age ;  and  in  Dr.  Maynes'  experience,  indi- 
viduals of  tlie  same  description  were  alone  attacked.  Dr.  Gillkrest,  in  his  account  of  the 
epidemic  at  Gibraltar,  (^3Ied.  Gaz.,  July,  1844,)  states,  that  in  the  majority  of  cases  the  dis- 
ease occurred  in  patients  between  two  and  fifteen  years  of  age,  and  few  only  were  attacked 
severely  above  the  age  of  thirty.  It  is  a  curious  circumstance  that  in  France  the  disease 
occurred,  for  the  most  part,  among  the  conscripts  who  had  lately  joined  their  regiments. 
Although  females  have  been  very  rarely  attacked,  yet  they  are  not  exempt  from  it :  one  of 
Mr.  M'Dowel's  patients  at  the  Hardwicke  Hospital  was  a  girl  of  seventeen,  and  the  other  a 
woman  of  thirty-six  years. 

The  symptoms  by  which  the  disease  commences  are,  in  general,  of  a  very  formidable 
character,  and  its  accession  is  usually  sudden  and  quite  unexpected  ;  in  the  majority  of 
cases  the  patient  was  in  his  ordinary  health  and  spirits  up  to  the  very  moment  of  the  seizure, 
and  had  experienced  no  premonitoiy  symptoms  to  warn  him  of  his  danger.  Ii:^four  of  the 
cases  at  the  South  Dublin  Union,  the  boys  had  eaten  a  hearty  dinner,  and  retired  to  bed  in  ap- 
parent health,  when  the  disease,  all  at  once,  declared  itself.  In  many  instances  it  commences 
with  severe  pain  in  the  abdomen,  followed  immediately  by  vomiting,  and  not  unfrequently 
by  purging.  In  the  worst  cases,  these  symptoms  are  accompanied  by  marked  collapse,  tho 
extremities  are  cold  and  bluish,  the  pulse  is  at  this  time  a  mere  thread,  and  altogether  the 
disease  assumes  very  much  the  aspect  of  cholera.  After  the  laj^se  of  a  few  hours,  reaction, 
more  or  less  perfect,  ensues ;  the  muscular  system  then  presents  characters  which  may  be 
considered  almost  pathognomonic.  The  muscles  of  the  extremities,  and  those  of  the  neck  in 
particidar,  become  remarkably  rigid,  the  head  is  drawn  back  upon  the  vertebral  column,  and 
firmly  fixed  in  that  unnatural  position ;  no  efforts  of  the  patient  can  bend  it  forward,  neither 
can  the  attendants  do  so,  at  least  by  the  employment  of  any  justifiable  force.  The  counte- 
nance at  this  period  often  assumes  very  much  the  tetanic  expression  ;  twitchings  of  the  mus- 
cles of  the  face  sometimes  ensue;  the  patient  loses,  in  a  great  measure,  the  power  of  moving 
his  extremities,  so  that  he  is  quite  unable  to  assume  the  erect  position ;  the  surface  becomes 
hot,  the  pulse  full  and  frequent,  from  120  to  140;  the  stomach  often  continues  irritable, 
whilst  an  insatiable  thirst  torments  the  sufferers,  and  the  epigastrium  evinces  marked  ten 
derness  upon  pressure. 

Symptoms  of  a  still  more  distressing  nature  quickly  supervene ;  the  patient  maybe  seized 
With  general  convulsions  of  a  frightful  severity,  requiring  personal  restraint  to  protect  him 
from  injury,  or  he  may  be  in  a  semi-comatose  condition,  constantly  moaning  and  grinding  hi!« 
teeth,  or  evei  crying  incessantly.     Towards  the  close  of  his  suflerings,  he  generallv  merge>«i 

z2 


294  DISEASES    OF   THE 

into  perfect  coma,  the  pulse  becomes  slow  and  laboured,  the  po\%'ers  of  speech  and  degluti- 
tion fail,  his  stools  are  passed  involuntarily,  and  death  finally  closes  the  scene.  All  this  may 
occur  in  a  surprisingly  short  space  of  time  ;  some  of  the  cases  ran  their  course  in  forty-eight 
hours,  and  the  greater  number  terminated  about  the  fourth  day,  whilst  some  few  were  pro- 
Jonged  over  a  fortnight  or  three  weeks.  Examples  are  on  record  of  death  from  the  disL-a^e 
in  so  short  a  period  as  fifteen  hours. 

Notwithstanding,  in  some  instances,  an  exalted  sensibility  of  the  cutaneous  surface  gene- 
rally was  obssrved,  such  as  pain  more  or  less  intense  in  the  head,  heat  of  scalp,  congestion 
of  the  conjunctiva,  strabismus,  intolerance  of  light,  &c. ;  yet.  in  many,  no  such  evidence 
occurred,  until  the  laboured  pulse,  the  dilated  pupil,  the  profound  coma,  or  the  severe  con- 
vulsion, told  but  too  plainly  that  the  death  struggle  was  at  hand. 

When  the  sensibility  of  the  cutaneous  surface  generally  was  in  a  state  of  exaltation,  the 
patient  complained  of  being  "  sore  all  over,"  and  winced,  upon  the  slightest  touch,  or  refused 
to  change  his  position  in  bed,  from  the  pain  consequent  upon  the  slightest  movement;  (the 
observation  of  this  symptom  is  due  to  Dr.  MDowel ;)  but  far  more  frequently  a  diminution 
of  tactile  sensibility  and  confirmed  stupor,  afforded  grounds  for  the  worst  anticipations. 

Dr.  ]\Iayne  more  than  once  noticed  irregular  and  laboured  respiration  as  a  leading  symp- 
tom ;  and  this,  in  itself,  provided  there  was  an  absence  of  stethoscopic  evidence  of  thoracic 
disease,  would  constimte  a  valuable  diagnostic. 

Notwithstanding  that  the  distressing  tenderness  of  the  epigastrium,  associated  with  cDnti- 
nued  irritability  of  stomach,  would  seem  to  indicate  decided  disease  of  that  viscus,  Dr.  M. 
has  nevertheless  found  the  abdominal  viscera  absolutely  healthy  in  the  post-mortem  exami- 
nation of  two  cases,  in  which  diese  symptoms  persisted  in  a  very  marked  manner  to  the 
close. 

The  fatality  of  the  disease,  as  it  appeared  in  Ireland,  was  very  great.  The  same  is  true 
in  regard  to  the  French  epidemics.  At  Avignon,  M.  Chauffard  lost  no  less  than  twenty-nine 
of  his  first  patients ;  and,  according  to  statistical  calculations,  not  less  than  eighty  per  cent, 
of  the  cases  noted  during  the  epidemic  in  France  terminated  fatally.  ]\I.  Faure-\  illar  lost 
66  out  of  154  cases  ;  M.  Forget  24  out  of  40.  M.  Tourdes  states  that  of  195  soldiers  attacked, 
122  died.  In  Gibraltar,  according  to  Dr.  Gillkrest,  42  deaths  occurred  among  450  persons 
attacked.  The  line  of  treatment  most  likely  to  prove  successful  requires  our  fullest  consi- 
deration. It  is  much  to  be  feared.  Dr.  M.  remarks,  that  where  sjTnptoms  denoting  extreme 
collapse  show  themselves  from  the  commencement,  all  tlie  resources  of  our  art  will  prove 
unavailing.  The  prompt  application  of  the  most  powerful  excitants  to  the  cutaneous  surface, 
particularly  mustard  and  turpentine,  aided  by  heat  and  friction,  and  directed  especially  to 
the  region  of  the  spine,  and  to  the  extremities,  seems  to  promise  some  advantage.  Difl'usible 
stimulants  should  be  employed  as  sparingly  as  possible,  seeing  that  an  intense  inflammation, 
affecting  the  very  centre  of  animal  life,  must  remain  to  be  combated  after  reaction  sets  in. 
General  and  topical  depletion,  so  soon  as  it  can  be  borne  with  safety,  and  the  early  and  free 
exhibition  of  mercury,  both  by  the  skin  and  stomach,  should  constitute  our  chief  dependence. 
Even  this  active  treatment  will  often  disappoint  us.  In  one  case,  the  jugular  vein  was 
opened  by  Dr.  M.  within  a  few  hours  after  the  accession  of  the  disease,  and  blood  was 
drawn  in  a  fill  stream,  as  long  as  the  boy's  strength  would  permit;  this  was  followed  up, 
at  short  intervals,  by  relays  of  leeches  to  the  ten>p]es  and  inastoid  processes;  tlie  mercurial 
plan  was,  at  the  same  time,  most  energetically  pursued,  and  blisters,  with  mercurial  dress- 
ings, were  applied  to  the  head,  and  along  tlie  spine.  Yet  all  was  of  no  avail ;  the  patient 
died  in  convulsions,  on  the  fourth  day.  In  other  cases,  the  same  measures  have  been 
attended  with  perfect  success. 

The  French  physicians,  who  have  described  the  epidemic  form  of  cerebro-spinal  meningi- 
tis, are  not  agreed  as  to  the  most  successful  plan  of  treating  the  disease.  AI.  Faure-Villar 
tried,  it  is  said,  all  rational  methods,  but  declares  that  no  one  seemed  superior  to  the  rest. 
M.  Forget  recommends  the  antiphlogistic  plan  of  treatment  at  the  commencement  of  the 
case,  and  subsequently  opium.  M.  Rollet  found  that  all  the  cases  of  simple  cerebro-spinal 
meningitis — that  is  to  say,  of  inflammation  of  the  membranes  without  lesion  of  the  nervous 
centres  themselves — yielded  to  simple  but  energetic  antiphlogistic  treatment,  aided  by  coun- 
ter-irritants to  the  skin.  One  remedy  only  he  found  adequate  to  control  the  more  violent 
eases,  when  the  brain  and  spinal  cord  also  suffered,  and  this  was  cauterization.  In  one  case 
which  is  detailecf,  the  actual  cautery  was  applied  at  twelve  distinct  spots  along  tlie  spine, 
besides  counter-irritants 

M.  Gaussuud,  who  regards  the  disease  as  a  subintrant  cephalalgic  fever,  produced  by 
marsh  miasmata,  affirms  that,  of  162  soldiers  attacked,  only  two  died  afler  he  commenced  to 
neat  them  with  medium  doses  of  sulphate  of  quinia,  at  the  same  time  that  he  employed 
purges,  and,  at  the  commencement,  venesection.  M.  Chautlard  failed  to  cure  the  malady  by 
d.itiphlogistic  means,  the  most  prompt,  direct,  and  energetic — by  revulsives,  purgatives,  calo- 
mel, as  well  as  by  various  tonics.  Opium,  however,  he  found  to  triumph  o,ver  it,  but  it  was 
necessary  to  give  it  in  large  doses.  The  sulphate  of  quinia  was  advantageously  combined 
with  the  opium.     Before  this  plan  was  adopted,  only  one  case,  we  are  told,  was  cured  out 


SPINAL    COR    .  295 

of  thirty.  Afterwards,  the  disease  was  less  fatal  than  in  sporadic  cases.  M.  Tourdes  agrees 
with  M.  Chauifard  that  the  usual  antiphlogistic  means  were  of  no  avail ;  but  he  cannot  con- 
firm all  that  the  latter  has  said  in  favour  of  opium. — C] 

Inflammation  of  the  substance  of  the  spinal  cord  leads  to  the  same  changes  in 
its  texture  which  have  been  already  spoken  of  as  being  often  the  results,  in  the  brain, 
of  inflammation  of  the  cereim/ matter.  Softening — induration  —  suppuration.  I 
need  not,  therefore,  again  describe  the  physical  characters  of  these  alterations. 

The  symptoms  which  flow  from  inflammation  of  the  nervous  pulp  of  which  the 
spinal  marrow  is  composed,  are  by  no  means  uniform ;  nor  can  we  expect  that  they 
should  be  so,  when  we  recollect  what  has  been  already  stated  of  the  different  effects 
that  must  ensue  according  as  different  parts  of  the  cord  happen  to  be  implicated. 
The  phenomena  will  vary  likewise,  according  as  the  inflammation  is  acute  or  chronic. 
If  we  recollect  how  many  parts  of  the  body  depend  for  their  power  of  motion,  and 
for  their  sensibility,  upon  the  integrity  of  ihe  spinal  cord,  we  shall  not  be  surprised 
at  the  diversity  and  multiplicity  of  the  symptoms  produced  by  disease  of  the  cord. 
Tracking  inflammation  and  its  events  from  the  upper  portion  of  the  spinal  marrow 
downwards,  we  should  expect  to  find,  and  we  actually  do  find,  some  such  an  arrange- 
ment of  symptoms  as  the  following.  Convulsive  atfections  of  the  head  and  face, 
inarticulate  speech,  loss  of  voice,  trismus,  difficult  deglutition,  spasmodic  breathing, 
irregular  action  of  the  heart,  constriction  of  the  chest,  vomiting,  pain  of  the  belly, 
sensation  of  a  cord  tied  round  the  abdomen,  dysuria,  retention  of  urine,  incontinence 
of  urine,  constipation,  tenesmus,  involuntary  stools  :  and  with  respect  to  the  volun- 
tary muscles  corresponding  to  these  parts  of  the  spinal  marrow,  convulsions,  or  palsy  ; 
or  palsy  succeeding  to  convulsions. 

I  must  again  have  recourse  to  examples,  to  put  you,  more  fully  than  an}'-  attempted 
abstract  picture  could  put  you,  in  possession  of  such  forms  of  inflammation  of  the 
cord  as  you  may  expect  to  meet  with  in  practice. 

A  man,  fifty-six  years  old,  was  exposed  to  severe  cold,  while  travelling  on  the  out- 
side of  a  coach.  After  this  he  Xvas  attacked  with  pain  in  the  right  arm  and  leg,  most 
severe  about  the  shoulder,  but  affecting  the  whole  side,  and  he  had  also  considerable 
headache.  He  soon  perceived  some  loss  of  power  in  the  affected  hmbs ;  and  the 
progress  of  this  was  very  curious.  It  began  at  the  upper  part  of  the  arm,  and 
extended  downwards  so  gradually,  that  he  w^as  able  to  ivi'ite  distinctly,  after  he  had 
lost  the  power  of  raising  the  arm,  or  bending  the  elbow.  Then  the  leg  became 
affected  in  the  same  gradual  manner,  and  after  ten  or  twelve  days  from  the  com- 
mencement of  the  disease,  the  whole  leg  and  arm  had  become  completely  paralytic. 
Some  pain  continued  in  the  parts,  and  it  was  occasionally  severe,  especially  in  the 
leg.  Repeated  blood-letting,  and  purgatives,  and  blistering,  were  employed.  His 
mind  remained  quite  entire.  His  pulse  was  84,  and  rather  weak  ;  after  some  time 
the  Irfl  arm  became  paralytic,  rather  suddenly  ;  but  it  was  not  so  completely  motion- 
less as  the  limb  on  the  right  side  ;  the  left  leg  was  not  at  all  affected.  Slight  delirium 
occurred,  but  passed  off  again.  At  the  end  of  two  months  after  the  exposure  to  the 
cold,  he  again  became  delirious,  and  his  pulse  got  feebler  and  rapid  :  he  then  fell 
into  a  state  of  stupor,  muttering  incoherently,  but  answering  questions  distincll)"- 
when  he  was  aroused.  He  lost  his  speech  a  few  hours  before  death.  For  the  last 
eight  or  ten  daj-s  there  had  been  considerable  sloughing  of  the  sacrum. 

The  brain  was  found  to  be  healthy  throughout.  Much  bloody  fluid  was  dischaig^id 
from  the  spinal  canal  into  the  cavity  of  the  cranium  before  the  spine  was  laid  open. 
On  displaying  the  spina!  cavity  itself,  the  cord  was  found  in  a  state  of  complete 
softening,  from  the  second  to  the  last  cervical  vertebra.  The  portions  above  and 
below  that  part  were  quite  healthy.     (Abercrombte.) 

Comparing  this  case  with  the  one  I  detailed  of  meningitis,  we  find  that  pain  was 
present  in  both,  but  more  severely  so  in  the  case  of  inflammation  of  the  membranes ; 
we  find  also,  that  stiffness  and  spasm  of  the  mitscles  markedihe  meningitis  ;  palsy, 
the  inflammation  of  the  substance  of  the  spinal  cord.  In  neither  of  them  were  the 
intellectual  functions  disturbed  till  towards  the  last.  I  beheve  that  the  character? 
now  pointed  out  belong  to  these  forms  of  disease  respectively. 

I  shall  take,  from  the  same  store-house,  one  more  case,  in  wliich  both  the  mem  • 

z3 


296  DISEASES    OF   THE 

branes  and  the  cord  were  simultaneously  inflamed  ;  and  which,  therefore,  was  ana 
logons  to  encephalitis.  And  I  quote  it  the  rather  because  it  possesses  one  or  two 
pomts  of  peculiar  interest.  A  young  man,  of  unhealthy  constitution,  eighteen  years 
old,  had  suffered  for  some  time  from  ulcers  in  various  parts  of  the  body,  accompanieH 
by  exfoliations  of  bone  from  the  leg,  thigh,  and  sacrum.  For  several  months  before 
his  fatal  attack  he  had  a  sore  on  his  head,  as  big  as  a  shilling,  with  caries  of  the 
bone  beneath  it.  At  length  he  began  to  complain  of  pain  in  the  loins,  without  fever. 
On  the  2d  of  October  this  pain  had  increased  ;  it  was  chiefly  «eated  among  the  lower 
dorsal  vertebrae,  and  extended  downwards  in  the  course  of  the  ureter,  with  a  fre- 
quent desire  to  pass  urine.  Then  the  pain  descended  lower,  into  the  sacrum,  and 
the  symptoms  referable  to  the  bladder  ceased.  But  soon  afterwards  pain  in  the  "belly 
came  on,  and  numbness  of  the  inner  sides  of  the  thighs,  and  retention  of  urine  ;  and 
in  two  days  after  this  there  wexe  perfect  palsy  of  both  thighs  and  legs,  without  loss 
of  feeling,  retention  of  urine,  and  involuntary  stools.  He  had  still  some  pain  in  the 
)ower  part  of  the  dorsal  region.  He  died  at  length,  on  the  Mill  of  October,  having 
continued  quite  sensible  till  about  six  hours  before.  There  had  not  been  the  smallest 
approach  to  a  renewal  of  power  of  the  lower  extremities,  but  their  sensibility 
remained.     There  was  palsy,  but  no  ansesthesia. 

All  was  quite  sound  in  the  brain,  except  some  old  thickening  of  the  dura  mater  in 
the  neighbourhood  of  the  diseased  bone.  In  opening  the  spinal  canal,  some  purulent 
matter  flowed  out,  during  the. sawing,  from  about  the  middle  of  the  dorsal  region; 
and  one  of  the  vertebrae  at  that  place  was  found  carious.  There  was  an  extensive 
deposit  of  flocculent  matter,  having  a  purulent  appearance,  upon  the  outside  of  the 
membranes  of  the  cord.  Bloody  sanious  fluid  was  discharged  from  beneath  its  dura 
mater,  and  its  pia  mater  was  highly  vascular.  The  substance  of  the  cord  was  found 
most  extensively  disorganized  along  nearly  the  whole  extent  of  the  dorsal  portion. 
The  anterior  columns  of  this  part  were  completely  broken  down  into  a  soft  diffluent 
pulp  ;  on  the  posterior  part  the  cord  was  more  entire.  When  the  cord  was  taken 
out,  and  suspended,  it  hung  together  by  the  posterior  columns  of  the  dorsal  portion, 
while  the  anterior  part  of  it  fell  off"  entirely,  in  a  soft  half-fluid  state.  The  parts 
above  and  below  the  diseased  portion  were  quite  firm  and  healthy. 

The  complete  palsy  in  this  instance,  going  along  with  the  destruction  of  the  ante- 
nor  columns ;  and  the  persistence  of  the  sensibility,  the  posterior  columns  being 
comparatively  entire ;  invest  the  case  with  a  remarkable  degree  of  interest.  We 
might  infer  from  it  that  the  anterior  half  of  the  cord  is  the  channel  through  which 
the  power  to  move  the  hmbs  is  transmitted,  while  their  sensations  are  carried  along 
its  posterior  half;  but  we  are  checked  from  so  concluding,  by  such  cases  as  the  one 
recorded  by  Mr.  Stanley.  These  apparent  inconsistencies  may  puzzle,  hut  they 
ought  not  to  discourage  you.  That  time,  and  our  advancing  science,  wiU  at  length 
explain  and  reconcile  them  I  cannot  doubt.  Meanwhile  they  teach  a  lesson  which 
many  practitioners  much  need — viz.,  that  it  is  unphilosophical  and  unsafe  to  draw 
general  conclusions  from  single  cases  of  disease. 

At  the  time  when  these  cases  were  noted,  the  peculiar  reflex  properties  of  the 
spinal  cord  were  not  understood.  Henceforward  we  shah  study  its  diseases  from  a 
new  point  of  view,  and  with  a  clearer  vision. 

Much  may  be  learned  in  regard  to  the  effects  of  inflammation,  or  any  other  cause 
of  disorganization,  confined  to  a  limited  portion  of  the  cord,  by  observing  what  takes 
place  in  those  injuries  in  which  the  bones  of  the  vertebral  column  are  broken,  or  dis- 
placed. Of  course  I  do  not  dwell  upon  these  accidents,  for  they  belong  to  surgery-, 
but  I  have  seen  a  good  many  of  them,  and  watched  them  with  deep  interest.  The 
symptoms  are  much  more  uniform  than  when  inflammation  occurs  within  the  verte- 
bral canal,  independently  of  external  injury;  simply  because  the  injury  to  the  cord 
IS  more  definite  and  local.  But  such  cases  are  very  valuable  objects  of  study  to  the 
physician.  I  remember  several  that  occurred  when  I  was  a  dresser  in  St.  Bartholo- 
mew's Hosjiita! ;  and  I  will  state  very  briefly  the  particulars  of  one,  as  an  exemplar. 
In  the  year  l>!i20,  a  man  was  brought  there  who  had  been  thrown  out  of  a  tilt  cart, 
in  consequence  of  a  dray  running  foul  of  it.  He  had  pitched  upon  his  head,  which 
•*howed,  however,  no  trace  of  injury.    When  picked  up,  he  was  found  to  be  power- 


SPINAL    CORD.  297 

leys,  both  in  the  upper  and  lower  extremities.  His  stools  passed  from  him  without 
his  being-  aware  of  it,  and  it  was  necessary  to  use  the  catheter  to  empty  his  bladder. 
He  breathed  entirely  by  the  diaphragm — that  is,  his  thorax  was  motionless,  and  his 
abdomen  rose  and  fell  with  every  alternate  act  of  inspiration  and  expiration.  These 
symptoms  are  perfectly  distinctive  of  injury  to  the  cord  between  the  origins  of  the 
j.hrenic  and  intercostal  nerves.  He  suffered  pain  about  the  middle  part  of  the  neck 
b<'hind.  He  went  on  exceedingly  well  for  four  or  five  days,  and  then  the  nurse  very 
foolishly  acceded  to  his  recjiiest  to  be  turned  on  his  side,  which  caused  his  death  in 
a  very  tew  minutes.  This  is  not  the  only  instance  that  I  have  known,  in  which  life 
has  been  suddenly  extinguished  by  similar  imprudence.  The  lesson  may  be  useful. 
There  was  another  patient  in  the  same  hospital,  who  had  fractured  the  cervical  por- 
tion of  the  spinal  column.  Among  other  remedial  measures,  the  surgeon  had 
directed  that  his  head  should  be  shaved.  The  barber  had  performed  half  his 
task,  and  was  turning,  with  his  hands,  the  unfortunate  man's  head  into  a  more  con- 
venient position  for  completing  it,  when  he  suddenly  expired.  The  twist  was  fatal 
to  him. 

On  the  examination  of  the  body  of  the  patient  whose  case  I  was  mentioning,  a 
very  remarkable  state  of  the  spinal  column  was  found.  The  fifth  and  sixth  cervical 
vertebras  were  dislocated  from  each  other  without  any  fracture :  a  thing  which  has 
sometimes  been  pronounced  impossible.  The  articular  processes  were  fairly  sepa- 
rated ;  and  the  vertebrse  were  also  forced  asunder  by  the  detachment  of  one  of  them 
from  the  intervertebral  substance.  The  nervous  matter  of  the  cord  opposite  the 
point  of  dislocation  was  quite  soft. 

There  is  one  very  common  and  distressing  consequence  of  such  disease  of  the 
spinal  marrow  as  produces  paraplegia,  not  particularly  noted  in  any  of  the  cases 
which  I  have  related,  but  always  to  be  looked  for.  The  muscles,  by  means  of  which 
the  bladder  empties  itself,  are  liable  to  participate  in  the  palsy ;  and  then  the  bladder 
empties  itself  no  longer.  The  urine  accumulates  in  it,  and  distends  it,  and  even  the 
ureter  becomes  distended  ;  and  in  this  way  not  only  the  present  but  the  prospective 
danger  is  increased.  For  the  foundation  of  future  disease  in  the  kidneys  is  often 
thus  laid,  even  when  such  distension  of  the  bladder  by  its  retained  contents  occurs 
independently  of  any  disease  of  the  spine  ;  as  it  may  do  from  stricture ;  from  en- 
largement of  the  prostate  ;  or  even  from  the  voluntary  retention  of  the  urine  beyond 
a  certain  period,  through  feelings  of  delicacy.  You  are  to  look  out,  I  say,  for  this 
distension  of  the  bladder,  and  relieve  or  prevent  it  by  the  introduction  of  a  catheter 
through  the  urethra.  You  must  not  be  deceived  by  being  told  that  the  patient  passes 
plenty  of  water ;  that  it  even  runs  from  him.  Incontinence  of  urine  is,  in  fact,  in 
these  cases,  though  it  may  sound  paradoxical,  a  sign  of  retention  of  urine.  The 
urine  dribbles  away  because  the  bladder  admits  of  no  further  distension ;  it  over- 
flows and  runs  out  at  the  natural  orifice,  but  the  bladder  remains  constantly  full  and 
stretched.  You  must  make  an  examination,  therefore,  of  the  hypogastric  region 
with  your  hand.  If  you  find  that  part  of  the  belly  hard  and  resisting,  and  giving 
out  a  dull  sound  on  percussion,  you  may  be  sure,  in  these  cases  (where  there  is  para- 
lysis of  the  lower  extremities,  and  the  water  dribbles  away),  that  the  bladder  is  full, 
and  has  lost  the  power  of  expelling  its  contents.  Sometimes  you  may  recognize  the 
fluctuation  of  the  urine  in  the  distended  bladder,  and  ascertain  the  globular  shape  of 
that  organ.  It  will  rise  even  beyond  the  umbilicus.  But  what  I  chiefly  wished  to 
point  out  to  you  is  the  circumstance  that  the  bladder  becomes  diseased,  and  the  urine 
altered  in  quahty,  under  this  state  of  palsy.  The  urine  becomes  thick,  ropy,  and 
alkaline,  and  exhales  a  very  offensive  ammoniacal  smell;  and  the  inner  surface  of 
the  bladder  is  found,  after  death,  to  be  thickened,  red,  and  covered  with  adiiesiv© 
mucus — in  a  state  of  chronic  inflammation,  in  short. 


298  DISEASES    OF    THE    BRAIN. 


LECTURE  XXVIII. 


h 


Inflammatory  and  Structural  Diseases  of  the  Spinal  Cord,  continued.   Treatment. 
wipopkxy.      Its    General   Symptoms   and  Diagnosis.      Different  forms   of  the 

attack.     Predisposition  to  ..Apoplexy — Natural,  and  Accidental.     Precursory 

Symptoms. 

Allow  me  to  repeat  that  the  structural  diseases  of  the  spinal  cord  will  most  clearly 
reveal  themselves,  by  their  symptoms,  to  him  who  most  distinctly  perceives,  and 
most  accurately  bears  in  mind,  the  physiology  of  that  part  of  the  nervous  system. 
But  to  the  best  informed,  and  the  most  sagacious,  they  are  too  frequently  obscure  and 
perplexing. 

Disease  occupying  a  portion  only  of  the  cord,  but  affecting  the  whole  thickness  of 
th?.*,  portion,  from  centre  to  circumference,  will  be  hkely  to  disturb,  or  suspend,  the 
functions  of  sensation  and  voluntary  motion  in  all  the  parts  supplied  with  motor  or 
sentient  nerves  from  that  portion  of  the  cord,  and  from  the  portion  beyond  it.  So 
that  a  great  variety  of  symptoms  depend,  when  the  amount  of  disease  is  the  same, 
upon  the  place  of  the  disease.  A  total  interruption  of  the  conducting  function  of  the 
cord,  in  the  neck,  above  the  origin  of  the  phrenic  nerves,  extinguishes  hfe  by  stop- 
ping the  actions  of  respiration.  A  similar  intefruption  in  the  cervical  part  of  the 
cord,  above  the  origin  of  the  intercostals,  but  below  the  origin  of  the  phrenic  nerves, 
destroys  life  as  certainl)',  but  not  so  rapidly,  nor  in  exactly  the  same  manner.  We 
find  the  lungs  loaded  with  frothy  serous  fluid  in  sqch  cases ;  we  find  the  bladder 
inflamed ;  and,  often,  sloughing  of  the  integuments  and  muscles  of  the  nates  and 
hips.  A  similar  interruption  below  the  dorsal  vertebrae  is  not  necessarily  fatal, 
even  when  it  is  attended  with  permanent  paralysis :  but  it  usually  is  so,  sooner  or 
later. 

It  is  commonly  believed  that  disease  affecting  the  anterior  columns  only  of  the 
cord,  will  be  likely  to  disturb,  or  to  suspend,  the  power  of  voluntary  motion  in  the 
corresponding  parts  ;  to  produce  spasm  or  palsy :  and  that  disease  affecting  the  pos- 
terior columns  alone  will  be  likely  to  alter  or  abolish  the  faculty  of  sensation  in  the 
corresponding  parts  :  to  cause  pain,  tingling,  nuinbness  or  complete  amfthesia.  But 
I  have  mentioned  certain  facts  which  contravene  this  opinion.  Suspend  your  judg- 
ment respecting  it.  Neither  the  minute  anatomy  nor  the  physiology  belonging  to 
the  question  is  yet  conclusively  settled. 

There  seems  no  reason  to  doubt  that  disease  aflfecting  the  lateral  half  only  of  the 
cord  will  be  likely  to  derange  both  the  sensibility  and  the  power  of  movement,  in 
the  corresponding  part  on  the  same  side  of  the  body  alone. 

If  you  impress  upon  your  recollection  the  facts  thus  summarily  stated,  you  will 
find  in  them.  I  think,  a  key  to  many  of  the  phenomena  which  accompany,  and 
denote,  more  or  less  plainly,  disease  of  the  spinal  marrow. 

Inflammation  of  the  membruites  of  the  spine  is  most  apt  to  declare  itself  h\  pain, 
mcreased  on  motion,  of  the  spine  and  of  the  limbs ;  and  by  rigidity  and  spasm  of 
the  muscles  of  the  neck  and  back.  Inflammation  of  the  cord  itself,  which  readily 
passes  into,  or  rather  produces,  softening  of  its  substance,  is  most  commonly  marked, 
first,  with  convulsive  movements  of  some  parts  of  the  body  ;  secondly,  by  palsy  of 
those  parts,  with  or  without  ansesthesia.  The  same  may  be  said  of  suppuration 
■when  it  occurs  as  an  event  of  inflammation ;  and  the  pus  may  be  collected  into  an 
abscess  in  the  nervous  matter  of  the  cord,  or  it  may  be  difl^used  and  mixed  with 
softening. 

Now  I  need  not  dwell  upon  the  treatment  proper  to  be  adopted  in  inflammation  of 
the  spinal  cord  and  its  membranes.  Mutatis  mutandis,  it  is  the  treatment  already 
recommenaed  in  inflammation  of  the  brain  and  its  membranes.  When  the  inflain 
matioh  ]s  acute,  we  must  take  blood  freely ;  from  the  arm,  or  by  cupping-glasses 
along  the  sides  of  the  spine.  Blood  enough  may  be  taken  by  cupping  along  this 
tract  to  produce  the  effect  of  general  bleeding  as  well  as  of  local.     Perfect  rest  in 


APOPLEXY.  290 

the  horizontal  postu/e  must  be  strictly  enjoined  Mercury  will  generally  be 
proper. 

In  more  chronic  forms  of  inflammation  within  the  spinal  canal,  we  still  have  a 
capital  remedy  in  cupping:  and  counter-irritation  in  various  ways,  but  more  espe- 
cially by  means  of  issues  made  on  one  or  both  sides  of  the  spinous  ridge,  is  also,  in 
many  cases,  of  most  essential  and  unquestionable  service. 

Great  care  must  be  taken,  when  there  is  palsy  of  the  bladder,  not  only  (as  T 
admonished  you  in  the  last  lecture)  that  the  urine  be  regularly  drawn  off,  but  also 
that  the  patient  be  kept  dry  and  clean:  for  if  great  attention  be  not  paid  to  this  point, 
sores  will  form  where  the  urine  remains  in  contact  w'ith  the  skin,  to  the  great  increase 
of  his  suffering,  and  of  his  danger.  Indeed,  take  what  pains  we  may,  there  is  gene- 
rally a  strong  disposition  to  the  formation  of  sloughs  upon  the  sacrum  and  hips  in 
cases  of  paraplegia.  They  result  from  the  perpetual  pressure  made  upon  those 
projecting  points ;  from  the  feeble  state  of  the  circulation  in  the  palsied  parts ;  and 
(often)  from  the  irritation  of  the  urine  and  feces,  which  are  passed  without  the 
patient's  consciousness. 

When  the  patient  is  kept  clean  and  dry,  and  the  surfaces  on  which  the  weight  of 
his  body  has  been  supported  begin  to  be  red  and  angry,  you  may  protect  them  by  a 
plaster:  or  by  rubbing  them  with  brandy  you  may  sometimes  prevent  the  skin  from 
breaking:  or,  what  is  best  of  all,  you  may  put  your  patient  upon  one  of  Dr.  Arnott's 
hydrostatic  beds;  and  then  the  pressure  will  be  equally  distributed  over  all  that 
portion  of  the  body  which  comes  in  contact  with  the  water-proof  material  of  the  bed. 

To  bring  this  outline  of  the  diseased  states  of  the  spinal  cord  up  to  that  point  in 
which  we  left  those  of  the  encephalon,  I  may  state  that,  like  tlie  brain,  the  spinal 
marrow  may  become  hardened  by  chronic  inflammation ;  and,  like  the  brain,  it  may 
be  encroached  upon  by  tumours  ;  fibrous,  scrofulous,  or  malignant.  With  respect 
to  these,  all  that  I  can  now  say  likely  to  be  of  any  practical  benefit  to  you,  is  that 
the  symptoms  they  occasion  are  those  of  slowly  increasing  paralysis,  without  fever 
or  what  is  called  reaction  :  and  that  the  locality,  and  extent,  and  effects  of  the  para- 
lysis, will  vary  according  to  the  part  of  the  cord  in  which  these  changes  occur,  and 
the  depth  to  which  they  affect  it. 

I  proceed,  in  the  next  place,  to  a  perfectly  distinct  class  of  diseases  of  the  brain 
and  spinal  cord  ;  to  the  apoplectic  afft'Ctions  :  and  especially  to  cerebral  hemorrhage, 
and  spinal  hemorrhage. 

When  a  person  falls  down  suddenly,  and  lies  without  sense  or  motion,  except  that 
his  pulse  goes  on  beating,  and  his  breathing  continues,  he  is  said  to  have  been 
attacked  with  apoplexy.  He  appears  to  be  in  a  deep  sleep ;  but  this  is  not  all,  for 
you  cannot  awaken  him  by  the  same  means  which  would  rouse  a  healthy  man.  He 
is  not  in  a  state  of  syncope,  for  his  pulse  beats,  perhaps  with  unnatural  force ;  and 
often  his  face,  instead  of  being  pale,  is  flushed  and  turgid  ;  and  his  respiration  goes 
on,  though  it  may  be  laboured  and-  stertorous.  What  I  now  denominate  apoplexy, 
is  the  very  same  state  which  has  so  frequently  been  mentioned  already  in  these  lec- 
tures :  it  is  coma  occurring  suddenly,  or  coming  on  (at  least)  with  rapidity.  What 
is  coma?  it  is  that  condition  in  which  the  functions  of  animal  life  are  suspended, 
with  the  exception  of  the  mixed  function  of  respiration ;  while  the  functions  of 
organic  life,  and  especially  of  the  circulation,  continue  in  action.  There  is  neither 
thought,  nor  the  power  of  voluntary  motion,  nor  sensation :  but  the  pulmonary 
branches  of  the  par  vagum  continue  to  excite,  through  the  medudla  oblongata,  the 
invohmtary  movements  of  the  thorax.  When  this  upper  part  of  the  cranio-spinal 
axis  becomes  involved  in  the  disease,  and  its  reflex  power  ceases,  the  breathing 
ceases  also,  and  the  patient  is  presently  dead. 

It  is  a  common  question — how  would  you  distinguish  apoplexy  from  the  effects  ot 
a  narcotic  poison?  If  you  were  summoned  to  a  person  in  the  state  I  have  been  de- 
scribing, how  could  you  tell  whether  he  was  afllicted  with  apploplexy,  or  labouring 
under  the  influence  of  a  large  dose  of  opium,  or  merely  dead-drunk?  Why,  so  far 
as  the  condition  of  the  cerebral  functions  is  concerned,  you  cannot  discriminate  the 
one  from  the  other.     In  each  case  there  is  profound  coma ;  but  the  cause  of  vhe 


300  DISEASES    OF    THE    BRAIN. 

coma  is  different  in  each,  and  you  must  seek  to  ascertain  that  cause  in  the  history 
and  other  circumstances  of  the  patient :  you  inquire  whether  he  is  known  to  have 
been  drinking,  you  try  if  you  can  perceive  the  odour  of  spirits,  or  of  wine,  in  his 
breath ;  or  you  endeavour  to  make  out  whether  he  has  been  low-spirited,  or  in 
known  difficulties  ;  in  short,  whether  it  is  likely  that  he  may  have  swallowed  poison. 
But  from  the  actual  condition  of  his  sensorial  functions,  you  cannot  solve  the  question. 

Yet  let  me  say,  thus  in  the  outset  of  our  remarks  upon  apoplexy,  that  it  is  often 
/)f  great  importance  that  the  diagnosis  should  be  determined.  A  man  was  found 
lying  in  Smithfield  in  a  state  of  total  insensibility,  and  motionless,  except  that  he  still 
breathed.  He  was  carried  into  St.  Bartholomew's  Hospital.  The  house-surgeon 
thought  he  smell  the  smell  of  gin  in  his  mouth ;  and  thereupon  very  properly  made 
use  of  the  stomach-pump.  By  means  of  it  he  discharged  a  large  quantity  of  ardent 
spirit ;  and  in  the  course  of  a  few  minutes  the  man  revived,  shook  his  ears,  and 
walked  away.  If  the  gin  had  been  suffered  to  remain  in  his  stomach,  and  if  the 
remedies  of  apoplexy  had  been  vigorously  put  in  force,  the  absorption  of  the  poison 
would  have  been  thereby  accelerated  ;  and  the  debauch  would  probably  have  had  a 
fatal  termination.  The  same  remarks  apply  still  more  urgently  to  the  case  in  which 
opium,  or  any  other  strong  narcotic  poison,  is  lying  in  the  stomach.  Even  when 
there  is  no  great  danger,  either  in  the  person's  state,  or  in  the  remedies  used  for  it,  it 
is  not  a  very  pleasant  or  creditable  thing  to  make  a  false  point  of  this  kind.  If  we 
do  err,  however,  we  had  better  err  on  the  safe  side.  The  father  of  the  late  Professor 
James  Gregory,  of  Edinburgh,  (who  used  to  relate  the  case  in  his  lectures,)  was  once 
called  out  very  late  in  the  evening  to  visit  an  old  gentleman  of  that  place.  He  found 
him  in  a  completely  comatose  condition  ;  his  wife  crying,  and  his  household  all 
plunged  in  grief  and  distress.  They  told  him  that  the  patient,  whom  he  now  saw 
in  a  fit,  had  come  home,  and  upon  the  servant's  opening  the  door  to  him,  had  fallen 
into  the  passage,  on  his  back,  in  a  state  of  insensibility.  Dr.  Gregory  learned,  how- 
ever, that  he  had  been  at  the  "Club,"  and  he  knew  well  enough  that  this  club  was 
composed  of  choice  spirits,  fond  of  their  cups;  although  the  gentleman's  wife  did 
not  know  as  much.  Therefore  he  ventured  to  express  his  "  hopes"  to  the  wife  that 
her  husband  was  drunk :  a  charitable  view  of  the  case,  at  which  she  was  extremely 
affronted  and  indignant.  He  persisted,  however,  in  his  opinion,  and  not  long  after- 
wards the  patient  began  to  recover  his  senses.  It  turned  out  that  he  had  partaken 
more  fiberally  than  the  rest  of  the  club,  and  was  the  first  to  be  intoxicated.  Two  of 
his  companions  carried  him  home  quite  incapable  of  motion ;  but  not  hking  to  intro- 
duce him  themselves  to  his  wife  in  that  predicament,  they  placed  him  with  his  back 
against  the  door,  rang  the  bell,  and  decamped.  Of  course  when  the  servant  came  to 
open  the  door,  his  master  tumbled  sense^less  on  the  floor.  I  need  not  point  out  to  you 
the  ridicule  which  the  phys'cian  would  have  brought  upon  himself,  and  the  damage 
he  might  have  inflicted  upon  his  patient,  had  he  busily  apphed,  in  this  case,  the 
ordinary  remedies  of  apoplexy. 

The  state  of  coma,  such  as  I  have  described  as  being  characteristic  of  apoplexy, 
may  terminate  in  one  of  three  ways.  It  may  cease,  more  or  less  rapidly,  and  leave 
the  patient  in  perfect  health.  What  is  the  exact  condition  of  the  encephalon  during 
the  continuance  of  the  coma,  in  such  cases,  no  one  can  positively  tell.  But  the  oc- 
currence of  temporary  coma,  under  the  influence  of  a  narcotic  poison,  and  the 
perfect  disappearance  of  the  coma  as  the  effects  of  the  drug  pass  off,  teach  us  that  the 
functions  of  the  brain  may  be  almost  totally  suspended  for  a  time  by  causes  which 
do  not  injure  its  texture.  It  is  possible  that,  when  there  is  no  poison  at  work,  the 
coma  may  depend  upon  that  presumed  disturbance  of  the  balance  of  the  arterial 
and  venous  circulation  within  the  cranium,  which  I  mentioned  in  a  former  lecture. 
It  may  be  that  the  force  and  rapidity  of  the  circulation  in  the  cerebral  vessels  un- 
dergo some  great  alteration.  It  is  still  more  probable  (to  my  mind)  that  a  temporary 
Mress  upon  the  cerebral  blood-vessels  (produced  by  a  determination  of  blood  towards 
the  head,  through  the  arteries,  or  by  a  detention  of  blood  in  the  obstructed  veitis) 
may  really  exercise  pressure  enough  to  cause  transient  coma.  But  these  are  mere 
conjeciures. 

In  the  second  place,  the  apoplectic  coma  may  terminate,  more  or  less  quickly,  in 


APOPLEXY.  301 

death.  And  on  examining  the  brain,  we  may  find  a  large  quantity  o.  extravasated 
blood;  or  a  considerable  effusion  of  serous  fluid  in  its  ventricles,  or  beneath  the 
arachnoid  ;  or  we  may  detect  no  deviation  whatever  from  the  healthy  structure  and 
natural  appearance  of  the  organ.  The  congestive  pressure  (if  it  indeed  existed)  has 
left  no  prints  of  its  action. 

Fatal  coma,  without  obvious  disease  in  the  brain  to  account  for  it,  results,  not  un- 
frequently,  from  an  inbred  poison,  of  which  the  agency  was  not  recognized  until  a 
recent  period  :  the  poison  of  unpurified  blood.  When  speaking  of  the  general 
pathology  of  dropsy,  I  mentioned  a  peculiar  renal  disease  —  first  detected  and 
described  by  our  distinguished  countryman,  Dr.  Richard  Bright — which  unfits  the 
kidney  for  what  is  probably  its  most  important  office ;  that  of  removing  urea  from 
the  system.  When  this  excrement,  thus  retained,  accumulates  in  the  blood  beyond 
a  certain  amount,  it  is  very  apt,  among  other  injurious  tendencies,  to  cause  death  in 
the  way  of  coma. 

Dr.  Abercrombie  has  given  to  that  form  of  apoplexy,  which  destroys  life,  but 
leaves  no  traces  behind  it,  the  name  of  simple  apoplexy.  And  this  name,  for  its 
convenience  I  shall  retain.  Of  the  other  two  kinds  of  quickly  fatal  apoplexy,  that 
in  which  blood  is  found  extravasated,  is  more  common  than  that  in  which  there  is 
effusion  of  serum  only.  The  one  has  been  called  sanguineous  apoplexy  ;  a  better 
term  is  cerebral  hemorrhage :  the  other  has  been  named  serous  apoplexy. 

Thirdly,  the  apoplectic  coma  may  terminate  in  partial  or  imperfect  recovery.  One 
or  all  of  the  cerebral  functions  may  be  left  impaired ;  the  mind  enfeebled  ;  the 
power  of  motion  limited  or  lost  in  some  parts  of  the  frame ;  the  faculty  of  sensation 
benumbed  or  extinguished :  the  unhappy  subject  of  the  attack  remaining  more  or 
■  ess  crippled  in  body,  and  more  or  less  maimed  in  intellect.  In  these  cases,  when  at 
{englh  we  have  an  opportunity  of  examining  the  brain,  we  almost  always  find  that 
there  has  been  extravasation  of  blood,  to  a  small  or  moderate  extent.  I  say  almost 
always,  because  I  have  myself,  in  more  than  one  instance,  carefully  looked  for 
such  appearances,  after  such  a  series  of  symptoms.,  without  finding  them.  Oc- 
casionally, instead  of  a  clot  of  blood,  we  meet  with  circumscribed  softening  of  the 
brain. 

The  attack  of  apoplexy  does  not  always  occur  in  the  same  manner :  and  Dr. 
Abercrombie  has  pointed  out  three  several  ways  in  which  it  is  apt  to  come  on.  1 
am  confident,  from  the  result  of  my  own  observation,  that  the  distinctions  laid 
down  by  Dr.  Abercrombie  are  just  and  true  ;  and  it  is  of  importance  that  you 
should  be  aware  of  them.  "  In  the  first  form  of  the  attack,  the  patient  falls  down 
suddenly  deprived  of  sense  and  motion,  and  lies  like  a  person  in  a  deep  sleep ; 
his  face  generally  flushed,  his  breathing  stertorous,  his  pulse  full  and  not  frequent, 
sometimes  below  the  natural  standard.  In  some  of  these  cases  convulsions  occur  ; 
in  others,  rigidity  and  contraction  of  the  muscles  of  the  limbs,  sometimes  on  one 
side  only." 

Now,  respecting  persons  seen  in  this  condition,  the  immediate  prognosis  is  un- 
certain. Some  die  in  a  short  time,  and  much  blood  is  found  extravasated  within  the 
cranium.  Some  die  after  a  rather  longer  interval,  and  then  we  often  find  serous 
effusion  only,  and  that  of  no  great  amount.  And  in  some  that  die  early,  no  effusion 
either  of  blood  or  of  serum  can  be  detected.  Some  recover  altogether,  without  any 
ill  effect  of  the  attack  remaining.  Others  recover  from  the  coma,  but  are  left  para- 
lytic of  one  side,  and  with  some  imperfection  of  speech,  or  of  one  or  more  of  the 
senses.  And  this  paralysis  and  imperfection  may  disappear  in  a  few  days,  or  gra- 
dually subside,  or  remain  for  life. 

In  the  second  form  of  the  attack,  the  coma  is  not  the  earliest  symptom.  The  dis- 
ease generally  begins  with  a  sudden  attack  of  pain  in  the  head.  The  patient 
becomes  pale,  faint,  and  sick,  and  usually  vomits ;  and  sometimes,  but  not  always, 
falls  down  in  a  slate  of  syncope,  or  resembling  syncope,  with  a  bloodless  and  cold 
skin,  and  a  feeble  pulse.  This  also  is  occasionally  accompanied  by  some  degree  of 
convulsion.  Sometimes  he  does  not  fall  down,  the  sudden  attack  of  pain  being 
accompanied  only  by  slight  and  transient  confusion.  In  either  case,  he  commonly 
recovers  in  a  short  time  from  these  symptoms,  and  is  quite  sensible,  and  able  ii.» 

2a 


302  DISEASES    OF    THE    BRAIN. 

walk ;  but  the  headache  does  not  leave  him.  After  a  certain  interval,  which  may 
vary  from  a  few  minutes  to  several  hours — and  Dr.  Abercrombie  records  cases  in 
which  it  was  even  much  longer — the  patient  becomes  heavy,  forgetful,  incoherent, 
and  sinks  into  coma,  from  which  he  never  rises  again.  In  some  instances,  paralysis 
of  one  side  occurs ;  but  perhaps  more  often,  there  is  no  palsy  observed. 

The  disease,  when  it  comes  on  in  this  way,  is  much  more  uniform,  and  of  much 
worse  omen,  than  when  it  commences  after  the  former  fashion.  It  is  of  great  use 
to  know  this ;  for  to  an  inexperienced  eye  the  cases  do  not  seem  so  terrible  as  those 
in  which  the  patient  becomes  profoundly  comatose  from  the  very  first.  The  appa- 
rent amendment  is  fallacious,  and  apt  to  lead  one  into  giving  a  false  prognosis. 
Very  few  persons  come  out  of  the  coma,  and  a  large  quantity  of  blood  is  usually 
found  extravasated  in  the  brain.  These  cases  are  not,  as  Dr.  Abercrombie  well 
observes,  apoplectic  in  the  outset.  They  differ  remarkably  from  the  first  set  of  cases. 
If  there  be  at  the  ver}^  beginning  some  loss  of  sense  or  motion,  it  goes  off  again  in 
a  very  few  minutes,  or  perhaps  in  a  few  seconds :  the  prominent  symptom,  at  the 
commencement,  is  sudden  and  violent  pain  in  the  head,  with  faintness,  sickness,  anci 
often  with  vomiting.  The  pain  continues,  and  is  sometimes  confined  to  one  side  of  the 
head ;  the  face  is  pale  and  ghastly,  the  pulse  weak,  and  often  frequent  or  irregular  ; 
but  the  patient  is  quite  conscious,  and  in  full  possession  of  his  intellect.  At  length 
he  recovers  his  natural  temperature,  his  countenance  improves,  and  the  pulse  becomes 
stronger  and  steadier :  then  his  face  gets  flushed,  he  feels  oppressed,  answers  ques- 
tions slowly,  and  at  last  sinks  into  stupor  and  fatal  coma.  The  period  between  the 
first  attack  and  the  commencement  of  the  coma  is  variable.  Sometimes  the  stupor 
succeeds  the  pain  and  faintness  so  rapidly,  that  the  case  comes  greatly  to  resemble 
those  in  which  coma  is  the  first  symptom,  and  takes  place  suddenly  ;  but  still  a  short 
period  of  sense,  commonly  with  complaint  of  great  pain,  may  be  observed.  But  the 
interval  may  be  a  quarter  of  an  hour,  or  many  hours,  or  even  two  or  three  days. 
"  Upon  inspection,",  says  Dr.  Abercrombie,  "  we  find  none  of  those  varieties  and 
ambiguities,  which  occur  in  the  apoplectic  cases,  but  uniform  and  extensive  extra- 
vasation of  blood."  [I  should  state  that  he  calls  the  first  class  of  ca^es  apoplectic 
cases,  the  coma  being  present  from  the  first :  and  the  second  class,  which  we  are 
now  considering,  he  calls  cases  not  primarily  apoplectic.']  The  symptoms  in  this 
form  of  attack  depend,  no  doubt,  upon  the  giving  way  of  some  one  of  the  cerebral 
vessels.  At  the  moment  when  the  vessel  is  ruptured,  a  shock  is  given  to  the  brain ; 
a  temporary  derangement  of  its  functions  occurs  ;  but  this  passes  off.  The  circu- 
lation then  goes  on  as  before,  until  such  a  quantity  of  blood  has  escaped  from  the 
ruptured  vessel  as  is  sufficient  to  produce  coma.  There  is  no  part  of  Dr.  Aber- 
crombie's  book  more  admirable  and  clearly  put  than  that  which  is  occupied  with 
these  important  distinctions,  which  I  give  you  very  much  in  his  own  words.  He 
points  out  the  close  analogy  which  exists  between  this  variety  of  apoplexy,  and  the 
result  of  external  injuries,  when  they  occasion  extravasation  of  blood  on  the  surface 
of  the  brain.  The  hurt  person  recovers  from  the  immediate  effects  of  the  accident, 
walks  home  perhaps,  and  after  some  time  becomes  stupid,  and  at  last  comatose. 
The  surgeon  trephines  the  skull,  and  discovers  blood  upon  the  dura  mater;  and  the 
blood  being  removed,  the  coma  goes  off.  We  cannot  help  our  patients  by  a  similar 
expedient;  though  the  opinion  has  been  broached  that  trepanning  the  skull  will,  at 
some  future  period,  be  a  common  practice  in  apoplexy.  Dr.  Abercrombie  conjec- 
tures that  after  the  rupture  has  taken  place,  the  hemorrhage  is  sometimes  stopt  by 
the  formation  of  a  clot  at  the  orifice  in  the  vessel,  but  at  length  the  blood  bursts  out 
again,  and  proves  fatal.  He  relates  two  cases  in  which  this  probably  happened  ;  in 
one  of  them  an  interval  of  three  days,  and  in  the  other  an  interval  of  a  fortnight, 
elapsed  between  tiie  first  attack,  and  the  supervention  of  coma.  The  portions  of 
blood  extravasated  at  the  two  distinct  periods  may  sometimes  be  distinguished  by 
their  appearance — their  colour  and  consistence. 

The  third  form  of  attack  is  characterized  by  sudden  loss  of  power  on  one  side  of 
the  body,  and  frequently  by  loss  of  speech,  without  loss  of  consciousness  ;  or  at  most 
with  a  very  temporary  suspension  of  consciousness.  The  patient  is  sensible,  listens 
to  and  comprehends  your  questions,  and  answers  them  as  well  as  he  is  able,  either 


APOPLEXY.  303 

oy  words,  which  in  most  cases  he  articulates  imperfectly,  or  by  gestures  The 
further  progress  of  the  cases  that  commence  in  this  way  is  marked  by  considerable 
variety.  Sometimes  the  hemiplegia  passes  gradually  in  a  short  time  into  apoplexy. 
Sometimes  the  patient  soon  gets  well,  the  palsy  leaving  him  entirely.  Or  a  gradual 
recovery  takes  place,  which  is  not  complete  for  some  weeks  or  months.  Or  the 
patient  rallies  up  to  a  certain  point,  and  there  the  improvement  stops  ;  he  regains  the 
power  of  moving  his  leg,  but  it  drags  somewhat  after  him  ;  or  the  leg  recovers,  but 
the  arm  remains  feeble,  or  his  speech  continues  to  be  inarticulate.  And  in  another 
variety  of  this  form  the  patient  neither  improves  on  the  one  hand,  nor  becomes  apo- 
plectic on  the  other,  but  is  confined  to  his  bed,  paralytic,  and  perhaps  speechless, 
though  in  possession  of  his  faculties  in  other  respects,  and  dies  at  last  worn  out  and 
exhausted,  some  weeks,  or  months  it  may  be,  after  the  attack.  In  the  outset  of  these 
cases  there  is  not  always  complete  hemiplegia,  sometimes  the  arm  only  is  affected, 
sometimes  (but  much  more  rarely)  the  leg  only.  Or  some  other  voluntary  muscles 
are  the  first  to  lose  their  power. 

Now  the  appearances  discovered  after  death,  in  cases  that  have  thus  commenced 
(Dr.  Abercrombie  calls  them  the  class  of  paralytic  cases),  are,  as  in  the  apoplectic 
cases,  inconstant.  Much  the  most  common  of  all — according  to  my  own  experience — 
is  the  extravasation  of  blood,  to  a  moderate  or  small  amount,  and  definite  extent,  in 
the  substance  of  the  brain.  But  sometimes  nothing  is  found,  upon  dissection,  to 
account  for  the  symptoms,  or  slight  serous  effusion  only.  The  same  symptoms  attend 
some  cases  of  softening  of  the  brain  also  ;  or  inflammation  and  its  consequences.  In 
a  vast  majority  of  cases,  I  repeat,  this  sudden  hemiplegia  inarks  an  attack  of  cerebral 
hemorrhage. 

You  will  not  find  that  all  cases  of  apoplexy  commence  exactly  in  the  one  or  the 
other  of  the  three  ways  which  I  have  been  describing.  But  most  attacks  range 
themselves  in  one  of  these  classes,  and  by  attending  to  the  points  of  distinction,  I 
make  no  doubt  that  you  will  often  derive  much  assistance  from  them  in  regard  to 
diagnosis  and  prognosis  ;  and  that  the  distinctions  themselves  will  give  a  higher  inte- 
rest to  your  study  of  this  complaint,  than  it  would  possess  if  all  the  forms  of  attack 
were  jumbled  together  in  one  common  description. 

In  treating  of  this  large  subject,  this  multiform  disease,  the  main  points  will  best 
be  made  intelligible  by  my  breaking  what  I  have  to  say  into  separate  heads.  I  have 
told  you  the  different  ways  in  which  the  disease  may  make  its  assault.  I  will  next 
say  something  of  the  persons  who  are  most  liable,  cseieris  paribus,  to  attacks  of 
apoplexy :  and  afterwards  of  the  symptoms  which  in  many  cases,  though  not  in  all, 
precede  the  seizure,  and  lead  us  to  fear  that  it  may  be  impending.  It  is  of  great 
importance  to  attend  to  these  threatenings ;  for,  as  you  will  readily  conceive,  the 
chief  good  that  medicine  can  do  in  such  cases,  is  in  the  way  of  prevention.  After  the 
attack  has  taken  place,  the  effect  of  our  treatment  must  be  very  uncertain.  A  large 
effusion  of  blood  upon  the  brain  will  be  fatal  in  spite  of  us  :  and  a  smaller  amount  of 
extravasation  we  cannot  remove  ;  and  the  best  that  the  patient  can  expect  in  too  many 
cases,  is  long-continued  or  permanent  palsy,  a  weakening  of  the  mental  powers,  and 
sometimes  a  state  nearly  approaching  to  idiocy.  Also,  when  once  an  apoplectic  fit 
has  happened,  it  is  the  more  likely,  on  that  very  account,  to  happen  again.  These 
are  quite  sufficient  reasons  why  we  should  not  neglect  the  warnings  ;  the  symptoms 
which  are  apt  to  precede  and  herald  the  attack  of  apoplexy. 

The  classes  of  persons  in  whom,  cseteris  paribus,  attacks  of  apoplexy  are  espe- 
cially to  be  apprehended,  are  those  whose  ancestors  have  suffered  the  same  disease ; 
those  who  possess  a  particular  conformation  of  body  ;  and,  above  all,  those  who 
have  reached  a  certain  period  of  life.  No  doubt  apoplexy  may  and  does  occur  in 
persons  whose  progenitors  have  escaped  it ;  in  persons  of  every  conceivable  snape 
and  make  ;  and  in  persons  of  all  ages.  But  it  is  much  more  frequent  in  the  classes 
I  have  specified,  than  it  is  among  persons  not  comprehended  in  those  classes. 

The  first  and  second  class  sometimes  concur,  ?".  e.,  a  particular  conformation  of  the 
body  is  transmitted  from  parent  to  child,  and  with  it  is  transmitted  a  proclivity  to 
apoplectic  disease.  But  even  when  there  is  nothing  particular  in  their  bodily  form. 
or  in  their  habits  of  life,  practical  men  of  large  experience  declare  that  they  who 


304  DISEASES    OF    THE    BRAIN. 

come  of  an  apoplectic  stock  are  themselves  more  than  ordinarily  liable  to  apo- 
plexy. _ 

The  pattern  of  body  which  is  most  prone  to  apoplexy  is  denoted  by  a  large  head 
and  red  face,  shortness  and  thickness  of  the  neck,  and  a  short,  stout,  squat  build. 
This  remark  is  as  old  as  the  time  of  Hippocrates.  However,  apoplexy  is  common 
enough  in  men  and  women  who  are  thin,  and  pale,  and  tall.  Ceteris  paribus,  cor- 
pulent people  are  more  in  danger  of  apoplexy  than  spare  people  ;  but  it  attacks  both 
the  one  and  the  other. 

Advanced  life  is  certainly  a  very  strong  predisposing  cause,  and  the  reason  of  this 
will  be  apparent  when  we  come  to  inquire  more  particularly  into  the  morbid  appear- 
ances presented  after  death  by  apoplexy.  The  disease  begins  to  be  common  after 
50:  but  it  does  sometimes  occur  even  in  young  children.  I  am  speaking  principally 
of  that  form  of  apoplexy  which  depends  upon  cerebral  hemorrhage,  which  is  by 
far  the  most  frequent  of  all  its  forms. 

Of  sixty-three  examples  of  cerebral  hemorrhage,  collected  and  carefully  examined 
by  Rochoux  (who  has  written  a  very  good  treatise  on  this  affection),  two  only  hap- 
pened between  the  ages  of  20  and  30 ;  eight  between  30  and  40  ;  seven  between 
40  and  50 ;  ten  between  50  and  00 ;  twenty-three  (or  more  than  one-third  of  the 
whole)  between  60  and  70 ;  twelve  between  70  and  80 :  and  one  between  80  and 
90.  To  analyze  this  table  a  httle  further :  it  appears  that  of  the  sixty-three  casss 
seventeen  only  took  place  before  50 ;  forty-six  after  that  age.  There  are  also  twice 
as  many  victims  to  the  disease  between  the  ages  of  60  and  70,  as  between  70  a^d 
80.  And  from  this  fact  Rochoux  has  drawn,  I  conceive,  an  erroneous  conclusioKi ; 
and  I  mention  it  that,  in  case  his  treatise  falls  in  your  way,  j'ou  may  not  be  led  by 
it  into  what  I  imagine  would  be  a  mistake.  There  being  twenty-three  cases  between 
the  ages  of  60  and  70,  and  only  twelve  between  the  ages  of  70  and  80,  Rochoux 
infers  from  this  that  the  disposition  to  cerebral  hemorrhage  decreases  after  the  age 
of  70 ;  which  would  be  a  most  unaccountable  thing,  and  quite  inconsistent  with 
what  I  believe  to  be  the  true  pathology  of  the  disease.  But  I  make  no  doubt  that 
the  difference  in  the  actual  numbers  observed  in  these  two  decennial  periods  de- 
pended upon  the  number  of  persons  alive,  at  the  same  time,  of  the  ages  of  60  and 
70  respectively.  There  are  always  more  persons  living  whose  age  ranges  from 
60  to  70,  than  from  70  to  80 ;  and  therefore  more  persons  die  of  apoplexy  in  the 
former  period.  In  all  probability,  if  the  exact  truth  could  be  ascertained,  of  a  given 
number  of  persons,  there  are  more  attacked  with  apoplexy  between  70  and  80  than 
between  60  and  70. 

All  these  three  kinds  of  predisposition  are  beyond  our  power.  We  cannot  exter- 
minate the  hereditaiy  tendency  ;  nor  remodel  the  plan  upon  which  the  body  is  con- 
structed ;  nor  arrest,  or  put  back,  the  clockwork  of  human  life.  But  we  may  guard 
and  caution  persons,  thus  predisposed  by  nature  towards  apoplexy,  against  many  of 
its  exciting  causes. 

A  strong  predisposition  to  apoplexy  is,  moreover,  engendered  by  certain  other 
diseased  conditions ;  and  over  some  of  these  conditions  our  art  enables  us  to  exercise 
more  or  less  control. 

One  of  these  I  referred  to  just  now  —  the  kidney  disease  discoverea  by  Dr. 
Bright. 

Disease  of  the  cerebral  blood-vessels  is  a  very  common  and  a  ver}'  pregnant  cir- 
cumstance of  predisposition.  I  shall  revert  to  this  when  I  describe  more  particularly 
the  anatomical  characters  af  cerebral  hemorrhage. 

Diseases  of  the  chest  influence  very  materially  and  injuriously  the  circulation  in 
the  head.  Without  going  into  detail  respecting  complaints  with  wliich  I  am  obliged 
to  suppose  that  you  are  as  yet  unacquainted,  I  may  state,  by  anticipation,  that  impe- 
diments to  the  free  transmission  of  blood  through  the  heart  and  lungs  constitute  the 
mode  in  which  thoracic  disorders  predispose  to  apoplexy.  The  pletliora  capitis 
produced  by  such  impediments  is  frequently  visible  in  the  turgid  and  livid  features, 
and  in  the  distended  jutrular  veins. 

The  cessation  of  habitual  discharges,  of  the  catamenia,  of  bleeding  piles ;  the 
drying  up  of  old  sores ;  the  heaHng  of  long  established  issues  and  setons ;  all  have 


APOPLEXY.  305 

an  unquestionable  tendency,  by  causing  or  augmenting  plethora,  to  generate  a  pre- 
disposition to  apoplexy. 

And  large  observation  of  the  habits  of  those  who  fall  victinas  to  this  terrible  ma- 
lady, leaves  no  room  for  doubting  that  intemperance  often  paves  the  way  for  its  inva- 
sion. The  continued  abuse  of  ardent  spirits,  in  particular,  lays  the  foundation  of 
many  of  those  morbid  conditions  of  the  sanguiferous  system,  and  of  the  viscera, 
which  constitute  the  predisposition  we  are  now  considering. 

Among  the  premonitory  symptoms,  headache  is  of  frequent  occurrence  :  but  the 
same  symptom  is  abundantly  common  in  persons  who  are  in  no  danger  of  apoplexy  : 
it  derives  its  minatory  character  from  the  concurrent  circumstances.  Headaches 
awaken  our  fears  when  they  begin  to  be  troublesome  in  advanced  life.  They  are, 
then,  still  more  formidable  if  they  are  accompanied  by  vertigo;  or,  without  any 
other  evidence  of  gastric  derangement,  by  nausea  and  retching.  Sometimes,  as  I 
just  now  told  you,  severe  headache  ushers  in,  and  almost  forms  a  part  of  the  apo- 
plectic attack. 

Vertigo  itself,  even  without  headache,  is  a  very  common  precursor  or  warnmg  of 
an  approaching  seizure.  It  is  sometimes  slight  and  transient ;  sometimes  almost 
habitual.  Although  vertigo  may  depend  upon  other  causes  than  mischief  within  the 
head,  we  cannot  regard  it  without  apprehension  when  it  often  occurs  in  old  persons. 
It  should  teach  us  to  obviate  as  entirely  as  we  can  all  the  known  exciting  causes  of 
apoplexy.     The  principle  of  these  I  shall  by-and-by  describe  to  you. 

Transient  deafness,  or  transient  blindness,  blindness  or  deafness  for  a  few  seconds 
or  minutes,  is  another  of  these  warning  symptoms.  The  late  Dr.  Gregory,  of  Edin- 
burgh, used  always  to  mention  in  his  lectures  the  case  of  Dr.  Adam  Ferguson,  the 
celebrated  historian,  as  affording  one  of  the  strongest  illustrations  he  ever  met  with 
of  the  benefit  that  may  be  derived  from  timely  attention  to  the  avoidance  of  those 
circumstances  which  tend  to  produce  plethora  and  apoplexy.  It  is,  perhaps,  the 
most  strikmg  case  of  the  kind  on  record.  Dr.  Ferguson  experienced  several  attacks 
of  temporary  blindness  some  time  before  he  had  a  stroke  of  palsy  ;  and  he  did  not 
take  these  hints  so  readily  as  he  should  have  done.  He  observed  that  while  he  was 
deiivering  a  lecture,  his  class,  and  the  papers  before  him  would  disappear,  vanish 
from  his  sight,  and  reappear  again  in  a  few  seconds.  He  was  a  man  of  full  habit ; 
at  one  lime  corpulent  and  very  ruddy,  and,  though  by  no  means  intemperate,  he 
lived  fully.  1  say  he  did  not  attend  to  these  admonitions;  and  at  length,  in  the 
sixtieth  year  of  his  age,  he  suffered  a  decided  shock  of  paralysis.  He  recovered, 
however,  and  from  that  period,  under  the  advice  of  his  friend.  Dr.  Black,  became  a 
strict  Pythagorean  in  his  diet,  eating  nothing  but  vegetables,  and  drinking  only  water 
or  milk.  He  got  rid  of  every  paralytic  symptom,  became  even  robust  and  muscular 
for  a  man  of  his  time  of  life,  and  died  in  full  possession  of  his  mental  faculties  at  the 
advanced  age  of  n inety -three :  upwards  of  thirty  years  after  his  first  attack.  Sir 
Walter  Scott  describes  him  as  having  been,  "  long  after  his  eightieth  year,  one  ot  the 
most  striking  old  men  it  was  possible  to  look  at.  His  firm  step  and  ruddy  cheek 
contrasted  agreeably  and  unexpectedly  with  his  silver  locks  ;  and  the  dress  which  he 
usually  wore,  much  resembling  that  of  the  Flemish  peasant,  gave  an  air  of  peculi- 
arity to  his  whole  figure.  In  his  conversation,  the  mixture  of  original  thinking  with 
high  moral  feeling  and  extensive  learning,  his  love  of  country,  contempt  of  luxury, 
and  especially  the  strong  subjection  of  his  passions  and  feelings  to  the  dominion  of 
his  reason,  made  him,  perhaps,  the  most  striking  example  of  the  Stoic  philosophei 
which  could  be  seen  in  modern  days." 

This  anecdote,  which  I  have  made  use  of  as  a  wrapper  for  some  medical  instru*. 
tion,  will  not  be  the  less  acceptable  to  you  when  I  add  that  the  remarkable  man  to 
whom  it  relates  was  the  great-uncle  of  my  friend  and  present  colleague  in  this 
school.  Dr.  Robert  Ferguson. 

Very  frequently  slight  and  partial  paralysis  is  the  forerunner  of  an  attack  of  apo- 
plexy- Double  vision  is  one  form  in  which  such  hmited  palsy  is  apt  to  show  itself. 
It  is  evidently  connected  with  some  degree  of  squinting;  i.  e.,  some  one  or  more  of 
the  muscles  that  move  the  eyeball  are  paralyzed ;  the  person  cannot  direct  each 
eye  to  the  same  object  at  the  same  time.  This  is  a  very  suspicious  symptom.  Dr 
20  2a2 


306  DISEASES    OF    THE    BRAIN. 

Gregory  was  acquainted  with  a  sportsman  who  one  day,  when  out  shooting,  disputed 
with  his  gamekeeper  as  to  the  number  of  dogs  they  had  in  the  field.  He  asked  how 
he  came  to  bring  so  many  as  eight  dogs  with  him.  The  servant  assured  him  there 
were  but  four;  and  then  the  gentleman  became  at  once  aware  of  his  situation, 
mounted  his  horse  and  rode  home.  He  had  not  been  long  in  the  house  when  he 
was  attacked  with  apoplexy,  and  died. 

Sometimes  the  slight  and  local  paralysis  shows  itself  in  a  faltering  or  inarticulate 
mode  of  speaking.  The  rapidity  of  the  movements  of  the  tongue  requisite  for  dis- 
tinct utterance  is  so  great,  that  the  slightest  weakness  of  any  one  of  its  muschs  is 
rendered  obvious.  We  see  this  in  one  very  comition  form  of  what  may  in  truth  be 
considered  a  kind  of  apoplexy ;  viz.,  in  drunkenness.  In  many  persons  the  very- 
first  symptom  of  their  becoming  intoxicated  is  their  inability  to  speak  plainly.  "  Clip- 
ping the  King's  Enghsh  "  is  the  slang  expression  for  it ;  and  the  same  thing  often 
takes  place  in  respect  to  the  more  proper  forms  of  apoplexy. 

It  is  a  curious  circumstance,  by  the  way,  and  one  which  is  illustrative  of  what 
we  meet  with  in  disease,  that  different  sets  of  muscles  are  chiefly  aflected  by  inebri- 
ation in  different  persons ;  the  same  sets  being  always  the  first  afTected  in  the  same 
persons.  Thus,  some  men,  when  drunk,  lose  (as  I  have  just  stated)  the  proper 
command  over  the  muscles  of  the  tongue,  and  falter  in  speech,  while  they  can 
walk  very  well :  others  reel  and  stagger,  having  lost,  in  a  greater  or  less  degree,  the 
power  of  moving  and  governing  their  limbs,  and  of  balancing  themselves,  who  yet 
can  speak  quite  fluently  and  plainly:  and  in  a  few  cases,  drunken  persons  become 
delirious,  who  still  retain  the  power  of  distinct  articulation,  and  of  directing  their 
steps  aright.  This  being  so,  we  need  the  less  wonder  at  the  variety  in  the  nature 
of  the  warnings  that  precede  the  apoplectic  attack. 

In  many  instances  there  is  numbness  or  debility,  or  total  palsy  of  one  limb,  or  of 
a  single  finger,  or  even  of  a  sohtary  muscle,  as  of  the  levator  palpebrse.  The  patient 
cannot  grasp  your  hand  with  firmness,  or  sign  his  name  in  his  usual  way,  or  pick 
up  a  pin,  or  snuff  a  candle,  or  manage  an  obstinate  button,  or  tie  a  knot  in  a  thread 
cleverly  :  or,  perhaps,  one  of  his  eyelids  droops,  and  the  eye  is  half  closed.  Some- 
times, on  the  contrary,  the  patient  stares  at  you,  friglxlfully,  w^ith  one  eye,  which  he 
cannot  shut. 

The  numbness  also  assumes  various  characters,  according  to  its  place  and  degree. 
One  patient  will  tell  you  that  he  feels  as  if  his  limbs  were  muffled  in  flannel;  ano- 
ther, that  he  is  uncertain  whether,  in  walking,  his  foot  has  reached  the  ground  or 
not.  A  gentleman,  since  dead  of  apoplexy,  assured  me  that,  when  sitting,  he  did 
not  know  how  far  his  breech  covered  the  seat  of  the  chair. 

All  these  symptoms  are  modifications  of  the  function  of  voluntary  motion ;  or  of 
the  function  of  sensation.  Nor  are  manifestations  wanting,  among  these  precursory 
circumstances,  of  a  derangement  of  the  other  and  nobler  function,  of  which  the  brain 
and  nervous  system  form  the  material  instrument.     I  mean  the  function  o^  thought. 

Thus  one  very  deplorable  warning  is  the  loss  of  memory.  All  persons  find,  as 
■.hey  grow  older,  that  they  do  not  retain  so  tenaciously  in  their  recollection  things 
which  have  recently  occurred,  as  things  which  happened  when  they  were  youno-. 
This  partly  depends  upon  the  degree  of  atteniion  which  we  pay  to  different  circum- 
stances. Those  events  which  strongly  excite  the  curiosity,  and  rivet  the  attention 
of  the  boy,  become  familiar  to  the  man,  and  he  gives  them  but  little  notice,  and  is 
very  apt  to  forget  them.  But  the  loss  of  memory  that  threatens  apoplexy  is  some- 
thing more  than  this.  It  is  sometimes  partial,  and  extends  to  certain  sets  of  things 
(•nly.  For  example,  some  p-^rsons  entirely  forget  certain  words,  while  they  recollect 
others  perfectly.  Common  words  are  often  thus  forgotten,  while  unusual  or  remark- 
able words  are  remembered  ;  or  a  wrong  word  is  chosen.  One  w-ord  is  used  for 
another  that  sounds  something  like  it.  Thus  one  of  my  patients,  meaning  to  accuse 
a  certain  individual  o[ perjury,  always  called  it  purging:  and  many  other  words  he 
changed  after  the  same  fashion.  But  in  truth  the  modifications  of  a  partial  loss  of 
memory  that  have  been  known  to  precede  apoplexy  are  both  odd  and  endless :  some 
people  forget  their  own  names,  or  the  names  of  their  children.  Dr.  Gregory,  who 
u^d  paid  particular  attention  to  these  precursory  symptoms,  and  who  had  a  large 


APOPLEXY.  307 

practice  foi  a  great  number  of  years  to  furnish  them,  used  to  mention  a  case  of  this 
kind.  After  some  efforts  his  patient  could  recalJ  to  his  recollection  what  his  Chris' 
tian  name  was,  but  he  could  not  think  of  his  surname.  About  twelve  months  after 
his  memory  began  to  fail  in  this  strange  manner,  he  was  found  dead  in  his  bed. 
Another  gentleman,  for  some  time  before  his  death,  could  never  recollect  the  name 
of  the  street  in  which  he  lived.  Upon  one  occasion  of  his  visiting  Edinburgh,  he 
called  on  Dr.  Gregory,  and  partook  of  a  hearty  breakfast,  having  forgotten  that  he 
had  breakfasted  before  he  came  out.  On  the  same  day  he  attended,  with  Dr.  Gre- 
gory, the  funeral  of  a  young  lady  who  had  been  his  ward  ;  the  funeral  took  place  in 
the  country ;  and  when  they  returned  together  in  the  carriage,  the  doctor  found  that 
his  friend  had  forgotten  all  that  he  had  been  doing.  Next  day  he  met  him  in  the 
street,  and  saluted  him  with  all  the  kindness  of  an  old  acquaintance  at  first  meeting; 
saying  he  was  happy  to  have  flillen  in  with  him  now  that  he  was  in  town,  and 
totally  forgetful  of  their  former  interviews. 

Connected  with  this  failure  of  memory,  there  is  often  an  unnatural  degree  of 
drowsiness.  Sometimes,  without  any  permanent  affection  of  the  memory,  there  is  a 
temporary  confusion  or  suspension  of  thought ;  the  patient  suddenly  loses  the  train 
of  ideas  in  which  his  mind  had  been  occupied ;  stops  short  in  the  middle  of  a  sen- 
tence, and  endeavours,  in  vain,  to  recover  the  broken  thread  of  his  discourse. 

Among  the  mental  conditions  that  bespeak  a  tendency  to  apoplectic  disease,  I 
have  several  times  noticed  a  strange  and  vague  dread,  of  which  the  person  can  give 
no  reasonable  explanation ;  a  sense  of  apprehension  and  insecurity  not  accounted 
for  by  the  apparent  state  of  his  general  powers  and  functions ;  a  painful  degree  of 
indecision  and  irritability  ;  with  a  dislike  and  fear  of  being  left  alone.  One  patient 
of  mine  described  his  "  nervousness"  of  this  kind,  by  telling  me  that  in  descending 
a  staircase,  especially  a  winding  one,  he  was  obliged  to  turn  round,  and  come  down 
backwards,  as  one  descends  a  ladder ;  or  even  to  sit  down,  and  so  sHp,  stair  by  stair, 
from  the  top  to  the  bottom.  Yet  with  the  assurance  given  him  by  a  friend's  arm, 
or  by  a  convenient  baluster,  he  could  walk  down  stairs  without  difficulty.  He  had 
no  actual  vertigo. 

I  say,  all  these,  and  many  other  signs  that  indicate  a  disposition  to  apoplexy,  are 
well  worth  j^our  study ;  because  a  knowledge  of  them  may  enable  you  to  ward  off 
the  threatened  attack  by  medicine,  by  regimen,  and  by  admonition  to  the  patient  on 
the  subject  of  such  exciting  causes  of  the  disease  as  are  within  his  own  control. 
They  show  that,  even  before  the  stroke  descends,  there  is  some  morbid  process  going 
on  within  the  head. 


LECTURE  XXIX. 

Apoplexy  continued.  Symptoms  characterizing  the  Apoplectic  State.  Pressure 
the  ordinary  Physical  Cause.  Hem,iplegia.  Affection  of  Involuntary  Muscles. 
Anatomical  Characters.  Situation  of  the  Clot  of  Blood.  Disease  of  the  Cere- 
bral  Blood-Vessels. 

We  were  engaged  with  the  subject  of  apoplexy.  I  requested  your  particular 
attention  to  the  three-fold  mode  in  which  that  fearful  disorder  has  been  observed  to 
make  its  attack.  In  the  first,  the  coma  is  sudden  and  deep ;  the  condition  of  the 
patient,  thus  struck  in  an  instant  senseless  and  motionless,  warranting  those  epithets 
which  the  ancients  applied  to  the  victims  of  this  disease,  of  attoniti  and  siderati,  as 
if  they  were  thunder-smitten  or  planet-struck.  In  the  second  form  of  the  attack,  the 
earliest  symptom  is  acute  pain  of  the  head,  with  sickness  and  faintness  ;  the  coma 
supervening  usually  in  no  long  time.  The  third  form  is  ushered  in  by  sudden 
hemipl?gia,  which  may  or  may  not  lead  to  loss  of  consciousness  or  stupor.  The 
cases  which  range  themselves  under  the  one  or  the  other  of  these  three  forms  of 
attack  are  called  respectively,  by  Dr.  Abercrombie,  apoplectic  cases;  cases  not  p^'i 


308  DISEASES   OF   THE   BRAIN. 

marily  apoplectic ;  and  paralytic  cases :  and  so  as  you  bear  in  mind  what  these 
terms  really  imply,  they  appear  unobjectionable. 

I  next  pointed  out  the  classes  of  persons  in  whom  an  attack  of  apoplexy  is  chiefly 
to  be  apprehended :  those,  namely,  in  whose  famihes  that  disease  has  been  known 
to  be  common:  those  who  have  large  heads,  thick  necks,  red  faces,  square  shoul- 
ders, and  a  short  stature ;  although  persons  of  quite  the  opposite  configuration  are 
by  no  means  exempt  from  it :  and  lastly,  and  above  all,  those  who  have  passed  the 
middle  period  of  life,  and  are  advancing  towards  old  age  :  and  more  particularly  is 
apoplexy  to  be  apprehended  in  people  of  this  description  when  they  have  already 
suffered  what  are  called  head  symptoms ;  which  symptoms  have  reference  to  the 
three  great  functions  of  the  brain  and  nervous  system :  voluntary  motion,  sensation, 
and  thought.  Such  symptoms  consist,  therefore,  in  slight  and  often  transient  para- 
lytic aflections,  double  vision,  a  dropping  of  one  eyelid,  occasional  inarticulate  speech, 
weakness,  perhaps,  of  a  single  finger:  headache,  giddiness,  unnatural  sounds  in  the 
ears,  numbness  or  tingling  of  the  extremities,  which  last  are  all  modifications  of  sen- 
sibility :  some  impairment  of  the  intellect,  shown  most  commonly  bj^  partial  and 
strange  defects  of  memory,  and  temporary  confusion  of  thought.  When  several  or 
any  of  these  symptoms  occur,  and  especially  when  they  become  habitual  in  persons 
in  the  decline  of  life,  we  have  reason  to  dread  the  supervention  of  apoplexy ;  and  to 
exhort  and  protect  our  patients  against  its  ascertained  exciting  causes. 

When  the  apoplectic  state  is  fully  formed,  in  what  manner  soever  the  attack  may 
have  commenced,  it  is  marked  by  most  or  all  of  the  following  circumstances.  The 
patient  lies  totally  unconscious  of  all  that  may  be  going  on  about  him.  He  rephes 
to  no  questions,  he  is  unmoved  by  the  cries  and  lamentations  of  his  family  ;  in  fact, 
he  does  not  hear  them.  His  pulse  is  infrequent,  often  full,  perhaps  intermitting. 
His  breathing  is  peculiar,  being  slow,  sometimes  interrupted  or  irregular,  attended 
with  snoring  or  stertor  during  inspiration,  and  a  puffing  out  of  the  cheeks,  like  the 
action  of  one  who  smokes  a  pipe,  during  e:rpiration.  Both  these  peculiarities  are 
referable  to  the  same  principle,  and  both  denote  a  profound  sensibility  to  all  external 
impressions.  There  is  no  longer  any  voluntary  attempt  to  breathe,  yet  the  involun- 
tary movements  of  respiration  subsist:  the  medulla  oblongata  still  responds  to  the 
impressions  which  reach  it  from  the  lungs  and  from  the  skin,  still  prompts  contraction 
of  the  muscles  that  enlarge  the  capacity  of  the  thorax ;  but  the  loose  curtain  of  the 
palate,  and  the  fips  and  cheeks,  are  passive.  By  the  vibrations  of  the  one  the  stertor 
is  occasioned  ;  the  mouth  is  closed  by  the  mere  elasticity  of  the  others,  and  the  flaccid 
cheeks  flap  outwards  with  the  explosion  of  the  air,  as  it  escapes  when  the  chest  again 
collapses.  The  countenance  is  frequently  turgid,  and  livid  ;  the  blood  which  tinges 
It  is  already  but  half  arterialized  ;  the  pupils  are  commoni}'  contracted.  The  limba 
lie  motionless  :  either  they  are  all  absolutely  palsied  ;  or  (what  probably  is  often  the 
case)  the  capacity  of  motion  remaining,  the  7vill  to  move  them  is  wanting.  If  you 
raise  one  of  them  it  falls  passively  down  again,  when  you  leave  hold  of  it,  hke  a  dead 
limb.  Sometimes,  however,  they  are  rigid  and  stiff".  Sometimes  one  is  stiff,  and 
the  others  limber.  And  sometimes  one  or  more  of  them,  or  those  of  one  side,  tremble, 
or  are  distinctly  convulsed.  You  find  perhaps  that  the  patient  is  unable  to  swallow. 
If  you  put  fluids  into  his  mouth,  they  appear  to  choke  him,  or  they  run  out  again  at 
the  corners  of  his  lips.  His  bowels  are  usually  torpid  ;  but  if  they  act,  the  evacua 
tions  are  passed  in  the  bed  without  his  knowledge  or  concern.  His  urine  also  flows 
involuntarily ;  or  is  retained  in  the  distended  bladder  until  it  fairly  overflows,  and 
dribbles  away  perpetually. 

When  the  attack  terminates  in  death,  that  event  is  preceded,  I  believe  in  almost 
every  case,  by  profuse  perspiration,  which  bursts  forth  from  every  part  of  the  surface 
and  is  often  cold  and  clammy.  The  pupils  are  sometimes  at  this  period  dilated  :  and 
I  have  more  than  once  seen  them  of  unequal  size.  The  pulse  becomes  more  fre 
quent,  the  breathing  more  rare,  and  at  last  it  ceases  altogether. 

In  this  description  you  will  perceive  that  something  more  is  included  than  pure 
coma.  The  absence  of  consciousness — implying  the  suspension  of  thought,  of  sen- 
sation, and  of  volition — marks  plainly  the  afl^ection  of  the  cerebrum.  The  symptoms 
which  diversify  the  apoplectic  state,  and  distinguish  one  case  of  the  disease  from 


APOPLEXY.  309 

another,  proceed  from  an  associated  or  consecutive  affection  of  the  spinal  cord. 
There  may,  indeed,  be  merely  coma ;  profound  and  invincible  sopor  only.  In  this 
condition  a  morsel  of  food,  or  a  spoonful  of  drink,  passed  far  back  into  the  pharynx, 
is  instantly  carried  onwards  by  an  act  of  deglutition  :  the  excrements  are  duly 
retained,  and  duly  voided :  the  limbs  are  simply  passive  and  motionless  ;  neither 
stiff,  nor  convulsed.  But  in  the  severe  cases,  inabihty  to  swallow,  laxity  of  the 
sphincters,  spasms,  rigidity,  tremors  of  the  voluntary  muscles  —  more  or  fewer  of 
these  adjuncts  to  the  coma — are  very  apt  to  present  themselves  :  and  they  denote,  I 
say,  the  direct  or  indirect  extension  of  the  morbid  influence  on  which  the  apoplexy 
depends,  to  the  cranio-spinal  axis. 

An  easy  and  interesting  criterion  of  the  degree  in  which  the  reflex  apparatus  may 
be  concerned  has  been  pointed  out  by  Dr.  Hall.  The  orbicularis  is  the  sphincter 
muscle  of  the  eyelid.  Touch  the  eyelashes,  and  the  lids  involuntarily  close  ;  even 
during  sleep  the  movements  of  the  shut  lids  are  apparent.  If,  in  apoplexy,  they  do 
not  respond  to  this  mechanical  stimulus,  we  know  that  the  true  spinal  functions  are 
gravely  implicated. 

On  the  other  hand,  many  of  the  morbid  phenomena  just  mentioned  may  occur, 
without  any  affection,  from  first  to  last,  of  the  intelligence.  But  to  these  forms  of 
disease,  although  the  nature  of  their  exciting  cause  may  be  the  same,  the  term 
apoplexy  cannot  properly  be  apphed. 

This  state,  so  appalling  and  painful  to  look  upon,  but  fortunately  so  devoid  of 
suffering  for  the  patient  —  this  suspension  of  the  functions  of  animal  life  —  depends, 
we  have  reason  to  believe,  upon  pressure  applied  to  the  brain,  the  oi^an  subservient 
to  those  functions. 

That  excess  of  pressure  is  a  vera  causa  is  obvious,  and  that  it  is  adequate  to  the 
production  of  coma  is  capable  of  demonstrative  proof.  It  is  not  enough  to  show  that 
they  often  exist  together,  for  the  coincidence  must  be  casual.  Neither  does  their 
occasional  disjunction,  real  or  apparent,  furnish  any  conclusive  argument  against  the 
general  proposition,  that  coma,  in  many  and  in  most  cases,  is  the  result  of  pressure 
upon  the  encephalon. 

Coma  may  exist  without  pressure.  In  other  words,  coma  acknowledges  other 
causes  also,  besides  pressure.  It  is  produced  by  many  narcotic  poisons ;  by  the  cir- 
culation of  venous  blood  through  the  arteries.  In  these  cases  we  have  no  proof  of 
any  compression  of  the  cerebral  substance. 

The  other  disjunctive  condition  is  much  more  puzzling,  and  has  led  some  persons 
to  question  or  deny  the  general  proposition.  Can  there  be  unnatural  pressure,  yet 
no  coma?  It  would  seem  so.  Serum,'pus,  blood,  have  been  met  with  in  the  brain, 
foreign  matters  have  penetrated  the  cranium,  and  coma  has  not  occurred. 

The  force  of  this  difficulty  is  lessened  by  the  consideration  that  foreign  substances 
may  be  present  within  the  skull,  without  occasioning  any  preternatural  degree  of 
pressure.  We  read  of  bullets  being  carried  about  for  some  time  in  the  brain.  In 
such  instances  it  is  probable  that  a  portion  of  the  contents  of  the  skull  was  forced  out 
at  the  time  of  the  injury  ;  or  that  coma  has  come  on,  and  gone  off  again,  in  conse- 
quence of  the  gradual  absorption  of  the  cerebral  matter  to  make  room  for  the  foreign 
body.  The  same  explanation  may  be  applied  to  the  chronic  accumulation  of  water 
within  the  cranium,  and  to  the  slow  growth  of  tumours. 

Further,  it  is  open  to  conjecture  that  it  is  not  on  every  part  of  the  brain  that  the 
same  degree  of  pressure  made  will  produce  the  effect  ascribed  to  it.  It  is  stated  in 
Mr.  Mayo's  Physiology,  as  the  result  of  actual  experiments  on  animals,  that  lateral 
pressure  against  the  hemispheres  of  the  brain  produces  no  observable  ill  conse- 
quence;  but  that  vertical  pressure,  pressure  downwards,  occasions  stupor,  "  which 
is  attributable  to  the  compression  of  the  medulla  oblongata."  Now  it  is  obvious  that 
some  injuries  of  the  brain  may  tend  more  than  others  to  cause  pressure  in  that 
direction. 

I  confess  that  the  difficulty  is  not  wholly  relieved  by  these  considerations.  But  it 
is  a  difficulty  which  cannot  invalidate  the  evidence  of  numerous  facts  that  attest  the 
agency  of  pressure,  as,  at  least,  one  cause  of  coma.  The  presumption  of  such 
agency  arises  whenever  coma  immediately  succeeds  to  pressure  ;  and  it  .3  converted 


310  DISEASES    OF    THE    BRAIN. 

into  certainty  if,  upon  the  removal  of  the  pressure,  the  coma  immediately  departs 
Now  the  annals  of  physic  are  full  of  instances  of  this  kind.  In  experiments  upon 
animals,  stupor  has  been  brought  on,  and  made  to  cease,  at  the  pleasure  of  the  ope- 
rator, by  applying  pressure  to  the  exposed  brain,  and  by  remitting  that  pressure. 
Na)',  the  experiment  has  been  tried  on  the  human  brain  itself.  A  man  wno  had 
undergone  the  operation  of  trepanning,  and  had  recovered,  was  in  the  habit  of  exhibit- 
ing himself  for  money  in  Paris,  where  Haller  saw  him.  He  suffered  the  spectators 
to  make  pressure  upon  his  brain,  where  it  was  covered  b}''  the  integuments  only. 
This  always  put  him  into  a  state  of  coma  or  deep  sleep ;  but  sensibility  and  tiie 
power  of  voluntary  motion  returned  at  once  when  the  pressure  was  taken  off. 

A  most  remarkable  example  of  the  occurrence  of  coma  from  pressure  upon  the 
brain,  and  of  the  removal  of  the  coma  by  removing  the  pressure,  was  afforded  by  a 
patient  who  was  in  St.  Thomas's  Hospital  under  the  care  of  Mr.  Cline.  Mr.  Green, 
who  Avas  Mr.  Chne's  nephew,  was  in  the  habit  of  relating  the  case  in  his  lectures 
here.  It  is  quite  pertinent  to  my  present  purpose.  One  of  Mr.  Cline's  apprentices 
was  visiting  the  depot  at  Deptford,  and  discovered  there  a  man  who  had  been  for 
some  time  in  a  state  of  unconsciousness :  and  he  had  him  removed  to  St.  Thomas's. 
His  main  symptoms  were  apparent  insensibility  to  all  surrounding  objects,  and  a 
total  incapacity  to  make  any  communication  to  those  about  him ;  except  that  his 
attendants  learned  to  infer,  from  certain  instinctive  movements  or  gestures,  that  he 
felt  hunger,  or  thirst,  or  a  want  to  reUeve  his  bowels.  His  fingers  were  permanently 
bent  towards  the  palm  of  the  hand,  and  his  eyes  were  turned  upwards,  so  that  the 
corneas  were  completely  concealed  beneath  the  upper  lids. 

Upon  examining  this  man's  head,  Mr.  Cline  found  that  there  had  been  fracture 
with  depressure  of  one  of  the  parietal  bones.  He  trepanned  that  part,  and  elevated 
the  bone.  The  patient  seemed  to  feel  the  operation  ;  and  as  soon  as  it  was  con- 
cluded, his  eyes  and  fingers  were  restored  to  their  natural  position.  On  the  evening 
of  the  same  da\%  he  sat  up  in  bed,  and  though  at  first  stupid  and  incoherent,  soon 
became  rational  and  well. 

When  he  had  entirely  recovered  his  senses,  it  was  ascertained  that  the  last  thing 
he  remembered  was  his  serving  on  board  a  vessel  which  made  a  capture  off  Minorca. 
He  was  wounded  in  the  engagement,  -and  carried  afterwards  to  the  hospital  at  Gib- 
raltar. All  this  happened  upwards  of  twelve  months  before  the  operation.  So  that 
one  whole  year  of  this  patient's  life  was  a  complete  blank,  because  during  that 
period,  a  httle  piece  of  bone  was  pressing  upon  his  brain. 

Cases  of  this  kind  show  very  convincingly,  the  connection  that  subsists  between 
pressure  on  the  brain  and  coma,  and  their  relation  to  each  other  as  cause  and  effect. 
The  pressure  and  the  coma  begin  together ;  the  coma  continues  as  long  as  the  pres- 
sure continues ;  and  it  ceases  when  the  pressure  is  removed.  The  old  definition  of 
the  cause  of  a  morbid  condition  is  completely  satisfied :  "  Prtesens  morbum  facit, 
mutata  mutat,  sublata  toUit." 

From  this  digression — not  altogether  foreign  to  our  subject — I  return  to  the  consi- 
deration of  the  pathology  of  apoplexy. 

If  the  patient  recovers  from  the  coma,  he  may  live  a  few  hours,  or  days,  or  he 
may  live  for  many  years.  Sometimes,  as  the  coma  departs,  all  the  natural  functions 
are  gradually  restored  ;  but  much  more  commonly  paralysis  remains.  You  already 
know  that  it  is  apt  to  affect  one  moiety  of  the  body  only.  If  a  line  be  drawn  from 
the  vertex  to  the  perineum,  dividing  the  body  into  two  halves,  which,  as  far  as  the 
exterior  is  concerned,  are  symmetrical,  all  the  voluntary  muscles  that  lie  on  one  side 
will  be  found  powerless ;  or  if  they  are  not  all  so,  those  which  are  palsied  are 
situated  on  the  same  side  of  the  line.  And  this  state  of  things  is  called  hcmipl(2;ia. 
Paraplegia,  that  condition  in  which  all  the  parts  below  a  tranverse  line  are  palsied, 
though  it  sometimes  results  from  cerebral  disease,  is  much  more  commonly  the  con- 
sequence of  mischief  in  the  spine. 

Now,  of  this  hemiplegia,  when  it  is  complete,  there  are  several  particulars  worthy 
of  your  notice  ;  and  there  are  many  things  worthy  of  your  notice  when  it  is  incom- 
plete. But  we  will  take  one  of  these  predicaments  at  a  time.  By  complete  hemi- 
plegia, I  mean  palsy  of  all  the  voluntary  muscles  of  one  side.     The  patient  may 


APOPLEXY.  Sii 

ivill  the  motion  of  his  leg,  or  arm,  but  they  no  longer  obey  the  act  of  volition ;  if 
they  are  lifted  by  anotlier,  and  then  let  go,  they  drop  down  like  logs  of  wood.  You 
will  find  that,  in  well-marked  cases,  the  intercostal  muscles  of  the  palsied  side  do 
not  contract.  The  muscles  of  the  face,  also,  are  some  of  them  inert  on  the  same 
side.  I  have  known  many  persons  who  have  thought  that  the  muscles  of  the  face, 
in  hemiplegia,  when  they  were  affected  at  all,  were  affected  on  the  opposite  side  of 
the  body  from  that  to  which  the  palsied  limbs  belonged.  But  they  never  could  have 
examined  actual  cases  of  hemiplegia  with  any  attention.  How  the  error  arose  I 
cannot  tell,  but  I  have  known  a  professed  anatomist  make  it.  I  guess  that  it  may 
have  arisen  from  one  of  two  causes.  An  anatomist  who  had  not  looked  closely  upon 
disease,  would  expect,  and  not  unnaturally,  that  the  face  and  limbs  v/ould  be  affected 
on  opposite  sides  of  the  body,  seeing  that  the  nerves  w'hich  supply  the  muscles  of 
the  face  are  given  off  above  the  place  where  those  fasciculi  of  nervous  matter  which 
are  called  the  anterior  pyramids,  decussate  each  other.  And  a  common  observer, 
who  was  not  an  anatomist,  would  be  apt  to  conclude  that  the  side  towards  which  the 
mouth  was  drawn  was  the  affected  side :  whereas  it  is  just  the  reverse.  The  face  is 
drawn  to  the  healthy  side,  because  the  muscles  on  that  side  are  no  longer  counter- 
acted and  balanced  by  the  corresponding  muscles  of  the  palsied  side.  The  blank 
half  of  the  face  is  that  wliich  answers  to  the  paralyzed  limbs.  On  that  side  the 
patient  cannot  frown,  or  smile.  He  presents  a  singular  spectacle,  which  I  do  not 
dwell  upon  now,  because  I  shall  return  to  it  again  when  I  have  to  speak  of  certain 
important  varieties  of  local  palsy.  What  I  wish  you  to  bear  in  mind  at  present  is, 
that  when  the  muscles  of  the  face  are  affected  in  hemiplegia,  the  ride  is  that  they 
are  palsied  on  the  same  side  with  the  limbs.  But  there  is  no  rule,  they  say,  without 
an  exception :  certainl}'-  the  exceptions  to  this  rule  are  very  uncommon.  I  have  not 
had  leisure  to  look  over  the  records  of  the  very  many  cases  of  this  disease  which  my 
position  as  physician  to  an  hospital  has  brought  under  my  observation  ;  but  I  do  not 
recollect  more  than  two  exceptions  :  and  one  of  them,  as  it  happens,  is  now  exhibited  ' 
in  the  person  of  one  of  my  patients  in  the  Middlesex  Hospital.  Some  of  you  have 
seen  the  woman.  It  is  a  well-marked  exception  :  but  in  this  instance  the  hemiplegia 
followed  a  blow  on  the  head,  and  I  suspect  that  a  double  injury  was  inflicted  ;  that 
the  palsy  of  the  face  results  from  mischief  on  one  side  of  the  brain,  and  the  palsy  of 
the  limbs  from  mischief  on  the  other.  This  I  only  conjecture  ;  because  the  pheno- 
menon is  so  rare.* 

Then,  again,  with  respect  to  the  tongue:  when  put  out  beyond  the  lips,  its  point 
is  commonly  turned  to  one  side.  To  which  side  ?  Why  toivards  the  palsied  side. 
For  what  reason?  Clearly  because  the  muscles  that  protrude  the  tongue  are  power- 
less on  that  side,  and  in  full  vigour  on  the  other.  That  half  of  the  tongue  which 
corresponds  with  the  sound  side  is  pushed  further  out  than  the  other  half,  and  there- 
fore the  tongue  bends  to  the  palsied  side.  Such  is  the  usual  fact,  and  such  the  ex- 
planation of  it.  But  there  are  more  numerous  exceptions  to  this  than  to  the  paralysis 
of  the  external  facial  muscles.  Sometimes  the  tongue  comes  out  straight ;  some- 
times the  patient  cannot  protrude  it  at  all;  and  sometimes,  even,  it  deviates  towards 
the  sound  side.     But  the  rule  is  as  I  have  stated  it. 

This  also  has  been  noticed  of  the  tongue  in  such  cases ;  that  the  patient  has  been 
able,  after  some  effort,  to  thrust  it  suddenly  out,  and  then  has  required  a  certain 
interval  of  time  before  he  could  do  so  again  ;  as  if  the  spent  nervous  power  was 
slowly  regenerated.  With  these  different  affections  of  the  tongue,  the  patient's 
speech  is  variously  altered.  His  voice  is  thick,  muttering,  inarticulate,  or  unintelli- 
gible. Sometimes,  even  though  he  may  be  quite  conscious  and  rational,  he  is  unable 
to  utter  a  syllable  ;  and  seems  vexed  at  finding  that  his  attempts  to  speak  are  fruitless. 

Supposing  the  patient  to  recover,  wholly  or  partially,  from  the  paralysis,  it  is  th'.' 
leg,  in  nine  cases  out  of  ten,  ay,  and  in  a  much  larger  proportion  than  that,  whicii 
recovers  first  and  fastest:  sooner  and  quicker  than  the  arm,  I  mean.  And  another 
fact,  quite  analogous  to  this,  is,  that  when  one  of  the  extremities  alone  's  affected 


*  Tills  patient  died  afterwards,  at  lier  own  home  ;  and  no  opportunity  was  given  o:  i.i 
specting  the  body. 


312  DISEASES    OF    THE    BRAIN. 

\vith  paralysis,  it  is,  in  nineteen  cases  out  of  twenty,  the  arm  that  is  so  affected.  I 
give  you  again  the  rules  ;  they  are  Hable  to  occasional  exceptions.  The  reasons  that 
have  been  assigned  in  explanation  of  this  curious  circumstance  I  shall  lay  before  you 
by-and-by ;  after  I  have  had  an  opportunity  of  describing  the  morbid  appearances 
discovered  v^-iihin  the  cranium  in  these  cases. 

This,  then,  is  one  way  in  which  the  hemiplegia  may  become,  or  be  from  the  first, 
incomplete :  viz.,  in  extent.  One  limb  may  be  powerless  and  the  other  strono-. 
But  the  palsy  may  also  be  incomplete  in  degree.  The  patient  maybe  able  to  move 
and  use  his  limbs,  but  they  are  feeble.  He  cannot  bend  hi?  fist  firmly ;  nor  lift  his 
arm  beyond  a  certain  height.  Or  his  leg  feels  heavy  to  him,  and  trails  a  little  behind 
as  he  walks :  he  is  unable  to  stand  upon  that  limb ;  or  to  plant  his  foot  securely,  or 
with  the  usual  precision.  In  short,  there  are  innumerable  gradations  of  paralysis, 
from  slight  weakness  of  the  affected  muscles  to  perfect  immobility. 

Besides  the  palsy,  there  is  often  anxstliesia  also.  But  this  is  by  no  means  so  con- 
stant a  symptom  as  the  paralysis.  The  function  of  sensation  (wherefore  I  cannot 
tell)  is  less  frequently  abolished  or  perverted  than  the  function  of  voluntary  motion. 
When  the  sensibility  is  lost,  or  blunted,  or  any  how  modified,  it  is  so,  commonly,  in 
the  same  parts  that  are  affected  with  paralysis.  But  sometimes  there  is  anaesthesia, 
and  no  palsy ;  and,  more  strange  still,  there  has  been  sometimes  anaesthesia  of  one 
side,  and  palsy  of  the  other.  As  a  general  rule,  the  aneesthesia  is  less  common,  and 
less  intense  than  the  palsy ;  and  is  much  sooner  recovered  from. 

The  mental  faculties  are,  in  some  few  instances,  quite  unhurt  by  the  attack :  too 
frequently,  however,  they  suffer  irreparable  damage.  Of  many  persons,  a  striking 
alteration  is  evident  in  the  whole  character  and  temper.  The  brave  man  has  become 
timid  ;  the  prudent  man  foolish  ;  the  calm  and  cheerful  man  peevish  and  impatient. 
There  is  no  longer  the  same  power  of  attention,  the  same  capacity  for  business,  the 
same  clearness  and  comprehension  of  thought.  And  whatever  other  changes  may 
be  observable,  there  are  two  ways,  especially,  in  which  the  patient,  after  he  has 
emerged  from  the  coma,  is  very  apt  to  be  affected :  viz.,  by  a  defection  of  memorj^ 
more  or  less  partial ;  and  by  a  peculiar  tendency  to  emotion,  particularly  the  emo- 
tion of  grief :  he  will  weep  for  very  slight  causes,  sometimes  long  after  the  attack  of 
apoplexy  has  passed  over.  This  is  very  curious.  I  should  have  stated  before  that 
the  same  readiness  to  shed  tears,  and  to  be  immoderately  affected  by  trifling  causes 
of  emotion,  is  sometimes  noticed  among  the  precursory  symptoms  of  apoplexy. 

Tracing  these  cases  onwards  still  further — such  cases,  I  mean,  as  do  not  perfectly 
recover — we  find  that  the  palsied  limb  wastes.  Inaction  of  the  muscles,  according 
to  the  principle  which  I  explained  to  you  in  a  very  early  part  of  these  lectures,  leads 
to  lessened  nutrition,  and  a  consequent  diminution  of  bulk  :  in  one  word,  to  atrophy. 
Sometimes,  indeed,  the  size  of  the  helpless  limb  is  maintainetl,  or  even  augmented, 
by  ihe  supervention  of  oedema.  The  motion  of  the  blood  in  its  veins  not  being  aided 
by  the  play  of  its  muscles,  the  areolar  tissue  becomes  infiltered  with  serous  liquid. 

Again,  these  palsied  limbs  are  usually  colder  than  their  fellows.  This  probably 
is  owing  to  the  diminished  circulation  of  blood  through  the  capillaries  :  there  is  not 
so  much  blood  converted  into  venous  from  arterial ;  and  less  animal  heat  is  deve- 
loped. This  has  been  observed  even  when  the  main  artery  of  the  part  has  beat  as 
forcibly  as  in  the  corresponding  part  on  the  other  side. 

It  is  necessary  to  be  aware  that  these  palsied  parts  do  not  resist  the  influence  of 
cold  or  of  heat  so  well  as  the  sound  parts.  When  the  sensibility  is  blunted,  we  can 
readily  understand  how  the  limb  may  become  burned,  from  the  absence  of  any  warn- 
ing pain  that  an  injurious  degree  of  heat  is  applied  :  but  this  is  not  all,  A  lower 
degree  of  temperature  thay  would  injure  a  sound  part  has  often  been  found  prejudi- 
cial to  a  palsied  part :  and  if  these  palsied  parts  get  chilled  by  frost,  they  more 
readily  vesicate  and  inflame,  on  the  return  of  heat,  than  other  parts :  merely  warm 
vvater  will  sometimes  act  upon  them  like  scahlvig  water.  I  say  a  knowledge  of 
I  his  fact  is  of  practical  moment.  That  degree  of  warmth  which  the  palsied  limb 
fails  to  generate  for  itself,  we  must  accumulate  for  it  by  warm  clothing:  and  we 
Miust  tike  care  that  it  is  never  exposed  to  any  artificial  temperature  which  exceeds  a 


APOPLEXY.  313 

certain  point.     We  sometimes  see  mischief  done  by  applying  hot  bottles  or  bricks — ■ 
too  hot — to  such  limbs. 

In  speaking  of  the  palsy,  I  have  dwelt  especially  on  the  loss  of  action  and  power 
observed  in  the  voluntary  muscles  ;  but  the  strictly  involuntary  muscles  do  not  alto- 
gether or  always  escape.  The  pulse,  as  I  have  stated,  will  often  become  slow  or 
irregular  in  the  apoplectic  attack :  and  the  bowels  are  usually  very  obstinately  cos- 
tive ;  their  peristaltic  motion,  which  results  from  the  contraction  of  involuntary  mus- 
cles, is  suspended  or  diminished.  Now  the  old  writers  on  apoplexy  puzzled  them- 
selves with  devising  explanations  of  the  fact  that  the  involuntary  muscles  are  so  little 
affected  in  this  disease.  But  the  true  reason  is  not  far  to  seek.  The  involuntary 
muscles  —  so  called  because  they  never  acknowledge  the  mandates  of  the  will — ■ 
appertain  to  the  functions  of  organic  Hfe.  Their  movements  (as  I  have  heretofore 
had  occasion  to  show  you)  are  not  necessarily  dependent  upon  any  influence  derived 
from  the  nervous  centres;  and  might  continue,  provided  a  due  supply  of  arterial' 
blood  were  kept  up,  though  there  was  no  brain  at  all.  Foetuses  having  no  brain, 
ray,  some  unfurnished  with  either  brain  or  spinal  marrow,  have  nevertheless  grown, 
in  other  respects,  to  their  full  size.  It  is  well  known  that  the  action  of  the  heart 
may  go  on  for  some  time,  even  after  its  removal  from  the  body. 

In  truth  it  seems,  at  first  sight,  more  difficult  to  explain  why  the  organs  of  invo- 
luntary motion  are  sometimes  affected,  in  apoplectic  and  paralytic  diseases,  than 
why,  in  general,  they  are  not.  But  some  elucidation  of  this  matter  I  have  also 
attempted  to  give  in  a  former  part  of  the  course.  The  organs  of  involuntary  motion, 
though  not  dependent  upon  the  brain  and  nervous  system,  are  yet  liable  to  be  influ- 
enced through  their  medium  ;  as  we  know  by  the  effect  produced  upon  those  organs 
by  certain  emotions  of  mind.  Dr.  Wilson  Philip  has  shown  clearly,  by  his  experi- 
ments, that  the  way  to  afiect  the  action  of  the  heart,  and  of  the  other  involuntary 
muscles,  through  the  brain  and  nervous  system,  is  to  act  upon  a  large  portion  of 
that  system  at  once.  Hence  any  disease  which  inflicts  extensive  damage  upon  the 
encephalon  Avill  be  likely  to  disturb  and  weaken  the  functions  of  the  heart  and  ali- 
mentary canal. 

Conversely,  when  we  find,  in  a  case  of  apoplexy,  the  involuntary  muscles  sensi- 
bly affected,  we  may  infer,  I  believe,  that  the  injury  done  to  the  nervous  matter  is 
great  and  serious. 

Let  us  next,  with  the  view  of  further  elucidating  the  pathology  of  this  disease, 
direct  our  attention  to  the  appearances  which  are  met  with  after  death,  in  the  most 
common  forms  of  the  complaint. 

I  shall  pass  over  those  cases  in  which  no  morbid  condition  is  detected,  simply 
reminding  you  that  the  altered  relation  of  the  venous  to  the  arterial  circulation  in  the 
brain  may  perhaps  account  for  the  symptoms,  and  for  the  extinction  of  life  :  or  the 
altered  velocity  of  the  blood  circulating  in  the  brain  may  account  for  them  :  or,  what 
is  more  probable  still,  a  determination  of  blood  towards  the  head,  or  a  detention  of 
blood  in  the  head,  sufficient,  by  tightening  the  full  vessels,  to  occasion  extraordinary 
pressure  upon  the  nervous  pulp,  may  account  for  them :  or  the  presence  of  some 
poisonous  substance  in  the  circulating  blood  (such  as  urea)  may  account  for  them. 

I  pass  over,  likewise,  those  cases  in  which  serum  only  is  found  effused  beneath 
the  arachnoid,  or  into  the  ventricles.  A  moderate  quantity  of  serous  fluid  poured 
out  rapidly  during  life  would  certainly  occasion  a  degree  of  pressure  adequate  to  the 
production  of  fatal  coma.  How  the  serum  comes  to  be  so  effused,  it  is  not  always 
easy  to  say.  Yet  there  is  one  condition  of  the  blood-vessels  of  the  brain  which, 
when  it  can  be  proved  to  exist  in  a  given  case,  is  sufficient  to  account  for  the  effu- 
sion. Any  real  or  virtual  retardation  of  the  blood  in  the  cerebral  veins  would  lead 
to  what  is  tantamount  to  dropsy,  there,  as  well  as  in  any  other  part  of  the  body ; 
and  intelligible  causes  of  such  retardation  are  known  sometimes  to  be  .n  operation. 

But  I  wish  to  consider  more  particularly  the  appearances  that  are  met  with  in 
the  brain  after  death  by  cerebral  hemorrhage^  which,  after  all,  is  the  most  conunon 
source  of  apoplectic  and  paralytic  disorders. 

Tn  the  first  place  (as  I  have  more  than  once  stated  before)  the  popular  notion  that 
hemorrhage  is  owing  to  the  giving  way  of  a  considerable  blood-vessel — although  this 

2  b 


314  DISEASES    OF    THE    BRAIN. 


n 


notion  seldom  has  reference  to  the  brain,  because  the  blood  cannot  reach  the  ex- 
ternal surface  of  the  body,  and  therefore  does  not  strike  the  popular  sense— 
I  say  this  notion  is  more  true  of  cerebral  than  of  any  other  hemorrhage.  Much 
more  true,  especially  as  regards  the  brain  than  as  regards  the  lungs,  to  which 
latter  organ  the  bursting  of  a  blood-vessel  is,  in  vulgar  parlance,  most  commonly 
ascribed. 

This  comparative  frequency  of  hemorrhage  from  the  actual  rupture  of  vessels 
may,  in  some  measure,  be  accounted  for  by  their  peculiarities  of  texture  and  re- 
lation. The  blood-vessels  distributed  ■within  the  cranium  are  long  and  slender. 
Excepting  the  sinuses,  the  coats  of  both  arteries  and  veins  are  thinner  and  weaker 
than  in  other  parts  of  the  body :  the  middle  tunic  of  the  arteries  has  not  more 
than  one-half  its  ordinar}^  thickness ;  and  the  outer  or  cellular  coat  is  of  such  ex- 
treme tenuity  that  doubts  have  been  entertained  concerning  its  existence.  These 
vessels,  moreover,  are  not  protected,  as  elsewhere,  by  investing  sheaths  of  cellular 
membrane,  and  rsceive  but  slight  support  from  the  soft  and  delicate  substance  by 
which  they  are  immediately  surrounded.  They  are  hkewise  very  subject  to  a  par- 
ticular form  of  disease,  by  which  their  natural  fragihty  is  much  increased  :  and  lying 
near  to  the  heart,  and  in  the  primary  direction  of  the  blood  as  it  is  driven  from  the 
left  ventricle,  they  have  been  thought  especially  liable  to  sustain  the  additional  mo- 
mentum arising  from  the  more  forcible  contractions  of  that  chamber;  whether  these 
are  determined  by  occasional  transient  causes,  or  depend  upon  permanent  organic 
disease  of  the  heart  itself.  On  this  point,  however,  I  shall  have  something  more  to 
say  hereafter. 

Still  there  is  no  reason,  I  think,  for  doubting,  that  hemorrhage  by  exhalalion 
may  take  place,  though  rarely,  from  the  free  surface  of  the  brain,  or  rather  of  its 
investing  membranes.  But  the  rule  is,  that  it  proceeds  from  the  mechanical  rupture 
of  a  blood-vessel. 

In  cerebral  hemorrhage,  the  blood  may  be  effused  in  one  or  other  of  three  differ- 
ent situations  ;  viz.,  upon  the  external  surface  of  the  brain,  i.  e.,  upon  or  between  the 
membranes  ;  or  into  one  or  more  of  its  ventricles ;  or  into  the  very  substance  of  the 
brain  itself.  In  the  two  former  situations  it  is  sometimes,  perhaps,  poured  out  by 
exhalalion  :  in  the  latter,  which  is  infinitely  the  most  common,  it  always  proceeds 
from  the  rupture  of  one  or  more  blood-vessels. 

It  is  necessary  to  remember  that  even  when  blood  is  found  spread  over  the  surface, 
or  distending  the  ventricles  of  the  brain,  it  frequently  has  not  been  originally  poured 
out  in  those  situations.  If  the  hemorrhage  into  the  substance  of  the  brain  be  con- 
siderable in  amount,  the  blood  generally  forces  a  passage,  by  laceration  of  the  cerebral 
tissue,  either  into  the  ventricles,  or  (less  frequently)  to  the  surface  ;  or  even  in  both 
these  directions  at  once. 

In  some  rare  cases  blood  is  found  effused  beneath  or  into  the  pia  mater,  over  a 
small  space  onlj%  as  between  one  or  two  of  the  convolutions,  and  nowhere  else. 
Sometimes  it  is  spread  in  a  thin  layer  over  the  whole  of  one  hemisphere,  and  is  found 
nowhere  else.  Sometimes  blood  is  discovered  in  one  or  more  of  the  ventricles,  and 
nowhere  else  ;  but  all  these  are  comparatively  unfrequent  events. 

When  the  blood  is  effused  into  the  substance  of  the  brain,  and  does  not  break  a 
passage  out,  either  in  the  one  direction  or  the  other,  its  pressure  is  not  necessarily 
or  immediately  mortal.  The  patient,  as  I  have  already  explained,  may  survive  for 
weeks,  or  months,  or  years ;  and  the  clot  of  blood  will,  in  the  mean  time,  undergo 
very  remarkable  changes. 

The  cell,  or  cavity,  in  which  the  extravasated  blood  is  contained,  varies  much  as 
to  its  fiize.  It  is  sometimes  scarcely  of  sufficient  ca])acity  to  receive  a  large  pea: 
sometimes  it  occupies  nearly  the  whole  of  one  hemisphere.  It  is  seldom,  however, 
1  repeat,  that  a  communication  is  not  formed  between  the  original  cavity  and  the 
surface  in  the  one  direction,  or  the  ventricles  in  the  other,  when  much  blood  has 
been  shed.  Frequently  a  direct  opening  is  made  bj^  the  blood  from  one  lateral 
ventricle  to  the  other  through  the  septum  lucidum  ;  sometimes  it  passes  from  the  one 
to  the  other  through'  the  foramen  of  Monro  ;  and  even  the  chamber  of  the  septum 
lucidum  itself  has  been  found  distended  by  a  certain  quantity  of  blood. 


I 


APOPLEXY.  315 

If  the  clot  of  blood  in  an  isolated  cavity  be  examined  soon  after  its  effusion,  it  is 
found  to  be  of  a  soft  f^elatinous  consistence,  and  of  a  dark  colour,  much  like  blat-k 
currant  jell}'.  The  sides  of  the  cavity  are  irregular  and  ragged  ;  and  the  cerebral 
substance  of  which  they  are  formed  is  generally,  to  the  depth  of  a  line  or  two, 
moist,  soft,  and  as  if  stained  of  a  reddish  or  yellowish  colour,  which  is  fainter  in 
proportion  as  it  is  more  distant  from  the  coagulum,  and  gradually  loses  itself  in  the 
natural  tint  of  the  surrounding  parts.  This  latter  condition  would  seem  to  depend 
upon  a  slow  imbibition  of  the  serous  portion  of  the  effused  blood,  mixed  with  some 
of  its  colouring  matter.  It  begins  to  manifest  itself  about  the  third  day  from  the 
attack,  and  is  most  apparent  from  the  eighth  to  the  twelfth  day ;  at  which  period, 
under  ordinary  circumstances,  the  whole  of  the  serum  has  been  removed,  and  the 
process  of  absorption  seems  to  be  in  active  operation.  By  degrees  this  stain  dis- 
appears ;  the  coagulum  becomes  more  and  more  compact ;  assumes  first  a  brownish, 
and  subsequently  a  pale  red  or  even  yellowish  hue ;  diminishes  continually  in  mag- 
nitude; and  at  length  may  be  entirely  reabsorbed. 

In  the  mean  time  the  walls  of  the  cavity  are  becoming  less  uneven,  and  clothe 
themselves,  by  degrees,  as  they  contract  upon  the  shrinking  coagulum,  with  a  dis- 
tinct membrane  of  a  yellowish  colour,  sometimes  of  extreme  delicacy,  and  resem- 
bling the  serous  membranes ;  sometimes  thick  and  apparently  fibrous.  When  the 
opposite  sides  of  the  cell  at  length  meet,  they  adhere  together,  and  a  true  cicatrix 
ensues,  the  place  of  which  is  marked  by  a  sort  of  fibrous  knot,  forming  a  remark- 
able contrast  with  the  softer  texture  around  it ;  or  less  frequently  by  a  similar  indu- 
ration of  a  linear  form.  In  this  case,  the  sides  of  the  collapsed  cavity  are  sometimes 
found  to  be  merely  applied  to  each  other,  without  actual  adhesion.  When,  from  the 
great  extent  of  the  original  cavity,  or  from  some  other  cause,  its  parietes  are  not 
ultimately  brought  into  mutual  contact,  there  remains  a  kind  o^  cyst,  lined  by  a  smooth 
yellowish  membrane  ;  sometimes  traversed  by  a  few  slender  threads  of  areolar 
tissue  which  cross  each  other  in  various  directions  ;  sometimes  filled  with  a  soft,  fine, 
orange-coloured  spongy  tissue,  in  which  a  number  of  minute  blood-vessels  ramify; 
sometimes  containing  a  gelatinous  or  serous  liquid  ;  and  sometimes  apparenllj'  empty, 
having  been  occupied  by  some  kind  of  aeriform  fluid. 

It  is  impossible  to  assign  the  precise  period  within  which  these  remarkable 
changes  may  be  accomplished.  Dr.  Abercrombie  has  detailed  an  instance  in  which 
a  coagulum,  that  m.ust  have  been  of  very  considerable  size,  had  entirely  disappeared 
in  less  than  five  months.  In  another  of  his  cases  it  was  seen  to  be  partially  absorbed 
at  the  end  of  three  months.  "  On  the  other  hand,  Moulin  found  a  small  coagulum 
not  quite  gone  at  the  end  of  a  year :  and  Riobe  observed  some  of  the  blood  still 
remaining  in  a  cavity  of  small  extent  after  twenty  months.  In  two  cases  Serres 
found  a  hard  coagulum  of  blood  remaining;  in  one  at  the  end  of  two,  and  in  the 
other  at  the  end  of  three  years." 

It  has  been  said  that  the  cicatrization  of  the  cavity  takes  place  much  more  slowly 
and  imperfectly  when  the  effused  blood  has  passed  across  and  torn  the  fibres  of  the 
brain,  than  when  it  has  been  poured  out  in  a  direction  parallel  to  those  fibres,  so  as 
to  separate  without  breaking  them. 

Dr.  Abercrombie  states  that  he  had  never  seen  any  thing  to  satisfy  him  that  the 
cysts  are  capable  of  being  obliterated  by  cicatrization.  iXeilher  have  I.  But  Dr. 
Sims,  Dr.  Bright,  and  several  of  the  French  pathologists  of  approved  credit  and  ac- 
curacy, agree  in  their  description  of  this  obliteration  of  the  cells.  And  you  should 
bear  in  mind  that  a  small  cicatrix  in  the  brain  may  very  easily  escape  notice,  if  not 
expressly  sought  for;  especially  as  the  examination  of  that  organ  is  often  conducted, 
viz.,  by  cutting  away  thick  slices  from  the  hemispheres  in  rapid  succession,  in  order 
to  arrive  as  soon  as  possible  at  the  lateral  ventricles  and  the  base  of  the  brain. 

It  frequently  happens  that  a  patient  has  suffered,  during  life,  several  distinct  attacks 
of  apoplexy  or  of  cerebral  hemorrhage ;  and  that  as  many  cells  are  met  with  after 
death,  exhibiting  respectively  various  stages  of  that  process  of  repair  which  has  jus'l 
been  described. 

These  are  the  changes  that  mostly  take  place  in  the  coagulum,  ana  its  containinjij 
cell,  when  the  hemorrhage  does  not  prove  fatal,  and  the  patient,  recovers  more  or 


316  DISEASES    OF    THE    BRAIN. 

less  completely.  But  the  same  changes  do  not  always,  or  necessarily,  occur.  Instead 
of  being-  gradually  removed  by  absorption,  the  extravasated  blood  appears  occasionally 
to  become  a  solid,  organized,  and  consequently  living  mass,  deriving  its  nourishment 
from  the  arteries  of  the  brain.  A  man,  whose  case  is  related  by  Andral,  was  smitten 
with  apoplexy,  and  remained  thenceforward,  for  many  years,  hemiplegic.  At  lengtli 
he  died,  of  some  other  complaint,  in  the  wards  of  La  Charlie.  When  his  brain  was 
examined,  there  was  found,  in  one  of  the  hemispheres,  a  mass  of  a  pale  red  colour 
and  fibrous  appearance,  traversed  by  numerous  small  blood-vessels  which  anasto- 
mosed with  those  of  the  brain  :  the  surrounding  nervous  matter  retained  its  natural 
aspect ;  and  there  was  no  appearance  of  any  cyst. 

I  have  yet  to  mention  another,  and  a  fatal  consequence  of  hemorrhage  into  the 
substance  of  the  brain.  It  is  not,  I  think,  a  very  frequent  consequence  ;  yet  it  de- 
serves attention  the  more,  because  the  risk  of  its  occurrence  may  perhaps  be  lessened 
by  judicious  treatment  in  the  outset.  The  clot  sometimes  provokes  suppurative 
inflammation  of  the  cerebral  matter  around  it:  or  it  may  be  that  the  nervous  pulp, 
being  bruised  or  torn  bj^  the  first  violent  irruption  of  the  blood,  suppurates  spontane- 
ously afterwards.  It  is  affirmed  (by  what  French  author  I  forget)  that  the  patient 
cannot  be  considered  secure  against  this  consecutive  mischief,  until  eight  days  of 
safety  have  elapsed  from  the  period  of  the  apoplectic  seizure. 

Instances  of  this  result  of  cerebral  hemorrhage,  according  to  my  experience,  are 
not,  I  say,  very  common.  I  have  before  me  some  memoranda  of  the  last  case  of  it 
that  I  saw. 

I  received  on  the  3d  of  September,  a  note,  written  in  a  remarkably  clear  and  neat 
hand,  desiring  that  I  would  call  upon  the  writer,  as  he  had  had  a  severe  attack  of 
apoplexy  a  day  or  two  before. 

I  concluded  that  the  note  had  been  penned  by  some  member  of  the  patient's 
family,  and  I  expected  to  see  him  in  his  bed,  paralytic  probably,  or  manifestly  ill. 
But  I  found  a  stout  active  gentleman,  walking  about  in  his  drawing-room,  apparently 
in  perfect  health,  and  declaring  that  he  felt  so.  He  showed  me,  however,  a  paper 
written  by  a  surgeon,  who  on  the  previous  day  had  brought  him  to  town  from  a  dis- 
tance, and  who  had  been  obliged  to  return  immediately.     The  paper  stated  that 

Mr. had  suffered  a  sudden  and  decided  fit  of  apoplexy  on  the  30th  of  August; 

that  he  was  then  freely  bled ;  that  perfect  consciousness  was  not  restored,  nor  the 
force  of  the  pulse  subdued,  till  twenty  ounces  of  blood  had  issued  from  his  arm; 
and  that  on  the  evening  of  the  same  day  sixteen  ounces  more  were  drawn. 

Mj'^  patient  spoke  of  going  down  to  his  country-house,  where  he  had,  he  said,  "  a 
good  deal  of  shooting  to  do."  I  dissuaded  him  from  this,  and  enjoined  perfect  quiet 
for  at  least  a  fortnight  to  come. 

The  next  day,  after  a  long  and  imprudent  conversation  with  a  friend,  he  suddenly 
lost  the  thread  of  his  discourse,  and  could  not  recover  it.  Then  he  became  confused, 
and  misapplied  words.  I  asked  him  how  he  felt.  He  answered,  "not  quite  right," 
and  this  he  repeated  very  many  times,  abbreviating  it  first  into  "  not  right,"  and  at 
length  into  "  n'ight."  Wishing  to  mention  "  camphor,"  he  called  it  "  pamphlet." 
I  mention  these  as  specimens.  On  the  5th  it  was  evident  that  his  right  arm  and  leg 
were  weak  in  comparison  with  the  others  ;  but  their  sensibility  was  unimpaired.  By 
slow  degrees  the  weakness  degenerated  into  complete  palsy,  and  the  right  side  of 
the  face  became  motionless.  Gradually  also  he  grew  heavy,  stupid,  comatose, 
unable  to  swallow,  with  a  fixed  pupil ;  and  so,  on  the  morning  of  the  15th  of  Sep- 
tember, he  died. 

We  examined  his  head  the  next  day.  On  the  left  side,  the  dura  mater  adhered 
to  the  skull-cap  with  morbid  firmness.  During  the  endeavour  made  to  detach  it,  a 
tablespoonful,  or  more,  of  a  dirtj'-looking,  greenish,  very  offensive  pus  spurted  forth. 
This  was  found  to  have  proceeded  from  an  abscess,  which  must  have  contained 
iwo  ounces  of  pus,  and  which  was  situated  in  the  upper  part  cf  the  left  hemisphere 
of  the  cerebrum.  The  walls  of  the  abscess  looked  as  if  they  \vere  coated  with  a 
'layer  of  yellowish  plaster.  In  the  centre  of  this  cavity  was  a  small,  fibrous,  tough 
mass  o'"  a  dull  red  colour ;  the  coagulura,  doubtless,  of  blood  effused  on  the  30th  of 


APOPLEXY.  317 

August.     In  front  of  the  abscess  the  brain  seemed  natural,  but  its  consistence  waa 
that  of  hquid  custard. 

It  has  long  been  Icnown  that  hemorrhage  does  not  occur  in  all  parts  of  the  sub- 
stance  of  the  brain  inditferently.  Morgagni  had  remarked  the  frequency  of  sanguine 
ous  effusions  in  or  near  the  corpora  striata  and  optic  thalami ;  and  more  extensive 
subsequent  research  has  amply  verified  the  general  correctness  of  his  observation. 
Rochoux,  in  the  treatise  on  apoplexy  which  I  mentioned  before,  published  in  1814, 
has  given  a  tabular  account  of  the  morbid  appearances  observed  by  himself  in  the 
heads  of  41  persons,  dead  after  attacks  of  cerebral  hemorrhage. 

In  so  many  as  24  of  these,  i.  e.,  in  three-fifths  of  the  whole  number,  the  blood 
was  extra vasated  in  the  corpus  striatum  ;  in  two  others  in  the  optic  thalamus  ;  in 
one  it  was  effused  into  the  substance  of  both  the  corpus  striatum  and  the  optic  thala- 
mus of  the  same  side ;  and  in  another,  beneath  the  corpus  striatum :  so  that  alto- 
gether there  were  28  cases  out  of  41,  or  seven-tenths  of  the  whole  number,  in  which 
the  clot  was  confined  to  the  corpora  striata,  optic  thalami,  and  their  immediate  neigh- 
bourhood. In  the  remaining  three-tenths  the  blood  was  found  collected  in  several 
other  parts  of  the  cerebral  mass  ;  five  times  in  the  middle  of  one  of  the  hemispheres ; 
twice  towards  the  posterior  part  of  the  ventricles  ;  twice  in  the  inner  and  anterior, 
and  three  times  in  the  inner  and  posterior  portion  of  the  hemispheres  ;  and  once  in  the 
middle  lobe. 

In  Andral's  Pathological  .Anatomy  you  will  find  a  much  more  extensive  table 
relating  to  the  same  subject,  and  constructed  by  him  from  various  authentic  sources 
It  leads  to  the  same  general  conclusions.  Thus,  among  392  cases  of  hemorrhage 
into  the  nervous  substance,  there  were  202  (or  more  than  one-half)  in  which  the 
blood  was  extravasated  at  once  into  the  corpora  striata,  the  optic  thalami,  and  that 
part  of  the  hemispheres  of  the  brain  which  is  on  a  level  with  those  bodies.  In  61 
cases  (or  about  one-seventh  of  the  whole  number)  it  was  confined  to  the  corpus  stri 
atum.  In  35  (or  one-eleventh  of  the  whole)  it  was  limited  to  the  optic  thalamus; 
making,  in  all,  298  instances  (or  more  than  three-fourths  of  the  whole  number)  in 
which  the  sanguine  effusion  occupied  the  corpora  striata,  optic  thalami,  and  their 
immediate  vicinity. 

The  result  of  my  own  observation  coincides  entirely  with  this,  although  I  cannot, 
at  present,  reduce  it  to  a  numerical  statement. 

From  the  same  table  we  may  infer  also  the  comparative  infrequency  of  hemor- 
rhage into  the  cerebellum.  It  is  mentioned  as  having  occurred  in  21  of  the  92  cases  ; 
or  in  about  1  in  19. 

Dr.  Craigie  states  that  the  parts  which  are  the  seat  of  the  hemorrhage  may  be 
arranged,  in  the  order  of  frequency,  as  follows : — the  corpus  striatum ;  the  optic 
thalamus  ;  the  hemispheres  ;  the  pons  varoUi ;  the  crura  of  the  brain  ;  the  medulla 
oblongata  ;  and  the  cerebellum. 

It  is  natural  to  seek  for  some  physical  explanation  of  the  causes  which  determines 
the  extravasation  of  blood  in  certain  parts  of  the  brain  more  frequently  than  in 
others.  Some  light  may,  perhaps,  be  thrown  upon  this  inquiry,  by  a  consideration 
ot  the  sources  of  hemorrhage,  in  various  forms  of  its  occurrence. 

I  stated  before  that  the  blood  may  sometimes  be  poured  out  by  exhalation,  in 
those  less  frequent  forms  of  cerebral  hemorrhage  to  which  M.  Serres  has  applied  the 
term  meningeal  apoplexy,  and  in  which  the  blood  is  found  distending  the  ventricles, 
or  spread,  like  a  cap,  over  the  surface  of  the  hemispheres,  without  any  laceration  of 
the  cerebral  matter.  This  supposition  rests,  however,  rather  upon  the  analogy  drawn 
from  what  is  known  to  occur  in  other  parts  of  the  body,  than  upon  any  decisive  and 
unequivocal  evidence.  Blood  has  not  unfrequently  been  discovered  in  each  of  these 
situations,  when  the  most  careful  scrutiny  has  failed  to  trace  its  source  to  any  ruptured 
vessel.  Yet  we  cannot  doubt  that  such  rupture  may  have  existed — either  in  some 
one  or  more  of  the  numerous  vessels  of  the  pia  mater,  in  the  one  case,  or  of  the 
plexus  choroides  in  the  other — and  yet  have  escaped  detection  by  the  most  vigilant 
eye.     In  Dr.  Abercrombie's  book  there  are  two  interesting  examples  of  extravasa- 

2b2 


318  DISEASES    OF    THE    BRAIN. 

tion  upon  the  surface  of  the  brain,  without  any  obvious  source  of  the  hemorrhage  ; 
the  one  detailed  by  Dr.  Hunter,  of  Edinburgh,  the  other  by  Dr.  Barlow,  of  Bath. 

That  the  hemorrhage  proceeds  from  rupture  of  some  of  the  vessels  composing  the 
choroid  plexus,  rather  than  from  the  membrane  that  lines  the  inner  surface  of  the 
ventricles,  when  the  effused  blood  is  confined  to  those  cavities,  is  the  more  probable, 
because  the  vessels  have  been  actually  found  broken  (as  in  cases  of  ventricular  he- 
morrhage, described  by  De  Haen  and  Cruveilhier),  and  because  they  are  liable  to 
well-marked  disease  of  a  nature  to  render  them  more  than  usually  fragile.  The 
arteries,  for  example,  which  belong  to  that  plexus,  are  subject  to  a  peculiar  kind  of 
alteration  that  I  shall  presently  mention  as  frequently  pervading  the  whole  arterial 
system  of  the  brain  ;  and  its  veins  are  often  partially  enlarged  and  varicose.  This 
latter  condition  has  sometimes  been  mistaken  for  a  collection  of  small  hydatids. 

But  hemorrhage  into  the  substance  of  the  brain  depends  always  upon  rupture  of 
some  one  or  more  of  its  blood-vessels ;  and  it  is  to  this  fact  of  the  rupture  of  vessels 
ihat  we  must  chiefly  look  for  an  explanation  of  the  peculiar  liability  to  hemorrhage 
of  certain  portions  of  the  brain ;  the  corpora  striata,  namely,  the  optic  thalami,  and 
the  parts  immediately  adjacent  to  these.  The  corpora  striata  are  not  only  of  much 
softer  consistence  than  most  other  parts  of  the  brain,  but  they  are  also  traversed  by 
more  numerous  as  well  as  by  larger  blood-vessels  than  are  other  parts.  These  facts, 
and  the  conclusions  to  which  they  point,  did  not  escape  the  sagacity  of  Morgagni. 
"On  some  occasions  (says  he)  when  I  have  cut  the  corpora  striata  into  pieces  hori- 
zontally, I  remember  to  have  observed  in  the  external  anterior  part  of  each,  a  little 
pit,  as  it  were,  across  which  lay  a  very  conspicuous  blood-vessel.  And  on  other 
occasions,  upon  cutting  obliquely  and  slowly,  1  have  remarked,  in  the  same  situation, 
man)'-  red  lines,  Hke  threads,  which  were  in  fact  blood-vessels  running  parallel  to  one 
another,  and  of  a  larger  size  than  elsewhere."  In  truth,  you  may  often  notice  the 
open  mouths  of  a  cluster  of  such  vessels  that  have  been  divided.  Morgagni  saw  in 
this  anatomical  fact  a  probable  solution  of  the  pathological  fact  that  the  parts  in  ques- 
tion are  the  most  common  seals  of  extravasation.  In  corroboration  of  these  views  it 
is  worth  remarking  that  the  corpora  striata  are  especially  subject  to  laceration  and 
sanguine  effusion,  while  the  surrounding  parts  remain  unhurt,  in  violent  concussions 
of  the  brain.  And  when  injections  are  forced  into  the  cerebral  blood-vessels  in  the 
dead  body,  it  is  in  the  very  same  parts,  the  corpora  striata  above  all  others,  that  a 
sort  of  factitious  hemorrhage  is  produced  by  the  rupture  of  vessels,  and  the  escape 
of  their  contents. 

I  have  mentioned  some  original  peculiarities  of  texture  and  relation,  which  majr  be 
thought  to  predispose  the  blood-vessels  of  the  brain,  more  than  others,  to  laceration. 
But  the  main  predisposing  cause  of  that  event  is,  doubtless,  their  great  liability  to 
disease.  Except  the  commencing  portion  of  the  aorta  itself,  there  are  no  arteries  in 
the  body  so  frequently  found  in  a  morbid  state  as  the  cerebral  arteries.  And  the 
change  to  which  they  are  most  subject  is  that  deposition  between  their  tunics,  some- 
times of  a  substance  resembling  albumen  or  soft  cartilage,  sometimes  of  actual  phos- 
phate of  lime,  to  which  we  commonly  apply  the  term  ossificafion.  This  earthy  or 
cartilaginous  deposit  exists  usually  in  whitish  patches  of  a  roundish  or  oblong  form, 
disposed  at  various  distances  from  each  other:  sometimes  in  a  succession  of  bony 
rings,  with  healthier  portions  of  the  artery  between  them.  One  effect  of  this  morbid 
condition  is  to  diminish  the  bore  of  the  affected  artery,  and  to  make  it  of  unequal 
capacity.  And  as  this  variation  of  calibre  impedes  the  free  passage  of  the  blood,  it 
tends  indirectly  to  increase  the  pressure  of  that  fluid  against  the  sides  of  the  vessel. 
Another  eflect  is  to  deprive  the  coats  of  the  artery  of  their  natural  elasticity,  and  to 
diminish  their  power  of  cohesion ;  and  thus  to  render  them  v/eak  and  frangible,  and 
at  length  unable  to  sustain  the  increased  impulse  of  the  blood.  This  condition  occurs 
in  the  smaller  ramifications  as  well  as  in  the  larger  trunks  of  the  cerebral  arteries. 

'rhere  is  yet  another  occasional  cause  of  hemorrhage.  The  arteries  at  the  base 
ol  the  brain  are  subject  to  aneurism,  and  to  consequent  rupture.  Morgagni  has 
reported  cases  of  aneurism  afl^ecting  the  internal  carotid  and  basilar  arteries.  Serres 
has  described  a  case  of  apoplexy  resulting  from  perforation  of  the  basilar  artery, 
which  was  dilated,  not  far  from  its  superior  bifurcation,  into  an  aneurismal  pouch  as 


APOPLEXY.  319 

big  as  a  hen's  egg.  Dr.  Baillie  records  an  instance  where  both  the  internal  carotids, 
on  the  side  of  the  sella  turcica,  were  distended  into  little  aneurisms,  one  of  the  aneu- 
risms being  about  the  size  of  a  cherry,  the  other  somewhat  smaller:  and  similar 
examples  are  related  by  other  writers.  I  have  seen  two  such  myself;  a  beautiful 
preparation  of  one  of  them  is  preserved  in  the  museum  of  the  College  of  Physicians. 


LECTURE  XXX. 

Apoplexy  continued.    Relations  between  the  Symptoms  and  the  Appearances  found 
in  the  brain  after  death.    Exciting  Causes.    Prognosis.     Treatment. 

I  LEFT  off  in  the  last  lecture,  after  having  described  the  appearances  discoverable 
within  the  head,  at  different  periods  subsequent  to  an  attack  of  cerebral  hemorrhage ; 
and  pointed  out  the  various  sources  of  the  hemorrhage  ;  and  endeavoured  to  explain 
how  it  happens  that  the  blood  so  much  more  commonly  proceeds  from  a  ruptured 
vessel  in  or  near  the  corpus  striatum  and  optic  thalamus,  than  in  any  other  part 
of  the  brain. 

Some  account  of  the  connection  traceable,  in  these  cases,  between  the  physical 
injury  done  to  the  brain  and  the  symptoms,  has  already  been  given  by  anticipation. 
I  proceed  to  touch  upon  certain  points,  relative  to  that  connection,  which  have  not 
yet  been  noticed. 

One  of  the  most  remarkable  circumstances  Avhich  dissection  teaches  us,  when 
there  has  been  partial  palsy,  is,  that  the  palsy  is  on  the  one  side  of  the  body  and 
the  hemorrhage  of  the  brain  on  the  other.  This  is  a  very  general  law.  But  excep- 
tions to  it  are  said  to  have  been  observed.  Morgagni  mentions  such  Dr.  Brigh*' 
has  recorded  a  somewhat  doubtful  case  of  exception.  I  have  never  met  with  any : 
and  I  cannot  help  suspecting  that  in  some  of  those  which  are  said  to  have  occurred, 
mistakes  have  been  made  :  that  either  they  have  been  incorrectly  observed,  or  inac- 
curately described.  You  may  consider  the  rule  as  almost,  if  not  altogether,  universal. 

This  crossing  over  of  the  morbid  effect  of  the  extravasated  blood,  or  of  any  other 
diseased  state,  has  long  been  attributed  to  that  crossing  over  of  nervous  fibres  which 
takes  place  at  the  upper  part  of  the  spinal  cord.  Just  where  the  medulla  oblongata 
and  the  medulla  spinalis  unite,  the  anterior  pyramids  decussate  each  other,  and  send 
their  fibres  mutually  to  the  opposite  side  of  the  body.  All  this  of  course  you  kuow. 
The  right  anterior  pyramid  is  continued  into  the  centre  of  the  left  half  of  the  spinal 
cord ;  and  the  left  anterior  pyramid  into  the  centre  of  the  right  half  of  the  cord. 
Now  supposing,  as  we  have  every  reason  to  suppose,  that  the  nervous  influence, 
whatever  may  be  its  nature,  travels  in  the  course  of  the  fibres  of  the  brain,  we  see 
in  this  decussation  of  the  anterior  pyramids  an  easy  and  pleasing  solution  of  the 
phenomena  in  question.  But  then  comes  this  serious  clifHcully.  How  does  it  happen 
that  the  muscles  of  the  face  and  tongue — which  are  supplied  by  nerves  that  arife 
from  the  nervous  centres  above  the  place  of  decussation — how  does  it  come  to  pass 
that  these  muscles  sustain  the  same  cross  injury,  and  arc  paralyzed  on  the  same  side 
on  which  the  limbs  are  paralyzed  ?  And  again,  how  does  it  happen  (as  it  certainly 
does)  that  hemorrhage  into  the  cerebellum  should  have  a  similar  cross  influence  ? 

These  seeming  anomalies  have  never  been  satisfactorily  explained.  Indeed  I  do 
not  know  that  any  one  has  undertaken  to  explain  them  except  Mr.  Mayo  :  whose 
peculiar  speculations  concerning  hemiplegia — first  promulged,  as  they  were,  in  this 
place  ;  coming,  as  they  do,  from  so  eminent  a  physiologist ;  and  being,  as  I  deem 
them,  in  many  respects,  erroneous ; — demand  here  a  brief  consideration. 

He  takes  some  pains,  in  the  first  place,  to  show  that  the  morbid  influence  is  con\- 
municated  from  one  side  of  the  brain  to  the  limbs  of  the  other  side  of  the  body,  by 
means  of  the  fibres  of  decussation  already  described.  This  point  did  not,  I  thinli. 
require  any  laboured  demonstration;  but  he  has  made  a  happy  use  of  two  facut 
previously  ascertained,  which,  taken  together,  afford  a  very  neat  proof  that  the  t-aat 


320  DISEASES    OF    THE    BRAIN. 

ference  of  the  morbid  influence,  or  privation  of  influence,  from  one  side  to  the  other 
actually  takes  place  in  that  very  part  of  the  nervous  system  where  the  decussatino 
fibres  meet,  'Vhefads  are  stated  by  Dr.  Yelloly,  in  the  Medico-Chirurgical  Wan 
soctions.  Sir  Astley  Cooper  divided  the  right  half  of  the  spinal  cord  of  a  do?,  in 
the  space  between  the  occiput  and  the  atlas;  immediately,  that  is,  after  the  cord  ha? 
emerged  from  the  skull  through  the  foramen  magnum  :  the  result  of  this  division  ol 
the  cord  was  hemiplegia,  paralysis  of  the  limbs,  on  the  same  side  -with  the  injury 
The  bridge  by  which  the  morbid  effect  crosses  over  must  therefore  be  above  thai 
point.  We  have  got  a  limit  on  one  side.  And  a  case  observed  by  Dr.  Yelloly  gives  u? 
a  limit  on  the  other.  He  examined  the  head  of  a  man  who  had  died  hemiplegic  ; 
and  he  found  a  tumour,  as  big  as  a  filbert,  imbedded  in  and  pressing  upon  the  ric^hi 
side  of  the  anmdar  protuberance.  The  palsy  had  existed  on  the  left  side.  The 
bridge  of  communication  must  consequently  lie  below  that  point.  It  must  lie,  there- 
fore, between  the  two  points  now  indicated  ;  i.  e.,  it  must  be  either  in  the  medulla 
oblongata,  or  just  at  the  junction  of  the  medulla  oblongata  with  the  medulla  spinalis. 
Now  in  this  very  interval,  and  here  alone,  a  decussation  of  the  nervous  filaments  is 
tound  to  exist.  There  can  be  no  doubt  that  the  decussating  fibres  form  the  channel 
of  communication. 

Supposing  (what  perhaps  is  questionable)  that  the  prevalent  notion  respecting  the 
uses  of  the  anterior  and  posterior  columns  is  correct,  Mr.  Mayo  next  explains,  more 
clearly  than  I  have  found  it  explained  by  any  previous  writer,  that  the  decussation 
of  the  anterior  pyramids  accounts  both  "for  the  palsy  and  for  the  anaesthesia,  which 
are  apt  to  accompany  cerebral  hemorrhage  into  the  opposite  side  of  the  brain ;  inas- 
much as  the  decussating  fasciculi,  on  plunging  into  the  opposite  column  of  the  spinal 
marrow,  strike  into  its  centre  ;  and  implicate  themselves  nearly  as  much  with  the 
posterior,  as  with  the  anterior,  i.  e.,  nearly  as  much  with  what  is  thought  the  sen- 
tient, as  with  what  is  thought  the  motor  portion  of  the  cord.  The  wonder  seems  to 
be  why  the  numbness  is  not  more  constant ;  why  it  is  infrequent  in  comparison  with 
the  afl^ection  of  the  voluntary  muscles. 

Mr.  Mayo  holds  that  palsy  does  not  result  from  "the  interruption  of  the  ordinary 
supply  of  nervous  stimulation  furnished  by  the  brain  " — for  this  reason,  that  in  living 
animals  the  brain  has  been  gradually  removed,  sliced  away,  yet  sensation,  and  the 
power  of  voluntary  motion,  have  subsisted  ;  and  that  instances  of  acephalous  human 
infants,  which  have  survived  their  birth,  show  the  medulla  oblongata  and  spinal  cord 
to  be  sufficient,  tuithont  the  brain,  for  the  production  of  sensation  and  voluntary 
motion.  He  conjectures,  therefore,  that  the  immediate  cause  of  the  hemiplegia  is 
"  a  depressing  injhience,  or  shock,'"'  (a  withering  inflitence  he  elsewhere  calls  it,) 
"originating  in  the  brain  when  in  certain  states  of  lesion,  and  propagated  from  it  to 
the  medulla  oblongata  and  the  spinal  marrow." 

Now  it  can  scarcely  be  doubted,  at  least  I  cannot  doubt,  that  the  inference  here 
drawn  from  the  movements  observed  in  acephalous  monsters,  and  in  animals  after 
amputation  of  their  brain,  is  a  wrong  inference.  They  are  purely  automatic  move- 
ments, independent  of  sensation  and  of  the  will,  and  derived  from  the  reflex  endow- 
ment of  the  cord :  and  if  this  be  so,  the  main  foundation  of  Mr.  Mayo's  argument 
is  cut  away.  His  prime  error,  which  has  led  him  still  further  astray,  is  that  of  attri- 
buting sensation  and  volition  to  the  spinal  cord.  For  my  own  part,  I  can  form  no 
distinct  conception  of  any  positive  and  persistent  depressing  influence,  except 
pressure.  But  mere  pressure  Mr.  Mayo  repudiates;  asserting  that  in  many  cases 
of  hemiplegia  from  cerebral  disease  there  is  no  pressure.  And  this  maybe  granted: 
although  even  in  cases  of  softening,  such  as  he  refers  to,  the  mere  absence  of  sup- 
port in  some  parts  of  the  brain  might  lead  to  the  subsidence  or  settling  down  of  other 
parts,  so  as  to  cause  pressure  upon  the  medulla  oblongata.  I  took  some  pains,  in 
the  course  of  the  last  lecture,  to  show  you  that  pressure  is  adequate  to  the  produc- 
tion of  coma  and  general  paralysis  ;  and  pressure  on  a  nerve  in  its  course  we  are 
sure  is  capable  of  occasioning  local  paralysis  :  so  that  the  theory  would  not  seem 
ven,'  wild,  which  should  ascribe  the  hemiplegia  resulting  from  cerebral  hemorrhage, 
•»r  cerebral  disease,  to  the  benumbing  influence  of  pressure. 

Now.  if  Mr.  Mayo's  notion,  that  some  "  shock  "  or  "  withenng  influence  "  is  trans- 


APOPLEXY.  321 

mitted  from  the  injured  brain,  could  be  proved  to  be  true ;  or,  on  the  other  hand,  if 
it  could  be  established  that  this  influence  is  no  other  than  the  benumbing  influence 
of  pressure;  either  supposition  would  plausibly  account  for  these  facts,  viz.,  that 
"  in  general  hemiplegia  from  cerebral  lesion,  the  palsy  of  the  leg  is  (commonly)  less 
complete,  and  is  sooner  recovered  from,  than  palsy  of  the  arm,"  and  that  when  one 
of  these  limbs  only  is  aflected,  it  is  (commonly)  the  arm  alone.  The  shock,  or  the 
pressure,  would  be  most  felt  in  proportion  as  the  part  was  nearer  the  origin  of  the 
pressure  ;  and  less  felt  in  propurtion  as  we  receded  from  the  source  of  the  injurious 
influence. 

But,  unfortunately,  I  was  obliged  to  insert  the  word  [commonly)  in  the  statement 
just  made  of  the  facts :  which  word  Mr.  Mayo  does  not  employ.  To  make  either 
his  theory,  or  the  theory  of  pressure,  perfectly  satisfactory,  either  the  arm  alone 
should  be  affected  ;  or  the  aflection  of  the  arm  should  always  accompany  and  be 
more  intense  than,  or  at  any  rale  not  less  intense  than,  the  affection  of  the  leg.  But 
this  is  not  the  case.  Since  Mr.  Mayo's  observations  were  published,  I  have  met 
with  two  or  three  instances  and  pointed  them  out  to  him,  in  which  the  leg  alone,  or 
the  leg  first,  has  been  palsied,  from  cerebral  disease.  And  Andral,  among  seventy- 
five  cases  of  cerebral  hemorrhage  collected  for  another  purpose,  which  1  shall  pre- 
sently advert  to,  met  with  twelve  in  which  the  leg  only  was  affected.  It  is  a  great 
pity  that  these  stubborn  facts  should  thus  cross  and  thwart  what  might  else  be 
esteemed  a  very  pretty  theory. 

I  confess  that,  to  my  mind,  the  phenomena  of  hemiplegia  are  the  most  easily 
accounted  for  by  the  very  hypothesis  which  Mr.  Mayo  rejects,  viz.,  that  the  paralysis 
depends  upon  a  simple  interruption  of  the  nervous  influence,  a  breaking  up,  or  an 
obstruction,  of  the  road  by  which  the  changes  leading  to  sensation  travel  in  the  one 
direction,  and  the  mandates  of  volition  in  the  other.  We  may  easily  conceive  that 
the  conducting  fibres  which  lie  between  the  sensorium  and  the  muscles  of  the  les: 
may  alone  be  torn  across,  or  severed  by  a  process  of  softening,  or  strongly  compressed, 
while  the  residue  of  the  conducting  apparatus  is  entire.  This  notion,  of  some  breach, 
or  other  impediment  in  the  channels  of  communication,  seems  more  consonant  with 
what  we  know  both  of  the  physiology  and  of  the  pathology  of  the  brain,  than  any 
other  that  I  am  acquainted  with. 

I  must  not  omit  to  give  you  Mr.  Mayo's  explanation  of  the  other  and  main 
difficulties  to  which  I  referred — viz.,  that  when  one  side  of  the  cerebrum  is  injured, 
the  muscles  of  the  other  side  of  the  face  are  paralyzed  ;  and  /hat  hemiplegia, 
resulting  from  disease  of  the  cerebellum,  affects  also  the  opposite  side  of  the  body  : 
— and  having  given  you  it,  I  shall  leave  it,  without  further  comment,  to  your  consi- 
deration. 

Mr.  Mayo's  words  are  :  "  Where  the  decussating  fasciculi  of  the  anterior  pyramid 
plunge  into  the  opposite  half  of  the  spinal  marrow,  they  are  implicated,  in  a  wonder- 
ful closeness  of  intermixture,  with  fibres  which,  in  their  upward  course,  bend  towards 
the  places  of  origin  of  the  ninth  and  seventh,  and  of  the  eighth  and  fifth  nerves  of 
the  palsied  side.  May  it  not  be  supposed  that  this  interlacement  may  be  a  sufficient 
means  of  communicating  the  palsying  influence  to  the  ascending  fibres,  which  are 
in  close  relation  to  the  affected  cerebral  nerves  ?" 

Again,  "  How  is  the  fact  to  be  accounted  for,  that  hemiplegia  of  the  opposite  side 
is  produced  by  lesion  of  one  hemisphere  of  the  cerebellum/  I  have  little  doubt  that 
the.  following  explanation  of  the  phenomenon  will  eventually  prove  to  be  correct. 
The  fibres  of  the  anterior  pyramids  pass  through  the  pons  varolii.  The  |x)ns  varolii 
consists  in  great  part  of  filaments  which  issue  from  each  hemisphere  of  the  cerebel- 
lum. These  filaments  may  easily  be  supposed  to  convey  a  depressing:  influence 
from  the  diseased  hemisphere.  But  in  their  course  they  come  immediately  upon 
the  filaments  of  the  anterior  pyramid  of  the  same  side  ;  and  they  are  so  implicated 
widi  the  latter,  with  such  a  singular  closeness  of  reticulation,  and  often  with  so  much 
that  looks  like  an  actual  interchange  of  filament,  that  it  is  far  from  unlikely  that  they 
may  transmit  to  the  descending  fasciculi  of  the  pyramid  a  shock  which  may  ihence 
be  communicated  to  the  same  part  at  which  a  cerebral  lesion  exerts  us  paralyzing 
lorce." 

21 


322  DISEASES    OF    THE   BRAIN. 

I  will  only  say  further  of  this  hypothesis,  that  if  the  explanation  it  furnishes  of  the 
facts  in  question  be  not  the  best  and  most  satisfactory  in  the  world,  it  is  the  best  and 
most  satisfactory  that  we  yet  possess :  and  that,  at  any  rate,  we  may  make  use  of  it 
lo  bind  those  facts  to  our  recollection,  until  some  better  theory  shall  be  devised. 

There  is  one  very  curious  law  asserted,  by  Andral,  in  respect  to  hemorrhage  of 
the  cerebel/tnn.  If  the  blood  is  effused  into  one  side  of  the  cerebellum,  and  nowhert- 
else,  the  palsy  that  ensues  follows,  I  repeat,  the  general  rule ;  it  takes  place  in  the 
Umbs  of  the  opposite  side  of  the  body.  But  supposing  hemorrhage  to  take  place  on 
one  side  of  the  cerebrum,  and  on  the  other  side  of  the  cerebellum,  simultaneously  . 
what  then,  think  you,  happens?  Doubtless  you  would  expect  that  there  should  be 
palsy  on  both  sides  of  the  body.  Hemiplegia  on  the  one  side,  from  the  effusion  into 
the  brain  proper ;  hemiplegia  on  the  other  side,  from  the  effusion  into  the  cerebel- 
lum:  double  hemiplegia;  that  is  to  say,  general  palsy.  But  it  is  not  aiways  so,  in 
fact.  The  cerebral  affection  seems  to  overpower  and  master  that  of  the  cerebellum. 
Whatever  the  explanation  may  be,  the  palsy  has  been  found  to  occur  on  the  side 
opposite  to  the  lesion  in  the  brain  proper ;  and  not  to  occur  on  the  side  opposite  to*  the 
lesion  in  the  little  brain.  This  is  a  very  singular  fact,  of  which  Andral  relates  four 
or  five  examples.  But  1  suspect  ihat  they  will  ultimately  take  their  place  among 
the  "  anomalous"  cases.  As  facts  multiply,  the  law  will,  1  conjecture,  be  found  to 
be  a  different  one. 

The  complex  structure  of  the  brain,  and  the  dissimilar  consequences  that  ensue, 
in  different  cases,  from  its  injury  or  disease,  leads  directl}?^  to  the  belief  not  only  that 
the  organ  subserves  several  distinct  functions,  but  also  that  separate  parts  or  sections 
of  it  hold  peculiar  and  definite  relations  with  other  portions  of  the  body.  Ingenious 
men  have  even  attempted  to  settle  these  points  experimentall^^  By  wounding  or 
removing  various  portions  in  succession  of  the  cerebral  mass  in  living  animals,  and 
comparing  the  resuUs,  they  have  endeavoured  lo  assign  to  each  portion  its  particular 
province  and  function.  But  to  say  nothing  of  the  remarkable  differences  which  exist 
between  the  cerebral  functions  in  man  and  in  the  inferior  animals,  there  is  an  una- 
voidable source  of  fallacy  common  to  all  such  experiments.  We  cannot  reach  the 
particular  spot  in  the  brain  upon  which  the  contrived  injury  is  to  be  inflicted,  with- 
out penetrating  and  hurting  various  other  parts :  and  fronn  these  combined  injuries 
(dangerous,  indeed,  and  often  fatal  in  themselves)  arise  symptoms  which  the  experi- 
menter may  erroneously  conclude  to  be  characteristic  of  the  lesion  originally  in  his 
contemplation. 

Much  more  accurate  and  satisfactory  data  for  the  determination  of  this  interesting 
class  of  questions,  would  seem  to  be  furnished  by  the  spontaneous  operation  of  dis- 
ease, and  especially  of  the  disease  we  are  now  considering.  The  injury  done  to  the 
cerebral  substance  by  the  irruption  of  blood  is  not  less  sudden,  nor  less  mechanical, 
than  in  the  exf)erimen-ts  or  contrived  observations  to  which  I  have  alluded.  It  is 
capable,  also,  in  many  instances,  of  exact  appreciation  in  regard  to  its  extent ;  the 
parts  which  lie  round  the  seat  of  the  effusion  remain  undisturbed  ;  and  above  all, 
the  organ  that  is  the  subject  of  our  observation  is  the  human  brain  itself. 

Attempts  have  accordingly  been  made  to  connect  particular  symptoms  with  the 
disorganization  of  particular  parts  of  the  brain.  These  attempts  can  boast,  as  yet, 
.t  must  be  confessed,  but  little  success.  Very  few,  if  any,  of  the  conclusions  hitherto 
advanced  upon  this  intricate  subject  can  be  relied  on.  Yet  it  is  proper  that  you 
should  be  informed  of  them. 

Because  palsy  of  the  arm  is,  in  general,  more  complete,  and  more  persistent,  than 
palsy  of  the  leg,  it  has  been  maintained  that  the  former,  the  paralysis  of  the  arm,  is 
to  be  ascribed  to  hemorrhage  of  the  corpus  striahmi,  which  seems  to  be  more  com- 
mon than  any  other;  and  upon  similar  grounds  hemorrhage  of  the  optic  thalamus 
has  been  supposed  to  determine  paralj'sis  of  the  kg.  So  much  iiave  these  distinc- 
tions been  confided  in,  that  the  honour  of  having  first  pointed  them  out  has  actually, 
in  France,  been  made  a  subject  of  dispute.  Now  it  is  plain  that  one  example  of 
the  contrary  effect  of  these  particular  lesions,  would  suffice  to  upset  the  whole  theory : 
but  many  such  exceptions  have,  in  fact,  been  noticed.  It  was  with  the  view  of  set- 
nng  this  question  that  Andral  collected  and  collated  the  seventy-five  cases  of  cere- 


APOPLEXY.  323 

bral  hemorrhao^e  to  which  I  lately  referred.  In  each  of  these  seventy -five  cases  the 
clot  of  blood  was  sufficiently  limited  to  allow  of  that  case  being  applied  towards  the 
solution  of  the  controverted  points. 

In  forty  of  the  seventy-five,  both  the  leg  and  the  arm  were  paralyzed  together 
And  where  was  the  place  of  the  hemorrhage  in  these  forty  cases  ?  Why,  in  twenty 
one  of  them  the  corpus  striatum  was  the  only  part  injured  ;  and  in  nineteen  of  them 
the  optic  thalamus  was  the  only  part  injured.  Thus  you  see,  according  to  the  theory 
just  explained,  in  about  one-half  of  the  cases  the  arm  alone  should  have  been  pal- 
sied ;  and  in  about  half,  the  \eg  alone  :  whereas  both  leg  and  arm  were  palsied  in 
them  all. 

Again,  in  twenty-three  of  the  seventy-five  cases  the  palsy  was  confined  to  the  arm. 
Therefore,  according  to  the  theory,  the  injury  should  have  been  confined  to  the  cor- 
pus striatum.  What  was  the  fact  ?  Why,  in  this  class  of  cases  also  there  was  as 
nearly  as  possible  an  equal  sharing  of  the  injury  between  the  two  parts.  In  eleven 
of  the  twenty-three  the  corpus  striatum  alone  suffered ;  in  ten  the  optic  thalamus 
alone  ;  in  two  the  space  between  them. 

Once  more :  there  were,  as  I  stated  before,  twelve  out  of  the  seventy-five  cases  in 
which  the  leg  alone  was  palsied.  Consequently,  in  all  of  these  twelve,  if  the  theory 
Avere  sound,  there  should  have  been  damage  of  the  optic  thalamus  only.  But  in  ten 
of  them  the  mischief  was  confined  to  the  corpus  striatum  ;  in  two  only  to  the  optic 
thalamus. 

Gall  had  conjectured  that  the  faculty  of  speech  was  placed  under  the  governance 
of  the  anterior  lobe  of  the  brain :  and  Bouillaud  has  endeavoured  to  support  that 
opinion  by  a  number  of  facts  observed  in  connection  with  cerebral  hemorrhage  ;  but 
Cruveilhier  has  brought  forward  several  curious  instances  in  which  the  loss  of  speech 
was  a  prominent  symptom,  while  the  disease  was  not  found  in  the  anterior  lobe,  but 
in  some  other  part  of  the  brain. 

Andral,  with  his  accustomed  industry,  has  accumulated  evidence  upon  this  point 
also. 

In  thirty-seven  cases  of  cerebral  hemorrhage  observed  by  himself,  or  by  others, 
in  which  the  morbid  condition  occupied  one  or  both  of  the  anterior  lobes,  the  power 
of  speech  was  abolished  twenty-one  times,  and  unaffected  sixteen  times. 

On  the  other  hand,  he  has  collected  fourteen  cases,  in  which  the  power  of  speech 
was  lost,  yet  no  alteration  had  taken  place  in  the  anterior  lobes.  In  seven  of  these 
fourteen  cases  the  lesion  was  situated  in  the  middle  lobes ;  and  in  the  other  seven  in 
the  posterior  lobes  of  the  brain. 

There  can  be  no  doubt  that  there  are  certain  distinct  parts  of  the  brain  which  in 
fluence  respectively  the  upper  and  lower  Hmbs ;  inasmuch  as  they  are  often  sepa 
rately  palsied :  and  since  the  loss  of  speech  is  occasionally  the  only,  or  the  most 
prominent  symptom,  while  in  other  cases  the  speech  is  not  affected  at  all,  we  cannot 
but  believe  that  this  faculty  is  under  the  special  guidance  of  some  definite  part 
within  the  cranium.  But  the  facts  that  I  have  just  been  quoting,  show,  in  the  most 
convincing  manner,  that  we  are  not  able,  as  yet,  to  allot  these  separate  functions  to 
their  proper  spots  in  the  cerebral  mass. 

I  dwelt  some  little  time,  in  a  previous  lecture,  upon  the  circumstances  that  give 
ivarning  to  the  patient,  or  to  his  physician,  that  the  former  is  in  danger  of  being 
smitten  with  apoplexy.  The  great  use  of  being  acquainted  with  these  circum- 
stances,  and  of  looking  out  for  them,  consists  in  the  opportunity  and  the  authonhj 
which  they  furnish,  for  enforcing,  upon  the  person  in  whom  they  manifest  them- 
selves, the  absolute  necessity  of  avoiding  all  the  avoidable  exciting  causes  of  the 
disease.  But  our  means  of  advising  him  will  be  very  imperfect  if  we  have  not 
carefully  considered  what  these  exciting  causes  are.  I  propose  to  devote  n  few 
mmutes,  therefore,  to  the  consideration  of  the  circumstances  that  are  apt  to  bring  on 
the  attack.  There  are  many  cases  of  apoplexy  in  which  we  cannot  trace  the  ope- 
ration of  any  such  causes :  but  in  many  other  cases  their  influence  is  decidedly 
marked  ;  and  the  avoidance  of  them,  while  it  is  important  to  all  who  show  a  dispo- 


324  DISEASES    OF    THE    BRAIN. 

sition  to  apoplectic  disease,  is  especially  so  to  those  who,  having  once  suffered  an 
attack,  have  reason  to  dread  a  repetition  of  it. 

In  the  first  place,  any  thing  which  is  calculated  to  hurry  the  circulation,  and  to 
increase  the  force  of  the  heart's  action,  is  likely  to  operate  as  an  exciting  cause  of 
apoplexy :  simply  by  augmenting  the  momentum  of  the  blood  against  the  sides  of 
the  cerebral  vessels,  which  in  advanced  life  are  so  often  diseased  and  weak 
Strong  bodily  exercise,  therefore,  is  a  thing  to  be  avoided  by  all  persons  in  whom 
the  predisposition  to  apoplexy  has  declared  itself.  It  is  of  much  importance  to  make 
patients  aware  of  this ;  for  many  persons  think,  when  they  labour  under  uncom- 
fortable bodily  feelings  of  any  kind,  they  may  get  rid  of  them  by  a  brisk  walk ;  or 
by  galloping  some  miles  over  the  country  on  horseback. 

Another  dangerous  state  for  such  persons  arises  whenever  the  free  escape  of  the 
blood  from  the  head  is  suddenly  obstructed.  I  have  adverted  to  this  before. 
Certain  diseases,  chiefly  thoracic,  which  tend  to  keep  the  veins  of  the  head  inordi- 
nately full,  rank  among  the  predisposing  causes  of  apoplexy.  But,  upon  the  very 
same  principle,  various  conditions,  which  are  temporary  only,  may  operate  as  ex- 
citing  causes.  By  what  is  called  "  holding  the  breath,"  whether  upon  an  inspi- 
ration or  expiration,  the  transit  of  the  blood  through  the  lungs  is  impeded :  and  the 
check  is  felt  (through  the  pulmonary  artery,  right  chambers  of  the  heart,  and  great 
veins)  in  the  vessels  of  the  head.  And  this  effect  is  increased  when  straining  is  at 
the  same  time  performed  ;  that  is,  when  a  deep  breath  is  taken  and  retained,  while 
some  muscular  forcing  effort  is  made. 

Under  this  principle  fall  a  number  of  bodily  acts,  which,  however  harmless  in  a 
healthy  frame,  are  not  without  peril  to  a  person  having  a  predisposition  to  apoplexy. 
The  motion  of  the  blood  in  the  lungs,  and  therefore  in  the  head,  is  checked  in  the 
acts  of  coughina:,  vomitinn;,  sneezingf  laucrhinfr,  crvinaf,  shoutinof,  and  so  forth.  You 
cannot  have  looked  at  a  person  in  a  violent  paroxysm  of  coughing  without  seeing 
that  it  produced  a  determination  of  blood  to  the  head,  or  rather  a  congested  state  of 
the  veins  of  the  head.  The  jarring  pain  in  the  head  which  is  apt  to  follow  each 
succession  of  the  cough  depends  upon  this  principle  :  which  is  often  strikingly  illus- 
trated in  young  children  labouring  under  hooping-cough.  They  turn  purple  in  the 
face,  and  become  giddy  ;  and  not  uncommonly  ecchymosis  of  the  conjunctiva  occurs, 
giving  fearful  evidence  of  what  might  just  as  readily  take  place  ivithin  the  cranium. 
It  is  not  very  unusual  for  the  whole  of  the  white  part  of  the  eye  to  become  sud- 
denly blood-shot  in  these  violent  fits  of  coughing;  and  convulsions  even  have  hap- 
pened under  the  like  circumstances. 

Straining  at  stool  is  a  common  exciting  cause  of  apoplexy  in  those  who  are  pre- 
disposed to  it.  And  this  is  one  of  the  worst  dangers  attending  costiveness  of  the 
bowels  in  old  people  ;  but  it  is  one  which  it  is  often  in  our  power  effectually  to  obvi- 
ate. It  is  more  within  our  control  than  a  bad  cough  could  be.  Any  kind  of  strain- 
ing, indeed,  is  equally  perilous.  A  very  good  proof  of  this  danger  was  recently 
afforded  by  a  patient  of  my  own.  He  was  attacked  with  apoplexy  on  his  way  to 
Ascot  races ;  and  upon  recovering  somewhat,  was  found  to  be  paralytic  on  one  side 
of  the  body.  He  was  brought  back  to  town,  where  I  saw  him.  After  some  time 
he  regained  the  power  of  using  the  affected  limbs  to  a  very  considerable  extent;  so 
as  to  be  able  to  walk  about  and  follow  his  business,  which  was  that  of  a  job-master, 
or  proprietor  of  a  livery  stable.  I  cautioned  him  seriously,  inter  alia,  against  strain- 
ing: but  I  suppose  he  forgot  my  caution.  For,  while  dressing  one  morning,  he 
tugged  violently  in  attempts  to  pull  on  a  damp  boot,  and  in  the  midst  of  his  efforts 
fell  back  insensible ;  and  from  this  relapse  he  never  fairly  recovered. 

To  the  same  pr.nciple  is  to  be  referred  a  variety  of  things  from  which  a  patient, 
in  danger  of  this  disease,  must  most  carefully  abstain.  Lifting  heavy  weights  ;  leap- 
ing ;  striking  a  hard  blow ;  playing  on  wind  instruments ;  even  long  and  loud 
talking.  Dr.  Abercrombie  relates  two  instances  of  fatal  apoplexy  brought  on  (as  it 
wouW  seem)  by  a  sustained  exertion  of  the  voice :  one  of  the  attacks  happened  to  a 
clergyman  during  the  delivery  of  his  sermon  ;  the  other  to  a  htcrary  man  while 
speaking  in  a  public  assembly.  In  both  cases  a  large  quantity  of  blood  was  found 
ex'ravq.sated  within  and  upon  the  brain.     Dr.  James  Gregory'  used  to  mention  a 


APOPLEXY.  32S 

patient  of  his,  an  officer  in  tlie  army,  who  had  apoplexy,  and  in  wiom  the  attack 
had  been  preceded  by  pains  of  the  head  and  giddiness,  upon  his  giving  the  word  of" 
command,  and  particularly  when  dwelling  upon  the  last  sound  :  that  is,  when  he 
made  a  long  expiration.  Precisely  of  the  same  kind  is  a  case  told  by  Van  Swieten, 
of  a  singer  who  was  obliged  at  length  to  abandon  her  vocation  by  reason  of  gradually 
increasing  vertigo  whenever  she  had  to  hold  a  high  note.  Violent  emotion  is  another 
exciting  cause.  Large  fires,  crowded  rooms,  the  heat  even  of  the  sun,  favour  the 
access  of  apoplexy,  and  therefore  ought  to  be  shunned  by  those  who  have  a  ten- 
dency to  that  disease.  The  warm  bath  is  not  without  hazard  to  such  persons.  This 
is  so  well  known,  I  understand,  at  Bath,  that  the  physicians  there  will  not  allow 
paralytic  patients,  in  whom  the  paralysis  has  been  connected  with  apoplexy — hemi- 
plegic  patients,  for  example — to  go  into  their  hot  baths.  The  excitement  of  drunken- 
ness, and  the  venereal  excitement,  are  not  uncommon  causes  of  apoplexy,  especially 
in  old  persons.  I  had  a  man  of  middle  age  under  my  care  during  the  spring  oif 
1837,  in  whom  a  most  awful  attack  of  apoplexy  came  on  under  circumstances  such 
as  I  have  just  referred  to.  He  had  dined  at  a  large  festive  party,  and  afterwards 
accompanied  a  woman,  with  whom  he  was  acquainted,  to  a  brothel :  and  he  was 
struck  with  palsy  during  the  act  of  intercourse.  He  was  long  unable  to  speak;  and 
he  still  remains,  and  probably  will  ever  remain,  a  cripple ;  incompletely  hemi- 
plegic. 

I  have  been  since  consulted  upon  the  case  of  an  old  gentleman  residing  in  France, 
in  whom  an  attempt  at  sexual  connexion  was  attended  with  similar  consequences. 

"  The  Gods  are  just,  and  of  our  pleasant  vices 
Make  instruments  to  scourge  us." 

Posture,  again,  has  no  small  effect  upon  apoplectic  people.  Giddiness,  and  some 
degree  of  confusion  of  thought,  are  apt  to  be  occasioned,  in  most  persons,  by  long 
stooping.  There  is  one  peculiar  posture  or  position  mentioned  by  Dr.  Fothergill  as 
being  very  unsafe,  especially  for  short-necked  persons,  viz.,  that  position  which  is 
assumed  when  Ave  turn  the  head  to  look  backwards  for  any  length  of  time,  without 
turning  the  rest  of  the  body;  in  fact,  a  twisting  of  the  neck.  In  this  attitude  the  jugular 
veins  are  more  or  less  obstructed.  He  gives  an  account  of  a  man  who  was  seized  with 
apoplexy  as  he  was  crossing  the  Thames  in  an  open  boat ;  he  having  kept  his  eye 
fixed  upon  a  particular  ship  until,  and  after,  he  had  been  rowed  past  her.  On  the 
very  same  principle,  tight  ligatures  worn  about  the  neck,  and  compressing  the  ju- 
gular veins,  may  bring  on  apoplexy;  the  wearing  a  tight  neck-cloth,  for  example. 
A  continental  writer  informs  us  that  a  Swedish  officer,  who  was  desirous  that  his 
men  should  look  well  in  the  face,  caused  them  to  wear  tight  stocks,  and  the  conse- 
quence was,  that  in  a  short  time  a  great  many  in  that  regiment  died  of  apoplexy. 
Dr.  Abercrombie  quotes  from  Zitzilius  the  case  of  a  boy  who  had  drawn  his  neck- 
cloth very  tight,  and  was  whipping  a  top,  stooping  and  rising  alternately.  After  a 
short  time  he  fell  down  apoplectic.  The  neckcloth  being  loosened,  and  blood  drawn 
from  the  jugular  vein,  he  speedily  recovered. 

There  is  one  very  powerful  exciting  cause  of  apoplexy,  in  those  predisposed  to  it, 
which  I  need  only  refer  to  now,  because  the  facts  that  have  been  observed  in  proof 
of  its  agency  were  fully  detailed  in  a  former  part  of  the  course ;  I  mean  exposure  to 
cold.  You  will  recollect  my  teUing  you  that  the  number  of  deaths  in  London  from 
apoplexy  and  palsy  in  the  month  of  January,  1795,  which  was  a  bitterly  cold  month, 
very  much  exceeded  the  number  in  the  month  of  January,  1790,  which  was  a 
remarkably  mild  month.  The  cold  operates  in  two  ways,  in  the  production  of  apo- 
plexy. In  the  first  place  it  drives  the  blood  from  the  surface,  and  accumulates  it  m 
the  large  vessels  of  the  interior  of  the  body,  and  so  increases  the  stress  upon  the 
cerebral  arteries.  And  in  the  second  place,  the  cold  has  a  great  influence  in  causing 
or  aggravating  affections  of  the  chest ;  and  the  return  of  the  venous  blood  from  the 
head  is  impeded,  in  the  manner  just  now  explained,  by  fits  of  coughing  and  ob- 
structed respiration. 

This  influence  of  external  cold,  and  probably  certain  barometric  conditions  also  ot 

2c 


326  DISEASES    OF    THE    BRAIN. 

the  atmosphere,  hcip  to  explain,  what  I  am  sure  I  have  several  times  had  experience 
of,  namely,  the  epidemic  prevalence,  now  and  then,  of  apoplectic  seizures. 

There  is  an  alleged  exciting  cause  of  cerebral  hemorrhage,  which  I  think  it  the 
more  necessary  to  consider,  because  I  believe  that  very  erroneous  notions  prevail 
about  it,  even  among  pathologists  of  eminence.  I  allude  to  the  imputed  dependence 
of  cerebral  hemorrhage  upon  hypertrophy  9f  the  left  ventricle  of  the  heart.  It  has 
been  supposed  that  the  powerful  contractions  of  a  ventricle  thus  morbidly  strong  mav 
drive  forwards  the  blood  with  such  unusual  force,  as  to  strain  and  burst  the  cerebral 
arteries.  Dr.  Hope,  in  his  very  complete  work  upon  Diseases  of  the  Heart,  uses 
these  words  : — "  Instances  of  apoplexy  supervening  upon  hypertrophy  have  been  so 
frequently  noticed,  that  the  relation  of  the  two,  as  cause  and  effect,  is  one  of  the 
best  established  doctrines  of  modern  pathology."  Similar  opinions  are  entertained 
by  the  most  distinguished  of  the  French  writers  on  this  subject ;  Andral,  Bouillaud, 
Cruveilhier.  I  think  they  are  all  wrong :  or  that  at  least  they  state  their  proposition 
much  too  broadly  and  generally.  ' 

I  fully  admit,  no  less  from  my  own  observation  than  upon  the  testimony  of  others, 
the  frequent  coincidence  of  hemorrhage  of  the  brain  and  hypertrophy  of  the  left 
ventricle  of  the  heart ;  but  I  distrust  the  reasoning  which  would  always  connect 
these  events  with  each  other  as  cause  and  effect.  They  may  sometimes  have  that 
relation :  but  I  have  long  thought  that  in  most  cases,  if  not  in  all,  the  coincidence  is 
capable  of  being  explained  upon  other  and  more  satisfactory  principles. 

In  the  first  place,  hypertrophy  of  the  left  ventricle  of  the  heart  is  very  frequently, 
far  more  frequentlj'-  than  not,  accompanied  by  other  structural  changes  of  that  organ : 
changes  which  imply  some  impediment  to  the  circulation :  changes  which  involve 
or  influence  its  right  chambers  also.  In  fact,  disease  of  the  right  heart  is  not  very 
often  seen,  without  disease  of  the  left;  and  one  of  the  commonest  forms  of  alteration 
to  which  the  left  side  is  Hable,  is  hypertrophy  of  its  ventricle.  Now  I  have  already 
pointed  out  to  you  the  connection  which  sometimes  subsists  between  cerebral  hemor- 
rhage and  such  disease  of  the  heart  as  obstructs  the  ready  and  regular  descent  of 
the  blood  from  the  head  through  the  veins.  Many  of  the  cases  of  apoplexy  occurring 
in  persons  who  have  previously  had  cardiac  hypertrophy  are,  I  really  believe,  cases 
of  this  kind.  The  brain  affection  is  dependent,  in  part,  upon  disease  of  the  heart, 
but  not  upon  the  preternatural  strength  of  its  left  ventricle.  The  heart  acts  morbidly 
upon  the  brain  through  the  veins,  and  not  through  the  arteries. 

But  there  is  another  reason  for  the  coincidence ;  and  here  the  arteries  are  con- 
cerned. 

No  one  can  doubt  that  the  momentum,  with  which  the  blood  reaches  the  cerebral 
arteries,  in  healthy  persons,  under  violent  bodily  exercise  or  mental  excitement,  must 
often  exceed  the  momentum  produced  by  a  hypertrophic  heart  in  the  cerebral  arteries 
of  persons  who  are  tranquil  and  at  rest.  But  apoplectic  seizures  are  frequent  under 
the  latter  circumstance,  infrequent  under  the  former.  We  must  look,  therefore,  foi 
something  more  than  the  mere  hypertrophy  to  explain  the  coincidence.  Now  (sup- 
posing the  absence  of  any  check  to  the  flow  of  blood  from  the  head  through  the 
veins)  that  something  is  to  be  found  in  disease  of  the  arterial  system. 

When  the  arteries  of  the  brain  are  ossified,  or  changed,  and  rendered  brittle  in  the 
way  I  yesterday  described,  the  coimnencement  of  the  aorta  also  is  found,  in  a  great 
majority  of  cases,  to  be  the  seat  of  similar  alterations ;  and,  often,  to  be  sensibly 
dilated.  Now  the  mere  albuminous  deposit  beneath  its  inner  tunic  must  seriously 
impair  the  elasticity  of  the  vessel;  and  in  this  way  the  free  passage  of  the  blood 
out  of  the  heart  will  be  impeded.  Dilatation  of  the  aorta  at  that  part  will  produce 
the  same  hindrance  more  certainly  and  in  a  greater  measure.  Still  more  effectually 
and  obviously  will  any  contraction  of  the  outlet  prove  an  impediment.  It  is  in  con- 
sequence of  these  mechanical  obstacles  to  the  free  exit  of  the  blood  from  the  left 
ventricle,  that  the  walls  of  that  chamber,  urged  to  more  vigorous  contraction,  become 
thicker  and  more  powerful.  The  hypertrophy  is  the  natural  compensation  for  the 
morbid  state  of  the  aorta;  without  it  the  heart  would  much  sooner  become  unable  to 
propel  its  contents  at  all :  and  the  hypertrophy  does  not  often,  I  fancy,  become  greater 
than  is  needful  for  its  purpose.     The  strength  of  the  left  ventricle,  therefore,  in  such 


APOPLEXY.  327 

cases,  is  not  a  true  measure  of  the  force  with  which  the  blood  is  driven  into  the 
distant  arteries.  Q,uite  the  contrary.  It  is  a  measure  of  the  difficulty  with  which 
the  blood  is  circulated  through  the  primary  branches,  and  therefore  through  the 
entire  system  of  the  arteries.  It  indicates  the  diminished  force  with  which  the 
blood  is  likely  to  reach  the  cerebral  vessels.  And  in  point  of  fact,  you  will  find 
in  many  cases  of  hypertrophy  of  the  left  ventricle — I  do  not  say  in  all,  but  certainly 
in  very  many — you  will  find  the  pulse  at  the  wrist  to  be  disproportionately  small  and 
feeble.  So  that,  in  these  cases,  instead  of  regarding  the  cerebral  hemorrhage  as  the 
effect  of  the  hypertrophy,  (acknowledging,  as  I  do,  the  frequent  coexistence  of  these 
morbid  conditions,)  I  have  been  accustomed  to  look  upon  the  apoplexy  and  the  hy- 
pertrophy as  concomitant  effects  of  the  same  cause;  viz.,  of  disease  pervading  the 
arterial  tree.  The  hypertrophy  of  the  left  ventricle  is  the  effect  of  the  diseased  con- 
dition of  the  aorta  at  its  mouth ;  the  cerebral  hemorrhage  is  the  effect  of  the  same 
diseased  condition  of  the  arteries  in  the  brain.  When  you  find  each  of  these  lesions, 
and  nothing  to  retard  the  venous  current,  you  may,  I  believe,  safely  apply  this  ex 
planaiion  of  the  occurrence  of  apoplexy. 

Having  again  referred  to  the  frequent  existence  of  disease  in  the  cerebral  arteries 
as  a  predisposing  cause  of  hemorrhage  Avithin  the  brain,  I  will  just  point  out,  before 
1  leave  this  part  of  the  subject,  the  light  which  that  fact  throws  upon  the  circum- 
.-^lauce  than  sanguineous  apoplexy  is  so  peculiarly  a  disease  of  advanced  hfe.  Earthy 
concretions  in  the  coats  of  the  arteries  are  so  frequent  in  the  later  periods  of  existence, 
that  they  are  met  with,  according  to  Bichat,  in  seven  individuals  out  of  ten  of  those 
who  die  beyond  the  age  of  sixty  ;  and  Dr.  Baillie  considered  ossification  to  be  much 
more  common  in  old  persons  than  a  healthy  state  of  the  arteries. 

In  the  account  which  I  have  endeavoured  to  give  you  of  the  symptoms  of  apo- 
plexy, of  the  different  modes  in  which  the  attack  may  commence,  and  of  the  various 
morbid  appearances  discovered  within  the  cranium  in  the  fatal  cases,  I  have  already 
embodied  almost  all  that  can  be  stated,  with  any  confidence,  respecting  the  special 
diagnosis  and  the  prognosis  of  the  disease.  The  one  of  these  follows  the  other :  the 
exact  diagnosis  being  known,  the  prognosis  is  seldom  difficult.  By  the  diagnosis, 
however,  I  do  not  now  mean  simply  the  recognition  of  the  disease  as  a  case  of  apo- 
plexy :  of  that  general  diagnosis,  of  the  means  of  distinguishing  the  coma  of  apo- 
plexy from  the  coma  caused  by  opium  or  alcohol,  I  told  you  all  that  I  know  in  a 
former  lecture.  But  I  use  the  term  diagnosis  now  in  a  stricter  sense,  and  in  reference 
to  the  distinctions  that  exist  between  one  case  of  apoplexy  and  another;  and  I  say, 
that  in  proportion  to  the  accuracy  with  which  we  may  be  capable  of  determining  the 
precise  condition  of  the  contents  of  the  skull,  will  be  the  facility  of  predicting  the 
issue  of  the  complaint.  Let  me  remind  you,  then,  that  when  a  patient  suddenly 
becomes  apoplectic,  we  cannot  tell  whether  there  be  effusion  of  blood,  or  effusion  of 
serum,  or  no  effusion  at  all  within  the  cranium :  and  therefore  the  diagnosis  must  be 
precarious  and  uncertain.  If,  after  the  use  of  suitable  remedies,  the  coma  persists  for 
many  hours,  the  prognosis  becomes  worse.  In  those  cases  which  begin  with  pain 
of  head,  faintness,  and  nausea,  and  which  pass  on  to  coma,  the  prognosis  is  posi- 
tively bad  ;  for  the  diagnosis  is  easy,  and  we  are  tolerably  certain  that  a  blood-vessel 
has  given  way,  and  that  a  large  quantity  of  blood  has  ploughed  up  the  substance  of 
the  brain.  In  the  paralytic  cases  also,  if  coma  supervenes,  the  prognosis  is  gloomy ; 
but  frequently  coma  does  not  supervene,  and  then  our  prognosis,  so  far  as  life  is  con- 
cerned, may  be  pronounced  favourable. 

Among  the  symiHoms  that  belong  to  the  apoplectic  condition  itself,  there  are  some 
which  experience  has  selected  as  being  most  especially  of  evil  omen  ;  and  it  is  well 
worth  your  while  to  remark  that  these  discouraging  signs  relate,  almost  all  of  them, 
to  the  automatic  functions  of  the  cranio-spinal  axis.  The  open,  fixed,  unwinking 
eye;  the  explosive  flapping  of  the  cheeks  in  expiration ;  the  inability  to  swallow; 
the  slow,  sighing,  interrupted  breathing;  the  loosening  of  the  sphincter  muscles  oi 
the  bladder  and  anus ;  these  are  fearful,  and  too  often  fatal  symptoms,  and  they  all 
depend  upon  the  excito-motory  portion  of  the  nervous  system.  Perhaps  the  profuse 
sweat  that  so  often  attends  the  process  of  dissolution  may  be  referred  to  the  same 
source  ;  the  whole  tone  of  the  various  tissues  being  lost  or  relaxed.    I  would  not  say 


328  DISEASES    OF    THE    BRAIN. 

that  no  one  of  these  symptoms  is  ever  recovered  from :  but  I  may  say  that  of  twenty 
patients  in  whom  such  phenomena  occur,  nineteen  will  die. 

Now  symptoms  of  this  kind  may  be  expected  to  arise,  if  there  be  hemorrhafre  in 
or  near  the  medulla  oblongata;  or  if  there  be  mischief  so  extensive  in  the  brain 
as  to  cause  pressure  upon  the  medulla  oblongata.  We  should  reason  out  the 
hkelihood  that  such  symptoms  would  be  of  bad  augury.  But  the  fact  that  they  are 
so  was  ascertained  long  before  the  theory  which  accounts  for  them  was  devised. 
The  fact  is  independent  of  the  theory,  and  for  that  reason  helps  wonderfully  to 
confirm  it. 

The  older  writers  entertained  some  very  false  notions  in  respect  to  the  distinction 
between  sanguineous  and  serous  apoplexy.  They  laid  it  down  that  apoplexy  result- 
ing from  extravasation  of  blood  within  the  cranium  was  denoted  by  flushing  of  the 
face,  and  strength  of  the  pulse  ;  and  that  it  was  a  disease  of  persons  in  the  vigour  of 
life:  while  apoplexy  resulting  from  the  effusion  of  serum  was  marked  by  paleness 
of  the  countenance,  and  weakness  of  the  pulse ;  and  occurred  in  the  old  and  the 
infirm  :  and  they  directed  their  practice  according  to  this  distinction.  After  what  has 
already  been  said,  I  need  not  tell  you  that  this  classification  of  apoplexies  could  not 
have  been  founded  upon  the  actual  observation  of  disease  :  and  that  our  treatment, 
now-a-days,  is  not  regulated  by  any  such  erroneous  theory. 

Nevertheless,  I  do  not  mean  altogether  to  praise  the  modern  practice  in  apoplexy  ; 
for  it  is  often  one  of  mere  routine.  Practitioners  are  too  apt,  in  this  as  in  other 
instances,  to  be  guided  in  their  choice  of  remedies  by  the  name  of  the  disease,  and 
to  treat  all  cases  of  apoplexy  alike.  I  remember  being  much  amused  by  the  per- 
plexity which  a  friend  of  mine  once  told  me  he  had  felt  on  being  summoned  by 
letter  many  miles  into  the  country  to  see  a  gentleman  who  had  been  struck  with 
apoplexy.  As  he  posted  down  he  earnestly  revolved  in  his  mind  what  he  might  be 
able  to  advise  when  he  should  reach  the  house  of  sickness.  He  felt  confident  that 
the  patient  must  already  have  been  copiously  bled;  cupped,  or  leeched  ;  blistered  ; 
and  thoroughly  dosed  with  calomel,  senna,  and  croton  oil.  Mustard  poultices  had 
doubtless  been  applied  to  his  legs.  My  friend  was  distressed  to  think  that  while 
much  would  be  expected,  nothing  would  be  left  for  him  to  do  worthy  of  so  long  a 
journey,  and  so  heavy  an  expense  to  his  client.  A  clyster  of  turpentine  might  yet, 
perhaps,  be  an  untried  expedient.  His  Qogitations  were  cut  short,  however,  and  his 
cares  relieved,  by  an  express  which  met  him  half-way  on  the  road,  to  announce  that 
the  patient  was  dead.  Now  this  is  the  routine  of  which  I  speak:  most  proper  in 
many  cases ;  unnecessar}'  in  others ;  pernicious  in  some.  There  are  persons  who 
seem  to  think  that  they  have  not  done  their  patient  justice  if  any  part  of  this  active 
intermeddling  has  been  omitted.  Others  reijard  deplt'tion  as  being  worse  than  use- 
less, and  trust  entirely  to  stimulants  and  cordials.  These  are  still  more  dangerous 
routinicrs  than  the  others:  but  they  are  fewer  in  number. 

Our  practice  would  indeed  be  much  easier  than  it  is,  if  we  could  thus  make  one 
plan  fit  all  cases  which  are  nominally  the  same.  But  I  need  not  now  tell  you  that 
disease  alike  in  name — aye,  and  alike  in  their  essential  nature — are  ofttn  widely 
difTorent  in  their  circumstances.  I  formerly  explained  to  you  that  certain  symptoms 
tell  us  what  the  disease  is  ;  but  that  we  are  often  obliged  to  look  to  other  symptoms  ; 
which  ma)'-  inform  us  what  we  are  to  do.  I  know  of  no  rule  so  likely  to  guide  you 
aright  as  that  laid  down  generally  by  Cullen,  of  obviating  the  tendency  to  death. 
You  must  examine  and  judge  to  which  of  the  several  modes  of  dying  there  may  be 
any  obvious  approach.  If  tjie  tendency  be,  as  in  cases  of  apoplexy  it  mostly  is,  to 
death  by  coma,  then  blood-letting  and  the  evacuating  plan  will  generally  be  requi- 
site. If,  on  the  other  hand,  the  tendency  be  to  death  by  syncope,  you  must  with- 
hold the  lancet,  and  even  have  recourse  to  stimulating  and  restorative  measures.  The 
question  is  of  the  last  importance  ;  involving  often  (as  Celsus  taught)  the  alternative 
of  life  and  death  :  "sanguinis  detractio  vel  occidit,  vel  liberat."  Now  the  distinction 
between  these  modes  of  dying  is  to  be  made  by  attending  to  the  state,  not  so  much 
of  the  nervous,  as  of  the  sanguiferous  system.  Insensibilitj''  and  unconsciousness 
are  common  both  to  syncope  and  to  coma:  and  cases  which  fall  under  the  ''lass  of 


APOPLEXY.  329 

apoplexies,  and  which  we  cannot  separate  from  that  class,  are  sometimes  really  more 
hke  cases  of  concussion  than  any  thing  else  ;  the  shock  having  been  of  internaj 
instead  of  external  origin.  If  the  pulse  be  full,  or  hard,  or  thrilling  (sometimes  it 
feels  like  a  tense  vibrating  rope),  or  if  there  be  obvious  external  signs  of  plethora  of 
the  head,  you  must  abstract  blood.  You  are  not  to  refrain  from  bleeding  the  patient 
because  he  is  pale,  if  his  pulse  warrants  it ;  nor  may  you  omit  taking  blood  if  the 
head  and  face  be  turgid,  although  the  pulse  be  small ;  for  that  smallness  may  depend 
upon  organic  disease  of  the  heart. 

On  the  contrary,  if  his  skin  is  pale  and  cold,  and  his  pulse  feeble  and  flickering, 
you  would  probably  ensure  your  patient's  death,  or  determine  the  accession  of  palsy, 
if  you  withdrew  from  the  failing  heart  and  blood-vessels  a  portion  of  their  natural 
stimulus.  I  can  only  invite  your  attention  to  these  broad  features  of  distinction. 
Being  once  taught  to  look  for  and  attend  to  them,  your  own  judgment  must  instruct 
you  as  to  what  may  be  needful  in  particular  cases.  To  this,  as  to  most  other  dis- 
eases, the  remark  of  Boerhaave  is  strictly  applicable,  who  declares  that  he  knows 
of  nothing  which  can  be  called  a  remecly,  "  quin  solo  tempestivo  usu  tale  fiat." 

Having  made  up  your  mind  as  to  the  general  indications  of  treatment,  you  will 
pursue  them  steadily  in  detail.  If  the  patient  to  whom  you  are  summoned  be  stupid 
and  drowsy  rather  than  faint,  and  his  pulse  and  appearance  warrant  the  conclusion 
01  plethora  capitis,  the  first  thing  to  be  done  is  to  place  him  in  a  semi-recumbent 
position,  with  his  head  raised  ;  to  loosen  any  tight  parts  of  his  dress,  especially  his 
neckcloth  and  shirt-collar,  and  whatever  might  press  upon  the  neck;  and  then  as 
quickly  as  possible  to  bleed  him  from  the  arm.  We  know  that  in  some  cases  the 
apoplectic  slate  occurs,  when  as  yet  no  injury  has  been  done  to  the  brain ;  no  effu- 
sion, no  laceration  of  its  texture  ;  and  we  may  hope,  by  timely  and  vigorous  mea- 
sures, to  prevent  these  terrible  evils.  We  never  can  be  sure  that  there  is  blood 
exlravasated  in  such  cases,  and  we  must  act,  in  the  first  instance,  upon  the  presump- 
tion that  there  is  not.  We  are  especially  encouraged  to  take  away  a  considerable 
quantity  of  blood  by  venesection  when  we  perceive  external  signs  that  the  vessels  of 
the  head  are  full;  redness  and  turgescence  of  the  face,  throbbing  and  prominence 
of  the  temporal  arteries,  distension  of  the  superficial  veins  of  the  neck  and  forehead. 
Our  object  is  to  take  off  the  strain  upon  the  internal  vessels  by  bleeding  in  such  a 
manner  and  to  such  an  amount  as  shall  produce  a  decided  effect  upon  the  general 
circulation.  Sometimes  the  good  consequence  of  the  bleeding  is  very  marked  indeed, 
so  that  no  doubt  of  its  propriety  can  be  entertained ;  the  patient  being  so  insensible 
as  not  to  feel  the  puncture  of  the  lancet,  and  yet  emerging  from  his  coma  while  the 
blood  is  still  flowing.  It  is  seldom,  however,  that  we  can  expect  such  manifest  and 
immediate  melioration  as  this. 

After  one  siifficient  bleeding  from  the  arm,  the  vessels  of  the  head  may  be  further 
relieved  by  cupping  the  nape  of  the  neck,  or  the  temples ;  and  venesection  may  be 
repeated  if  the  condition  of  the  pulse,  and  the  symptoms  generally,  should  require 
its  repetition.  It  is  seldomer,  however,  in  cases  of  apoplexy  than  in  cases  of  acute 
inflammation,  that  a  second  or  third  recourse  to  the  lancet  becomes  advisable:  un- 
less, indeed,  the  first  blood-letting  has  been  mismanaged.  Enough  blood  must  be 
taken,  in  the  first  instance,  to  produce  some  evident  effect;  and  therefore  no  precise 
rules  can  be  laid  down  respecting  the  absolute  quantity  to  be  drawn ;  nor  can  we 
make  any  sure  estimate  beforehand  as  to  the  whole  amount  of  blood  which  it  may 
be  necessary  to  remove. 

Even  if  we  could  be  certain  that  a  blood-vessel  had  given  way,  and  that  blood 
Avas  already  poured  out  upon  the  brain,  there  are  good  reasons  why  (no  adverse  cir- 
cumstances withstanding)  we  ought  to  bleed  our  patient  largely,  and  at  once.  I 
will  enumerate  briefly  the  benefits  we  seek  to  obtain  by  the  abstraction  of  blood  in 
such  cases. 

1.  The  effusion  from  the  ruptured  artery  may  be  slowly  going  on.  Ble.ding 
irom  a  vein,  so  as  to  make  a  sensible  impression  on  the  general  circulation,  will 
diminish  the  stress  upon  the  cerebral  arteries,  and  so  tend  to  put  a  stop  to  the  he 
morrhage.     Both  of  these  two  objects  are  of  primary  importance. 

2.  By  early  and  free  bleeding  we  lessen  the  hazard  of  inflammation  «upervt>nmg 

2c2 


330  DISEASES    OF    THE    BRAIN. 

upon  the  mechanical  injury  done  to  the  brain  by  the  sudden  tearing  and  contusior- 
of  its  texture  by  thc'effused  blood  ;  and 

3.  We  thereby  bring  the  system  into  the  most  favourable  condition  for  the  rapid 
absorption  of  the  extravasated  blood,  and  for  expediting  the  patient's  recovery  from 
those  symptoms  which  depend  upon  the  presence  of  the  clot  in  the  brain. 

But  although,  in  that  form  of  disease  which  we  are  now  considering,  bleeding  is 
our  sheet-anchor,  it  may  be  carried  too  far,  or  repeated  too  often.  We  must  not  lose 
sight  of  the  fact  that  many  of  these  patients  are  old,  and  will  not  survive  undue  deple- 
tion ;  and  that  if  they  survive  at  all,  they  will  need  all  the  strength  that  we  dare 
suffer  them  to  retain  for  carrj'ing  on  the  vital  actions,  when  the  chief  instrument  of 
the  most  important  of  the  animal  functions  is  so  greatly  damaged :  nor  of  the  fact 
that  if  there  be  blood  extravasated,  we  cannot  touch  it,  except  indirectly,  by  the 
abstraction  of  more  blood  from  the  arm :  nor  of  the  fact  that  a  patient  may  be  bled 
into  convulsions,  and  fatal  syncope.  In  short,  after  the  first  free  bleeding,  you  must 
be  guided  by  the  special  circumstances  of  the  case,  and  particularly  by  the  pulse. 
The  woman  at  present  in  the  Middlesex  Hospital,  with  paralysis  of  the  limbs  on  one 
side,  and  of  the  face  on  the  other,  attributes  her  palsy  (erroneously  most  likely)  to 
her  having  been  cupped.  She  had  had  a  blow  some  weeks  before,  and  suffered 
headache  from  that  time.  At  length  she  was  cupped,  from  the  neighbourhood  of 
the  head  ;  and  the  next  morning  she  was  paralytic.  This  might  have  been  an  acci- 
dental coincidence.  But  I  remember  being  sent  for,  a  few  years  ago,  to  see  a  patient 
at  Greenwich,  who  had  alreadj'  three  physicians  about  him,  and  was  apparently  in 
danger  of  apoplexy,  of  which  he  had  for  some  time  experienced  distinct  warnings. 
The  three  physicians  had  agreed  that  he  ought  to  be  cupped  from  the  back  of  the 
neck;  to  which  I  assented;  and  while  blood  was  being  rapidly  extracted  in  that 
manner,  he  became  all  at  once  hemiplegic.  Similar  cases  have  been  noticed  by 
other  persons.     Therefore  we  are  not  to  bleed  without  measure  or  discretion. 

The  pulse  may  be  small,  and  the  arterial  action  feeble,  while  yet  the  veins  are 
turgid,  and  the  capillaries  of  the  head  and  face  loaded  with  blood.  Changes  may 
have  occurred  in  the  heart,  such  as  to  obstruct  the  stream  which  it  is  its  healthy 
office  to  transmit.  These  are  cases  to  which  the  local  abstraction  of  blood  from  the 
head,  by  leeches  and  cupping-glasses,  is  pecuharly  adapted. 

Again,  the  whole  state  of  the  patient  may  approximate  more  or  less  nearly  to  the 
state  of  syncope  ;  the  pulse  being  weak,  the  aspect  pinched  and  bloodless,  and  the 
skin  cool.  In  this  condition,  no  good,  but  the  contrary,  is  to  be  expected  from  blood- 
letting of  any  kind.  You  will  do  better  to  apply  warmth,  cautiously,  to  the  surface, 
and  cautiously  to  administer  what  are  called  diffusible  stimuli,  of  which  the  prepa- 
rations of  ammonia  afford  the  most  eligible  forms.  Five  grains  of  the  sesquicarbo- 
nate  or  half  a  drachm  of  sal  volatile,  mixed  with  camphor  julep,  are  ordinary  doses. 
Stand  by  till  the  first  stunning  effect  of  the  internal  shock  passes  off;  and  careluily 
watch  meanwhile  for  symptoms  of  reaction. 

In  more  ambicuous  cases,  when  you  scarcely  can  tell  which  way  the  baLuice 
inclines,  I  would  advise  you  to  wait  the  effect  of  the  next  remedies  I  have  to  men- 
tion, viz.,  purgatives,  about  giving  which  you  need  not  entertain  the  same  doubt  and 
hesitation. 

Purgative  medicines  are  of  signal  service  in  apoplexy.  They  empty  the  intes- 
tines, whicJi  are  oftentimes  loaded,  and  which,  by  distending  the  abdomen,  have 
occasioned,  perhaps,  undue  pressure  against  the  diaphragm,  embarrassed  the  breath- 
ing, and  through  it  the  cerebral  circulation.  Another  very  important  purpose  of 
hard  purtring,  which  I  have  frequently  pointed  out  before,  is  the  producing  of  copi- 
ous watrry  discharges  from  the  bowels,  whereby  the  blood-vessels  are  drained,  and 
the  tendency  of  blood  to  the  head  especially  relieved.  If  the  patient  can  still  swal- 
low, you  may  give  him  half  a  scruple  of  calomel,  and  follow  it  up  by  a  black  dose. 
Il  the  power  of  deglutition  be  lost,  the  croton  oil  becomes  a  most  valuable  remedy. 
Dr.  Abercrombie  suggests  that  it  may  be  conveniently  introduced  into  the  stomach, 
suspended  m  thick  gruel  or  mucilage,  by  means  of  an  elastic  gum  tube.  But  really 
this  is  not  necessary.  If  two  or  three  drops  of  the  oil  be  put  upon  the  tongue,  as  far 
back  as  is  possible,  it  will  produce  its  speciiic  effect  ver}''  readily  and  v/ell     But  we 


APOPLEXY.  33 1 

are  not  to  wait  for  the  operation  of  aperients  given  by  the  mouth.  Strong  purgative 
and  stimulating  enemata  must  be  thrown  into  the  rectum:  half  an  ounce  or  six 
drachms  of  turpentine  susperfded,  by  the  help  of  the  yolk  of  an  egg,  in  gruel  or 
>^arm  water.  We  very  often  witness  decided  signs  of  amendment  upon  the  free 
operation  of  a  purgative.  I  may  mention  one  instance  of  tliis  while  it  is  fresh  in  xny 
recollection.  I  was  asked,  a  few  evenings  ago,  by  a  medical  friend,  to  see  an  old 
general,  a  patient  of  his.  I  found  him  in  bed,  comatose,  though  capable  of  being 
roused  when  loudly  spoken  to :  but  he  j^resently  fell  off  again  into  stupor.  His  respi- 
ration was  peculiar.  For  a  minute  or  two  he  would  breathe,  snoring  strongly:  then 
the  breathing  would  cease  altogether  for  half  a  minute  or  thereabouts :  and  then  the 
stertorous  respiration  recommenced  :  and  so  on  alternately. 

He  had  been  found  by  his  servant  on  the  floor,  nearly  insensible,  in  the  morning, 
having  either  fallen  out  of,  or  upon  rising  from,  his  bed.  He  had  very  properly 
been  cupped ;  and  calomel  and  aperient  medicine  had  been  given :  but  the  coma 
had  been  growing  more  profound  all  the  afternoon.  His  bowels  had  been  but  scantily 
moved ;  and  the  feces  and  urine  were  passed  as  he  lay.  His  extremities  were 
coldish.     The  pulse  was  neither  full  nor  strong. 

I  learned  that  for  four  or  five  years  he  had  had  some  very  significant  warnings  ; 
and  within  that  period  had  suffered  one  or  two  slight  apoplectic  seizures,  which  had 
left  him  \\'iih  impaired  mind  and  memory. 

I  recommended  bhsters  behind  the  ears,  and  two  drops  of  croton  oil,  with  two 
drachms  of  castor  oil,  in  a  draught.  The  next  morning  I  expected  to  hear  that  he 
was  dead;  but  I  found  him  quite  conscious,  speaking  somewhat  inarticulately,  witk 
the  right  side  of  his  face  chopfallen  and  inexpressive.  There  seemed  no  particular 
weakness  of  the  corresponding  extremities.  The  oils  had  been  followed  by  copious 
evacuations  from  the  bowels.  The  day  afterwards  he  was  sitting  up,  and  so  well 
that  I  took  my  leave. 

In  combination  with  blood-letting  and  purgatives,  cold  lotions  to  the  head  are  often 
found  useful  in  this  disease,  especially  if  its  surface  is  hot.  I  need  not  trouble  you 
by  rehearsing  the  modes  in  which  the  application  of  this  remedy  may  be  managed. 
Blisters  near  or  upon  the  head,  are  also  frequently  of  service,  after  due  abstraction 
of  blood,  in  rousing  the  patient  from  his  state  of  coma. 

Formerly,  at  the  suggestion,  I  fancy,  of  Dr.  Fothergill,  it  was  much  the  fashion 
to  give  an  emetic  in  the  outset  of  the  treatment  of  apoplexy.  But  this  also  is  a 
ticklish  remedy,  capable  of  doing  good  or  harm  according  as  it  is  well  or  ill  timed. 
If  there  be  already  extravasation  of  blood,  or  even  plethora  capitis,  the  act  of  vomiting 
will  be  likely  to  increase  the  existing  mischief,  and  to  enhance  the  danger.  On  the 
other  hand  it  may  rouse  and  rally  the  nervous  power  when  the  patient  is  pale,  and 
cold,  and  faint.  Yet  this  can  never  be  regarded  as  a  legitimate  purpose  of  emetics 
in  apoplexy.  They  can  safely  be  recommended  in  those  cases  only  in  which  the 
coma  may  appear  to  depend,  wholly  or  in  part,  upon  a  loaded  stomach.  Hence  the 
propriety  of  giving  an  emetic  will  deserve  consideration  whenever  an  attack  of  apo- 
plexy follows  close  upon  a  heavy  meal. 

When  the  immediate  danger  has  passed  by,  and  parslysis  remains,  we  are  not  to 
be  over-busy.  If  the  palsy  is  to  get  gradually  well,  it  must  be  by  virtue  of  time, 
and  the  resources  of  nature.  To  young  and  strong  persons  I  should,  under  such 
circumstances,  give  small  and  repeated  doses  of  mercury :  and  in  all  cases  I  should 
prescribe  aperient  medicines,  so  as  to  keep  the  bowels  freely  open  twice  or  thrice  a 
du}- ;  enjoin  perfect  quiet ;  and  put  the  patient  upon  ver_y  short  commons.  Diuretics 
are  also  very  proper  when  the  urine  is  not  plentiful  without  them. 

1:  ou  will  often  have  to  contend  against  the  ignorance  and  impatience  of  the  sick, 
or  of  their  friends,  on  these  occasions.  Thoy  think  that  ivcakness  is  to  be  remedied 
by  sircagthcning  food  ;  by  naeat  and  drink,  and  tonic  medicines ;  or  if  they  are  not 
so  foolish  as  this,  they  will  want  to  be  electrified,  or  lo  be  put  into  a  warm  bath. 
Certainly  in  the  earher  states  of  the  palsy  that  remains  a'ter  apoplexy,  none  of  those 
measures  ought  to  be  permitted.  If,  after  some  time,  when  all  febrile  action  has 
ceased,  the  palsy  seems  stationary,  it  may  be  warrantable  and  right  to  attempt  to 
stimulate  the  torpid  nerves,  and  to  accelerate  the  acquirement  of  power  by  the  mino 


332  SPINAL   HEMORRHAGE. 


over  the  muscular  contractions ;  but  when  any  means  for  attaining  these  objects  are 
employed  at  all,  they  must  be  used  with  the  utmost  caution ;  for  they  are  much 
more  likely  to  stimulate  the  vascular  system,  and  so  to  do  harm  :  or  even  to  n^new 
the  apoplectic  attack.  Electricity,  and  strychnia,  are  the  remedies  most  relied  upon". 
In  cases  of  long-standing  palsy,  it  may  also,  no  doubt,  be  proper  to  try  to  awaken, 
by  stimulating  frictions,  the  dormant  powers  of  the  muscles,  which  by  protracted 
inaction  becomes  forgetful,  as  it  were,  rather  than  incapable,  of  their  natural  otfice  : 
and  in  these  old  cases  we  sometimes  are  able  to  benefit  our  patient's  condition  by  the 
cautious  exhibition  of  some  of  the  preparations  of  iron. 


I 


LECTURE  XXXI. 

Spinal  Hemorrhage.  Paraplegia.  Facial  Palsy  and  Facial  Ansesthesia ;  their 
Symptoms,  Prognosis,  and  Treatment.  Other  Forms  of  Local  Paralysis,  and 
Local  Anxsthesia. 

I  HAVE  done  with  apoplexy  as  it  respects  the  brain ;  which  is  the  same  thing  as  to 
say  that  I  have  done  with  apoplexy.  You  will  find  the  same  term  applied,  indeed, 
to  effusions  of  blood  in  other  organs  of  the  body ;  but  this  use  of  the  word  is  a  per- 
version of  language.  Apoplexy,  as  I  have  frequently  observed  before,  is  the  abolition 
of  the  functions  proper  to  the  brain;  of  sensation,  voluntary  motion,  and  thought. 
In  short,  it  is  coma,  coming  on  under  certain  circumstances. 

I  shall  not  speak  therefore  of  spinal  apoplexy  (though  that  would  be  less  improper 
than  pulmonary  apoplexy,  or  hepatic  apoplexy),  but  of  spinal  hemorrhage.  Of 
this  I  really  have  little  to  say,  except  that  it  is  well  known  occasionally  to  occur ;  and 
that  the  symptoms  to  which  it  gives  rise  are  by  no  means  peculiar  or  distinctive. 
They  consist  of  pain  in  some  part  of  the  spine  ;  compulsions  ;  palsy  ;  that  is,  they 
are  the  very  same  symptoms  which  inflammation,  softening,  mechanical  injury,  and 
other  disorders  of  the  same  part  may  produce.  Spinal  hemorrhage  is  much  more 
rare  than  cerebral  hemorrhage.  Dr.  Abercrombie  had  met  with  only  one  case  of  it. 
He  gives  the  heads  of  seven  others  which  have  been  recorded  by  different  authors. 
Dr.  Bright  has  never  seen  it:  but  he  publishes  the  particulars  of  one  case,  which 
were  communicated  to  him  by  Dr.  Stroud. 

I  will  read  you  one  or  two  short  examples  of  spinal  hemorrhage,  as  specimens. 
A  girl,  fourteen  3'ears  old,  was  attacked  with  headache, /)f/m  in  the  back,  and  a  ten- 
dency to  sickness  in  the  erect  posture.  At  the  end  of  a  week  the  pain  in  the  back 
became  suddenly  and  very  greatly  aggravated ;  and  this  was  followed  by  general 
convulsions,  which  proved  fatal  in  five  or  six  hours.  The  spinal  canal  was  found 
filled  with  extravasated  blood,  in  the  lumbar  region,  where  she  had  felt  the  pain.  The 
brain  and  all  the  other  viscera  were  sound.  The  case  is  detailed  by  JVIr.  Chevalier 
in  the  third  volume  of  the  Medico-Chirurgical  Transactions. 

Take  one  more  instance  from  OUivier,  whose  work  on  the  spinal  marrow  you  may 
read  hereafter,  when  you  have  leisure,  with  advantage. 

A.  gentleman,  aged  sixty-one,  had  just  arrived  in  Paris  after  a  long  journey,  when 
he  was  seized  with  pain  of  the  back,  all  the  way  down  from  the  cervical  vertebrce 
\o  the  sacrum.  In  the  course  of  a  few  hours  he  became  paraplegic,  and  was  unable 
to  retain  his  urine  or  feces.  He  then  sent  for  a  physician,  and  died  while  talking  to 
liim  A  very  extensive  extravasation  of  blood  was  found  in  the  spinal  canal,  beneath 
the  membranes  of  the  cord.  The  lower  part  of  the  canal  was  filled  with  a  bloody 
mass,  in  which  the  substance  of  the  cord  could  not  be  distinguished.  Above  the 
ih'rd  dorsal  vertebrae  the  cord  was  entire,  but  of  a  deep-red  colour,  and  very  soft. 

The  suddenness  of  the  symptoms  may  lead  you  to  suspect  the  true  nature  of 
these  cases ;  but  I  cannot  pretend  to  point  out  any  other  feature  by  which  they  may 
be  distinguisnea  from  other  morbid  conditions  of  the  spine,  already  spoken  of.  T 
show  vou  one  prejiaration ;  of  which,  however,  I  do  not  know  the  history. 


PARAPLEGIA.  333 

I  have  nothing  to  add,  to  what  I  have  already  said,  respecting  that  species  of  palsy 
which  is  called"  hemiplegia :  and  I  have  only  a  very  few  further  observations  to 
make  in  regard  to  paraplegia. 

The  cause  of  this  kind  of  palsy  is  sometimes  obvious  ;  sometimes  most  obscure. 
If  we  find,  in  the  spinal  canal,  blood  effused,  softening  of  the  substance  of  the  cord, 
traces  of  inflammation  of  its  investing  membranes,  tumours  pressing  upon  it,  pressure 
from  disease  or  displacement  of  the  bones,  we  have  a  sufficient  explanation  of  the 
paralysis  of  those  parts  of  the  body,  the  nerves  of  which  come  from  the  spinal 
marrow  at  or  below  the  place  of  the  disease.  There  are  three  preparations  on  the 
table  of  tumours  that  pressed  upon  the  cord  ;  scrofulous  tumours  I  believe  they  are  • 
each  of  the  three  persons  from  whose  bodies  they  were  respectively  taken  was  more 
or  less  completely  paraplegic. 

But  in  very  many  cases  we  detect  no  alteration  that  seems  adequate  to  explain  the 
paraplegia.  The  palsy  creeps  on  slowly  and  insidiously,  without  any  particular  pain, 
or  violent  symptoms :  there  is  no  tenderness  or  bending  of  the  vertebras.  The 
weakness  commences  mostly  in  the  legs,  which  appear  to  the  patient  heavier  than 
usual,  and  of  which  the  healthy  sensations  are  often  perverted.  The  toes  tingle,  or 
are  numb :  he  experiences  a  feehng  in  them  as  if  a  number  of  ants  were  crawling 
on  the  skin.  This  is  so  common  a  circumstance  as  to  have  given  a  name  to  the 
symptom,  formication.  The  patient  straddles  as  he  walks.  His  legs  are  lifted 
awkwardly,  the  toes  being  often  the  last  part  to  quit  the  ground  :  they  are  then  flung 
obhquely  forwards  and  outwards,  and  the  feet  flap  doAvn  heavily  and  uncertainly  at 
every  step.  By  degrees  the  weakness  of  the  lower  limbs  increases :  the  palsy 
creeps  upwards,  affects  the  bladder  and  rectum,  at  length  invades  the  arms,  and 
ultimately  the  patient  dies :  yet  very  faint  traces  of  disease,  or  no  traces  at  all,  may 
be  visible  upon  inspecting  the  brain  and  spinal  cord.  The  commonest  morbid  con- 
dition is  softening  of  some  portion  of  the  cord ;  and  this  is  also  the  condition  which 
is  the  most  liable  to  be  overlooked. 

Very  recently  I  had  a  patient  with  these  symptoms  in  the  Middlesex  Hospital. 
He  went  out  contrarily  to  my  wishes  ;  he  was  discharged,  in  fact,  by  mistake  :  he 
took  refuge  in  St.  Bartholomew's,  where  he  died  after  a  few  days.  I  have  been 
informed  that  serum  was  found  beneath  the  arachnoid,  and  that  the  whole  brain  had 
a  wasted  appearance ;  but  nothing  satisfactory  was  made  out.  The  palsy  had  by 
slow  degrees  ascended  from  his  legs  to  his  arms ;  he  had  had  no  head  symptoms 
beyond  some  occasional  confusion  and  vague  uneasy  feelings  there.  At  this 
present  time  a  patient  in  a  similar  condition  comes  to  the  hospital  every  Thursday, 
dragged  by  a  friend  in  a  hand-chair.  He  looks  very  well  in  the  face,  but  is  help- 
less below. 

It  is  in  these  cases  that  you  may  expect  to  witness  the  very  remarkable  pheno- 
mena which  I  mentioned  before  as  evincing  the  separate  existence  of  a  "  true  spmal 
marrow,"  distinct  from  the  brain  and  its  prolongations  into  the  spinal  canal,  endowed 
whh  special  and  peculiar  properties,  and  performing  functions  that  are  independent 
of  sensation,  of  consciousness,  and  of  the  will.  If  you  pinch  or  tickle  the  surface  of 
the  paralytic  members,  or  apply  a  hot  spoon  to  the  sole  of  one  foot,  the  limbs  will, 
in  many  cases,  start  up  and  move  strongly,  not  only  without  any  voluntary  effort  on 
the  part  of  the  patient,  but  in  spite  of  him;  or  even  (in  those  instances  in  which 
there  is  anaesthesia  as  well  as  palsy)  without  his  knowing  it.  The  legs  often  spring 
up  of  their  oivn  accord  as  it  seems ;  but,  no  doubt,  the  apparendy  spontaneous 
movement  is  frequently  an  excited  movement,  and  takes  place  in  obedience  to  the 
lavv  that  governs  the  automatic  motions  of  the  body.  Some  impression,  made  first 
upon  the  peripheral  extremities  of  afferent  nerves,  runs  through  the  nervous  arc  of 
communication,  and  exhibits  its  uUimate  effect  at  the  extremities  of  the  corresponding 
efferent  motor  nerves.  We  can  imagine  many  such  accidental  and  unsuspected 
sources  of  excitement ;  a  casual  touch,  the  varying  contact  of  the  bed-clothes,  the 
bite  of  a  flea,  for  aught  I  know  to  the  contrary,  may  suffice.  Even  the  passage  of 
faeces  or  of  flatus  along  the  lower  bowel,  or  of  urine  through  the  urinary  passages, 
may  be  enough  (as  we  are  taught  by  unquestionable,  facts)  to  produce  these  move 


334  PARAPLEGIA. 

ments.     They  are  more  readily  excited,  cssteris  paribus,  in  proportion  as  tlie  inter- 
fering- influence  of  the  will  is  more  completely  cut  off. 

I  knew  a  gentleman,  who  had  retired  from  the  medical  profession,  and  who, 
though  not  paraplegic,  laboured,  I  believe,  under  some  morbid  condition  of  the  spine. 
He  had  been,  in  early  life,  a  hard  drinker,  and  had  suffered  dehrium  tremens.  Every 
night,  sometimes  more  than  once  or  twice,  the  trunk  of  his  body,  and  all  his  limbs, 
became  for  a  while  fixed  and  stiff,  from  rigidity  of  the  muscles.  A  few  days  before 
his  death,  he  told  me  this  curious  fact.  Whenever  he  scraped  his  shoes  on  thf. 
scraper  at  the  door,  his  leg  flew  up,  with  a  spasmodic  suddenness  from  the  iron,  not- 
withstanding his  endeavour  to  prevent  it.  He  died  suddenly.  I  believe  he  was 
found  dead  in  his  bed. 

In  some  cases  of  paraplegia  involuntary  retractions  of  the  palsied  limbs  can  be 
excited  ;  in  some  cases  they  cannot.  When  the  influence  of  the  cerebrum  is  quite 
excluded  by  the  operation  of  disease  affecting  the  spinal  cord  itself,  then  is  the  sus- 
ceptibility of  excited  movements  the  most  lively.  But  the  increased  susceptibility 
Avhich  has  this  inverse  relation  to  the  voluntary  power,  is  limited  to  that  portion  of 
the  body,  the  nervous  arcs  belonging  to  which  lie  beyond  the  seat  of  the  disease ; 
more  distant,  I  mean,  from  the  brain.  Hence  it  follows  that  we  may  determine, 
approximately,  the  place  of  the  disease,  by  the  test  of  these  reflex  actions.  The 
mischief  may  be  situated,  or  may  extend,  so  low  down,  that  there  are  no  unin- 
terrupted nervous  arcs  below  it.  Supposing  it  to  lie  as  low  as,  or  to  reach,  the  com- 
mencement of  the  Cauda  equina,  we  should  have  no  involuntary  movements. 
Conversely,  when  no  involuntary  movements  can  be  excited,  the  spinal  disease  is, 
at  least,  as  low  as  the  upper  lumbar  vertebrae.  Thus,  I  say,  we  have  another  mode, 
in  addition  to  those  pointed  out  in  a  former  lecture,  of  determining,  in  a  given 
case  of  spinal  palsy,  whereabouts,  or  to  what  extent,  the  cord  is  implicated  in  the 
disease. 

We  do  not  so  often  observe  these  reflex  movements  in  cases  of  hemiplegia ; 
apparently  for  this  reason,  that  in  hemiplegia  the  sensorial  influence  is  not,  usually, 
so  completely  shut  out  as  it  is  apt  to  be  in  paraplegia.  Yet  I  have  seen  some  of 
these  phenomena  in  several  hemiplegic  patients.  One  of  them,  whose  right  hand 
and  arm  were  quite  passive  under  the  strongest  efforts  of  his  will  to  stir  them,  took 
notice  himself,  as  did  his  nurse,  that  whenever  he  yawned  and  stretched  himself  the 
lingers  of  the  palsied  hand  participated  in  the  action,  and  were  thoroughly  extended  : 
and  I  could,  by  tickling  the  sole  of  his  foot,  excite  some  starting  of  the  leg,  long 
before  any  power  of  voluntary  movement  returned. 

Emolion  has  sometimes  the  same  singular  effect  upon  limbs  and  muscles  over 
which  volition  has  no  dominion  whatever.  An  artist  with  whom  I  am  acquainted, 
and  whose  arm  was  almost  completely  powerless  after  a  recent  attack  of  paralysis, 
do  that  no  effort  of  his  will  sufficed  to  raise  it  from  his  side  —  was  one  day  startled, 
as  he  Avas  hobbling  across  a  road,  by  the  unexpected  approach  of  a  carriage.  He 
noticed,  with  wonder,  that  during  his  endeavours  to  get  out  of  the  way,  the  palsied 
arm  was'  suddenly  jerked  up  above  his  head.  But  he  could  not  again  lift  it  there 
after  the  fright  was  over. 

Paraplegia  has  been  ascribed  to  some  primary  morbid  condition  of  the  nerves 
which  belong  to  the  spinal  cord.  That  the  functions  of  the  efferent,  or  motor,  nerves 
may  be  impaired,  and  even  arrested,  by  exposure  to  cold,  and  by  other  injurious 
mfluences,  is  both  possible  and  probable.  But  a  diseased  or  disordered  state  c/  the 
afferent  nerves  has  been  assigned  as  a  cause  of  the  palsy.  This  is  less  clearly  con- 
ceivable. Coexisting  disease  of  the  kidneys,  and  coexisting  enteritis,  have  been 
thought  suflicient  to  produce  and  keep  up  a  paralytic  condition  of  the  lower  limbs. 
Tne  extremities  of  certain  incident  nerves  being  affected,  a  morbid  impression  is 
transmitted  to  the  cord,  suspensive  of  its  central  function.  The  efforts  even  of  voli- 
tion, which  come  from  the  brain,  are  no  longer  successful.  Such  is  the  theory.  I 
<lo  not  say  it  is  an  erroneous  theory ;  but  I  am  bound  to  tell  you  that  I  think  it 
un proven.  Mv  own  experience  has  furnished  me  with  no  facts  which  go  to 
support  it. 

Do  not  forget  the  imponant  fact  that,  in  many,  nay,  in  most  cases  of  paraplegia, 


PARAPLEGIA.  335 

the  urine  at  length  becomes  ropy,  alkaline,  and  stinking  ;  and  that  the  bladder,  after 
ieath,  presents  appearances  such  as  chronic  inflammation  might  produce;  rough- 
ness and  redness  of  its  inner  surface,  and  thickening  of  its  coats.  What  may  be  the 
order  and  relation  of  these  changes,  I  confess  I  do  not  know :  whether  the  quality 
of  the  urine  is  first  altered,  and  then  the  bladder  suffers  from  the  perpetual  contact 
of  this  unnatural  secretion  ;  or  whether  the  bladder  becomes  diseased  in  consequence 
of  the  palsy,  and  pours  forth  unhealthy  mucus,  whereby  the  quality  of  the  urine  is 
afTected;  has  not,  I  believe,  been  clearly  ascertained.  The  minute  particulars  of 
such  cases  require  more  careful  investigation  than  they  have  hitherto  received.  In 
support  of  the  latter  proposition  I  have  heard  the  following  facts  affirmed.  The 
urine  voided  being  alkaline,  the  bladder  was  washed  out  by  the  injection  and  with- 
drawal of  warm  water.  Then  the  next  portions  of  the  urine  that  descended  from  the 
kidneys  were  immediately  removed  and  tested,  and  found  to  be  acid.  So  also,  after 
death,  the  urine  has  proved  to  be  alkaline  and  mucous  in  the  bladder,  acid  in  the 
pelvis  of  the  kidney.  But  in  other  instances  of  paraplegia,  the  urine  is  said  to  have 
been  secreted  alkaline.  Disease,  in  these  last  cases,  may  perhaps  have  been  propa- 
gated from  the  bladder,  backwards.  Or  the  disorganization  of  the  bladder,  and  the 
alkaline  quahty  of  the  urine,  may  both  have  been  common  results  of  the  interruption 
of  the  nervous  influence.  I  would  suggest  to  you  to  inquire,  whenever  opportunities 
occur,  at  what  period  of  the  spinal  disease  or  injury  the  urine  began  to  be  secreted 
alkalescent. 

We  have  reason  to  believe  that  the  defect  in  some  of  these  cases  of  paraplegia  is 
merely  functional :  independent,  I  mean,  of  any  such  change  in  the  nervous  matter 
as  is  cognizable  by  our  senses.  It  may  be  brought  on  by  various  causes :  by  cold ; 
by  intemperance  in  drinking ;  by  excessive  sexual  intercourse  :  or,  still  more  surely, 
by  self-abuse.  I  have  had  the  last  cause  assigned  to  me  voluntarily  by  patients 
themselves.  In  such  cases  we  may  presume  that  the  loss  of  function  is  confined  to  the 
spinal  marrow.  But  there  is  another  way  in  which  paraplegia  may  be  accounted 
i"or,  although  its  physical  cause  is  very  liable  to  be  overlooked.  It  may  result  from 
serous  eflusion  into  the  spinal  canal ;  which  efllision  may  have  originated  there,  or, 
what  seems  sometimes  to  be  more  probable,  may  have  been  poured  out  within  the 
cranium.,  and  descended  by  the  force  of  gravity  to  the  lower  part  of  the  cavity  of 
the  spine.  Dr.  Baillie  read  a  paper  on  this  subject  before  the  College  of  Physi- 
cians :  it  is  contained  in  the  sixth  volume  of  the  Medical  Transactions.  He  was 
not  the  first  person  to  whom  this  mode  of  explaining  certain  obscure  cases  of  para- 
plegia suggested  itself;  but  he  was  the  first  I  beheve  who  published  upon  it.  This 
eflusion  may  very  readily  be  overlooked.  Commonly  the  brain  is  examined  first ; 
and  no  great  attention  is  paid  to  the  escape  of  fluid  from  the  vertebral  canal.  It 
would  be  better  to  lay  open  the  spinal  cavity  first,  at  its  lowest  part,  and  to  puncture 
the  iheca,  and  then  to  observe  what  quantity  of  fluid  runs  out  when  the  body  is 
placed  upright.  I'here  shoidd  be  a  certain  quantity  :  but  if  much  serum  so  escaped, 
we  might  conclude  that  it  had  existed  in  hurtful  abundance  during  life,  and  had 
caused  the  paraplegia.  In  most  of  these  obscure  cases  you  may  trace  some  head 
symptoms  ;  giddiness,  transient  confusion  of  thought,  loss  of  memory ;  and  it  really  will 
be  worth  your  while  to  make  the  examination  in  the  way  I  have  pointed  out,  when- 
ever you  have  occasion  to  inspect  the  body  of  a  patient  who  has  died  paraplegic. 

I  regret  very  much  that  I  had  not  the  opportunity  of  doing  this  in  the  case  of  the 
man  whom  I  had  been  for  some  time  watching  in  the  hospital. 

Cases,  such  as  I  have  now  been  describing,  are  by  no  means  uncommon.  They 
are  usually  slow  and  tedious;  and  you  will  be  called  upon  to  administer  to  their 
relief.  1  need  not  repeat  the  caution  which  I  have  several  times  given,  in  respect  to 
the  condition  of  the  bladder;  you  must  take  care  that  it  does  not  become  over  dis- 
tended with  urine ;  and  you  must  enjoin  strict  attention  on  the  part  of  the  nurse  as 
to  keeping  the  patient  clean  and  dry.  Friction  along  the  course  of  the  spine  ;  blis- 
ters to  the  loins  or  sacrum,  frequently  repeated ;  issues;  and  electricity:  all  these 
means  you  will  generally  have  opportunity  enough  for  trying,  and  for  regretting 
their  mutility.  In  such  cases  it  may  sometimes  be  warrantable  and  proper  to  employ 
strj'chnia ;  a  poison  which  mainly  affects  the  spinal  cord,  causing,  when  given  jn  h 


336  FACIAL    PALSY. 

sufficient  dose,  tetanic  spasnas  of  the  limbs,  with  very  little  o  no  affection  ol  the  cen 
soriuni.  I  have  heard  of  some  striking  instances  of  recovery  from  paraplegia  uudei 
the  exhibition  of  this  drug.  I  wish  I  could  tell  you  that  I  had  ever  seen  such.  Let 
me  caption  you  against  its  indiscriminate  use  ;  or  rather  its  abuse.  No  good  can 
reasonably  be  expected  from  it,  but  much  harm,  unless  the  cord  be  free  from  orsjanic 
disease.  Even  then  I  would  not  advise  you  to  begin  with  a  stronger  dose  of  strych- 
nia, or  of  the  sulphate  of  strychnia,  than  the  twelfth  part  of  a  grain  every  six  hours  : 
this  may  be  gradually  and  cautiously  increased,  until  it  gives  rise  to  tvviichings  of  the 
hmbs,  or  to  some  other  obvious  effect.  The  twitching  is  usually  confined  to  the 
palsied  limbs.  This  shows  that  it  results  from  the  agency  of  the  remedy  upon  the 
excito-motory  system,  or  true  spinal  marrow  ;  of  which  the  reflex  function  is  always 
more  readily  excited  when  the  sensorium  has  lost  its  customary  controlling  power. 
When  this  symptom  occurs,  you  had  better  go  on  with  the  same  dose  ;  it  would  be 
unsafe  to  increase  it :  and  the  progress  of  the  case  will  soon  inform  you  whether 
any  benefit  is  likely  to  accrue  from  a  continuance  of  the  medicine.  The  out-patient 
now  attending  has  taken  the  strychnia.  It  made  the  palsied  hmbs  start  and  extend 
themselves ;   but  no  permanent  power  has  been  gained. 

There  is  one  other  drug  which  I  should  recormnend  you  to  try  in  such  cases,  viz.; 
the  tincture  of  cantharides.  It  certainly  has  sometimes  a  very  beneficial  effect 
Generally,  w'hen  it  does  good,  it  acts  as  a  diuretic ;  and  Dr.  Seymour  has  thrown 
out  a  suggestion  that  it  is  most  likely  to  be  useful  in  those  cases  of  serous  effusion 
into  the  spinal  cavity,  of  spinal  dropsy,  which  I  just  now  described.  He  record- 
mends  the  tincture  as  a  good  diuretic  in  several  forms  of  dropsy :  and  supposes  that 
it  benefits  paraplegia  by  tending  to  produce  absorption  of  the  serum  effused  \v:thin 
the  vertebral  canal. 

Moreover,  there  is  another  principle  upon  which  this  medicine  may  be  sometimes 
advisable.  Cantharides  are  well  known  to  have  a  pecuhar  effect  upon  the  bladder; 
which  effect  is  doubtless  produced  through  the  corresponding  part  of  the  spinal 
cord.  If,  by  means  of  the  Spanish  fly,  we  can  excite,  though  but  from  time  to  time, 
the  function  of  that  part,  we  may  obviate,  in  a  great  degree,  the  distressing  conse- 
quences of  incontinence  of  urine,  arising  from  paralysis  of  the  sphincter  vesicsc. 
Dr.  Marshall  Hall  relates  a  very  interesting  fact,  bearing  directly  upon  this  point. 
A  young  lady  had  a  tumour  within  the  tenth  and  eleventh  dorsal  vertebrce.  It 
gradually,  but  completely,  severed  the  spinal  marrow,  and  induced  perfect  para- 
plegia. The  bladder  lost  its  power  of  retention.  But  on  giving  a  dose  of  the 
tmcture  of  cantharides,  the  power  of  retaining  the  urine  was  always  restoredybr  the 
time.  That  power  would  cease,  and  again  be  restored,  on  suspending  and  repeating 
the  medicine. 

Dr.  Hall  remarks  that  the  cantharides  obviously  acted  through  the  segment  of  the 
excito-motory  system  left  below  the  division  of  the  spinal  marrow. 

The  tincture  may  be  given  in  half-drachm  doses. 

The  forms  of  paralysis  that  have  hitherto  been  noticed  are  forms  oi partial  para- 
lysis. y\  hen  the  palsy  is  still  more  limited,  although  the  epithet  partial  would  be 
equally  applicable,  the  term  local  palsy  is  more  commonly  used.  There  is  one  of 
these  local  palsies  which  is  exceeding  interesting,  and  of  much  importance  :  I  mean 
palsy  as  it  affects,  exclusively,  one  side  of  the  visage  :  facial  palsy.  It  is  sometimes 
called,  not  very  correctly,  paralysis  of  the  portio  dura  of  the  seventh  nerve.  The 
most  common  kind  of  facial  palsy  is  indeed  paralysis  of  the  muscles  supplied  by 
that  nerve.  But  the  word  paralysis  is  misused  when  it  is  intended  to  express  any 
other  loss  of  function  than  that  of  the  faculty  of  motion  in  muscular  pans.  It  is 
incorrect  to  speak,  as  some  authors  do,  of  palsy  of  the  kidney ;  it  is  equally  inexact 
to  speak  of  palsy  of  a  nerve. 

I  say  that  facial  palsy,  and  facial  anassthesia  (for  the  two  should  be  considered 
•ogether),  are  very  interesting  affections,  because  they  elucidate,  in  the  human 
subject,  some  of  the  most  curious  speculations  of  modern  physiology  :  and  they  are 
important  affections  for  you  to  study  and  understand,  inasmuch  as,  though  always 
ilislressful  and  alarming  to  the  patient  and  his  friends,  and  sometimes,  indeed,  in- 


FACIAL    PALSY.  337 

dicative  of  extreme  danger,  they  often  are  merely  inconvenient  and  disfiffurino-,  and 
bespeak  no  peril  at  all. 

Let  us  first  consider  that  affection  in  which  the  majority  of  the  muscles  on  one 
side  of  the  face  alone  are  palsied.  I  have  already  briefly  touched  upon  this  form 
of  palsy  when  it  constitutes  a  part  of  hemiphlegia.  But  it  is  of  more  consequence 
■to  attend  to  it  when  it  occurs  without  any  similar  afl^ection  of  the  limbs.  If  the  arm, 
or  leg,  or  both,  are  paralyzed  at  the  same  time  with  one  side  of  the  face,  we  know 
that  the  whole  results  from  disease  in  the  brain,  or  in  the  upper  end  of  the  spinal 
cord.  But  it  is  not  necessarily  so  when  the  face  alone  is  palsied  ;  and  it  is  often  of 
great  moment  to  the  comfort  and  the  safety  of  the  patient,  that  we  should  be  able  to 
tell  whether  the  palsy  does  imply  disease  within  the  skull,  or  not. 

The  appearance  presented  by  patients  affected  with  facial  palsy  is  peculiar,  and 
very  striking.  From  one  half  of  the  countenance  all  power  of  expression  is  o-one ; 
the  features  are  blank,  still,  and  unmeaning.  The  other  half  retains  its  natural 
cast,  except  that,  in  some  cases,  the  angle  of  the  mouth  on  that  side  seems  drawn 
a  little  awry.  This  is  apt  to  be  mistaken  for  proof  of  a  spasmodic  condition  of 
that  part;  but  it  is  owing  simply,  as  I  stated  before,  to  the  want  of  the  usual 
balance  or  counterpoise  from  the  corresponding  muscular  fibres  of  the  palsied 
side.  The  patient  cannot  laugh,  or  weep,  or  frown,  or  express  any  feeling  or 
emotion  with  one  side  of  his  face,  while  the  features  of  the  other  may  be  in  full  play. 
One  half  of  the  aspect  is  that  of  a  sleeping,  or  of  a  dead  person  :  the  other  half  is 
alive  and  merry.  Tha  incoJigruity  would  be  ludicrously  droll,  were  it  not  so 
frightful  also,  and  distressing.  To  the  vulgar,  who  do  not  comprehend  the  pos- 
sible extent  of  the  misfortune,  the  whimsical  appearance  of  such  a  patient  is 
always  a  matter  of  mirth  and  laughter.  On  the  other  hand,  his  friends  and  rela- 
tions imagine  that  he  has  had  a  fit,  and  are  in  great  alarm  for  his  life.  In  th^ 
majority  of  these  cases  there  is  not,  however,  any  real  danofer  of  that  kind  to  be 
apprehended;  a  circumstance  which,  of  itself,  would  render  the  exact  diagnosis 
of  the  complaint  peculiarly  interesting.  In  general  there  is  no  deficiency  of  sen- 
sation. And,  vice  versa,  we  sometimes  have  loss  of  sensibility  in  the  same  parts, 
without  any  diminution  of  the  power  of  motion.  The  best  way,  I  believe,  to 
place  the  phenomena  of  these  curious  affections  plainly  be  tore  you,  will  be  by 
examples. 

A  housemaid,  Jane  Smith  by  name,  twenty-eight  years  old,  became  one  of  my 
out-patients  at  the  Middlesex  Hospital,  with  the  following  symptoms.  She  had  lost 
all  power  of  moving  the  right  side  of  her  face.  When  she  endeavoured  to  raise 
her  eyebrows,  the  right  side  of  the  forehead  remained  smooth,  and  the  left  was 
wrinkled.  When  she  attempted  to  close  her  eyes,  the  right  eye  was  but  partially 
covered,  the  eyeball  rolling  upwards,  and  carrying  the  cornea  within  the  curtain 
of  the  upper  lid,  which  descended  a  little  to  meet  it.  When  she  tried  to  snuff  in 
air  through  the  nose,  not  being  able  to  keep  the  right  nostril  stiff  and  open,  its  sides 
came  together,  and  no  air  passed  up  on  that  side.  ""When  she  smiled,  the  right  side^ 
of  the  face  remained  perfectly  still,  like  a  mask :  and  it  wore  at  all  times  a  vacant 
and  inanimate  character.  When  she  was  told  to  perform  the  action  of  blowing,  her 
right  cheek  was  puffed  out  like  a  loose  bag,  and  the  breath  issued,  whether  she 
would  or  no,  at  the  right  angle  of  her  mouth.  The  same  thing  happened  with  hep 
food  and  drink  ;  she  could  not  prevent  their  escaping  at  the  right  corner  of  her 
mouth :  nor  could  she  convey  morsels  of  food  from  the'right  to  the" left  jaw,  without 
the  aid  of  her  hand  applied  externally  in  support  of  the  paralyzed  cheek.  The 
masseter  and  temporal  muscles,  however,  acted  as  strondy  on  the  one  side  as  on  the 
other;  she  could  chew  perfectly  well  on  the  palsied  side,  and  the  sensation  of  the 
palsied  parts  remained  perfect ;  and  there  was  no  paralysis  of  any  other  part  of  th'« 
body. 

All  these  phenomena  are  invariably  met  with  in  all  complete  cases  of  tnis  Kmd. 
r  will  contrast  them  with  the  phenomena  presented  by  another  of  my  patients 
who  was.  in  the  hospital,  and  whose  name  was  Ann  Church.  I  give  their  names, 
that  I  may  the  more  readily  distinguish  the  one  from  the  other.  AVhen  this 
*-oman.  Church,  applied  for  admission,  she  complained  of  intense  pain,  witb 
22  2d 


338  FACIAL    PALSY. 

some  swelling  in  the  right  temple,  and  extending  thence  generally  over  the  right 
side  of  the  face  and  head.  It  was  soon  discovered,  however,  that  although  she 
complained  of  most  severe  pain  in  these  parts,  they  had  entirely  lost  their  ordinary 
sensibility  to  external  impressions.  She  felt  nothing  when  her  forehead,  or  cheek, 
or  nose,  or  chin,  was  touched  on  that  side.  In  short,  there  was  complete  wixs- 
thesia  of  the  right  half  of  the  face;  just  as  in  Smith's  case  there  was  complete 
pahy.  The  insensibility  was  very  exactly  limited  to  the  right  half,  and  termi- 
nated ahruptly  at  the  middle  line.  It  was  remarkably  evident  in  a  part  in  respect 
to  which  the  bj'standers  could  scarcely  be  deceived,  even  if  there  had  been  any 
reason  (which  there  was  not)  for  distrusting  the  patient's  own  statement.  The 
surface  of  the  ej'eball  is  proverbially  sensitive,  even  to  sHght  impressions.  But 
you  might  place  your  finger  upon  this  woman's  right  eye,  or  you  might  brush  it 
with  a  feather,  without  giving  her  the  smallest  pain,  or  producing  any  sensation  at 
all:  whereas,  on  the  left  side,  the  lightest  touch  caused  involuntary  shrinking, 
and  closure  of  the  eyelids,  and.  a  gush  of  tears.  She  declared  also  that  she  had 
no  feeling  in  the  right  half  of  her  mouth ;  she  neither  tasted  sapid  substances,  nor 
was  she  at  all  conscious,  from  any  sensation  produced  by  them,  that  they  were 
placed  there.  Her  lips  on  the  same  side,  were  equally  destitute  of  sensibility ; 
so  that  when  she  drank,  having  no  perception  of  the  contact  of  the  cup  with  her  lips 
beyond  their  middle  point,  she  felt  as  if  she  Avere  drinking  from  a  vessel  with  a 
broken  rim.  This  is  a  circumstance  which  all  persons  who  are  thus  affected  are 
much  struck  with :  and  it  almost  always  forms  a  part  of  their  voluntary  account 
of  themselves. 

Besides  this  defect  of  sensibihty,  the  power  of  contracting  the  masseter  and  tem- 
poral muscles  on  the  right  side  was  entirely  abolished  in  this  patient.  You  may 
deceive  yourselves  on  this  point,  if  yon  do  not  investigate  it  carefully,  and  with 
certain  precautions.  At  least  I  have  known  persons  doubt,  because,  having  directed 
the  patient  to  open  and  shut  his  mouth,  they  hav^e  confounded  the  movement  of  the 
w^hole  jaw  with  the  action  of  the  masseter  muscle.  But  if  you  tell  the  patient  first 
to  close  his  mouth,  and  then  to  perform  the  action  of  grinding  with  his  teeth, 
placing  your  fingers  at  the  same  time  on  the  corresponding  muscles  on  each  side, 
the  difference,  when  it  exists,  will  be  very  striking.  In  the  woman  of  whom  I 
speak,  no  swelling  of  the  masseter  or  temporal  muscle  on  the  affected  side  took  place 
when  she  forcibly  closed  her  jaw^s.     There  was  no  other  paralysis. 

Now  wf  cannot  separate  the  physiology  from  the  pathology  of  such  affections  as 
these.  Nor  ought  we.  The  morbid  conditions  of  which  the  two  cases  just  de- 
scribed furnish  samples,  illustrate  in  a  very  beautiful  manner  the  modern  doctrine 
respecting  the  special  uses  of  particular  nerves.  In  the  first  of  the  two  cases  the 
palsy  resulted  from  suppression  of  the  function  of  the  hard  portion  of  the  seventh 
pair  of  cerebral  nerves ;  and  the  anteslhesia,  in  the  last  of  the  cases,  depended  upon 
suspension  of  the  function  of  the  fifth  pair.  You  know  the  experiments  performed 
upon  living  animals  have  proved  that  the  division,  by  the  scalpel,  of  the  portio  dura, 
before  it  spreads  out  into  that  remarkable  nervous  net-^vork  on  the  side  of  the  face, 
paralyzes  all  the  muscles  the  combined  play  of  which  gives  varietj'  and  significant 
expression  to  the  countenance  ;  and  that,  on  the  other  hand,  the  division  of  the  fifth 
nerve  deprives  the  same  parts  of  their  sensibility.  In  these  two  cases,  and  in  such 
as  these,  for  they  are  by  no  means  infrequent,  a  similar  set  of  experiments  upon  the 
same  nerves,  in  "the  hi/man  living  body,  is  performed  before  our  eyes  by  the  agency 
of  the  disease,  or  accident;  and  the  result  justifies  most  completely  those  conclusions 
which  had  been  deduced  in  the  first  instance,  from  contrived  observations  made  upon 
the  lower  animals. 

There  is  one  point  in  the  history  of  these  cases  upon  which  I  must  dwell  a  mo- 
ment longer;  for  it  is  a  most  interesting  point.  That  the  condition  of  the  temporal 
and  masseter  muscles  should  be  reversed  in  two  patients  so  oppositely  situated,  was 
no  more  than  might  have  been  expected.  But  in  each  these  muscles  were  affected 
in  a  manner  the  very  contrary  of  that  which  the  general  circumstances  of  the  case 
•vould,  a  priori,  have  prepared  us  to  anticipate.  Where  the  superficial  muscles 
were  paralyzed,  and  the  principal  movements  of  the  face  suspended,  there  the  mas- 


FACIAL    PALSY.  339 

seter  and  temporal  muscles  were  in  full  power  and  action ;  and  where  the  loss  of 
st'usation  was  the  predominant  phenomenon,  and  the  ordinary  motion  and  expression 
of  the  countenance  remained,  there  these  muscles  were  in  a  slate  of  complete  palsy. 
A  few  years  only  ago,  this  difference  and  apparent  inconsistency  would  have  been 
quite  inexplicable.  The  progress  of  modern  science  has  removed  the  difficulty,  by 
establishing  a  general  agreement  between  the  functions  of  different  nerves,  and  cer- 
lain  observed  peculiarities  in  their  anatomical  relations  and  arrangements. 

Suffer  me  to  remind  you  (for  I  know  that  these  interesting  points  of  physiology 
must  have  already  been  taught  you)  that  the  nerves  which  proceed  from  the  spinal 
column  on  each  side  are  connected  with  it  by  two  fascicuh  of  nervous  fibrils  —  two 
roots,  as  they  are  metaphorically  called — of  unequal  size  ;  that  when  the  larger  of 
these,  which  is  situated  posteriorly,  and  is  furnished  with  a  ganglion,  is  divided  in  a 
living  animal,  the  parts  to  which  the  nerve  is  distributed  lose  the  faculty  of  sensa- 
tion, while  the  power  of  voluntary  motion  remains  unimpaired ;  and  that  when  the 
smaller  and  anterior,  which  has  no  ganglion,  is  alone  cut,  the  same  parts  are  instantly 
palsied,  but  retain  their  sensibility.  In  other  words,  the  posterior  fascicuh  minister 
to  the  faculty  of  sensation,  the  anterior  to  that  of  motion. 

Now  the  fifth  pair  of  nerves  was  observed  to  have  a  similar  origin ;  to  be  com- 
posed, that  is  to  say,  of  two  fasciculi  or  roots,  one  larger  than  the  other,  and  invested 
with  a  ganglion ;  the  other  smaller,  and  having  no  ganglion.  It  was  natural  to  infer 
that  the  function  of  these  roots  would  be  analogous  to  those  of  the  corresponding 
portions  of  the  spinal  nerves ;  that  the  ganglionic  fasciculus  would  relate  to  sensa- 
tion, and  the  other  to  motion.  And  such  is  found  to  be  the  case ;  and  the  arrange- 
ment here  is  very  curious.  The  smaller  portion  of  the  fifth  nerve  is  exclusively 
expended  upon  a  very  few  muscles  ;  viz.,  the  masseter,  the  temporal,  two  pterygoid 
muscles,  the  circumflexus  palati,  and  the  tensor  tympani.  The  action  of  the  first 
two  of  these,  of  the  masseter,  and  temporal  muscles,  is  obvious  to  common  observa- 
tion; and  therefore  their  condition  is  noticed  in  such  cases  as  I  have  related. 
Again,  these  very  same  muscles  have  been  shown,  by  careful  dissection,  to  receive 
no  nervous  branches  from  the  seventh  nerve,  which  is  a  motor  nerve,  and  which 
ramifies  so  abundantly  upon  the  superficial  muscles  of  the  face- 
It  was  to  be  expected,  therefore,  that  any  diseased  state  confined  to  the  portio  dura 
of  the  seventh  nerve,  would  leave  the  temporal  and  masseter  muscles  fully  effective: 
and  that  disease  involving  the  fifth  nerve,  but  leaving  the  seventh  untouched,  would 
destroy,  not  only  the  general  sensibihty  of  the  face  on  that  side,  but  also  the  power 
of  contracting  these  particular  muscles.  And  this  was  thoroughly  exemplified  in  the 
two  cases  that  I  have  detailed.  The  girl  Smith  had  total  palsy  of  the  superficial 
muscles ;  but  sensation,  and  the  action  of  the  deeper-seated  muscles,  continued  per- 
fect: while  in  the  woman  Church  there  were  default  of  sensibility,  and  paralysis  of 
the  temporal  and  masseter  muscles  :  but  the  movements  of  the  superficial  muscles 
were  unimpeded. 

Total  interruption  of  the  function  of  the  portio  dura  will  paralyze  these  superficial 
muscles  of  the  face :  and  such  interruption  may  be  occasioned  either  by  sudden 
injury  done  to  the  trunk  of  the  nerve  ;  or  by  disease  affecting  its  proper  structure  ; 
or  by  pressure,  the  consequence  of  disease  in  the  parts  contiguous  to  it.  And  it  is 
of  great  importance  to  observe  that  the  morbid  condition  which  causes  the  interrup- 
tion may  be  situated  in  any  part  of  the  course  of  the  trunk  of  the  nerve :  while  it  is 
yet  within  the  cranium ;  or  during  its  passage  through  the  petrous  portion  of  the 
temporal  bone  ;  or  after  it  emerges  upon  the  face,  through  the  stylo-mastoid  foramen, 
to  be  ultimately  spread  in  meshes  over  the  cheek  and  temple.  The  nerve  is  often 
compressed  or  hurt  while  still  within  the  skull ;  but  in  most  cases  of  this  kind  other 
portions  also  of  the  nervous  matter  are  involved  in  the  mischief,  and  other  sets  of 
voluntary  muscles  testify  this  by  their  immobility  or  their  irregular  action.  This  is 
sometimes  the  case  when  facial  palsy  occurs  as  a  part  of  hemiplegia.  In  many 
instances,  however,  of  hemiplegia,  there  is  but  slight  distortion  of  the  countenance,  a 
mere  hanging  of  the  cheek,  with  no  paralysis  of  the  orbicularis  muscle  of  the  eye» 
In  these  cases,  it  has  been  suggested  to  me  by  my  colleague.  Dr.  Todd,  that  the 
♦seventh  nerve  is  probably  not  affected  at  all,  but  the  motor  branch  of  the  fifth  nerve 


340  FACIAL   PALSY. 

only.  When  ihe  facial  muscles  alone  are  paralyzed,  it  happens  in  a  great  majority 
of  instances  that  the  nervous  function  is  interrupted  in  that  part  of  the  portio  dura 
which  Hes  incased  in  the  bone,  or  in  the  more  exposed  part  which  issues  in  front  of 
the  ear :  and  hence  it  arises  that  this  particular  form  of  palsy  is,  in  general,  unat- 
tended with  any  danger  to  life. 

The  physical  cause  of  this  remarkable  disfigurement,  and  the  true  explanation  of 
its  prevailing  immunity  from  danger,  were  first  pointed  out  by  Sir  Charles  Bell: 
but  both  the  existence  of  the  malady  as  a  distinct  form  of  disease,  and  its  compara- 
tive hannlessness  of  character,  had  been  observed  and  described  some  years  previ- 
ously :  although  the  reason  neither  of  the  one  nor  of  the  other  was  at  that  time 
understood.  Dr.  Powell  had  narrated,  in  the  fifth  ^volume  of  the  Transactions  of 
the  College  of  Physicians,  three  marked  instances  of  this  form  of  local  palsy;  and 
had  noticed  at  the  same  time  its  apparent  independence  of  any  apoplectic  tendency, 
or  cerebral  disease. 

The  exciting  causes  of  the  complaint  are  various.  Sometimes  it  is  the  conse- 
quence of  mechanical  violence,  by  which  it  is  plain  that  the  nerve  has  been  lace- 
rated, or  otherwise  injured.  Sir  Charles  Bell,  to  whom  we  are  indebted  for  much 
information  on  the  subject,  mentions  several  examples  of  this  kind.  In  one  a  man 
was  shot  by  a  pistol-ball,  which  entered  the  ear  and  tore  the  portio  dura  across  at  its 
root.  In  another,  the  patient  was  gored  by  an  ox ;  the  horn  of  the  animal  entered 
beneath  the  angle  of  the  jaw,  and  came  out  in  front  of  the  ear,  tearing  the  nerve 
across.  In  a  third,  the  nerve  was  divided  by  a  surgeon's  scalpel,  in  an  operation 
for  the  removal  of  a  tumour  which  lay  above  and  around  its  course.  In  all  these 
cases  the  injury  was  external  and  obvious.  In  a  fourth  the  palsy  followed  a  blow 
on  the  ear  which  caused  hemorrhage  from  that  part :  here  probably  the  nerve  was 
hurt  in  its  passage  through  the  bone.  Some  time  ago,  a  man  was  brought  into  the 
Middlesex  Hospital  who  had  fallen  from  a  height,  upon  his  head.  The  muscles  of 
the  left  side  of  the  face  were  paralyzed.  He  died  in  a  few  days ;  and  examination 
of  the  head  showed  a  fracture  in  the  base  of  the  skull,  passing  through  the  petrous 
portion  of  the  temporal  bone,  and  rending  the  seventh  nerve  at  its  entrance  into  the 
meatus  auditorius  internus.  In  the  year  1832  I  had  a  patient  (Richard  Hills)  in  the 
hospital  with  the  same  kind  of  paralysis,  which  seemed,  in  him,  to  have  been  occa- 
sioned by  a  mere  shock  or  jar.  He  was  a  coachman,  and  one  day,  when  he  was 
ofThis  box,  his  horses  started  away,  and  he  ran  to  their  heads  to  stop  them,  but  was 
thrown  down  in  the  attempt,  striking  his  hip  and  elbow.  He  received  no  blow  on 
the  head  at  all.  Three  hours  afterwards  he  found  that  he  could  not  spit  properly. 
The  affection  is  not  unfrequently  discovered  by  that  circumstance.  He  could  not 
avoid  spitting  on  his  clothes  on  one  side ;  and  he  could  not  whistle.  Another  cir- 
cumstance worthy  of  notice  took  place  in  this  man,  which  often,  though  not  always, 
happens  in  these  cases,  and  which  I  did  not  mention  before.  He  remained  for  about 
two  months  in  the  hospital ;  and  regained,  during  that  time  in  some  degree,  the 
power  of  exercising  the  affected  muscles  ;  but  he  still  was  unable  to  bring  the  ri^ht 
eyelids  together.  The  eye  itself  was  unharmed.  After  he  was  made  an  out-patient 
he  resumed  his  functions  on  the  coach-box ;  and  his  eye,  permanently  half-open  and 
unprotected,  was  more  exposed  to  cold  and  to  currents  of  wind  than  it  had  been 
when  he  was  an  in-patient.  Moreover,  he  got  drunk  ;  and  he  soon  presented  him- 
self again  with  universal  redness  and  inflammation  of  the  conjunctiva.  Sometimes 
the  inflammation  in  such  cases  produces  opacity  of  the  cornea  and  a  total  loss  of 
vision.  This  is  one  of  the  worst  consequences  of  facial  palsy.  Fortunately  it  is 
only  an  occasional  consequence :  and  it  will  occur  or  not,  according  to  the  quantity 
of  motion  which  remains  to  the  eyelids,  and  the  degree  of  exposure  to  the  ordinary 
causes  of  inflammation. 

Sometimes  the  palsy  depends  upon  manifest  external  disease ;  sometimes  upon 
disease  which  is  hidden,  and  probably  internal,  in  the  bony  canal.  Sir  C.  Bell 
describes  an  instance  in  which  it  accompanied  the  disorder  called  the  mumps.  Dr. 
Maiden,  of  Worcester,  witnessed  another  in  which  a  fixed,  hard,  indolent  tumour 
had  formed  between  the  ramus  of  the  lower  jaw  and  the  mastoid  process  of  iho 
temporal  bone.    As  this  tumour  gradually  subsided,  the  palsy  disappeared.    In  pnc]» 


FACIAL    PALSY.  341 

of  Dr.  Powell's  three  cases  the  affection  was  apparently  caused  by  exposure  of  the 
side  of  the  head  for  some  time  to  a  stream  of  cold  air.  A  medical  acquaintance  of 
mine  residing  in  London,  had  a  patient  at  Greenwich,  whom  he  visited  daily.  It 
was  cold  weather  ;  and  on  one  occasion,  as  lie  was  returning  in  the  cabin  of  a  steam- 
boat, he  was  sensibly  incommoded  by  a  keen  east  wind,  which  blew  through  an  open 
window  directly  upon  his  ear.  The  next  day  he  presented  himself  to  me  with  that 
side  of  his  face  fixed  in  the  manner  I  have  been  describing.  Exactly  the  same 
mishap  befell  a  Scottish  physician  while  travelling  to  London  by  a  coach ;  and  sent 
him  in  great  alarm  to  Sir  C  Bell.  Some  years  ago  a  marked  example  of  facial  palsy 
occurred  in  one  of  my  hospital  patients ;  it  appeared  to  be  owing  to  his  having  been 
constantly  in  the  streets  for  some  days  without  shoes  or  stockings,  during  a  cold  thaw. 
It  may  be  presumed  that  in  these  instances  some  swelling  was  produced  in  the  soft 
parts  around  the  nerve,  compressing  it  where  it  lies  within  the  unyielding  bone. 
Exposure  to  cold  in  this  way  is  the  commonest  of  all  the  exciting  causes  of  the  com- 
plaint, and  cases  thus  arising  are  more  obedient  to  treatment  than  most  others.  Pro- 
bably some  of  you  saw  a  female  patient  who  came  under  my  care  in  the  hospital  in 
May  last  (1838),  in  Avhom  facial  palsy  had  existed  on  one  side  for  eighteen  years. 
When  about  three  years  old  she  had  the  measles ;  and  a  scrofulous  tumour  formed 
behind  the  ear,  and  broke ;  and  after  some  time,  a  portion  of  carious  bone  came 
away.  Then  the  wound  healed  (of  which  deep  traces  are  still  visible) ;  and  the 
peculiarity  of  her  features  was  observed.  There  are  still  other  cases  in  which  we 
fail  to  discover  any  direct  explanation  of  the  paralysis,  either  in  the  history  of  the 
patient,  or  in  his  physical  condition.  In  the  girl  Smith,  whose  symptoms  I  stated 
in  detail  as  an  example  of  the  appearances  uniformly  present,  the  malady  came 
on  without  any  obvious  cause,  and  it  resisted  all  the  means  employed  for  its 
removal. 

That  the  greater  number  of  cases  of  this  kind  are  free  from  serious  peril,  is  a  fact 
of  great  practical  importance.  It  enables  us  to  quiet  the  alarm  of  the  patient  and  of 
his  family:  and  it  regulates  in  many  instances  the  treatment;  rendering  it  less 
severe  tjian  it  might  and  ought  to  be,  if  the  palsy  were  really  the  harbinger  of  apo- 
plexy. At  the  same  time  you  should  not  be  ignorant  that  a  similar  limitation  of 
paralysis  to  the  particular  muscles  supplied  by  the  portio  dura  is  sometimes  (tnough 
rarely)  observed,  when  the  disease  has  a  more  inward  origin  ;  when  it  affects  and 
involves  the  brain  itself.  The  following  case  caused  me  much  anxiety,  for  the  sub- 
ject of  it  was  a  personal  friend  of  mine.  —  I  was  summoned  to  his  house  in  the 
autumn  of  1820,  and  found  him  with  complete  palsy  of  the  left  side  of  the  face.  It 
had  existed  a  day  or  two.  I  shall  not  describe  the  appearances  and  symptoms  that 
resulted  from  the  paralysis ;  for  they  were  precisely  the  same  as  were  presented  by 
the  girl  Smith ;  and  they  are  always,  and  necessarily,  very  much  alike.  But  though 
the  palsy  was  strictly  limited  to  this  set  of  muscles,  there  were  other  symptoms  pre- 
sent which  indicated  that  the  interruption  of  the  functions  of  the  portio  dura  was 
connected  with  some  morbid  condition  within  the  cranium :  nausea  and  vomiting, 
twitchings  of  the  muscles  of  the  other  side  of  the  face,  great  drowsiness,  and  a  slow 
pulse,  48  only  in  the  minute.  He  lurched  also,  and  staggered  as  he  walked ;  but 
he  distinguished  this  from  the  reeling  of  vertigo,  and  denied  the  latter  sensation 
altogether.     He  was  deaf  too,  on  the  affected  side. 

His  previous  history  did  not  tend  to  diminish  the  fears  which  his  actual  state 
excited. 

In  the  preceding  February  he  had  been  attacked,  rather  suddenly,  with  intense 
pain  just  above  the  right  eyebrow,  and  became  extremely  drowsy.  Being  desirous, 
on  account  of  these  feelings,  to  excuse  himself  from  a  dinner  engagement,  he  found 
that  he  was  unable  to  write  a  proper  note :  he  could  not  remember  how  he  ought  to 
express  himself. 

All  these  symptoms  soon  passed  off;  after  the  operation,  I  beheve,  of  an  emetic. 
But  he  had  another  attack  of  the  same  kind  in  the  subsequent  May  :  the  same 
severe  pain  over  the  right  brow,  wiih  great  drowsiness  and  confusion  of  mind.  Ho 
could  rot  recollect  the  first  line  of  the  ^Eneid.  He  wished  a  friend  to  look  at  the 
signatures  of  some  letters  that  had  arrived :  and  though  he  knew  the  root,  he  could 

3d3 


342  FACIAL    PALSY. 


1 


rot  tell  how  the  word  he  wished  to  use  was  formed ;  whether  it  was  sionition,  or 
sig-nation,  or  signature.  The  digestive  organs  on  this  occasion  were  made  the  object 
of  treatment,  and  he  soon  got  well. 

There  was  another  instructive  part  of  his  history ;  and  therefore  I  mention  it. 
Before  these  attacks  he  was  in  the  habit  of  eating  and  drinking  freely ;  and  his 
power  of  digestion  was  supposed  to  be  enormous.  After  the  attack  in  May  he 
commenced  a  strict  course  of  temperance.  He  drank  no  wine  till  three  or  four 
days  before  the  occurrence  of  the  facial  palsy:  he  had  then  taken  it  again,  and  had 
about  four  glasses  daily  ;  and  on  one  of  the  days  he  drank  two  glasses  of  champagne. 

It  was  of  some  moment  to  this  gentleman,  not  only  that  he  should  recover,  but 
that  he  should  recover  quickly.  He  had  been  appointed  by  government  to  a  mission 
to  Ceylon,  and  all  his  equipment  was  already  on  board  a  vessel,  which  would  sail  in 
a  fortnight. 

Cupping  behind  the  ears,  Mistering,  purgatives,  and  small  doses  of  calom.el  con- 
tinued till  the  gums  were  slightly  sore,  removed  the  paralysis,  and  all  the  other 
symptoms,  in  about  ten  days.  He  went  to  Ceylon,  and  performed  his  mission  so 
ably  that  after  his  return  the  government  appointed  him  to  one  of  far  greater  import- 
ance in  India,  where  he  now  is.  He  has  remained  perfectly  well ;  and  possesses 
one  of  the  clearest  and  strongest  intellects  that  I  am  acquainted  with. 

I  must  trouble  j^ou  with  one  more  case,  to  complete  the  history  of  this  disease  :  a 
case  in  which  the  cause  of  the  facial  palsy  was  situated  within  the  cranium  and 
proved  fatal,  and  became  visible  after  death. 

Samuel  Dobey,  a  tailor,  fifty-seven  years  old,  was  admitted  under  my  care  into  the 
hospital,  in  February,  1833,  with  complete  palsy  of  the  muscles  supplied  by  the 
portio  dura  on  the  right  side ;  and  of  no  others.  There  were  symptoms  enough, 
however,  to  show  that  some  serious  mischief  was  going  on  within  the  skull.  He 
suffered  intense  headache,  more  on  the  left  than  the  right  side ;  was  dizzy  and  stag- 
gering ;  and  could  not  get  to  the  ward  without  being  led. 

The  palsy  had  come  on  about  ten  days  before,  in  the  night.  He  found  when  he  came 
down  stairs  the  next  morning  that  he  could  not  spit  as  usual,  and  his  friends  observed 
the  unnatural  state  of  his  features.  He  had  had  no  fit,  nor  loss  of  consciousness  ; 
but  he  thought  his  memory  was  failing.  At  the  time  when  the  paralj-sis  was  first 
noticed,  he  had  some  numbness  and  tingling  of  the  right  arm,  extending  to  the  last 
two  fingers.  He  was  quite  deaf  in  the  right  ear.  This  is  a  point  deserving  attention 
in  such  cases.  The  deafness,  when  it  occurs,  marks  an  affection  of  both  the  por- 
tions of  the  seventh  nerve ;  and  therefore  indicates  the  probability  of  an  internal 
cause. 

The  whole  progress  of  this  case  was  very  interesting;  but  I  must  confine  myself 
to  those  circumstances  which  bear  upon  our  present  topic.  He  lived  about  a  month 
after  his  admission,  and  during  that  interval  he  suffered  great  pain  in  the  head, 
was  delirious  at  times,  and  at  other  times  in  a  state  of  coma  :  at  one  period  he 
suddenly  presented  the  ordinary  symptoms  of  apoplexy,  from  which  he  partly 
recovered. 

I  found  a  cancerous  tumour  occupying  the  right  hemisphere  of  the  brain ;  at  its 
under  part  was  an  apoplectic  clot,  as  big  as  a  hazel-nut.  I  found,  also,  a  very  satis- 
factory explanation  of  the  deafness  and  of  the  facial  palsy  which  had  been  noticed 
during  his  hfetimiC.  The  portio  dura  and  the  portio  mollis,  where  they  emerge  as 
distinct  cords  from  the  medulla  oblongata  on  the  right  side,  were  adherent  to  each 
other.  The  portio  dura  was  both  harder  and  larger  than  the  corresponding  nerve 
on  the  opposite  side,  while  the  portio  mollis  was  wasted  and  diffluent.  The  same 
change  was  traced  up  to  their  entrance  into  the  petrous  portion  of  the  temporal  bone. 
Immediately  over  the  medulla  oblongata,  and  in  a  vertical  line  above  the  point  of 
emergence  of  the  seventh  pair  of  nerves,  a  nipple-like  portion  of  brain  projected 
downwards,  and  had  apparently  communicated  pressure  to  these  nerves  ;  and  this 
projection  from  the  lower  surface  of  the  brain  seemed  to  have  been  produced  by  the 
general  pressure  resulting  from  the  growth  of  the  tumour. 

The  remarks  which  I  have  been  applying  {o  palsy  of  these  parts  hold  true  also  m 
respect  to  their  loss  of  sensibility.     The  anaesthesia  may  or  may  not  portend  danger 


LOCAL    ANAESTHESIA.  343 

to  life,  according  as  the  interruption  of  nervous  function  on  which  it  depends  is 
situated  more  or  less  near  to  the  origin  of  the  fifth  pair  of  nerves  in  the  brain.  The 
patient,  Church,  whose  case  I  have  several  times  referred  to  in  this  lecture,  left  the 
hospital  with  the  sensibihty  of  her  face  nearly  as  perfect  as  ever.  The  treatment 
consisted  in  local  blood-letting  and  counter-irritation.  She  had  erysipelas  of  the 
head  while  in  the  hospital,  and  was  in  some  danger  from  that  complaint,  which  was 
attended  with  a  good  deal  of  fever  and  delirium.  With  the  exception  of  the  delirium, 
which  belonged  no  doubt  to  the  erysipelas,  there  was  no  reason  to  suspect  any  affec- 
tion of  her  brain. 

I  have  incidentally  adverted  to  the  plan  of  treatment  to  be  pursued  in  these  cases 
of  facial  palsy.  When  the  complaint  is  recent,  and  has  an  obvious  cause,  the  appro- 
j)riate  remedies  will  readily  suggest  themselves.  When,  for  example,  it  fias  come 
on  after  exposure  to  a  current  of  cold  air,  or  after  a  blow,  or  any  circumstance  hkely 
to  give  rise  to  inflammation,  you  must  treat  the  case  as  you  would  treat  inflammation  ; 
bearing  always  in  mind  that  a  sniall  amount  of  disorganization,  a  little  thickeninsf  or 
induration  of  the  parts  around  the  nerve,  may  render  the  deformity  and  the  incon- 
venience permanent .  If  there  be  inflammatory  fever,  bleed  from  the  arm  :  if  there 
be  not,  take  blood  from  the  neighbourhood  of  the  affected  nerve  by  cupping:  apply 
fomentations  ;  or,  what  is  better  in  these  cases,  conduct  the  steam  of  hot  water  against 
and  into  the  ear  :  and  administer  mercury  so  as  just  to  touch  the  gums.  I  should 
always  take  this  latter  precaution,  lest  any  effusion  of  lymph  should  cause  abidino- 
pressure  on  the  nerve.  If '  the  palsy  gives  way  before  the  gums  become  tender,  the 
mercury  need  not  be  pressed  further. 

Where  there  is  any  ground  to  suspect  that  the  brain  is  implicated,  the  treatment 
just  described  must  be  pursued  with  greater  diligence,  and  with  such  modifications 
as  the  nature  of  the  case  may  require.  If  there  be  evidence  of  chronic  disease  m 
the  petrous  portion  of  the  temporal  bone,  such  as  tenderness  of  the  mastoid  process, 
deafness,  a  protracted  discharge  from  the  ear,  and  an  imperfect  state  of  the  membrana 
tympani,  we  can  scarcely  expect  much  good  from  very  active  treatment.  We  must 
then  have  recourse  to  counter-irritation,  and  such  other  measures  as  I  spoke  of  when 
the  subject  of  otitis  was  briefly  considered. 

The  examples  which  are  met  with,  of  local  palsy  and  local  ancesthesia,  are 
numberless  ;  but  those  which  I  have  mentioned  are  the  most  common  and  the  most 
important.  They  are  always  deserving  of  attention ;  but  more  so  when  any  sus- 
picion arises  that  they  may  be  connected  with  cerebral  disease.  Sometimes  they 
evidently  have  no  such  connection.  In  the  month  of  November,  1834,  a  coachman 
became  my  patient  in  the  hospital,  with  incomplete  paralysis  affecting  some  of  the 
muscles  of  the  right  leg  alone,  with  numbness  of  the  foot.  He  could  both  stand  and 
walk ;  but  on  advancing  that  leg,  his  foot  flapped  suddenly  down,  and  he  could  not 
deliberately  direct  and  plant  it,  like  the  other.  His  general  health  was  quite  good  ; 
he  had  no  headache,  nor  giddiness,  nor  palsy  of  any  other  part.  But  a  month  ago 
he  had  been  sitting  with  the  right  leg  thrown  over  the  opposite  knee  ;  and  he  con- 
tinued in  that  position  until  the  foot  felt  numb  and  tingling,  and  was  (what  is  called) 
asleep ;  and  it  had  remained  in  the  same  condition  from  that  time.  After  some 
general  treatment  (cupping  and  purgatives)  before  he  came  to  the  hospital  —  treat- 
ment which  was  quite  proper  in  the  way  of  precaution,  but  which  was  probably,  in 
truth,  unnecessary  —  I  had  his  leg  electrified;  and  in  about  ten  Jays  the  sensation 
and  the  power  of  the  limb  were  almost  restored.  Mr.  Shaw  mentions  a  somewhat 
similar  case,  in  which  anaesthesia  of  the  hand  was  produced  by  strong  pressure  made 
upon  the  wrist. 

There  are  some  very  curious  facts  connected  with  anresthcsia,  showing  that  thi. 
voluntary  exercise  of  the  muscles  is  regulated  in  some  measure  by  the  sensations  of 
the  limb  that  is  employed.  The  sense  of  resistance  prompts  to  such  contraction  of 
the  muscles  as  is  required  to  balance  that  resistance  ;  reminding  the  will  (so  to  speakj 
of  the  necessity  that  exists  for  its  perpetual  and  vigilant  operation.  Continued 
volition  is  essential  to  the  continuance  of  the  muscular  tension.  Thus  Dr.  Yellol-y 
descrioes  a  woman  who  had  no  power  of  feeling  in  her  hand  and  fingers,  althouglt 
the  power  of  moving  them,  and  of  grasping  any  objects,  was  entire.     This  woman 


344  REMARKABLE    CASES. 

found  that  she  could  carry  glasses  or  plates  in  that  haiid  very  well  and  safely,  if  she 
continued  to  look  at  and  attend  to  them :  but  if  her  eyes  were  turned  another  way, 
as  she  did  not  feel  what  she  held,  she  was  very  apt  to  drop  it.  Dr.  Ley  met  with 
just  such  another  case.  A  woman  had  defective  sensibility  on  one  side  of  the  body  : 
she  could  hold  her  child  in  the  arm  of  that  side  so  long  as  her  attention  was  directed 
to  it ;  but  if  surrounding  objects  diverted  her  from  taking  notice  of  the  state  of  her 
arm,  the  flexor  muscles  soon  began  to  slacken,  and  the  child  was  in  danger  of  falling. 
All  this  is  exceedingly  curious. 

Andral  has  recorded  a  most  singular  example  of  local  anfesthesia,  which  preceded 
an  attack  of  apoplexy.  The  patient  lost,  from  lime  to  time,  all  sensation  in  certain 
isolated  parts  of  the  skin  upon  the  thorax ;  there  were  five  or  six  of  these  insensible 
spots,  each  about  the  size  of  a  five-franc  piece.  You  might  pinch  the  skin  in  these 
places  without  producing  the  slightest  feeling  in  the  patient.  In  all  other  parts  the 
sensibility  was  perfect  and  lively. 

There  are  other  cases  also  on  record,  more  remarkable  still;  in  which  the  patients 
have  lost  both  the  power  of  motion  and  the  faculty  of  sensation  in  almost  every  part 
of  the  body,  and  yet  have  survived  for  a  considerable  time.  Thus  one  person 
(whose  case  is  related  in  the  Bulletin  des  Scieiiccs  Medicales  for  January,  1S28,) 
became  first  amaurotic,  then  deaf,  and  then  by  degrees  lost  all  power  of  sensation 
and  motion  except  in  the  tongue  and  in  the  muscles  of  deglutition  and  respiration. 
His  speech  and  intellects  were  unimpaired.  It  was  accidentally  discovered  that  a 
small  patch  on  the  right  cheek  retained  its  sensibility  ;  and  by  tracing  letters  on  ihia 
sensible  spot,  his  wife  and  children  were  enabled  to  interchange  ideas  with  him.  He 
died  at  length,  and  his  body  was  not  examined. 

I  shall  finish  what  1  have  to  say  on  this  head,  by  relating  a  case  of  the  same  kind, 
which  occurred  under  Dr.  Abercrombie's  notice ;  and  which  we  are  sure  therefore 
would  be  observed  with  care,  and  recorded  with  fidehty. 

A  servant  girl,  about  20  yeai-s  old,  sprained  her  back  in  lifting  some  heavy  article 
of  furniture.  She  felt  no  great  inconvenience  at  the  time  ;  but  some  liule  while 
after,  weakness  of  the  legs  came  on,  and  gradually  increased  to  complete  paraplegia. 
After  an  interval,  the  affection  extended  to  her  arms,  and  she  then  had  not  a  vestige 
of  motion  of  any  of  the  parts  below  the  head,  except  a  very  slight  movement  of  one 
of  the  fingers :  but  the  internal  functions  were  all  perfect,  and  her  speech  was 
distinct,  except  that  in  speaking  she  was  sometimes  seized  with  spasmodic  twitches 
of  the  lips  and  lower  jaw.  She  lived  in  that  state,  without  any  change  of  the 
symptoms,  and  her  general  health  continuing  good,  for  about  twenty  years.  In  the 
morning  she  was  taken  out  of  bed,  and  placed  in  a  chair,  so  contrived  as  to  support 
her  in  a  sitting  posture.  Her  arms  rested  on  a  cross  board  which  passed  before  her ; 
and  if  by  any  accident  one  of  them  slipped  from  this  support,  she  had  no  resource 
but  to  call  for  the  assistance  of  another  person  to  replace  it.  Having  been  on  one 
occasion  left  alone  for  about  two  hours  after  one  of  her  arms  had  thus  slipped  down, 
the  hand  had  become  extensively  oedematous.  In  the  same  manner,  if  her  head 
fell  forward  upon  the  thorax,  it  remained  in  that  position  until  raised  by  an  atten- 
dant. Her  mind  was  entire.  She  died  after  four  days'  illness  with  symptoms  of 
low  typhus  fever.  You  may  suppose  that  Dr.  Abercrombie  looked  with  the  greatest 
interest  for  the  cause  of  these  most  remarkable  symptoms.  "  I  examined  the  body 
v.'ith  the  utm.ost  care,  (says  he,)  along  with  Dr.  Pitcairn,  who  had  been  in  the  habit 
of  seeing  her  for  several  3'ears  ;  and  we  could  not  discover  any  disease  either  in  the 
brain  or  in  the  spinal  cord." 

It  is  much  to  be  regretted  that  when  this  case  was  under  observation,  the  excito- 
inotory  functions  were  not  understood,  nor  attended  to. 

I  shall  next  proceed  to  consider  those  diseases  (and  there  are  several  of  them) 
which  are  marked  by  definite  symptoms,  which  consist  essentially  in  some  disturb- 
ance or  disorder  of  the  nervous  system,  but  which  are  not  accounted  for  by  any 
physical  changes  that  we  can  appreciate  in  any  part  of  that  system.  After  some  of 
lliese  diseases  we  do,  to  be  sure,  sometimes  meet  with  morbid  appearances  in  the 
bmin  or  the  spinal  marrow :  but  none  that  are  constant,  or  uniform. 


TETANUS.  345 


LECTURE  XXXII. 

Tetanus.      Its   Symptoms  and   Varieties.      Causes.      Diagnosis.      Pathology 
Treatment :  Opium  ;   Blood-letting ;  the  Warm  Bath  ;  the  Cold  Bath. 

In  those  diseases  of  the  nervous  system  which,  have  hitherto  engaged  our  attention, 
the  function  of  voluntary  motion,  when  it  has  been  affected  at  all,  has  mostly  suffered 
in  the  way  of  diminution,  or  suspension  ;  the  power  of  moving  has  been  impaired, 
or  lost ;  there  has  been  complete  or  incomplete  palsy.  Sometimes,  indeed,  convul- 
sion, or  an  irregular  and  involuntary  action  of  the  muscles,  has  also  occurred.  But, 
distinct  from  the  paralytic  affections,  there  is  a  class  of  spasmodic  diseases,  of  which 
it  is  the  main  and  leading  feature,  that  the  function  of  voluntary  motion  is  (not  mor- 
bidly heightened,  as  in  the  preternatural  strength  of  a  madman ;  nor  lowered,  as  in 
palsy;  hut)  perverted :  performed  in  an  irregular  and  unnatural  manner. 

There  are  two  sorts  of  spasm.  One  of  these  is  marked  by  a  long-continued  con- 
traction of  the  affected  muscles,  not  rapidly  akernating  with  relaxation  :  the  relaxa- 
"tion  taking  place  slowly,  after  some  time  :  and  then,  perhaps,  the  contraction,  after 
another  interval,  coming  on  again.  This  is  called  tonic  spasm ;  and,  by  Cullen, 
spastic  rigidity.  A  very  familiar  example  of  it  is  the  common  cramp  of  the  leg.  In 
the  other  form  of  spasm,  the  contractions  of  the  affected  muscles  take  place  repeat- 
edly, forcibly,  and  in  quick  succession;  and  the  relaxation  is,  of  course,  as  sudden 
and  frequent.  This  has  been  named  clonic  spasm.  We  find  illustrations  of  it  in 
convulsions. 

Sometimes  the  two  are  mixed  together  in  the  same  disease  ;  certain  muscles  under- 
going convulsions  or  clonic  spasm,  and  certain  other  muscles  being  affected  with 
rigidity  or  tonic  spasm.     But  it  is  convenient  to  keep  the  distinction  in  mind. 

We  recognize  these  disorders  by  the  unnatural  conditions  of  the  muscles  ;  but  you 
will  please  remember  that  the  fault  lies  in  the  nervous  system. 

With  regard  to  spasmodic  diseases  generally,  I  may  say  that  some  of  them  con- 
stitute the  most  appalling  and  fatal  maladies  to  which  the  human  body  is  liable  ;  and 
some  of  them,  though  frightful  to  look  upon,  and  productive  of  extreme  distress  to 
patients  and  to  their  friends,  are  trivial  in  their  consequences,  and  scarcely  ever 
attended  with  any  peril  to  life. 

I  propose  first  of  all  to  consider  one  of  the  most  formidable  and  worst  of  these 
spasmodic  diseases,  viz.,  tetanus ;  of  which  tonic  spasm  is  essentially  chamcteristic. 
Its  name  is  derived  from  rstVu,  to  stretch. 

In  respect  to  all  those  diseases  concerning  the  exact  pathology  of  which  w'e  are 
ignorant,  and  which  we  identify  b}''  the  group  of  symptoms  they  present,  rather  than 
by  any  organic  changes  of  structure  in  any  part  of  the  body,  the  most  convenient 
mode  of  proceeding  will  be,  first  to  describe  the  distinctive  symptoms. 

Tetanus,  then,  is  characterized  by  an  involuntary,  long-continued,  violent,  and 
painful  contraction — in  one  word,  by  cramp  of  the  voluntary  muscles  of  various 
parts,  or  of  nearly  the  whole  body. 

There  is  no  difficulty  in  recognizing  the  disease  Avhen  it  is  fully  formed.  But  it 
is  of  much  importance  to  be  aware  of  the  marks  of  its  approach,  and  of  its  earhest 
symptoms ;  in  respect  to  the  treatment  to  be  then  adopted. 

In  general,  the  muscles  that  seem  to  be  the  earliest  affected  are  those  of  the  neck, 
jaws,  and  throat.  The  patient  feels  a  difficulty  and  uneasiness  in  bending  or  turning 
his  head;  and  supposes  that  he  has  got  what  is  called  a  stiff  neck.  He  finds  also 
that  he  is  unable  to  open  his  mouth  with  the  customary  facility.  At  length  the  jaws 
close  :  sometimes  gradually,  but  with  great  firmness ;  sometimes  (it  is  said)  suddenly, 
and  with  a  snap.  In  four  cases,  perhaps,  out  of  five,  the  disease  begins  in  this  way, 
with  trismus  or  locked  jaiv  ;  so  that  this  last  is  the  vulgar  name  for  the  complaint. 
Along  with  this  symptom,  or  very  soon  after  it,  the  muscles  concerned  in  swallowing 
become  affected  ;  and  in  a  short  time  there  comes  on,  what  is  often  the  most  distress- 
ing part  of  the  disorder,  an  acute  pain  at  the  lower  part  of  the  sternum,  piercing 


346  TETANUS. 

thiougli  to  the  back.  This  depends,  it  can  scarcely  be  doubted,  upon  cramp  of  the 
diaphragm.  The  pain  is  subject  to  aggravation  in  paroxysms ;  and  each  paroxysm 
of  pain  is  attended  with  increased  contraction  of  the  other  parts  also  that  are  impli- 
cated. The  spasm  extends  to  the  muscles  of  the  trunk;  to  the  large  muscles  of  the 
extremities  ;  the  muscles  of  the  face;  and  last  of  all,  in  general,  to  the  muscles  of 
the  tongue,  and  of  the  hands  and  fingers,  which  often  remain  movable  at  the  wall 
of  the  patient,  after  all  the  other  voluntary  muscles  of  the  body  have  become  fixed ; 
and  frequently  the  muscles  of  the  wrists  and  hands  escape  altogether. 

With  respect  to  all  the  muscles  involved,  from  the  time  when  they  are  first 
afltcted  to  the  time  when  the  disease  is  relieved,  or  the  patient  dies,  they  continue  in 
a  state  of  contraction,  and  are  swelled  and  hard  in  their  centres.  The  jaw,  for  in- 
stance, can  never  be  completely  opened ;  and  the  muscles  of  the  abdomen  are  so 
rigid  as  to  make  it  as  hard  as  a  board.  But,  besides  this,  they  are  all  subject  to 
aggravations  or  exacerbations  of  the  spasm,  which  occur  perhaps  every  ten  minutes, 
or  quarter  of  an  hour,  and  last  for  two  or  three  minutes  at  a  time ;  and  then  the 
muscles  fall  back  into  the  minor  degree  of  contraction  in  which  they  were  prior  to 
the  exacerbation.  In  a  very  few  instances  only  has  a  perfect  remission  of  the  spasm 
been  observed.  The  exacerbations  usually  begin  by  an  increase  of  the  pain  fell  at 
the  sternum.  Sometimes  there  is  no  obvious  exciting  cause  of  their  occurrence ; 
but  frequently  it  is  evident  that  they  are  brought  on  by  exertions  of  the  body  ;  even 
by  slight  movements,  such  as  belong  to  a  change  of  posture,  to  the  attempt  at  swal- 
lowing, or  speaking.  As  the  disease  advances,  these  paroxysms  of  aggravation 
become  more  frequent,  and  a  rapid  increase  in  the  frequency  of  their  recurrence  is 
one  of  the  most  unequivocal  signs  that  the  case  is  severe  and  dangerous.  The  more 
speedil}^  the  intervals  between  the  paroxysms  shorten,  the  worse. 

It  is  a  curious  thing,  that  the  spasm  is  observed  to  give  way,  sometimes  at  least, 
and  the  muscles  to  be  relaxed,  during  sleep.  To  be  sure,  in  the  severer  cases,  the 
patient  is  seldom  able  to  sleep ;  and  it  may  be  that  in  the  less  violent  instances,  the 
spasm  abates  or  ceases,  and  the  exhausted  sufferer  sinks  into  repose,  in  consequence 
of  this  abatement.  However,  a  similar  phenomenon  occurs  in  at  least  another  of 
these  spasmodic  diseases,  as  we  shall  see  hereafter.  Mr.  iNIayo  had  a  boy  afflicted 
with  tetanus,  in  the  Middlesex  Hospital.  On  visiting  him  one  day,  he  found  him 
asleep,  and  remarked  that  he  lay  perfectly  relaxed.  The  abdominal  muscles  w^ere 
soft  and  yielding,  and  had  not  the  least  tension.  The  boy  was  awakened,  and  at  the 
instant  the  full  tension  of  the  muscles  returned.  Not  being  further  disturbed,  he  fell 
asleep  again  in  a  few  minutes,  when  the  muscles  again  slackened ;  and  again,  upon 
his  being  a  second  time  aroused,  resumed  the  state  of  spasm. 

In  most  cases  the  strong  muscles  of  the  back  are  the  most  affected,  and  they 
overcome  those  on  the  anterior  part  of  the  body  ;  so  that  sometimes  the  patient 
during  the  paroxysm  rests  only  upon  his  head  and  his  heels,  while  his  body  is 
raised  into  the  shape  of  an  arch.  This  form  of  the  complaint  is  called  opisthotonos, 
a  bending  backwards.  The  sterno-mastoid  muscles  of  the  neck  have  been  so 
stretched  and  misplaced  as  to  become  powerful  extensors  of  the  head.  In  a  few 
instances  the  body  is  bent  forwards,  so  that  the  head  and  knees  are  in  contact,  and 
the  patient  is  rolled  together  like  a  ball.  This  is  called  emproslhotonos.  In  the 
only  example  of  emprosthotonos  which  I  ever  saw,  these  two  conditions  alternated 
with  one  another.  The  patient  was  a  girl  in  Edinburgh,  under  the  care  of  a  friend 
of  mine,  who  took  me  to  see  her.  It  was  a  case  of  hysteria  rather  than  of  tetanus  ; 
but  all  at  once  she  would  be  drawn  into  a  position  such,  that  the  top  of  her  head, 
and  her  feet,  were  alone  supported  on  the  bed,  while  her  body  was  bent  backwards, 
like  a  bow  ;  then,  after  a  time,  with  equal  suddenness,  the  opposite  posture  was  as- 
sumed, her  forehead  and  knees  being  brought  together.  Still  more  rarely  the  body 
is  bent  to  one  side.  This  is  pleurosthotonos,  or  tetanus  lateralis ;  and  this  I 
never  saw.  Sometimes,  again,  in  the  height  of  the  spasm,  the  antagonist  muscles 
counteract  each  other  exactly  ;  and  the  head  and  trunk  are  rigidly  extended  ;  and 
ine  term  tetanus  is  by  some  writers  confined  to  this  form  of  the  disease.  It  is  called 
trismus  when  the  jaw  only  is  affected. 

It  is  well  to  know  that  thfise  varieties  occur,  and  may  be  looked  for ;  but  in  all  of 


TETiiNUS.  347 

them — trismus,  opisthotonos,  emprosthotonos,  or  pleurosthotonos — it  is  the  same  dis- 
ease ;  and  the  j  rognosis  is  not  altered,  any  more  than  the  diagnosis,  by  the  variety 
that  happens. 

»  During  the  fit  of  exacerbation,  the  aspect  of  the  sufferer  is  often  frightful.  The 
forehead  is  corrugated  and  the  brow  knit,  the  orbicularis  muscle  of  the  eye  rigid, 
the  eyeball  motionless  and  staring,  the  nostril  spread,  the  corners  of  the  mouth  are 
drawn  back,  the  set  teeth  exposed,  and  all  the  features  fixed  in  a  ghastly  grin — the 
true  rlsus  sardouicus.  The  tongue  is  apt  to  get  between  the  teeth,  and  to  be 
severely  bitten. 

All  the  contractions  are  attended  with  intense  pain.  You  may  form  some  notion 
of  the  severity  of  this  pain,  if  you  have  ever  been  troubled  by  spasm  of  the  gas- 
trocnemius, or  cramp  of  the  leg,  and  if  you  can  bring  your  mind  to  conceive  that 
the  same  sensation  which  you  then  felt  in  the  calf,  involves  nearly  all  the  voluntary 
muscles  of  the  body.  The  pain  is  worst  during  the  exacerbations,  and  that  which 
is  experienced  at  the  sternum  is  commonly  the  most  complained  of.  Even  to  this, 
however,  there  are  occasional,  though  very  rare,  exceptions.  Sir  Gilbert  Blane  has 
described  a  case  of  tetanus,  which  ran  the  usual  course,  and  terminated  fatally,  yet 
the  patient  suffered  no  pain :  the  sensation  excited  by  the  violent  muscular  con- 
tractions was  a  sort  of  tinghng,  of  rather  a  pleasurable  kind. 

So  violent  are  the  contractions  sometimes,  that  the  teeth  have  been  broken  by 
them.  There  is  one  case  related  in  which  the  thigh-bones  were  fractured  by  the 
forcible  action  of  the  femoral  muscles  ;  and  another  in  which  the  psoas  muscles  were 
found,  after  death,  to  have  been  torn  across.  Dr.  Latham  tells  me  that  he  once  saw 
one  of  the  recti  muscles,  in  front  of  the  abdomen,  thus  rent  asunder. 

With  all  this  disturbance  of  the  muscular  system,  there  is  commonly  very  little 
derangement  of  the  oiher  functions  of  the  body.  The  disorder  is  almost  always 
attended  with  obstinate  costiveness ;  partly,  perhaps,  from  the  spasmodic  closure 
of  the  anus,  partly,  perhaps,  in  some  cases,  from  the  medicines  that  are  given. 
When  stools  are  obtained,  they  are  usually  very  offensive  and  unnatural.  There  is 
no  fever.  The  pulse  and  respiration  are  quickened,  and  a  sweat  frequently  breaks 
out  during  the  exacerbations,  from  the  pain  and  anxiety  then  experienced;  but  ihis 
is  not  the  case  during  the  intervals  between  the  paroxysms.  In  the  last  stages  of  the 
fatal  cases,  the  pulse  becomes  quick  and  feeble,  and  the  sweat  is  cold,  as  in  other 
instances  of  approaching  dissolution. 

What  is  still  more  worthy  of  observation  is  that  the  mental  functions  are  un- 
affected. There  is  seldom  any  delirium,  or  coma,  or  disturbance  of  the  intellect. 
These  symptoms  only  appear  (if  they  appear  at  all)  when  other  indications  of  the 
failure  of  the  powers  of  life  come  on. 

The  mode  of  death  in  this  disease  seems  to  be  of  a  mixed  nature.  Partly  it 
appears  to  result  from  apncca ;  the  thorax  being  held  as  in  a  vice  by  the  spasm  of 
the  muscles,  and  the  breathing  for  a  time  suspended,  or  much  embarrassed:  partly, 
and  cliiefly,  it  occurs  from  asthenia:  the  power  of  the  heart  flags  and  is  exhausted 
by  the  continuance  of  the  suffering,  by  the  fatigue  and  expenditure  consequent 
upon  the  muscular  action,  and  by  the  patient's  inability,  in  many  cases,  to  take  suf- 
ficient nourishment.  When  death  happens  suddenly  as  it  sometimes  does,  in  a 
paroxysm,  it  is  owing,  in  all  probability,  to  spasm  of  the  respiratory  muscles,  and 
perhaps  of  those  of  the  glottis  among  the  rest. 

Most  cnses  of  tetanus  may  be  traced  to  one  of  two  causes :  which  are,  exposure 
to  cold,  especially  to  sudden  alternations  of  temperature,  and  hodiJij  injuries.  In 
many  instances  both  these  causes  co-operate  in  producing  the  disease.  When  it 
supervenes  upon  some  bodily  hurt,  it  is  called  traumatic  tetanus;  when  it  arises 
spontaneously,  or  after  exposure  to  cold,  it  is  held  to  be  idiopathic.  In  this  country, 
and  1  believe  in  every  other,  the  traumatic  variety  of  the  disease  is  much  more  common 
than  the  spontaneous.  But  in  what  manner  soever  it  may  originate,  tetanus  is  far 
more  frequent  in  hot  than  in  temperate  climates  and  seasons.  In  this  case,  however, 
as  in  so  many  others,  the  heat  appears  to  act  as  a  predisposing  cause  only ;  the 
exciting  cause,  in  addition  to  the  wound  in  the  traumatic  species,  being  the  appli- 
cation of  cold  (particularly,  according  to  Hennen,  of  cold  air  in  motion)  after  tiie 


348  TETANUS. 

heat  or  during  the  prevalence  of  hot  weather.  Thus  it  is  stated  that  after  the  battle  of 
Muskau,  in  the  midst  of  great  heats,  very  few  of  the  French  troops  were  affected 
with  tetanus ;  whereas  those  who  were  wounded  in  the  battle  of  Dresden,  when  the 
weather  was  cold  and  wet,  just  after  a  very  hot  season,  were  decimated  by  that 
complaint ;  which  did  not  spare  even  those  who  underwent  immediate  amputation. 

Idiopathic  tetanus  is  extremely  rare  in  this  country.  Dr.  Gregory,  of  Edinburgh, 
used  to  mention  in  his  lectures  the  case  seen  and  treated  by  himself,  of  a  man  who, 
having  fallen  asleep  in  moist  grass,  awoke  with  a  stiff  neck,  which  afterwards  went 
on  into  regular  tetanus.  A  good  example  of  well-marked  tetanus,  arising  from  ex- 
posure to  cold,  is  narrated  in  the  Edinburgh  Medical  and  Surgical  Journal,  by  Dr. 
Hall,  of  Berwick. 

The  history  of  that  species  of  tetanus  which  occurs  in  connection  with  wounds 
and  injuries,  presents  nothing  constant  or  uniform.  The  disease  is  liable  to  follow 
hurts  of  any  parts  of  the  body,  and  of  every  kind,  degree,  and  extent;  from  a  slight 
cut  or  scratch,  to  a  compound  fracture,  or  a  severe  surgical  operation.  It  comes  on 
also  in  various  stages  and  conditions  of  the  injury.  Sir  James  M'Grigor  tells  us  (in 
the  sixth  volume  of  the  Medico-Chirurgical  Transaciions)  that  in  the  Peninsular 
war  the  complaint  supervened  "  in  every  description,  and  in  every  stage  of  wounds, 
from  the  slightest  to  the  most  formidable :  the  healthy  and  the  sloughing;  the  incised 
and  the  lacerated  ;  the  most  simple  and  the  most  complicated."  Sometimes,  how- 
ever, the  discharge  from  the  wound  has  been  observed  to  be  remarkably  diminished 
or  suppressed,  at  the  coming  on  of  the  tetanic  symptoms ;  and  sometimes  the  wound 
has  healed  completely  before  the  commencement  of  the  attack  of  tetanus.  To  show 
you  how  very  trivial  the  injury  may  be,  how  various  in  kind  and  in  place,  I  may 
mention  a  few  instances  that  have  been  collected,  in  illustration  of  the  manner  in 
which  this  terrible  disorder  may  originate.  It  has  been  known  to  arise  from  the 
sticking  of  a  fish-bone  in  the  fauces  ;  from  a  slight  wound  of  the  ear  by  a  musket- 
shot  ;  from  the  mere  stroke  of  a  whip-lash  under  the  eye,  although  the  skin  was  not 
broken  ;  from  cutting  a  corn ;  from  a  bite  on  the  finger  by  a  tame  sparrow  ;  from  the 
blow  of  a  stick  on  the  neck  and  on  the  hand  ;  from  a  seton  in  the  chest ;  from  the 
extraction  of  a  tooth ;  from  the  injection  of  a  hydrocele  ;  from  the  operation  of 
cupping. 

Nevertheless  there  are  some  sorts  of  injury,  and  some  parts  of  the  body,  more  fre- 
quently than  others  concerned  in  the  pathogeny  of  tetanus.  The  disorder  more  often 
supervenes  upon  injuries  of  the  extremities,  than  of  the  trunk,  head  or  neck ;  and 
upon  wounds  made  by  puncture,  than  upon  most  other  hurts.  Penetrating  wounds 
in  the  sole  of  the  foot,  such  as  are  not  seldom  inflicted  by  treading  upon  a  nail  or  a 
splinter;  and  laceration,  or  other  violence  done  to  the  muscles  that  constitute  the  ball 
of  the  thumb,  are  very  apt  to  be  followed  by  tetanic  spasm.  Some  have  supposed 
jhat  the  disease  has  some  special  connection  with  injuries  of  tendinous  parts;  but 
diere  can  be  no  doubt  that  it  is  essentially  a  malady  of  the  nervous  tissue. 

The  tetanic  symptoms  occur  at  no  fixed  period  after  the  reception  of  the  injur}'. 
Professor  Robinson,  of  Edinburgh,  was  once  at  table,  when  a  negro  servant  lacerated 
nis  thumb  by  the  fracture  of  a  china  dish.  He  was  seized  with  convulsions  almost 
mstantly,  and  died  with  tetanic  symptoms  in  a  quarter  of  an  hour.  Such  a  rapid 
progress  as  this  is,  however,  quite  out  of  the  usual  course  of  the  disease :  probably 
fright  had  something  to  do  with  it.  Hennen,  in  his  work  on  Military  Surgery, 
states  that  terror  is  frequently  the  immediate  antecedent  of  the  attack.  In  general, 
tne  tetanus  supervenes  between  the  fourth  and  the  fourteenth  day  after  the  infliction 
of  the  injury  :  some  time  in  the  second  week  is  the  most  common  period  of  all.  In 
the  Peninsular  war  it  did  not  commence  later  than  the  twenty-second  day.  In  some 
rare  instances  its  accession  is  still  longer  deferred.  "Of  the  nature  of  the  changes 
that  take  place  in  the  interval  (justly  remarks  Dr.  Alison)  we  have  no  informniion 
wnatever."  The  longer,  however,  that  the  disease  delays  its  assault  in  these  t';iu 
matic  cases,  after  the  reception  of  the  local  injury,  the  milder,  in  general,  do(>  it 
prove,  and  the  more  room  is  there  for  hoping  that  it  will  end  favourably. 

When  the  disorder  arises  from  exposure  to  cold  and  damp,  it  comes  on  much 


TETANUS.  349 

earlier;  often  in  a  few  hours.     If,  for  example,  the  exposure  takes  place  during  the 
night,  the  complaint  may  begin  to  declare  itself  the  next  morning. 

Although  tetanus  may  be  excited  by  a  wound,  independently  of  any  exposure  to 
cold,  or  by  cold  without  any  injury,  there  is  good  reason  for  thinking  that,  in  many 
instances,  one  of  these  causes  alone  would  fail  to  produce  it,  while  both  together  call 
it  into  action. 

After  the  disease  has  set  in,  its  rate  of  progress  is  various.  Almost  all  writers 
divide  it  into  acute  and  chronic  tetanus.  But  the  difference  is  merely  in  the  degree 
of  severity.  When  the  spasms  come  on  suddenly,  recur  often  from  the  beginning, 
and  increase  in  frequency  and  violence,  the  chance  of  recovery  is  but  small.  The 
patient,  in  thete  cases,  sometimes  dies  on  the  second,  and  generally  before  the  fifth 
day.  If  he  li  /es  to  the  ninth  day  of  the  disease,  his  prospect  is  somewhat  better,  and 
the  spasmodic  symptoms  may  gradually  abate  and  disappear.  Some,  however,  have 
died  as  late  as  the  sixteenth,  the  twentieth,  and  even  the  thirty-fifth  day :  but  this 
last  is  very  rare. 

The  idiopathic  tetanus,  or  that  which  is  produced  by  cold,  although  it  commences 
earlier,  is  more  generally  of  a  chronic  character  than  the  traumatic :  that  is  to  say, 
the  spasmodic  contractions  take  place  more  slowly,  and  the  paroxysms  do  not  increase 
in  violence,  and  in  rapidity  of  recurrence,  as  they  are  apt  to  do  in  the  symptomatic 
variety :  and  accordingly  this  form  of  the  malady  is  much  oftener,  I  dare  not  say 
cured,  but  recovered  from,  than  the  other. 

With  respect  to  the  diagnosis  of  tetanus,  there  is  only  one  point  in  which  it  is  at 
all  ambiguous  or  important.  There  is  no  other  disease  that  is  likely  to  be  confounded 
with  it,  except,  perhaps,  that  extraordinary  disease,  hysteria,  which  sometime?: 
mimics  its  phenomena.  I  have  already  alluded  to  one  example  of  this  kind  that  I 
myself  saw.  But  there  is  a  form  of  poisoning  that  may  easily  be  mistaken  for  teta- 
nus. The  symptoms  produced  by  a  poisonous  dose  of  strychnia,  or  its  salts,  or  the 
vegetables  from  which  it  is  procured,  are  the  symptoms  of  tetanus.  And  as  this 
drug  is  now  readily  obtained,  and  its  noxious  qualities  are  well  known,  it  is  not  un- 
likely to  be  made  an  instrument  of  suicide,  or  of  murder.  It  is  necessary,  therefore, 
that  you  should  be  acquainted  with  the  effects  of  this  poison,  which  constitutes  the 
active  principle  of  the  nux  vomica,  the  fama  S''  Ignatii,  and  the  ifpus  tieute.  Dr. 
Christison  has  excellently  well  described  these  effects  as  they  are  observable  in 
brutes ;  and  I  have  once,  by  accident,  had  an  opportunity  of  witnessing  them  in  the 
human  body.  I  shall  not  be  wandering  from  our  present  subject,  if  I  enumerate  the 
symptoms  to  be  expected  from  a  large  dose  of  strychnia,  especially  as  I  have  lately 
been  advising  you  to  make  trial  of  it  as  a  remedy  in  certain  forms  of  disease.  Dr. 
Christison,  who  had  made  experiments  with  it  upon  animals,  tells  us  that  the  crea- 
ture "  becomes  agitated,  and  trembles,  and  is  then  seized  with  stiffness  and  starting 
of  the  limbs.  These  symptoms  increase,  until  at  length  it  is  attacked  with  a  fit  of 
general  spasm,  in  which  the  head  is  bent  back,  and  the  spine  stiffened,  the  limbs 
extended  and  rigid,  and  the  respiration  checked  by  the  fixing  of  the  chest.  The  fit 
is  then  succeeded  by  an  interval  of  calm,  during  which  the  senses  are  quite  entire, 
or  unnaturally  acute.  But  another  paroxysm  soon  sets  in,  and  then  another  and 
another,  till  at  length  a  fit  takes  place  more  violent  than  any  before  it,  and  the  ani- 
mal perishes  suffocated." 

Some  time  ago  I  had  occasion  to  prescribe  the  strychnia  for  two  patients  in  the 
Middlesex  Hospital,  both  of  whom  had  paraplegia.  I  directed  one  grain  to  be  inti- 
mately mixed  with  crumb  of  bread,  so  that  it  might  be  divided  into  twelve  pills: 
and  one  of  these  pills,  or  one-twelfth  of  a  grain  of  strychnia,  was  to  be  taken  by 
each  patient  every  six  hours.  Unluckily,  through  mistake  or  negligence  of  the  per- 
son who  was  at  that  time  the  dispenser,  a  grain  of  the  poison  was  administered  at 
once  to  each  patient.  It  was  given  about  seven  in  the  evening.  At  half-past  seven 
It  began  to  produce  its  characteristic  effect  upon  one  of  the  patients.  He  was  sud 
denly  seized  with  tetanic  spasms ;  his  legs  were  separated  widely  from  each  other, 
and  rigidly  extended :  and  his  head  and  trunk  bent  backwards.  He  was,  in  fact, 
in  a  state  of  opisthotonos.  His  abdomen  was  quite  hard,  and  his  limbs  were  stiff', 
even  when  the  violence  of  the  paroxysms  abated.     He  cried  out  with  the  pain  at 

2b 


350  TETANUS. 

the  coming  on  of  these  spasms.  Any  attempt  at  movement,  even  the  touchmg  him 
by  another  person,  brought  them  on.  This  is  just  what  happens  in  the  disease 
The  opening  of  a  door,  a  sudden  current  of  air,  the  smallest  bodily  effort,  the  act  of 
swallowing,  nay,  even  the  imagination  of  these  influences,  will  be  sufficient  to  renew 
the  spasmodic  tightening  of  the  affected  muscles.  My  patient  spoke  of  a  particular 
sense  of  constriction  all  over  the  abdomen,  as  if  it  were  drawn  in.  His  intellect  was 
quite  unaffected.  He  had  two  extremely  violent  attacks  of  the  kind  1  have  been 
describing,  in  which  he  thought  he  should  have  died  :  and  to  say  the  truth  I  was 
myself  horribly  afraid  of  the  same  catastrophe.  Afterwards,  from  half-past  eight 
o'clock  to  between  eleven  and  twelve,  he  had  several  slighter  and  shorter  fits.  He 
was  left  weak  and  exhausted  by  them :  but  he  soon  recovered.  I  may  as  well  tell 
you  that  his  paraplegia  was  not  a  whit  benefited  by  this  violent  action  of  the 
remedy. 

You  may  suppose  that  when  I  found  one  of  my  patients  in  this  alarming  state,  I 
became  very  anxious  to  ascertain  the  condition  of  the  other,  who  had  taken  the  same 
C|uantity  of  the  strychnia,  and  lay  in  another  ward.  He  told  me  that  he  had  been 
for  a  short  period  very  dizzy,  and  had  trembled  all  over ;  and  at  the  time  when  I 
saw  him,  he  had  a  weight  or  uneasy  sensation  at  the  nape  of  his  neck,  which  drew 
his  head  backwards ;  and  he  experienced  some  difficulty  in  opening  his  mouth,  and 
in  articulating  his  words.  But  he  thought  these  symptoms  were  diminishing  rather 
than  increasing.  He  was  perspiring  profusely.  It  is  stated  by  Dr.  Chrislison,  that 
if  the  spasms  do  not  come  on  Avithin  two  hours  after  the  poison  was  swallowed,  the 
patient  is  safe.  It  was  more  than  two  hours  since  tliis  patient  had  taken  the  strych- 
nia. I  gave  him  a  full  dose  of  purgative  medicine,  which  acted  as  an  emetic:  and, 
after  he  had  vomited,  the  unpleasant  sensations  about  his  head  and  neck  left  him. 

I  scarcely  knew  what  to  do  with  the  other  patient,  in  whom  the  spasms  had  com- 
menced. There  is  nothing  satisfactorily  made  out,  that  I  know  of,  concerning  the 
mode  of  treating  such  cases.  Of  course,  if  one  saw  the  patient  early,  and  knew 
what  he  had  swallowed,  the  first  thing  to  be  done  would  be  to  procure  its  evacuation 
from  the  stomach.  But  here  it  had  had  full  time  to  get  into  the  circulation :  and  no 
emetic  could  have  withdrawn  that  part  of  it  at  least,  which  had  already  found  its 
way  into  the  blood-vessels.  When  I  reached  him,  though  the  spasms  were  strong, 
they  were  less  violent  than  they  had  been,  and  their  violence  seemed  upon  the  wane  : 
but  they  were  brought  en  by  any,  almost  the  slightest,  muscular  effort,  or  change  of 
position.  I  hoped  therefore  that  the  most  dangerous  period  was  passing  off  (and  so 
it  turned  out),  and  I  was  fearful  of  doing  harm  by  exciting  those  movements  of  the 
body  which  accompany  the  act  of  vomiting.  I  recollected,  too,  that  another  patient 
in  the  hospital,  under  the  care  of  one  of  my  colleagues,  had  once  been  attacked  with 
opisthotonos  after  taking  half  a  grain  of  strychnia ;  and  that  brandy  and  water  had 
been  given  to  him ;  and  that  he  got  well  from  that  time,  without  having  another 
paroxysm.  So  I  gave  my  patient  some  brandy  and  water ;  and  he  seemed  the  better 
for  it :  but  whether  or  no  it  contributed  much  to  his  recovery  I  cannot  be  sure. 

Now  how  are  we  to  tell,  when  we  meet  with  such  symptoms  as  these,  whether 
they  are  the  result  of  disease,  or  of  poisoning?  The  symptoms  are  the  symptoms 
of  tetanus ;  I  know  of  no  means  of  distinguishing  them  from  the  symptoms  of 
tetanus  caused  by  exposure  to  cold,  or  supervening  upon  a  wound.  Dr.  Christison 
has  suggested  that  the  cases  of  fatal  poisoning  by  strichnia  that  are  quickly  fatal,  are 
fatal  in  a  shorter  time  than  the  disease  ever  is.  But  if  the  case  related  by  Professor 
Robinson,  in  which  the  negro  was  dead  in  fifteen  minutes,  is  to  be  regarded  as  a 
genuine  instance  of  tetanus,  this  distinction,  drawn  from  the  rapidity  with  which  the 
poison  kills,  will  scarcely  hold.  Again,  persons  who  have  taken  an  over-dose  of 
strychnia  sometimes  survive  the  tetanic  symptoms,  but  die  afterwards  from  the  irritant 
efft'Cts  of  the  poison  upon  the  mucous  membrane  of  the  alimentary  canal.  This  we 
do  not  observe  in  the  disease.  In  suspicious  or  questionable  cases,  we  must  look 
into  the  history  of  the  'patient ;  inquire  whether  he  were  likely  to  wish  to  destroy 
himself;  what  he  last  swallowed,  and  when  it  was  taken;  whether  he  has  lately 
been  exposed  to  the  injurious  influence  of  cold,  especially  to  a  stream  of  cold  air 
*bile  he  was  perspiring;  and  whether  he  has  recently  received  any  bodily  hurt. 


TETANUS.  351 

By  a  careful  investigation  of  all  the  circumstances,  we  shall  generally  be  enabled  tr 
decide  the  true  nature  of  the  case ;  but  it  is  clearly  necessary  that  our  eyes  should 
be  open  to  the  possibility  of  a  case  of  poisoning,  by  some  of  the  preparations  of 
strychnia,  being  palmed  upon  us  for  a  case  of  natural  disease. 

The  pathology  of  tetanus  is  undoubtedly  obscure :  but  not  more  so,  I  conceive, 
than  that  of  those  nervous  diseases  in  general  which  produce  violent  symptoms,  and 
even  death  itself,  without  leaving  any  traces  of  their  operation  inscribed  upon  the 
dead  materials  of  the  body.  Nay,  it  is  not  so  obscure  as  several  others.  I  think  we 
may  fairly  come  to  the  conclusion  that  the  symptoms  result  from  irritation  of  the 
spinal  cord,  or  of  its  afferent  nerves ;  and  that  the  bruin  is  not  involved  in  the 
disease.  The  French  (at  least  some  of  the  most  modern  writers  on  tetanus)  hold 
that  it  is  always  an  inflammatory  complaint ;  and  that  it  consists  essentially  in  inflam- 
mation of  the  spinal  marrow :  and  some  of  them  have  sought  to  remedy  it  by  enor- 
mous blood-lettings;  from  fourteen  to  fifteen  pounds  of  blood  being  taken  in  the 
course  of  a  few  days  by  one  practitioner;  and  another  bleeding  his  patient  eight 
times,  and  applying  792  leeches  along  the  course  of  the  spine,  and  to  the  epigas- 
trium. But  this  do'ctrine  of  inflammation  being  at  the  bottom  of  every  case  of  tetanus 
is  contradicted  by  the  plainest  facts ;  and  the  practice  founded  upon  it  has  been 
pushed  to  a  most  extravagant  and  absurd  extent.  Numberless  instances  occur  of 
inflammation  of  the  spinal  cord  and  its  membranes  without  any  tetanus  ;  and  equally 
numerous  examples  of  tetanus  have  been  met  with,  when  no  Unnatural  appearance 
at  all  could  be  discovered  within  the  vertebral  canal.  I  say  we  must  content  our- 
selves with  referring  the  phenomena  of  the  disease  to  irritation,  direct  or  indirect, 
of  the  spinal  cord ;  or  its  nervous  appendages ;  and  I  am  quite  proof  against  all 
sneers  against  the  alleged  vagueness  of  that  term. 

If  you  irritate,  mechanically,  by  means  of  a  pair  of  forceps,  the  exposed  spinal 
cord  of  a  recently  decapitated  animal,  a  turtle,  for  example,  you  produce  spasmodic 
contraction  of  the  hmbs..  What  difficulty  is  there  in  supposing  that  some  mechanical 
irritation  existing  within  the  spinal  canal  of  a  living  man  may  have  a  similar  effect  ? 
It  may  be,  and  probably  is,  sometimes,  the  mechanical  irritation  caused  by  the  altered 
state  of  the  blood-vessels  under  inflammation ;  for  we  sometimes  find  traces  of  such 
inflammation  in  the  spinal  marrow  after  death  by  tetanus. 

Again,  if  you  irritate,  by  pinching,  one  of  the  spinal  nerves  of  a  turtle  whose 
head  has  just  been  cut  off'— if  you  thus  irritate  one  of  these  nerves  in  any  part  of 
its  course,  what  happens?  why  the  muscles  of  the  hmbs  contract  spasmodically; 
those  on  the  side  to  which  that  nerve  belongs  becomes  rigid,  and  those  on  the  other 
side  also.  That  property  of  the  cord  comes  into  play  which  I  have  so  often  men- 
tioned :  a  property  which  it  possesses  independently  of  the  brain  ;  which  it  evinces 
when  all  communication  with  the  brain  is  cut  off";  a  property,  therefore,  which  may 
be  manifested  without  any  exercise  of  volition,  and  even  in  spite  of  efforts  made  by 
the  will  to  restrain  its  manifestation :  I  mean,  of  course,  the  property  whereby  it  is 
capable  of  receiving  impressions  through  the  medium  of  its  afferent  nerves,  from 
parts  at  a  distance,  and  of  originating  motion  in  the  muscles  of  the  trunk  and  limbs 
through  the  medium  of  its  efferent  nerves.  By  the  courtesy  of  Dr.  Marsha.l  Hall 
I  have  been  afforded  the  opportunity  of  witnessing,  in  the  headless  turtle,  the  phe- 
nomena that  I  have  been  describing  to  you.  Surely  they  throw  a  broad  light  upon 
the  pathology  of  tetanus,  and  of  sundry  other  affections.  We  infer  from  them,  most 
legitimately  as  it  seems  to  me,  that  the  tonic  spasm  which  characterizes  the  disease 
we  are  considering  may  be  caused  by  a  diseased  state  of  the  spinal  marrow  itself; 
or  by  a  morbid  condition  of  the  nerves  that  belong  to  it.  In  the  latter  case,  irritation 
is  set  up  at  the  free  extremity,  or  somewhere  in  the  course,  of  incident  nerves  ;  along 
these  nerves  an  influence  is  conducted  to  the  cranio-spinal  axis,  in  which  a  process 
or  change  takes  place,  whereby  an  answering  influence  is  reflected  to  the  muscles 
along  the  motor  nerves,  and  the  whole  circle  of  action  and  reaction  is  run  through 
with  the  suddenness  and  swiftness  of  lightning,  or  of  thought.  You  cannot  expect 
that  visible  marks  of  the  irritating  cause  should,  in  all  cases,  be  left  upon  the  body 
any  more  than  you  could  discern  the  pinch  made  by  the  forceps  after  they  wer«i 
withdrawn. 


352  TETANUS. 

When,  in  the  experiments  to  which  I  have  referred,  Dr.  Hall  plucked  or  com- 
pressed one  of  the  denuded  spinal  nerves,  spasmodic  motions  were  excited  in  the 
muscles  of  both  sides  ;  and  above,  as  well  as  below,  the  junction  of  that  nerve  with 
the  cord.  This  shows  that  the  change  (whatever  it  be)  that  is  wrought  in  the  cord 
by  impressions  made  upon  one  of  its  afferent  nerves,  is  not  necessarily  confined  to 
the  corresponding  segment  of  the  cord  ;  but  may  be  instantly  communicated,  in  both 
directions,  throughout  its  entire  course  :  the  whole  of  this  centre  of  the  excito-motory 
system,  respondmg  to  the  influence  conveyed  by  a  single  nerve,  as  completely  as  a 
tight  string  vibrates  from  end  to  end,  when  struck  at  any  one  point.  We  frequently, 
indeed,  find  that  the  excited  motions  are  more  limited  ;  but  it  is  important  to  mark 
this  ready  consent  of  the  whole  cord,  under  sufficient  excitement. 

Dr.  Hall  has  given  certain  distinguished  epithets  to  tetanus,  according  to  the  sup- 
posed source  and  locality  of  the  irritation.  When  the  irritating  cause  operates 
directly  upon  the  spinal  cord  itself,  he  calls  the  disease  cm/?7'c  tetanus:  when  it 
resides  in  some  part  of  the  body  distant  from  the  spinal  cord,  he  calls  the  disease 
eccentric  tetanus.  These  are  good  and  intelligible  names  ;  and  I  shall  take  leave  to 
adopt  them. 

Observe  now  how  well  this  explanation  meets  the  facts  of  the  case.  We  some- 
times find  the  spinal  cord  or  its  membranes  inflamed,  when  there  has  been  teianic 
spasm.  We  then  refcr  the  spasm  to  the  centric  irritation.  But  in  a  far  greater 
number  of  cases  we  can  detect  no  marks  whatever  of  disease  in  the  spinal  canal, 
while  we  know  that  an  irritating  cause  has  been  applied  to  parts  at  a  distance. 
Often  we  have  evidence  which  is  visible,  that  a  nerve  has  been  injured,  torn  across 
perhaps,  or  half  torn,  or  compressed  in  some  way  or  other;  just  as  we  might  com- 
press a  nerve,  with  a  pair  of  forceps,  in  a  decapitated  turtle.  That  experiment 
shows  us  that  very  slight  irritation  may  be  enough  lo  produce  the  spasmodic  action ; 
and  we  find  that  slight  injuries,  as  well  as  severe,  will  bring  on  the  disease,  when, 
by  the  operation  of  certain  injurious  agencies,  the  frame  has  been  predisposed,  and 
rendered  morbidly  susceptible.  There  is  no  part  of  the  trunk  or  limbs  which  is  not 
supplied  with  nerves  from  the  spinal  cord  ;  and  we  find  that  injuries  of  various  parts, 
or  of  almost  any  part,  in  an  individual  predisposed  to  take  on  the  disordered  action, 
may  produce  it.  The  exciting  cause  may  be  a  wound  irritating  a  particular  nerve  ; 
it  may  be  exposure  to  cold,  acting  upon  the  extremities  of  various  nerves  that  pro- 
ceed from  the  surface :  it  may  be  a  bundle  of  worms,  irritating  the  nerves  spread 
upon  the  mucous  tissue  of  the  alimentary  canal ;  for  I  omitted  to  state  before  that 
some  writers,  especially  MM.  Laurent  and  Lombard,  have  maintained  that  tetanus 
is  almost  always,  even  when  it  supervenes  after  wounds,  the  result  of  the  presence 
of  worms  in  the  digestive  organs.  They  have  founded  this  opinion  upon  the  fact, 
that-worms  have  been  very  frequently  indeed  discovered  in  the  stomach  or  intestines 
of  persons  dead  of  this  disorder.  I  think  this  a  point  well  worth  attending  to.  It  is 
objected  that  worms  infest  the  human  body  without  causing  tetanus :  but  the  very 
same  thing  may  be  said  of  the  operation  of  cold  ;  and  of  external  injuries.  Any  of 
f.hcse  may  probably  excite  the  disorder,  when  the  body  is  preternaturally  susceptible 
of  it.  The  real  mystery  lies  in  this  predisposition.  We  have  reason  to  suppose 
that  a  high  atmospheric  temperature,  continued  for  some  time,  is  one  predisposing 
rause ;  but  how  it  operates,  or  what  is  that  state  of  system  in  which  the  increased 
susceptibility  consists,  these  are  points  concerning  which  we  are  really  in  the  darlc 

The  disease  is  common  enough  in  brutes :  and  it  is  frequently  eccentric  in  them ; 
brought  on  by  injuries,  mostly  of  the  extremities.  Locked-jaw  is  well  known  in  the 
nosology  of  farriers.  It  is  not  uncommon  in  the  horse  after  castration.  I  remember 
a  mare  belonging  to  my  father  dying  of  that  disease  a  few  days  after  foaling.  It 
o'tcn  results,  in  these  animals,  from  a  prick  in  the  foot  by  a  nail  in  shoeing.  Dr. 
Parry  noticed  eccentric  tetanus  in  lambs.  "I  have  often  seen  lambs,"  says  he, 
•'  whose  ears,  for  the  purpose  of  marking  them,  have  been  bored  with  a  red-hot  iron 
too  near  the  root,  so  rigid  all  over  with  tetanus,  alternating  with  convulsions,  thai 
'.heir  bodies  would  project  in  a  right  line  with  their  hind  legs,  when  one  held  them 
f^ut  horizontally  bj"-  the  hind  feet."     Dr.  Mason  Good  tells  us  that  parrots  abo  are 


TETANUS.  -  353 

frequently  affected  with  trismus  :  a  calamity  which,  supposing  the  bird  to  be  within 
ear-shot,  it  would  be  difficult  to  commiserate. 

We  are  not  advancing  any  wild  theory,  then,  respecting  the  controverted  patho- 
log}'  of  this  disease,  when  we  lay  down  the  following  propositions :  that  it  is  essen- 
tially a  disorder  of  the  excito-motory  apparatus ;  that  it  results  from  irritation  of  a 
peculiar  kind,  affectincr  that  part  of  the  nervous  system ;  that  the  irritating  cause 
rnay  be  centric, — within  the  spinal  canal  itself;  and  that  it  may  also  be,  and  often  is 
eccentric, — situated  at  the  extremity,  or  somewhere  in  the  course,  of  one  or  more  of 
the  afferent  spinal  nerves :  and  that  a  certain  predisposition  of  the  body  is  for  the 
most  part  necessary,  to  render  it  susceptible  of  the  disease  under  the  operation  of 
the  exciting  irritation. 

At  one  time  it  was  supposed  that  the  physical  cause  of  the  disease  was  detected, 
in  the  presence  of  more  or  fewer  thin  scales  of  bony  matter,  lying  in  or  upon  the 
arachnoid  of  the  cord.  I  have  myself  seen  these  after  death  preceded  by  tetanic 
symptoms.  But  tetanus  often  happens  and  proves  fatal  without  them  :  and  they  are 
often  rnet  with  when  there  has  been  no  tetanus.  If,  therefore,  there  be  any  connec- 
tion between  these  thin  plates  of  ossification  and  the  occurrence  of  tetanus  (which 
may  well  be  questioned),  it  must  be  of  this  kind  ;  that  the  scales  of  bony  matter 
predispose  the  spinal  cord,  somehow,  to  be  affected  by  the  exciting  causes  of  the 
disease. 

The  doctrines  recently  propounded  by  Dr.  Marshall  Hall,  of  which  the  import- 
ance becomes  daily  more  apparent,  and  by  which  his  name  will  be  enduringly  con- 
nected with  the  physiology  of  the  nervous  system,  receive  a  strong  confirmation  from 
the  phenomena  of  tetanus.  They  furnish  a  key  to  many  })roblems  which  had  pre- 
viously perplexed  the  pathologist;  and  they  do  this  simply  by  distinguishing  the 
proper  functions  of  the  two  distinct  nervous  centres ;  the  brain  and  the  spinal  cord. 
But  the  practical  application  of  these  new  views  is  yet  in  its  infancy. 

The  treatment  of  tetanus  is  a  mortifying  subject.  The  disease  is  and  has  always 
been  a  lamentably  fatal  one.  Hippocrates  says,  fTtt  rpco^aTt.  cnm^oi  iTivyevowrioi, 
ewvaai^Lov,  tetanus  supervening  on  a  wound,  is  mortal:  and  the  aphorism  holds  true, 
with  very  few  exceptions,  in  the  present  day.  Almost  all  the  acute  and  severe  trau- 
matic cases  are  fatal.  Hennen  declares  that  he  never  saw  a  case  of  "acute  symp- 
tomatic tetanus"  recover.  Dr.  Dickson  found  all  curative  measures  followed  by 
"unqualified  disappointment."  Mr.  Morgan  uses  these  words;  "I  have  never  yet 
seen  or  heard  of  an  instance  of  recovery  from  acute  tetanus."  Another  of  Hippo- 
crates' aphorisms  is  oxouot.  vno  -ti-COA'ov  aXiaxwfat,  tx  tsaaa^aiv  ^^fpjjffti'  artoXXvvtM,  they 
who  are  seized  with  tetanus,  die  within  four  days  ;  but  he  adds,  fjv  Ss  ■fowraj  Sia^vyuctc 
iytsii  ywovtat;  if  they  get  over  this  period  they  recover.  And  to  this  Ave  can  only 
add  now,  that  those  who  survive  the  first  few  days,  and  ultimately  get  well,  recover 
in  a  variety  of  different  ways,  and  under  various  modes  of  treatment.  But  as  to  the 
mode  of  treatment  which  is  to  be  preferred,  or  even  as  to  the  real  efficacy  of  any 
mode,  thi-^re  is  much  room  for  doubt.  Under  every  plan  of  management  a  vast 
majority  die. 

Let  us  briefly  pass  in  review  the  principal  remedies  that  have  been  tried,  and 
inquire  what  degree  of  success  has  followed  their  employment. 

One  drug  from  which  much  benefit  has  been  hoped  for,  is  opium.  In  some  spas- 
modic disorders  it  is  of  unquestionable  service.  Very  lartje  doses  of  it  have  been 
given  and  borne  in  tetanus;  and  some  have  recovered  under  its  use,  and  more  have 
died. 

It  is  well  known  that  pain  fclifies  the  nervous  system  against  the  peculiar  influ- 
ence of  narcotic  substances.  We  need  not,  therefore,  be  surprised  that  opium,  admi- 
nistered in  enormous  quantities,  in  this  painful  disease,  has  had  but  little  efl^-ct.  I 
was, assured  by  a  physician,  with  whom  I  formed  an  acquaintance  in  Edinburgh 
some  years  ago,  and  who  is  known,  I  find,  to  a  student  now  present,  that  his  own 
wife,  while  labouring  under  a  tetanic  affection,  swallowed,  in  twenty  successive  days, 
upwards  of  40,000  drops  of  laudanum,  which  is  at  the  rate  of  more  than  four  ounces 
a  day ;  in  all,  more  than  two  imperial  quarts.  The  lady  recovered.  A  case  is 
recorded  in  the  second  volume  of  the  Medico-Chinirgical  Transactions,  in  which 
23  2  E  2 


354  TETANUS. 

an  ounce  of  solid  opium  was  taken,  in  divided  doses,  every  day,  for  t\venty4wo 
days.  This  appears  a  more  astounding  instance  than  the  former  ;  but  I  am  not  sure 
that  it  was  so ;  for,  in  this  complaint,  solid  opium  does  not  always  dissolve  in  the 
stomach.  I  have  heard  the  late  Mr.  Abernethy  say  that  he  had  found  enough  un- 
dissolved pills  of  opium  in  the  stomach  after  death,  to  poison  a  dozen  healthy  per- 
sons. This  fact  should  teach  you,  if  you  resolve  on  trying  opium  at  all,  to  exhibit 
it  in  a  liquid  form ;  laudanum,  or  a  solution  of  the  acetate  or  of  the  muriate  of  mor- 
phia. And  wath  the  internal  administration  of  opium,  it  would  be  well,  perhaps,  to 
combine  its  external  use  ;  to  apply  a  broad  strip  of  opiate  plaster  along  the  whole 
length  of  the  spinal  column. 

It  is  sometimes  a  difficult  matter  to  introduce  medicine  by  the  mouth,  so  strong  is 
the  spasmodic  contraction  of  the  muscles  that  close  the  jaws.  You  cannot  get  the 
mouth  open.  Some  persons  set  to  work  to  heave  it  open,  by  levers ;  and  it  has  been 
proposed,  and  I  believe  practised,  to  break  off  or  extract  a  tooth  or  two,  to  make  a 
passage  for  the  introduction  of  medicine  and  of  nourishment;  but  1  hope  you  will 
never  be  guilty  of  such  clumsy  barbarity  as  this.  Food,  and  physic,  may  be  carried 
into  the  fauces  and  into  the  stomach  by  means  of  a  flexible  tube  :  and  this  may  be 
inserted  through  the  nostril ;  or  through  the  mouth,  by  passing  it  between  the  jaws, 
behind  the  back  teeth,  where  there  is  always  an  aperture  that  will  admit  a  tube  suffi- 
ciently large. 

After  all,  in  respect  to  the  cures  that  have  been  ascribed  to  the  opiate  treatment, 
they  have  all  (so  far  as  I  know)  occurred  in  cases  of  the  milder  or  more  chronic 
tetanus ;  and  mostly  in  the  idiopathic  form  of  the  disease ;  and  this  circumstance 
makes  it  a  question  whether  they  were  cures  at  all :  whether  they  w^ere  not  simply 
recoveries. 

Dr.  William  Budd  (in  the  paper  already  referred  to)  challenges  the  propriety,  on 
phj-siological  principles,  of  giving  any  opium  in  this  disease.  He  says,  "  It  has  been 
ascertained  that  the  effect  of  that  drug  is  to  excite,  and  not  to  quiet,  the  motor  func- 
tion of  the  spinal  cord  :  indeed,  it  is  well  known  that  the  motor  acts  of  the  cord  may 
be  rendered  much  more  active  and  powerful,  by  giving,  before  decapitation,  opium 
to  animals  that  are  to  be  subjects  of  experiment."  He  considers  "  these  objections, 
furnished  by  theory,  to  be  motives  sufficient  for  the  future  exclusion  of  opium  from 
the  treatment  of  tetanus." 

I  had  long  been  aware  that  the  effect  of  opium  upon  frogs  was  to  produce  tetanic 
spasms.  But  in  no  case  of  poisoning  by  opium  in  the  human  subject  (and  I  have 
seen  a  great  many)  have  I  ever  witnessed  any  approach  to  tetanus:  and  I  much 
question  the  safety  of  arguing,  in  such  matters,  from  what  we  know  to  happen  in  the 
mferior  animals,  to  what  we  suppose  would  happen  in  man. 

The  failure,  however,  of  opium  in  the  severer  forms  of  the  malady,  and  its  equi- 
vocal utility  in  any,  taken  together  with  these  theoretical  objections,  prevent  my 
recommending  opium  as  a  remedy  for  tetanus. 

What  is  the  result  of  experience  in  regard  to  blood-letting  in  tetanus  ?  I  am  afraid 
that  as  a  curative  agent,  it  has  very  little  power  over  the  disease.  Yet  it  may  be, 
and  probably  is,  of  considerable  use,  as  an  auxiliary  to  other  measures.  When  the 
disorder  bears  any  aspect  of  inflammation — when,  for  instance,  fever  is  lighted  up, 
and  pain  is  felt  along  the  course  of  the  spine,  or  when  the  approach  of  the  spasm  is 
marked  by  the  supervention  or  the  increase  of  pain  in  the  wound — then  our  chance 
of  doing  good  by  venesection  is  the  greatest.  Some  of  the  cases  that  happened  in 
the  Peninsular  war,  were  decidedly  benefited  by  blood-letting  practised  under  such 
circumstances.  I  need  scarcely  say  that  though  the  bleeding,  when  adopted,  should 
be  enrly,  free,  and  full,  so  as  to  produce  some  sensible  impression  upon  the  system, 
yet  we  must  always  use  this  remedy  with  caution.  The  tendency  of  the  disease  is 
to  exhaust  the  power  of  the  heart ;  and  if  by  one  over-bleeding  we  bring  that  organ 
10  a  stand-still,  it  may  refuse  to  begin  agiin. 

In  a  complaint  whic'^  depends  so  much  on  irritation,  and  so  often  on  manifest 
.rritation  of  external  parts,  we  look  naturally  to  the  icarm  bath  for  help.  And  ii 
hcLs  been  fairly  tried :  and  some  persons  have  found  it  useful ;  and  others  have 


TETANUS.  355 

found  it  useless,  doing  neither  good  nor  harm :  and  some  have  condemned  it  as  actu- 
ally hurtful. 

The  cold  bath  has  been  extolled  as  a  much  more  powerful  agent  than  the  warm , 
and  so,  doubtless,  it  is.  But  it  is  more  potent  for  harm  as  well  as  for  good.  For 
example :  a  tetanic  patient,  in  St.  Thomas's  Hospital,  was  plunged  into  a  cold  bath, 
at  his  own  request.  "All  the  symptoms  disappeared  (says  Mr.  Morgan)  in  a  moment ; 
and  he  was  almost  immediately  taken  out  of  the  bath :  but  he  was  taken  out  life- 
less." Sir  James  M'Grigor  says  that,  during  the  campaign  of  Spain,  "the  warm 
bath  gave  only  a  momentary  relief;  and  the  cold  bnth  was  worse  ihan  useless." 

However,  the  application  of  cold  water  to  the  surface  has,  in  many  recorded 
instances,  been  of  at  least  temporary  benefit  and  comfort :  and,  in  the  West  Indies, 
where  the  disease  is  common,  the  cold  effusion  still  continues,  I  believe,  to  be  tho 
most  favourite  expedient.  After  it,  the  patient  is  rubbed  dry,  put  to  bed,  and  has 
laudanum  administered.  I  have  again  to  observe,  of  this  remedy  also,  that  it  is 
chiefly  serviceable  in  the  idiopathic  form  of  tetanus.  It  has  been  tried  upon  animals. 
Dr.  Parry  says  that  it  was  quite  unavailing  in  the  case  of  certain  lambs  that  had  the 
disease.  In  a  note,  which  I  made  at  the  time,  of  Mr.  Abernethy's  lecture  on  teta- 
nus, I  find  the  following  statement.  "The  effect  of  cold  in  diminishing  excessive 
muscular  action  was  strikingly  shown  in  the  case  of  a  horse  belonging  to  Professor 
Coleman,  which  had  tetanus.  The  animal  was  slung,  and  carried  out  of  the  stable, 
and  laid  on  the  snow,  which  was  then  on  the  ground  :  and  he  was  covered  over  with 
snow  also.  A  horse  affected  with  tetanus  is  a  curious  sight.  His  legs  straddle,  and 
become  stiff';  his  ears  are  pricked  up ;  and  his  tail  sticks  out.  In  this  case,  on  the 
application  of  the  snow,  his  ears  sunk,  his  tail  became  pliant,  and  the  rigidity  of  his 
muscles  was  removed.  He  was  again  taken  into  the  stable,  and  the  spasms  returned." 
Mr,  Abernethy  said,  that  were  he  himself  the  subject  of  tetanus,  he  would  desire  to 
have  the  cold  effusion  tried.  If  you  are  wiUing  to  assay  the  same  remedy,  do  not 
plunge  your  patient  into  a  cold  bath,  but  take  him  out  of  his  bed  on  an  extended 
sheet,  pour  cold  water  over  his  body,  wipe  him  dry,  and  place  him  in  another  dry 
bed.  This  will  often,  for  a  time  at  least,  diminish  the  spasmodic  action;  and  the 
patient  will  sometimes  sleep  comfortably  after  it. 

Dr.  Todd  has  suggested  to  me  the  application  of  ice  to  the  spine ;  a  measure 
which  he  has  found  eminently  beneficial  in  convulsions.  This  mode  of  employing 
cold  as  a  remedy  in  tetanus  seems  well  worthy  of  trial.  It  would  have  the  "advan- 
tage of  not  inflicting  any  shock  which  might  excite  or  disturb  the  reflex  function  of 
the  cord,  through  its  incident  nerves. 


LECTURE  XXXIII. 

Treatment  of  Tetanus,  continued.  PFine;  Mercury;  Purgatives;  Digitalis; 
Tobacco ;  Musk;  Frussic  Acid;  Belladonna;  Carbonate  of  Iron;  Oil  of  Tur- 
pentine; Strychnia;   Surgical  Expedients ;   General  Bales.     Hydrophobia. 

In  the  last  lecture  we'  considered  the  symptoms,  the  nature,  the  causes,  and  to  a 
certain  extent  the  treatment,  of  that  terrible  malady,  tetanus.  There  is  good  reason 
for  believing  that  it  is  essentially  a  disorder  of  the  excito-motory  apparatus;  that  it 
is  caused  by  irritation  of  a  peculiar  kind,  affecting  that  part  of  the  nervous  system, 
and  producing  tonic  spasm  of  the  voluntary  muscles  ;  that  the  irritating  cause  may 
be  centric,  situated  within  the  spinal  canal,  and  applied  directly  to  the  cord;  o'r 
eccentric,  situated  out  of  the  spinal  canal,  applied  to  some  part  of  one  or  more  of  its 
aff"erent  nerves  directly,  and  thus  influencing  indirectly  the  cord  itself,  and  througn 
it  the  reflex  motor  nerves  :  and  that  a  certain  ill-understood  state  of  the  system"  s 
necessary,  a  certain  aptitude  to  take  on  the  disease,  before  the  exciting  ^ause  caa 
be  efficient;   and  that  one  circumstance  which  has  been  ascertained  to  tend  to 


356  TETANUS. 

the  production  of  such  an  aptitude,  is  a  long-continued  high  temperature  of  tne 
atmosphere. 

I  mentioned  several  remedies  and  plans  of  treatment  which  have  been  fairly  tried, 
and  mostly  tried  in  vain,  for  the  removal  of  this  disease.  The  severe  cases,  and 
especially  the  severe  traumatic  cases,  almost  all  prove  fatal ;  the  less  severe  cases, 
those  in  which  the  paroxysms  are  less  violent  and  less  frequent,  and  which  run  on 
for  several  days,  sometimes  terminate  in  health  :  whether  in  consequence  of  the 
measures  employed,  or  whether  in  spite  of  them,  it  is  not  easy  to  say.  The  idio- 
pathic cases,  as  they  are  called,  those  which  appear  to  be  produced  by  exposure  to 
cold  and  wet,  are  usually  the  least  severe,  and  the  more  hopeful.  The  remedies 
that  have  been  tried,  and  which  were  mentioned  in  the  last  lecture,  are  opium  ; 
blood-letting;  the  warm-bath;  the  cold-bath.  I  showed  you  that,  under  each  of  these 
remedies,  a  great  number  of  patients  died,  and  some  recovered  ;  and  that  the  reco« 
verics  had  been  almost  exclusively  among  those  patients  in  whom  the  disease  ap- 
peared originally  in  its  milder  form.  So  that  whether  the  complaint  was  actually 
cured  in  any  of  these  cases,  whether,  i.  e.,  any  single  patient  recovered,  or  recovered 
sooner,  from  using  any  of  these  remedies,  who  would  have  died,  or  in  whom 
the  disease  would  have  been  protracted  if  he  had  not  used  them,  is  a  matter  of 
uncertainty. 

The  celebrated  American  physician.  Dr.  Rush,  regarding  the  disease  as  essentially 
a  disease  of  debility,  and  looking  probably  at  its  common  tendency  to  death  by 
asthenia,  wrote  a  paper  to  recommend  the  employment  of  bark,  and  wine,  and 
spirits,  in  full  doses.  It  is  curious  enough,  but  quite  in  agreement  with  what  has 
been  already  stated  of  opium,  that  how  much  wine  soever  may  be  swallowed  by  the 
patient,  nothing  hke  intoxication  is  produced  by  it.  The  system  resists  the  ordinary 
influence  of  the  alcohol.  In  one  instance  related  by  Dr.  Currie,  the  disease  lasted 
six  weeks,  and  in  that  space  of  time  the  patient  drank  1 10  bottles  of  port  wine.  The 
same  author  mentions  a  remarkable  case,  in  which  a  horse,  which  was  attacked  by 
tetanus,  and  happened  to  be  a  great  favourite  with  its  master,  was  treated  with  wine, 
and  got  well,  after  swallowing  more  port  wine  than  he  was  worth.  Whenever  this 
plan  has  appeared  to  do  good,  it  has  been  in  the  more  chronic  variety  of  the 
complaint. 

Mercury,  you  may  be  sure,  has  not  been  left  untried.  It  is  said  that  the  system 
is  slow  in  submitting  to  its  influence,  in  this  malady.  The  specific  effect  of  mercury 
upon  the  gums  is  not,  however,  so  strongly  resisted  as  that  of  wine  or  opium  upon 
the  nerves.  Nor  can  we  be  surprised  at  this,  when  we  consider  that  in  tetanus  the 
functions  of  organic  life  are,  comparatively,  but  little  involved.  It  is  clear  that  there 
is  not  time  for  any  effectual  exhibition  of  mercury  in  those  severe  cases  that  are  early 
fatal.  In  its  more  chronic  form  the  disorder  has  been  known  to  yield  upon  the  mouth 
becoming  affected.  This  happened,  if  I  mistake  not,  in  Mr.  Mayo's  patient,  men- 
tioned in  the  last  lecture.  Tetanus  has  sometimes,  however,  commenced  while  the 
patient  Avas  in  a  state  of  salivation.  Dr.  Wells  has  recorded  three  instances  of  that 
kind.  The  experience  of  the  military  surgeons  who  were  in  Spain,  is,  upon  the 
whole,  agamst  the  reputed  efficacy  of  mercury.  We  must  take  care  not  to  conclude 
too  hastily,  that  because  a  patient  uses  a  certain  remedy  and  recovers,  he  recovers 
through  the  operation  of  that  remedy :  any  more  than  we  should  conclude,  if  he 
recovered  during  a  general  election,  that  the  election  had  cured  him.  Yet  this 
absurd  and  unsafe  mode  of  reasoning  is  for  ever  employed  in  respect  to  disease,  by 
the  public ;  and  too  often,  I  fear,  by  ourselves. 

Purgatives  have  been  much  given  in  tetanus  ;  and  often  with  manifest  advantage  : 
I  mean  in  the  less  severe  cases.  But  very  large  doses  are  commonly  required  to 
procure  evacuations  from  the  bowels.  Whether  the  torpor  of  the  intestines  be  always 
the  effect  of  the  disease,  or  whether  it  may  not  sometimes  be,  in  part  at  least,  a  con- 
sequence of  the  opium  that  is  given,  I  am  not  sure.  When  they  do  act,  very  unna- 
tural motions  are  frequently  produced.  Mr.  Abernethy  tells  us  of  a  hospital  patient 
of  his  who  recovered  under  the  use  of  purgatives  ;  they  were  long  before  they  had 
any  effect,  and  when  they  did  at  last  operate,  such  foetid  stuff"  came  from  him  that 
no  one  who  could  crawl  out  of  the  ward  would  remain  in  it.     He  says  also  that  the 


TETANUS. 

nurses,  in  other  cases,  have  reported  the  stools  to  be  more  -ike  sloughs  than  feces. 
Enormous  quantities  of  drastic  purgatives  have  been  given.  You  may  read  an 
instance  of  this  in  the  second  volume  of  the  Medico-Chirurgical  Transactions.  It 
is  related  by  Mr.  Harkness.  There  is  a  still  more  extraordinary  case  detailed  by  Dr. 
Briggs,  in  the  fifth  volume  of  the  Edinburgh  Medical  and  Surgical  Journal.  In 
little  more  than  48  hours,  the  patient  in  that  case  took  210  grains  of  scammony,  89 
of  gamboge,  80  of  calomel,  an  ounce  and  four  scruples  of  jalap,  and  2i  pints  of 
what  we  call  black  dose,  the  infusion  and  tincture  of  senna :  and  all  this  without 
either  sickness  or  griping ;  but,  on  the  contrary,  with  the  most  decided  benefit.  In 
the  first  week  of  his  disease,  the  patient  swallowed — of  calomel,  2-80  grains ;  scam- 
mony, 2G0;  gamboge,  110;  jalap,  3  ounces  and  10  grains;  infusion  of  senna,  5f 
pints.  And  altogether  in  the  first  25  days — of  calomel,  320  grains ;  scammony, 
340 ;  gamboge,  126 ;  jalap,  5  ounces  and  71  drachms  ;  infusion  of  senna,  lOf  pints; 
besides  an  ounce  and  a  half  and  35  grains  of  the  colocynth  pill.  I  mention  all  this 
to  show  what  the  system  will  bear,  under  the  bondage  of  the  disease ;  not  as  an  en. 
couragement  to  you  to  prescribe  such  doses. 

It  is  certainly  proper  and  necessary  to  clear  out  the  bowels,  and  to  endeavour  to 
correct  unhealthy  secretions ;  yet  numerous  evacuations,  the  act  of  going  to  stool 
often  repeated,  should  be  avoided.  Under  such  obstinacy  of  the  bowels,  the  croton 
oil  would  perhaps  be  the  most  eligible  purgative. 

Foxglove  and  tobacco  are  two  medicines,  or  rather  poisons,  which  have  been 
used ;  both,  probably,  upon  the  same  principle.  Their  effects,  when  full  doses  have 
been  given,  are  much  alike  :  sickness,  faintness,  feebleness  and  fluttering  of  the  pulse, 
coldness  of  the  surface,  with  that  slack  and  passive  state  of  the  muscles  which 
belongs  to  syncope.  But  if  we  consider  that  the  influence  of  these  substances  upon 
the  involuntary  muscles,  especially  upon  the  heart,  is  more  certain  and  decided  than 
upon  the  muscles  of  voluntary  motion,  which  are  the  muscles  involved  in  the  tetanic 
spasm,  and  if  we  take  also  into  account  the  strong  disposition  observable  in  tetanus 
towards  death  by  asthenia,  we  shall  scarcely  be  prepared  to  expect  any  good,  but 
the  contrary,  from  digitahs,  or  tobacco ;  especially  in  the  latter  periods,  when,  so  far 
from  obviating  the  tendency  to  death,  they  would  seem  to  co-operate  with  the  disease 
in  extinguishing  life.  However,  if  the  result  of  experience  were  clearly  in  their 
favour,  we  should  not  be  warranted,  by  mere  theoretical  views,  in  withholding  these 
drugs.  The  army  surgeons,  some  of  them,  have  fancied  digitalis  useful.  Sir  James 
M'Grigor  mentions  a  case  in  which  it  caused  a  relaxation  of  the  spasn^s ;  but  the 
man  died  afterwards,  apparently  from  the  effects  of  the  remedy.  And  t-'iis  is  just 
what  I  find  with  digitalis.  When  given  in  large  doses  (and  small  ones  here  must 
be  useless)  it  becomes  unmanageable.  Certainly  we  have  no  such  accounts  of  its 
salutary  power  as  would  induce  me  to  give  it  with  much  expectation  of  success,  or 
to  give  it  at  all. 

The  tobacco  is  not  given  by  the  mouth,  but  thrown  up  into  the  rectum :  either 
the  smoke  of  its  burning  leaves,  or  (what  is  probably  as  efficacious,  and  I  should 
think  more  uniform  and  less  unsafe)  an  infusion  of  them  in  water.  Mr.  Curling, 
after  analyzing  a  large  number  of  cases  of  tetanus,  thinks  tobacco  the  best  remedy 
we  at  present  possess.  Mr.  Travers  is  of  the  same  opinion.  However,  I  should 
recommend  great  caution  in  the  use  of  this  ticklish  remedy.  You  ought  to  know 
that,  when  injected  in  other  emergencies,  in  strangulated  hernia,  for  example,  mortal 
syncope  has  followed  such  enemata. 

Musk,  in  large  doses,  has  been  strongly  recommended  by  a  Frenchman,  Fornier- 
Pescay,  who  has  written  on  this  disease.  He  gave  ten  or  twenty  grains,  at  intervals  - 
so  that  a  drachm,  or  even  two  drachms,  were  taken  in  the  course  of  the  day  ;  and 
he  declares  that  he  found  it  more  efficacious  than  any  thing  else  that  he  had  tried. 

Prussic  acid  and  belladonna  are  said,  by  Dr.  Elliotson,  to  have  been  freely  pre 
scribed,  and  to  have  failed;  whether  in  his  own  hands,  or  in  those  of  others,  I  do 
not  know. 

There  is  another  remedy  which  the  same  physician  has  employed  :  and  employed 
not  without  success :  the  carbonate  of  iron.  Reflecting,  he  tells  us,  upon  the  good 
eflTect  of  this  medicine  in  another  complaint  which  has  some  points  o^  analogy  witn 


358  TETANUS. 

tetanus,  viz.,  chorea,  of  which  I  shall  soon  speak,  and  considering  how  miserahty 
narcotics  had  failed,  he  determined  to  give  the  carbonate  of  iron  a  fair  trial  upon  the 
first  opportunity.  He  has  published  some  account  of  its  effects  in  tetanus,  in  ihe 
Medico-Chirurgical  Transactions.  In  the  first  case  in  which  he  used  it,  the  tetanus 
supervened  upon  a  compound  dislocation  of  the  great  toe.  The  method  in  Avhich 
the  remedy  was  administered  was  this.  The  carbonate  was  made  into  an  electuary 
by  niixing  it  with  twice  its  weight  of  treacle.  The  electuary  thus  made  was  well 
stirred  in  beef-tea  just  as  the  patient  was  about  to  drink  it.  He  took  this  every  two 
hours,  as  much  as  he  could  swallow  :  and  he  got  well.  The  next  case  is  described 
as  being  a  very  severe  one  ;  it  resulted  from  a  contusion  of  the  thumb.  Dr.  EUiotson 
says  that  he  never  saw  a  case,  ivhich  did  well,  that  was  more  severe.  This  patient 
also  took  the  carbonate  of  iron,  as  much  as  could  be  got  down ;  and  that  was  about 
two  pounds  a  day.  He  had  injections  twice  daily,  to  keep  the  bowels  unloaded  ;  and 
the  iron  is  described  as  having  come  away  in  large  red  lumps,  in  shape  like  horse 
dung.  This  man  recovered.  In  a  third  case,  where  a  chilblain  above  the  heel  was 
the  exciting  cause,  the  boy  died  within  twenty-hours  of  the  time  when  the  remedy 
was  first  prescribed.  To  produce  its  effects  upon  the  system  (Dr.  EUiotson  observes, 
very  truly),  iron  must  be  given  ybr  a  few  days:  nay,  he  holds  that  months  some- 
times elapse  before  it  has  any  effect.  So  that  if  it  really  be  useful  in  tetanus,  we 
cannot  expect  much  good  from  it  in  the  more  acute  cases  :  and  these  are  the  cases 
for  which  we  want  a  remedy. 

Oil  of  turpentine  is  one  of  the  many  substances  that  have  been  praised  as  useful 
in  tetanus.  Now,  bearing  in  mind  its  power  (which  I  shall  hereafter  describe, 
but  which  you  must  at  present  take  for  granted)  as  a  worm-killer,  and  also  the 
frequency  with  which  worms  are  met  with  in  the  stomach  and  bowels  after  death 
bj"-  tetanus,  this  is  one  of  the  drugs  which  I  should  employ  as  a  purgative,  taking 
my  chance  of  whatever  good  might  possibly  arise  from  its  specific  or  anthelmintic 
qualities.  It  may  be  given  in  such  cases  either  by  the  mouth,  or  in  an  enema,  or  at 
both  ends  together:  but  it  must  be  given  in  large  doses,  not  less  than  an  ounce  at  a 
time ;  and  it  may  be  mixed  with  an  equal  quantity  of  castor  oil.  The  one  oil  dis- 
solves or  becomes  incorporated  in  the  other. 

Sfrychnia  has  been  suggested  as  a  remedy  for  severe  tetanus  ;  not  in  infinitesimal 
doses,  as  Hahnemann  would,  I  suppose,  prescribe  it,  but  in  sufficient  quantity  to 
produce  a  sensible  effect.  The  principle  upon  which  this  has  been  recommended 
}s  the  same  with  that  on  which  the  nitrate  of  silver  ointment  is  applied  to  the  in- 
flamed conjunctiva  in  purulent  ophthalmia.  We  know  that  strychnia  acts  upon  the 
fpinal  cord,  affecting  apparently  those  parts  and  those  functions  of  the  cord  which 
are  affected  in  tetanus :  and  in  so  fatal  a  malady,  it  would  be  justifiable,  I  conceive, 
to  give  the  strychnia,  in  the  hope  that  it  might  occasion  a  morbid  action  which  would 
supersede  the  morbid  action  of  the  disease,  and  yet  be  less  perilous  and  more 
manageable  than  it.  But  it  would  be  right  to  try  such  a  remedy  as  this  in  the  first 
instance,  in  corpore  vili ;  upon  one  of  the  lower  animals.  This,  were  it  successful, 
would  be  a  cure,  according  to  the  Hahnemannic  doctrine — similia  similibus  curaii' 
fur — a  doctrine  much  older,  however,  than  Hahnemann.  But  the  opposite  maxim, 
contraria  contrariis  has  been  suggested.  Mr.  Morgan  proposes  to  give  such  poi- 
sons as  are  knoAvn  to  cause  paralysis,  with  the  view  of  countervailing  the  undue 
action  of  the  muscles  in  tetanus.  He  produces  artificial  tetanus  by  inserting  a 
poison  brought  from  Java,  called  "chatic,"  into  a  wound,  and  then  relieves  the 
tetanic  symptoms  by  a  North  American  poison,  the  ticunas.  Professor  Sewell  of 
the  Veterinary  College,  has  tried  this  principle  in  one  case  at  least,  where  the  tetanus 
was  the  result,  not  of  any  poison,  but  of  disease.  Not  having  had  an  opportunity 
of  getting  the  particulars  of  this  case  from  Mr.  Sewell  himself,  I  give  you  Mr. 
Mayo's  account  of  it.  "  A  horse,  suffering  from  a  severe  attack  of  tetanus  and 
locked-jaw,  the  mouth  being  too  firmly  closed  to  admit  the  introduction  of  either  food 
or  medicine,  was  inoculated  on  the  fleshy  part  of  the  shoulder  with  an  arrow-point 
coated  with  wourali  poison.  In  ten  minutes  apparent  death  was  produced.  Arti- 
ficial respiration  was  immediately  conimenced,  and  kept  up  about  four  hours,  when 
reanimation  took  place.     The  animal  rose  up,  apparently  perfectly  recovered,  and 


TETANUS.  359 

eagerly  partook  of  corn  and  hay.  He  was  unluckily  too  abundantly  supplied  with 
food  during  the  night.  The  consequence  was  over-distension  of  the  stomach,  of 
which  the  animal  died  the  following  day,  without,  however,  having  the  slightest  re- 
currence of  tetanic  symptoms."  I  had  fancied  that  the  death  had  resuhed  from  some 
injurious  effect  upon  the  lungs,  produced  by  the  artificial  breathing.  But  I  have 
little  doubt  that  Mr.  Mayo  derived  his  statement  from  Mr.  Sewell  himself.  The 
experiment  deserves  to  be  carefully  repeated. 

I  have  but  httle  to  say  concerning  what  may  be  called  the  surgical  treatment  of  trau- 
matic tetanus.  It  was  a  natural  thing,  the  source  of  the  irritation  being  supposed 
to  be  the  wound,  to  expect  relief  from  amputation  of  the  limb.  But  that  will  not 
arrest  the  morbid  action  after  it  has  once  been  fairly  established.  Dr.  EUiotson  says  he 
has  searched  scores  of  books,  and  found  only  one  case  in  which  the  hmb  and  the 
disease  were  lopped  away  together.  However,  Mr.  Blizard  Curling,  in  his  Essay 
on  Tttanus,  refers  to  seven  instances  of  recovery,  after  the  injured  part  had  been 
amputated.  Yet  he  states  that  "it  is  almost  impossible  to  ascertain  with  certainty 
how  far  the  amputation,  in  these  cases,  was  of  service.  I  beheve  I  cannot  offer  you 
better  advice  on  this  subject  than  may  be  gathered  from  the  concluding  remarks  of 
a  very  distinguished  and  philosophical  surgeon,  in  his  lectures  on  this  disease.  I 
allude  to  the  late  Mr.  Abernethy,  whose  pupil  I  had  the  good  fortune  to  be.  He 
said,  "  The  state  of  the  part  injured  is  not  the  sole  cause  of  tetanus.  In  cases  of 
tetanus  I  have  often  amputated  injured  fingers;  and  though  I  did  not  thereby  save 
my  patients,  yet  I  think  that  the  symptoms  were  mitigated  after  such  amputations. 
In  such  cases,  then,  I  would  not  amputate  any  considerable  member;  nor  even  a 
small  one,  unless  I  thought  that,  from  the  injury  sustained,  it  would  prove  useless  to 
its  possessor,  even  though  the  case  should  terminate  favourably." 

The  tourniquet  has  been  applied  to  the  hurt  limb ;  but  not,  so  far  as  I  know,  with 
any  good  effect.  The  most  promising  expedient  which  surgery  offers  is  the  divi- 
sion of  the  principal  nerve  proceeding  to,  or  rather  from,  the  seat  of  the  injury. 
This,  supposing  the  nerve  to  be  known  and  accessible,  is  less  formidable,  less  severe, 
less  hazardous,  less  maiming,  and,  if  we  may  judge  from  past  experience,  more 
effectual,  too,  than  amputation  of  the  part.  Dr.  Murray  has  recorded  (in  the 
eleventh  volume  of  the  Medical  Gazette),  a  very  interesting  case,  in  which  the 
operation  Avas  followed  by  most  decided  and  instant  relief.  The  patient  was  a  young 
midshipman  who,  having  trodden  on  a  rusty  nail,  which  pierced  the  sole  of  his  left 
foot,  had  kept  watch  the  same  night  upon  deck,  the  weather  being  very  cold.  The 
disease  began  the  next  day,  and  the  symptoms  ran  high.  It  was  a  case,  therefore, 
of  severe  or  acute  tetanus.  Without  loss  of  time,  the  posterior  tibial  nerve  was  divided. 
The  limb  was  previously  cold,  and,  as  the  patient  said,  dead,  and  he  had  httle  power 
of  moving  it.  He  could  not  articulate  distinctly,  on  account  of  the  closed  state  of 
his  jaws.  The  nerve  was  cut  through  by  one  stroke  of  the  scalpel :  and  "immedi- 
ately (says  Dr.  Murray)  he  opened  his  mouth  with  an  exclamation ;  and  on  looking 
at  his  countenance  I  was  astonished  at  tlie  striking  improvement  in  it.  I  asked  him 
how  he  felt,  and  he  said  he  was  already  much  better,  and  that  his  leg  had  come  to 
life  again."  Some  stiffliess  of  the  jaws  and  neck  remained  for  a  day  or  two ;  but 
he  soon  recovered.  Dr.  Murray  rel'ers  to  another  case,  mentioned  by  Baron  Larrey, 
in  which  division  of  the  nerve  had  a  similar  result. 

Probably,  to  be  successful,  the  operation  must  be  early ;  before  the  morbid  con- 
dition peculiar  to  the  disorder  has  had  time  to  root  itself  in  the  nervous  system. 

Although,  in  the  present  state  of  our  knowledge,  there  is  no  one  remedy  or 
plan  on  which  we  can  rely  for  the  cure  of  this  fearful  malady,  we  may  with 
much  confidence  lay  down  certain  general  rules,  the  observance  of  which  will  secure 
to  the  patient  the  best  chance  of  a  favourable  result. 

Since  any,  the  smallest  movement,  or  impression  made  upon  the  surface,  or  upon 
the  senses,  will  bring  on  the  severer  degrees  of  spasm,  it  is  of  primary  importance 
to  protect  the  patient  against  these  sources  of  trouble,  so  sure  to  aggravate  his  suf- 
ferings, and  so  likely  to  augment  his  danger.  Hence  if  blood-letting  should  be 
thought  advisable,  it  should  be  done  early,  sufficiently,  and  once  for  all.  There 
should  be  no  repetition  of  venesection,  or  of  cupping,  or  of  leeches,  unless  the  cu- 


'i60  HYDROPHOBIA. 

cumstances  and  progress  of  the  case  plainly  demand  them.  The  same  remark 
applies  to  the  frequent  use  of  purgatives.  The  bowels  should  be  well  cleared  in  the 
outset,  and  then  let  alone.  The  patient  should  lie  in  a  darkened  room ;  from  which 
noise  also  should,  as  much  as  possible,  be  excluded.  He  should  not  be  surrounded 
by  a  multitude  of  friends  or  attendants.  He  should  be  enjoined  to  speak,  to  move, 
to  swallow  as  seldom  as  he  can.  In  the  severe  traumatic  cases,  the  nerve,  in  mv 
judgment,  should  be  promptly  divided.  And  in  all  cases,  there  being  no  special 
indications  to  the  contrary,  I  should  be  more  inchned  to  administer  wine  in  large 
doses,  and  nutriment,  than  any  particular  drug.  If  the  tendency  to  mortal  asthenia 
can  be  staved  off,  the  disturbance  of  the  excito-motory  apparatus  may,  perchance, 
subside  or  pass  away. 

There  is  a  form  of  this  complaint  called  trismus  nascentium.  As  the  name  im- 
plies, it  occurs  in  newly-born  children.  It  is  very  frequent  and  very  fatal  in  the 
West  Indies ;  coming  on  usually  in  the  second  week  after  birth.  Hence  it-iias  been 
called  "  the  ninth-day  disease."  Another  of  its  names  in  the  British  settlements 
there,  is  "  the  jaw-fall ;"  from  the  circumstance  that  shortly  before  death  the  lower 
jaw,  which  had  previously  been  firmly  pressed  against  the  upper,  drops  on  the 
breast.  It  has  been  said  that  a  fourth  of'  the  infant  negroes  in  Jamaica  used  to  die 
of  this  disorder.  Some  persons  refer  it  to  the  irritation  produced  by  the  retention 
of  the  meconium  in  the  intestines ;  others  to  irritation  from  the  wound  made  by 
dividing  the  navel-string.  A  dose  of  purgative  medicine  appears  to  be  the  most 
hopeful  remedy.  The  complaint  is  common,  I  am  told,  in  ill-ventilated  lying-in 
hospitals.     Pure  air  must,  therefore,  be  desirable  as  an  adjuvant. 

Tetanic  symptoms  sotnetimes  occur  (but  I  should  think  very  rarely)  in  ague.  Or 
paroxysms  of  tetanus  return  at  regular  intervals,  and  terminate  by  profuse  perspira- 
tion :  the  patient  being  well  during  the  intermissions.  When  such  phenomena 
arise,  the  treatment  proper  in  severe  forms  of  ague  must  be  adopted  :  what  that  treat- 
ment is,  I  shall  in  no  long  time  be  able,  I  hope,  to  lay  before  you. 

Again,  tetanus  is  occasionally  a  symptom  in  hysteria;  and  then  the  treatment 
applicable  to  hysteria  must  be  had  recourse  to  ;  especially  encmata  of  oil  of  turpen- 
tine, or  the  same  medicine  given  by  the  mouth ;  and  the  cold  affusion. 

If  the  disease  of  which  I  have  been  speaking  be  dangerous,  and  very  often  fatal, 
in  spite  of  all  remedial  measures,  that  which  I  propose  to  bring  next  under  your 
attention  is  still  more  appaUing ;  for  I  believe  that  hitherto  it  has  been  uniformly 
mortal.  I  know  not  that  any  one  has  ever  been  rescued  by  art,  or  saved  by  the 
efforts  of  nature,  from  Hydrophobia,  after  that  frightful  disease  has  once  declared 
itself  by  its  characteristic  symptoms.  The  nature  of  those  symptoms,  and  the 
absence  of  all  definite  or  constant  traces  of  organic  change  in  the  dead  body,  suffi- 
ciently mark  the  disease  as  belonging  essentially  to  the  nervous  system,  and  as  being 
essentially  a  spasmodic  disease  also. 

What  are  the  symptoms  stated  in  broad  outline  ?  These.  Excessive  nervous 
irritability  and  apprehension;  spasmodic  contractions  of  the  muscles  of  the  fauces, 
excited  by  various  external  influences,  and  especially  by  the  sight  or  sound  of  liquids, 
and  by  attempts  to  swallow  them  ;  and  extreme  difficulty,  amounting  sometimes  to 
impossibility,  of  drinking. 

'Vhh  is  one  of  the  diseases  which  are  produced  by  animal  poisons ;  and  its  course 
will  be  most  conveniently  traced  if  we  include  in  our  description  of  it  the  very  first 
step  towards  its  production, — the  application  of  the  specific  poison  to  the  body.  A 
man  is  bitten  by  a  dog.  After  a  time  the  symptoms  proper  to  hydrophobia  come 
on.  After  another  interval  the  man  is  dead.  Before  we  advert  to  the  many  very 
interesting  points  of  inquiry  which  arise  out  of  the  contemplation  of  this  malady,  let 
•is  follow  the  tragedy  from  its  commencement  to  its  closing  scene. 

A  person  is  bitten,  then,  by  a  mad  dog.  Does  the  existence  of  rabies  in  the  ani- 
mal modify  in  any  way  the  injury  thus  inflicted?  No;  the  wound  that  is  made 
behaves  just  the  same,  to  all  appearance,  as  it  would  have  behaved  if  the  dog  had 
not  been  rabid;  and  it  gradually  heals.  After  an  uncertain  interval — which  lies, 
for  the  most  part,  between  six  weeks  and  eighteen  months,  and  which  ha.-  l.'et-n 


HYDROPHOBIA.  361 

called  the  period  of  incubation  —  the  following  symptoms  begin  to  be  noticeable. 
The  patient  experiences  pain,  or  some  uneasy  or  unnatural  sensation,  in  the  situa- 
tion of  the  bite.  If  it  has  healed  up,  the  cicatrix  tingles,  or  aches,  or  feels  cold,  or 
stiff,  or  numb :  sometimes  it  becomes  visibly  red,  swelled,  or  livid  ;  on  one  occasion 
a  papular  eruption  took  place  around  it;  sometimes  it  opens  afresh,  and  discharges 
a  peculiar  ichor.  The  pain  or  uneasiness  extends  from  the  sore  or  scar  towards  the 
central  parts  of  the  body :  i.  e.,  if  the  bite  has  been  inflicted  on  a  limb,  the  morbid 
sensations  extend  towards  the  trunk.  All  this  gives  fearful  notice  of  what  is  about 
to  happen.  This  period  is  called  the  period  of  recrudescence.  I  believe  it  seldom 
fails  to  occur,  although  it  sometimes  is  not  noticed ;  the  attention  of  the  patient,  and 
of  his  medical  advisers,  being  absorbed  by  the  horrible  sequel.  Very  soon  after  this 
renewal  of  local  irritation — within  a  few  hours,  perhaps,  but  certainly  within  a  very- 
few  days,  during  which  the  patient  feels  uncomfortable  and  ill — the  specific  consti- 
tutional symptoms  begin :  he  is  hurried  and  irritable  ;  speaks  of  pain  and  stiffness, 
perhaps,  about  his  neck  and  throat :  unexpectedly  he  finds  himself  unable  to  swal- 
low fluids,  and  every  attempt  to  do  so  brings  on  a  paroxysm  of  choking  and  sobbing, 
of  a  very  distressful  kind  to  behold  ;  and  this  continues  for  two  or  three  days,  till  the 
patient  dies  exhausted,  in  the  way  of  asthenia. 

I  have  seen  only  two  examples  of  this  terrific  malady  ;  one  in  St.  Bartholomew's 
Hospital,  in  the  year  1826 ;  one  much  more  recently  in  the  Middlesex  Hospital. 
As  they  constitute  the  whole  of  my  personal  experience  in  the  matter,  I  shall  relate 
these  cases. 

The  first  occurred  in  a  coachman,  the  back  of  whose  right  hand  had  been  struck, 
ten  weeks  previously,  by  the  teeth  of  a  terrier  dog;  but,  as  both  the  patient  and  his 
fellow-servants  declared,  there  was  no  wound  made,  no  blood  drawn,  no  breach  or 
lifting  of  the  skin  ;  but  merely  an  indentation,  showing  where  the  animal's  teeth  had 
pressed.  He  was  brought  to  the  hospital  on  a  Tuesday.  On  the  preceding  Thurs- 
day his  hand  had  become  painful,  and  swelled  a  little.  On  Friday  the  pain  ex- 
tended into  the  arm,  and  became  more  severe.  His  wife  stated  that  he  had  been  in 
the  habit  of  sponging  his  head  and  body  every  morning  with  cold  water,  but  that, 
on  this  morning,  he  refrained  from  doing  so,  on  account  of  some  feeling  of  spasra 
about  the  throat.  His  own  remark  on  this  was,  that  "  he  could  not  think  how  he 
could  be  so  silly." 

On  Saturday  the  extent  and  the  severity  of  the  pain  had  still  further  increased. 
On  this  and  the  preceding  night  he  got  no  sleep.  He  felt  ill  and  drowsy  on  the 
Sunday,  but  drove  the  carriage  to  Kensington  Gardens :  he  was,  however,  obliged 
to  hold  both  whip  and  reins  in  his  left  hand.  The  pain  extended  to  the  shoulder. 
He  was  then  bled.  A  slop-basin  full  of  blood  was  taken,  with  much  relief  to  the 
pain  ;  and  purgative  medicine  was  given,  which  operated  well. 

The  next  day  he  complained  of  "  feeling  very  ill  all  over,"  and  he  told  his  medi- 
cal attendant  that  he  could  not  take  his  draughts,  because  of  the  spasm  in  his  throat. 
That  gentleman  (Mr.  Macdonald),  concealing  his  own  suspicions  as  to  the  true 
nature  of  the  disease,  said,  "Oh,  you  don't  like  the  taste  of  your  phj^sic!  drink 
some  water."  But  he  declared  he  had  the  same  difficulty  with  water.  The  next 
day  he  came  to  the  hospital.  When  there,  water  was  brought  and  placed  before 
him  in  a  basin,  for  the  alleged  purpose  of  allowing  him  to  wash  his  hands.  It  did 
not  seem  to  disturb  him,  nor  to  excite  any  particular  attention.  Water  was  then 
offered  him  to  drink,  which  he  took,  and  carried  to  his  mouth,  but  drew  his  head 
from  it  with  a  convulsive- shudder.  After  this,  on  the  same  morning,  he  was  much 
questioned  by  several  persons  about  the  supposed  cause  of  his  iUness ;  and  water 
was  again  brought  him,  which  agitated  him,  and  he  became  exceedingly  distressed 
and  unquiet,  complaining  of  the  air  which  blew  upon  him. 

I  first  saw  him  myself  soon  after  this.  He  was  then,  to  all  outward  appearance, 
wt'l! ;  lying  on  his  back,  without  spasm,  without  anxiety ;  his  face  somewhat 
flushed.  He  said  he  had  a  little  headache,  but  no  pain  in  the  arm.  His  pulse 
was  i:3"2,  full,  and  strong;  his  tongue  moist,  and  shghlly  furred.  He  appeared  to 
be  a  very  quiet,  good-tempered  man ;  and  smiled  generally  when  he  was  spoken  to. 

I  was  naturally  much  interested  by  this  case,  and  at  nine  in  the  evening  I  visited 

2f 


362  HYDROPHOBIA. 


1 


the  patieni  again.  Ht;  was  composed  and  tranquil.  Gruel  was  mentioned,  and 
then  he  sighed  two  or  three  times  deeply  ;  then  sat  up,  and,  after  a  moment's  look 
of  serious  terror,  took  half  a  spoonful  of  the  gruel  in  a  hurried  gasping  manner; 
and  said  he  would  not  take  more  at  a  time,  lest  the  sensalion  should  come  on.  He 
was  desired  to  drink  the  last  portion  of  the  gruel  from  the  basin.  He  accordingly 
seized  it  with  a  hurry,  carried,  it  to  his  mouth  with  an  air  of  determination,  and 
then  a  violent  choking  spasm  of  the  muscles  about  the  throat  ensued,  the  stemo- 
mastoidei  starting  strongly  forwards.  Most  of  the  gruel  was  spilled  over  his  chin  ; 
and  he  observed  that  he  had  been  too  much  in  a  hurry,  or  he  should  have  managed  it. 

The  treatment  consisted  in  full  doses  of  opium,  repeated  at  frequent  intervals.  On 
this  visit  to  him  I  noticed,  that  while  attempting  to  take  some  of  the  gruel  with  a 
spoon,  he  seemed  inclined  to  doze  as  he  sat.  Otherwise  there  were  no  signs  of  his 
being  overwhelmed,  or  even  sensibly  affected  by  the  opium,  unless  indeed  his  gene- 
ral quietness  was  the  consequence  of  it.  He  was  quite  rational  and  calm,  except 
when  attempting  to  take  fluids. 

On  the  Wednesday,  at  noon,  he  was  in  nearly  the  same  state,  but  said  he  was 
better.  In  the  course  of  the  night  some  morsels  of  ice  had  been  given  him :  with 
considerable  effort  he  swallowed  two  or  three  of  these ;  the  third  or  fourth  caused 
so  much  spasm,  however,  that  he  was  obliged  to  throw  it  out  of  his  mouth  :  but  so 
great  was  his  resolution  that  he  seized  it  again,  and,  by  a  strong  exertion,  succeeded 
in  swallowing  it.  He  complained  now  that  his  mouth  was  and  had  been  clammy  ; 
and  he  champed  much,  and  spat  out  a  good  deal  of  tough  mucus.  At  his  own 
request,  and  ("as  he  said)  that  he  might  injure  no  one,  a  strait-waistcoat  was  brought, 
which  he  assisted  in  putting  on.     But  he  was  perfectly  tranquil  then. 

I  now  had  an  opportunity  of  seeing  him  take  some  arrow-root.  He  sat  up  in  bed 
to  eat  it ;  and  before  attempting  to  do  so,  he  made  hurried  inspirations,  and  sobbings 
precisely  resembling  those  which  occur  when  one  wades  gradually  into  cold  water. 
He  swallowed  small  quantities  of  arrow-root  eight  or  nine  times,  with  hurry  and 
difficulty,  and  with  sighs  that  succeeded  each  other  rapidly.  He  said  that  he  felt 
the  upper  part  of  his  throat  narrower  than  it  should  be.  He  continued  to  take 
laudanum  mixed  with  sugar  and  bread  into  a  kind  of  pulp. 

By  the  evening  of  that  day  the  disease  had  not  made  much  further  progress.  He 
again  sat  up  and  tried  to  eat  some  thinnish  gruel.  While  taking  the  basin  into  his 
hand,  he  drew  back  his  head  to  a  distance  from  it,  apparently  involuntarily.  He 
took  one  half-spoonful  with  effort  and  distress,  then  sighed  deeply  and  rapidly,  or 
rather  his  breathing  consisted  of  a  succession  of  sighs  at  short  intervals  :  he  gave  up 
the  basin,  and  sank  back  on  his  pillow  still  sighing.  In  the  course  of  that  night  he 
ceased  to  take  the  laudanum  ;  he  could  no  longer  attempt  it.  The  next  day  ne  was 
still  composed,  though  more  easily  irritated ;  and  it  was  found  that  he  had  lost  the 
power  of  moving  the  left  arm.  His  pulse  was  140,  and  much  weaker  than  before, 
and  his  mental  powers  Avere  failing.  He  gradually  sank,  and  died  in  the  evening, 
having  repeated  the  Lord's  Prayer  an  hour  previously.  During  the  last  hours  of 
life  he  had  been  moaning,  and  tossing  from  side  to  side :  his  bowels  were  purged ; 
fluid  stools  ran  from  him,  and  distressed  him  greatly.  His  lower  extremities  first 
became  cold,  and  the  coldness  extended  by  degrees  up  to  his  chest.  He  hawked  up 
in  the  course  of  the  day  a  considerable  quantity  of  ropy  mucus,  and  much  frothy 
saliva  came  from  his  mouth  towards  the  close.  As  his  wife  was  wiping  this  away, 
his  teeth,  whether  by  convulsive  accident  or  otherwise,  came  in  contact  with  her 
finger,  and  drew  blood.  The  part  was  cut  out ;  and  no  bad  consequence  followed 
that  I  know  of. 

The  examination  of  his  body  threw  no  satisfactory  light  ujwn  the  essential  nature 
of  the  disease.  Blood  and  serous  fluid  escaped  on  the  removal  of  the  calvarium. 
The  vessels  of  the  membranes  were  full,  and  the  brain  itself  was  mottled  somewhat 
by  Its  vascularity.  There  were  a  few  spots  of  ccchymosis  on  the  heart.  The  back 
part  of  the  tongue  was  very  vascular.  The  stomach  presented  the  most  notable 
appearance.  There  was  a  quantity  of  brownish-coloured  mucus  on  its  inner  surface, 
and  the  mucous  membrane  had  disappeared  from  a  space  about  four  inches  in 
diameter  at  its  left  and  larger  end.     That  space  alone  was  diaphanous ;  its  edges 


HYDROPHOBIA.  363 

sloped  inwards  ;  and  a  segment  of  this  thin  place  looked  exactly  like  a  piece  oi  china. 
On  a  white  ground,  there  were  inosculating  vessels,  some  of  them  blue,  and  some 
of  them  of  a  coffee-coloured  brown.  I  conclude  that  this  appearance  was  produced 
by  the  action  of  the  gastric  juice  after  death. 

This  was  in  some  respects  a  remarkable  case.  It  was  remarkable  for  its  duration. 
Dr.  Bardsley,  in  the  article  on  Hydrophobia  in  the  Cyclopxdia  of  Practical  Medicine, 
states  that  the  patients  "  invariably  go  on  from  bad  to  worse,  and  finally  die  before 
the  sixth  day."  Now  if  we  reckon  that  stage  of  the  complaint  here  referred  to  by 
Dr.  Bardsley  to  have  begun  on  the  morning  of  Friday,  when  he  was  obliged,  to  omit 
his  sponging  because  of  the  spasm  about  his  throat,  this  patient  did  not  die  till  the 
middle  of  the  seventh  day.  In  fact  it  was  a  very  protracted  case,  and  the  symp- 
toms were  less  violent  than  usual.  Whether  this  was  owing  to  the  opium  he  took 
or  not,  it  would  be  difficult  to  determine. 

In  the  second  of  the  two  cases  which  it  has  been  my  lot  to  witness,  the  charac- 
teristic symptoms  of  hydrophobia  were  more  faintly  pronounced  than  is  usual. 

On  my  arrival  at  the  Middlesex  Hospital,  on  Thursday,  the  5th  of  October,  1837, 
I  was  told  that  a  patient  had  been  admitted  (under  one  of  my  colleagues)  labouring 
probably  under  hydrophobia.  He  had  applied  at  the  hospital  in  the  middle  of  the 
night ;  but  was  then  sent  away,  after  receiving  some  aperient  pills,  with  assurances 
that  he  was  only  feverish  and  nervous.  On  his  reapplication  in  the  morning,  he  had 
been  admitted. 

I  found  him  in  the  ward :  a  man  twenty-five  years  old,  of  dark  complexion  and 
hair.  He  expressed  his  conviction  that  he  was  afiiicted  with  hydrophobia ;  and  said 
he  was  prepared  for  his  fate.  I  observed  that  every  now  and  then  he  suddenly 
sighed  in  a  very  pecuhar  manner  ;  just  as  I  had  seen  the  former  patient  sigh.  This 
would  happen  sometimes  in  the  middle  of  a  sentence,  while  he  was  speaking.  He 
told  us  that  he  had  been  bitten  by  a  dog  in  the  latter  end  of  July  ;  the  dog  was  swim- 
ming, and  like  to  drown,  in  a  canal,  and  upon  his  reaching  over  to  lift  him  out  of  the 
water,  the  animal  seized  upon  his  hand.  After  dragging  the  dog  out,  he  beat  him 
for  his  ingratitude ;  and  then  the  dog  ran  off,  and  was  pursued  by  a  mob  of  boys, 
who  had  previously  been  pelting  him  as  a  mad  dog.  There  was  a  scar  on  the 
middle  finger  of  the  right  hand  ;  the  nail  of  that  finger  had  (he  said)  been  torn 
through,  and  each  of  the  two  adjacent  fingers  had  been  more  slightly  bitten.  His 
pulse  was  84  ;  but  varied  in  frequency  at  short  intervals. 

He  acknowledged  that  after  receiving  the  bite  he  was  uneasy  as  to  its  possible 
effects,  and  read  books  about  hydrophobia  at  the  time  :  but  he  affirmed  that  he  had 
afterwards  ceased  entirely  to  think  about  it.  He  had  persuaded  himself  that  the 
dog  could  not  be  mad,  from  its  being  in  the  water.  On  Tuesday,  if  not  earlier,  he" 
had  been  uncomfortable  and  restless  ;  and  on  Wednesday  he  found  he  could  not 
swallow  liquids.  On  one  of  these  days  he  experienced  a  slight  pricking  sensation, 
without  any  redness  or  tenderness,  in  the  site  of  the  scar ;  his  right  arm  and  leg 
seemed  to  himself  hotter  than  the  opposite  limbs ;  and  the  arm,  though  not  tender, 
felt  raw,  and  he  could  not  bear  the  light  contact  of  his  clothes  upon  it.  Fie  became 
feverish  also.  From  time  to  time  a  slight  expression  of  terror  passed  across  his 
features,  and  then  he  made  a  sudden,  deep,  sighing  inspiration  :  at  other  times  his 
breathing  and  appearance  were  perfectly  natural.  It  was  said  that  when  some 
water  was  brought  him  he  drew  himself  back  from  it  with  horror.  He  talked  a 
good  deal. 

I  saw  him  eat  rice,  made  pulpy  with  milk.  He  took  it  without  looking  at  the 
spoon,  from  which  he  averted  his  eyes,  and  ate  several  mouthfuls,  in  a  gulping  man- 
ner, and  with  evident  effort.  His  bowels  had  been  purged  by  the  pills,  and  he 
declared  that  the  noise  of  the  water  in  the  water-closet  had  distressed  him.  The 
sound  of  some  water  poured  from  one  vessel  into  another  by  the  pa-tient  in  the  next 
bed,  had  also  agitated  him.  So  did  the  contact  of  my  cold  hand  on  his  arm ;  and 
currents  of  air,  even  the  breath  of  any  one  speaking  to  him ;  so  that  he  insisted  on 
conversing  with  the  apothecary  in  such  a  position  that  the  chin  of  each  was  upon 
the  other's  shoulder.     But  there  was  no  actual  or  apparent  spasm. 

At  this  time  he  affirmed  that  the  presence  of  company  cheered  him,  and  did  hnu 


364  HYDROPHOBIA. 


I 


good  ;  and  beg-ged  that  he  might  not  be  removed  into  a  separate  room.     And  he 
wished  for  some  amusing  book  that  he  might  read. 

In  the  evening  I  again  went  to  see  him.  He  did  not  seem  worse,  thoutrh  he 
said  "his  symptoms  were  increasing."  He  had  taken  a  dose  of  musk  and'some 
morphia. 

The  next  day  I  found  the  hospital  in  some  confusion.  Between  eleven  and  twelve 
o'clock  in  the  preceding  night  some  of  the  officers  of  the  hospital  had  gone  to  his 
bed,  while  he  was  apparently  asleep,  and  certainly  very  quiet.  They  asked  him  if 
he  would  like  some  water.  This  seems  to  have  greatly  excited  him ;  and  imme- 
diately after  their  departure  he  rushed  out  of  bed,  (terrified  he  said,)  became  furious 
and  unmanageable,  and  was  never  again  tranquil  till  he  died,  about  the  same  time 
next  night.  He  was  now  put  into  a  room  by  himself;  and,  taking  advantage  of  the 
momentary  absence  of  the  nurse,  he  bolted  himself  in  alone :  and  he  declared  he 
would  admit  no  person  but  her.  The  door  was  at  length  forced,  and  a  strait- 
waistcoat  was  put  upon  him.  He  then  became  quieter  in  his  manner ;  begged  that 
no  unnecessary  violence  might  be  used  ;  asked  to  be  poisoned  ;  spat  at  some  of  the 
bj'standers,  and  reproached  them,  talking  rapidly  and  wildly  like  an  insane  person ; 
yet  loudly  and  angrily  imposing  silence  on  every  one  who  addressed  him.  He  said 
he  could  not  bear  to  hear  any  one  speak;  that  he  did  not  like  my  bass  voice.  Then 
he  would  sneer  at  the  students,  and  say  they  showed  bravery  enough  now  he  was 
confined :  "  Was  it  right  for  3'oung  gentlemen  of  education  to  stand  there  gazing 
with  curiosity  on  a  dying  man  ?"  asked  for  bread  soaked  in  water,  and  when  it  was 
held  towards  him,  snatched  it  in  his  mouth  in  a  savage  manner ;  spoke  of  his  "  poi- 
soned tooth,"  and  talked  perpetually.  He  took  a  fancy  to  one  of  the  students,  and 
begged  that  he  might  remain  with  him. 

About  this  time  he  vomited  some  yellow  fluid,  and  thought  he  felt  the  better  for 
it,  and  asked  for  an  emetic  ;  and  some  tartarized  antimony  was  exhibited.  He  was 
now  pale,  and  his  lips  were  Hvid ;  but  none  of  the  distinctive  spasmodic  attacks 
occurred  :  indeed  water  was  not  at  this  time  suffered  to  be  brought  near  him.  This 
circumstance  it  was,  this  absence  of  the  peculiar  spasmodic  paroxysms  which  char- 
acterize hydrophobia,  that  induced  several  medical  men  of  much  sagacity  and  expe- 
rience to  doubt,  and  even  with  some  positiveness  to  deny,  that  the  patient  was  suffering 
under  that  disease  at  all.  The}''  supposed  him  to  be  hysterical,  half-crazj'',  or  on  the 
brink  of  delirium  tremens.  But  though  slightly  expressed,  the  symptoms  were 
unlike  anything  I  had  ever  witnessed,  except  in  the  previous  instance.  And  the 
closing  scene  was  quite  distinctive. 

It  appeared,  and  he  spoke  of  it  as  a  thing  which  distressed  him,  that  when  he  was 
most  excited,  his  urine  passed  involuntar}'. 

In  the  ev^ening  I  found  his  father  with  him.  He  had  recognized  him,  and  kissed 
his  mother-in-law  ;  but  soon  began  to  rave,  and  to  be  apparently  occupied  with 
absent  persons.  He  was  pale  and  weak,  and  lay  with  his  head  over  the  side  of  the 
bed,  spitting  continually  upon  the  floor,  which  was  thus  made  quite  wet.  He  wished 
to  have  his  hands  at  liberty  that  he  might  "  clear  his  mouth."  He  was  soliloquizing 
when  I  went  into  the  room  in  this  way:  "Monsters — monsters — see  that  monster, 
Susan — take  her  away."  (It  appeared  that  he  was  now  speaking  of  a  young  woman 
who  had  had  a  child  by  him.)  "I  thought  they  would  do  much  for  science,  but 
never  sujiposed  they  would  inflict  such  agony  as  this  ;"  and  so  on. 

A  little  later  Mr.  Arnott  visited  him.  He  had  then  no  pulse  at  the  wrist.  The 
waistcoat  was  removed.  He  sat  up,  and  used  some  water,  brought  to  wash  his 
hands,  without  apparent  distress.     Soon  after  he  sank  back  exhausted  ;  and  expired. 

His  father  corroborated  what  the  patient  had  said  of  the  dog ;  and  told  us  his  son 
was  clever,  and  better  educated  than  many  of  his  rank  (he  wai  a  tailor),  but  always 
exceedingly  nervous. 

The  bodj'  was  examined  the  next  day.  Its  posterior  and  undermost  surface  was 
very  livid.  The  blood  everywhere  quite  fluid.  The  veins  of  the  spinal  cord,  on  its 
posterior  part,  were  turgid;  not  at  all  so  on  the  anterior.  The  substance  of  the  cord 
was  quite  natural.  There  was  some  fluid  in  the  theca.  The  brain  appeared  to  me 
in  every  pari,  quite  sound  and  healthy. 


HYDROPHOBIA.  365 

The  head  and  face,  which  had  been  hanging  over  the  table  while  the  spinal  canal 
was  opened  from  behind,  were  deeply  purple  as  though  universally  bruised.  This 
colour  diminished  rapidly  after  the  corpse  was  placed  supine,  and  the  head  raised 
somewhat  above  the  level  of  the  body.  The  papilte  at  the  back  part  of  the  tongue 
were  greatly  exaggerated,  and  looked  like  large  vesicles.  The  cartilage  of  the 
epiglottis,  at  its  lower  part,  was  red.  At  about  the  middle  portion  of  the  oesophagus 
there  was  an  appearance  as  if  the  cuticle  was  abraded.  The  mucous  membrane  of 
the  stomach  was  soft,  and  red  here  and  there,  with  a  dotted  injection  resembling 
ecchymosis,  especially  on  its  rugae.     The  air-passages  were  apparently  heakhy. 

Generally,  the  disease,  when  it  has  once  set  in,  and  shown  the  peculiar  hydro- 
phobic symptoms,  runs  a  short  and  fierce  course.  The  nervous  irritability  becomes 
extreme.  The  peculiar  paroxysms  of  choking  spasm,  and  sobbing,  are  excited,  not 
only  by  attempts  to  swallow  liquids,  but  by  the  very  sight  or  sound  of  them.  Dr. 
Elliotson  mentions  a  boy  who  was  thrown  into  a  state  of  violent  agitation  by  hearing 
a  dresser  who  sat  up  with  him  make  water.  The  passage  of  a  gust  of  wind  across 
his  face,  the  waving  of  a  polished  surface,  as  of  a  mirror,  before  his  eyes,  the  crawl- 
ing of  an  insect  over  his  skin,  is  often  sufficient  to  excite  great  irritation,  and  the 
peculiar  strangling  sensation  about  the  fauces,  in  a  hydrophobic  patient.  These 
circumstances  were  but  little  observable  in  the  men  whose  cases  I  have  related.  The 
first  of  them  indeed  was  remarkably  calm  and  tranquil  under  the  disease.  In  general 
the  patient  is  dreadfully  irritable,  and  apprehensive  and  suspicious ;  and  in  most 
cases  there  is  a  degree  of  mania  or  delirium  mixed  up  with  the  irritability ;  the  suf- 
ferer is  very  garrulous  and  excited.  In  this  respect  there  is  a  marked  difference 
between  hydrophobia  and  tetanus.  In  the  latter  disorder  the  mental  facukies  are 
clear,  and  the  patients  serene,  and  what  is  called  heart-whole,  to  the  last.  The  two 
diseases  differ  in  another  striking  particular:  the  spasm  in  the  one  case  is  tonic,  in 
the  other  clonic.  In  tetanus,  again,  there  is  no  thirst,  and  seldom  any  accumulation 
of  tough  and  stringy  mucus  in  the  fauces  and  about  the  angles  of  the  mouth  ;  in 
hydrophobia  both  these  symptoms  are  always,  J  believe,  present.  So  probably  is 
vomiting;  but  vomiting  in  tetanus  is  rare.  The  nervous  irritability  in  hydrophobia 
is  doubtless  a  part  of  the  disease,  and  is  very  seldom  absent  even  now-a-days.  Some- 
time ago  it  might  perhaps  have  been  plausibly  attributed  to  the  treatment  adopted. 
I  allude  to  that  period  in  which  it  was  believed  that  these  miserable  persons  had  both 
the  power,  and  the  inclination,  to  impart  the  disease  to  others  by  biting  them  ;  and 
when,  under  pretence  of  shortening  his  sufferings,  but  really,  I  am  afraid,  with  the 
cowardly  view  of  protecting  themselves,  his  friends  were  accustomed  to  smother  the 
unhappy  patient  between  two  feather-beds,  or  to  open  a  vein,  and  to  leave  him  to 
bleed  to  death.  Any  person  suspecting  what  was  the  matter,  and  foreseeing  such  a 
termination  to  his  disease,  might  well  be  nervous  and  irritable.  But  now  that  this 
barbarous  practice  has  been  exploded,  and  the  dread  of  being  smothered  does  not 
occur  to  the  mind  of  the  patient,  he  is  still  found  to  be  exquisitely  frritable  and  timo- 
rous. The  foam  and  sticky  mucus  that  gather  in  the  throat  and  mouth,  these  patients 
make  great  efforts,  by  spitting  and  blowing,  to  get  rid  of;  and  the  sounds  tl.cy  thus 
produce  have  been  exaggerated  by  ignorance  and  credulity  into  the  barking  and 
loaming  of  a  dog.  In  the  same  way  the  paraplegia  which  sometimes  takes  place, 
rendering  the  patient  unable  to  stand  upright,  has  been  misconstrued  into  a  desire  on 
his  part  to  go  on  all  fours  like  a  dog.  The  pulse,  though  it  may  be  strong  and  hard 
at  the  outset,  becomes,  in  a  short  time,  frequent  and  feeble,  and  the  general  strength 
declines  with  great  rapidity.  Death  occasionally  takes  place  within  twenty-four 
hours  after  the  commencement  of  the  specific  symptoms.  Most  commonly  of  all  it 
happens  on  the  second  or  third  day  ;  now  and  then  it  is  postponed  to  the  fifth  day  , 
and  in  still  rarer  instances,  of  which  my  first  case  Avas  one,  death  does  not  occur  till 
the  seventh,  or  eighth,  or  nin-th  day.  In  most  cases  the  paroxysms  becoming  more 
violent  and  frequent,  exhaust  the  patient ;  but  in  a  few  instances  the  symptoms  un- 
dergo a  marked  alteration  before  death.  The  paroxysms  cease,  the  nervous  irritabi- 
Uty  disappears,  the  patient  is  able  to  eat  and  drink,  and  converse  with  ease ;  thoso 
Sights  and  sounds  which  so  annoyed  and  distressed  hira  before,  no  longer  cause  him 

2f2 


366  HYDROPHOBIA. 

any  disquiet.  In  this  state  he  often  sinks  into  a  sleep,  and  suddenly  wakes  from  it 
to  die  :  sometimes  his  existence  is  put  an  end  to  by  a  sudden  and  violent  convulsion. 

It  is  needless  for  me  to  go  into  a  minute  account  of  the  morbid  appearances  that 
l^ave  been  met  with  in  persons  dead  of  hydrophobia.  They  are  various,  uncertain, 
unsatisfactory.  In  some  bodies  the  most  careful  examination  has  discovered  nolhinc 
amiss.  In  others,  vascularity  of  the  brain,  or  of  the  spinal  cord,  has  been  noticed. 
And  in  not  a  few  instances  the  mucous  membrane  of  the  fauces,  ossophagus,  and 
stomach — or  of  the  larynx  and  trachea — or  of  both  these  tracts — has  been  found  red, 
and  covered  with  adhesive  mucus.  But  we  must  take  care  not  to  attribute  undue 
importance  to  these  last  appearances — not  to  conclude  that  they  have  been  the  cause 
of  the  symptoms,  when,  in  truth,  they  may  have  been  the  effect  of  the  disease.  That 
we  should  find  the  parts  in  the  throat  red  and  congested  is  what  we  might  naturally 
expect,  when  we  consider  the  violent  straining  spasmodic  action  of  these  parts  for 
some  time  before  death.  The  morbid  anatomy  of  this  disease  throws  but  little  hght 
upon  its  nature,  or  upon  its  proper  treatment. 

There  are  many  very  interesting  questions  connected  with  hydrophobia.  I  will 
state  the  principal  of  these  as  shortly  as  I  can. 

1.  You  will  be  surprised  when  I  tell  you  that  some  persons  have  made  it  a  ques- 
tion whether  there  is  any  such  disease  at  all.  I  have  known  such.  The  late  Sir 
Isaac  Pennington,  who  was  Regius  Professor  of  Physic  at  Cambridge,  had  never 
seen  a  case  of  hydrophobia,  and  nothing  could  persuade  him  that  any  one  else  had 
seen  any  thing  more  than  a  nervous  complaint  produced  by  the  alarmed  imagination 
of  the  patient,  who,  having  been  bitten  by  a  dog  reputed  to  be  mad,  and  having  the 
fear  of  feather  beds  before  his  eyes,  was  frightened  into  a  belief  that  he  had  hydro- 
phobia, and  ultimately  scared  out  of  his  very  existence.  Now  if  you  meet  with  such 
incredulous  persons,  and  think  it  worth  your  while  to  argue  the  point  with  them,  you 
may  object  to  their  unbehef,  the  improbability  that  so  many  persons  who  have  been 
bitten  by  mad  dogs  should  have  suffered  so  precisely  the  same  train  of  symptoms, 
and  at  last  have  died,  from  the  mere  force  of  a  morbid  imagination.  You  may  urge 
them  with  the  fact  that  many  of  these  persons  have  been  under  no  apprehension  at 
all  until  the  disease  has  seized  upon  them  ;  that  many  also  have  been  men  of  na- 
turally strong  and  firm  minds,  not  at  all  hkely  to  be  frightened  into  beheving  that 
they  were  seriously  ill  unless  they  really  were  so,  and  still  less  likely  to  be  terrified 
into  their  graves.  And  if  this  has  no  weight  Avith  such  reasoners,  you  may  bring 
forward  the  conclusive  facts  that  the  disease  has  befallen  infants  and  idiots,  who  had 
never  heard  or  understood  a  word  about  mad  dogs  or  hydrophobia,  and  in  whom  the 
imagination  could  have  had  no  power  in  calling  forth  the  complaint.  And  if  they 
are  proof  against  this,  you  must  give  them  up :  I  can  suggest  nothing  more. 

2.  Allow  that  the  disease  exists  as  a  real,  and  not  merely  imaginary  disease,  and 
also  that  it  is  caused  by  the  bite  of  a  rabid  animal :  this  important  question  arises — 
has  it  any  other  cause  ? 

Setting  aside  that  quibbhng  apphcation  of  the  term  hydrophobia,  which  some 
writers  have  chosen  to  make,  to  diseases  in  which,  from  some  painful  affection  of 
the  throat,  the  patients  have  been  unwilling  to  attempt  to  swallow  fluids,  there  are 
cases  recorded,  exactly  resembling  hydrophobia  in  their  symptoms,  and  occurrincr 
in  persons  who  were  never  known  to  have  been  bitten  by,  or  even  to  have  been  in 
the  presence  of,  a  rabid  animal.  The  celebrated  and  accurate  Pinel  has  given  the 
history  of  such  a  case.  There  is  another  by  Savirotte,  in  the  Journal  des  Savans 
(August,  1757).  Now  it  is  just  possible  that  this  disease  may  sometimes  develop 
itself  in  the  human  body  without  any  contagion  having  been  applied :  and  it  is  also 
possible,  and  much  more  probable,  in  my  judgment,  that  the  poison  may  have  been 
applied  without  the  person's  being  aware  of  it.  We  shall  see,  by  and  by,  some  very 
possible  ways  in  which  that  might  happen.  All  that  we  need  concern  ourselves  with 
practically,  is  this — that  in  999  cases  out  of  1000  the  disease  in  the  human  body  is 
uerived  from  a  rabid  animal.  If  it  ever  be  spontaneous,  we  cannot  reckon  upon 
meeting  with  such  a  case  :  indeed,  many  medical  men  pass  through  life  without 
witnessing  the  disorder  at  all. 


HYDROPHOBIA.  367 

3.  Granting,  then,  that  the  disease  in  man  is  the  result  of  an  animal  poison,  the 
next  question  is,  from  what  animals  may  he  receive  the  infection  ? 

We  are  sure  that  the  disease,  by  the  inoculation  of  which  hydrophobia  may  be 
produced  in  man,  is  common  in  the  dog,  and  that  it  has  been  communicated  to  the 
human  animal  by  the  fox  also,  the  wolf,  the  jackal,  and  the  cat.  Mr.  Youatt  says 
that  the  sahva  of  the  badger,  the  horse,  the  human  being,  has  undoubtedly  produced 
rabies,  and  some  affirm  that  it  has  been  propagated  even  by  the  hen  and  the  duck. 
The  same  author  mentions  a  case  in  which  a  groom  became  affected  with  hydro- 
phobia through  a  scratch  which  he  received  from  the  tooth  of  a  horse  that  was 
labouring  under  the  disease.  All  animals,  even  fowls,  are  susceptible  of  the  disorder 
when  bitten  by  the  rabid  dog.  Of  course  it  is  an  important  question  to  have  resolved, 
whether  the  saliva  of  all  these  is  capable  of  conveying  the  malady.  The  case  just 
now  mentioned  on  Mr.  Youatt's  authority  would  seem  to  settle  the  question  as 
respects  the  horse  ;  but  as  horses,  cows,  turkeys,  &c.,  do  not  generally  bite,  we  have 
not  many  opportunities  of  supplying  a  positive  answer  to  the  general  question  :  there 
can  be  no  doubt  about  the  cat,  the  fox,  the  wolf,  and  the  jackal. 

The  late  Duke  of  Richmond  died  abroad  of  hydrophobia,  communicated,  it  was 
though.,  by  a  tame  fox.  In  the  13th  volume  of  the  Medico-Chirurgical  Transac- 
tions, an  account  is  given  by  Mr.  Hewitt,  of  several  cases  of  fatal  hydrophobia  from 
the  bite  of  a  wild  and  rabid  jackal.  Many  examples  are  on  record  of  the  produc- 
tion of  the  disease  by  the  bites  of  mad  cats  and  wolves. 

The  first  case  which  I  have  spoken  of,  as  having  been  seen  by  myself,  would  seem 
to  prove,  if  all  the  facts  were  correctly  stated  at  the  time,  that  the  saliva  of  the  dog 
may  be  sufficient  to  produce  the  disease,  when  it  is  merely  applied  to  the  unbroken 
skin.  It  was  affirmed  by  various  persons  that  the  teeth  of  the  terrier  did  not  break 
the  cuticle.  But  we  must  take  care  not  to  draw  a  hasty  general  inference  from  a 
single  case.  Mr.  Youatt,  who  has  seen  more  of  the  disease  probably  both  in  man 
and  in  other  animals,  than  any  person  alive,  does  not  think  that  the  saliva  of  a  rabid 
animal  can  communicate  the  disorder  through  the  unbroken  cuticle :  he  believes  that 
there  must  be  some  abrasion  or  breach  of  surface.  He  holds,  however,  that  it  may 
be  communicated  by  mere  contact  with  the  mucous  membranes. 

Of  its  harmlessness  on  the  sound  integument  he  offers  this  presumption — that  his 
own  hands  have  many  times,  with  perfect  impunity,  been  covered  with  the  sahva 
cf  the  mad  dog.  He  mentions  some  singular  instances  in  Avhich  the  disease  had 
been  transmitted  by  contact  of  the  saliva  with  the  mucous  membranes.  "  A  man 
had  endeavoured  to  untie  with  his  teeth  a  knot  that  had  been  firmly  drawn  in  a 
cord.  Eight  weeks  afterwards  he  perished,  undeniably  rabid.  It  was  then  recol- 
lected that  with  this  cord  a  mad  dog  had  been  confined.  A  woman  was  attacked 
by  a  rabid  dog,  and  escaped  with  the  laceration  of  her  gown.  In  the  act  of  mend- 
ing it  she  thoughtlessly  pressed  down  the  seam  with  her  teeth.  She  died."  If 
these  cases  be  authentic,  they  are  conclusive  of  this  question ;  unless,  indeed,  the 
hps  of  those  who  perished  happened  to  have  been  chapped  or  abraded.  But  Mr. 
Youatt's  own  opinion  is,  that  the  virus  cannot  be  received  on  a  mucous  surface 
without  imminent  danger. 

The  disease  is  said  to  have  been  caused  by  the  scratch  of  a  cat.  But  as  we  know 
that  cats  as  well  as  dogs  frequently  apply  their  paws  to  their  mouths,  especially 
when  the  latter  part  is  uneasy,  (as  it  clearly  is  in  mad  dogs,)  this  fact,  of  the  produc- 
tion of  the  disease  by  a  scratch,  if  thoroughly  made  out,  would  not  prove  that  the 
disease  can  be  introduced  into  the  system  m  any  other  way  than  by  means  of  the 
slaver. 


368  HYDROPHOBIA. 


LECTURE  XXXIV. 

Hydrophobia,  concluded.  Various  Queslions  considered  respcctins;  the  Disease  as 
if  appears  in  the  Human  Subject,  and  respecting  Rabies  in  the  Hog.  Pathology 
of  the  Disorder.     Treatment.     Preventive  Measures. 

After  giving  you  some  account  of  the  phenomena  of  hydrophobia,  or  rabies 
canina,  I  began  to  notice,  in  the  last  lecture,  the  chief  of  the  interesting  questions 
which  naturally  present  themselves  to  the  minds  of  most  men,  and  especially  of 
medical  men,  in  respect  to  that  shocking  disorder. 

In  the  first  place,  there  is  such  a  disorder.  It  appears,  too,  secondly,  from  state- 
ments made  upon  credible  authority,  that  the  same  group  and  succession  of  symp- 
toms as  characterize  the  disease  when  it  is  produced  by  the  bite  of  a  rabid  animal, 
have  been  observed  to  occur  in  persons  who  were  never  known  to  have  been  bitten. 
In  my  own  opinion  it  is  more  probable  that  these  persons  had  been  exposed  to  the 
virus  without  being  aware  of  it,  than  that  the  disease  was  spontaneously  engendered 
in  their  bodies.  1  would  make  the  same  remark  with  regard  to  an  instance  which 
is  said  to  have  happened  of  hydrophobia  in  a  lad  who  had  been  bitten  five  weeks 
before  by  a  healthy  dog :  the  dog  remaining  well  at  the  time  of  his  seizure  and 
death.  Mr.  Youatt  holds,  indeed,  that  however  the  disease  originated,  it  never 
occurs  now,  not  even  in  the  dog,  except  as  a  consequence  of  the  application  of  the 
specific  contagion.  It  is  certain,  in  the  third  place,  that  (besides  the  dog)  the  wolf, 
the  fox,  the  jackal,  and  the  cat,  have  communicated  the  disorder  to  the  human  ani- 
mal. Mr.  Youatt  affirms,  that  the  saliva  of  the  badger,  of  the  horse,  and  of  the  human 
being,  has  caused  rabies  ;  and  I  mentioned,  on  his  authority,  a  case  in  which  a  groom 
contracted  the  disease  through  a  scratch  which  he  received  while  administering  a 
ball  to  a  rabid  horse.  But  1  feel  much  less  certain  about  these  latter  animals.  Re 
specting  the  dog,  the  fox,  the  wolf,  the  jackal,  the  cat,  there  can  be  no  question. 
The  result  of  certain  experiments  made  at  the  Veterinary  School,  at  Alfort,  is  opposed 
to  Mr.  Youatt's  statement.  Professor  Dupuy  made  wounds  in  cows  and  sheep,  and 
rubbed  upon  these  wounds  sponges  which  had  been  chewed  by  rabid  animals  of  the 
same  species:  yet  he  never  succeeded  in  communicating  the  disorder  in  this  way; 
but  when  he  used  a  sponge  that  had  been  mumbled  by  a  mad  dog,  then  the  disease 
occurred  in  the  sheep  and  cows. 

It  is  still  more  interesting  to  inquire,  whether  the  saliva  of  a  human  being,  labour- 
ing under  hydrophobia,  is  capable  of  inoculating  another  human  being  with  the  same 
complaint?  Mr.  Youatt  says  yes :  that  the  disease  has  undoubtedly  been  so  pro- 
duced. If  this  be  so,  the  fact  will  teach  us — not  to  desert  or  neglect  these  unhappy 
patients,  still  less  to  murder  them  by  smothering — but  to  minister  to  their  wants  with 
certain  precautions:  so  as  not  to  suffer  their  saliva  to  come  in  contact  with  any  sore 
or  abraded  surface;  nor,  if  it  can  be  avoided,  with  any  mucous  surface.  On  the 
other  hand,  all  carefuhiess  of  that  kind  will  be  unnecessary^  if  the  disease  cannot  he 
propagated  by  the  human  saliva.  Certainly  many  experimenters  have  tried  in  vain 
{0  inoculate  dogs  with  the  spittle  of  a  hydrophobic  n)an ;  but  there  is  one  authentic 
experiment  on  record,  which  makes  it  too  probable  that  the  disease,  though  it  may 
not  be  communirft/fc/  often,  or  easily,  is  yet  communit'«/)/e.  The  experiment  is  said 
to  have  been  made  by  MM.  Magendie  and  Breschet,  at  the  Hotel-Dieu,  and  to  have 
been  witnessed  by  a  great  number  of  medical  men  and  students.  Two  healthy  dogs 
were  inoculated,  on  the  18th  of  June,  181;3,  with  the  saliva  of  a  patient,  named  Surlu, 
who  died  of  hydrophobia  the  same  day  in  that  hospital.  One  of  these  dogs  became 
mad  on  the  '27th  of  the  following  month.  They  caused  this  dog  to  bite  others, 
which,  in  their  turn,  became  rabid  also :  and  in  this  way  they  propagated  the  mala- 
dy, among  do2s,  during  the  whole  summer.  Now  this  is  a  very  striking  fact,  yet  it 
uught  not  to  be  considered  conclusive :  for  it  is  possible  that  the  dog  might  have 
erne  mad  at  that  time,  whether  he  had  been  so  inoculated,  or  not.  It  may  have 
been  a  mere  coincidence.     We  want  repetitions  of  such  experiments  to  settle  the 


HYDROPHOBIA.  369 

point :  nevertheless,  we  have  enough  in  this  one  experiment  to  make  u;?  use  all 
necessary  caution  when  engaged  in  attending  upon  a  hydrophobic  patient. 

I  just  touched  upon  the  question,  whether  the  saliva  of  a  rabid  dog  could  produce 
the  disease  if  it  fell  upon  the  sound  skin?  The  first  of  the  two  cases  which  I  related 
as  having  been  witnessed  by  mysel-f,  would  appear  to  give  an  affirmative  answer  to 
this  question.  Mr.  Youatt  thinks  the  disease  would  not  follow  such  an  application 
of  the  virus ;  but  that  it  cannot  be  received  upon  even  the  unbroken  surface  of  a 
mucous  membrane  without  the  greatest  danger.  Horses  are  said  to  have  died  mad 
after  eating  straw  upon  which  rabid  pigs  had  died.  Portal  was  assured  that  two 
dogs,  which  had  licked  the  mouth  of  another  dog  that  was  rabid,  were  attacked  with 
rabies  seven  or  eight  days  afterwards.  Mr.  Oilman,  of  Highgate,  in  a  little  pam- 
phlet on  Hydrophobia,  quotes  an  instance  from  Dr.  Perceval,  in  which  a  mad  dog 
licked  the  face  of  a  sleeping  man,  near  his  mouth,  and  the  man  died  of  hydrophobia, 
although  the  strictest  search  failed  to  discover  the  smallest  scratch  or  abrasion  on 
any  part  of  his  skin. 

At  the  very  close  of  the  lecture  I  observed,  that  even  should  it  be  clearly  proved 
that  hydrophobia  has  ever  resulted  from  the  scratch  of  a  rabid  animal's  daws — the 
claws  of  a  cat,  for  example — we  are  not  to  set  it  down  as  a  sure  thing  that  the  dis- 
ease can  be  introduced  into  the  system  independently  of  the  saliva  of  the  diseased 
animal.  As  we  know  that  dogs  and  cats  are  in  the  habit  of  putting  their  paws  to 
their  mouths  when  they  feel  uneasy  there,  we  may  readily  understand  how  the  poi- 
sonous saHva  may  be  introduced  by  a  mere  scratch  with  the  creature's  nails.  Mr. 
Youatt  believes  that  the  sahva  only  is  capable  of  conveying  the  disease. 

4.  Supposing  the  virus  to  have  been  inserted  into  the  part  bitten,  what  becomes 
of  it  ?  Is  it  immediately  taken  into  the  system,  and  does  it,  like  the  poison  of  small- 
pox, in  some  mysterious  way,  multiply  and  diffuse  itself  in  the  body,  until  the  dis- 
ease explodes?  Or  does  it  remain  imprisoned  in  the  wound,  or  in  the  cicatrix,  for 
a  time  ?  This  is  an  important  practical  question.  For  if  the  poison  lurks  for  some 
weeks  in  the  place  where  it  was  originally  deposited,  we  mirrht  successfully  remove 
it  at  any  time  between  the  infliction  of  the  bite  and  the  period  of  recrudescence. 
Now,  the  facts  that  at  this  period  of  recrudescence  the  wound  or  scar  is  re-inflamed 
often,  and  almost  always  becomes  the  seat  of  some  fresh  morbid  phenomena,  pain, 
swelling,  numbness  and  the  like,  spreading  towards  the  trunk — and  that,  soon  after 
this,  the  peculiar  paroxysmal  symptoms  begin — these  facts  are  strong  in  favour  of 
the  belief  that  the  poison  does  lie  inert  in  the  place  of  the  original  hurt,  for  some 
time.  Dr.  Bardsley  states  that  the  recrudescent  pains  seem  always  to  follow  the 
course  of  the  nerves,  and  do  certainly  never  inflame  or  irritate  the  lymphatic  glands 
in  the  vicinity,  though  passing  in  a  parallel  course  towards  the  trunk.  He  affirms 
the  entire  absence  of  any  fact  contrary  to  this  observation  in  the  works  of  the  nume- 
rous authors  who  have  written  on  the  subject.  I  mention  this  statement  because  it 
certainly  is  not  correct.  Mr.  Mayo  says,  "  in  one  case  which  I  witnessed  and  exa- 
mined after  death,  the  inner  part  of  the  cicatrix  was  bloodshot ;  and  a  gland  in  the 
axilla  had  swelled  at  the  coming  on  of  the  hydrophobic  symptoms."  And  I  find 
among  my  notes  of  Mr.  Abernethy's  lectures,  another  striking  case,  still  more  to  the 
point.  " A  very  intelhgent  boy  had  been  bitten  by  a  dog  in  the  finger:  he  was 
brought  into  St.  Bartholomew's  Hospital.  Caustic  had  been  liberally  used,  affecting 
the  sinewy  parts,  and  producing  a  terrible  sore :  yet  the  boy  was  recovering  him- 
self, and  the  sore  was  healing.  One  day  as  Mr.  Abernethy  was  going  round  tlie 
hospital,  he  saw  and  spoke  to  the  boy,  who  said  he  thought  himself  getting  well, 
but  that  he  had  that  day  an  odd  sennation  in  his  fingers,  stretching  upwards  into  his 
hand  and  arm.  Going  up  the  arm,  Mr.  Abernethy  saw  two  red  lines,  like  inflamed 
absorbents  :  they  doubtless  were  so.  He  affected  to  make  light  of  the  matter,  ordered 
a  poultice,  and  recommended  the  boy  to  take  some  medicine.  Early  the  next  morn- 
ing Mr.  Abernethy  visited  the  ward,  pretending  he  had  some  other  patient  thoni 
whom  he  wished  particularly  to  see  :  and  when  going  out  again,  he  asked  the  boy, 
in  a  careless  tone,  how  he  was.  He  said  that  he  had  lost  the  pain,  but  that  he  wau' 
very  unwell,  and  had  not  slept  all  night.  Mr.  Abernethy  felt  his  pulse,  told  him  hi; 
was  a  little  feverish,  as  might  be  expected,  and  asked  him  if  he  were  not  thiritv, 
24 


370  HYDROPHOUIA. 

and  would  like  some  toast  and  water.  The  boy  said  he  was  thirsty,  and  that  he 
should  like  some  drink;  when,  however,  the  cup  was  brought,  he  pushed  ic  from 
him  :  he  could  not  drink.     In  forty-eight  hours  he  was  dead." 

Facts,  such  as  these,  would  lead  to  the  conclusion  that,  in  cases  in  which  ex- 
cision had  not  been  performed  in  the  first  instance,  the  scar  or  the  sore  might  be  cut 
out  with  propriety  at  any  time  before  the  period  of  recrudescence :  and  if  the  case 
happened  to  be  my  own,  I  would  have  done  this  even  at  that  period,  the  moment 
any  new  sensation  manifested  itself  in  the  seat  of  the  injury.  Mr.  Mayo,  on  the 
same  grounds,  advocates  the  removal  of  the  cicatrix,  even  although  the  hydrophobic 
symptoms  may  have  appeared.  I  do  not  mean  to  sajr  that  the  facts  now  referred  to, 
show  with  any  certainty  that  the  poison  remains  in  the  place  where  it  was  first  de- 
posited, until  the  phenomena  of  recrudescence  take  place :  but  they  afford  some 
presumption  in  favour  of  that  notion ;  and  in  such  a  disease  as  hydrophol|ia,  we  are 
bound  to  act  upon  the  very  lowest  presumption  that  affords  a  chance  for  our  patient's 
hfe.  The  poison  may  be  absorbed  into  the  general  system  at  the  period  of  recru- 
descence, although  no  affection  of  the  absorbing  vessels  or  glands  should  be  mani 
fest :  through  the  veins,  namely. 

Considermg  the  matter  philosophically,  we  might  be  inclined  to  suppose  that  the 
poison  was  silently  maturing  its  force  in  the  general  sj'stem  during  the  period  of  in- 
cubation, just  as  the  poisons  of  small-pox  and  of  measles  are  presumed  to  do.  But 
looking  at  it  practically,  I  should  recommend,  under  tlie  circumstances  already 
stated,  the  excision  of  the  cicatrix. 

5.  Another  important  question  is  this.  Is  a  man  who  has  been  bitten  b}'  a  mad 
dog,  and  in  whose  case  no  precautions  have  been  taken,  a  doomed  man  ?  will  he  be 
sure  to  have  the  disease,  and  therefore  to  die  of  it  ?  By  no  fneans.  But  few,  upon 
the  whole,  of  those  which  are  so  bitten,  become  affected  with  the  hydrophobia. 

It  is  curious  that  different  species  of  animals  appear  to  bo  susceptible  of  hydro- 
phobia in  different  degrees.  Thus,  according  to  Mr.  Youatt,  two  dogs  out  of  three, 
bitten  by  one  that  is  rabid,  become  rabid.  The  majority  of  horses  inoculated  with 
the  virus,  perish.  Cattle  have  a  better  chance  :  perhaps  because  in  them  the  skin 
is  looser  and  less  easily  penetrated.  A  full  half  (he  thinks)  of  those  that  were 
seized  by  a  mad  dog,  would  escape.  With  sheep  the  bite  is  still  less  dangerous. 
He  Reckons  that  not  more  than  one  in  three  would  be  affected.  The  tooth,  perhaps, 
has  been  wiped  clean  in  its  passage  through  the  wool.  The  human  being  is  least  of 
all  in  danger.  John  Hunter  states  that  he  knew  an  instance  in  which,  of  twenty- 
one  persons  bitten,  one  alone  fell  a  victim  to  hydrophobia.  Dr.  Hamilton  estimates 
the  proportion  to  be  one  in  twenty-five.  But  I  fear  these  computations  are  much 
too  low.  In  1780,  a  mad  dog,  in  the  neighbourhood  of  Senlis,  took  his  course 
within  a  small  circle,  and  bit  fifteen  persons  before  he  was  killed:  three  of  these 
died  of  hydrophobia.  The  slaver  of  a  rabid  wolf  would  seem  to  be  highly  virulent 
and  effective.  These  beasts  fly  always,  I  believe,  at  a  naked  part.  Hence,  probably, 
the  fatality  of  their  bites.  The  following  statement  applies  exclusively  to  the  wolf. 
In  December,  1774,  twenty  persons  were  bitten  in  the  neighbourhood  of  Troyes ; 
nine  of  them  died.  Of  seventeen  persons  similarly  bitten  in  1784,  near  Brive,  ten 
died  rabid.  In  May,  1817,  twenty-three  persons  were  bitten  and  fourteen  perished. 
Four  died  out  of  eleven  that  were  bitten  near  Dijon :  and  eighteen  of  twenty-four 
bitten  near  Rochelle.  At  Bar-sur-Ornain,  nineteen  were  bitten,  of  whom  twelve 
died  of  hydrophobia  within  two  months.  Here  we  have  one  hundred  and  fourteen 
persons  bitten  by  rabid  wolves,  and  among  them  no  less  than  sixty-seven  victims ; 
considerably  more  than  one-half.  There  is  no  doubt,  however,  that  the  majority  of 
persons  who  are  bitten  by  a  mad  dog  escape  the  disease.  This  may  partly  be 
owing  to  an  inherent  inaptitude  for  accepting  it.  We  see  some  persons  who,  though 
often  in  the  way  of  it,  do  not  contract  syphilis ;  there  are  others  upon  whom  the 
contagion  of  small-pox  has  no  influence.  This  difference  exists,  apparently,  even 
among  dogs.  There  was  once  a  dog,  at  Charenton,  that  did  not  become  rabid  after 
being  bitten  by  a  rabid  dog;  and  it  was  so  managed  that,  at  different  times,  he  was 
bitten  by  thirty  different  mad  dogs  ;  but  he  outlived  it  all.  Much  will  depend  also 
upon  the  circumstances  and  manner  in  which  the  bite  is  inflicted.     Ifitbemade 


HYDROPHOBIA.  371 

throigli  clothes,  and  especially  through  thick  woollen  garments,  or  through  leather, 
the  saii-va  may  be  wiped  clean  away  from  the  tooth  before  it  reaches  the  flesh.  In 
the  fifth  volume  of  the  Edinburgh  Medical  and  Surgical  Journal,  there  is  a  case 
described  by  Mr.  Oldknow,  of  Nottingham,  in  which  a  man  was  bitten  in  three  dif- 
ferent places  by  the  same  dog ;  viz.,  in  the  scrotum,  the  thigh,  and  the  left  hand  ; 
the  bite  on  the  hand  was  the  last.  Now  it  seems  not  improbable  that  but  for  this 
last  bite,  on  a  naked  part,  he  might  have  escaped.  At  least  it  was  a  remarkable 
circumstance  that  the  phenomena  of  recrudescence  occurred  only  in  the  hand  and 
arm.  The  dog  is  supposed  to  have  closed  his  mouth  after  inflicting  the  first  two 
bites ;  and  thus  to  have  charged  his  teeth  afresh  with  the  poisonous  saliva. 

It  is  this  frequent  immunity  from  the  disease  in  persons  who  have  been  bitten, 
that  has  tended  to  confer  reputation  upon  so  many  vaunted  methods  of  prevention. 
Ignorant  persons,  and  knavish  persons,  have  not  failed  to  take  advantage  of  this. 
They  announce  that  they  are  in  possession  of  some  secret  remedy  which  will  prevent 
the  virus  from  operating;  they  persuade  the  friends  of  those  who  die  that  the 
remedy  was  not  rightly  employed,  or  not  resorted  to  sufficiently  early :  and  they 
persuade  those  who  escape  that  they  escape  by  virtue  of  the  preventive  remedy. 
If  the  plunder  they  reap  from  the  foolish  and  the  frightened  was  all,  this  would 
be  of  less  consequence :  but  unfortunately  the  hope  of  security  without  under- 
going a  painful  operation,  leads  many  to  neglect  the  only  sure  mode  of  obtaining 
safety. 

Mr.  Youatt  is  of  opinion  that  the  power  of  the  virus  ceases  with  the  life  of  the 
animal.  He  states,  that  in  many  dissections  of  the  dog,  the  saliva,  in  spite  of  all 
care,  must  have  come  in  abundant  contact  with  his  hands,  and  they  were  not  always 
sound.  I  should  strongly  recommend  you  not  to  act  upon  this  opinion  :  but  to  use 
the  same  precautions,  in  dissecting  a  rabid  animal,  as  you  would  use  if  you  were 
persuaded  that  the  disease  might  be  communicated  with  equal  certainty  before  and 
after  the  death  of  the  animal. 

6.  A  still  more  anxious  inquiry  next  arises.  Whoever  has  been  bitten  bj''  a 
rabid  or  a  suspected  animal,  must  be  considered,  and  will  generally  consider  himself 
as  being  in  more  or  less  danger  of  hydrophobia.  This  dread  is  not  entirely  removed, 
even  by  the  adoption  of  the  best  means  of  prevention.  Now,  how  long  does  this 
state  of  hazard  continue  ?  When  is  the  peril  fairly  over  ?  After  what  period  may 
the  person  who  has  received  the  injury  lay  aside  all  apprehension  of  the  disease  ? 
To  this  inquiry  no  satisfactory  reply  can  be  given.  In  a  vast  majority  of  instances, 
indeed,  the  disorder  has  broken  out  ivithin  tivo  months  from  the  infliction  of  the  bite. 
But  the  exceptions  to  this  rule  are  too  numerous  to  permit  us  to  put  firm  trust  in 
the  immunity  afforded  by  that  interval.  Cases  are  recorded  in  which  five,  six, 
eleven,  nineteen  months  have  intervened,  between  the  insertion  of  the  poison  and 
the  eruption  of  the  consequent  malady.  Nay,  in  one  instance,  three  j'^ears  are  said 
to  have  elapsed,  and  in  another  the  enormous  period  of  twelve  years.  In  these 
cases  one  cannot  help  supposing  that  some  unsuspected  re-inoculation,  some  fresh 
application  of  the  peculiar  virus,  must  have  taken  place.  If  not,  then  we  must  con- 
clude that  the  poison  really  hes  imprisoned  in  the  part ;  and  only  becomes  destructive 
when,  under  certain  obscure  conditions,  and  at  indefinite  periods,  it  is  set  afloat  in  the 
circulating  blood. 

It  is  interesting  to  know  that  the  same  uncertainty  of  access  has  been  noticed 
among  infected  dogs.  On  the  night  of  the  8th  of  June,  1791,  the  man  in  charge  of 
Lord  Fitzwilliam's  kennel  was  much  disturbed  by  the  hounds  fighting;  and  got  up 
several  times  to  quiet  them.  On  each  occasion  he  found  the  same  dog  quarrelling  ; 
at  last,  therefore,  he  shut  that  dog  up  by  himself,  and  then  there  was  no  further  dis- 
turbance. On  the  third  day  afterwards,  the  quarrelsome  hound  became  unequivocally 
rabid ;  and  on  the  fifth  day  he  died.  The  whole  pack  were  thereupon  separately 
confined  and  watched.  Six  of  the  dogs  became  subsequently  mad ;  and  at  the 
following  widely  different  intervals  from  the  8th  of  June,  viz.,  23  days,  56,  67,  88, 
155,  and  183  days. 

There  are  some  considerations  respecting  this  disease  which  relate  both  to  tho 
biter  and  the  bitten ;  the  canine  and  the  human  being.     And  there  are  some  which 


372  HYDROPHOBIA. 

relate  exclusively  to  the  dog,  yet  concerning  which,  we,  as  medical  philosophers, 
ought  not  to  be  ignorant.     I  shall  advert  to  a  few  of  these. 

One  question  I  have  already  glanced  at,  viz.,  whether  the  disease  mav  be  pro- 
duced by  a  heahhy,  though  angry  dog  or  cat.  I  referred  to  one  instance  in  which 
this  was  supposed  to  have  been  the  case  ;  and  I  repeat  that  I  should  be  more  inclined 
to  think,  unless  we  had  other  examples  of  the  same  kind,  that  the  person  had  been 
inoculated  in  some  way  that  he  was  not  aware  of.  But  I  have  heard  INIr.  Youatt 
describe  cases  in  which  there  had  been  no  symptoms  of  rabies  observed  in  the  doer 
at  the  time  the  injury  was  inflicted,  though  soon  afterwards  the  animal  became 
decidedly  rabid.  It  is  much  to  be  regretted  that  the  dog  is  so  often  destroyed.  When 
a  person  has  been  bitten  by  a  dog  or  cat  suspected  to  be  rabid,  the  beast  ought  by 
no  means  to  be  killed,  but  to  be  secured,  and  kept  under  surveillance,  and  suffered, 
if  it  shall  so  happen,  to  die  of  the  disease.  If  he  does  not  die,  in  other  words,  if  he 
is  really  not  rabid,  that  will  soon  appear;  and  the  mind  of  the  patient  will  then  be 
relieved  from  a  very  painful  state  of  suspense  and  uncertaintj^  which  might  other- 
wise have  haunted  him  for  months  or  years.  If  the  dog  dies  mad,  the  injured  person 
will  be  no  worse  off  than  if  the  animal  had  been  killed  in  the  first  instance  :  nay, 
in  one  respect,  he  will  be  better  off,  inasmuch  as  certainty  of  evil  is  preferable  to 
perpetual  and  uneasy  doubt.  "  Give  a  dog  a  bad  name  (says  the  proverb),  and  hang 
him :"  and  it  is  literally  so  with  the  imputation  of  madness.  A  poor  wretch  of  a 
dog  is  perhaps  ill,  or  weary,  or  cross,  or  he  may  have  been  worried  already  by  mis- 
chievous boys :  the  cry  of  mad  dog  is  raised ;  and  then  he  can  expect  no  mercy. 
There  are  gross  errors  prevalent  with  regard  to  the  signs  of  madness  in  the  dog. 
If  a  dog  be  seen  in  a  fit  in  the  street,  some  person  charitably  offers  a  conjecture  thai 
perhaps  he  may  be  mad  ;  the  next  person  has  no  doubt  of  it ;  and  then,  woe  to  that 
dog  !  But  Mr.  Youatt  assures  us  that  the  rabid  dog  never  has  fits  :  that  the  exist- 
ence of  epilepsy  is  a  clear  proof  that  there  is  no  rabies.  Again,  it  is  a  verj'  common 
belief  that  a  rabid  dog,  like  a  hydrophobic  man,  will  shun  water;  and  if  he  takes 
to  a  river,  that  is  thought  to  be  conclusive  evidence  that  he  is  not  mad.  But  the 
truth  is,  that  the  disease,  in  the  quadruped,  cannot  be  called  hydrophobia :  there  is 
no  dread  of  water,  but  an  unquenchable  thirst ;  no  spasm  attending  the  effort  to 
swallow,  but  sometimes  in  dogs  an  inability  to  swallow,  from  paralysis  of  the  muscles 
about  the  jaws  and  throat.  They  will  stand  and  lap,  lapping,  without  getting  any 
of  the  liquid  down.  They  fly  eagerly  to  the  water ;  and  Mr.  Youatt  states  that  all 
other  quadrupeds,  with,  perhaps,  an  occasional  exception  in  the  horse,  drink  with 
ease,  and  with  an  increased  avidity.  This  erroneus  impression  is  not  confined  to  the 
vulgar.  In  the  case  which  I  have  more  than  once  alluded  to,  and  which  is  men- 
tioned in  Hufeland's  Journal,  of  a  lad  who  died  of  hydrophobia  after  having  been 
bitten  by  a  dog  that  had  not  been,  and  was  not  then,  mad,  one  circumstance  stated  in 
evidence  of  the  animal's  freedom  from  rabies  is,  that  he  drank  without  difficulty  a 
large  quantity  of  water. 

There  is  another  superstitious  opinion  not  at  all  uncommon,  viz.,  that  healthy  dogs 
recognize  one  that  is  mad,  and  fear  him,  and  run  away  from  his  presence,  in  conse- 
quence of  some  mysterious  and  wonderful  instinct,  warning  them  of  danger.  This 
is  quite  unfounded.  Equally  mistaken  are  the  notions  that  the  mad  dog  exhales  a 
peculiar  and  offensive  smell,  and  that  he  may  be  known  by  his  running  with  his  tail 
between  his  legs ;  except,  as  Mr.  Youatt  says,  when,  wearj'  and  exhausted,  he  is 
seeking  his  home. 

It  will  not  be  out  of  place  to  state  what  are,  the  symptoms  of  rabies  as  observed  in 
the  dog,  and  as  described  by  Mr.  Youatt. 

The  earliest*  symptoms  of  madness  in  the  dog  (he  says),  are  sullenness,  fidgeti- 
ness, continual  shifting  of  posture,  a  steadfast  gaze  expressive  of  suspicion,  an  ear- 
nest hcking  of  some  part,  on  which  a  scar  may  generallj^  be  found.  If  the  ear  be 
the  affected  part,  the  dog  is  incessantly  and  violently  scratching  it.  If  it  be  the  foot, 
he  gnaws  it  till  the  integuments  are  destroyed. 

Occasional  vomiting  and  a  depraved  appetite  are  very  early  noticeable.  The  dog 
will  pick  up  and  swallow  bits  of  thread  or  silk  from  the  carpet,  hair,  or  straw,  even 
Hung:  and  frequently  he  will  lap  his  own  urine,  and  devour  his  own  excrement. 


HYDROPHOBIA.  373 

Then  the  animal  becomes  irascible ;  flies  fiercely  at  strangers  ;  is  impatient  of  cor- 
rection ;  seizes  the  whip  or  stick ;  quarrels  with  his  own  companions ;  eagerly  hunts 
and  worries  the  cats ;  demolislies  his  bed ;  and  if  chained  up,  makes  violent  efforts 
to  escape,  tearing  his  kennel  to  pieces  with  his  teeth.  If  he  be  at  large  he  usually 
attacks  only  those  dogs  that  come  in  his  way ;  but  if  he  be  naturally  ferocious  he 
will  dilisently  and  perseveringly  seek  his  enemy.  .  According  to  Mr.  Youatt,  the 
disease  is  principally  propagated  by  the  fighting  dog  in  towns  ;  and  by  the  cur  or 
lurcher  in  the  country :  by  those  dogs,  therefore,  which  minister  to  the  vices  of  the 
lower  classes  in  town  and  country  respectively.  He  maintains  that  if  a  well- 
enforced  quarantine  could  be  established,  and  every  dog  in  the  kingdom  confined 
separately  for  seven  months,  the  disease  might  be  extirpated.  This  opinion  is  founded 
of  course  upon  the  behef  that  rabies  never  originates  at  present,  any  more  than 
small-pox  does,  spontaneously  ;  but  is  always  propagated  by  the  specific  virus.  And 
it  is  corroborated  by  the  fact  that  rabies  and  hydrophobia  are  unknown  in  some 
countries.  I  fancy  that  South  America  is,  or  was,  a  stranger  to  it.  It  appears  to 
have  been  imported  into  Jamacia,  after  that  island  had  enjoyed  an  immunity  from 
the  disease  for  at  least  fifty  years  previously ;  and  Dr.  Heineken  states  that  curs  of 
the  most  wretched  description  abound  in  the  island  of  Madeira ;  that  they  are 
afflicted  with  almost  every  disease,  tormented  by  flies,  and  heat,  and  thirst,  and 
famine,  yet  no  rabid  dog  was  ever  seen  there.  On  the  contrary,  1666  deaths  from 
hydrophobia  in  the  human  subject,  are  stated  to  have  occurred  in  Prussia  in  the 
space  of  ten  years. 

Very  early  in  the  disease,  as  it  appears  in  the  dog,  the  expression  of  countenance 
IS  remarkably  changed ;  the  eyes  ghsten,  and  there  is  slight  strabismus.  Twitch- 
mgs  of  the  face  come  on.  About  the  second  day  a  considerable  discharge  of  saliva 
commences  ;  but  this  does  not  continue  more  than  ten  or  twelve  hours,  and  is  suc- 
ceeded by  insatiable  thirst :  the  dog  is  incessantly  drinking,  or  attempting  to  drink  : 
he  plunges  his  muzzle  into  the  water.  When  the  flow  of  saliva  has  ceased  he  ap- 
pears to  be  annoyed  by  some  viscid  matter  in  his  fauces ;  and  in  the  most  eager  and 
extraordinary  manner  he  works  with  his  paws  at  the  corners  of  his  mouth,  to  get  rid 
of  it:  and  while  thus  employed  he  frequently  loses  his  balance  and  rolls  over. 

A  loss  of  power  over  the  voluntary  muscles  is  next  observed.  It  begins  with  the 
lower  jaw,  which  hangs  down,  and  the  mouth  is  partially  open;  but  by  a  sudden 
effort  the  dog  can  sometimes  close  it,  though  occasionally  the  paralysis  is  complete. 
The  tongue  is  afl^ected  in  a  less  degree.  The  dog  is  able  to  use  it  in  the  act  of  lap- 
ping: but  the  mouth  is  not  sufficiently  closed  to  retain  the  water.  Therefore,  while 
he  hangs  over  the  fluid,  eagerly  lapping  for  several  minutes,  it  is  very  little  or  not 
at  all  diminished.  The  paralj'sis  often  attacks  the  loins  and  extremities  also.  The 
animal  staggers  about,  and  frequently  falls.  Previously  to  this  he  is  in  almost  inces- 
sant action.  Mr.  Youatt  fancies  that  the  dog  is  subject  to  what  we  call  spectral  illu- 
sions. He  says  he  starts  up  and  gazes  eagerly  at  some  real  or  imaginary  object. 
He  appears  to  be  tracing  the  path  of  something  floating  around  him,  or  he  fixes  his 
eye  intently  upon  some  spot  in  the  wall,  and  suddenly  plunges  at  it ;  then  his  eyes 
close,  and  his  head  droops. 

Frequently,  with  kis  head  erect,  the  dog  utters  a  short  and  very  peculiar  howl; 
or  if  he  barks,  it  is  in  a  hoarse  inward  sound,  altogether  dissimilar  from  his  usual 
tone,  and  generally  terminating  with  this  characteristic  howl.  Respiration  is  always 
afl^ected  :  often  the  breathing  is  very  laborious  ;  and  the  inspiration  is  attended  with 
a  very  singular  grating,  choking  noise.  On  the  fourth,  fifth,  or  sixth  day  of  the  dis- 
ease, he  dies:  occasionally  in  slight  convulsions,  but  oftener  without  a  struggle. 

Mr.  Youatt  gives  a  detailed  account  of  the  appearances  met  with  after  death  \u 
the  carcases  of  these  rabid  dogs.  They  are  not  very  constant  or  distinctive.  The 
most  curious  and  uniform  consist  in  the  presence  of  unnatural  ingesta  in  the  stomach  . 
straw,  hay,  hair,  horse-dung,  earth.  Sometimes  the  stomach  is  perfectly  distended 
with  these  substances;  and  when  it  contains  none  of  them,  there  is  a  fluid  of  the 
deepest  chocolate  colour  mixed  with  olive ;  or  still  darker,  like  coffee  :  and  when 
neither  the  unnatural  ingesta  nor  the  dark  fluid  appear,  it  will  be  found,  Mr.  Youatt 

2o 


374  HYDROPHOBIA. 

says,  upon  carefal  inquiry,  that  the  dog  has  vomited  much  hair,  hay,  straw,  or  the 
like. 

In  1837,  a  few  daj^s  after  the  case  of  hydrophobia  occurred  in  the  Middlesex  Hos- 
pital, I  saw  the  carcass  of  a  dog,  that  had  died  rabid,  examined  by  Mr.  Ainslie  at  his 
and  Mr.  Youatt's  Infirmary.  The  most  remarka-ble  morbid  appearances  were  in  the 
stomach,  Avhich  contained  some  bits  of  straw  and  stick,  and  a  considerable  quantity 
of  a  dark  fluid  like  thin  treacle.  In  various  parts  of  the  stomach  there  were  spots 
almost  black,  of  a  considerable  size  ;  apparently  produced  by  dark  blood  partly  exlra- 
vasated  beneath,  and  partly  incorporated  with,  the  mucous  membrane. 

I  believe  that  Mr.  Youatt's  opinion,  already  mentioned,  of  the  cause  of  rabies  ir. 
dogs,  and  in  all  creatures — viz.,  that  it  always  results  from  the  introduction  of  a  spe 
cific  virus  into  the  system  —  I  believe  this  opinion  is  not  commonly  entertained. 
Most  people  think  that  the  disease  is  generated,  de  novo,  in  the  dog  at  least ;  and 
causes  have  been  assigned  for  it  which  certainly  are  not  the  true  or  the  sole  causes. 
Thus  hydrophobia  in  the  dog  has  been  ascribed  to  extreme  heat  of  the  weather.  It 
is  thought  by  many  to  be  particularly  likely  to  occur  in  the  dog-daj's ;  and  to  be,  as 
Mr.  Mayo  observes,  "a  sort  of  dog-lunacy,  having  the  same  relation  to  Sirius  that 
insanity  has  to  the  moon  :  which,  indeed,  in  another  sense,  is  probably  true."  Many 
cautions  are  annually  put  forth,  about  that  period,  for  muzzling  dogs,  and  so  on: 
verj'  good  and  proper  advice,  but,  if  those  who  have  noted  the  statistics  of  the  dis- 
ease majr  be  depended  upon,  it  would  be  as  appropriate  at  one  period  of  the  3'ear  as 
at  another.  Rabies  occurs  nearly  as  often  in  the  spring,  in  the  autumn,  and  even  in 
winter,  as  it  does  in  summer.  M.  Trolliet,  wiio  has  written  an  interesting  essay  on 
rabies,  states  that  January,  which  is  the  coldest,  and  August,  which  is  the  hottest 
month  in  the  year,  are  the  very  months  which  furnish  the  fewest  examples  of  the 
disease.  The  disorder  has  often  been  ascribed  to  want  of  water  in  hot  weather,  and 
sometimes  to  want  of  food.  But  M]M.  Dupuytren,  Breschet,  and  Magendie,  have 
caused  both  dogs  and  cats  to  perish  with  hunger  and  thirst,  without  producino-  the 
smallest  approach  to  a  state  of  rabies.  At  the  Veterinary  School  at  Alfort,  three 
dogs  were  subjected  to  some  very  cruel  but  decisive  experiments.  It  was  during 
the  heat  of  summer,  and  they  were  all  chained  in  the  full  blaze  of  the  sun.  To  one 
salted  meat  was  given ;  to  the  second  water  only ;  and  to  the  third  neither  food  nor 
drink.  They  all  died;  but  none  of  them  became  rabid.  Nor  does  the  supposition 
that  the  disorder  has  some  connection  with  the  period  of  sexual  heat  in  these  ani- 
mals appear  to  have  any  better  foundation. 

If  you  are  desirous  of  knowing  what  my  own  opinion  on  this  matter  is,  I  must 
say  that  I  think  Mr.  Youatt's  doctrine  by  far  the  most  probable  one ;  that  rabies 
never  occurs  except  from  inoculation  of  the  specific  virus.  It  has  never  been  proved, 
and  indeed  it  would  scarcely  be  susceptible  of  proof,  that  the  disease  ever  breaks  out 
spontaneously  ;  large  tracts  of  country  are  totally  free  from  it ;  and  in  nineteen  cases 
out  of  twenty,  perhaps,  we  trace  the  bite  or  the  fray  in  which  the  inoculation  has 
been  efTected. 

If  I  were  asked  to  define  the  seat  of  this  terrible  disease,  I  should  place  it,  without 
hesitation,  in  that  division  of  the  nervous  system  which  comprises  the  excito-motory 
apparatus ;  the  true  spinal  marrow,  with  its  appendages  of  afferent  and  efferent 
nerves.  Nay,  I  should  go  further,  and  say  that  it  is  the  uppei^oart  of  this  appara- 
tus, of  which  the  functions  are  primarily  and  chiefly  deranged :  that  the  poison  acts 
mainly  upon  the  nervous  arcs  which  pertain  to  the  throat,  and  with  which  the  eighth 
pair  of  nerves  in  particular  is  connected.  There  is  nothing  singular  in  this  locahza- 
tion  of  the  influence  of  a  specific  poison.  The  ergot  of  rye  affects  principally  those 
arcs  which  belong  to  the  uterus ;  cantharides,  those  which  govern  the  muscular 
fibres  of  the  bladder.  It  is  true  that  the  mental  functions  are  remarkably  modified, 
and  that  paralysis  of  the  lower  extremities  occurs,  in  most  instances  of  the  disease. 
But  neither  of  these  phenomena  is  constant ;  and  they  simply  illustrate,  when  they 
do  happen,  the  facility  with  which  any  morbid  state  of  the  spinal  cord  may  propa- 
Stite  its  influence  in  either  direction.  Whether,  in  hydrophobia,  the  essential  change 
Be  centiic  or  eccentric,  cannot  be  determined  with  any  thing  like  certainty :  but  it 
ysems  tc  me  to  be  most  probable  that  the  sensibility  of  the  afferent  nerves  of  th& 


HYDROPHOBIA.  375 

fauces,  of  the  skin,  and  of  the  air-passages,  is  altered  or  morbidly  exalted  ,  vvhencs^, 
upon  the  application  of  the  exciting  stimulus,  the  peculiar  sighing  dyspncea,  and  the 
strangling  dysphagia,  are  produced  by  a  reflected  influence  through  the  central  axis 
upon  the  muscles  concerned  in  these  actions.  But,  as  I  said  before,  the  pathology 
of  the  excito-molory  apparatus  is  as  yet  in  its  new  birth. 

What  can  I  say  of  the  treatment  in  hydrophobia,  or  in  rabies  ?  There  is  no  well 
authenticated  case  on  record,  that  I  am  aware  of,  in  which  a  hydrophobic  person  has 
recovered.  As  it  has  been,  so  it  is  still,  larpoj  iarai  9amroj.  The  physician  that  cures 
is  death.  There  can  be  no  ground  therefore  for  the  recommendation  of  any  espe- 
cial drug,  or  form  of  medicine,  nor  even  for  any  general  plan  of  treatment,  after  the 
peculiar  sj'mptoms  of  the  disease  have  once  set  in. 

Of  course  those  powerful  remedial  agencies  that  are  in  common  use  among  medi- 
cal men,  have  been  fairly  tried ;  copious  blood-letting,  mercury,  opium,  arsenic, 
sugar  of  lead,  oil  of  turpentine,  the  cold  affusion  even :  and  not  only  those,  but  the 
strong  poisons  that  are  sometimes,  but  not  so  generally,  employed  for  other  diseases: 
belladonna,  stramonium,  prussic  acid,,white  hellebore,  strychnia,  cantharides,  the 
nitrous  oxide  gas  :  and  no  end  of  less  gigantic  remedies ;  such  as  alkalies,  and  espe- 
cially ammonia,  carbonate  of  iron,  electricity  and  galvanism,  tobacco-juice  and  the 
guaco  (which  was  introduced  into  this  country  a  few  years  ago  with  high  encomi- 
ums for  its  power  over  the  disease),  the  mineral  acids,  violent  exercise  :  and  if  we 
take  into  account  the  substances  administered  to  the  brute  also,  we  may  increase 
this  list  by  the  alisma  plantago,  Scutellaria,  box,  and  rue,  all  of  which,  at  one  *ime 
or  another,  have  been  vaunted  as  successful  remedies,  veratrum  sabadilla,  and  cicu- 
nas  poison. 

The  difficulty  of  swallowing  fluids,  and  in  some  cases  of  swallowing  at  all,  is  a 
serious  obstacle  to  the  fair  trial  of  almost  every  form  of  internal  remedy.  It  has 
been  proposed  to  introduce  powerful  medicines  into  the  rectum,  in  clysters ;  but  to 
this  also  the  patients  have  been  found  to  make  great  resistance.  The  injection  of 
medicines  into  the  veins  has  been  tried.  Magendie  hoped  that  he  had  discovered  a 
cure,  in  first  largely  bleeding  the  patient,  and  then  injecting  his  veins  with  a  corres- 
ponding quantity  of  warm  water :  but  it  has  always  happened  with  this,  and  with, 
other  promising  experiments,  that  just  as  the  patient  seemed  to  be  about  to  recover, 
he  has  died.  The  nervous  irritability  has  in  one  instance  or  two  been  much  calmed 
by  the  injection  of  a  solution  of  a  salt  of  morphia  into  the  veins.  In  a  case  treated 
by  Professor  Todd  the  symptoms  appeared  to  be  greatly  mitigated  for  a  time,  by 
applying  ice  to  the  cervical  portion  of  the  spine,  and  to  the  fauces. 

Mr.  Mayo  has  suggested  bronchotomy :  upon  this  ground  (to  use  his  own  words), 
"that  the  principal  character  of  the  disease,  and  the  rapid  exhaustion  which  attends 
it,  appear  to  depend  in  great  part  upon  the  fits  of  spasm  and  closure  of  the  glottis, 
brought  on,  not  merely  by  the  attempt,  or  the  idea  of  drinking,  but  by  any  sudden 
impression  upon  the  senses.  Now  it  is  clear  (he  adds)  that  as  far  as  the  distressing 
feelings  in  the  throat  consist  in  a  sense  of  suffocation,  they  would  be  put  an  end  to 
or  relieved  by  the  establishment  of  a  free  opening  in  the  windpipe."  Dr.  Marshall 
Hall  would  use,  in  combination  with  tracheotomj^,  the  hydrocyanic  acid.  Now  I 
should  be  sorrj'  to  say  any  thing  to  damp  your  reasonable  hope  of  benefit  from  any 
experiment ;  but  I  am  bound  to  confess  to  you  that  I  should  not  expect  the  smallest 
advantage  from  tracheotomy  in  this  disease.  The  mode  of  death  offers  no  encour- 
agement to  its  use.  There  may  be  spasm  of  the  glottis,  but  I  doubt  it.  At  any  rate 
the  patients  do  not  die  of  suffocation.  The  death  is  not  death  by  apnoea,  but  by 
asthenia.  We  see  persons  labouring  grievously  for  their  breath  for  hours  together, 
who  yet  survive,  and  are  presently  themselves  again ;  persons,  for  instance,  who  are 
affected  with  severe  spasmodic  asthma.  I  have  seen  a  man  sitting  up  in  bed  a  whole 
night  long,  inspiring  with  such  difficulty  that,  if  I  had  not  been  aware  of  his  having 
scores  of  times,  been  as  bad  before,  I  should  not  have  thought  lie  could  exist  five 
minutes  longer.  Now  we  have  nothing  of  this  dyspnoea  in  hydrophobia :  and,  as  I 
said  already,  I  am  sorry,  and  diffident  too,  when  I  difler  from  great  authorities  on 

Practical  points,  but  I  see  no  hope  of  cure,  nor  even  of  sufficient  benefit  to  counter- 
dance  the  inconvenience  and  hazard  of  the  operation  from  the  perform.mce  of 


376  HYDROPHOBIA. 

bronchotomy.  The  principle  is  that  of  suffering  the  parts  gradually  to  recover 
themselves,  and  of  allowing  the  patient  in  the  meanwhile  to  breathe  through  another 
channel.  The  principle  is  excellent  (as  I  shall  show  you  by  and  by),  where  there  is 
a  permanent  obstacle  to  the  admission  of  air  to  the  lungs  through  the  larynx  ;  but  ia 
hydrophobia  there  is  no  such  permanent  obstacle  to  surmount.  Though  )'Our  patient 
in  laryngitis  should  be  at  the  point  of  death,  yet  open  his  wind-pipe,  and  he  breathes 
again  and  is  safe  ;  but  it  is  not  at  all  uncommon  for  a  hydrophobic  patient  to  lose  his 
spasms,  to  swallow  well,  and  to  breathe  easily,  yet  he  does  not  recover.  This  amend- 
ment is  the  prelude  of  death,  the  last  flicker  of  the  expiring  lamp.  Since  I  lectured 
upon  this  subject  last  year.  Dr.  Latham  has  told  me  the  following  circumstance 
respecting  a  patient  whom  he  treated  for  hydrophobia,  in  the  Middlesex  Hospital. 
He  went  one  day  to  the  ward,  fully  expecting  to  hear  that  the  patient  was  dead.  But 
he  found  him  sitting  up  in  his  bed,  quite  calm,  and  free  from  spasm :  and  he  had 
just  drunk  a  larije  jug  of  porter.  "Lawk,  sir  (said  a  nurse  who  sat  by),  what  a 
wonderful  cure  !"  The  man  himself  seemed  surprised  at  the  change.  But  he  had 
no  pulse;  his  surface  was  cold  as  marble.  In  half  an  hour,  he  sank  back,  and 
expired.  Furthermore  the  experiment  in  question  has  been  tried,  and  it  has  been 
tried  by  its  proposer,  Mr.  Mayo,  upon  the  dog,  without  affording,  as  Mr.  Youatt 
assures  us,  the  slightest  rehef.  In  the  matter  of  cure,  surgery,  I  fear,  is  as  impotent 
as  physic. 

Not  so,  however,  in  the  matter  of  prevention :  this  is  the  most  important  part  of 
the  practice.  The  early  and  complete  excision  of  the  bitten  part  is  the  only  measure 
in  which  we  can  put  anj'  confidence:  and  even  here  we  are  met  with  a  source  of 
fallacy.  In  the  majority  of  cases  no  hydrophobia  would  ensue,  though  nothing  at 
all  were  done  to  the  wound.  How  can  we  know,  then,  that  the  disease  is  ever  pre- 
vented by  its  excision  ?  No  doubt  many  persons  go  through  the  pain  of  the  operation 
needlessly.  But  in  no  given  case  can  we  be  sure  of  this.  They  get  at  any  rate  relief 
from  the  most  harassing  suspense,  with  which  they  would  probably  have  been  tortured 
for  months.  And  if  a  large  number  of  bitten  persons,  who  had  suffered  the  wound 
to  heal  as  it  would,  could  be  compared  with  an  equal  number  who  had  had  the  bitten 
part  cut  out,  hydrophobia  would  be  found  a  frequent  consequence  of  the  bite  in  the 
first  class — a  very  rare  consequence  of  it  in  the  second.  Mr.  Youatt,  who  trusts  to 
caustic,  and  who  has  himself  been  bitten  seven  times,  and  is  yet  alive  and  well,  tells 
us  that  he  has  operated,  with  the  caustic,  on  more  than  four  hundred  persons,  aU 
bitten  by  dogs,  respecting  the  nature  of  whose  disease  there  could  be  no  question  ; 
and  that  he  has  not  lost  a  case.  One  man  died  of  fright,  but  not  one  of  hydrophobia. 
Moreover,  a  surgeon  of  St.  George's  Hospital  told  him  that  ten  times  that  number 
had  undergone  the  operation  of  excision  there,  after  being  bitten  by  dogs  (all  of 
which  might  not,  however,  have  been  rabid),  and  that  it  was  not  known  that  any  one 
had  been  lost.  Mr.  Youatt,  I  say,  trusts  to  caustic ;  and  the  caustic  he  uses  is  the 
nitrate  of  silver.  But  I  advise  you  to  trust  to  nothing  but  the  knife,  if  the  situation 
of  the  bite  will  allow  you  to  employ  it  effectually.  If  the  injury  be  so  deep  or 
extensive,  or  so  situated,  that  you  cannot  remove  the  whole  surface  of  the  wound, 
cut  away  what  you  can  ;  then  wash  the  wound  thoroughly,  and  for  some  hours 
together,  by  means  of  a  stream  of  warm  water,  which  may  be  poured  from  a  tea- 
kettle ;  place  an  exhausted  cupping-glass  from  time  to  time  over  the  exposed  wound; 
and  finally  apply  to  every  point  of  it  a  pencil  of  lunar  caustic.  If  you  cannot  get 
the  solid  caustic  in  contact  with  every  part,  you  had  better  make  use  of  some  liquid 
escharotic  :  the  nitric  acid,  for  example.  In  my  own  case — and  what  I  should  choose 
for  myself  I  should  advise  for  another — if  I  had  received  a  bite  from  a  decidedly 
rabid  animal  upon  my  arm  or  leg,  and  the  bite  was  of  such  a  kind  that  the  whole 
wound  could  not  be  excised,  my  reason  would  teach  me  to  desire,  and  I  hope  I 
jhould  have  fortitude  enough  to  endure,  amputation  of  the  limb,  above  the  place  of 
the  injury. 

But  if  the  wound  is  of  such  a  size,  and  in  such  a  part,  that  it  can  be  excised,  what 
IS  the  proper  way  of  cutting  it  out?  Were  I  to  give  you  any  opinion,  as  from 
myself,  upon  that  point,  you  might  think,  perhaps,  that  I  was  stepping  beyond  my 
proper  province.     I  shall,  therefore,  again  retail  to  you  the  advice  of  my  old  master. 


HYDROPHOBIA.  ^71 

Mr.  Abernethy.  The  cell  (he  says)  into  which  a  penetrating  tooth  has  gone,  must 
be  cut  out.  Let  a  skewer  be  shaped,  as  nearly  as  may  be,  into  the  form  of  the  tooth, 
and  then  be  placed  in  the  cavity  formed  by  the  tooth ;  and  next  let  the  skewer,  and 
the  whole  cell  containing  it,  be  removed  by  an  elliptical  incision.  We  may  examine 
the  removed  cell,  to  see  if  every  portion  with  which  the  tooth  might  have  come  in 
contact  has  been  taken  away  :  the  cell  may  even  be  filled  with  quicksilver,  to  see  if  a 
globule  will  escape.  The  efficient  performance  of  the  excision  does  not  depend  upon 
the  extent,  but  upon  the  accuracy,  of  the  operation."  Mr.  Aberneihy  was  of  opinion 
that  when  once  the  poison  had  been  imbibed  into  the  system,  nothing  ever  had  done 
good,  and  nothing,  probably,  ever  would.  I  should  be  sorry  to  be  so  absolutely 
despairing  in  respect  to  a  disorder  from  which  dissection  after  death  discloses  no 
reason  why  the  patient  might  not  recover.  He  used  to  add,  that  as  bleeding  had 
been  much  extolled,  had  he  hydrophobia  he  wfiuld  allow  a  surgeon  to  bleed  him, 
even  to  death.  Like  Seneca  he  would  be  willing  to  have  his  veins  opened,  though 
his  disease  might  not  permit  him  to  indulge  at  the  same  time,  like  Seneca,  in  the 
luxury  of  a  warm  bath. 

I  say  early  excision  is  the  only  sure  preventive  ;  but  let  me  repeat  that  it  will,  in 
all  suspicious  cases,  be  advisable,  if,  for  any  reason,  the  operation  has  been  omitted 
in  the  first  instance,  to  cut  out  the  wound,  or  the  cicatrix,  within  the  first  two  months, 
or  at  any  time  before  the  symptoms  of  recrudescence  have  appeared.  One  would 
do  it,  though  with  less  hope,  as  soon  as  possible  ufter  they  had  appeared ;  but  I  do 
not  expect  to  hear  of  excision  being  successful  then  in  stopping  the  disease.  Dr. 
Bright  has  recorded  a  case  in  which  the  arm  was  amputated  upon  the  supervention 
of  tingUng,  and  other  symptoms,  in  the  hand,  in  which  the  patient  had  been  bitten 
some  time  before ;  but  the  amputation  did  not  save  him. 

It  has  been  proposed  to  fill  the  wound  with  ink,  and  then  to  wash  it  until  every 
trace  of  the  ink  is  gone;  in  this  way,  it  is  conceived,  the  complete  ablution  of  the 
poison  also  will  be  ensured.  With  a  timid  or  an  obstinate  patient,  who  would  not 
submit  to  the  knife  or  the  caustic,  some  such  expedient  ought  to  be  diligently  tried ; 
but  it  would  be  better  to  try  it  after  the  excision,  or  after  the  application  of  the  escha- 
rotic  substance.  It  is  impossible  to  take  superfluous  pains  to  obviate  so  fearful  a 
disease  as  hydrophobia. 

It  has  been  recommended,  after  the  wound  has  been  excised  or  cauterized,  that  it 
should  be  prevented  from  healing,  and  made  to  discharge  for  a  long  time,  by  means 
of  irritating  applications.  This  may  be  advisable  when  thorough  excision,  or  com- 
plete cauterization,  cannot  be  effected  ;  but  I  should  think  it  quite  useless  as  auxihary 
to  those  expedients,  and  only  likely  to  keep  up,  or  to  produce,  a  hurtful  irritability 
of  the  system. 

I  should  perhaps  have  mentioned  before,  a  theory,  and  a  plan  of  preventive  treat- 
ment, which  made  a  great  figure  in  all  the  journals,  foreign  and  domestic,  a  (o\v  yeaisi 
ago.  It  was  pretended  by  a  Russian  physician.  Dr.  Marochetti,  that  some  time  be- 
tween the  third  and  the  ninth  day  after  a  person  has  been  inoculated  with  the  hydro- 
phobic poison,  by  the  bite  of  a  rabid  dog,  small  pustules  appear  on  or  about  the 
frasnum  of  the  tongue,  containing  a  small  quantity  of  sanious  fluid,  of  a  yellow  or 
greenish  colour.  Pustules  of  the  same  kind  were  declared  to  exist  also  under  the 
tongues  of  the  mad  dogs  themselves.  Now  Dr.  Marochetti  pretended  further,  that 
if,  from  the  very  time  of  the  bite,  you  gave  the  patient  large  doses  of  the  decoction 
of  broom  tops,  and  looked  out  for  the  eruption  of  these  pustules,  which  seldom  lasted 
more  than  twenty-four  hours,  you  might  infallibly  prevent  the  disease  by  opening 
and  emptying  the  pustules,  and  then  cauterizing  them  with  a  red-hot  iron  ;  and  after- 
wards causing  the  patient  to  gargle  his  mouth  with  that  same  decoction  of  broom. 
He  held  that  the  poison  was  deposited  there  for  a  short  time,  and  then  re-absorbed 
into  the  sj^stem ;  and  he  proposed  to  prevent  such  re-absorption.  This  was  a  very 
pretty  theory ;  and  took  mightily  in  the  medical  world.  But  it  has  turned  out  a  sort 
of  hoax.  I  do  not  mean  a  wilful  hoax  on  the  part  of  Dr.  Marochetti ;  for  I  have  no 
doubt  that  he  contrived  to  hoax  himself.  These  pustules  have  been  looked  for  again 
and  again  ;  but  they  have  never  been  discovered  in  Englishmen  affected  with  hydro- 
phobia ;  nor  in  Enghsh  mad  dogs.     The  truth  seems  to  be  that  the  mucous  foDicles 

2g2 


378  HYDROPHOBIA. 

of  the  mouth,  geneially,  and  those  at  the  base  of  the  tongue,  and  those  beneath  the 
tongue,  in  particular,  are  commonly  enlarged  and  exaggerated  in  the  dog,  and  in  the 
human  animal,  labouring  under  the  disease  ;  and  these  enlarged  and  altered  follicles 
were  regarded  by  the  Russian  phj'sician  as  a  specific  eruption,  which  furnished  the 
virus  and  pabulum  of  the  complaint. 

As  almost  every  drug  that  has  ever  been  included  in  any  Pharmacopoeia  has  been 
administered  with  the  hope  of  checkinp^  the  disease,  so  a  great  number  of  medicines 
and  measures  have  been  praised  as  preventives.  Some  people  have  great  fuith  in 
sea  bathing;  and  they  go  to  the  coast  to  be  ducked  and  half  drowned  every  day  for 
six  weeks :  and  if  they  escape  hydrophobia  they  conclude  that  the  immersion  in  the 
salt  water  has  saved  them.  Some  of  the  specifics,  as  you  may  suppose,  are  great 
secrets  ;  and  they  who  possess  them — Avhether  they  beheve  in  them  or  not  is  another 
matter — sell  them  at  no  cheap  rate  to  those  who,  having  been  bitten  by  the  dog,  are 
weak  enough  to  be  bitten  again  by  the  quack.  The  composition  of  several  of  them 
has  transpired  ;  and  they  are  found  to  consist  either  of  ingredients  the  most  insigni- 
ficant and  worthless,  or  of  poisons  of  which  the  inefficacy  had  already  been  ascer- 
tained. The  celebrated  pii'  is  antili/ssus,  which  was  introduced  by  no  less  a  person 
than  Dr.  Mead,  into  the  London  Pharmacopoeia,  was  a  mixture  of  ash-coloured 
liverwort  and  black  pepper.  The  Ormskirk  medicine,  long  famous,  and  scarcely 
obsolete  yet  in  the  north  of  England,  was  made  up  of  bole  armeniac,  alum,  chalk, 
elecampane,  and  oil  of  aniseed.  The  Tonqidn  medicine  was  composed  of  cinnabai 
and  musk  :  and  the  Tanjore  pills  Avere  a  combination  of  mercury  and  arsenic.  Even 
now  scarce  a  year  elapses  but  some  correspondent  of  the  newspapers,  whose  philan- 
thropy is  more  conspicuous  than  his  judgment  or  his  knowledge,  recommends  a  new 
and  infallible  preventive.  I  confess  to  you  that  1  have  not  the  slightest  faith  in  any 
one  of  them ;  but  as  I  have  a  great  respect  for  Air.  Youatt,  and  as  he  is  not  fjidtc  so 
sceptical  as  I  am  on  this  point,  and  as  patients  or  their  friends  will  insist  upon  the 
adoption  of  protective  measures  sometimes,  when  the  local  means  of  prevention 
have  been  omitted  or  imperfect,  I  will  tell  you  what  he  (Mr.  Youatt)  has  -done  in 
respect  to  these  prophylactic  drugs. 

In  the  first  place  he  never  succeeded  in  curing  the  disease  in  the  dog  with  any 
thing  that  he  had  ever  tried. 

In  the  way  of  prophylaxis,  he  experimented  with  a  great  number  of  substances. 
He  thought  that  the  box-wood,  which  is  the  basis  of  some  celebrated  preventive 
drinks  in  Hertfordshire  and  Kent,  had  some  efl^ect.  He  tried  the  alisma  plantfigo,  the 
boasted  elRcacy  of  which  had  been  strictlj^  inquired  into  by  the  magistracy  of  Toula, 
and  the  receipt  purchased  by  the  Russian  government  at  an  immense  price.  But 
he  had  no  success  with  it.  He  then  put  the  belladonna  to  the  test,  beginning  with 
two  grains,  and  increasing  the  dose  to  a  scruple  twice  every  day,  and  continuing  this 
for  six  weeks :  and  he  says  he  is  confident  that  he  saved  several  dogs  ;  but  he  lost 
almost  as  many.     They  all  became  debihtated  and  most  rapidly  emaciated. 

Then,  in  the  year  1820,  his  attention  was  directed  to  the  Scutellaria  lateriflora, 
which  Dr.  Spalding,  an  American  physician,  had  found  highly  successful  as  a  pre- 
ventive of  rabies:  and  upon  trial  of  it,  he  soon  was  brought  to  regard  it  as  really 
valuable  :  and  (not  to  tire  you  with  a  detail  of  his  proceedings  in  the  interim)  he  at 
length  combined  it  with  belladonna:  "and  the  result"  (I  here  quote  his  own  lan- 
guage) "has  been  a  medicine  which  I  cannot,  dare  not,  call  a  specific;  for  it  has 
failed  :  but  the  use  of  which,  in  the  cases  of  doubt  and  fear  to  which  I  have  alluded, 
1  would  most  earnestly  recommend."  He  relates  two  experiments,  which  seem  to 
have  made  a  great  impression  upon  his  mind.     They  are  as  follows : — 

"  Three  pieces  of  tape  were  thoroughly  moistened  with  the  saliva  of  a  rabid  dog, 
and  inserted  as  rowels  in  the  polls  of  three  other  dogs.  To  two  the  Scutellaria  and 
belladonna  were  given  :  the  third,  a  fox-hound  bitch,  was  abandoned  to  her  fate.  On 
the  2;Jth  aay  after  the  inoculation  she  became  rabid."  The  others,  at  the  time  this 
was  written,  i.  c,  some  months  afterwards,  were  living  and  well. 

He  afterwards  took  the  same  two  dogs,  and  a  third.  He  moistened  two  pieces  of 
tape  with  the  saliva  of  a  rabid  dog,  and  inserted  them  in  the  polls  of  one  of  the  old 
dogs,  and  of  the  third  dog.     Another  piece  of  tape,  dragged  repeatedly  through  the 


EPILEPSY.  B^ 

mouth  of  tho  same  rabid  dog  twenty-four  hours  after  its  death,  was  inserted  m  the 
poll  of  the  second  of  the  old  dogs.  This  dog  and  the  new  one  were  suffered  lo  lake 
i.heir  chance.  To  the  other  old  dog  the  medicine  was  given.  In  the  fourth  week 
the  new  dog  died  undeniably  rabid.     The  other  two  survived. 

I  repeat  that  I  have  no  faith  in  these  preventives.  But  sometimes  some  of  them 
piust  be  tried  ;  and  I  would  prefer  those  which  are  thus  sanctioned  b}''  Mr.  Youatt's 
good  opinion  to  any  others. 

And  with  respect  to  the  established  disease,  I  think  that  if  I  were  tho  unhappy 
subject  of  it,  I  should  wish  to  be  put  into  a  hot  air  bath,  and  thoroughly  sweated, 
and  to  lake  opiates ;  not  so  much  in  the  hope  of  recovering  as  with  a  view  to  the 
euthanasia.  But  with  all  respect  to  those  gendemen  who  advocate  that  practice,  no 
one,  if  I  could  help  it,  should  make  a  hole  in  my  wind-pipe. 


LECTURE  XXXV. 

Epilepsy.  Its  symptoms  and  varieties;  duration  and  recurrence  of  the  parox- 
ysms ;  periods  of  life  at  which  they  commence ;  warnings.  Effects  of  the 
paroxysms,  immediate  and  ultimate.  Pathology.  Anatomical  characters. 
Causes. 

The  great  functions  of  which  the  brain  is  the  material  instrument,  are  sensation, 
thought,  and  voluntary  motion.  The  influence  of  the  will  is  a  cerebral  influence : 
it  reaches  and  acts  upon  the  muscles  through  the  interposition  of  the  spinal  cord. 
Motions  that  are  involuntary  belong  more  exclusively  to  the  system  of  the  true 
spinal  marrow.  Yet  cerebral  changes,  morbid  states  of  the  brain,  may  excite 
them.     . 

I  have  shown  you  that  all  these  functions  are  liable,  under  disease,  to  be  sepa- 
rately affected,  and  each  in  various  ways  and  degrees.  The  number  of  combina- 
tions capable  of  arising  out  of  disordered  conditions  of  two,  or  three,  or  all  of  these 
functions,  is  very  great.  Yet  the  symptoms  proper  to  the  nervous  system  do  arrange 
themselves  into  groups  sufficiently  detinite  and  constant  to  allow  of  our  giving  them 
distinctive  names,  and  making  them  separate  objects  of  inquiry. 

At  the  same  lime,  as  might  indeed  be  expected,  these  several  groups  have  strong 
resemblances  to  each  other.  They  are  obviously  of  the  same  family  :  "  facies  non 
omnibus  una,  nee  diversa  tamen ;  quahs  debet  esse  sororum."  Occasionally  the 
features  are  so  near  alike,  that  we  find  it  somewhat  puzzling  to  determine  with 
which  of  the  sisters  we  are  conversing ;  but  usually  there  is  some  mark  or  oilier  by 
which  the  individual  may  be  identified. 

Of  these  essentially  nervous  diseases,  there  are  several  in  which  the  most  promi- 
nent and  obvious  of  the  phenomena  relate  to  the  muscular  system  ;  irregular,  violent, 
and  involuntary  contractions  occurring  of  muscles  which,  in  the  healthy  state  of  the 
body,  are  subject  to  the  control  of  the  will.  I  have  spoken  of  two  very  frightful  dis- 
orders belonging  to  this  head: — oi^  tetanus,  namely,  in  which  the  muscles  of  volun- 
tary motion  present  the  most  striking  changes,  being  affected  with  tonic  spasm ; 
while  the  sensibility  undergoes  no  other  alteration  than  what  is  a  consequence  of 
that  spasm,  pain  I  mean  in  the  muscles  themselves  ;  and  the  intellectual  functions 
continue  undisturbed  : — and  of  hydrophobia,  in  which  the  natural  sensibility  suffers 
much,  and  the  mental  functions  some  derangement ;  yet  still  the  characteristic  fea- 
tures of  the  malady  depend  upon  the  irregular  and  uncontrollable  action  of  muscles 
usually  obedient  to  volition. 

The  disease  which  I  am  next  to  consider  is  scarcely  less  terrible  to  witness,  when 
It  occurs  in  its  severer  forms,  than  tetanus  or  hydrophobia ;  but  it  is  not  attended 
with  the  same  urgent  and  immediate  peril  to  life.  Yet  it  is,  upon  the  whole,  pro- 
ductive of  even  more  distress  and  misery;  and  is  liable  to  terminate  in  worse  than 
death.     You  will  understand  that  I  am  alluding  to  Epilepsy:  a  disease  not  paiotul 


^80  EPILEPSY. 

probably  in  itself ;  seldom  immediately  fatal ;  often  recovered  from  altogether :  yet 
apt,  in  many  cases,  to  end  in  fatuity  or  insanity ;  and  carrying  perpetual  anxiety 
and  dismay  into  those  families  which  it  has  once  visited. 

The  leading  symptoms  of  epilepsy  are,  a  temporary  suspension  of  consciousness, 
with  clonic  spasm  ;  recurring  at  intervals. 

It  is  impossible  to  frame  a  perfect  dcfinilion  of  epilepsy ;  nay,  so  various  are  its 
forms,  so  numerous  its  modifications,  that  no  general  descriptmi  even  of  it  can  be 
given.  It  will  be  necessary  for  me  therefore  here  (as  it  has  been  stated  before)  to 
describe  first  the  most  ordinary  type  of  the  disease,  as  a  standard ;  and  then 
*.o  note  the  several  variations  from  that  standard  which  are  known  to  occur  in 
practice. 

A  man,  then,  in  the  apparent  enjoyment  of  perfect  health,  shall  suddenly  utter  a 
loud  cry,  and  fall  instantly  to  the  ground,  senseless  and  convulsed.  He  strains 
and  struggles  violently.  His  breathing  is  embarrassed  or  suspended  ;  his  face 
turgid  and  livid :  he  foams  at  the  mouth ;  a  choking  sound  is  heard  in  his  wind- 
pipe ;  he  appears  to  be  at  the  point  of  death  by  apncea.  But  presently,  and  by 
degrees,  these  alarming  phenomena  diminish,  and  at  length  cease ;  the  patient  is 
left  exhausted,  heavy,  stupid,  comatose  :  but  his  life  is  no  longer  threatened.  And 
in  a  short  time  he  is  once  more,  to  all  appearance,  perfectly  well.  The  same  train 
of  morbid  phenomena  recur,  however,  again  and  again,  at  different,  and  mostly 
at  irregular  intervals. — This  is  a  brief  description  of  the  most  ordinary  form  of 
epilepsy. 

The  suddenness  of  the  attack  is  remarkable :  in  an  instant,  when  it  is  least  ex- 
pected by  himself  or  by  those  around  him,  in  the  middle  of  a  sentence,  or  of  a  ges- 
ture, the  change  takes  place  ;  and  the  iniserable  sufferer  is  stretched  foaming,  strug- 
gling, and  insensible  upon  the  earth.  This  fearful  suddenness  is  expressed  in  the 
name  of  the  disease,  ln'a»;4''a,  a  seizure,  an  abrupt  invasion.  The  ancients,  among 
whom  the  complaint  was  well  known,  superstitiously  ascribed  it  to  the  malice  of 
demons,  or  to  the  anger  of  their  offended  deities.  If  a  person  Avas  seized  with  epi- 
lepsy in  the  forum,  it  was  considered  an  ill  omen,  and  the  meeting  was  at  once 
dissolved,  and  all  public  business  suspended  for  that  day.  Hence  the  disease  was 
called  morbus  comiticdis.  3Iorbus  qui  sputatur  was  another  of  its  names,  because 
those  present  were  accustomed  to  spit  upon  the  epileptic  man,  or  into  their  own 
bosoms ;  either  to  express  their  abomination,  or  to  avert  the  evil  omen  from  them- 
selves. In  this  country  its  common  designation  is  the  falling  sickness :  or,  more 
vaguely  Jits.  The  cry  which  is  frequently,  though  by  no  means  always,  uttered,  is 
generally  a  piercing  and  terrifying  scream.  Women  have  often  been  thrown  into 
hj'-gierics  upon  hearing  it.  It  is  said  to  have  caused  pregnant  females  to  miscarry. 
Even  the  lower  animals  appear  to  be  sometimes  startled  and  alarmed  by  a  note  so 
harsh  and  unnatural.  Dr.  Cheyne  informs  us  that,  upon  one  occasion,  "a  parrot, 
himself  no  mean  performer  in  discords,  dropt  from  his  perch  seemingly  frightened 
to  death  by  the  appalling  sound."  The  muscular  convulsions  are  strong,  irregular, 
and  often  universal.  In  most  of  the  fits  of  which  I  have  happened  to  see  the  com- 
mencement, the  first  effect  of  the  spasm  has  been  a  twisting  of  the  neck,  the  chin 
being  raised,  and  brought  round  by  a  succession  of  jerks,  towards  one  shoulder:  and 
one  side  of  the  body  is,  usually,  more  strongly  agitated  than  the  other.  The 
features  are  always  greatly  distorted.  The  brows  are  knit ;  the  eyes  sometimes 
quiver  and  roll  about,  sometimes  are  fixed  and  staring,  sometimes  are  turned  up 
beneath  the  lids,  so  that  the  cornea  cannot  be  seen,  and  the  white  sclerotica  alone  is 
visible  ;  the  mouth  is  twisted  awry  ;  the  tongue  thrust  between  the  teeth,  and  caught 
by  the  violent  closure  of  the  jaws,  is  bitten,  often  severely ;  and  the  foam  which 
•ssues  from  the  mouth  is  reddened  by  blood.  The  hands  are  firmly  clenched,  and 
the  thumbs  bent  inwards  upon  the  palms  :  the  arms  are  thrown  about,  striking  the 
chest  of  the  patient  with  great  force,  or  bruising  themselves  against  surrounding 
objects,  or  inflicting  hard  knocks  upon  the  friends  and  neighbours  who  have  has- 
tened to  the  patient's  assistance.  It  frequently  happens  that  the  urine  and  excie- 
ment  are  expelled  during  the  violence  of  the  spasm :  and  seminal  emission  some- 
f'mes  takes  place.     The  spasmodic  contraction  of  the  muscles  is  occasionally  so 


EPILEPSY.  381 

powerful  as  to  dislocate  the  bones  to  which  they  are  attached  :  the  joints  of  the 
jaw,  and  of  the  shoulder,  have  been  thus  put  out ;  and  the  teeth  are  sometimes  frac- 
tured. 

When  the  convulsive  paroxysm  is  over,  the  patient  falls  into  a  deep  sleep.  You 
might  imagine  that  he  slept  from  exhaustion,  hke  a  man  Avorn  out  by  great  fatigue; 
but  there  is  something  more  than  this ;  the  patient  passes  into  a  state  of  incomplete 
coma,  or  rather  the  insensibility  continues  after  the  convulsions  have  ceased.  When 
he  wakes  he  is  often  confused  and  incoherent  for  a  time  ;  by  degrees,  however,  he 
resumes  his  ordinary  appearance  and  condition  :  but  he  remembers  nothing  of  what 
passed  during  the  fit. 

You  may  suppose  that  so  much  irregular  contraction  of  the  muscles  of  voluntary 
motion  is  not  likely  to  occur  without  some  derangement  or  modification  of  the  func- 
tions of  the  circulation.  The  breathing  is  irregular,  gasping,  or  arrested.  The  heart 
palpitates  violently  against  the  ribs  during  the  paroxysm ;  the  pulse  becomes  fre- 
quent and  feeble ;  and  sometimes  it  ceases  to  be  tangible  at  the  wrist  during  the 
height  of  the  fit,  and  begins  to  be  felt  again  as  the  spasms  subside.  The  turgescence 
of  the  face  indicates  obstruction  of  the  venous  circulation ;  the  cheeks  and  lips 
become  purplish  and  livid,  and  the  veins  of  the  neck  and  forehead  are  visibly  dis- 
tended. 

This,  then,  is  one  form,  the  most  severe  and  the  most  common  as  well  as  the  best 
marked  form,  in  which  an  epileptic  attack  occurs. 

But  there  is  a  large  class  of  cases,  in  which  the  symptoms  are  much  more  mild. 
There  is  very  shght  and  transient,  or  even  no  convulsion  at  all ;  no  turgescence  of 
the  face  ;  no  foaming  at  the  mouth  ;  no  cry ;  but  a  sudden  suspension  of  conscious- 
ness, a  short  period  of  insensibility,  a  fixed  gaze,  a  totter  perhaps,  a  look  of  confu- 
sion ;  but  the  patient  does  not  fall.  This  is  momentary ;  consciousness  presently 
returns ;  the  patient  resumes  the  action  in  which  he  had  been  previously  engaged, 
and  is  not  always  aware  that  it  has  been  interrupted.  Sometimes,  with  this  tempo- 
rary abeyance  of  the  mental  functions,  there  is  some  shght  evidence  of  convulsion  or 
involuntary  action ;  the  fingers  of  one  hand,  or  less  commonly  of  both,  are  moved 
irregularly,  and  without  any  object ;  or  the  eyes  roll  or  are  turned  upwards :  or  the 
muscles  of  the  face  are  twitched.  Sometimes  the  patient  is  himself  aware  of  what 
has  been  his  condition,  but  shows  some  cunning  in  endeavouring  to  conceal  it. 

This  slighter  attack  is  called  by  the  French,  petit  mal;  while  the  severer  form  is 
named  grand  mal.  The  former  is  spoken  of  also  as  epileptic  vertigo,  and  distin- 
guished by  that  appellation  from  the  epileptic  fit. 

Of  afl^ections  so  different  in  degree,  and  in  some  respects  so  dissimilar  in  kind, 
you  may  be  disposed  to  ask  whether  they  really  constitute  the  same  disease.  That 
they  are  essentially  of  the  same  stamp,  we  have  this  evidence ;  that  both  forms  of 
attack  occur  in  the  same  individuals.  Sometimes  a  patient  will  suffer  many  recur- 
rences of  the  epileptic  vertigo,  and  at  length  will  become  affected  with  violent  epi- 
leptic fits.  Or  the  two  forms  will  intermingle,  sometimes  the  milder  happening, 
sometimes  the  severer.  In  such  cases  we  cannot  doubt  that  the  attacks  are  the  same 
in  nature,  though  different  in  form  and  degree.  And  when  (as  sometimes  happens) 
we  meet  with  the  slighter  disease  alone,  we  cannot  refuse  to  assign  to  it  the  charac- 
ter and  the  name  of  epilepsy. 

Between  the  two  extremes  there  are  many  links  of  gradation.  Sometimes  the 
sufferer  sinks  or  slides  down  quietly,  and  without  noise ;  is  pale,  is  not  convulsed  at 
all,  but  insensible ;  much  like  one  in  a  state  of  syncope.  After  recovering,  he 
remains  sick,  languid  and  confused,  during  the  remainder  of  the  day. 

You  will  ])erceive,  from  what  I  have  now  said,  the  difficulty  of  giving  any  single 
description  of  epilepsy,  which  will  include  all  its  varieties.  It  is  of  course  still  more 
difficult  to  offer  a  strict  definition  of  the  disease.  CuUen  defines  it  to  be  "  musculo- 
rum convulsio,  cum  sopore."  Dr.  Copland  furnishes  a  larger  and  more  compre- 
hensive definition :  "  Sudden  loss  of  sensation  and  consciousness,  with  spasmodic 
contraction  of  the  voluntary  muscles,  quickly  passing  into  violent  convulsive  distor- 
tions, attended  and  followed  by  sopor,  recurring  in  paroxysms  often  more  or  less 
regular." 


382  EPILEPSY. 

But  almost  every  one  of  these  circumstances  may,  in  its  turn,  be  wanting.  There 
may  be  no  convulsion ;  there  may  even  be  very  slight  and  transient  interruption  of 
consciousness  ;  there  may  be  no  subsequent  coma  or  sopor ;  there  may  be  no  recur 
rence  of  the  attack. 

Yet  I  trust  that  you  now  have  obtained  some  general  notion  of  what  is  meant  by 
an  epileptic  seizure.  And  I  go  on  to  inquire  into  several  most  important  points  con- 
nected with  the  paroxysms. 

In  the  first  place  they  vary  considerably  in  duration.  Sometimes,  as  T  have 
already  staled,  the  seizure  is  slight,  and  does  not  occupy  more  than  a  moment  or 
two  of  time.  But  even  the  severer  attacks  are  often  over  in  a  few  minutes.  They 
seldom  continue  longer  than  half  an  hour,  and  probably  the  average  duration  may 
safely  be  laid  at  between  five  and  ten  minutes.  Attacks  that  are  spread  over  three 
or  four  or  more  hours,  generally  consist  of  a  succession  of  paroxysms,  with  indistinct 
intervals  of  comatose  exhaustion.  In  the  long-continued  fits,  or  in  the  protracted  suc- 
cession of  fits,  the  patient  often  dies. 

The  periods  at  which  the  paroxysms  return  are  also  extremely  variable.  Occa- 
sionally the  patient  dies  in  the  first  paroxysm ;  occasionally,  though  he  recovers 
from  it,  he  never  has  another.  Both  of  these  occurrences  are  rare.  Rather  more 
frequently  the  fits  recur  at  very  long  intervals ;  at  the  distance,  I  mean,  of  many 
years.  Most  commonly  of  all,  they  revisit  the  sufferer  at  irregular  periods  of  a  few 
months  or  weeks :  sometimes  they  are  repeated  at  intervals  of  a  few  days :  some- 
times every  day  or  every  night :  and  not  very  unfrequently  they  take  place  many 
times  in  the  twenty-four  hours.  This  extreme  frequency  of  repetition  belongs  prin- 
cipally to  the  slighter  imperfect  seizure,  the  petit  mal.  Sometimes  the  fits  observe 
a  strictly  regular  period  of  return ;  but,  for  the  most  part,  they  are  quite  uncertain 
and  ij-regular. 

The  time  of  life  at  which  the  fits  commence,  and  the  circumstances  attending 
their  commencement,  are  deserving  of  notice.  They  not  uncommonl)^  begin  in 
infancy.  Those  fits  of  convulsion  to  which  young  children  are  subject  during  the 
first  dentition,  and  which  sometimes  appear  to  depend  upon  the  irritation  of  teeth- 
ing, and  sometimes  upon  manifest  disorder  of  stomach  and  bowels  —  these  fits  are 
not  distinguishable  in  their  phenomena  from  genuine  epdepsy  ;  and  we  must  reckon 
them  as  instances  of  epilepsy.  It  has  been  remarked  by  some  one,  that  if  a'ou  can 
trace  the  early  histor)''  of  an  adult  epileptic,  you  will  almost  always  find  that  he  or 
she  suffered  infantile  convulsions. 

[This  is  true.  Epileptics,  it  will  very  generally  be  found,  were  affected  with  repeated 
attacks  of  convulsions  during  the  period  of  infancy.  In  many  subjects,  however,  we  have 
known  the  disease  to  commence  immediately  subsequent  to  puberty,  or  even  late  in  life. 
In  the  majority  of  these  latter  cases  the  disease  appeared  to  be  the  result  of  a  life  of  intem- 
perance.— C] 

To  what  extent  this  is  true  I  do  not  know,  but  I  recommend  it  to  you  as  a  point 
worth  attending  to  in  your  future  opportunities  of  observation. 

The  epileptic  attack  may  come  on,  for  the  first  time,  at  any  age.  According  to 
Dr.  Bright  (whose  account  of  the  disease,  though  short,  is  particularly  perspicuous), 
the  most  common  periods  are  about  the  age  of  seven  or  eight  years,  probably  about 
the  time  of  the  second  dentition ;  and  from  fourteen  to  sixteen,  shortly  before  the  age  of 
puberty.  And  the  disease  (he  says)  is  very  apt  to  occur  for  a  few  years  subsequently 
to  this.  But  sometimes  the  first  fit  has  taken  place  between  the  ages  of  thirty  and 
forty  ;  in  not  a  few  cases  after  sixty  ;  and  occasionally  quite  in  the  decline  of  life. 

Dr.  Bright  offers  a  little  piece  of  theory  in  respect  to  the  periods  at  which  epi- 
lepsy is  apt  to  begin.  It  is  a  reasonable  piece  of  theor}%  and  serves  to  tie  the  alleged 
facts  to  one's  memory,  even  if  it  be  not  yet  proved  to  be  true.  Doubtless  in  many 
cases  the  circumstances  that  determine  the  first  attack  are  quite  accidental.  But 
setting  aside  these  casualties,  he  says  "  there  are  leading  periods  in  the  evolution  of 
the  frame,  and  peculiar  circumstances  connected  with  certain  periods,  which  may 
well  be  considered  as  influential  in  the  production  of  the  disease.  In  infancy  the 
nervous  system  is  delicate,  and  easily  acted  upon  by  various  causes  of  irritation. 
Then  follows  the  trying  period  of  teething.     In  a  few  years  the  second  dentition 


EPILEPSY.  383 

occurs.  In  a  few  years  later,  all  the  great  changes  connected  with  the  age  of  pu- 
bert3^  To  this  follow  the  excesses  and  exposures  of  manhood  ;  and  after  the  lapse 
of  years,  the  vigour  of  the  system  fails,  and  many  causes  act  to  derange  the  nice 
balance  of  the  constitution;  the  bowels  often  become  sluggish;  changes  more  or 
less  serious  take  place  in  the  structure  of  the  arterial  and  venous  system ;  and  many 
causes,  organic  or  functional,  which  had  before  been  unable  to  exert  an  influence  oa 
the  vigorous  frame,  acquire  power  from  its  relative  weakness." 

The  first  accession  of  the  disease  takes  place  more  commonly  before  than  after 
puberty.  Of  sixty-six  epileptic  women,  in  whom  the  outset  of  that  disease  and  the 
first  period  of  menstruation  were  carefully  noted,  thirty-eight  had  epileptic  fits  before, 
and  twenty-eight  not  till  after  that  period. 

The  attacks  are  very  apt  to  come  on  during  the  night ;  in  the  commencement  of 
the  disease,  they  frequently  are  confined  to  'he  night.  They  are  said  chiefly  to 
occur  at  the  moment  when  the  patient  is  sinking  into  sleep,  or  awaking  from  sleep. 
How  far  this  is  true  I  cannot  tell.  When  the  disease  is  yielding,  the  fits  often 
happen  in  the  night  only;  so  that  after  they  have,  for  a  certain  period,  taken  place 
in  the  day-time,  or  during  the  day  and  night,  indiscriminately,  it  is  reckoned  a  good 
prognostic  sign  if  they  begin  to  restrict  themselves  to  the  night.  Som.e  patients, 
under  these  circumstances,  suppose  that  the  physician  has  particular  remedies  that 
will  make  the  fits  happen  in  the  night  rather  than  in  the  day  ;  and  they  ask  for  these 
r^edies. 

Sometimes  each  paroxysm  arrives  unannounced  and  unexpected  ;  sometimes  dis- 
tinct ivurnings  of  its  approach  are  given.  The  latter  is  less  frequent  than  the  former. 
Georget  affirms  that  the  premonitory  symptoms  do  not  occur  more  than  four  or  five 
times  in  a  hundred  cases.  I  am  sure  that  this  is  much  understated.  When  warning 
symptoms  do  happen,  they  are  sometimes  spread  over  a  considerable  period  ;  several 
hours,  or  a  whole  day  ;  sometimes  they  last  just  long  enough  to  enable  the  patient  to 
remove  from  a  situation  in  which  a  fall  would  be  attended  with  unusual  danger:  to 
dismount  from  horseback,  to  lie  down  in  a  boat,  to  get  away  from  the  fireplace,  from 
the  edge  of  a  precipice,  from  the  vicinity  of  water,  to  assume  the  horizontal  position 
of  his  own  free  will  and  in  his  own  manner,  or  to  give  notice  to  those  about  him  of 
what  is  going  to  befall  him.  In  some  cases  the  warning  is  too  short  and  sudden  even 
for  this.  The  kind  of  notice  that  he  receives  is  very  variable  indeed.  Often  it 
consists  in  some  unnatural  state  of  the  mind,  the  feelings,  the  temper ;  the  patient  is 
fidgety,  irritable,  low-spirited,  timid,  sullen ;  or,  on  the  other  hand,  he  feels  unusually 
strong,  and  hearty,  and  cheerful.  Sometimes  there  is  a  notable  change  in  some  one 
or  more  of  the  natural  functions,  or  of  the  bodily  sensations ;  the  patient  loses  his 
appetite,  or  his  appetite  becomes  voracious ;  a  great  flow  of  urine  takes  place ;  ho 
smells  an  ill  smell,  is  aware  of  a  strange  taste,  hears  extraordinary  noises,  or  seesr 
spectral  illusions  ;  not  mere  specks  floating  before  him — muscce  vohtantes — but  dis- 
tinct forms  of  persons  and  things.  This  is  not  very  common,  but  it  certainly  happens. 
The  late  Dr.  Gregory,  of  Edinburgh,  was  assured  by  a  patient  of  undoubted  veracity, 
that  always,  when  he  had  a  fit  of  epilepsy  approaching,  he  fancied  that  he  saw  a 
httle  old  woman  in  a  red  cloak,  who  came  up  to  him,  and  struck  him  a  blow  on  the 
head,  and  then  he  immediately  lost  all  recollection,  and  fell  down. 

Headache,  giddiness,  dim  or  dazzled  vision,  are  all  of  them  common  symptoms 
among  those  which  have  been  observed  to  be  precursory  of  epilepsy.  Sometimes 
there  are  circumstances  which  are  obvious  to  a  bystander :  a  flushing  of  the  face, 
or  lividity  :  difficult  articulation  ;  vomiting.  Of  twenty-one  epileptics  treated  in  the 
hospital  at  Wilna,  by  Joseph  Frank,  vomiting  announced  the  paroxysm  in  seven. 
Som.e  of  the  uneasy  feelings  are  apt  to  come  on  and  continue  even  for  several  days 
previously  to  the  attack ;  restlessness  in  particular,  disturbed  sleep,  distressf'ul 
dreams,  a  peculiar  and  sudden  coldness  of  the  extremities.  An  internal  working 
is  a  phrase  often  used  by  such  persons  to  express  a  sensation  which  is  probably  in 
describable. 

But  the  most  curious  precursory  symptom  of  all,  if  we  except  the  spectral  illu 
sions,  is  what  is  called  the  epileptic  aura.  This  is  a  sensation  which  is  likened  by 
different  patients  to  different  things ;  to  a  stream  of  water  or  cold  air,  to  th*^  tmkiing 


364  EPILEPSY. 

of  water,  to  the  creeping  of  a  spider.  The  sensation  proceeds  commonly  from  some 
distant  part  of  the  body. — from  one  of  the  extremities,  from  a  thumb  or  linger,  or 
to  some  spot  on  the  trunk,  —  and  runs  along  the  skin  towards  the  head  :  occasion- 
ally it  gets  no  further  than  the  pit  of  the  stomach:  as  soon  as  it  reaches  the  head, 
or  stops  at  the  epigastrium,  or  elsewhere,  the  patient's  consciousness  forsakes  him, 
and  the  paroxysm  declares  itself. 

There  seems  to  be  some  analogy  between  this  epileptic  aura  and  the  well-known 
sensation,  to  be  spoken  of  hereafter,  of  a  ball  rising  from  the  stomach  to  the  throat, 
and  constituting  the  globus  hystericus ;  except  that  in  cases  of  epilepsy  the  sensation 
commonly  begins  in  an  extremity,  and  not  in  the  stomach :  and  the  fit  comes  on 
when  it  reaches  the  head  and  not  the  throat.  Sometimes,  I  think,  these  two  sensa- 
tions are  blended. 

In  some  instances,  spasms  of  the  muscles  of  the  part  whence  the  aura  proceeds 
»re  observed  to  take  place  prior  to  the  more  general  state  of  spasm. 

This  aura  is  certainly  a  very  curious  phenomenon.  It  has  been  thought  to  depend 
upon  some  change  propagated  along  the  nerve  upwards  to  the  brain,  and  to  be  some 
times  connected  with  some  injury  done  to,  or  some  morbid  impression  made  upon, 
an  afferent  nerve.     I  think  that  this  explanation  may  apply  to  some  cases. 

Dr.  John  Thomson,  of  Edinburgh,  used  to  state  in  his  lectures,  that  h-e.  had  known 
epilepsy  to  begin  with  an  aura  proceeding  from  an  old  cicatrix  in  the  side.  In  a 
patient  of  my  own,  who  was  subject  to  epilepsy,  the  warning  sensation  commenctd 
in  one  of  his  thumbs,  which  presently  after  began  to  be  twisted  inwards ;  but  by 
tying  his  handkerchief  tightly  round  the  thumb,  he  could  prevent  the  fit.  Dr.  Sey- 
mour mentions  the  case  of  an  epileptic  boy,  who  had  learned  to  protect  himself 
against  a  threatened  paroxysm,  by  biting  his  tongue. 

In  other  cases  the  aura  probably  originates  in  some  change  w'ithin  the  head,  and 
is  analogous  to  the  numbness  or  tingling  that  is  often  felt  in  some  part  of  the  body  or 
extremities  immediately  before  an  attack  of  palsy  or  apoplexy.  There  is  no  real 
inconsistency  in  this  twofold  explanation  :  the  source  of  the  aura  may  be  centric  or 
eccentric  ;  so  also  may  the  exciting  cause  of  the  paroxysm  ;  as,  in  due  time,  I  shall 
explain  to  you. 

A  knowledge  of  these  warning  circumstances  is  clearly  of  importance,  always  as 
far  as  respects  the  comparative  security  of  the  patient  during  the  attack ;  sometimes 
as  afibrding  us  the  opportunity  of  slaving  off  the  fit  altogether.  And  it  is  necessary 
to  remark,  that  they  sometimes  give,  as  it  were,  a  false  alarm;  they  occur,  and  yet, 
although  no  measures  of  prevention  are  taken,  no  paroxysm  follows. 

The  phenomena  that  succeed  the  paroxysm  are  also  of  great  interest  and  moment. 

I  have  already  apprised  you  that  the  convulsions  generally  terminate  before  the 
insensibility  is  over:  the  patient  draws,  perhaps,  two  or  three  deep  sighs,  and  ceases 
to  struggle.  Some  few  persons  are  quite  themselves  again  in  a  few  moments ;  some 
appear  to  recover  consciousness,  and  then  fall  into  a  deep  and  prolonged  slumber; 
but  many  do  not  regain  their  consciousness  at  all  upon  the  cessation  of  the  convul- 
sions, remaining  in  a  state  of  profound  stupor,  from  which,  however,  they  can  gene- 
rally be  roused  for  a  time.  This  state  of  coma  (for  it  is  nothing  else)  has  been 
known  to  last  a  week.  After  the  patient  emerges  from  it,  he  is  sometimes  merely 
languid  and  inert:  sometimes  he  is  like  a  person  stunned,  or  in  a  state  approaching 
to  idiocy,  which  gradually  clears  up ;  sometimes  he  is  furiously  delirious  for  a  short 
time:  not  unfrequenlly  there  is  a  degree  of  partial  paralysis,  which  also  usually 
soon  goes  off",  though  it  occasionally  is  permanent ;  the  eyes  are  fixed,  or  he  squints, 
or  the  pupils  are  dilated,  or  he  drags  a  leg,  or  he  falters  in  speech.  Most  commonly 
he  speaks  of  headache,  or  discomfort  of  some  kind. 

It  is  very  seldom  that  the  patients  have  any  recollection  whatever  of  what  has 
passed  during  the  fit.  Many  of  them  are  not  aware  that  they  have  had  a  fit:  and 
those  who  do  know  it,  discover  the  fact  by  finding  themselves  wet  or  dirty ;  by  the 
injuries  they  have  received  during  the  convulsions ;  by  the  soreness  of  the  bitten 
longue ;  by  the  bruises  of  their  limbs ;  or  by  the  confused  or  painful  sensations 
which  they  subsequently  experience,  and  which  they  have  learned  to  associate  with 
me  conviction  that  a  fit  lias  happened,  by  having  been  informed  on  previous  occasions 


EPILEPSY.  385 

when  they  felt  the  same  sensations,  that  they  had  suffered  a  paroxysm  of  insensi- 
biUiy  and  convulsions. 

Upon  the  whole,  it  is  seldom  that  any  permanent  ill  effect  can  be  noticed  as 
having  been  left  behind  it  by  any  one  single  fit ;  but,  alas !  this  cannot  often  be  said 
of  I  heir  repetition. 

Doubtless  a  single  paroxysm  does  often  leave  the  patient  in  a  worse  condition  than 
that  in  which  it  found  him ;  but  this  does  not  become  perceptible  to  an  ordinary  ob- 
server, until  after  the  alteration  has  been  rendered  apparent  by  repeated  fits,  and 
repeated  small  additions  to  the  permanent  injury.  The  friends  of  the  patient 
remark  that  his  memory  is  enfeebled  in  proportion  to  the  number  of  his  attacks  ; 
that  his  mental  power  and  intelligence  decline.  His  features  even  assume,  by 
degrees,  a  peculiar  character;  and  too  often  he  sinks  into  hopeless  fatuity,  or  con- 
firmed imbecility  or  insanity.  It  is  this  tendency  which  renders  epilepsy  so  sad 
anu  fearful  a  disease. 

Foville  affirms,  that  the  intellectual  degeneration  is  more  constant,  and  comes  on 
more  early,  in  persons  who  are  principally  afflicted  with  the  epileptic  vertigo,  the 
petit  mal,  the  imperfect  seizure,  than  in  persons  in  whom  the  grand  mat,  the  vio- 
lent and  decided  paroxysm,  takes  place.  Dr.  Copland,  on  the  other  hand,  is  of 
opinion,  that  "  the  more  severe  the  fits,  the  more  is  that  result  to  be  dreaded.  This 
is  a  point  which  can  only  be  settled  by  statistical  facts.  And  as  we  all  have  the 
opportunity  of  collecting  some  such  facts,  and  of  adding  them  to  the  general  stock, 
I  mention  this,  and  some  other  points  that  are  still  uncertain  or  disputed,  as  worth 
bearing  in  mind.  More,  probably,  depends  upon  the  repetition  of  the  fits,  than 
upon  their  precise  nature  or  severity.  Cases  do  occur  in  which  epileptic  persons 
preserve  their  faculties  to  a  good  old  age;  but  those  who  are  early  epileptic  do 
not  often  attain  old  age ;  and  ivhcnever  the  disease  comes  on,  if  it  repeats  itself 
frequently,  it  is  much  more  often  than  not  followed  by  impairment  of  the  mind, 
or  by  some  apoplectic  or  paralytic  affection,  which  implies  and  accompanies  the 
mental  change.  You  will  sometimes  hear  the  cases  of  Julius  Ccesar,  of  Ma- 
homet, and  of  Bonaparte  quoted,  as  examples  of  high  intellectual  power,  existing 
and  remaining  in  spite  of  epilepsy  : — and  it  is  allowable,  perhaps,  to  make  use  of 
such  cases  for  comforting  the  friends  of  epileptic  persons :  or  for  giving  the 
advantage  of  sustained  hope  to  the  patient  himself.  But,  in  truth,  these  cases 
are  not  worth  much.  Napoleon  is  said,  I  know  not  upon  what  authority  how- 
ever, to  have  suffered  something  like  epilepsy  during  sexual  intercourse.  This  is 
not  very  uncommon  in  persons  subject  to  that  disease.  And,  with  respect  to  Julius 
Caesar,  we  learn  from  Suetonius,  that  it  was  only  in  the  latter  part  of  his  life  that 
he  laboured  under  epileps}^ ;  and  that  he  had  two  attacks  while  engaged  in  business. 

Having  now  described  the  phenomena  of  epilepsy ;  the  periods  of  life  at  which 
it  is  most  apt  to  commence ;  its  varieties ;  and  its  tendency  and  termination :  let 
us  next  inquire  what  is  known  respecting  the  real  seat  and  nature  of  this  strange  and 
melancholy  complaint. 

The  functions  that  are  affected  are  clearly  the  functions  of  the  brain.  Sensation, 
thought,  and  motion  regulated  by  the  will,  are  the  natural  functions  of  that  organ. 
The  temporary  abeyance  of  sensibility,  thought,  and  volition,  and  violent  and  ir- 
regular action  of  the  muscles  which  are  thus  withdrawn  from  the  empire  of  the 
will,  constitute  a  paroxysm  of  epilepsy.  We  have,  in  this  malady,  another  illus- 
tration of  the  fact,  that  when  the  controlling  influence  of  the  sensorium  is  suspended, 
the  peculiar  functions  of  the  spinal  marrow  are  exercised,  not  only  in  a  disorderly, 
but  also  in  an  unusually  energetic  manner.  That  the  brain  and  the  spinal  marrow, 
though  physiologically  distinct,  are  )'et  intimately  connected  with,  and  dependent 
upon,  each  other,  a  thousand  familiar  facts  assure  us :  and  there  are  good  reasons 
for  believing  that  the  change,  whatever  it  is,  w'hich  is  the  immediate  precursor  and 
cause  of  the  epileptic  fit,  may  sometimes  originate  in  the  spinal  cord,  and  thence 
extend  to  the  brain  ;  and  sometimes  originate  in  the  brain,  and  communicate  itself 
to  the  spinal  cord.  Dr,  Marshall  Hall's  doctrine,  that  all  convulsive  diseases  are 
diseases  of  the  spinal  marrow,  cannot  be  properly  applied  to  this  convulsive  disease 
25  2h 


(i86  EPILEPSY. 

of  epilepsy.  It  is  true  that  the  spinal  cord  is  concerned  whenever  there  is  convul- 
sion ;  but  it  is  concerned  in  every  voluntarij  movement  also,  through  the  inslru- 
mentalit}'  of  the  brain  itself;  and  it  ma}'  be,  and  often  is,  irregularly  influenced  by 
a  disordered  and  unnatural  state  of  the  brain.  Tetanus  may  fairly  be  regarded  as 
1  disease  of  the  cord  and  its  proper  appendages.  The  spasms  arise  and  reach  their 
height,  while  the  powers  of  thought  and  sensation  are  undisturbed,  and  while  vo- 
lition remains,  although  the  morbid  condition  of  the  cord  renders  it  inefTectual.  In 
epilepsy,  these  cerebral  functions  are  always  implicated.  There  is  always  a  loss  of 
consciousness :  and  in  epileptic  vertigo,  the  petit  mal,  there  is  frequently  a  suspen- 
sion of  consciousness  only,  icithout  any  convulsion  at  all.  The  brain,  therefore, 
.  we  must  consider  to  be  essentially  concerned  in  this  disorder. 

What  the  precise  state  of  the  nervous  matter  may  be,  which  determines  the  loss 
of  consciousness  and  the  spasms,  we  can  only  conjecture.  A  derangement  in  the 
relation  between  the  arterial  and  venous  circulation  within  the  head ;  a  temporary 
pressure  somehow  arising  ;  a  determination  of  blood  towards  the  head ;  a  diminu- 
tion of  the  natura^  ''uantity  of  blood  sent  thither  from  the  heart ;  all  these  have 
been  assigned  as  possible  causes  of  the  paroxysms.  Plausible  reasons  might  be 
given  in  favour  of  the  operation  of  each  of  them ;  but  the  speculation  is  more 
curious  than  useful.  We  have  not  yet  penetrated  the  mystery  of  these  remarkable 
phenomena,  and  it  will  be  more  profitable  to  turn  to  another  question,  which 
admits  of  a  somewhat  more  definite  answer,  viz. :  what  is  the  morbid  anatomy  of 
epilepsy  ? 

Suppose  that  a  person  who  has  had  epileptic  fits,  but  in  whom  they  have  not  been 
followed  by  any  durable  affection  of  the  intellectual  or  locomotive  functions,  dies  of 
some  other  malady  ;  and  you  may  have  the  opportunity  of  minutely  examining  the 
condition  of  the  nervous  system.  Ofien  you  will  find  nothing  at  all  which  can  throw 
any  light  upon  the  occurrence  of  the  epileptic  paroxysms ;  no  appreciable  alteration 
whatever  in  any  part  either  of  the  brain  or  of  the  spinal  cord.  In  other  cases  you 
may  discover  some  organic  disease  within  the  head  :  a  scrofulous  tubercle,  a  spicu- 
lum  of  bone  projecting  from  the  skull.  Have  you  then  detected  the  cause  of  the 
disease  I  All  that  can  be  said  is,  that  the  piece  of  bone  or  the  tubercle  was 
probably  a  predisposing  cause  of  that  derangement  of  the  nervous  substance  which 
determined  the  parox)^sms ;  the  derangement  itself,  if,  indeed,  it  was  of  such  a 
nature  as  to  be  cognizable  by  our  senses,  has  gone,  with  the  symptoms ;  the  tuber- 
cle or  bone  having  in  the  meantime  remained,  without  any  sign  which  could  betray 
its  presence. 

M.  Foville,  whose  testimony  in  this  matter  is  entitled  to  much  weight,  affirms 
that  ifi  persons  who  have  been  subject  to  epilepsy,  uncomplicated  as  yet  with  any 
permanent  disorder  of  the  intelleci,  or  of  the  faculty  of  voluntary  motion,  and  who 
have  died  in  the  Jit,  constant  alterations  are  observable  within  the  head;  viz.,  a 
strong  injection  of  the  vessels  of  the  encephalon.  The  membranes,  the  brain,  and 
the  cerebellum,  are  gorged,  he  asserts,  with  Hvid  blood.  But  he  goes  on  to  say  that 
thi  i  is  to  je  ascribed  to  the  mode  of  death :  that  we  see  the  same  appearances  in 
persons  who  have  died  by  hanging,  or  any  form  of  apnoea  ;  that  they  are  not  pecu- 
liar to  epileps}',  and  do  not  explain  the  attack,  but  only  point  out  the  way  in  which 
it  has  been  fatal. 

It  is,  I  fancy,  a  very  common  notion,  both  that  such  congestion  does  take  place, 
and  that  it  is  the  cause  of  the  paroxysm :  and  it  may  be  worth  while  shortly  to  state 
the  reasons  which  are  opposed  to  the  conclusion,  that  the  congestion  (granting  for 
the  moment  that  it  does  happen)  is  a  sufficient  explanation  of  the  attack. 

In  the  first  place  it  is  not  easy  to  conceive  that  the  congestion  could  so  suddenly 
arise  and  subside  again,  as  it  must  sometimes  do,  if  it  be  the  immediate  determining 
cause  of  the  fit :  within  the  space  of  a  single  minute,  for  example. 

And  in  the  second  place,  the  signs  of  external  congestion  and  plethora,  by  which 
signs  we  measure  the  amount  of  the  internal,  are  most  marked  just  when  the  symp- 
toms of  the  paroxysm  begin  to  subside  and  disappear.  So  that  we  cannot,  I  think, 
look  upon  the  congestion  as  the  cause  of  the  convulsive  symptoms. 

Ijet  us  go  a  step  further,  and  inquire  into  the  state  of  the  encephalon  in  those 


EPILEPSY.  •  387 

persons  who,  having  suffered  epilepsy,  had,  before  death  arrived,  been  affected 
with  some  permanent  impairment  of  the  mental  functions,  or  (what  often  goes 
along  with  such  impairment)  with  some  degree  or  other  of  muscular  paralysis  or 
debility. 

The  most  common  alterations  met  with  in  the  brain  in  such  cases  are  the 
following. 

Induration  of  the  white  matter  of  the  brain,  which  presents  a  dull  appearance  ; 
sometimes,  besides  the  hardening,  a  general  injection  of  the  white  matter ;  and  in 
the  majority  of  cases  a  marked  dilatation  of  the  blood-vessels.  In  some  instances  tbe 
consistence  of  the  white  matter  is  diminished ;  it  is  soft  and  flabby ;  but  there  is  the 
same  dilatation  of  the  blood-vessels.  These  changes  pervade  the  whole  of  the  white 
matter  in  every  part  of  the  brain.  At  the  same  time  the  gray  matter  is  found  irre- 
gular on  its  surface,  marbled  or  of  a  rosy  colour  in  its  substance,  and  sometimeo 
altered  in  consistence.  And  in  many  cases  the  membranes  are  found  to  be  adherent 
in  some  parts  to  the  convolutions  with  which  they  he  in  contact. 

Such  are  the  results  of  the  experience  of  careful  observers  in  respect  to  the 
morbid  anatomy  of  epilepsy;  of  Morgagni,  of  Foville,  and  of  MM.  Bouchet  and 
Casauvielh.  The  changes  last  described  are  such  as  are  produced  by  chronic  inflam- 
mation of  the  brain  and  its  membranes.  They  are  the  consequences  (I  imagine)  of 
repeated  paroxysms  of  epilepsy ;  they  are  the  very  same  as  are  frequently  met 
with  in  cases  of  insanity  complicated  with  paralysis,  and  they  elucidate,  therefore, 
the  connection  of  these  affections ;  but  they  certainly  teach  us  little  or  nothing  of 
that  actual  condition  of  the  nervous  mass  upon  which  the  epileptic  paroxysms  de- 
pend. And,  in  truth,  to  expect  to  find  in  the  brain  the  traces  of  convulsions  that 
have  passed  away,  would  be  as  unreasonable  as  to  expect  to  find  the  traces  of  former 
voluntary  movements. 

Of  those  organic  changes  which  may  be  regarded  as  strong  predisposing  causes 
of  the  paroxysms,  my  own  experience  accords  with  that  of  Dr.  Bright ;  who  states, 
that  they  are  more  frequently  such  as  affect  the  surface,  than  the  deeper-seated  parts 
of  the  brain :  tumours  external  to  the  cerebral  matter ;  alterations  in  the  bones  of 
the  skull ;  or  in  the  membranes  that  envelop  the  organ.  Various  altered  states  of 
the  spinal  marrow  have  also  been  recorded. 

But  besides  the  morbid  appearances  that  are  sometimes  only  visible  in  the  nervous 
centres  themselves,  there  are  others,  which  it  is  of  great  importance  to  attend  to,  situ- 
ated in  other  parts  of  the  body,  and  at  a  distance  from  those  centres :  diseased  states 
of  the  liver;  biliary  concretion;  granular  kidneys;  renal  calculi;  stones  in  the 
bladder ;  worms  in  the  alimentary  canal ;  diseases  of  the  uterus ;  and  of  various 
oiher  parts.  And  these  morbid  conditions  have  often,  no  doubt,  an  intimate  connec- 
tion with  the  epileptic  paroxysms.  Accordingly,  some  authors  make  almost  as  many 
varieties  of  epilepsy  as  there  are  organs  of  the  body ;  they  specify  the  cerebral,  the 
spinal,  the  cardiac,  hepatic,  gastric,  intestinal,  nephritic,  genital,  uterine,  and  so  on. 
It  will  be  sufficient,  however,  to  consider  two  species  only  ;  that,  namely,  in  which 
the  disease  originates  in  the  nervous  centres  themselves,  and  especially  in  the  brain; 
and  that  in  which  it  originates  in  some  other  part.  Most  persons  who  have  written 
on  epilepsy  make  this  distinction,  although  they  employ  different  terms  to  express  it. 
Cerebral  and  occasional ;  primary  and  secondary;  idiopathic  and  sympathetic  ;  cen- 
tric and  eccentric.  The  last  two  terms  are  the  best.  But  let  us  clearly  understand 
them.  The  disease  may,  in  one  sense,  be  considered  eccentric,  even  when  it  is  situ- 
ated in  the  brain ;  eccentric,  i.  e.,  in  respect  to  the  true  spinal  marrow.  But  I  ap[)ly 
the  epithet  centric  to  epilepsy  when  its  cause  lies  in  either  of  the  two  great  nervous 
centres;  the  brain,  or  the  cranio-spinal  axis.  The  distinction  itself  we  shall  find  to 
be  an  important  one,  both  as  regards  the  prognosis  and  the  treatment.  But  I  must 
first  say  a  few  words  respecting  the  causes  and  the  diagnosis  of  epilepsy. 

There  is  no  doubt  that  a  tendency  to  epileptic  disease  is  frequently  hereditary. 
It  may  be  derived  from  parent  to  child  ;  or  it  may  skip  over  a  generation  or  two,  and 
appear  in  the  grandchild  or  great-grandchild;  or  it  may  be  traceable  only  in  the  col 
lateral  branches  of  the  ancestors.     This  is  just  what  takes  place  in  other  hereditary 


388  EPILEPSY. 

maladies.    You  may  often  notice  also  that  other  forms  of  nervous  disorder  prevail  in 
the  same  families. 

MM.  Bouchet  and  Casauvielh  found  that  among  110  instances  of  epilepsy,  31 
were  hereditary.  Of  321  persons  afflicted  with  epileptic  insanity,  and  seen  by 
Esquirol,  105  were  descended  from  insane  or  epileptic  parent^. 

Again,  a  tendency  to  epilepsy  is  very  often  found  to  go  along  with  an  tinnatttra' 
form  of  the  head,  which  is  pinched  up  hke  a  sugar-loaf;  or  misshapen  and  unsym 
metrical,  one-half  being  unlike  the  other ;  or  oddly  configurated  in  some  way  ot 
other.     Epilepsy  is  no  uncommon  attendant  of  chronic  hydrocephalus. 

And  thirdly,  the  scrofulous  diathesis  is  a  strong  predisposing  cause  of  epilepsy 
Dr.  Cheyne  even  holds  that  epilepsy  is  as  certain  a  manifestation  of  the  strumou:; 
disposition,  as  tubercular  consumption,  or  psoas  abscess.  Now  of  the  two  predis- 
posing circumstances  last  mentioned,  it  may  be  observed,  that  they  commonly 
merge  in  that  which  preceded  them :  the  strumous  diathesis,  and  a  particular  con  • 
formation  of  the  he^d,  are  both  very  likely  to  descend  from  parents  to  their  progeny 

Whether  the  sex  has  any  influence  in  determining  a  predisposition  to  epilepsy,  it 
a  question  that  remains  to  be  settled.  Foville  thinks  it  is  most  common  in  females  . 
Dr.  EUiotson  in  males.  I  have  certainly  seen  more  epileptic  boys  and  men,  than 
girls  and  women.  But  the  casual  experience  of  a  single  observer  is  not  enough  tc 
determine  the  point.  We  want  numerical  statements  on  a  large  scale.  At  the  close 
of  the  year  IS  13  there  were  102  male  epileptics  in  the  Bicetre ;  289  female  cases  in 
the  Salpetriere      Jos.  Frank  observed  that  of  75  patients,  40  were  females. 


LECTURE  XXXVI. 

Epilepsy,  continued.  Recapitulation.  Exciting  causes.  Simidafed  epilepsy. 
Diagnosis.  Prognosis.  Treatment:  during  the  Jit ^  during  the  intervals  } 
during  the  warnings. 

At  our  last  meeting  I  began  to  speak  of  epilepsy.  Let  me  rapidly  retrace  the 
ground  we  then  passed  over. 

An  epileptic  seizure  may  be  very  severe  ;  or  very  slight.  The  very  severe  attack* 
are  characterized  by  a  sudden  cry,  immediate  loss  of  consciousness,  general  and  vio 
lent  convulsions,  and  subsequent  coma  or  heavy  sleep.  The  very  slight  attacks 
consist  in  a  momentary  abeyance  of  the  mental  faculties,  sometimes  with  and  some- 
times without  shght  and  partial  convulsion.  The  extreme  forms  of  epilepsy  we 
judge  to  differ  only  in  degree,  inasmuch  as  they  both  attack  the  same  persons  at 
difftirent  times  ;  or  the  one  form  conducts  to  the  other.  Betweep  these  the  gradations 
are  innumerable.  We  call  the  extremes  the  ejnhpticfit,  and  the  epileptic  vertigo  ; 
the  French  name  them  the  grand  mcd  and  the  petit  mul. 

These  fits  may  last  from  a  few  seconds  to  half  an  hour.  Paroxysms  apparently 
longer  than  this  commonly  consist  of  a  succession  of  fits.  The  average  duration  is 
from  five  to  ten  minutes. 

The  fits  recur  at  variable  intervals  ;  which  are  sometimes  periodic,  mostly  irregular. 
There  may  be  many  in  a  single  day :  there  may  be  only  one  for  many  years.  They 
are  commonly  more  severe  in  proportion  as  they  are  less  frequent. 

The  epileptic  seizures  sometimes  begin  in  early  infancy  :  another  period  at  which 
they  often  commence  is  about  the  age  of  seven  or  eight :  another  period  at  fourteen 
or  sixteen,  or  for  some  few  years  after  that  age.  They  more  frequently  begin  before 
puberty  than  after  it.  Sometimes  the  first  fit  takes  place  in  the  middle  period  of 
life :  sometimes  even  in  declining  age.  They  often  occur  in  the  night,  espe- 
cially in  the  outset  and  the  dechne  of  the  disease ;  usually  when  the  patient  if 
between  asleep  and  awake ;  i.  e.,  at  the  commencement  or  the  termination  of  his 
slumber. 

In  the  majority,  perhaps,  of  cases,  the  fit  is  unexpected,  and  preceded  by  no 


EPILEPSY.  389 

warning.  But  in  other  instances  there  is  some  alteration  perceptible  by  the  patient 
himself,  or  by  his  friends,  sjiving  notice  of  its  approach  ;  some  change  in  the  temper, 
feeHngs,  appearance  ;  some  disturbance  of  the  senses  ;  ocular  spectra ;  or  what  is 
called  the  epileptic  aura,  a  creeping  sensation  arising  in  some  part  of  the  surface, 
generally  of  the  extremities,  and  gliding  towards  the  head.  Some  of  these  warnings 
precede  the  paroxysm  by  a  day  or  two,  or  by  a  few  hours ;  some  by  two  or  three 
seconds  only.  Sometimes  the  blow  is  threatened  by  their  appearance,  but  it  does 
not  fall. 

The  fit  is  almost  always,  in  its  severer  forms,  attended  and  followed  by  coma ; 
sometimes,  after  the  coma,  by  temporary  confusion  of  mind  ;  deafness ;  slight  para- 
jysis  ;  delirium  ;  inarticulate  speech.  There  is  seldom  any  appreciable  permanent 
'damage  effected  by  a  single  fit. 

A  repetition  of  the  fits  leads,  in  a  large  majority  of  instances,  first,  to  a  defect  of 
the  memory,  and  of  the  general  intelligence  ;  and  at  length  to  a  peculiar  expression 
of  countenance,  to  decided  imbecihty  of  mind,  to  complete  fatuity ;  and  with  this 
there  is  often  associated  some  paralysis  or  muscular  debihty. 

The  convulsions  take  place,  necessarily,  through  the  medium  of  the  spinal  cord 
and  nerves  —  just  as  voluntary  movements  do;  but  the  suspension  of  sensation, 
thought,  and  volition  (which  suspension  is  seldom  absent,  while  the  irregular  mus- 
cular action  often  is  wanting)  shows  that  the  brain  is  essentially  involved  in  the 
disease. 

Accidental  organic  lesions  are  sometimes  (and  sometimes  only)  found  in  the  ence- 
phalon,  or  in  the  spinal  cord,  of  persons  who  have  suffered  epilepsy  uncomplicated 
with  any  permanent  mental  or  paralytic  affection ;  tubercles,  for  example,  or  bony 
groyvths  from  the  interior  of  the  skull :  but  as  these  are  constant,  while  the  paroxysms 
are  occasional,  and  as  in  the  intervals  they  give  no  signal  of  their  presence,  we  can 
only  regard  them  as  being  probably  predisposing  causes  of  the  seizures. 

When  the  epilepsy  has  been  complicated  with  permanent  alienation  of  mind,  or 
with  some  degree  of  paralysis,  evidence  of  chronic  inflammation  of  the  brain  and 
its  membranes  is  generally  discovered.  This  has  been  the  consequence  of  the 
repetition  of  the  paroxysms.  This  explains  the  frequent  connection  of  fatuity  and 
palsy  with  epilepsy  of  long  standing. 

The  diseased  condition  which  excites  the  paroxysms  may  be  situated  in  the  nervous 
centres  themselves,  or  in  some  other  part  of  the  body.  In  the  one  case  we  call  the 
disorder  centric,  or  idiopathic  ;  in  the  other,  eccentric,  or  sympathetic.  We  cannot 
always  be  sure  with  which  species  of  the  disease,  the  centric,  or  the  eccentric,  we 
have  to  deal :  but  the  distinction,  when  it  can  be  made,  is  of  considerable  importance, 
in  respect  to  the  prognosis,  and  in  respect  to  the  management  of  the  case. 

The  predisposition  to  this  fearful  complaint  is  often  hereditary.  Malformation,  or 
defect  of  symmetry  in  the  two  sides  of  the  head,  is  a  frequent  predisposing  cause. 
So,  pre-eminently,  is  the  scrofulous  diathesis.  And  these  two,  viz.,  the  scrofulous 
diathesis,  and  a  peculiar  conformation  of  the  head,  are  both  liable  and  hkely  to  be 
propagated  from  parents  to  children.  But  the  predisposition  is  found  to  be  here 
ditary,  even  when  the  shape  and  structure  of  the  body  is,  to  all  appearance,  quite 
perfect  and  natural ;  and  when  no  outward  indication  of  the  strumous  diathesis  if 
perceptible. 

[The  following  statistics  are  presented  by  M.  Leiiret,  in  an  interesting  paper  on  Epilepsy 
in  the  Archives  Ge.ntrales  for  May,  1843.  Among  106  epileptics,  in  24,  or  nearly  one-fourth, 
the  disease  commenced  between  the  tenth  and  fourteenth  years  of  their  age  ;  in  18,  or  nearly 
one-sixth,  between  the  fifteenth  and  nineteenth  years,  and  in  16,  between  the  fourteenth  and 
twcnty-fonrth  years.  Thus  58  patients,  or  more  than  one-half,  were  first  attacked  between 
their  fourteenth  and  twenty-fourth  years,  Of  the  whole  number  of  cases,  in  six  only  vvas  it 
ascertained  that  the  disease  existed  in  one  or  other  parent,  and  in  but  eight  was  it  found  that 
one  of  the  parents  had  died  of  any  disease  of  the  brain,  namely,  tliree  of  insanity,  two  of 
apoplexy,  one  of  paralysis,  one  of  siucide,  and  one  of  meningo-cephalitis.  Of  the  106  patients, 
thirty  had  been  drunkards,  twenty-four  masturbaters,  and  fifteen  addicted  to  women.  In 
fifteen  cases,  the  actual  or  presumed  cause  of  the  first  attack  of  epilepsy  was  ascribed  ti 
terror;  in  twelve  to  onanism  ;  in  six  to  drunkenness  ;  in  two  to  anger;  in  two  to  distress  ;  ib 
two  to  fa'ls  :  in  one  to  libertinage,  S(c.     Thirty  cf  the  patients  hal  an  attack  \fry  r-guiai'v 

2h3 


390  EPILEPSY. 

once  a  fortnigh; ;  17  suffered  attacks  once  a  month;  13  once  a  week;  9  every  three  or  foui 
daj's ;  4  almos-;  every  day;  2  every  day;  1  every  two  months;  3  every  three  months;  and 
24  at  very  irre^lar  intervals.  In  35,  the  attacks  took  place  in  the  night  especially ;  in  29, 
they  were  as  frequent  in  the  day  as  in  the  night;  in  12,  they  frequently  opcurred  in  th*e  day  ; 
in  8,  they  occurred  during  the  day  only;  in  S,  during  the  night  only;  in  3,  in  the  morning 
only;  in  3  others  generally  in  the  morning;  and  in  4,  in  the  evening  only. — C] 

At  the  very  close  of  the  lecture  I  informed  you  that  it  is  an  unsettled  question 
—  and  it  is  not  a  question  of  very  great  importance  —  whether  the  disease  is  more 
common  in  females  or  males :  whether  the  sex  has  any  thing  to  do  with  the  pre- 
disposition. 

There  are  certain  vices  which  are  justly  considered  as  influential  in  aggravating 
and  even  in  creating  a  disposition  to  epilepsy;  debauchery  of  all  kinds;  the  ha- 
bitual indulgence  in  intoxicating  liquors ;  and,  above  all,  the  most  powerful  predis- 
posing cause  of  any,  not  congenital,  is  masturbation — a  vice  which  it  is  painful  and 
difficult  even  to  allude  to  in  this  manner,  and  still  more  difficult  to  make  the  subject 
of  inquiry  with  a  patient.  But  there  is  too  much  reason  to  be  certain  that  many 
cases  of  epilepsy  owe  their  origin  to  this  wretched  and  degrading  habit :  and  more 
than  one  or  two  patients  have  voluntarily  confessed  to  me  their  conviction  that  they 
had  thus  brought  upon  themselves  epileptic  paroxj^sms  for  which  they  sought  my 
advice. 

Among  the  exciting  causes  of  epilepsy,  fright  is  conspicuous.  And  any  strong 
mental  emotion  is  apt  to  produce  the  fit  in  a  person  who  is  already  subject  to  the 
disease.  This  fac*  alone  would  be  enough,  I  conceive,  to  forbid  our  ascribing  the 
paroxysms  exclusi\ely  to  an  affection  of  the  spinal  cord.  Bodily  pain  ;  manifest  and 
{Treat  disturbance  of  almost  any  of  the  principal  functions  of  the  body,  may  act  also 
as  exciting  causes.  Sometimes  the  cause  is  obvious  ;  sometimes  it  is  quite  inscru- 
table. If  the  attack  occurs  every  night.  Dr.  Bright  thinks  it  may  be  attributed  to 
the  "congestion"  of  sleep  :  if  it  takes  place  at  monthly  intervals  in  women,  we  may 
"  often  trace  it  to  nervous  irritation  in  sympathy  with  the  uterus  :  and  when  long 
periods  h^ve  intervened  we  may  usually  trace  each  distant  paroxysm  to  the  repe- 
tition of  some  excess,  or  to  a  neglected  state  of  the  bowels."  In  these  latter  cases 
the  epilepsy  is  of  the  sympathetic  or  eccentric  kind  ;  the  irritation  being  seated  in 
some  part  at  a  distance  from  the  nervous  masses  in  the  stomach,  or  intestines,  oi 
uterus.  Now  I  would  suggest  the  expediency  of  observing  what  muscles  or  sets 
of  muscles  are  Jirst  affected  by  the  spasm  in  such  cases,  and  in  what  part  the 
warning  aura  (if  there  be  any)  arises :  because  by  accurately  noting  these  parti- 
culars, we  may,  perhaps,  be  led  to  a  knowledge  of  the  part  or  organ  in  which  the 
irritation  operates  ;  and  if  we  know  the  seat  of  the  irritation,  we  shall  be  more  likely 
to  know  its  nature  and  its  cure. 

[M.  Lamonthe  relates,  in  the  Journ.  de  Med.  de  JBourdeattx,  a  case  in  which  the  ejjilepsy 
was  caused  by  a  foreign  body  in  the  ear,  and  ceased  upon  its  removal.  The  patient  was  a 
man  thirty  years  of  age,  in  whose  external  meatus  a  pebble  had  been  accidentally  introduced. 
He  at  first  experienced  only  a  slight  diminution  of  hearing ;  afterwards  suppuration 
occurred,  and  finally  epileptic  attacks  supervened  ;  from  which  he  had  suffered  for  two  years 
before  he  consulted  M.  Lamothe.  This  gentleman,  being  informed  of  the  probable  existence 
of  a  foreign  body  in  the  ear,  made  an  examination,  and  detecting  it,  by  proper  means,  sue 
ceeded  in  removing  from  the  meatus  a  rough  pebble  of  nearly  a  triangular  shape,  and  from 
that  period  the  patient  had  no  more  attacks  of  epilepsy.  In  the  same  Journal,  another  case 
of  the  same  kind  is  related  by  M.  Roussilhe. — C] 

Among  the  exciting  causes  of  epileptic  fits  are  also  enumerated — and  I  beheve, 
from  what  I  have  myself  noticed,  with  great  justice — the  repulsion  of  eruptions,  and 
especially  of  eruptions  about  the  head,  when  proper  artificial  evacuations  are  not 
obtained  at  the  same  time ;  the  cessation  of  habitual  discharges ;  and,  on  the  other 
hand,  profuse  and  unusual  discharges.  Hemorrhage  certainly  will  often  bring  oa 
convulsions  and  a  state  of  insensibility  exactly  like  certain  forms  of  epilepsy.  Per- 
sons who  are  bled  till  they  actually  faint,  are  often  at  the  same  time  convulsed. 
And  animals  that  are  killed  by  loss  of  blood  are  always  afTected,  with  convulsions 
before  they  expire. 

There  is  yet  another  very  singular  occasional  cause  of  epilepsy  that  deserves  to 


EPILEPSY.  '  391 

be  mentioned,  viz.,  the  sight  of  a  person  in  a  fit  of  that  disease.  This  has  been 
noticed  over  and  over  again.  Not  only  will  a  patient  who  has  already  suffered  such 
attacks,  often  fall  into  one  upon  seeing  another  so  afTecled ;  but  people  will  even 
sometimes  do  so  who  have  never  before  shown  any  symptom  of  epilepsy.  In  this 
way  the  disease  will  now  and  then  run  through  a  boarding-school:  or  through  a 
ward  in  an  hospital.  There  is  a  very  good  example  of  this  recorded  in  the  11th 
volume  of  the  Medical  Gazette,  by  Dr.  Hardy,  of  Bath.  A  strong,  healthy  young 
man  was  hired  to  take  care  of  an  older  patient,  who  sufTered  frequent  and  exceed- 
ingly violent  paroxysms  of  epilepsy.  He  remained  with  the  patient  night  and  day  ; 
and  at  the  end  of  seven  weeks  became  himself  epileptic  in  a  very  high  degree.  An 
acquaintance  of  his,  of  equally  robust  make,  but  some  years  older,  occasionally 
visited  the  parties.  In  a  fortnight  from  his  first  visit  he  also  was  seized  with  simi- 
larly violent  attacks.  Dr.  Hardy  quotes  the  following  short  case,  also,  from  Baglivi : 
— "  Vidimus,  anno  IGOO,  in  Dalmatia  juvenum  gravissimis  correptum  convulsionibus, 
propterea  quod  inspexerat  solummodo  ahum  juvenem  dum  epilepsia  humi  contor- 
quebatur." 

[M.  iNIeyer  has  recently  given  an  account  of  a  mimber  of  the  pupils  in  a  female  school  that 
were  attacked  with  epilepsy,  in  consequence  of  seeing  one  of  their  number  under  the  influ- 
ence of  the  disease.  Most  of  the  subjects  were  approaching  the  period  of  puberty ;  whilst 
they  were  all  of  a  highly  excitable  temperament. — C] 

Dr.  Cullen,  w'ho,  as  well  as  many  others,  had  noticed  the  same  things,  starts  the 
question  whether  this  mode  of  propagation  of  the  disease  be  imputable  to  dread  and 
horror;  or  the  mere  force  of  imitation,  which  is  often  so  strong,  in  health  as  well  as 
in  disease :  and  he  decide*  in  favour  of  the  force  af  imitation.  In  fact  there  are 
many  other  signs  equally  horrifying  with  that  of  a  person  in  convulsions ;  yet  there 
is  no  spectacle  of  horror  so  efficacious  in  producing  a  fit  of  epilepsy  in  others,  as  that 
of  a  person  suffering  under  epilepsy. 

This  principle  of  imitation  holds  good  in  many  of  the  spasmodic  diseases:  and 
in  sume  of  them,  especially  in  hysteria,  its  influence  is  more  remarkably  seen  than 
in  epilepsy  :  I  shall  therefore  have  to  recur  to  it  again.  There  is  one  very  curious 
fact,  however,  which  relates  to  epilepsy  in  particular.  You  are  aware  that  this 
disease  is  often  feigned,  by  impostors.  Now  I  believe  it  is  ascertained,  beyond  the 
possibility  of  doubt,  that  fits  and  actions  which  were  at  first,  in  these  pretenders, 
strictly  voluntary,  have  at  length  become  involuntary  and  uncontrollable,  and  have 
passed  into  paroxysms  of  real  epilepsy.     The  rogue  is  caught  in  his  own  trap. 

And  the  mention  of  these  impostors  leads  me  to  consider  the  diagnosis  of  epilepsy. 
First,  how  are  we  to  distinguish  the  feigned  disease  from  the  true  ?  Secondly,  are 
there  any  other  real  diseases  which  may  be  mistaken  for  epilepsy,  or  for  which 
epilepsy  may  be  mistaken? 

In  the  number  o{  feigned  diseases  epilepsy  is  one  of  the  most  common.  Soldiers 
and  sailors  pretend  to  have  epileptic  fits,  in  the  hope  of  obtaining  their  discharge 
from  the  service.  Cases  of  simulated  epilepsy  occur  also  continually  in  our  streets 
among  mendicants  and  impostors,  who  think  to  excite  the  compassion  and  pecuniary 
charity  of  the  credulous ;  and  are  even  sometimes  actuated  I  believe  by  a  desire  to 
obtain  admission  into  hospitals,  where  they  five  tolerably  well,  and  quite  idly.  It  is 
easy  enough,  they  think,  to  throw  their  legs  and  arms  about,  and  to  grin ;  and  many 
of  them  get  up  a  capital  show  of  foaming  at  the  mouth,  by  placing  a  bit  of  soap 
between  the  gums  and  cheek.  The  means  of  detecting  these  vagabonds  are  of 
some  importance  to  us  all ;  and  it  is  more  particularly  necessary  that  they  shoul(# 
be  well  known  to  those  who  are  likely  to  join  the  medical  department  of  our  fleets 
or  armies. 

It  is  of  course  desirable,  in  questionable  cases,  to  witness  a  fit.  But  pretenderf 
are  not  very  willing  to  perform  when  they  know  that  a  medical  man  is  looking  on 
You  may  sometimes  convict  them,  in  the  absence  of  the  fits;  as  cross-examination, 
A  cheat  will  seldom  be  consistent  in  the  account  which  he  gives  of  his  fits ;  as  lo 
whether  they  are  regular  or  irregular ;  and  as  to  the  times  and  places  in  which  he 
has  sufllered  them.  An  impostor  chooses  such  situations  for  his  exhibition  as  are 
most  suitable  to  his  own  purposes ;  a  crowded  street,  or  a  well-frequented  public 


392  EPILEPSY. 

walk.  True  epileptics  almost  always  select  retired  places  to  take  exercise  in  ;  espe- 
cially if  they  have  any  warning  or  expectation  of  the  approach  of  a  paroxysm.  You 
will  find  also  that  the  impostor  is  not  attacked  at  his  own  home ;  but  always  fixes 
upon  some  spot  in  which  he  is  not  only  sure  to  be  seen  by  others,  but  in  which  he 
is  not  likely  to  sustain  any  injury  by  tumbhng  down.  True  epileptics  are  often 
seriously  hurt  by  their  falls ;  feigned  ones  generally  come  ofT  without  much  bodily 
damage.  However,  if  the  fits  are  alleged  to  be  frequent,  and  if  also  they  are  reorular, 
you  may  soon  expect  one,  and  must  make  a  point  of  being  present :  and  then  you 
will  seldom  fail  to  remove  or  to  verify  your  suspicions.  In  the  first  place  the  mus- 
cular power  of  epileptics  is  far  beyond  what  is  natural.  It  will  sometimes  take  four 
or  five  stout  men  to  hold  a  weak  emaciated  lad,  in  a  fit  of  epilepsy.  Of  course  no 
impostor  can  command  more  than  his  natural  strength.  In  the  second  place  a  real 
epileptic  fit,  if  it  lasts  long,  is  seldom  violent ;  whereas  impostors,  for  obvious  reasons, 
make  their  fits  both  long  and  violent.  You  may  often  get  much  information  from 
the  state  of  the  eyes,  which  usually  in  true  epilepsy  are  partly  open,  with  the  eye- 
ball visibly  rolling  and  distorted.  In  feigned  epilepsy  the  actor  almost  always  prefers 
to  shut  his  eyes  completely.  Sometimes,  if  he  be  closely  w^atched,  and  no  suspicion 
is  expressed,  he  will  be  seen  to  open  his  eyes  occasionally,  to  ascertain  the  effect  of 
his  exhibition  upon  the  bj^standers.  In  real  epilepsy,  too,  the  pupils  are  often  con 
siderably  dilated,  and  do  not  contract  when  stimulated  by  light.  This  is  a  very  sure 
criterion  ;  for  no  impostor  can  prevent  his  iris  from  acting  on  exposure  to  vivid  fight. 
The  pulse,  in  true  epilepsy,  is  not  only  frequent  but  often  irregular  also ;  a  circum- 
stance which  can  never  be  imitated.  The  skin  of  an  epileptic,  during  the  fit,  is 
commonly  cold  ;  but  that  of  an  exhibitor  is  hot,  and  covered  with  sweat,  obviously 
the  consequence  of  his  violent  and  voluntary  exertions.  In  this  respect,  also,  it  ia 
scarcel}'  possible  for  him  to  deceive  us.  Again,  an  impostor  will  not  bite  his  tongue, 
as  epileptics  often  do  ;  nor  very  willingly  void  (Hke  them)  his  excrements  and  urine 
during  the  fit;  indeed,  it  would  not  be  very  easy  for  him  to  do  so,  and  at  the  same 
time  to  carry  on  the  necessary  pretence  of  convulsions.  Besides,  epileptics,  during 
a  fit,  are  quite  insensible  to  external  impressions ;  and  hence  the  vulgar  modes  of 
detection,  though  harsh  and  not  to  be  recommended,  are  often  effectual  ones  ;  such 
as  dropping  melted  sealing-wax  upon  the  patient;  putting  some  gin  into  his  eyes; 
burning  him  with  a  hot  poker ;  or  (what  I  beheve  is  more  fashionable  among  beadles 
and  pohce  constables,  when  they  have  to  administer  to  such  patients),  the  pressing 
your  thumb  nail  violently  under  that  of  the  supposed  impostor.  This  causes  exqui- 
site pain,  yet  inflicts  no  lasting  or  serious  injury  ;  and  I  believe  that  few  pretenders 
stand  out  against  this  expedient.  It  is  astonishing,  however,  how  much  torture  some 
of  them  will  bear  before  they  can  be  brought  to  confess  their  imposition.  If  we 
speak  of  having  recourse  to  some  of  these  painful  tests  in  the  hearing  of  the  pre- 
tender, we  shall  find  that  the  fit  will  soon  come  to  an  end.  Dr.  Cheyne  mentions  an 
instance  in  which  one  table  was  placed  upon  another,  and  a  soldier,  who  was  sup- 
posed to  be  shamming,  was  laid  upon  the  upper  one,  while  his  paroxysm  was  on 
him  ;  and  the  fear  of  faUing  from  such  a  height  soon  stopped  the  convulsions.  Mr. 
Hutchinson  relates  the  case  of  a  sailor  who  was  suspected  to  be  a  cheat,  in  whom 
the  convulsions  were  instantly  removed  by  blowing  some  fine  Scotch  snuff'  up  his 
nostrils  through  a  quill.  This  brought  on  another  kind  of  fit,  viz.,  a  fit  of  sneezing, 
which  lasted  nearly  half  an  hour ;  and  there  was  no  return  of  the  epilepsy  so  long 
as  Mr.  Hutchinson  remained  in  that  ship.  He  tried  the  same  expedient  in  cases  of 
real  epilepsy,  but  never  could  produce  any  similar  efTects,  although  the  patients  were 
not  snuff'-takers.  There  was  a  beggar  in  Paris,  who  often  fell  into  epileptic  fits  in 
the  streets ;  one  day  some  compassionate  spectators,  fearing  that  he  might  injure 
himself  in  his  struggles,  got  a  truss  of  straw  and  placed  him  upon  it :  but  when  he 
was  in  the  height  of  his  paroxysm,  and  performing  remarkably  well,  they  sat  fire  to 
the  straw ;  and  he  presently  took  to  his  heels. 

There  is  another  ingenious  plan,  very  likely,  I  should  think,  to  detect  an  impostor, 
and  yet  not  calculated,  like  the  one  last  mentioned,  to  injure  a  real  sufferer:  which 
s  to  propose  gravely,  in  his  hearing,  to  pour  boiling  water  upon  his  legs,  and  then 
to  proceed  actually  to  pour  cold  watgr  upon  them. 


EPILEPSY.  393 

« 

Of  the  real  diseases  which  are  apt  to  be  confounded  wiih  epilepsy,  hysteria  is  the 
chief.  The  question  whether  a  given  case  be  one  of  epilepsy  or  of  hysteria,  very 
often  arises.  By  a  careful  attention  to  several  circumstances,  the  discrimination  is 
generally  to  be  made.  In  the  first  place  the  total  suspension  of  consciousness,  which 
is  so  constant  an  accompaniment  of  the  epileptic  paroxysm,  does  not  take  place  in 
the  hysterical :  in  epilepsy  there  is  no  globus  hystericus,  no  alternations  of  laughter 
and  tears ;  the  solitary  cry  which  ushers  in  the  epileptic  attack  so  frequently,  and 
which  is  so  characteristic,  is  not  heard  in  hysteria ;  not  that  hysterical  girls  do  not 
scream,  for  they  often  do;  but  then  it  is  repeatedly  and  continuously.  The  heavy 
comatose  sleep  that  succeeds  epilepsy  is  not  common  in  hysteria.  Hysterical  patients 
contrive  also  to  avoid  hurting  themselves  by  their  contortions :  they  do  not  bite 
their  tongues,  nor  foam  at  the  mouth.  Dr.  M.  Hall  tells  us  that,  in  epilepsy,  there 
is  a  forcible  closure  of  the  larynx,  and  expiratory  efforts  which  suffuse  the  counte- 
nance, and  probably  congest  the  brain  with  venous  blood.  In  hysteria  the  respira- 
tion, on  the  contrary,  is  rapid  and  sobbing. 

Observe  that  I  have  been  speaking,  all  along,  of  what  has  been  sometimes  called 
habitual  epilepsy.  It  is  not  every  attack  of  convulsions  with  insensibility  which 
ought  to  be  so  named.  Such  attacks  are  apt  to  follow  sudden  injuries  done  to  the 
brain ;  stunning  blows  on  the  head,  fractures  of  the  skull,  the  eruption  of  blood  in 
anguineous  apoplexy,  and  even  overwhelming  emotions  of  the  mind.  The  reten- 
tion of  urea  in  the  unpurified  blood,  occurring  in  connection  with  a  peculiar  renal 
disease  to  be  hereafter  described,  appears  to  be  a  frequent  cause  of  similar  seizures. 
With  these  casual  occurrences  of  epileptiform  convulsion  I  do  not  here  meddle. 

Epilepsy  is  one  of  those  complaints  concerning  the  probable  issue  of  which  the 
patient,  and  still  more  the  patient's  friends,  are  sure  to  make  repeated  and  anxious 
inquiries.  It  is  seldom  that  we  can  pronounce  with  any  confidence  a  favourable 
prognosis ;  but  there  are  some  cases  in  which  the  prospect  is  much  worse  than  in 
others. 

If  we  have  reason  to  believe  that  the  disease  is  centric,  and  connected  with  any 
organic  derangement  of  the  nervous  centres  themselves,  the  prognosis  must  be  bad. 
Cseieris  paribus  it  is  rendered  worse  by  the  coexistence  of  any  sign  of  scrofulous 
disease,  or  of  the  well-known  bodily  characteristics  of  the  scrofulous  diathesis :  it  is 
rendered  worse,  also,  when  the  disease  has  happened  in  the  parents  or  among  the 
more  immediate  ancestors  of  the  patient ;  whenever,  in  short,  there  is  reason  to  think 
the  disposition  to  it  is  inherited.  The  prognosis  is  bad  when  the  complaint  occurs 
in  persons  who  have  slanting  foreheads  and  misshapen  skulls :  and  when  the  epi- 
leptic physiognomy  has  become  established.  The  prognosis  is  always  the  more 
unfavourable  the  longer. the  disorder  has  lasted;  the  oftener  the  fits  have  been 
repeated ;  and  the  more  habitual  they  have  become.  And  when  the  memory  is 
permanently  enfeebled,  or  fatuity  has  come  on,  or  the  disease  is  complicated  with 
any  form  or  degree  of  paralysis,  the  case  is  hopeless ;  so  far,  at  least,  as  a  perfect 
cure  is  concerned. 

On  the  other  hand,  the  prognosis  is  better  when  the  disease  is  eccentric:  i.  c, 
when  there  is  any  obvious  exciting  cause  of  the  paroxysms,  manifest  in  structural 
or  functional  disorder  of  some  part  of  the  body  other  than  the  nervous  matter.  And 
when  this  eccentric  cause  is  removable — a  stone  in  the  bladder,  for  instance,  worms 
in  the  intestines  —  then  the  prognosis  still  further  improves.  On  this  account  the 
prognosis  is  better  in  children  than  in  older  persons,  for  the  exciting  cause  is  often 
clearly  eccentric,  and  likely  to  be  transitory  ;  the  irritation  of  teething,  for  example  : 
and  besides  this,  it  is  staled  by  many  practical  writers  that  even  repeated  and  habitual 
attacks  of  epilepsy  in  children  often  go  off" as  the  patients  grow  older  ;  and  especially 
at  the  age  of  puberty.  The  experience  of  Heberden,  however,  was  against  this. 
He  says  that  he  had  known  several  persons  become  epileptic  at  that  time ;  but  that 
he  had  never  met  with  one  who  had  then  got  rid  of  the  disease.  He  had  seen  a 
few  who  had  recovered  before,  and  some  after,  the  age  of  puberty.  Dr.  EUiotson 
mentions  a  case  in  which  a  girl  had  epilepsy  prior  to  the  first  period  of  menstrua- 
tion :  then  the  fits  stopped  ;  and  she  remained  free  from  them  until  in  advanced  life 
the  catamenia  ceased  to  recur ;  and  then  the  epilepsy  returned.     In  all  those  cases 


394  EPILEPSY. 

in  which  we  can  assign  some  evident  cause  for  the  fit — such  as  the  use  of  improper 
food,  uterine  irritation,  mental  emotion,  and  so  on— the  prognosis  is  somewhat  better 
than  usual. 

[In  the  predisposed,  one  of  the  most  frequent  causes  by  which  the  paroxysm  is  brought 
on,  is  errors  in  diet,  either  in  regard  to  the  quality  or  quantity  of  the  food  taken.  We  have 
known  cases  in  which  the  patients  remained  free  from  an  attack  so  long  as  they  abstained 
from  a  particular  article  of  food,  but  invariably  experienced  one  on  partaking  of  it. — C] 

"  The  eccentric  epilepsy  (says  Dr.  Hall)  is  to  be  viewed  as  curable,  however 
difficult  of  cure."  And  however  unfavourable  the  prognosis  may  be,  there  is  nothing 
that  can  excuse  any  apathy  or  neglect  on  the  part  of  the  practitioner.  Though  few 
cases  of  habitual  epilepsy  admit  of  a  cifre  under  any  treatment,  yet  there  are  few 
which  may  not  be  relieved  by  treatment,  so  far  as  regards  the  frequency  or  the  vio- 
lence of  the  fits,  or  both. 

The  treatment  of  epileps}^  resolves  itself  into  the  measures  to  be  adopted  during 
the  fit ;  and  the  measures  to  be  adopted  during  the  intervals  between  the  fits. 

In  the  paroxysm  itself  we  have  to  provide  against  the  risk  of  injury  from  the 
struggles  and  contortions  of  the  patient ;  and  if  possible,  to  mitigate  the  violence,  and 
to  shorten  the  duration  of  the  fit.  The  patient  should  be  placed  in  the  centre  of  a 
large  bed  ;  his  neckcloth,  and  any  ligatures  about  his  person,  should  be  loosened ; 
his  head  should  be  somewhat  elevated.  When  the  risk  of  his  hurting  himself  can- 
not be  avoided  in  any  other  way,  his  limbs  should  be  restrained  by  the  bystanders, 
or  secured  in  a  waistcoat.  Some  persons  have  advised  that  a  piece  of  cork  or  soft 
wood  should  be  placed  between  his  teeth,  to  prevent  him  from  biting  his  tongue,  or 
breaking  his  teeth.  But  it  is  not  easy  to  manage  this  expedient  cleverly.  If  the 
head  be  visibly  congested,  and  hot,  cold  wet  cloths  may  be  applied  to  it  with  pro- 
priety ;  and  if,  at  the  same  time,  the  extremities  be  cold,  means  of  restoring  warmth 
to  them  should  be  adopted. 

I  do  not  know  whether  art  can  abbreviate  the  paroxysm.  Some  years  ago  the 
late  Barry  O'Meara  sent  a  letter  to  one  of  the  newspapers,  saying  that  he  fancied  he 
had  seen  a  popular  remedy  useful  in  such  cases;  that,  namely,  of  cramming  salt 
into  the  patient's  mouth  :  he  thought  he  had  succeeded  in  bringing  the  patient  about 
by  that  expedient.  In  the  epileptic  patients  that  come  into  hospitals,  the  physician, 
not  being  always  on  the  spot,  does  not  see  all,  nor  even  many  of  the  paroxysnis  ;  but 
after  reading  that  letter,  I  desired  the  nurses  to  treat  all  my  patients  who  might  ba 
seized  with  epilepsy  in  the  wards  upon  that  plan  :  and  on  comparing  the  length  of 
the  paroxysms  when  the  salt  was  used,  with  their  ordinary  duration  as  reported  by 
the  friends  of  the  patient,  or  as  previously  observed  in  the  hospital  during  some  of 
the  earlier  fits,  it  certainly  did  seem  to  curtail  the  convulsions.  Probably  it  is  more 
calculated  to  relieve  an  hysterical  than  an  epileptic  fit.  In  the  epileptic  fits  of  chil- 
dren much  benefit  often  results  from  immersing  them  in  warm  water:  particularly 
if  there  be  any  coldness  of  the  extremities. 

It  is  very  much  the  fashion  to  bleed  persons  who  are  seen  in  a  fit,  of  whatever 
kind  ;  and  to  bleed  them  largely.  I  have  already  given  you  my  opinion  respecting 
the  indiscriminate  use  of  this  decided  measure  in  apoplectic  attacks.  If  it  be  clear, 
from  the  phenomena,  or  from  the  known  history  of  the  patient,  that  the  case  is  one 
of  epilepsy,  bleeding,  during  the  Jit,  will  seldom  be  necessary  or  proper;  unless, 
indeed,  the  evidence  of  cerebral  plethora  is  very  strongly  marked  :  and  even  then  I 
would  advise  you  not  to  do  more  than  take  a  moderate  quantity  of  blood,  by  cup- 
ping, from  the  neck  or  temples.  The  convulsions  and  the  sopor  may  be  expected 
soon  to  pass  off;  as  soon,  probably,  and  as  completely  without,  as  with,  any  abstrac- 
tion of  blood.  Whereas  the  difference  of  the  alternative  is  not  trifling,  in  respect  to 
the  condition  in  which  the  patient  will  be  left  when  the  fit  is  over.  The  injurious 
efltct  of  excessive  blood-letting  upon  the  system  at  large,  is  manifest,  sometimes,  foi 
months  afterwards. 

During  the  intervals  between  the  attacks  we  seek  to  prevent  their  recurrence ; 
and  this  end  is  to  be  attained,  when  it  is  attainable  at  all,  by  getting  rid  of  the  pre- 
disposition to  the  disease  on  the  one  hand,  and  by  protecting  the  patient  against  its 
exciting  causes  on  the  other.     Now  there  are  certain  kinds  and  causes  of  predispo- 


EPILEPSY.  395 

silion  which  we  cannot  get  riJ  of;  such  are  the  tendency  that  is  inherited;  the 
strumous  diathesis;  malformation  of  the  head;  the  presence  of  some  organic  lesion 
in  the  brain  or  spinal  cord.  Vicious  and  dissolute  habits  are  also  di.licult,  but  not 
impossible  to  eradicate.  It  will  be  our  duty,  when  such  are  discovered,  to  set  strongly 
before  the  unhappy  patient  the  dreadful  end  towards  which  he  is  hastening ;  the 
certain  loss  of  reason  to  which,  when  once  the  disease  has  shown  itself,  the  continu- 
ance of  his  baneful  indulgences  will  drive  him  ;  and  to  urge  upon  him  the  necessity 
for  a  short  and  sudden  turn  on  his  part,  if  he  would  expect  any  aid  from  medicine. 
Where  no  physical  cause  of  the  proclivity  exists,  or  can  be  detected,  it  is  of  much 
importance  to  ascertain  whether  there  be  any  deviation  from  the  standard  condition 
of  health ;  towards  general  plethora  in  the  one  direction,  or  towards  emptiness  and 
asthenia  in  the  other.  The  first  of  these  unnatural  states  may  be  redressed  by  regi- 
men and  exercise,  by  abstinence  from  stimulating  food  and  drink ;  by  a  slender  diet 
also ;  and,  if  need  be,  by  direct  depletion.  The  second,  which,  perhaps,  is  the  most 
common  of  the  two,  and  which  often  leads  (as  I  have  explained  before)  to  local  ple- 
thora, may  be  removed  or  lessened  by  a  tonic  treatment.  The  object  in  both  cases 
is  to  give  stability  and  firmness  to  the  nervous  system ;  to  diminish  that  mobility,  or 
readiness  to  be  impressed,  which  is  so  strong  a  characteristic  of  the  class  of  patients 
affected  with  epilepsy,  although  it  may  not  be  very  apparent  in  some  "ew  individuals 
among  them.  It  is  upon  this  principle  that  mineral  tonics  sometimes  do  good  in 
epilepsy,  and  not  by  any  specific  virtue  which  they  possess  in  restraining  the  fiti. 

It  is  owing,  perhaps,  to  a  neglect  of  these  two  somewhat  opposite  conditions  of 
general  plethora  and  general  debility,  or  to  the  difficulty  which  sometimes  is  met 
with  in  distinguishing  them,  that  such  a  variety  of  opinions  have  been  expressed 
concerning  the  proper  treatment  of  habitual  epilepsy.  Plethora  is  to  be  reduced 
without  causing  hurtful  debility:  tone  is  to  be  given  without  inducing  dangerous 
fullness.  It  requires  some  nicety  to  carry  the  balance  even  ;  to  attain  the  hoped-for 
good,  and  at  the  same  time  to  avoid  the  evil  that  is  apt  to  wait  upon  it.  In  very 
many  cases  the  requisite  extent  and  measure  of  the  tonic  plan  on  the  one  hand,  or 
of  the  lowering  system  on  the  other,  can  only  be  learned  by  careful  trials.  But 
sometimes  the  indications  of  treatment  are  more  plain.  When  the  patient  is  young 
and  strong,  and  full  of  blood,  and  not  of  a  particularly  movable  temperament;  when 
he  has  a  hard  pulse,  or  any  degree  of  feverishness ;  when  the  disorder  has  super- 
A'ened  upon  the  suspension  of  some  customary  discharge,  so  that  there  is  an  obvious 
cause  of  plethora;  and  when  the  disease  is  in  its  early  stage,  and  the  recurrence  of 
the  fits  has  not  yet  been  established  by  habit;  in  any  or  all  of  these  circumstances  it 
will  often  be  proper  to  abstract  blood  from  the  patient,  and  it  will  always  be  right  to 
purge  him  actively,  and  to  insist  upon  an  abstinent  regimen.  When  former  pa- 
roxysms have  been  preceded  by  signs  of  fullness  of  the  vessels  of  the  head  —  by 
headache,  for  instance,  throbbing  of  the  temporal  arteries,  distension  of  the  superfi- 
cial veins,  a  flushed  or  loaded  countenance  —  you  may  sometimes,  by  a  timely  use 
of  the  lancet  or  the  cupping-glass,  avert  an  attack  that  was  apparently  impending. 

On  the  other  hand,  if  the  patient  is  pale  and  weak;  or  unduly  susceptible;  or  if 
his  malady  has  been  fastened  upon  him  through  many  repetitions  of  the  fit ;  you 
will  generally  find  that  any  form  of  active  depletion  is  injurious,  and  learn  to  place 
your  best  hope  in  measures  which  are  calculated  to  invigorate  the  frame. 

One  of  the  most  useful  of  the  particular  remedies  employed  for  strengthening  the 
body,  is  the  cold  shower-bath.  This  tends  more,  perhaps,  than  any  single  measure, 
to  give  permanent  firmness  and  steadiness  to  the  system.  The  best  test,  in  all  cases, 
of  the  tonic  and  bracing  effl'ct  of  this  remedy  is  the  occtn-rence  of  a  pleasant  and 
general  glow  after  each  application  of  it.  It  is  the  only  safe  mode  in  which  the  cold 
bath  can  be  used  by  an  epileptic  person. 

You  will  find,  in  books,  a  great  many  tonic  medicines  recommended  for  this  dis- 
ease, which  medicines  you  will  have  opportunity  and  ample  time  for  trying.  Of  the 
mineral  tonics,  the  salts  of  silver,  zinc,  copper,  and  iron,  have  been  chiefly  praised. 
The  nitrate  of  silver  used  to  be  highly  thought  of;  but  there  is  one  very  serious 
objection  to  it  which  must  never  be  forgotten  :  viz.,  that  it  is  apt  to  produce  a  perma- 
nent discoloration  of  the  skin,  a  frightful  lead-colour.   There  is  a  footman  in  ii  house 


396  EPILEPSY. 

near  Cavendish  Square  who  has  been  thus  blackened :  and  there  is  a  gentleman  of 
property  resident  at  Brighton  in  the  same  predicament ;  his  face  looks  as  if  it  had 
been  thoroughly  and  carefully  pencilled  over  with  plumbago.  A  barrister,  a  frienc. 
of  my  own,  had  a  narrow  escape  from  a  similar  misfortune :  in  fact  his  skin  haa 
acquired  a  just  perceptible  tinge  of  gray.  Now  if  the  remedy  were  sure  to  cure  the 
disease,  I  am  not  certain  that  every  one  Avould  accept  of  a  curs  on  such  terms.  It 
would  be  proper,  even  on  that  supposition,  to  tell  the  patient  that  though  he  (or,  a 
fortiori,  she)  would  get  rid  of  the  epilepsy,  there  was  a  likelihood  that  this  unamia- 
ble  complexion  might  ensue.  But  the  truth  is,  that  in  giving  this  nitrate  of  silver 
we  run  a  great  risk  of  obtaining  its  disfiguring  effect,  for  the  sake  of  a  very  small 
chance  of  curing  the  epilepsy.  I  have  been  assured,  by  one  of  his  friends,  that  the 
Brighton  gentleman  has  carried  a  dark  outside  for  a  quarter  of  a  century  at  least ; 
and  that  he  is  as  subject  to  epileptic  fits  now*  as  ever  he  was.  If  the  lunar  caustic  is 
to  do  good,  it  must  be  given  for  some  time  together,  and  the  probability  is  that  it 
will  not  do  good  even  then ;  and  if  it  be  given  for  some  time  together,  there  is  great 
danger  of  its  changing  the  colour  of  the  skin.  For  these  reasons  I  never  give  it 
myself,  and  therefore  I  cannot  recommend  it  to  you.  If  j^ou  wish  to  try  it,  or  if  you 
have  a  patient  who  insists  on  trying  it,  as  some  will,  you  may  begin  with  half  a 
grain  in  a  pill  three  times  a  day  ;  and  the  dose  has  sometimes  been  carried  as  high 
as  fifteen  grains.  And  it  is  worth  observing  that  in  the  larger  doses  this  drug  proves 
purgative.  It  is  possible  that  its  good  efTect,  when  it  has  any,  may  be  attributable 
to  its  operation  in  that  way. 

There  is  no  danger  of  spoiling  the  beauty  of  your  patient  by  administering  the 
oxide  or  the  sulphate  of  zinc  ;  or  the  cuprum  ammoniatum.  The  liquor  arsenicalis 
has  been  thought  useful ;  but  it  requires  to  be  exhibited  with  great  caution.  Of  all 
the  metallic  remedies  I  should  prefer  some  preparation  of  iron.  I  think  I  have 
seen  much  good  done  by  the  vinum  ferri ;  not  by  any  specific  agency,  however,  but 
by  its  giving  what  is  called  tone  to  the  nervous  system,  and  rendering  it  less  prone 
to  be  affected  by  the  slighter  exciting  causes  of  the  disease.  I  cannot  pretend  to 
weigh  the  merits  of  the  long  list  of  substances  which  have  been  lauded  as  efficacious 
in  keeping  off  and  curing  the  disease  ;  and  which,  when  they  have  been  useful  at 
all,  have  operated,  I  conclude,  in  diminishing  the  disposition  to  epilepsy  by  corro- 
borating the  nervous  system.  The  most  renowned  of  them  are  valerian,  assafetida, 
wormwo(xl,  the  misletoe  of  the  oak,  the  cardamine  pratensis,  rue,  the  sedum  acre, 
indigo  ;  narcotic  vegetable  preparations,  stramonium,  belladonna,  hemlock,  lettuce ; 
animal  substances,  musk,  castor,  ox-gall;  and  the  number  might  be  many  times 
multiplied :  and  this  long  array  of  drugs,  all  of  which  have  been  known,  or  sup- 
posed, to  accomplish  a  cure,  affords,  in  truth,  one  of  the  strongest  evidences  of  the 
intractability  of  the  disease  under  any  plan  of  treatment.  There  is  a  shrewd  remark 
of  Esquirol's  which  I  believe  to  be  quite  true,  however  difficult  it  may  be  to  account 
for  the  fact,  which  is,  that  epileptics  are  apt  to  improve  for  a  time  under  every  new 
plan  of  treatment. 

Whatever  drug  you  may  see  reason  to  prefer  (and  the  patients  will  have  drugs, 
Mid  you  must  be  prepared  to  ring  the  changes  upon  them),  there  are  certain  other 
points  in  the  management  of  the  disease  which  are  of  considerable  importance.  The 
patient  who  is  subject  to  epilepsy  should  live  bj^  rule,  and  be  temperate  in  all  things. 
His  diet  should  be  simple,  nutritious,  but  not  stimulating :  he  should  renounce  all 
strong  liquor,  and  become,  in  the  new-fangled  and  vulgar  phrase,  a  tee-totaller.  He 
Ehouid  rise  early,  and  take  regular  exercise  in  the  open  air;  keeping  his  head  cool, 
find  his  extremities  warm.  He  should  avoid  all  menial  excitement,  and  the  fatiguing 
pursuit  of  what  is  called  pleasure:  all  probable  sources  of  sudden  anger,  surprise, 
alarm,  or  deep  emotion  of  any  kind  ;  all  striving  and  contention  of  the  intellect.  The 
student,  of  whatever  age  and  sort,  in  whom  epilepsy  has  declared  itself,  should  shut 
his  books:  the  man  of  business  abandon  or  abridge  his  professional  toil:  at  least 
ihej^  must  be  instructed  to  abstain  habitually  in  their  respective  callings,  from  such 
applications  as  would  task  and  strain  their  powers,  whether  mental  or  bodily:  and 
endeavours  should  be  made  to  engage  their  thoughts  and  to  interest  their  minds  in 
<;ss  engrossing  objects  of  attention.     No  minute  rules  can  be  laid  down  on  these 


EPILEPSY.  397 

points,  but,  keeping  the  general  indication  in  view,  it  will  seldom  be  difficult  to  foDow 
it  up  in  practice. 

When  the  fits  appear  to  have  been  brought  on  by  a  species  of  moral  contagion,  or 
by  imitation  of  the  same  disease  seen  in  others,  care  should  be  taken  to  exclude  as 
much  as  possible  those  objects  or  trains  of  thought  which  produce  the  mental  emotion 
or  the  morbid  propensity.  In  these  cases,  and,  indeed,  I  may  say  in  almost  afl  cases, 
it  is  more  rational  to  expect  benefit  from  such  measures  as  tend  to  calm  the  mind 
and  to  fortify  the  nerves,  than  from  this  or  that  substance  thrown  at  random  into  the 
stomach. 

There  is  cause  for  suspecting  that  epileptic  fits  sometimes  depend  upon  a  syphi 
jitic  affection  of  the  bones  of  the  ^kull ;  I  am  much  mistaken  if  I  have  not  seen  such 
cases.  When  that  suspicion  arises,  it  will  be  proper  to  give  mercury  a  full  and  fair 
trial.  Such  a  plan  has  been  followed  by  success.  I  should  always  premise,  how- 
ever, in  such  cases,  the  iodide  of  potassium;  the  efficacy  of  which  in  dispersing 
syphilitic  nodes  is  no  longer  doubtful.  I  am  accustomed  to  recommend  a  gentle  and 
long-continued  course  of  mercury  whenever  organic  disease  of  the  brain  is  sus- 
pected ;  the  irifluence  of  that  remedy  being  carefully  watched.  It  will  be  right  and 
proper  also  to  try  the  effect  of  counter-irritation  ;  of  blisters,  a  seton  in  the  neck,  or 
the  tartar-emetic  ointment.  But  I  must  confess  to  you  that,  often  as  this  expedient 
is  employed,  I  have  seldom  witnessed  any  such  resuk  from  it  as  would  encourage 
me  to  expect  benefit  from  repeating  it  in  another  case.  There  is  one  form  of  counter- 
irritation  which  I  have  never  seen  put  to  the  test,  but  which  has  of  late  been  strongly 
recommended  by  a  very  able  and  observing  physician.  Dr.  Pritchard  ;  and  of  which 
I  have  heard  very  good  accounts  from  a  gentleman  who  had  seen  it  extensively 
employed  in  Bristol ;  I  mean  the  making  a  long  issue  in  the  head  itself,  dividing 
the  integuments  down  to  the  bone  by  means  of  a  scalpel  in  the  direction  of  the 
sagittal  suture,  and  keeping  the  incision  open  and  discharging  for  some  time,  by 
means  of  issue  peas.  The  formation  of  the  issue  is  said  to  be  not  so  painful  as  one 
might  suppose. 

Dr.  Gluain,  in  his  edition  of  Martinet'' s  Pathology,  relates  the  following  case  •■ 
"  Some  years  ago  I  saw  a  boy  who  was  epileptic  from  infancy,  and  who,  in  one  of 
his  usual  fits,  fell  over  the  chff  by  the  sea-side,  and  received  a  very  severe  lacerated 
wound  of  the  scalp,  which  healed  slowly  and  with  a  copious  suppuration.  While 
the  discharge  continued  he  was  free  from  any  epileptic  attack  ;  but  as  soon  as  the 
wound  healed,  the  fits  returned  as  before." 

Twice  I  have  seen  similar  good  effects  from  the  insertion  of  a  seton  in  the  neck. 
Twenty  times  that  measure  has  disappointed  my  hopes. 

When  the  disease  is  ascertained  or  believed  to  be  of  the  eccentric  kind,  we  must 
search  diligently  to  find  the  seat  of  the  distant  irritation,  in  some  disturbance  of 
function  ;  and  apply  our  remedies  accordingly.  The  irritation  may  be  found,  as  I 
have  already  intimated,  in  almost  any  organ  of  the  body.  Painful  or  irregular 
dentition  is  perhaps  one  of  the  commonest  of  the  eccentric  sources  of  epilepsy. 
Sometimes  the  attacks  are  attended  with  symptoms  of  disease  in  the  liver ;  shght 
yellowness  of  the  skin,  uneasiness  and  tenderness  of  the  right  hypochondrium,  and 
lowness  of  spirits.  In  such  a  case  we  must  rectify  that  state  of  the  hver,  by  such 
means  as  I  shall  have  to  specify  hereafter.  If  the  disorder  depends  on  a  stone  in 
the  bladder,  the  cure  must  be  committed  to  the  surgeon.  I  have  a  patient  at  present 
under  my  occasional  inspection,  who  from  time  to  time  has  slight  fits  of  epilepsy  ; 
on  most  occasions  he  passes  about  the  same  time  a  small  calculus  by  the  urethra. 
I  make  no  doubt  that  in  his  case  the  exciting  cause  of  the  epilepsy  hes  in  the 
kidney. 

You  will  find  that  most  persons,  in  respect  to  such  diseases  as  that  which  we  are 
now  considering,  have  some  favourite  or  usual  mode  of  treatment ;  and  if  I  were 
called  upon  to  name  any  single  drug,  from  which,  in  ordinary  cases  of  epilepsy,  I 
should  most  hope  for  relief,  I  should  say  it  was  the  oil  of  turpentine.  And  I  find 
that  other  physicians  have  come  to  the  same  conclusion.  Dr.  Latham  the  elder  was, 
I  believe,  the  first  person  who  made  known  its  efficacy  in  this  disorder.  Foville 
states  that  he  has  seen  excellent  effects  from  it.     It  is  highly  spoken  of  by  Dr.  Per 

2i 


S98  EPILEPSY. 

cival,  in  the  Dublin  Flospital  Reports.  It  is  not  to  be  given  in  large  doses,  3ut  in 
smaller  ones,  frequently  repeated  ;  from  half  a  drachm  to  a  drachm  every  six  hours. 
You  are  aware  that  it  sometimes  produces  strangury,  and  therefore  the  patient  must 
be  forewarned  of  this,  or  carefully  watched.  Occasionally  turpentine  has  done  (rood 
in  virtue  of  its  anthelmintic  properties.  I  know  that  a  physician  of  my  acquaint- 
ance cured  a  case  of  epilepsy  in  this  way,  somewhat  to  his  own  surprise.  Without 
having  in  his  mind  any  notion  of  worms,  he  thought  it  "might  be  well  to  pur^e  his 
patient,  who  had  laboured  under  epilepsj^  for  some  time,  with  the  oleum  terebinthintc. 
The  patient,  who  is  the  brother  of  a  person  holding  at  present  a  high  office  in  this 
country,  was  residing  two  or  three  miles  out  of  town.  In  the  middle  of  the  night  the 
doctor  was  summoned  to  him  in  a  great  hurry  ;  the  messenger  said  he  was  supposed 
to  be  dying.  He  was  only  intoxicated,  however,  by  the  free  dose  of  turpentine  he 
had  swallowed  :  the  next  morning  he  voided  into  the  close  stool  a  large  tape-worm ; 
and  he  has  never  had  epilepsy  since.  A  nobleman  residing  in  Cambridgeshire  was 
long  epileptic  ;  and  he  too  got  rid  of  his  epilepsy  and  of  a  worm  at  the  same  time.  I 
believe  that  the  cure  was  effected  by  turpentine  in  his  case  also  ;  but  I  am  not  certain 
of  that.  Such  cases  are  remarkably  interesting :  they  show  that  irritation  of  the 
stomach  or  intestines  may  be  sufficient  to  cause  the  fits  ;  they  illustrate  excellently 
well  the  eccentric  form  of  the  disease  ;  and  they  deserve  to  be  always  borne  in  mind 
when  we  are  asked  to  prescribe  for  an  epileptic  patient.  A  cure  from  so  dreadful  a 
complaint,  by  such  simple  means — the  cause  of  his  malady,  and  the  certainty  of  his 
having  got  rid  of  that  cause,  being  both  so  obvious  and  intelligible  to  the  patient  — 
ma3^  be  enough,  sometimes,  to  make  a  practitioner's  fortune.  But  I  think  you  will 
sometimes  find  the  oil  of  turpentine  very  useful,  even  though  it  expels  no  worm,  and 
when  there  is  no  worm  to  expel.  If  the  bowels  should  be  costive,  the  oil  of  turpen- 
tine and  castor  oil,  in  equal  proportions,  go  exceedingly  well  together. 

When  the  patient  has  a  distinct  warning  of  an  approaching  paroxysm,  can  any- 
thing be  done  to  ward  it  off'?  Why,  in  some  cases,  b}'  interrupting  the  precursory 
symptoms,  it  certainly  may  be  prevented.  A  pupil  of  the  class  informs  me  that  a 
brother  of  his,  twelve  or  thirteen  years  old,  has  been  subject  to  epileptic  fits  for  two 
years.  They  occur  in  the  night,  especially  if  he  is  waked,  even  though  the  awaken- 
ing cause  has  no  tendency  to  startle  him.  He  often  is  dull  and  drowsy  the  evening 
before,  and  if  he  is  roused  from  this  lethargic  state  by  conversation  or  amusements, 
the  attack  expected  that  night  sometimes  does  not  happen.  Another  student  knows 
a  young  girl,  in  whom  the  occurrence  of  very  high  spirits  is  always  precursory  of 
the  paroxysm ;  when  this  extreme  vivacity  is  moderated  by  those  about  her,  the 
threatened  fit  is  sometimes  averted.  I  mentioned  before  an  instance  in  which  the 
aura,  proceeding  from  one  of  the  thumbs,  was  frequently  checked  by  tying  a  hgature 
tightly  round  the  thumb.  Other  examples  of  exactly  the  same  kind  are  on  record. 
Mr.  Wardrop  cured  a  case  beginning  with  an  aura  in  one  finger,  by  amputating  a 
joint  of  the  finger.  Dr.  M.  Hall  states  that  the  immediate  accession  of  the  parox- 
ysm may  sometimes  be  prevented  by  dashing  cold  water  on  the  face,  or  by  exciting 
the  nostiils  by  snuff".  In  this  manner  the  disposition  to  closure  of  the  larynx,  and  to 
expiratory  efforts,  is  exchanged  for  sudden  acts  of  inspiration.  Another  patient  of 
my  own,  an  old  college  friend,  indeed,  who  is  afflicted  with  epilepsy,  feels  convinced 
that  he  sometimes  staves  off  a  fit  by  applying  smelling  salts  to  his  nose :  and  he 
always  carries  a  bottle  about  with  him  for  that  purpose  :  but  unfortunately  the  warn- 
ing (which  consists  chiefly  in  giddiness)  is  generally  so  short  that  he  has  not  time  to 
have  recourse  to  his  preventive  before  ne  falls  down.  It  is  a  question  whether  the 
fit  may  not  be  obv'iated  by  a  strong  mental  effort  in  some  cases.  I  make  no  doubt 
that  it  may,  especially  in  th«  imitative  form  of  the  disease,  which  originates  in  and 
depends  upon  mental  and  moral  causes. 

It  is  scarcely  necessary  that  I  should  do  more  than  aavert  generally  to  those  pre- 
cautions which  every  one  who  is  subject  to  epilepsy  ought  to  observe,  and  which 
it  is  the  business  of  his  medical  adviser  to  enforce,  both  upon  the  patient  himself, 
»nd  upon  his  friends.  His  bed  should  be  large  ;  or  if  not  large,  it  should  be  enclosed 
with  some  netting  or  other  defence  against  his  falling  out  of  it.  If  he  sleeps  in  a 
room  by  himself,  care  should  be  taken  that  in  the  winter  a  proper  temperature  ib 


CHOREA.  399 

kept  up,  for  if  in  his  attacks  he  gets  out  of  bed  and  on  the  floor  he  may  be  seriously- 
injured  by  the  cold.  He  should  not,  however,  be  left  alone  if  it  can  be  helped. 
Guards  should  be  placed  over  every  grate  near  which  the  patient  may  come.  He 
should  avoid  ascending  and  descending  stairs  as  much  as  he  can.  He  should  not 
ride  on  horseback ;  nor  on  the  outside  of  a  coach ;  nor  even  in  a  gig ;  nor  go  about 
especially  in  solitary  places,  without  an  attendant.  A  patient  of  Dr.  Cheyne's,  a 
young  man  of  twenty,  was  drowned  in  his  own  garden  by  falling  into  a  little  runnel 
of  water,  which  was  not  four  inches  deep.  Neither,  on  the  other  hand,  will  it  be 
proper  or  safe  for  him  to  frequent  crowded  or  hot  rooms  ;  or  the  streets  of  a  popu- 
lous town,  in  which  the  multiplicity  and  distraction  of  objects  are  apt  to  produce, 
even  in  a  healthy  person  who  is  not  accustomed  to  them,  a  degree  of  vertigo  and 
confusion.  Dr.  Cheyne  advises  that  when  the  patient's  circumstances  will  admit  of 
his  having  a  constant  attendant  with  him,  the  latter  should  be  provided  with  some 
diffusible  stimulus  ;  a  potion,  for  example,  composed  of  camphor  mixture  and  aether, 
by  swalloAving  which  the  impending  paroxysm  may  sometimes  be  repelled. 


LECTURE  XXXVII. 

Cliorea.     Symptoms  ;  Pathology  ;  Complications  ;  Causes  ;  Treatment.     Chronic 
Chorea.     Other  Nervous  Disorders  to  which  the  same  name  has  been  applied. 

Another  disease  of  a  spasmodic  kind,  and  essentially  belonging  to  the  nervous 
system,  is  Chorea^St.  Vitus's  dance.  This  is  far  less  serious  than  the  complaints 
which  we  have  recently  been  considering;  but  it  is  a  very  unpleasant  disorder  to 
suffer,  and  it  has  several  points  of  analogy  with  the  other  nervous  and  spasmodic 
ailments.  Its  prominent  symptom  is  an  irregular  and  involuntary  clonic  contraction 
of  some  of  the  voluntary  muscles,  which,  however,  are  not  wholly  or  constantly 
withdrawn  from  the  government  of  the  will.  In  tetanus  we  had  a  rigid  spasm, 
while  the  mind  was  clear  and  free ;  voHtion  was  unaffected,  but  the  muscles  which 
should  have  obeyed  the  effort  of  the  will,  were  seized  upon  by  some  stronger  over- 
ruling power.  In  epilepsy,  with  convulsive  spasm,  there  was  suspension  of  the 
mental  functions  :  a  temporary  interruption  of  consciousness,  and  therefore  of  volition. 
But  in  chorea  we  have  a  different  state  from  either  of  these.  There  is  no  loss  of 
consciousness  ;  no  defect  of  vohtion.  The  ordinary  movements  of  the  body  can  be 
performed  in  some  degree,  or  sometimes,  under  the  direction  of  the  will ;  but  it 
would  seem  as  if  some  other  power  wantonly  interfered  to  excite  them  when  they 
are  not  needed,  to  render  them  unsteady  and  imperfect,  to  arrest  the  natural  action, 
and  give  a  new  direction  to  the  limbs,  and  to  cause  the  patient  to  gesticulate  and 
grimace  like  a  Merry-Andrew.  Moreover,  these  apparently  absurd  movements  do 
not  occur  in  paroxysms,  but  continue  throughout  the  day,  sometimes  for  weelfs  toge- 
ther;  but  they  generally  cease  during  sleep  :  for  the  most  part,  but  not  always,  the 
agitated  limbs  are  still,  while  the  senses  are  shut  up  in  slumber.  The  complaint  is 
not  attended  withyeyer. 

This  disorder  was  first  distinctly  described  by  Sydenham,  whose  account  of  it  is 
very  graphic  and  excellent,  and  has  been  copied  by  most  subsequent  writers.  With- 
out reference,  however,  to  the  portrait  which  he  has  left  us,  I  will  sketch  the  disease 
as  it  has  occurred  under  my  own  observation.  It  usually  begins  with  slight  twitches 
of  a  few  musles  in  the  face,  or  in  one  of  the  extremities  ;  and  by  degrees  the  spas- 
modic action  becomes  more  decided  and  more  general.  All  the  voluntary  muscles 
are  liable  to  be  affected  by  it.  Those  of  the  face  seldom  escape.  The  features  are 
twisted  into  all  sorts  of  ridiculous  forms ;  you  might  suppose  that  the  patient  was 
what  is  called  pulling  a  face,  or  making  mouths  at  you  :  but  there  is  neither  mirth 
nor  mockery  in  the  contortion  ;  it  is  a  convulsion.  It  is  succeeded  by  a  vacant  look, 
and  then  it  begins  afresh.  The  disease  occurs  much  oftener  in  young  girls  than  in 
any  other  persons.     If  you  ask  the  patient  to  put  out  her  tongue,  she  makes  sundry 


400  CHOREA. 

attempts  to  do  so  before  she  can  accomplish  it ;  and  then  the  tongue  is  suddenly- 
thrust  out,  and  as  suddenly  withdrawn,  and  the  jaws  snap  together  as  if  she  were 
resolved  that  you  should  have  as  short  a  glimpse  of  it  as  possible.  She  writhes  and 
contorts  her  shoulders.  She  cannot  keep  her  hand  or  arm  half  a  minute  in  the  same 
position.  When,  at  meals,  she  desires  to  carry  her  hand  to  her  mouth,  it  is  arrested 
midway,  and  suddenly  pulled  back  again,  or  pushed  off  in  some  other  direction  ;  and 
it  is  only  after  many  deviations  and  fruitless  efforts  that  she  succeeds.  The  lower 
extremities  are  equally  affected.  When  the  patient  intends  to  sit  or  stand  still,  her 
feet  scrape  and  shuffle  on  the  floor,  or  one  is  thrown  over  the  other;  and  if  she  en- 
deavours to  walk,  her  progress  is  most  uncertain ;  she  halts  and  drags  her  leg  rather 
than  lifts  it  up,  and  advances  in  a  jumping  manner  by  fits  and  starts.  In  short,  the 
voluntary  muscles  are  moved  in  that  capricious  and  fantastic  way  in  which  we  might 
fancy  they  would  be  moved  if  some  invisible  mischievous  being,  some  Puck  or  Robin 
Goodfellow,  were  behind  the  patient,  and  prompted  the  discordant  gestures.  With 
all  this  the  articulation  is  impeded  :  there  is  the  same  perverse  interference  with 
some  of  the  muscles  concerned  in  the  utterance  of  the  voice.  By  a  strong  figure 
of  speech,  the  disorder  has  been  called  "  insanity  of  the  muscles." 

Such  is  a  picture  of  the  main  symptoms  of  this  strange  malady,  as  they  have 
presented  themselves  to  me ;  and  such,  I  venture  to  say,  you  will  often  see  in  your 
future  practice.  You  will  find,  moreover,  that  the  irregular  jactitations  are  usually 
more  marked  and  general  on  one  side  of  the  body  than  on  the  other :  and  sometimes 
they  are  confined  to  the  muscles  of  one  side.  Here,  therefore,  we  have  a  trait  of 
resemblance  to  epilepsy  and  to  hemiplegia.  If  you  take  hold  of  the  only  limb  which 
happens  to  be  thus  agitated,  and  keep  it  still  by  main  force,  some  other  limb  or  part 
will  take  on  the  convulsive  action.  The  persons  who  are  subject  to  chorea  are 
always  inordinately  sensitive,  and  what  is  popularly  called  "nervous."  They  are 
easily  stirred  up  by  new  ideas  and  sudden  feelings,  and  pass  readily,  and  upon 
slight  occasions,  from  one  mood  of  mind  to  another.  The  mind  is  affected,  as  Dr. 
Cullen  remarks,  in  the  same  way,  and  often  shows  the  same  varied,  desultory,  and 
causeless  emotions,  as  in  hysteria.  You  see  the  indication  of  this  nervousness  in 
the  fact  that  the  fidgety  catching  of  the  muscles  increases  when  the  patient  is  spoken 
to,  especially  by  a  stranger — by  the  physician,  for  example.  The  nurses  of  the 
hospital  constantly  tell  me  that  such  or  such  a  patient,  who  has  chorea,  is  much 
more  composed  at  other  times  than  she  is  during  my  visit,  when  she  is  surrounded 
by  students,  and  made  the  object  of  their  attention.  In  most  cases  the  jactitations 
are  partly  and  in  some  degree  under  the  influence  of  the  will.  Sometimes  the  pa- 
tient seems  to  give  way  to  them,  indulges  in  or  exaggerates  them :  at  other  times 
she  can,  by  making  an  effort,  control  them.  Many  of  the  patients,  especially  such 
as  are  old  and  intelligent  enough  to  understand  the  directions  given  them,  and  to 
make  the  trial  fairly,  can  suspend  for  some  seconds  the  convulsive  movements,  by 
taking  a  deep  inspiration,  and  resting  upon  it,  without  expiring,  for  a  little  while. 
Like  other  spasmodic  diseases  occurring  in  movable  constitutions,  chorea  is  liable  to 
be  propagated  also  by  a  species  of  contagion,  or  rather  of  involuntary  imitation. 
These  diseases  constantly  approximate  and  touch  each  other  in  some  of  their 
characters. 

Chorea,  in  this  its  standard  form,  is  essentially  a  disease  of  youth.  Sydenham, 
and  Cullen,  who  closely  copies  him,  state  that  for  the  most  part  it  attacks  boys 
and  girls,  who  have  not  reached  the  period  of  puberty ;  between  the  tenth  and 
fourteenth  years  of  their  age.  These  limits  are,  however,  too  scanty.  It  is  very 
common  between  the  eighth  and  sixteenth  years ;  it  sometime  comes  on  as  early 
as  five  or  six :  and  now  and  then  it  begins  in  adult  life,  or  in  old  age.  I  have 
already  intimated  that  it  is  much  more  frequent  in  girls  than  in  boys.  Dr.  Heber- 
den  says  the  proportion  is  as  3  to  1.  Dr.  Elliotson,  out  of  30  patients,  had  22 
females  and  8  males.  Of  84  cases  reported  by  Dr.  Reeves,  of  Norwich,  57  were 
females,  and  27  males.  Of  72  occurring  in  Dr.  Manson's  practice,  at  Notting- 
ham, 5J?  were  females,  19  males.  Of  18  cases  in  the  Hampshire  County  Hos- 
pital, 12  were  girls,  and  the  rest  boys.  Now  taking  all  these  numbers  together, 
we  hav?  204  cases,  of  which  there  were  144  females  and  60  males ;  the  proper- 


CHOREA.  401 

tion  13  as  12 : 5,  or  a  little  more  than  2:1;  and  leaving  out  Dr.  Reeves'  list  — 
which  differs  considerably  from  the  others  in  containing  a  larger  number  of  males 
— we  have  129  cases,  of  which  87  were  females,  and  83  males ;  this  ratio  is  as 
29  :  11  ;  or  nearly,  but  not  quite,  3  :  1.  [In  429  cases  referred  to  by  Dufossi 
and  Rufz,  130  occurred  in  boys  and  299  in  girls. — C]  I  have  also  observed 
that  the  disease  occurs  much  more  frequently  in  children  having  dark  hair  and  eyes, 
than  in  those  of  a  light  complexion ;  and  I  think  I  have  seen  the  same  remark  in 
some  book,  but  I  forget  where. 

[According  to  Mr.  W.  H.  Bell — (Did.  des  Etudes  Mediralcs)  Diifosse  (ibid.),  and  Rufz  {Ar- 
chives Generates  de  Med.,  iv.  239) — ihe  subjects  of  chorea  have  chiefly  light  hair. — C] 

When  the  disease  is  strongly  marked,  or  lasts  long,  there  is  usually  some  imbe- 
cility of  mind  manifested ;  a  slight  degree  of  fatuity,  and  a  foolish  expression  of  the 
features.  But  this  goes  off  with  the  other  symptoms.  The  child  generally  recovers, 
but  the  malady  is  apt  to  recur,  and  that  more  than  once.  In  this  respect  we  may 
trace  a  distant  resemblance  to  epilepsy ;  if  we  regard  each  attack  as  a  long  and 
mild  paroxysm,  then  these  paroxysms  are  liable  to  repetition.  No  doubt  the  du- 
ration of  the  disorder  is  often  abbreviated  by  proper  treatment ;  there  are  cures  in 
this  disease  as  well  as  recoveries.  It  is  a  very  rare  thing  for  chorea  to  prove  fatal ; 
and  the  few  fatal  cases  that  have  occurred  have  thrown  no  light  on  its  pathology. 
Dr.  Elliotson  saw  a  strong  girl  affected  with  it  die  of  apoplexy  ;  but  perhaps  she 
would  have  died  of  apoplexy  whether  she  had  had  chorea  or  no.  Chorea  offers 
no  protection  against  the  invasion  of  other  diseases.  My  colleague  at  the  Middle- 
sex Hospital,  Dr.  Hawkins,  had  a  fatal  case.  He  found  great  vascularity  of  the 
uterus,  earthy  concretions  in  the  pancreas,  omentum,  and  mesentery,  and  tubercles 
in  the  lungs.  But  these  conditions  had  no  connection  probably  with  the  chorea. 
In  an  instance  that  proved  fatal  under  Dr.  Bright's  observation,  there  was  consider- 
able disease  in  the  uterus  and  its  appendages.  I  am  afraid  that  we  shall  seek  in 
vain  in  the  dead  body  to  discern  the  nature  of  chorea.  When  we  find  organic  disease 
accompanying  it,  we  must  look  upon  such  organic  disease,  if  it  have  any  connection 
with  the  chorea  at  all,  as  being  a  predisposing  cause ;  as  producing  or  increasing 
that  irritability  and  mobility  of  the  nervous  system  which  fit  it  for  submitting  to  the 
exciting  causes  of  various  nervous  diseases. 

There  is  a  speculation  of  some  of  the  French  writers  respecting  the  seat  and 
nature  of  chorea  so  ingenious,  that  I  cannot  refrain  from  mentioning  it. 

It  is  affirmed  by  certain  modern  physiologists,  as  you  may  perhaps  know,  that 
one  of  the  functions,  the  principal  office  indeed,  of  the  cerebellum,  is  to  preside 
over  and  regulate  the  faculty  of  locomotion  ;  to  keep  the  muscles  in  due  subordi- 
nation, as  it  were,  to  the  will.  No  voluntary  movement,  almost,  can  be  executed 
without  the  combined  and  consenting  action  of  many  muscles ;  it  is  the  business  of 
the  cerebellum,  they  say,  to  maintain  this  consent  and  community  of  purpose ;  to 
prevent  any  mutiny  of  individual  muscles,  and  to  make  them  unanimously  co-ope- 
rate in  producing  a  given  movement.  How  far  this  doctrine  is  true  I  do  not  intend 
to  inquire:  but  supposing  it  well  founded,  then  they  very  ingeniously  assign  the 
cerebellum  as  the  seat  of  that  change,  whatever  it  is,  which  gives  rise  to  the  phe- 
nomena of  chorea.  And  it  is  most  certain  that  the  irregular  movements  by  which 
chorea  is  characterized  can  neither  be  considered  as  the  effects  of  imperfect  paraly- 
sis, as  some  ha"e  slated,  nor  of  convulsion,  in  the  proper  sense  of  that  word,  as  others 
have  asserted  ;  but  rather  as  consequences  of  the  want  of  due  harmony  and  agree- 
ment between  the  various  muscles,  which  should  combine  to  produce  the  desired 
state  either  of  rest  or  of  motion.  There  is  a  defect  of  the  requisite  association  in 
the  actions  of  the  different  muscles  ;  and  it  is  in  this  sense  that  chorea  has  been  de 
nominated  insanity  of  the  muscles.  There  is  a  certain  portion  of  the  brain  which 
ministers  to  the  intellectual  functions  ;  there  are  certain  altered  states  of  that  portion, 
which  lead  to  mental  aberration ;  the  persons  so  affected  form  false  judgments ; 
cannot  associate  their  ideas  aright.  So  also  there  is  a  certain  portion  of  the  ence- 
phalon  which  presides  over  the  locomotive  functions  ;  and  there  are  altered  states  of 
that  portion,  which  lead  to  a  loss  of  the  due  association  of  muscular  contraction)! 
2e  2i2 


402  CHOREA. 

That  portion  is  the  ccrebtllum.  Such  is  their  theory ;  and  it  is  a  very  plausible  and 
pleasant,  but  withal  an  unsatisfying  theory.  The  disorder  really  belongs,  I  appre- 
hend, to  the  excito-motory  department  of  the  nervous  system.  From  some  infirm 
or  unnatural  state,  either  of  the  cord  or  of  the  incident  nerves  that  convey  impres- 
sions to  it,  its  reflex  function  is  called  into  irregular  play,  and  voluntary  muscles  con- 
tract independently  of  volition.  Sometimes,  at  the  same  instant,  the  patient  ivilla 
certain  definite  movements  through  the  instrumentality  of  the  very  same  muscles. 
But  the  authority  of  the  will  is  impaired,  and  the  automatic  motions  are  proportion- 
all}^  strong  and  unruly.  The  consequence  is,  that  the  same  muscles,  receiving  at 
the  same  time  contradictory  orders  from  these  two  sources,  obey  neither  mandate 
completely,  but  give  rise,  by  their  discordant  action,  to  the  grotesque  and  seemingly 
antic  gestures  which  these  patients  exhibit. 

But  to  leave  these  seductive  theories,  and  return  to  duller  matters  of  fact.  Chorea 
is  a  complaint  that  is  seldom  attended  with  any  bodily  pain.  I  have  in  several 
instances,  however,  known  it  to  be  accompanied  by  pain  in  the  head  ;  and  in  some 
of  them,  with  pain  on  that  side  only  of  the  head  which  was  opposite  to  the  agitated 
limbs.  I  mention  this  as  being  of  some  practical  importance ;  for  I  have  found  the 
disease  to  become  sensibly  less  severe,  and  very  soon  to  cease,  upon  drawing  blood 
by  leeches,  or  cupping,  from  the  painful  side  of  the  head.  In  a  greater  number  of 
cases,  however,  no  such  pain  is  experienced.  Sometimes  you  wall  find  that  in  all 
respects,  excepting  the  nervousness,  and  the  irregular  movements,  the  patient  is  in 
the  enjoyment  of  perfect  health.  But  neither  is  this  very  common  :  generally  there 
is  something  manifestly  wrong  in  the  state  of  the  stomach  and  bowels,  either  before 
or  during  the  complaint ;  a  capricious  appetite,  costiveness,  a  tumid  abdomen,  offen- 
sive breath,  a  foul  tongue. 

Chorea  is  sometimes  complicated  with  other  disorders,  and  above  all  with  hysteria  : 
and  no  wonder,  since  they  both  occur  chiefly  in  persons  of  the  same  sex,  of  the  same 
susceptible  temperament,  and  at  nearly  the  same  period  of  life.  It  is  said  also  to 
happen  in  conjunction  with  acute  rheumatism  and  rheumatic  pericarditis;  and  with 
certain  affections  of  the  skin.  Its  coincidence  with  cutaneous  complaints,  if  not 
merely  accidental,  may  perhaps  be  owing  to  irritation  of  the  peripheral  extremities 
of  afferent  nerves,  by  the  eruption.  Judging  from  my  own  experienQg  alone,  I  should 
not  say  that  the  disease  was  often  associated  with  acute  rheumatism.  Dr.  Copland 
and  Dr.  Bright  have  both,  however,  noted  that  connection,  and  therefore  I  cannot 
doubt  that  it  does  sometimes  exist.  I  certainly  have  seen  jactitations  hke  those  of 
chorea  in  a  few  instances  of  rheumatic  carditis.  Very  lately  a  boy,  affeQted  with 
chorea,  became  my  patient  in  the  hospital.  We  soon  detected  a  strong  bellows  sound 
of  his  heart ;  and  tracing  his  history  back  a  little,  we  found  that  he  had  suffered 
acute  articular  rheumatism.  In  a  recent  volume  of  the  Medico-Chirurgical  Trans- 
actions, there  is  a  paper  by  Dr.  Bright,  detailing  "  cases  of  spasmodic  disease, 
accompanying  aflections  of  the  pericardium."  Now  we  do  not  perceive  any  obvious 
or  direct  connection  between  the  cardiac  disorder  and  the  nervous  disorder.  There 
are  just  two  conjectures  which  occur  to  me  upon  the  subject,-  Rheumatism  (as  we 
shall  see  by  and  by)  is  especially  a  disease  of  fibrous  structures,  and  it  usually  affects 
various  fibrous  parts  at  the  same  time.  It  is  not  improbable,  therefore,  that  in  the 
cases  in  question,  some  morbid  condition  of  the  membranes  of  the  spinal  canal  may 
have  arisen,  simultaneously  with  the  inflammation  of  the  pericardium.  Or  the  car- 
diac disease  may  perhaps  operate,  by  some  ill-understood  influence,  upon  afferent 
nerves  of  the  cord,  as  an  eccentric  cause  of  the  irregular  movements. 

Probably  any  thing  which  makes  a  forcible  impression  upon  the  nervous  system 
ma}^  act  as  an  exciting  cause  of  chorea.  Strong  mental  emotion,  or  a  sudden  menta 
shock,  is  very  likely  to  bring  it  on  in  those  of  a  movable  constitution  who  are  pre 
disposed  to  it.  Of  its  ascertained  or  alleged  exciting  causes,  fright  is  beyond  al 
comparison  the  commonest.  It  has  been  known  to  follow  a  blow  or  fall  on  the  head 
but  even  in  these  cases  the  alarm  may  have  had  more  to  do  with  the  disorder  than 
the  blow  itself.  It  sometimes  seems  to  depend  upon  irritation  of  the  stomach  o' 
Iwwels,  by  improper  diet,  by  accumulated  feces,  or  by  worms  ;  and  it  is  found  to  be 
connectea,  m  not  a  few  cases,  with  difficult  and  painful  menstruation.    It  frequently 


CHOREA.  403 

begins  about  the  period  of  the  second  dentition :  the  late  Dr.  Gregory,  of  Edinburgh, 
was  in  the  habit  of  relating  instances  of  that  kind.  In  one  case,  the  old  teeth  were 
remaining  while  the  new  ones  were  appearing  by  their  sides.  The  old  teeth  were 
drawn,  and  the  removal  of  the  chorea  were  complete.  This  Dr.  M.  Hail  would 
justly  call  eccentric  chorea.  But  even  in  such  cases  the  state  of  the  gums  cannot 
be  regarded  as  the  sole  cause  of  the  chorea:  there  must  be  the  predisposition,  as 
well  as  the  accidental  exciting  cause ;  for  the  complaint  is  apt  to  recur  under  the 
agency  of  some  new  irritation,  and  may  then  be  removed  by  other  means. 

[We  have  not  found  the  disease  to  be  much  influenced  by  the  season  of  the  year  or  con- 
dition of  the  atmosphere.  Duges,  Rufz,  Spangenburg,  and  Blache  state  that  it  occurs  most 
frequently  in  summer.  According  to  the  statements  of  Rochoux,  Chervin,  and  Danste,  it  is 
a  rare  affection  in  the  southern  hemisphere.  It  is  not  a  very  frequent  disease  in  Philadel- 
phia.—C] 

Chorea,  such  as  I  have  been  describing  it,  may  last  from  a  week  or  two  to  some 
months.  In  those  eighty-four  cases  which  I  have  already  mentioned  as  having  been 
reported  by  Dr.  Reeves,  the  shortest  period  of  medical  treatment  was  two  weeks  ; 
the  longest  eight  months ;  and  the  common  average  seven  weeks.  This  appears  to 
me  a  long  average.  The  disorder  often  terminates — at  any  rate  much  more  often 
than  epilepsy  does — at  the  period  of  puberty ;  especially  upon  the  first  coming  on 
of  the  menstrual  discharge  in  the  female. 

[Chorea,  like  epilepsy,  may  be  excited  by  imitation  (Andral)  ;  the  fact  is,  however,  denied 
by  Rufz  and  Blache. — C.] 

I  had  occasion,  in  the  last  lecture,  to  remark,  that  when  a  vast  number  of  different 
drugs  are  recommended  as  specifics  in  any  given  disease,  we  may  sometimes  infer 
from  that  very  circumstance  that  the  disease  is  difficult  of  cure,  and  generally  in- 
tractable under  all  plans  of  management.  But  there  is  another  class  of  diseases 
which  a  variety  of  drugs  are  supposed  capable  of  curing, — those,  namely,  which 
tend  to  terminate  in  health,  I  believe  that  many  cases  of  chorea — most  cases — 
would  at  length  get  well  without  any  aid  from  physic :  I  believe  also  that  many  of 
the  boasted  specifics  have  been  quite  innocent  of  any  share  in  the  recovery  of  the 
patients  to  Avhom  they  were  administered  ;  at  the  same  time  I  am  quite  certain  that 
treatment  has  a  great  influence  over  the  disease. 

It  was  Sydenham's  practice  first  to  bleed  and  purge  his  patients,  and  then  to  ad- 
minister bitters,  aromatics,  and  antispasmodics,  with  a  view  of  strengthening  the 
nerves.  After  his  time  the  blood-letting  and  purgatives  fell  into  disuse,  until  the 
publication  of  Dr.  Hamilton's  well-known  work  again  brought  the  latter  deservedly 
into  favour. 

The  treatment  of  chorea  embraces  two  definite  objects.  The  first,  and  chief,  is  to 
give  stability  to  the  unduly  movable  nervous  centres.  The  second  is  to  remove 
or  avert  whatever  may  be  likely  to  produce  unnatural  excitement  of  their  incident 
nerves. 

Now  the  complaint  is  seldom  (in  its  genuine  form  I  may  say  it  is  never)  dependent 
upon  any  organic  or  inflammatory  disease.  The  instrument  is  not  broken  anywhere, 
but  it  is  slackened,  jangling,  and  out  of  tune :  and  (to  pursue  the  metaphor)  we 
often  can  restore  its  harmony  by  bracing  it  up  again. 

I  can  confidently  recommend  you  to  abstract  blood  locally  in  those  cases  in  which 
there  is  a  fixed  pain  in  the  head ;  but  with  this  exception,  blood-letting  is  neither 
useful,  nor  even  (in  my  opinion)  justifiable.  There  is  oftener  a  deficiency  than  a 
redundance  of  red  blood  in  the  system. 

I  shall  not  attempt  to  distract  your  attention  by  discussing  the  various  remedies 
that  have  been  vaunted  against  chorea;  but  shall  take  the  hberty  of  referring  )0u  to 
books  (to  Dr.  Copeland's  Dictionary,  for  example)  for  further  information  on  thai 
subject,  and  content  myself  with  teUing  you  what  modes  of  treatment  I  have  been 
in  the  habit  of  employing,  with  very  satisfactory  resuhs.  I  think,  then,  setting  aside 
the  complication  with  headache  just  mentioned,  you  will  be  able  to  deal  successfully 
with  most  of  the  cases  of  chorea  which  you  may  have  to  treat,  if  you  have  xi  vour 


404  CHOREA. 

command  purgative  medicines,  the  shower-bath,  preparations  of  iron  and  of  arsenic, 
and  the  oil  of  turpentine. 

It  will  be  right,  in  all  cases,  to  begin  by  clearing  out  the  bowels  with  calomel  and 
jalap,  or  some  active  aperient ;  and  you  should  persist  in  the  regulated  use  of  purga- 
tive medicines,  if  they  continue  to  bring  away  much  fecal  matter.  You  are  to  be 
guided  less  by  the  amount  of  the  doses  than  by  the  effects  they  produce  ;  at  any 
rale  one  fuU  evacuation  of  the  bowels  should  take  place  every  day.  But  though 
purgatives  are  good  auxiliaries,  we  cannot  trust  to  them  alone  for  the  cure  of  the 
complaint. 

One  of  the  most  effectual  of  the  tonic  remedies  is  the  cold  shower  bath.  If  the 
patient  be  of  a  feeble  constitution,  the  water  may  at  first  be  used  tepid ;  by  degrees 
it  should  be  used  cold.  This  remedy  should  be  employed  every  morning,  or  every 
other  morning,  early,  as  soon  as  the  patient  gets  out  of  bed.  Of  the  best  indications 
of  the  propriety  of  its  continuance  I  spoke  in  the  last  lecture  only ;  I  need  not  tire 
you,  therefore,  by  repeating  the  observations  I  then  made. 

With  this  external  tonic  it  will  be  right  to  combine  some  internal  one ;  and  for  the 
most  part,  the  best  for  the  purpose  is  some  preparation  of  iron.  The  carbonate  of 
iron  is  an  exceedingly  good  form,  and  it  may  be  given  in  the  way  recommended  by 
Dr.  EUiotson,  one  of  whose  pets  it  is,  —  namely,  mixed  with  twice  its  weight  of 
treacle,  so  as  to  form  an  electuary.  You  may  begin  with  it  in  half-drachm  doses, 
and  presently  increase  the  quantity  to  a  drachm,  or  a  drachm  and  a  half,  or  two 
drachms.  Much  larger  quantities  indeed  have  been  given,  and  that  for  a  long  time 
together ;  but  I  am  not  in  the  habit  of  so  pushing  this  drug.  Patients  do  not  like  to 
swallow  from  half  an  ounce  to  an  ounce  of  the  powder  and  twice  as  much  treacle 
three  or  four  times  a  day ;  and  some  of  them  cannot  get  so  much  down.  And  I 
mentioned  on  a  former  occasion  that  the  iron  is  apt  to  accumulate  in  the  large  intes- 
tines, and  to  be  expelled  at  last,  often  with  difficulty  and  pain,  in  large,  hard,  red 
masses,  like  what  is  called,  I  fancy,  slag,  or  the  dross  of  iron  ore  from  a  furnace. 
When  one  or  at  most  two  drachms  given  three  or  four  times  a  da}^  make  no  impres- 
sion on  the  disease,  you  had  better  (in  my  humble  judgment)  change  the  form  of 
the  medicine.  Give  two  or  three  grains  of  the  sulphate  of  iron  for  a  dose,  or  fre- 
quent draughts  of  Griffith's  mixture  (mistura  ferri  composita),  or  twenty  or  thirty 
minims  of  the  tinctura  ferri  muriatis.  Dr.  Bright  says  he  has  found  the  sulphate  of 
zinc  answer  when  the  carbonate  of  iron  had  failed,  and  the  iron  succeed  when  the 
zinc  had  done  no  good.  One  most  severe  case,  about  which  I  was  consulted,  and 
which  had  resisted  other  remedies,  got  well  under  the  use  of  the  sulphate  of  zinc ; 
the  dose  of  which  was  gradually  increased  to  ten  grains,  given  three  times  a  day. 
Whenever  the  medicine  was  pushed  beyond  this  point  it  became  emetic.  Certainly 
the  disease  is  often  very  obedient  to  arsenic ;  but,  for  plain  reasons,  it  is  better  ta 
effect  a  cure,  when  we  can,  by  less  hazardous  substances.  The  gravest  case  I  ever 
had  to  treat  occurred,  not  long  since,  in  one  of  my  hospital  patients.  I  tried  the  carbo- 
nate of  iron  in  vain.  The  shower  bath  so  terrified  and  agitated  the  girl  that  I  could 
not  persist  with  it.  I  then  gave  her  arsenic,  under  which  she  improved  at  first,  but 
it  ultimately  was  very  injurious  ;  her  bowels  were  greatly  irritated  by  it,  she  became 
paralytic  in  her  lower  extremities,  and  sank  into  a  typhoid  state  ;  and  I  really  was 
afraid  that  I  should  lose  her.  But  she  recovered  from  this  condition,  which  I  could 
uot  but  ascribe  to  the  arsenic ;  and  as  soon  as  I  dared  venture,  I  began  to  give  her 
the  muriated  tincture  of  iron,  twenty  drops  at  a  time,  every  six  hours.  Under  this 
treatment  she  steadily  and  rapidly  improved,  and  was  soon  quite  well. 

[Recently  very  decided  testimony  has  been  presented  by  Young,  of  Pennsylvania,  Lindsly, 
of  Washington,  Hildbreth,  of  Ohio,  Kirkbride  and  Professor  Wood,  of  Philadelphia,  and 
Beadle,  of  New  York,  in  favour  of  the  efficacy  of  the  cimicifuga,  or  black  snake-root,  in  cases 
of  chorea.  It  may  be  given  in  the  dose  of  half  a  teaspoonful  of  the  powdered  root  three 
*i»nes  a  day ;  or  from  one  to  two  drachms  of  the  saturated  tincture,  or  a  winegiassful  of  the 
decoction.  The  cyanuret  of  iron,  in  the  dose  of  three  grains  three  times  a  day,  in  the 
form  of  a  pill,  has  been  strongly  recommended  by  Dr.  Zollickoffer,  of  Maryland.  The 
cyanuret  of  zinc,  in  the  dose  of  one-third  of  a  grain,  twice  a  day,  gradually  increased  tc 
fourteen  grains  in  the  twenty-four  hours,  has  recently  been  highly  spoken  of  by  the  physi 
<»&j)S  of  Berlin  and  elsewhere.     See  Condie  on  Diseases  of  Children. — C] 


CHOREA.  405 

The  oil  of  turpentine  also  is  certainly  a  valuable  medicine  in  this  disease  ;  whether 
there  be  worms  at  the  bottom  of  it  or  not.  When  the  bowels  are  torpid,  and  the 
girl  is  of  that  age  when  menstruation  may  be  conjectured  to  be  at  hand,  its  arrival 
seems  sometimes  to  be  accelerated,  and  great  relief  to  be  produced  by  the  turpentine. 
The  best  way  of  exhibiting  it  in  such  cases  is  in  combination  with  an  equal  quantity 
of  castor  oil;  two  drachms  or  half  an  ounce  of  the  mixture  may  be  given  every 
morning,  or  every  other  morning,  according  to  its  effect  upon  the  bowels ;  and  when 
they  are  very  sluggish,  or  the  stools  are  unnatural,  it  will  often  be  serviceable  to  give 
a  couple  of  grains  of  calomel  also,  twice  or  thrice  a  week,  at  bed-time. 

It  is  scarcely  necessary  for  me  to  say  that  due  attention  must  be  paid  to  the  diet. 
This  ought  to  be  plain  and  simple,  but  at  the  same  time  nourishing,  and  even  gene- 
rous. Exercise,  short  of  that  which  produces  fatigue,  in  the  open  air,  in  fine  and 
dry  weather,  will  also  conduce  much  to  the  patient's  recovery.  And  all  kinds  of 
immoderate  emotion  should  be  guarded  against :  for  the  contest  often  seems  to  lie 
between  the  emotional  and  the  voluntary  impulses  to  action.  The  stillness  of  the 
muscles  during  sleep  is  in  accordance  with  this  behef. 

There  is  an  affection  (it  scarcely  deserves  to  be  spoken  of  as  a  disease)  which  is 
Bometimes  called  chorea,  of  a  chronic  nature,  and  resembling  the  disorder  I  have  just 
been  speaking  of,  inasmuch  as  it  commonly  is  met  with  in  nervous  persons,  and 
consists  in  the  irregular,  unmeaning,  and  involuntary  contraction  of  certain  muscles, 
especially  in  the  limbs,  neck,  or  face :  but  differing  from  it  in  this,  that  the  same 
muscles  are  always  affected,  and  in  the  same  way;  that  it  lasts  long,  almost  always 
for  life,  and  implies  no  accompanying  derangement  of  the  general  health.  In  its 
slighter  form  the  irregular  movements  are  ratlaer  awkward  tricks  than  spasms :  a 
repeated  shake  of  the  head,  or  knitting  of  the  eyebrows,  or  corrugation  of  the  integu- 
ments of  the  nose,  or  shrugging  of  the  shoulders — which  the  person  seems  hardly 
conscious  of.  At  other  times,  however,  the  motions  are  more  extensive ;  a  limb 
starts  out,  or  the  head  is  turned  awry  ;  and  the  individual  who  performs  these  evolu- 
tions is  quite  aware  that  he  does  so,  and  vexed  and  annoyed  at  the  ridiculous  figure 
he  makes,  but  he  cannot  help  performing  them  ;  or  if  he  can  prevent  it,  the  necessary 
effort  is  worse  than  the  disease.  One  young  man  who  was  subject  to  this  infirmity 
told  a  friend  that  he  could  stop  the  movement  by  a  strong  exertion  of  the  will ;  but 
that  tJutt  exertion  was  extremely  painful,  and  was  followed  by  languor  and  much 
discomfort.  In  some  instances  1  make  no  doubt  that  the  continuance  of  the  affection 
is  the  result  of  a  long-established  habit.  It  occurs  more  frequently  in  men  than  in 
women.  I  had  for  a  long  lime,  as  an  out-patient  at  the  hospital,  a  girl  about  seven- 
teen years  old,  in  all  other  respects  the  picture  of  health,  but  who  was  annoyed  by 
an  involuntary  shake  of  the  head,  which  took  place  two  or  three  times  in  a  minute. 
She  received  no  benefit  from  medicine.  A  lad  in  my  own  service  was  affected  in  a 
similar  manner.  He  seemed  to  be  giving  me,  and  my  friends,  from  time  to  time,  a 
famihar  nod  ;  and  I  was  obliged  to  part  with  him.  Others  are  subject  to  twitchings 
of  the  face.  I  am  acquainted  with  one  gentleman  who  is  perpetually  wrinkling  his 
nose:  and  he  has  assured  me  that  he  was  subject,  when  young,  to  an  involuntary 
shake  of  the  head,  hke  the  two  persons  just  mentioned  ;  but  a  blister  having  been 
once  applied  to  his  throat  for  some  disorder  in  his  air-passages,  the  shaking  of  the 
head  was  thereby  rendered  painful  and  difficult,  and  the  movement  there  ceased  : 
but  (as  he  expressed  it)  it  broke  out  in  his  nose,  where  it  triumphs  to  this  day.  This 
chronic  chorea,  as  it  has  been  called,  I  merely  mention  to  prevent  your  confounding 
together  two  affections  which,  though  they  have  received  the  same  name,  and  are  in 
some  respects  analogous,  yet  differ  in  still  more  points,  and  those  points  of  more  im 
portance.  1  believe  that  medicine  has  no  power  over  any  of  these  tricks.  They 
are  distressing  and  unsightly ;  but  in  no  way  dangerous. 

The  word  chorea,  which  you  know  signifies  a  dance — and  the  trivial  term  of  St. 
Vitus's  dance — are  not  very  appropriate  to  either  of  the  nioaifications  of  the  nervou:i 
affection  which  I  have  been  noticing.  In  fact  that  terra  was  originally  apphed,  and 
much  more  suitably,  to  another  set  of  symptoms  of  a  most  singular  kind,  concerning 


406  CHOREA. 

the  real  occurrence  of  which  we  mifrht  well  be  sceptical,  if  we  had  not  authentic 
narratives  of  many  instances  of  such  disorder  from  different  persons  of  credit,  as 
well  in  this  country  as  in  others.  What  has  happened  many  times  before,  may 
happen  again  ;  and  you  ought  not  to  be  in  ignorance  of  the  histories  to  which  I 
allude.  They  relate  to  an  affection  cliaracterized  by  movements  that  cannot  be 
called  spasmodic,  but  are  rather  owing  to  an  irresistible  propensity  to  muscular  action, 
increased  sometimes  to  a  sort  of  mania  by  the  force  of  imitation,  or  by  the  sound  of 
music.  It  is  the  voUliori  that,  in  these  cases,  is  morbid  and  perverse.  You  might 
fancy  the  patient  to  be  possessed  and  coerced  by  an  evil  spirit,  like  the  Sat.^uom^nfx.si>oi, 
of  the  Gospel  history. 

Some  of  the  subjects  of  these  extraordinary  affections,  impelled  by  a  strange  unin- 
telligible necessity,  execute  measured  and  regular  movements  with  surprising  energy, 
rapidity,  and  perseverance.  When  music  is  performed  in  their  hearing,  the  move- 
ments become  an  actual  dance  ;  and  where  crowds  are  collected  together,  the  dancing 
mania  is  apt  to  spread  from  person  to  person  by  a  sort  of  imitative  infection  ;  real- 
izing the  fable  of  Orpheus,  and  giving  origin  (it  may  be  presumed)  to  those  romantic 
legends  met  with  in  the  hterature  of  most  ages  and  countries,  of  universal,  involun- 
tary, and  unceasing  saltation,  at  the  sound  of  a  magic  pipe.  To  these  feats  the  term 
chorea  is  apposite  enough.  Indeed  I  have  seen  it  somewhere  suggested  that  the 
phrase  chorea  Sancti  Viti  is  but  a  vulgar  corruption  of  chorea  Sancii  inviti ;  and 
took  its  rise  in  the  misfortune  of  some  holy  person  who  chanced  to  be  afflicted  with 
one  of  these  unwilling  but  invincible  impulses  to  caper.  The  common  explanation 
makes  this  holy  person  to  have  been  a  certain  German  saint  Weit,  to  whom  a  chapel 
is  said  (I  know  not  with  how  much  truth)  to  be  dedicated  at  Ulm,  in  Suabia. 

Sometimes,  instead  of  dancing  on  their  feet,  these  patients  drum  and  beat  with 
their  hands,  either  upon  their  own  knees,  or  upon  the  objects  near  them.  This 
variety  has  received  the  bombastic  title  of  "malleation."  Sometimes  they  circum- 
volve  with  great  rapidity  ;  or  they  turn  their  heads  repeatedly  from  side  to  side  with 
great  velocity:  this  is  "rotation."  When  they  are  irresistibly  impelled  to  move  in 
a  given  direction,  the  term  "  propulsion"  is  employed.  The  very  invention  of  these 
names  attests  the  reaHty  of  the  disorder. 

You  will  find  one  of  these  singular  cases  related  by  Mr.  Kinder  Wood  in  the 
seventh  volume  of  the  Medico- CI drurgical  Transactions. 

The  patient  was  a  young  married  woman.  After  having  suffered  severe  pain  in 
one  side  of  her  face,  she  began  to  be  troubled  with  involuntary  movements.  They 
commenced  in  the  eyelids,  which  were  opened  and  shut  with  excessive  rapidity. 
Then  the  muscles  of  the  extremities  became  affected.  The  palms  of  the  hands  were 
beat  rapidly  upon  the  thighs,  and  the  feet  upon  the  floor.  The  motions  soon  ex- 
tended to  the  trunk  and  pelvis.  The  patient  was  suddenly  half  raised  from  her 
chair,  and  instantly  reseated.  This  was  repeated  as  quickly  as  one  action  could 
possibly  succeed  another.  Sometimes  she  had  a  propensity  to  leap  upwards,  and 
strike  the  ceiling  with  the  palm  of  her  hand ;  or  to  touch  little  spots  or  holes  in  the 
furniture  of  the  room.  Or  she  would  dance  on  one  leg,  holding  the  other  in  her 
hand.  These  attacks  were  accompanied  by  headache,  sickness,  and  vomiting.  At 
last  she  took  to  making  steps  about  the  room,  regulated  b};-  an  air,  or  by  a  series  of 
strokes  on  the  furniture  as  she  passed,  her  lips  moving  as  if  words  were  articulated, 
but  no  sound  escaping  them.  A  person,  thinking  he  recognized  the  tune  which  she 
beat  on  the  furniture,  began  to  sing  it ;  and  she  danced  directly  up  to  him,  and  con- 
tinued dancing  till  he  was  out  of  breath.  A  drum  and  fife  were  now  procured,  and 
the  same  air  played  upon  them.  She  immediately  danced  up  to  the  drum,  and  as 
close  to  it  as  possible,  till  she  missed  the  step,  when  the  motions  instantly  ceased ; 
and  this  was  found  always  to  be  the  case.  The  motions  stopped  also  when  the 
measure  was  changed ;  or  was  increased  in  rapidity  beyond  her  power  to  keep  pace 
with  it.  A  continued  roll  on  the  drum  had  also  the  effect  of  putting  an  end  to  her 
movements.  This  being  discovered,  their  approach  was  Avatched  ;  and  by  always 
rolling  the  drum  as  soon  as  they  threatened  to  begin,  the  chain  of  association  which 
seemed  to  constitute  the  disease  was  at  length  broken.  The  bowels  were  in  an 
unnatural  state  during  the  complaint ;  and  the  menstrual  discharge  appeared  on  the 


CHOREA.  40"" 

evening'  cf  the  day  on  which  it  ceased.  One  might  conceive  that  the  conduct  here 
described  was  an  indication  of  folly  or  of  insanity ;  but  Mr.  Wood  declares  that  the 
patient's  spirits  were  good,  and  her  perception  and  judgment  accurate  and  just ;  that 
during  the  absence  of  the  paroxysms  she  went  about  her  household  affiiirs  as  usual ; 
and  that  she  had  a  correct  knowledge  of  her  situation,  and  of  the  advantage  she 
derived  from  the  drum,  with  an  anxious  desire  to  continue  its  use.  She  stated  "  that 
there  always  was  a  tune  dwelhng  upon  her  mind,  which  at  times  becoming  more 
pressing,  irresistibly  compelled  her  to  commence  the  involuntary  motions." 

In  a  lady,  whom  Dr.  Abercrombie  saw,  the  following  symptoms,  among  others, 
occurred : — After  she  had  been  ill  with  various  nervous  affections  for  two  years,  she 
began  to  suffer  convulsive  action  of  the  muscles  of  the  back,  and  involuntary  twitches 
of  the  legs  and  arms,  producing  a  variety  of  movements  of  the  whole  body  very  diffi- 
cult to  describe.  These  were  much  increased  by  touching  her,  especially  on  any 
part  of  her  back.  This  is  a  symptom  quite  in  conformity  with  Dr.  Hall's  doctrine 
of  eccentric  irritation.  At  one  time  there  was  difficulty  of  deglutition,  so  that  attempts 
to  sv/allow  produced  spasms,  resembling  those  of  tetanus.  At  other  times,  after  lying 
for  a  long  while  quiet,  she  would  in  an  instant  throw  her  whole  body  into  a  kind  of 
convulsive  spring,  by  which  she  was  jerked  entirely  out  of  bed :  and  in  the  same 
manner,  while  sitting  or  lying  on  the  floor,  she  would  fiing  herself  into  bed,  or  would 
.eap,  as  a  fish  might  do,  upon  the  top  of  a  wardrobe  fully  five  feet  high.  These  are 
feats  that  surpass  the  powers  of  a  person  in  health :  and  I  say  we  should  hesitate  to 
believe  them  if  they  were  not  related  by  a  physician  of  such  sober  judgment  and 
unquestionable  veracity  as  Dr.  Abercrombie.  He  tells  us  that  during  the  whole  of 
these  symptoms  her  mind  continued  entire  :  and  the  only  account  she  could  give  of 
her  extravagance  was,  a  secret  impulse  which  she  could  not  resist. 

But  after  a  time  motions  still  more  wonderful  commenced,  affecting  the  muscles 
of  the  upper  part  of  the  back  and  neck,  and  producing  a  constant  semi-rotatory  mo- 
tion of  the  head.  This  sometimes  continued  without  interruption  night  and  day  for 
several  weeks  together ;  and  if  the  head  or  neck  were  touched,  the  motion  was 
increased  to  a  most  extraordinary  degree  of  rapidity.  These  paroxysms  were 
relieved  by  nothing  but  cupping  on  the  temples  to  the  amount  of  ten  or  twelve 
ounces,  when  the  affection  suddenly  ceased,  with  a  general  convulsive  start  of  the 
whole  body.  She  was  then  immediately  well,  got  up,  and  was  able  to  walk  about 
in  good  health  for  several  weeks ;  when  the  same  symptoms  returned,  and  required 
a  repetition  of  the  same  treatment.  All  this  went  on,  at  intervals,  for  four  years ; 
the  menstruation  during  that  time  being  irregular  and  scanty,  and  the  bowels  torpid 
She  was  pale  and  bloodless  from  the  frequent  bleedings,  but  not  reduced  in  flesh 
At  last,  in  the  spring  of  1829,  she  had  a  severe  paroxysm  of  the  rotatory  motion  of 
the  head ;  and  it  was  then  determined  to  allow  the  attack  to  take  its  course,  and  to 
direct  the  treatment  entirely  to  the  menstruation.  Sulphate  of  iron,  and  Barbadoes 
aloes,  were  prescribed.  She  went  on  for  three  weeks,  the  convulsive  motion  of  the 
head  continuing  without  intermission  night  and  day.  At  length,  in  the  middle  of 
the  night,  the  paroxysm  ceased  in  an  instant,  with  the  same  kind  of  convulsive  star' 
of  the  whole  body  with  which  it  used  to  cease  after  cupping.  At  the  same  instant 
menstruation  took  place  in  a  more  full  and  healthy  manner  than  it  had  done  for 
many  years.  From  that  time  she  remained  well ;  at  least  up  to  the  period  when 
Dr.  Abercrombie  wrote  the  account. 

The  alternating  rotatory  motion  of  the  head  is  by  no  means  an  uncommon  feature 
of  these  singular  cases.  It  occurred  in  a  patient  of  Dr.  Conolly's ;  in  whom  the 
menstruation  was  irregular,  and  about  to  cease  altogether.  It  came  on  in  parox)?-sms 
which  were  repeated  many  times  a  day,  and  was  attended  with  inordinate  loquacity. 
The  head  was  turned  from  side  to  side  about  eight  times  in  a  second,  and  each 
paroxysm  lasted  three  or  four  minutes.  The  patient  got  well  after  being  cupped 
and  leeched,  and  thoroughly  purged.  I  have  seen  precisely  the  same  thing  in  a 
hospital  patient.  Dr.  Crawford  met  with  an  instance  of  involuntary  rotation  of  the 
head,  without  pain,  but  attended  with  intolerance  of  light.  And  there  is  a  striking 
example  of  it  described  in  the  twenty-third  volume  of  the  Edinburgh  Medical  and 
Surgical  Journal,  by  Mr.  Hunter,  of  Glasgow,  who  speaks  of  it  under  the  name  o/ 


408  CHOREA 

"rotatio  or  chorea."  The  motions  are  said  to  have  been  furious  and  alarming:  they 
were  executed  with  such  extreme  rapidity,  that  it  was  difficult  even  for  the  eye  to 
follow  them.  She  appeared,  Mr.  Hunter  says,  absolutely  to  be  looking  backwards 
and  forwards,  and  in  every  direction,  at  the  same  moment.  This  woman  had  some- 
times fifty  paroxysms  of  this  kind  in  a  day :  they  greatly  exhausted  her ;  but  she 
was  perfectly  rational  in  the  intervals.  A  modification  of  the  same  kind  of  affection 
took  place  in  a  most  extraordinary  case  recorded  by  Dr.  Watt,  of  Glasgow,  in  the 
fifth  volume  of  the  Medico-Chirurgical  Transactions.  His  patient  was  a  girl  ten 
years  old.  First  she  had  headache,  accompanied  by  vomiting,  and  increased  by  the 
slightest  deviation  of  the  body  from  the  erect  posture,  either  backwards,  or  forwards 
or  to  one  side.  These  symptoms  lasted  about  a  month  ;  and  during  that  time  she 
lost  the  power  of  speech  and  of  walking.  At  the  end  of  that  period  she  was  seized 
with  a  propensity  to  twirl  round  on  her  feet,  hke  a  top,  with  great  velocity,  always 
in  one  direction ;  and  was  pleased  when  those  about  her  assisted  in  increasing  the 
rapidity  of  her  movements.  After  continuing  nearly  a  month,  these  motions  ceased, 
the  headache  relumed,  and  she  became  unable  to  move  her  neck,  or  support  her 
head.  Soon  after,  she  was  visited  with  a  new  kind  of  motion  ;  she  would  lay  her- 
self across  the  bed,  and  turning  over  like  a  roller,  move  rapidly  from  one  end  of  it 
to  the  other.  At  first  the  fits  of  this  kind  lasted  two  hours ;  but  they  gradually 
extended  to  six  or  seven  hours  every  day.  On  being  carried  into  the  garden  she 
rolled  rapidly  from  one  end  of  a  gravel  walk  to  the  other ;  and  even  when  laid  in 
the  shallow  part  of  a  river,  though  apparently  on  the  point  of  being  drowned,  she 
began  to  turn  round  as  usual.  The  rotations  were  about  sixty  a  minute.  She  made 
httle  or  no  use  of  her  arms  in  revolving.  In  about  another  month  or  six  weeks  an 
entirely  new  set  of  movements  began.  She  lay  upon  her  back,  and,  by  drawing  her 
head  and  heels  together,  bent  herself  like  a  bow,  and  then  allowing  her  head  and 
heels  to  separate,  her  buttocks  fell  with  considerable  force  upon  the  bed.  She 
repeated  these  movements  ten  or  twelve  times  in  a  minute,  first  for  six  hours  daily, 
and  at  length  for  fourteen.  After  another  space  of  about  five  weeks  had  elapsed, 
the  most  singular  freak  of  all  ensued  ;  she  became  possessed  with  a  propensity  to 
stand  upon  her  head  with  her  feet  perpendicularly  upwards.  As  soon  as  the  feet 
were  elevated  in  this  manner,  all  muscular  exertion  seemed  to  be  withheld,  and  the 
body  fell  down  as  if  dead;  her  knees  striking  the  bed  first.  This  was  no  sooner 
done  than  she  instantly  mounted  up  as  before  ;  and  continued  to  do  so  from  twelve 
to  fifteen  times  in  a  minute,  for  fifteen  hours  a  day.  After  a  variety  of  fruitless 
treatment,  a  spontaneous  diarrhosa  came  on,  and  she  recovered. 

The  spinning  motions  observed  during  a  part  of  this  case  have  been  observed  in 
other  instances. 

In  Magendie's  Journal  de  F/u/sioIogie,  the  two  following  singular  forms  of  dis- 
ease are  referred  to.  A  man,  after  some  other  symptoms  of  cerebral  disorder,  was 
seized  with  an  irresistible  inclination  to  move  forwards,  stopping  only  when  ex- 
hausted. He  would  sally  forth  into  the  streets,  and  continue  walking  straight 
forward  until  he  dropped  down  from  fatigue,  and  was  obliged  to  be  brought  home  in 
some  conveyance.  This  man  at  length  died,  and  several  tubercles  were  found  in 
the  anterior  hemispheres  of  his  brain.  Dr.  Laurent  of  Versailles,  exhibited  to  the 
Academy  of  Medicine  a  young  girl,  labouring  under  the  exactly  opposite  necessity. 
In  the  attacks  of  a  nervous  disease  she  was  irresistibly  propelled  backwards,  and 
with  some  rapidity  :  being  unable  to  avoid  obstacles  or  hollows,  she  received  many 
falls  and  bruises  in  her  course. 

I  say  that  histories  such  as  I  have  been  giving  vou  some  samples  of,  and  those 
mostly  in  an  abridged  form,  would  sound  very  like  romances,  if  they  were  met 
with  in  the  old  authors  alone,  or  if  they  were  not  attested  by  unimpeachable  au- 
thority They  resemble  chorea  in  this  respect,  that  they  are  examples  of  muscular 
actions  performed  by  persons  in  possession  of  consciousness,  and  performed  in 
spite  of  themselves.  But  in  most  other  respects  they  differ  from  what  we  now-a- 
days  mean  when  we  speak  of  chorea.  Perhaps  they  may  rank  among  hysterical 
vagaries.  It  is  remarkable  that  the  majority  of  them  occur  in  young  women,  in 
wnom  :ne  menstrual  function  is  suspended  or  irregularly  performed.     Some  persons 


CHOREA.  409 

may  consider  them  as  varieties  of  insanity.  The  patients  certainly  did  not  feign  to 
be  ill,  for  the  feats  of  strength  and  agility  which  many  of  them  enacted  were  much 
beyond  their  natural  power  and  endurance.  The  truth  seems  to  be,  that  there  are 
*  innumerable  modifications  of  the  nervous  functions,  and  that  some  of  them  are  more 
common  and  more  capable  of  being  arranged  into  groups  than  others  ;  but  that  they 
all  offer  points  of  resemblance,  like  (as  I  observed  before)  the  different  members  of 
a  large  family,  in  which  the  individuals  have  the  same  general  cast  of  features,  and 
yet  preserve  each  his  particular  identity. 

I  advert  to  these  odd  forms  of  disease  with  a  view  of  directing  your  attention  to 
such  of  them  as  may  come  in  your  way.  We  are  yet  terribly  in  the  dark  about 
morbid  affections  of  the  nerves,  both  organic  and  functional.  Hereafter  some  medi- 
cal Newton  will  arise,  and  reduce  all  these  apparently  compHcated  phenomena 
under  one  simpler  law.  At  present  all  that  we  can  do  is  to  collect  and,  as  far  as  we 
may,  to  arrange  facts,  in  the  hope  that  at  length  some  better  light  will  be  shed  upon 
the  subject.  And  it  must  be  observed  that  some  of  the  modern  researches  into  phy- 
siology do  throw  a  little  glimmering  of  illumination  into  these  dark  corners  of  pa- 
thology. In  certain  of  M.  Magendie's  experiments  on  animals  the  following  curious 
facts  were  ascertained : — When  a  vertical  section  of  the  cerebellum  of  a  rabbit  was 
made,  leaving  one-fourth  of  the  whole  adhering  to  the  crus  of  the  right  side,  and 
three-fourths  to  the  left,  the  animal  rolled  over  and  over  incessantly,  turning  itself 
towards  the  injured  side.  The  same  phenomenon  occurred  upon  the  division  of  the 
crus  cerebelli.  The  animal  lived  for  eight  days,  and  continued  during  the  whole  of 
that  time  to  revolve  upon  its  long  axis,  unless  stopped  by  coming  in  contact  with 
some  obstacle.  How  like  is  this  to  the  symptoms  exhibited  at  one  period  in  the 
girl  whose  case  is  related  by  Dr.  Watt !  Nor  is  Dr.  Watt's  case  a  singular  one  ;  M. 
Serres  has  described  another  much  resembling  it.  A  shoemaker,  sixty-eight  years 
old,  of  intemperate  habits,  after  one  of  his  debauches,  exhibited  a  kind  of  drunken- 
ness which  surprised  his  friends.  Instead  of  seeing  objects  turn  round  him,  as  a 
drunken  person  is  apt  to  do,  he  thought  he  was  himself  turning,  and  soon  began  to 
revolve  ;  and  this  lasted  till  he  died  ;  and  when  his  head  was  examined,  extensive 
mischief  was  found  in  one  of  the  peduncles  of  his  cerebellum. 

Again,  M.  Magendie  noticed  that  when  the  upper  part  of  the  cerebrum  is  gently 
removed  in  birds  and  mammalia,  they  become  blind ;  but  no  affection  of  the  locomo- 
tive powers  is  produced.  No  further  result  is  occasioned  by  the  removal  of  a  portion 
of  the  gray  matter  of  the  corpus  striatum :  but  when  the  striated  part  is  cut  away, 
the  animal  immediately  darts  forward  with  rapidity,  and  continues  to  advance  as  if 
impelled  by  some  irresistible  force,  until  stopped  by  an  obstacle ;  and  even  then  it 
retains  the  attitude  of  one  advancing.  The  experiment  was  tried  with  the  same 
resuk  upon  various  species  of  animals — dogs,  cats,  hedgehogs,  rabbits.  Guinea-pigs, 
and  squirrels.  It  seems  that  there  are  horses  that  cannot  back  ;  although  they  make 
good  progress  enough  in  a  straightforward  direction.  Now  Magendie  says  that  he 
has  opened  the  heads  of  such  horses  ;  and  has  always  found,  in  the  lateral  ventricles 
of  their  brains,  a  collection  of  water,  which  must  have  compressed  and  even  disor- 
ganized the  corpora  striata.  It  has  further  been  ascertained,  by  the  same  experi- 
menter and  by  others,  that  certain  injuries  of  the  cerebellum  cause  animals  to  move 
backwards  contrarily  to  their  will.  If  the  tail  of  the  animal  so  mutilated  be  pinched, 
he  still  persists  in  his  retrograde  course.  Injuries  of  the  medulla  oblongata  had  the 
same  effect.  Pigeons  into  which  he  forced  a  pin  through  that  part,  constantly  re- 
ceded for  more  than  a  month,  and  evenjleiv  backwards.  A  section  of  the  medulla 
oblongata,  where  it  approaches  the  anterior  pyramid,  gives  rise  to  a  movement  in  a 
•circle,  like  that  of  a  horse  in  a  mill:  the  animal,  in  its  walk  or  its  flight,  bearing 
round  continually  to  the  injured  side.  Surely  we  have,  in  these  facts,  supplied  by 
experiments  on  living  animals,  and  by  observation  of  the  phenomena  of  disease  in 
the  living  human  body,  some  of  the  materials  for  a  more  exact  knowledge,  both  of 
the  physiology  and  of  the  pathology  of  the  nervous  system,  than  we  have  yet 
reached.  M.  Magendie  supposes  that  different  portions  of  the  encephalon  are  en 
dowed  with  energies  which  tend  to  cause  motion  in  various  directions ;  that  in  the 
healthy  state  these  balance  each  other,  and  that  a  prcponderalmg  impulse  can  be 

2  k 


410  CHOREA. 

given  to  any  one  of  these  forces  by  the  will ;  but  that  when  the  equilibrium  is: 
destroyed  by  disease,  the  will  is  not  sufficient  to  counteract  the  tendencies  which  are' 
then  brought  into  play.     Mr.  Mayo  offers  a  different  explanation  of  the  phenomena. 
He  supposes  that  the  injuries  inflicted  on  the  nervous  matter  produce  a  sensation] 
analogous  to  vertigo;  and  that  the  animal  conceives  itself  either  to  be  hurried  for- 
ward, and  makes  an  exertion  to  repel  the  imaginary  force  ;  or  to  be  moving  back 
ward,  or  turning  round  in  one  direction,  and  endeavours  to  correct  this  by  moving  ; 
the  corresponding  muscles.      Whatever  may  be  the  true  explanation,  lihe   facts 
themselves  are  abundantly  curious  and  interesting,  and  I  recommend  them  to  your 
attention. 

Some  of  the  affections  that  I  have  been  describing,  fall,  perhaps,  under  th^  cate- 
gory of  those  to  which  the  appellation  of  the  leaping  ague  has  been  given  in  some 
parts  of  Scotland.  There  is  a  class  also  of  convulsive  spasmodic  affections  which 
resemble  epilepsy  on  the  one  hand,  and  chorea  on  the  other,  or  rather  form  a  hnk  of 
alliance  between  the  two,  and  which  are  especially  remarkable  for  this,  that  they  are 
capable  of  being  propagated  by  that  kind  of  imitative  contagion  of  which  I  have 
several  times  spoken.  This  point  might  be  well  illustrated  by  the  history  of  various 
sects  of  religious  enthusiasts.  One  or  two  of  those  enthusiasts  have  apparently  at 
first  worked  themselves  up  into  a  state  approaching  to  epilepsy,  accompanied  even 
by  insensibility  sometimes  ;  and  then  this  state  has  been  communicated  by  sympathy 
to  the  more  susceptible  of  their  auditors.  I  must  not,  however,  go  into  any  further 
details  on  this  subject ;  and  perhaps  I  have  prosecuted  it  too  far  already.  Those 
among  you  who  are  inclined  to  pursue  it  further  may  find  some  curious  accounts  of 
an  epidemic  which  occurred  in  Lanarkshire,  in  Sir  John  Sinclair's  Statistical  Ac- 
count of  Scotland,  under  the  head  of  the  "  Conversions  of  Cambuslang ;"  a:nd  in 
one  of  the  early  volumes  of  the  Edinburgh  Medical  and  Surgical  Journal.  Dr. 
Robertson  has  described,  in  an  inaugural  dissertation  De  Chorsed  Sancti  Viti,  a 
similar  epidemic,  which  occurred  in  the  states  of  Tennessee  and  Kentucky,  in  the 
western  districts  of  America.  This  is  also  referred  to  in  the  same  volume  of  the 
journal.  Among  other  things.  Dr.  Robertson  says,  that  while  extravagant  sounds, 
and  actions,  and  gesticulations,  were  in  the  first  instance  7vilful,  the  actors  "  at  length 
to  their  own  astonishment,  and  the  diversion  of  many  of  the  spectators,  continued  to 
act  from  necessity  the  curious  character  which  they  had  commenced  from  choice." 
I  will  only  remark  further  of  such  forms  of  nervous  disease,  that  as  they  spring  often 
from  moral  causes,  so  they  admit,  in  a  great  degree,  of  moral  remedies.  The  pranks 
played  by  the  Scotch  enthusiasts  were  brought  to  an  end  by  threatening  to  duck 
every  one  who  should  thereafter  be  attacked ;  and,  I  believe,  a  few  of  them  loere 
horseponded,  by  way  of  example.  With  respect  to  the  solitary  instances  of  per- 
verted locomotion,  our  business  must  be  to  correct  whatever  is  wrong  in  the  state  of 
the  bowels  :  in  women,  to  amend  the  disordered  uterine  functions  ;  to  strengthen  and 
confirm  the  system  generally  ;  and,  in  addition  to  the  measures  proper  to  effect  these 
objects,  I  suspect  that  the  cold  sousing  would  in  many  cases  be  found  of  most 
material  service. 


LECTURE  XXXVIII. 

Paralysis  Agitans.  Mercurial  Tremor.  Hysteria :  Two  forms  of  Hysteric  Pa- 
roxysm; Diagnosis  from  Epilepsy  ;  Class  of  Persons  most  liable  to  Hysteria  ; 
Diseases  apt  to  be  simulated  by  Hysterui ;   Treatment  ;    Prevention. 

In  the  last  lecture  I  spoke  of  chorea,  and  of  some  singular  forms  of  disorder  that 
have  sometimes  been  included  under  the  samtj  appellation;  and  I  shall  begin  the 
present  with  a  few  observations  concerning  a  disease  very  closely  allied  to  some  of 
those  which  we  were  then  considering,  and  yet  distinct  enough  to  deserve  and  require 
a  separate  notice.    I  refer  to  what  has  been  called  the  shaking  pcdsy — paralysis  agi 


PARALYSIS   AGITANS.  411 

tans.  Allusions  to  this  fo/m  of  diseaiie  are  to  be  found  in  manj-  of  tli'^,  older  sys- 
tematic writers  on  physic ;  but  it  never  was  much  attended  to  in  this  country  until 
Mr.  Parkinson  published  an  essay  upon  it  in  the  year  1817;  and  a  very  interesting 
little  pamphlet  it  is.  He  defines  the  disease  thus : — "Involuntary  tremulous  motion, 
A'ith  lessened  muscular  power,  in  parts  not  in  action,  and  even  when  supported : 
with  a  propensity  to  bend  the  trunk  forwards,  and  to  pass  from  a  walking  to  a  run- 
ning pace  :  the  senses  and  intellects  being  uninjured."  The  latter  symptoms  consti- 
tute the  scelotyrbe festinans  of  Sauvages  ;  and  the  former  symptoms  of  the  definition 
are  not  always  attended  by  the  latter.  In  old  persons  you  may  often  observe  incessant 
and  involuntary  nodding  and  shaking  of  the  head,  without  any  tendency  to  run  for- 
wards. There  is  an  old  woman  whom  I  see  regularly  sitting  in  the  aisle  at  church 
every  Sunday ;  she  walks  to  her  seat  slowly  and  steadily  enough,  and  sufficiently 
upright ;  but  her  head  never  ceases  to  nod,  and  wag,  and  tremble  in  various  directions. 
It  may  be  that  she  is  in  the  less  advanced  stage  of  the  malady ;  but  I  have  remarked 
her  for  three  or  four  or  more  years,  and  I  see  no  change. 

Mr.  Parkinson's  notice  was  first  called  to  the  disease  during  his  professional  attend- 
ance upon  a  person  afl^ected  by  it.  From  observation  of  that  case,  and  of  several 
others  that  he  subsequently  met  with,  his  account  of  the  disorder  was  drawn  up. 
He  states  that  its  first  approach  is  insidious,  and  its  progress  often  so  slow  and  imper- 
ceptible that  the  patient  cannot  recollect  precisely  when  it  began.  A  sense  of  weak- 
ness, and  a  disposition  to  trembling,  fastens  on  some  particular  part :  sometimes  it  is 
the  head,  but  more  commonly  it  is  one  of  the  hands  or  arms.  These  symptoms 
gradually  become  more  decided ;  and  at  length  the  morbid  influence  is  felt  in  some 
other  part.  At  a  still  more  advanced  period  the  patient  is  found  to  be  less  strict  than 
usual  in  preserving  an  upright  posture,  even  when  standing  or  sitting,  but  especially 
when  walking.  By  degrees  he  finds  a  difficulty  in  making  the  hand  obey  the  dictates 
of  the  will  when  he  is  engaged  in  any  delicate  manipulation — in  writing,  for  exam- 
ple ;  and  he  is  obliged  to  walk  with  circumspection  and  care  :  his  legs  are  not  raised 
t(»  that  height,  nor  with  that  promptitude  which  the  will  directs;  so  that  much 
attention  is  necessary  to  prevent  frequent  falls.  Then,  as  the  malady  proceeds,  the 
propensity  to  lean  forwards  becomes  more  strong — the  patient  is  forced  to  step  on 
the  toes  and  fore-part  of  the  feet,  while  the  upper  part  of  the  body  is  thrown  so  far 
forward  as  to  render  it  difficult  to  avoid  falling  on  the  face :  in  some  cases  he  is  irre- 
sistibly impelled  to  take  much  quicker  and  shorter  steps  than  common,  and  thereby 
to  adopt  unwillingly  a  running  pace.  When  once  this  state  has  been  pointed  out,  I 
make  no  doubt  that  some  of  you  may  recognize  it  in  old  persons  whom  you  may 
have  seen  walking  about.  But  the  disorder  does  not  stop  here  :  the  unhappy  patient 
becomes  unable  to  feed  himself;  or  to  walk  at  all  without  an  attendant,  who  walks 
backwards  before  him,  and  prevents  his  faUing  forwards  by  the  pressure  of  his 
hands  against  the  fore  part  of  the  patient's  shoulders :  his  powers  of  speech  and 
deglutition  fail;  and  the  saliva  dribbles  from  his  mouth ;  he  can  no  longer  retain  his 
urine  or  feces ;  and  at  length  death  closes  the  miserable  scene. 

Mr.  Parkinson  conjectures  that  this  complaint  results  from  some  chronic  change 
of  the  upper  part  of  the  spinal  cord,  or  of  the  medulla  oblongata :  but  dissections 
are  wanting  to  support  or  to  refute  that  conjecture.  Some  of  the  patients,  whose 
cases  he  has  given,  had  been  intemperate  livers  ;  hard  drinkers  ;  others  had  not 
been  guilty  of  any  such  excesses :  several  had  suffered  a  good  deal  from  rheuma- 
tism, which  he  thought  might  have  laid  the  foundation  of  their  lamentable  disease. 
But  a  more  exact  pathology  of  the  shaking  palsy  is  still  needed.  Dr.  M.  Hall 
observes  that  the  symptoms  have,  in  several  particulars  a  marked  resemblance  to  the 
effects  observed  by  M.  Serres  (and  related  in  his  Jlnatomie  du  Cerveau)  of  disease 
of  the  tuber  annulare,  or  of  the  tubercula  quadrigemina. 

Nor  have  we  any  ascertained  means  of  curing  this  disease ;  or  rather  this  state  ot 
decay.  Dr.  Elliotson  indeed  says  that  he  succeeded  in  one  instance  (of  which,  how- 
ever, the  particulars  are  not  given),  with  the  carbonate  of  iron ;  but  that  he  had 
tried  the  same  medicine  in  vain  in  several  other  cases.  We  must  administer  to 
symptoms,  and  endeavour  to  set  those  functions  right  which  may  be  obviously 
wrong:  to  regulate  .the  bowels,  to  procure  sleep,  to  nourish  and  uphold  the  pa 


412  MERCURIAL    TREMOR. 

tient  without  unduly  stimulating  him;  and  this  is  all  that  I  can  tell  you  of  the 
shaking  palsy. 

Another  analogous  disorder,  meriting  a  moment's  notice,  is  that  peculiar  kind  of 
trembling  which  is  apt  to  occur  in  persons  who  are  much  exposed  to  the  poisonous 
lumes  of  mercury :  mercurial  tremor  it  is  called  ;  and  popularly,  the  trembles.  It 
consists  of  a  sort  of  convulsive  agitation  of  the  voluntary  muscles,  which  is  most 
violent  whenever  efforts  are  made  to  move  the  hmbs  by  the  help  of  those  muscles ; 
whenever,  in  fact,  volition  is  brought  to  bear  upon  them.  It  differs,  therefore,  from 
the  shaking  palsy,  inasmuch  as  the  tremor  ceases  when  the  muscles  are  supported, 
or  are  not  called  into  action.  It  is  also  more  susceptible  of  relief  by  medicine.  The 
last  person  in  whom  I  have  witnessed  this  curious  affection  has  been  twice  my  patient 
in  the  Middlesex  Hospital,  and  has  twice  got  well  there.  John  Chattin,  33  years 
old,  was  first  admitted  in  August,  1837.  He  was  led  into  the  room,  walking  with 
uncertain  steps,  his  limbs  trembling  and  dancing  as  though  they  had  been  hung  upon 
wires.  While  sitting  on  a  chair  he  was  comparatively  quiet ;  you  would  not  have 
supposed  that  he  ailed  any  thing ;  but  as  soon  as  he  attempted  to  rise  and  to  walk, 
his  legs  began  to  shake  violently  with  a  rapid,  incessant,  and  irregular  motion.  He 
could  neither  hold  them  steady,  nor  direct  them  with  precision.  Indeed  without  sup- 
port he  must  have  fallen  down.  His  arms  were  agitated  with  similar  involuntary 
movements.  His  tongue  was  tremulous,  and  he  spoke  in  a  hurried,  abrupt,  inter 
rupted,  staccato  manner,  not  natural  to  him.  He  had  no  fever.  His  pulse  was  (56, 
and  soft ;  his  skin  natural :  his  bowels  costive.  He  complained  of  shght  nausea. 
At  the  end  of  six  weeks  he  went  out  w^ell,  or  with  very  slight  remaining  weakness 
of  his  knees,  and  a  httle  occasional  tremor  upon  unusual  exertion.  In  June,  1S39, 
he  again  presented  himself,  in  a  similar  state  of  agitation  and  helplessness. 

This  man  was  a  water-gilder ;  and  had  been  employed  in  that  business  for  18  years. 
Till  somewhat  more  than  a  twelvemonth  prior  to  his  first  appearance  at  the  hospital, 
he  had  been  free  from  disease.  Then  he  began  to  tremble  a  little  ;  but  for  a  fortnight 
before  his  admission  the  shaking  had  become  so  much  worse  that  he  could  not  go  up 
stairs,  nor  even  walk  upon  uneven  ground.  The  trembling,  when  once  brought  on 
by  efforts  to  move,  did  not  cease  until  he  sat  down,  or  got  one  of  his  fellow- workmen 
to  grasp  his  limbs  tightly. 

This  singular  disorder  is  produced  by  the  agency  of  mercury  as  a  poison  upon 
the  body ;  and  especially  by  the  abforplion  of  that  metal  when  raised  into  vapour 
by  heat,  and  inhaled  in  breathing.  It  is  accordingly  very  common  among  water- 
gilders.  Water-gilding  is  the  gildinc  of  metals,  and  of  silver  in  particular,  by  means 
of  fire.  It  is  called  ?ra/e;--gilding  (  believe,  to  distinguish  it  from  other  kinds  of 
gilding,  called  gilding  in  oil.  Thf.  silver  to  be  gilded  is  covered  with  an  amalgam 
of  gold  and  mercury,  and  then  is  placed  over  a  charcoal  fire,  by  which  the  mercury 
is  raised  in  fumes  and  driven  oflj  and  the  gold  alone  is  left  adhering.  To  these 
fumes  the  workmen  are  necessarily  exposed ;  and  numbers  of  them  become  affected 
with  this  tremor,  which  is  not  a  common  result  of  mercury  applied  to  the  system 
in  other  ways.  The  same  complaint  is  frequent  among  the  workmen  in  the  quick- 
silver mines  of  Friuli  and  of  Almaden,  where  the  crude  ore  is  purified  by  the  aid  of 
heat.  Dr.  Bateman  relates,  in  the  8th  volume  of  the  Mcdico-Ckinirgicul  Traaaac- 
tions,  some  cases  like  that  which  I  have  been  describing.  But  the  best  account  of 
the  disorder  that  I  have  seen  is  given  by  Merat,  in  an  appendix  to  his  book  on  the 
Cohque  MetaUiqiie. 

The  malady  comes  on  sometimes  suddenly,  more  often  by  degrees.  The  patient 
is  less  sure  of  his  arms  than  usual:  they  become  tremulous,  and  at  last  shake,  and, 
if  he  continues  to  pursue  his  employment,  the  force  of  the  trembling  goes  on 
mcreasing,  tin  at  length  it  is  so  general  and  violent  that  he  can  persist  no  longer. 
His  power  of  locomotion  is  impaired ;  his  mastication,  his  speech,  all  his  n)anual 
operations,  are  interfered  with  ;  he  becomes  unable  to  convey  food  to  his  moudi,  and 
is  obliged  to  be  attended  to  and  fed,  like  an  infant;  and  by  and  by,  if  he  does  not 
quit  the  poisonous  atmosphere,  graver  symptoms  supervene — wakefulness,  dehrium 
loss  of  consciousness.  . 


MERCURIAL    TREMOR.  413 

As  the  tremor  increases,  the  digestive  organs  become  disordered  ;  the  appetite  falls 
off;  nausea  is  felt,  the  tongue  becomes  furred,  and  gas  collects  in  the  intestines.  The 
patients  acquire  a  remarkable  brown  hue  ;  and  their  teeth  turn  black.  The  pulse  is 
generally  full  and  slow. 

The  time  required  for  the  production  of  these  effects  varies  much  in  different 
cases ;  from  two  years  to  five-and-twenty.  Something  depends  no  doubt  upon  the 
quantity  and  intensity  of  the  fumes.  Chattin  told  us  that  the  workmen  became  ill 
whenever  they  had  a  large  job  on  hand.  In  both  his  severe  attacks  (and  very  often 
besides,  both  in  him  and  his  companions)  the  mercury  produced  salivation.  This 
was  unfrequent  in  the  patients  observed  by  Merat.  The  duration  of  the  complaint 
is  considerable  :  it  may  last  two  or  three  months,  or  longer ;  and  sometimes  it  is  not 
completely  recovered  from  at  all.     Yet  it  is  not  a  fatal  disorder. 

Although  the  visible  affection  is  of  the  muscles,  the  mischievous  operation  of  the 
poison  is  really  upon  the  nerves,  weakening  their  natural  influence.  When  the  will 
is  directed  upon  the  muscles,  they  contract  unsteadily,  and  with  frequent  remissions  ; 
their  action  is  not  sustained  ;  and  it  is  a  general  observation  by  all  who  have  written 
upon  the  disease,  that  it  is  aggravated  by  all  kinds  of  mental  emotion,  by  alarm, 
anger,  surprise.  My  patient's  shaking  was,  at  first,  augmented  by  the  shock  of  the 
shower-bath  :  and  always  became  excessive  in  thundery  weather.  So,  on  the  other 
hand,  it  has  been  noticed  that  whatever  tends  to  stimulate  and  fortify  the  nervous 
power,  does  temporary  good :  a  glass  of  wine  for  example.  Chattin  informed  us 
that,  while  the  malady  was  coming  on,  he  could  not  get  up  stairs  to  his  work  with- 
out first  swallowing  half  a  quartern  of  gin ;  and  that  he  was  obliged  to  drink  porter 
two  or  three  times  a  day. 

The  treatment  consists  in  withdrawing  the  patient  from  the  injurious  atmosphere, 
and  m  administering  tonics. 

Conium  has  been  recommended  by  Mr.  M'Whinnie.  Q,uina  has  been  found 
useful.  But  I  have  most  faith  in  preparations  of  iron.  My  patient  Chattin  mended 
decidedly  and  rapidly  when  he  began  to  take  steel.  It  was  not  the  mere  avoidance 
of  the  cause  of  the  complaint  that  produced  the  improvement,  for  he  had  been  away 
from  his  work  for  a  fortnight  before  he  applied  for  admission. 

To  prevent  this  effect  of  mercury,  the  workmen  should  be  mstructed  to  avoid,  as 
much  as  possible,  inhahng  the  poisonous  fumes,  to  ventilate  the  room  thoroughly, 
and  to  pay  great  attention  to  cleanliness.     I  believe  the  furnaces  may  be  so  built 
that  the  metallic  vapour  shall  not  reach  the  operator.      If  he  cannot  avoid  being  in 
volved  in  it,  perhaps  some  sort  of  respirator  might  afford  protection. 

[A  very  peculiar  form  of  convulsive  disease  has  recently  been  described.  It  is  charactei 
ized  by  repeated  bobbings  of  the  head  forward,  at  first  slight  and  occasional,  but  becoming, 
in  process  of  time,  so  frequent  and  powerful,  as  to  cause  a  heaving  of  the  head  forwards, 
towards  the  knees,  succeeded  by  an  immediate  return  to  the  upright  position,  somewhat 
similar  to  the  attacks  of  emprosthotonos.  In  one  case,  related  by  J.  W.  West,  these  bobbings 
were  repeated  at  intervals  of  a  few  seconds,  ten,  twenty,  or  more  times,  in  each  attack,  which 
continued  from  two  to  three  minutes,  and  recurred  twice,  thrice  or  oftener  in  the  day;  the 
filtack  occurring  whether  the  patient  was  sitting  or  lying.  Durnig  the  attack,  the  child  re- 
tained his  consciousness.  The  other  cases  that  have  been  since  recorded  by  Drs.  Barton  and 
Bennett,  in  their  general  symptoms,  differ  in  no  degree  from  that  of  Mr.  West,  with  the 
exception  of  that  of  Dr.  Bennett,  in  which  the  disease  was  of  a  more  aggravated  character. 
Sir  Charles  Clarke  has  seen  four  cases  of  the  disease,  and  from  the  peculiar  bobbing  of  the 
head,  has  named  it  the  Salaam  Convulsion ;  Dr.  Locock  has  seen  two  cases.  One  of  Sir 
Charles  Clarke's  patients  recovered  perfectly,  the  other  became  paralytic  and  idiotic,  and  died 
at  the  age  of  seventeen.  Mr.  West  has  heard  of  two  other  cases — one  of  the  patients  lived 
to  the  age  of  seventeen ;  the  other  to  nineteen, — both  became  idiotic.  The  sex  and  ages  of 
the  patients  whose  cases  are  on  record,  are  one  female  of  seven  years,  and  two  boys  of  on© 
and  six  years — death  did  not  occur  in  either ;  in  the  female  and  one  of  tlie  boys  the  distase 
appears  to  have  ceased. 

Of  this  strange  form  of  convulsions,  the  pathology  is  still  a  subject  for  future  investigation, 
and  until  that  is  ascertained,  its  treatment  must  be  tentative  and  experimental. — C] 

I  proceed  to  the  subject  of  hysteria :  a  subject  highly  interesting  and  important, 
as  well  as  obscure  and  difficult.  I  scarcely  know  how  to  arrange  what "  have  to  say 
so  as  to  present  the  disorder  to  your  notice  in  the  most  intelligible  manner.    Hysteria 

2k3 


414  HYSTERIA. 

has  characters  peculiar  to  itself:  but  it  is  apt  also  to  assume  the  form,  and  mimic 
the  symptoms,  of  various  other  diseases  of  a  much  graver  nature.  If  we  are  not 
capable  of  distinguishing  the  true  malady  from  that  which  is  its  double,  we  shall  be 
constantly  committing  most  serious  mistakes  in  the  prognosis,  to  our  own  damage 
and  discredit;  and  in  the  treatment,  to  the  injury  of  our  patient.  I  shall  hrst 
attempt  to  describe  to  you  the  phenomena  which  are  peculiar  to  hysteria;  and  then 
to  point  out  the  class  of  persons  who  are  most  subject  to  it;  and  afterwards  I  shall 
briefly  advert  to  the  imitative  freaks  which  we  are  almost  daily  witnessing  in  hys- 
terical consiitutions,  and  to  some  other  points  connected  with  this  extraordinary 
complaint. 

I  need  not  tell  you  that  the  hysterical  joaroa:!/*^  '^  almost  exclusively  confined  to 
women. 

[We  have  repeatedly  seen  all  the  phenomena  characteristic  of  hysteria  in  the  male  sub- 
ject. The  fact  of  their  occurrence  in  males  is  also  stated  by  Sydenham,  Louyr  Villermay, 
Georget,  Ferriar,  Frotten,  Conolly  and  others.  See  also  the  admissions  of  Dr.  Watson  to- 
wards the  close  of  his  remarks  on  the  pathology  of  the  disease.-r^C] 

It  occurs  under  a  great  variety  of  forms,  but  they  may  all  be  reduced,  for  conve- 
nience of  description,  to  two.  The  first  of  these  has  a  general  resemblance  to  an 
epileptic  fit.  The  trunk  and  limbs  of  the  patient  are  agitated  with  strong  convulsive 
movements;  she  struggles  violently,  hke  a  person  contending;  rises  into  a  sitting 
posture,  and  then  throws  herself  back  again;  forcibly  retracts  and  extends  her  legs, 
while  her  body  is  twisted  from  side  to  side;  and  so  powerful  are  these  muscular 
contortions  tliat  it  often  is  all  that  three  or  four  strong  persons  can  do  to  restrain  a 
shght  girl,  and  prevent  her  from  injuring  herself  or  others.  The  head  is  generally 
thrown  backwards,  and  the  throat  projects ;  the  face  is  flushed ;  the  eyehds  are 
closed  and  tremulous  ;  the  nostrils  distended  ;  the  jaws  often  firmly  shut ;  but  there 
is  no  distortion  of  the  countenance :  the  cheeks  are  at  rest,  unless  when,  as  often 
happens,  the  patient  is  uttering  screams,  or  exclamations.  If  the  hands  are  left  at 
hberty,  she  will  often  strike  her  breast  repeatedly  and  quickly,  or  carry  her  fingers 
to  her  throat,  as  if  to  remove  some  oppression  there ;  or  she  will  sometimes  tear  her 
hair,  or  rend  her  clothes  or  attempt  to  bite  those  about  her.  With  all  this  her  breath- 
ing is  deep,  labouring,  irregular;  and  the  heart  palpitates.  After  a  short  time  this 
violent  agitation  is  calmed  :  but  the  patient  lies  panting  and  trembling,  and  starthng 
at  the  slightest  noise  or  the  gentlest  touch ;  or  sometimes  she  remains  motionless 
during  the  remissions,  with  a  fixed  eye  ;  till  at  once  the  convulsive  movements  are 
renewed  :  and  this  alternation  of  spasm  and  quiet  will  go  on  for  a  space  of  time  that 
varies  considerably  in  different  cases :  and  the  whole  attack  frequently  terminates  in 
an  explosion  of  tears  and  sobs,  and  convulsive  laughter. 

There  is  a  variety  of  this  form  of  hysterical  paroxysm,  in  which  the  patient  sud- 
denly sinks  down  insensible,  and  without  convulsions :  with  slow  and  interrupted 
breathing,  a  turgid  neck  and  flushed  cheeks;  and  she  recovers  from  that  condition, 
depressed  in  spirits,  fatigued  and  crying. 

You  will  observe  that  the  symptoms  I  have  been  enumerating  belong  to  the  nerv- 
ous system  ;  and  indicate  great  derangement  in  th^  functions  of  animal  life.  In  the 
other  of  the  two  forms  to  which  all  the  various  modifications  of  the  attack  may  be 
reduced,  the  principal  marks  of  disturbance  are  referable  to  some  of  the  viscera. 
The  patient  experiences  a  sense  of  uneasiness  in  some  part  of  the  abdomen,  fre- 
•juently  towards  the  left  flank ;  a  ball  appears  to  roll  about,  and  to  rise  first  to  the 
situation  of  the  stomach,  and  then  to  the  throat,  where  the  patient  feels  a  choking 
sensation ;  the  action  of  swallowing  is  frequently  rej>eated ;  the  abdomen  becomes 
distended  \vith  u-ind,  loud  rumblings  and  sudden  eructations  take  place ;  there 
is  much  palpitation  of  the  heart,  the  patient  is  sad  and  sorrowful,  and  prone  to 
fched  tears. 

After  the  paroxysms,  these  patients  commonly  void  a  large  quantity  of  hmpid,  pale 
anne,  looking  almost  like  water;  and  this  sometimes  expelled  during  the  fit. 

Such  is  a  brief,  and,  I  am  aware,  incomplete  account  of  the  hysterical  pa.oxysm. 
U  sets  forth,  however,  in  outline,  the  two  principal  varieties  of  the  attack  :  -xfA  yoii 


HYSTERIA.  415 

are  to  observe  that  the  last,  the  quieter  form,  is  often  the  prelude  to  the  convulsive ; 
out  it  not  seldom  also  occurs  alone,  and  then  is  as  indicative  of  hysteria,  as  the  petit 
inal,  to  which  it  is  somewhat  analogous,  is  of  epilepsy. 

And  before  I  go  any  further,  let  us  again  inquire  into  the  circumstances  which 
distinguish  the  paroxysms  of  those  two  diseases,  epilepsy  and  hysteria.  I  have 
shortly  adverted  to  these  discriminative  circumstances  before  ;  but  we  shall  be  better 
able  to  appreciate  them  now  that  the  main  features  of  each  diseased  state  have  been 
under  our  consideration.  It  is  of  great  importance  to  be  able  to  render  the  dianrnosis 
certain  and  accurate.  It  is  a  dreadful  announcement  to  have  to  make  to  a  father  or 
a  mother  that  their  child  is  epileptic ;  whereas  hysteria,  though  it  is  sufficiently  dis- 
tressing, is  attended,  in  nine  hundred  and  ninety  cases  out  of  a  thousand,  with  no 
ultimate  peril  either  to  mind  or  body.  In  some  instances  the  diagnosis  is  perfectly 
easy  :  in  others  it  is  dubious  and  full  of  anxiety.  Whenever  you  fail  to  satisfy  your- 
selves completely  as  to  the  nature  of  a  given  case,  you  will  do  well,  in  legal  phrase, 
to  give  your  patient  the  benefit  of  your  doubt,  and  acquit  her  of  epilepsy ;  or  pro- 
nounce her  guilty  of  the  minor  offence  of  hysteria. 

The  points  of  resemblance,  and  the  points  of  distinction,  belonging  to  the  hys- 
terical and  epileptic  paroxysm  respectively,  have  been  very  clearly  summed  up  by 
Foville. 

There  are  two  principal  forms  of  each  disorder.  In  each,  one  of  these  forms  is 
convulsive,  and  the  other  is  not.  The  non-convulsive  form  of  epilepsy  relates  exclu- 
sively to  the  sensorium  :  it  is  characterized  by  vertigo,  and  by  a  suspension  (how- 
ever brief  and  transitory)  of  the  mental  powers.  The  non-convulsive  form  of  hysteria 
has  little  apparent  connection  with  the  animal  functions :  its  palpable  phenomena 
consist  in  derangement  of  the  organic  functions  of  the  thorax  and  abdomen.  It  is 
the  ganglionic  portion  of  the  nervous  system  that  seems  chiefly  disturbed. 

In  the  epileptic  j^^  there  is  an  entire  loss  of  consciousness.  The  patient,  oa 
emerging  from  the  paroxysm,  recollects  nothing  of  what  has  been  going  on  durino- 
Its  continuance.  It  is  not  so  in  the  hysterical  fit.  The  loss  of  consciousness  is  very 
seldom  complete  ;  and  it  never  occurs  at  the  outset  of  the  attack.  The  patient  often 
is  able  to  repeat  (though  she  may  not  always  choose  to  confess  it)  what  has  been 
said  by  the  bystanders  during  the  period  when  she  seemed  insensible.  This  is  a 
point  of  distinction  well  worth  remembering,  for  more  reasons  than  one.  It  not  only 
helps  the  diagnosis  when  the  fact  comes  out ;  but  it  suggests  certain  cautions  to  our- 
selves. VVe  must  take  care  not  to  say  any  thing  by  the  bed-side  of  an  hysterical 
patient  which  we  do  not  wish  her  to  hear ;  and  we  may  take  advantage  of  her  appa- 
rent unconsciousness,  and  pretend  to  believe  in  it,  and  speak  of  certain  modes  of 
treatment  which  she  will  not  much  approve  of,  but  the  very  mention  of  which  may 
serve  to  bring  her  out  of  the  fit. 

In  the  epileptic  paroxysm  the  face  is  usually  livid ;  and  foam,  which  is  frothy 
with  air,  or  red  with  blood,  escapes  from  the  patient's  mouth.  These  are  symp- 
toms which  we  do  not  see  in  the  fits  of  hysteria.  The  convulsive  movements  even, 
offer  some  characteristic  shades  of  distinction.  In  epilepsy  they  are  often  more 
marked  on  one  side  of  the  body  than  on  the  other,  and  less  irregular :  the  same 
movements  are  rapidly  repeated:  there  is  a  strangling  rattle  in  the  breathing: 
while  in  hysteria  the  forcible  flexion  and  extension  of  the  limbs,  and  the  contortions 
of  the  trunk,  are  more  sudden,  and,  as  it  were,  capricious ;  the  respiration  is  deep, 
sighing,  mixed  with  cries,  and  sobs,  and  often  with  laughter.  But,  perhaps,  the  con- 
vulsive motions  differ  most  in  the  face.  The  epileptic  expression  is  usually  fright- 
ful ;  the  eyehds  half  open,  the  eyeballs  rolling,  the  mouth  drawn  to  one  side,  the 
teeth  grinding,  the  gums  exposed  by  the  retraction  of  the  lips,  the  tongue  protruded 
and  bleeding,  the  complexion  leaden :  while  in  hysteria  the  cheeks  are  red,  but  at 
rest;  the  eyelids  are  closed  and  trembling;  if  you  raise  the  upper  one,  you  will  see 
the  eye  fixed,  perhaps,  but  it  is  bright,  and  very  different  from  that  of  the  epileptic, 
which,  if  it  be  not  rolling,  is  dull,  projecting,  and  the  pupil  usually  dilated. 

Foville  states  that  when,  besides  a  sudden  loss  of  consciousness  with  convulsive 
movements,  there  are  also  lividity  of  the  face,  and  an  escape  of  frothy  saliva  from 
between  the  hps,  and  the  con'ulsions  are  more  pronounced  on  the  one  side  of  the 


416  HYSTERIA. 

body  than  on  the  other,  the  disease  is  epilepsy,  and  not  hysteria :  and  I  think  he  is 
right. 

By  Dr.  Marshall  Hall  the  grand  distinction  between  the  two  diseases  is  affirmed 
to  be  this : — that  in  hysteria,  much  as  the  larynx  may  be  affected,  it  is  never 
closed  ;  in  epilepsy,  it  is  closed.  Accordingly,  in  the  former  we  have  heaving, 
sighing,  inspiration ;  in  the  latter,  violent  ineffectual  efforts  at  expiration.  In 
the  very  outset  of  the  epileptic  paroxysm  the  respiration,  I  believe,  is  thus  sus- 
pended. 

The  hysterical  seizure  may  be  over  in  a  quarter  of  an  hour,  or  in  less  time  than 
that ;  or  it  may  last  many  hours,  or  even  several  days. 

The  hysterical  seizure  is  almost  peculiar  to  women :  and  it  seldom  occurs  in  them 
except  during  that  period  of  their  lives  in  which  the  menstrual  function  of  the  uterus 
is  or  ought  to  be  in  activity.  In  this  country  it  is  most  apt  to  occur  between  the 
ages  of  fifteen  and  forty ;  and  in  the  vast  majority  of  patients  who  do  suffer  it,  you 
will  find  some  marked  derangement  of  that  particular  function.  These  facts  alone 
afford  a  strong  corroboration  of  the  ancient  theory,  which  ascribed  the  whole  of  the 
phenomena  to  uterine  disorder ;  and  named  the  disease  accordingly.  You  will  hear 
or  read  of  disputes  as  to  whether  the  womb,  with  its  appendages,  or  the  nervous 
system,  is  the  seat  of  hysteria.  But  such  disputes  are  merely  verbal,  I  conceive. 
No  doubt  the  convulsive  movements,  and  the  mental  affection,  and  the  unnatural 
sensations,  depend  upon  some  altered  condition  of  the  brain  and  nerves ;  but  it  does 
not  follow  that  the  disease  originates  in  that  altered  condition.  We  know  that  the 
uterus  or  the  ovaries  cannot  of  themselves  determine  the  muscles  to  contract; 
but  if  they  be  in  an  unhealthy  state  they  may  act  upon  the  muscles  through  the 
inedhan  of  the  nervous  system :  and  such  I  take  to  be  the  fact.  How  they  do  so 
we  no  more  know  than  we  know  how  the  little  finger  is  bent  when  we  resolve  to 
bend  it. 

But,  say  some,  we  every  day  meet  with  diseased  conditions  of  the  uterus  and 
ovaries — amenorrhoea,  dysmenorrhoea,  monorrhagia,  even  disorganization — without 
any  of  these  nervous  symptoms.  True  ;  and  we  cannot  always  fathom  the  mystery 
of  this.  But  one  thing  is  certain,  that  there  exists  in  some  persons  a  much  greater 
readiness  to  take  on  the  disease,  upon  the  application  of  the  exciting  cause,  than  in 
others.  This  predisposition  I  have  had  occasion  to  advert  to  again  and  again,  since 
I  began  to  speak  of  the  spasmodic  diseases  of  the  nervous  system.  Such  diseases 
occur  in  certain  individuals  only;  and  in  these  individuals  there  pre-exists  a  pecu- 
liar condition  of  the  nervous  system,  "for  which,"  says  Dr.  Alison,  "we  have  no 
more  precise  or  definite  expression  than  nervous  irritability  or  mobility;  a  con- 
dition which  is  more  common  in  women  and  children  than  in  men ;  and  more  com- 
mon in  all  persons  when  in  a  state  of  weakness,  than  when  in  the  full  enjoyment 
of  muscular  strength ;  in  women,  particularly,  more  common  about  the  menstrual 
periods,  and  immediately  after  delivery,  than  at  other  times ;  more  common  likewise 
in  those  in  whom  the  monthly  discharge  is  habitually  excessive  or  altered  as  in  leu- 
corrhoettt  or  suddenly  suppressed,  or  more  gradually  obstructed  in  the  different  forms 
of  amenorrhoea,  than  in  others.  In  this  condition  of  mobility,  both  sensations  and 
»;motions  are  intensely  felt;  and  their  agency  on  the  body  is  stronger  and  more 
lasting  than  usual ;  continued  voluntary  efforts  of  the  mind,  and  steady  or  sus- 
tained exertions  of  the  voluntary  muscles  arc  difficult,  or  impossible;  the  muscular 
motions  are  usually  rapid  and  irregular,  and  the  'animus,  nee  sponte,  varius  et  mu- 
tabilis.'  "  In  persons  of  this  movable  temperament,  spasmodic  complaints  are  easily 
excited :  and  the  tendency  to  their  recurrence  is  increased  by  each  repetition  of 
them. 

Now  the  persons  who  suffer  hysteria  are  of  this  class.  They  are  commonly 
young  women,  in  whom  the  process  of  menstruation  is  in  some  way  or  other  dis- 
ordered ;  and  who  either  are  naturally  of  a  feeble  constitution,  or  have  been  debili- 
tated by  disease,  or  by  their  habits  of  hfe.  They  often  are  pale ;  have  cold  hands 
and  feet ;  are  subject  to  chilblains  ;  eat  but  little,  and  do  not  fancy  meat,  which  they 
sometimes  absolutely  dislike  and  refuse ;  or  their  taste  is  depraved  and  capricious 
♦hey  will  devour  wax  candles,  wafers,  chalk,  sealing  wax,  slate  pencil,  and  such 


I 


HYSTERIA.  417 

irash.  And,  what  is  very  curious  and  cliaracterislic,  although  they  often  abstain 
ahnost  entirely  from  animal  food  for  weeks  or  months  together,  and  take  very  little 
nourishment  of  any  kind,  they  do  not  in  general  emaciate.  You  might  expect  that, 
under  such  a  mode  of  life,  they  would  waste  away  :  but  they  continue  round,  and 
plump,  and  smooth.     Some  of  them  are  even  ruddy. 

And  belonging  to  women  of  this  pecuhar  constitution  there  is  one  other  very  re- 
markable character,  which  it  behoves  us  to  make  ourselves  thoroughly  acquainted 
with.  Almost  any  part  of  the  nervous  system,  in  these  persons,  is  liable,  under  the 
influence  of  slight  causes,  and  even  without  any  obvious  cause,  to  fall  into  a  disor- 
dered state  of  action  and  suffering  more  or  less  resembhng  that  which  inflammation 
or  organic  disease  might  excite  in  the  same  part. 

This  is  a  most  important  fact ;  because  if  we  erroneously  ascribe  symptoms  which 
really  result  from  inflammation  to  mere  nervous  or  hysterical  disorder,  we  may 
suffer  the  patient  to  perish  for  want  of  active  measures  that  would  have  saved  her: 
and  on  the  other  hand,  if  we  apply  to  these  nervous,  imitative,  hysteric  complaints, 
the  treatment  proper  for  inflammation,  we  shall  generally,  indeed,  relieve  our  pa- 
tient for  the  time  ;  but  we  shall  leave  her  more  prone  to  the  nervous  affection  than 
before,  and  permanently  damaged  by  our  mischievous  activity. 

[On  the  subject  of  the  pathology  of  hysteria  the  reader  is  referred  to  the  very  judicious 
paper  of  Dr.  Conolly  in  the  2d  vol.  of  tlie  Cyclopa;dia  of  Practical  Medicine,  Philadelphia 
edition.  562  ct  seq. — C] 

I  say  that  almost  every  kind  of  serious  disease  may  be  mimicked  b}''  what  we  must 
call  hysteria.  And  your  skill  will  sometimes  be  severely  tasked  to  determine  the 
true  import  of  the  symptoms,  and  the  real  nature  of  the  case. 

One  of  the  diseases  which  is  most  often  copied  by  hysteria,  is  inflammation  of 
the  pcrilonmm.  You  will  find  a  patient  complaining  of  acute  pain  of  the  abdomen, 
aggravated  by  the  slightest  pressure ;  and  she  shall  have,  perhaps,  a  hot  skin,  a 
quick  pulse,  and  a  furred  tongue.  When  you  meet  with  such  symptoms  in  a 
young  female,  in  whom  there  is  any  derangement  or  irregularity  of  the  uterine 
functions,  you  will  do  well,  before  you  bleed  her  to  syncope,  and  cover  her  abdomen 
with  leeches,  to  ask  yourselves  whether  all  this  suffering  may  not  be  simply  ner- 
vous. Search  into  her  previous  history  as  narrowly  as  you  can ;  if  you  find  that 
she  has  had  similar  attacks  before  ;  if  she  has  been  known  to  suffer  hysterical  fits ; 
and  if  the  tenderness  is  excessive,  and,  as  it  were,  superficial,  felt  upon  the  slightest 
touch  as  much  as  when  firmer  pressure  is  made,  you  may  generally  spare  the  blood- 
letting, purge  the  patient  well,  and  cause  an  asafcetida  enema  to  be  thrown  into  the 
rectum ;  and  in  a  {^iw  hours  you  will  find  that  the  peritonitis  has  vanished. 

Among  the  pains  which  infest  females  of  the  hysteric  constitution,  and  which  are 
apt  to  be  erroneously  ascribed  to  inflammation,  stitches  and  pains  in  the  hypochon- 
dria are  probably  the  most  common.  They  are  oftener  complained  of  in  the  left 
hypochondrium  than  in  the  right.  These  things  are  much  more  generally  under- 
stood now  than  they  used  to  be  even  a  few  years  ago.  I  cannot  tell  you  how  many 
persons  I  have  seen  who  had  been  diligently  treated  with  leeches,  and  blisters,  and 
blue  pill,  for  supposed  chronic  inflammation  of  the  liver  or  spleen,  or  still  more 
actively  depleted  lor  presumed  pleurisy  or  pericarditis,  when  no  such  inflammation 
existed,  and  when  the  treatment,  by  reducing  the  strength,  tended  to  rivet  that 
mobility  of  system  which  was  the  chief  predisposing  cause  of  the  pains. 

You  would  scarcely  suppose  that  palsy — perfect  hemiplegia  or  paraplegia — could 
De  simulated  by  hysteria  :  yet  this  certainly  is  the  case;  and  I  have  seen  instances 
of  it  even  among  hospital  patients.  They  are  difficult  and  perplexing  cases.  The 
sudden  occurrence  of  the  paralysis,  witliout  any  of  the  other  symptoms  which 
commonly  mark  the  real  disease,  its  sudden  disappeamnce,  and,  above  all,  the 
supervention  of  an  hysterical  paroxysm,  will  often  disclose  the  true  nature  of  the 
affection.  Hysterical  affections  referred  to  the  throat  are  very  common.  Aphonia, 
for  exami)le  :  the  voice  being  lost  on  a  sudden,  and  returning  as  suddenly.  Mock 
laryngitis.  I  remember  being  a.sked  by  Sir  Charles  Bell  some  years  ago  to  see  a 
young  woman  in  the  INIiddlesex  Hospital  under  his  care.  She  had  recently  arrived, 
27 


418  HYSTERIA. 

and  was  breathing  with  the  stridulous  noise  peculiar  to  inflammation  of  the  larynx 
She  had  twice  before,  in  the  country,  had  tracheotomy  perfornried  for  similar  attacks; 
and  there  were  the  scars  of  the  operations  on  her  neck :  but  both  Sir  Charles  and 
myself  were  satisfied,  upon  considering  all  the  circumstances  of  the  case,  that  the 
difficult  inspirations  Avere  spasmodic  and  hysterical;  and  she  recovered  under  the 
remedies  which  do  good  in  hysteria.  Inability  to  swallow,  dysphagia,  is  anolhei 
of  the  hysterical  vagaries  relating  to  the  parts  about  the  throat.  Dr.  Bright  has  a 
veiy  instructive  case  of  that  kind.  A  patient  was  sent  to  Guy's  Hospital  for  stric- 
ture of  the  CESophagus.  It  was  stated  that  the  difficulty  of  deglutition  had  existed 
for  several  weeks,  and  was  increasing.  The  surgeon  under  whose  care  she  was 
admitted  was  instantly  struck  by  certain  circumstances  which  did  not  seem  to  consist 
very  well  with  the  notion  that  there  was  organic  disease.  Her  appearance  belied  it, 
and  her  age.  But  he  thought  it  right  to  examine  the  esophagus  by  means  of  a 
probang  ;  and  no  sooner  was  the  instrument  introduced,  than  the  patient  went  into 
an  hysterical  fit,  which  was  followed  immediately  by  hi'steria  in  several  females  in 
the  same  ward.  The  complaint  turned  out  to  be  nothii  g  but  an  hysteric  constric- 
tion, and  was  soon  completely  removed. 

Surgeons  are  familiar  with  the  "  hysterical  breast."  The  mamma  becomes 
painful,  tender,  enlarges  somewhat  perhaps.  The  girl  fears  that  a  cancer  .is  breeding. 
She  communicates  her  alarm  to  her  friends,  and  a  medical  man  is  consulted.  If  he 
happens  to  be  timid  and  inexperienced,  he  makes  matters  infinitely  worse  by  apply- 
ing leeches  and  fomentations  ;  by  examining  the  breast  at  every  visit;  and  by  keeping 
the  patient's  attention  anxiously  fixed  upon  it.  Whereas  the  treatment  ought  to  be 
directed  to  the  state  of  the  general  system ;  and  the  local  uneasiness  spoken  lightly 
of,  or  disregarded. 

Among  the  hysteric  affections  of  the  air-passages,  there  is  a  pecuhar  kind  of  cough 
which  you  ought  to  be  acquainted  with.  It  is  loud,  harsh,  dry,  more  like  a  bark 
than  a  cough.  Sometimes  it  is  incessant,  sometimes  it  occurs  in  paroxysms  which, 
I  verily  believe,  are  more  annoying  to  hear  than  to  suffer.  Hysterical  afl^ections  of 
the  diaphragm  again  are  by  no  means  rare.  I  had  a  very  obstinate  case  of  that  sort 
in  one  of  my  hospital  patients.  She  Avould  sit  in  her  bed  all  day  long,  uttering 
every  eight  or  ten  seconds  a  loud  and  most  discordant  hiccup.  And  I  remember  an 
out-patient,  who  presented  a  picture  of  perfect  health,  and  who  came  week  after 
week,  to  be  cured  of  what  I  could  consider  nothing  but  an  hysterical  eructation :  it 
was  continual  and  distressing,  and  prevented  her  from  obtaining  any  employment  as 
a  servant.  Hysterical  vomiting  is  also  frequent,  simulating  cancer  of  the  stomach. 
Nay,  hysterical  hmnatemesis.  A  romantic  girl  was  for  some  months  under  my  care 
in  the  hospital  with  that  complaint.  She  vomited  such  quantities  of  dark  blood, 
(which  did  not  coagulate,  however,)  as  I  would  not  have  believed  if  I  had  not  seen 
them.  Day  after  day  there  were  poifuls  of  this  stuff';  yet  she  did  not  lose  her  flesh, 
and  she  menstruated  regularly  ;  and  what  was  very  curious,  the  vomiting  was 
always  suspended  during  the  menstrual  period,  and  recurred  again  as  soon  as  the 
natural  discharge  ceased.  I  said  she  was  romantic;  but  I  should  rather  have  said 
that  she  had  that  peculiar  mental  constitution  which  belongs  to  hysterical  females. 
She  used  to  write  me  long  letters  of  thanks  for  my  attention,  though  I  was  heartily 
tired  of  her ;  and  these  were  couched  in  all  the  fine  language  of  the  Minerva  press 
At  last  I  sent  her  away :  just  as  bad  as  when  she  came  into  the  hospital.  This 
was  five  or  six  years  ago  ;  and  last  year  she  called  at  my  house  with  a  present  of 
some  game,  and  told  me  that  she  had  got  married  to  a  hair-dresser,  and  was  quito 
recovered. 

There  is  a  kind  of  sanguineous  expectoration  belonging  to  females  of  this  class, 
and  very  likely  to  mislead  the  unwary.  I  meet  with  two  or  three  instances  of  it 
every  year.  The  patient  excreates  daily,  or  at  irregular  intervals,  a  thinnish  fluid 
something  like  saliva,  more  or  less  tinged  and  streaked  with  brown  or  florid  blood. 
A  young  hand  investigates  diligendy  the  source  of  the  bleeding,  and  puzzles  himself 
to  determine  whether  the  case  be  one  of  hxmutemesis  or  of  hsemoplysis.  Nine  times 
out  of  ten  it  is  neither  the  one  nor  the  other.  The  blood  comes  from  the  moutii  or 
ihe  fauc('5 


HYSTERIA.  419 

Hysterical  affections  of  the  joints  are  very  common.  A  young  girl  became  my 
patient  in  the  hospital  for  some  trifling  ailment,  and  after  a  short  time  she  began  to 
complain  of  great  pain  in  her  knee  and  hip  ;  she  could  not  stand  upon  the  Hmb,  nor 
bear  to  have  it  moved  or  touched.  I  got  Sir  Charles  Bell  to  see  her :  he  was  so 
satisfied  of  the  nature  of  the  case  —  so  convinced  that  it  was  a  genuine  example  of 
inflammation  and  ulceration  of  the  hip-joint — that  he  gave  a  httle  lecture  to  the  pupils 
who  stood  round  the  bed  upon  the  characteristic  position  in  which  the  patient  lay ; 
and  he  took  her  into  one  of  the  surgical  wards  to  be  under  his  own  care.  Some 
time  afterwards  I  had  occasion  to  go  into  that  ward,  and  there  I  found  my  former 
patient  with  her  heel  drawn  tight  up  against  her  buttock.  It  turned  out  that  she 
had  had  no  serious  disease  of  the  hip  at  all :  both  it,  and  the  rigid  contraction,  gave 
way  under  measures  which  could  have  done  no  good  to  an  ulcerated  joint.  I  think 
the  first  clue  to  the  real  nature  of  her  malady  was  the  occurrence  of  a  fit  of  hysteria. 
Sir  Benjamin  Brodie  says,  that  among  the  higher  classes  of  society,  at  least  four-fifths 
of  the  female  patients  who  are  commonly  supposed  to  labour  under  diseases  of  the 
joints,  labour  under  hj^steria,  and  nothing  else. 

Another  prank  belonging  to  hysteria,  and  one  which  it  is  very  necessary  that  you 
should  be  on  your  guard  against,  is  that  of  mimicking  disease  of  the  bones  of  the 
spine.  The  patient  complains  of  pain  and  tenderness  in  her  back,  and  of  weakness 
probably  in  her  lower  extremities ;  and  it  is  now  become  notorious  that  scores  of 
young  women  have  been  unnecessarily  confined  for  months  or  years  to  a  horizontal 
position,  and  have  had  their  backs  seamed  with  issues,  for  supposed  disease  of  the 
bodies  of  the  vertebrae,  who  had  really  nothing  the  matter  with  them  but  hj'steria, 
and  who  would  probably  have  soon  ceased  to  complain  if,  instead  of  being  restricted 
to  that  unnatural  imprisonment  and  posture,  they  had  taken  a  daily  gallop  on  horse- 
back. 

It  is  curious  enough  to  notice  how  the  mind  is  apt  to  become  affected  in  some  of 
these  cases.  After  the  patient  has  been  lying  supine  for  some  weeks,  she  is  unable 
to  stand  or  walk,  simply  because  she  thinks  she  is  unable.  The  instant  she  makes 
a  fair  effort  to  use  her  limbs  again,  she  can  and  does  use  them.  Her  condition  in  at 
once  reversed.  Potest  quia  posse  videticr.  Mr.  Corfe,  the  present  apothecary  to 
the  Middlesex  Hospital,  has  no  little  trouble  with  patients  of  this  kind ;  but  he  gene- 
rally succeeds  in  7naking  them  walk,  and  in  convincing  them,  as  well  as  himself, 
that  they  may  do  so  with  impunity.  Sometimes,  though  the  authority  of  the  doctor 
may  not  be  efficacious  in  this  respect,  some  stronger  influence  prevails.  A  lady  told 
me  not  very  long  ago  that  an  acquaintance  of  hers,  a  member  of  a  family  of  distinc- 
tion, had  been  lying  I  knov/  not  how  long  on  her  back ;  that  position  having  been 
prescribed  to  her  by  some  medical  man  for  a  presumed  disease  of  the  spine.  She 
lost  all  power  of  using  her  legs,  but  she  got  quite  fat,  as,  indeed,  well  she  might,  for 
her  appetite  was  remarkably  sharp,  and  she  hved  chiefly  upon  chickens ;  and  the 
number  of  chickens  she  devoured  was  incredible.  She'hved  at  a  little  distance  from 
town,  and  at  last  Sir  Benjamin  Brodie  was  sent  for  to  her.  Now  Sir  Benjamin,  to 
use  a  vulgar  phrase,  is  up  to  these  cases;  and  he  wished  to  see  her  try  to  walk: 
but  she  declared  that  the  attempt  to  do  so  would  kill  her.  He  was  resolute,  how- 
ever, and  had  her  got  out  of  bed :  and  in  a  few  days'  time  she  was  walking  about 
quite  well,  and  very  grateful  to  him  for  his  judicious  conduct.  A  medical  man  of 
less  name,  or  of  less  determination,  would  probably  have  failed.  Dr.  Bright  has  a 
good  example  of  a  somewhat  similar  kind ;  showing  the  power  of  another  form  of 
influence.  He  was  asked  to  see  a  young  lady  who  had  been  confined  to  her  bed  for 
nine  months.  If  she  attempted  to  move  she  was  thrown  into  a  paroxysm  of  agita- 
tion, and  of  excruciating  agony,  affecting  more  particularly  her  abdomen.  She  had 
almost  lost  the  use  of  the  lower  extremities  ;  and  she  and  her  friends  seemed  to  have 
given  up  all  hope  of  her  restoration.  But  she  presented  no  appearance  of  important 
disease ;  her  countenance  bore  no  marks  of  visceral  mischief;  nor  was  it  possible  to 
discover  any  proof  of  organic  change.  Dr.  Bright  set  the  case  down  in  his  own 
mind  as  one  of  hysteria.  She  seemed  to  have  derived  relief  from  some  stimulating 
injection,  and  from  certain  pills.  As  her  friends  were  in  moderate  circumstances, 
Dr.  Bright  talked  seriously  to  the  mother,  and  recommended  that  simple  water  should 
% 


420  HYSTERIA. 

be  employed  for  the  injection,  and  that  bread  pills  should  be  substituted  for  those  the 
girl  had  been  taking.  The  mother  soon  perceived  that  these  means  produced  the 
same  tranquillizing  effects  on  her  daughter  which  had  hitherto  been  ascribed  to  the 
medicine.  "My  visits,"  he  says,  "became  less  frequent ;  I  was  absent  a  fortnight 
on  my  renewing  my  visit,  no  change  had  taken  place.  I  attempted  to  get  her  shifted 
gently  from  the  bed  to  the  sofa,  but  it  was  impossible ;  the  paroxysm  almost  over- 
came her.  Once  (after  having  attended  altogether  about  nine  months)  I  called  after 
an  absence  of  nearly  a  month ;  her  sister  met  me  at  the  street-door  with  a  smiling 
face  to  tell  me  that  our  patient  was  quite  well :  and  on  inquiry,  she  related  how, 
ihree  mornings  before,  under  a  deep  religious  impression,  she  had  completely  reco- 
vered U.11  her  powers ;  and  I  found  her  sitting  up,  working  and  amusing  herself  as 
if  she  were  completely  convalescent  from  some  ordinary  illness." 

These  are  the  cases  which  suit  the  purposes  of  miracle  mongers.  A  few  years 
ago  all  the  journals  belonging  to  a  certain  party  in  the  rehgious  world  were  full  of 
an  instance  of  miraculous  cure.  The  patient  was  a  young  woman;  her  legs  had 
been  paralytic,  or  contracted,  I  forget  which  ;  some  enthusiastic  preacher  had  influ- 
ence enough  with  her  to  make  her  believe  that  if  on  a  certain  day  she  prayed  for 
recover}''  with  a  strong  faith,  her  prayer  would  be  successful,  she  would  recover  at 
once  ;  and  she  did  so.  No  one  can  doubt  that  it  was  just  such  a  case  as  those  I  have 
now  been  mentioning.  Many  of  these  pseudo-diseases  terminate  suddenly  under 
some  strong  moral  emotion.  A  fall — a  fire  in  the  house — any  overwhelming  terror, 
will  sometimes  put  an  end  to  them.  And  where  the  joints  have  been  the  parts 
affected,  several  patients  have  declared  that  they  felt  a  sensation  as  if  something  had 
snapped  or  given  way  in  the  part,  immediately  before  the  sudden  recovery  took 
place. 

Some  of  the  shapes  assumed  by  this  pathological  Proteus  are  hideous  and  dis- 
gusting. Paralysis  of  the  muscular  fibres  of  the  bladder,  or  spasm  of  its  sphincter, 
sometimes  really  occurs,  sometimes  is  only  aped,  in  hysteria.  It  is  a  common  trick 
with  these  patients  to  pretend  that  they  labour  under  retention  of  urine;  and  that, 
although  the  bladder  is  full,  they  cannot  make  water.  The  daily  introduction  of  the 
catheter  by  a  dresser  or  apprentice  appears  to  gratify  their  morbid  and  prurient  feel- 
ings. Sometimes,  no  doubt,  the  difficulty  is  real ;  but  it  is  oftener  feigned  or  exag- 
gerated. I  have  again  and  again  known  it  to  disappear  upon  the  patient's  being  left, 
without  pity,  to  her  own  resources.  But  girls  have  been  known  to  drink  their  urine, 
in  order  to  conceal  the  fact  of  their  having  been  obhged  and  able  to  void  it.  The 
state  of  mind  evinced  by  many  of  these  hysterical  young  persons  is  such  as  to  entitle 
them  to  our  deepest  commiseration.  The  deceptive  appearances  displayed  in  the 
bodily  functions  and  feelings  find  their  counterpart  in  the  menial.  The  patients  are 
deceitful,  perverse,  and  obstinate :  practising,  or  attempting  to  practise,  the  most 
aimless  and  unnatural  impositions.  They  will  produce  fragments  of  common  gravel, 
and  assert  that  these  were  voided  with  the  urine  :  or  they  will  secrete  cinders  and 
stones  in  the  vagina,  and  pretend  to  be  suffering  under  some  calculous  disease.  A 
young  woman  contrived,  in  one  of  our  hospitals,  to  make  the  surgeons  believe  that 
she  had  stone  in  the  bladder ;  and  she  actually  submitted  to  be  placed  upon  the 
operating  table,  and  to  be  tied  up  in  the  posture  for  lithotomy,  bei'ore  a  theatre-full 
of  students ;  and  then  the  imposture  was  detected.  Sometimes  they  simulate  sup- 
pression of  urine,  and  after  swallowing  what  they  have  passed,  vomit  it  up  again, 
to  induce  the  belief  that  the  secretion  has  taken  place  through  the  new  and  unnatural 
channel. 

it  is  impossible,  I  say,  not  to  pity  the  unhappy  victims  of  this  wretched  disorder, 
when  their  morbid  propensities  drive  them  to  such  acts  as  these.  1  mention  them 
because  you  must  expect  to  meet  with  such  cases  ;  and  because,  while  you  take  care 
not  to  express  your  suspicions  prematurely,  or  on  light  evidence,  you  should  be 
upon  your  guard  against  the  mortification  of  being  deceived,  by  the  false  signals 
held  out,  into  active  and  ill-directed  measures  of  treatment. 

There  is  another  very  common  hysterical  pain  which  I  ought  to  have  mentioned, 
VIZ.,  a  pain  occupying  some  one  point  in  the  head ;  the  patient  speaks  of  it  as  a 
sensaiion  like  that  which  would  be  caused  by  driving  a  nail  into  the  part ;  and  the 


HYSTERIA.  421 

afTection  has  therefore  been  called  the  clavus  hysterictis.  It  is  often  situated  just 
above  one  eyebrow ;  and  it  sometimes  comes  on  every  day%  at  the  same  hour.  Now 
\n  these  cases  it  imitates  very  closely  the  hemicrania,  which  constitutes  no  uncom- 
mon form  of  an  intermittent,  and  is  called,  accordingly,  the  brow  ague.  The  dis- 
tinction between  the  two — whether  the  affection,  I  mean,  be  hysterical  or  aguish — 
is  not  of  any  great  consequence  :  but  in  many  of  the  previous  examples  of  hysterical 
pain  mimicking  organic  or  inflammatory  disease,  the  diagnosis  is  obviously  of  the 
greatest  moment. 

How,  then,  is  it  to  be  made  ?  You  may,  generally,  I  believe,  be  led  to  a  right 
judgment  if  you  look  to  the  several  points  that  I  have  incidentally  touched  already. 
You  may  guess  that  the  affection  is  hysterical  if  the  patient  be  a  young  unmarried 
woman  :  if  there  be  any  disorder  or  irregularity  in  the  uterine  functions  ;  if  you  can 
gather  any  history  of  former  hysterical  disease  ;  and  especially  if  she  is  subject  to 
Jits  of  hysteria.  The  suspicious  symptoms  may  often  be  traced  back,  and  found  to 
spread  themselves  over  a  considerable  previous  period  of  time  :  yet  there  is  no  such 
wasting,  or  commensurate  deterioration  of  the  general  health  and  strength,  as  might 
be  expected  in  organic  disease.  When  the  complaint  simulated  is  some  acute  local 
inflammation,  and  there  is  pain  increased  upon  pressing  the  part,  you  will  find  that 
the  pain  is  aggravated  by  the  gentlest  touch ;  it  is  more  felt  if  you  brush  your  hand 
over  the  surface,  or  slightly  pinch  the  integuments,  than  when  firm  pressure  is  made  : 
and  you  will  find  also  that  this  exquisite  tenderness  is  not  limited  to  the  part  com- 
plained of.  Suppose  it  is  the  abdomen,  the  patient  will  shrink  and  exclaim  if  you 
suddenly  put  your  finger  on  her  neck,  or  her  arm.  The  suspicion  that  the  disorder 
is  nervous  or  hysterical  will  also  be  corroborated  if  the  symptoms  which  resemble 
the  symptoms  of  inflammation  arise  and  subside  rapidly,  without  obvious  cause  for 
such  fluctuation ;  anJ  if  various  organs  appear  to  be  attacked  in  succession.  Be- 
tween the  several  symptoms  that  mark  real  disease  there  is  always  (as  we  learn  by 
experience)  a  certain  congruity  and  relation ;  but  in  the  simulative  displays  of 
hysteria  the  symptoms  are  apt  to  be  irregular,  inconsistent,  contradictory.  When, 
after  the  most  careful  investigation  of  the  case,  you  still  doubt,  it  will  be  right  either 
10  pause,  or  to  treat  it  upon  the  most  tmfavourable  supposition.  The  consequences 
of  suffering  active  inflammation  to  go  on  unchecked  would  be  far  worse  than  the  tem- 
porary and  slight  and  remedial  injary  to  the  system  which  might  result  from  once 
applying  the  remedies  of  inflammation  to  a  case  of  mere  hysteria.  There  is  another 
hazard  also  which  you  must  be  aware  of,  and  seek  to  avoid  ;  that  of  overlooking  real 
disease,  when  it  is  mixed  with,  and  masked  by  hysterical  symptoms.  It  is  not  easy 
to  lay  down  positive  rules  of  action  for  all  these  supposable  cases ;  but  I  trust  that  I 
have  said  enough  to  convince  you  of  the  importance  of  making  the  diagnosis  of 
nysleric  complaints  a  careful  object  of  your  future  study. 

I  have  hitherto  spoken  of  hysteria  as  if  it  were  exclusively  a  malady  of  females. 
Etymolofrically  to  apply  that  teim  to  the  diseases  of  males  would  be  absurd.  But 
that  peculiar  modification  of  the  nervous  system  which  is  observed  in  hysteric  girls 
does  certainly  present  itself,  though  rarely,  in  young  men.  I  have  seen  two  or  three 
instances  of  what  I  could  give  no  other  name  to  than  hysteria  in  males.  One  of 
them  was  in  the  person  of  a  young  surgeon,  who  had  been  house-surgeon  to  the 
Middlesex  Hospital.  I  believe  he  applied  to  not  less  than  a  dozen  medical  men  for 
advice  ;  and  in  that  batch  I  happened  to  have  my  turn.  He  had  some  of  the  symp- 
toms that  are  ascribed  to  hypochondriasis ;  i.  e.,  he  was  exceedingly  attentive  to  his 
own  sensations,  and  fancied  he  had  a  number  of  diseases  which  had  no  existence 
but  in  his  own  imagination  :  he  showed  great  unsteadiness  and  infirmity  of  purpose; 
was  what  is  called  "  very  nervous  ;"  and  had  occasional  bursts  of  choking,  and  tears. 
and  laughter,  exactly  resembling  those  which  we  so  often  witness  in  the  other  sex. 
Many  cases  of  hysteria  in  the  male  have  been  recorded  by  different  writers.  The 
same  movable  stale  of  the  nervous  system,  and  the  same  symptoms  referable  to  lAat 
system,  may  oxist  in  both  sexes.  In  females,  in  nine  cases  out  often,  or  in  a  mu^h 
larger  proportion,  the  exciting  cause  of  the  hysteria  is  connected  with  the  sexual 
tuuctions ;  and  that  is  all  that  can  be  meant  when  it  is  asserted  that,  for  the  female 
the  complaint  is  not  badly  named,  but  has  an  intimate  dependence  upon  the  utenne 

2l 


422  HYSTERIA. 

sympathies.  At  the  same  time  it  is  quite  true  that  the  "  uterus  is  not  the  only  orgar 
0?  which  the  irritation  niaj^  so  affect  the  nervous  system  as  to  produce  hysteria." 

As  in  epilepsy,  so  also  in  h3'steria,  the  treatment  to  be  adopted  regards,  first,  the 
paroxysm  itself;  secondl}^  the  condition  of  the  patient  during  the  absence  of  the 
paroxysm. 

One  object,  during  the  paroxj'sm,  is  to  prevent  the  patient  from  injuring  herself, 
by  her  hands,  or  by  her  teeth,  or  in  her  convulsive  movements.  Her  dress  should 
be  loosened ;  but  it  may  be  necessary  to  confine  her  hands  and  arms.  The  next 
thing  to  be  aimed  at  is  the  putting  an  end  to  the  fit.  Various  measures  are  found 
more  or  less  useful  for  that  purpose.  The  patient  should  be  surrounded,  as  far  as 
that  is  possible,  with  cool  fresh  air.  If  she  is  able  to  swallow,  j'ou  may  sometimes 
shorten  the  attack  by  administering  a  couple  of  ounces  of  the  n:iistura  assafetida ;  oi 
half  a  drachm  of  ether,  with  fifteen  or  twentj'  minims  of  laudanum,  in  camphor  julep, 
or  a  draught  containing  a  drachm  of  the  ammoniated  tincture  of  valerian.  When 
the  patient  cannot  or  will  not  SAvallow,  she  may  sometimes  be  brought  about  by 
stimulating  volatile  substances  offered  to  the  nostrils.  Signal  good  may  also  be 
effected  by  fetid  or  stimulant  enemata ;  the  enema  assafetida,  for  example,  made  by 
mixing  two  drachms  of  assafetida  with  half  a  pint  of  water,  by  means  of  the  yolk  of 
an  es.g ;  or  the  turpentine  injection,  made  in  the  same  manner,  and  containing  half 
an  ounce  of  turpentine ;  or  the  same  quantity  of  ice-cold  water  thrown  into  the  rec- 
tum, or  applied  to  the  pudenda,  will  often  bring  the  fit  to  a  speedy  termination. 
Indeed  I  believe  thq^-e  is  more  virtue  in  cold  water,  in  hysterical  diseases,  than  in 
any  other  single  remedy.  In  the  parox5-sm  it  may  be  freely  and  repeatedly  sprinkled, 
or  dashed  with  some  force,  upon  the  face  and  chest.  Active  purges  are  beneficial 
and  requisite  in  almost  all  these  cases.  There  is  coramonl}^  a  costive,  sometimes  an 
obstinate,  and  alwa)-s  an  unnatural,  state  of  the  bowels. 

In  those  long  paroxj^sms — if  they  may  be  so  called — in  which  some  other  disease 
is  simulated  by  hysteria,  the  cold  afflision  is  a  most  valuable  resource :  especially  in 
those  forms  of  the  disorder  in  which  a  limb  is  permanently  bent,  or  incapable  of 
motion.  In  several  instances,  in  which  such  contraction  had  existed  for  a  long 
time,  it  has  yielded,  in  the  Middlesex  Hospital,  to  a  few  minutes'  application  of  the 
cold  douche.  Mr.  Corfe,  as  I  stated  before,  takes  much  pains  with  these  cases  :  he 
pours  cold  water  from  a  tea-kettle,  or  any  other  convenient  vessel,  in  a  small  stream, 
from  a  moderate  height,  upon  the  contracted  limb.  It  has  been  bent  up  for  weeks 
perhaps ;  no  power  that  you  are  able  to  exert  can  extend  it ;  and  any  very  forcible 
attempts  to  straighten  it  give  the  patient  extreme  pain.  After  the  stream  of  water 
has  been  kept  up  for  a  short  time,  the  patient  complains  of  it  very  much ;  but  Mr. 
Corfe  is  inflexible — more  so  than  the  culprit  limb — he  goes  on.  Presentlj"  the  limb 
begins  to  tremble,  the  tight  state  of  the  muscles  is  evidently  on  the  point  of  yield- 
ing, and  in  no  long  time  they  are  entirely  relaxed  and  manageable,  and  the  member 
becomes  as  lithe  and  movable  as  ever.  It  often  happens  that  the  state  of  contraction 
recurs ;  but  a  repetition  of  the  douche  has  always  the  same  good  efltct,  and  by  de- 
grees the  habit  is  broken,  and  the  patient  set  free.  It  requires  some  determination 
to  put  this  expedient  in  practice.  The  patient  looks  upon  j-ou  as  a  monster  of  cru- 
elty :  and,  in  private,  the  friends  will  not  always  allow  such  "  rough"  treatment,  as 
they  consider  it.  Sir  Charles  Clarke,  who  necessarily  sees  a  great  number  of  these 
cases — they  are  more  common  in  the  upper  than  the  lower  classes  of  society — is  a 
great  advocate  of  this  ducking  system.  A  paper  of  his  upon  the  subject  was  read 
before  the  College  of  Physicians  a  few  years  ago.  He  recommends  a  "sudden  and 
lavish"  application  of  water  to  the  face  ;  or  the  immersion  of  the  Avhole  body.  He 
describes  the  class  of  patients,  in  whom  the  hysterical  affection  which  is  curable  by 
that  method  occurs,  as  being  generally  females  of  a  pasty  complexion,  fat,  pale,  and 
weak  ;  or  such  as  evince  the  ordinary  signs  of  debility,  a  feeble  pulse,  cold  extremi- 
ues,  and  purpleness  of  parts  distant  from  the  centre  of  circulation.  The  age  of  the 
patients  varied  from  ten  to  thirty  years ;  in  many  of  them  menstruation  was  imper- 
fect, or  absent.  * 

A  medical  practitioner  whom  I  met  lately  at  a  patient's  house,  told  me  he  had 
just  come  from  another  patient,  upon  whom  he  had  seen  a  surprising  cure  performed. 


HYSTERIA.  423 

A  young  lady,  for  many  days,  had  been  affected  with  trismus.  She  was  unable  to 
open  her  jaws,  and  therefore  could  neither  speak  nor  eat.  At  last  Sir  C.  Clarke 
was  called  in  to  see  her.  He  presently  comprehended  the  nature  of  her  ailment, 
Had  her  placed  with  her  head  hanging  over  a  tub  by  the  side  of  the  bed :  and  pro- 
ceeded to  pour  pitchers  of  cold  water  on  her  face.  Before  he  had  emptied  the 
second  the  patient  began  to  scream  and  complain,  giving  very  audible  indications 
that  she  could  open  her  mouth.  I  say  although  these  patients  get  great  relief  by  the 
treatment,  they  do  not  like  it ;  and  if  they  are  convinced  that  it  will  be  put  in  force, 
they  will  generally  contrive  not  to  require  it. 

Of  all  the  spasmodic  affections,  hysteria  is  that  which  is  most  readily  propagable 
by  what  may  be  called  moral  contagion.  If,  in  a  large  ward,  one  girl  goes  off  in  a 
fit,  half  a  dozen  others  perhaps,  all  who  happen  to  possess  the  hysteric  diathesis,  will 
experience  a  strong  inclination  to  follow  her  example.  But  this  chorus,  as  it  were, 
of  hysteria,  is  much  more  common  in  some  wards  than  in  others.  A  stern  nurse,  or 
a  general  order  that  the  cold  affusion  shall  at  once  be  employed  in  every  instance  of 
an  hysterical  fit,  will  keep  the  complaint  wonderfully  in  check:  and  on  the  other 
hand,  great  sympathy  with  such  patients  has  a  striking  effect  in  encouraging  the 
paroxj'sms.  These  facts  show  that  the  symptoms  are,  to  a  certain  degree,  under  the 
patient's  control.  The  fits  are  not  wholly  wilful ;  neither  are  they  wholly  uncon- 
querable. 

I  have  but  little  to  say  respecting  the  medical  management  of  such  patients  in 
the  intervals  between  the  paroxysms.  The  objects  to  be  aimed  at  are,  to  restore  the 
nervous  system  to  the  requisite  degree  of  stability :  and  to  correct  the  disordered 
functions  of  the  uterine  system.  Now  much  the  same  plan  of  treatment  is  applica- 
ble to  both  these  objects ;  and  I  spoke  of  the  remedies  that  are  found  most  beneficial 
for  giving  tone  and  firmness  to  the  system,  when  I  was  upon  the  subject  of  epilepsy, 
and  other  nervous  spasmodic  ailments.  The  following  points  must  be  kept  in  view. 
The  regulation  of  the  bowels,  which  are  mostly  sluggish,  by  aloetic  aperients ;  the 
exhibition  of  some  form  or  other  of  steel ;  the  steady  employment  of  the  shower  bath  ; 
regulated  exercise,  both  on  foot  and  on  horseback;  the  avoidance  of  hot  rooms  and 
of  late  hours,  both  in  respect  to  going  to  bed,  and  to  rising  from  it ;  the  avoidance 
also  of  strong  moral  emotions,  of  novel-reading,  and  of  all  the  other  thousand  modes 
of  dissipation,  mental  and  bodily,  which  always  accompany,  and  abate  the  blessings 
of,  a  high  state  of  civilization.  Marriage  often  proves  a  cure :  sometimes  it  does 
not. 

The  disposition  to  hysterical  disorder  may  be  more  easily  prevented  than  cured  ; 
but  upon  this  point  medical  men  are  not  consulted.  Parents  do  not  foresee  the 
misery  they  are  often  laying  up  for  their  daughters  by  the  unnatural  mode  of  hfe 
to  which  they  are  subjected  for  the  sake  of  filling  them  with  fashionable  accomplish- 
ments. I  cannot  close  this  subject,  and  this  lecture,  better  than  by  quoting  Sir  Ben- 
jamin Brodie's  remarks  on  the  same  point,  as  I  find  them  in  a  little  work  recently 
published  by  him,  and  containing  many  highly  valuable  observations  and  instruc- 
tions in  respect  to  local  hysterical  affections. 

"  You  can  render  (he  sa3''s)  no  more  essential  service  to  the  more  affluent  classes 
of  society,  than  by  availing  yourselves  of  every  opportunity  of  explaining  to  those 
among  them  who  are  parents,  how  much  the  ordinar}'  system  of  education  tends  to 
engender  the  disposition  to  these  diseases  among  their  female  children.  If  you 
would  go  further,  so  as  to  make  them  understand  in  what  their  error  consists,  what 
they  ought  to  do,  and  what  the}'  ought  to  leave  undone,  you  need  only  point  out  the  dif- 
ference between  the  plans  usually  pursued  in  the  bringing  up  of  the  two  sexes. 
The  boys  are  sent  at  an  early  age  to  school,  where  a  large  portion  of  their  time  is 
passed  in  taking  exercise  in  the  open  air;  while  their  sisters  are  confined  to  heated 
rooms,  taking  little  exercise  out  of  doors,  and  often  none  at  all,  except  in  a  car- 
riage. Then,  for  the  most  part,  the  latter  spend  much  more  of  their  time  in  actual 
study  than  the  former.  The  mind  is  over-educated  at  the  expense  of  the  physical 
structure:  and  after  all  with  little  advantage  to  the  mind  itself:  for  who  can  doubc 
that  the  principal  object  of  this  part  of  education  ought  to  be,  not  so  much  to  fill 
the  mind  with  knowledge,  as  to  train  it  to  a  right  exercise  of  its  intellectual  and 


424  CATALEPSY. 


moral  faculties ;  or  that,  other  things  being  the  same,  this  is  more  easily  accom    ll 
plished  in  those  whose  animal  functions  are  preserved  in  a  healthy  state,  than  it  is 
in  others." 


LECTURE  XXXIX. 

Catalepsy.     Ecstasy.     Neuralgia:      Tic  Douloureux;  Sciatica;  Hemicrania 

There  are  yet  some  strange  forms  of  nervous  disorder  which  require  to  be  men- 
tioned;  but  upon  which  I  do  not  intend  to  (hcell.  Catalepsy  is  one  of  these  ;  and 
what  is  called  ecstasy  another.  These  affections  are  very  rare  as  well  as  very  W07i- 
derful :  so  wonderful  and  rare,  that  weak  and  superstitious  persons  have  referred 
them  to  the  interposition  of  supernatural  agents  in  human  affairs ;  and  stronger 
minded  persons,  who  happen  never  to  have  witnessed  such  diseases,  deny  their  oc- 
currence as  fabulous,  or  laugh  at  them  as  the  tricks  and  cheatings  of  imposture. 
They  certainly  do  happen,  however  ;  and  they  happen  mostly  in  the  same  class  of 
persons  in  whom  hysterical  and  nervous  complaints  of  all  kinds  are  most  common 
They  often  appear  to  be  produced  by  similar  causes  with  these ;  they  resemble  hys- 
teria in  being  seldom  attended  with  any  danger  to  life  :  their  pathology  is,  if  possible, 
still  more  obscure  than  that  of  hysteria :  and  if  I  were  to  speak  of  the  treatment 
which  would  seem  to  be  most  suitable  for  their  cure  or  prevention,  I  should  merely 
have  to  repeat  what  1  said  upon  the  treatment  and  prevention  of  hysteria,  in  yester- 
day's lecture.  I  shall  content  myself,  therefore,  with  a  short  description  of  these 
Uvo  affections,  that  you  may  be  aware  of  their  characteristic  phenomena,  and 
not  be  taken  by  surprise  in  case  either  of  them  should  occur  to  you  in  your 
practice. 

A  fit  of  catalepsy  implies  a  sudden  suspension  of  thought,  of  sensibility,  and  of 
voluntary  motion :  the  patient  remaining,  during  the  paroxysm,  in  the  position  in 
which  she  (for  it  is  almost  always  a  female)  happened  to  be  at  the  instant  of  the 
attack,  or  in  the  position  in  which  she  may  be  placed  during  its  continuance ;  and 
all  this  without  any  notable  affection  of  the  functions  of  organic  life. 

This  is  certainly  a  very  curious  state,  and  one  different  from  any  that  we  have 
yet  contemplated.  We  have  had  the  muscles  rigidly  contracted  with  tonic  spasm, 
while  the  powers  of  the  mind,  and  the  sensibility  of  the  body,  were  unimpaired. 
^Ve  have  had  the  same  muscles  shaken  with  clonic  convulsions;  both  with  and 
without  coexistent  disorder  of  the  intellectual  functions.  But  here  we  have  a  ne'n 
phenomenon ;  the  mental  faculties  are  in  abeyance,  and  the  sensibility  is  abohshed, 
and  so  also  is  the  function  of  voluntary  motion  ;  but  the  limbs  are  not  tied  down  b} 
spasm;  nor  agitated  by  successive  contraction  and  relaxation  of  their  muscles;  noi 
yet  left,  like  portions  of  dead  matter,  passively  obedient  to  the  laws  of  gravity :  thej 
assume  any  posture,  however  absurd,  however  (to  all  appearance)  inconvenieni 
and  fatiguing,  and  that  posture  they  retain,  until  some  new  force  from  without  is  ap- 
plied to  them,  or  until  the  paroxysm  is  at  an  end.  The  patient  so  affected,  with 
open  staring  eyes  often,  and  outstretched  limbs,  looks  like  a  waxen  figure ;  or  an 
manimate  statue  ;  or  a  frozen  corpse.  Indeed,  Hoffman  seems  to  have  formed  the 
strange  conclusion  that,  as  catalepsy,  so  far  as  he  knew,  occurred  most  frequently  in 
winter,  it  must  depend  on  congelation  of  the  nervous  fluid. 

'J'liese  singular  attacks  occur  in  paroxj'sms ;  and  they  have  been  known  to  alter- 
nate with  well-marked  hysteria;  and  to  take  place  in  connection  with  insanity.  1 
have  never  seen  an  instance  of  perfect  catalepsy ;  which  I  now  regret,  as  I  once  had 
an  oii})oriunity  of  doing  so  of  which  I  did  not  avail  myself.  Dr.  Gooch  has  described 
a  ciise  of  it,  as  he  witnessed  the  disease  in  a  patient  who  suffered  puerperal  mania. 
She  had  long  been  subject  to  the  common  forms  of  hysteria.  This  is  iUustrative  of 
wnat  1  have  often  stated  respecting  the  consanguinity  of  these  nervous  disorders.  It 
had  become  necessary  to  confine  this  patient  in  a  strait- waistcoat ;  she  was  at- 
tended by  Dr.  GJooch  and  Dr.  Sutherland.     I  will  quote  Dr.  Gooch's  account  of  the 


ECSTASY.  425 

cataleptic  state  ;  for  it  is  authentic  and  modern.  He  says,  "  A  few  days  after  our 
first  visit  we  were  summoned  to  observe  a  reriiarkable  change  in  her  symptoms :  the 
attendants  said  she  Avas  dying,  or  in  a  trance.  She  was  lying  in  bed,  motionless, 
and  apparently  senseless.  It  had  been  said  that  the  pupils  were  dilated,  and  mo- 
tionless, and  some  apprehensions  of  effusion  on  the  brain  had  been  entertained :  but 
on  coming  to  examine  them  closely,  it  was  found  that  they  readily  contracted  when 
the  light  fell  upon  them ;  her  eyes  were  open,  but  no  rising  of  the  chest,  no  move- 
ments of  the  nostrils,  no  appearance  of  respiration,  could  be  seen;  the  only  signs  of 
life  were  her  warmth  and  pulse  ;  the  latter  was,  as  we  had  hitherto  observed  it,  weak, 
and  about  120." 

"  The  trunk  of  the  body  was  now  lifted,  so  as  to  form  rather  an  obtuse  angle  with 
the  Hmbs  (a  most  uncomfortable  posture),  and  there  left  with  nothing  to  support 
it ;  there  she  continued  sitting  while  we  were  asking  questions  and  conversing ;  so 
that  many  minutes  must  have  passed.  One  arm  was  now  raised,  then  the  other ; 
and  where  they  were  left,  there  they  remained.  It  was  now  a  curious  sight  to  see 
her,  silting  up  in  bed,  her  eyes  open,  staring  hfelesslj^,  her  arms  outstretched,  yet 
without  any  visible  sign  of  animation.  She  was  very  thin  and  pallid,  and  looked 
like  a  corpse  that  had  been  propped  up,  and  had  stiffened  in  this  attitude.  We  now 
took  her  out  of  bed,  placed  her  upright,  and  endeavoured  to  rouse  her  by  calhng 
loudly  in  her  ears ;  but  in  vain.  She  stood  up,  but  as  inanimate  as  a  statue.  The 
slightest  push  put  her  off  her  balance.  No  exertion  was  made  to  regain  it.  She 
would  have  fallen  if  I  had  not  caught  her." 

"  She  went  into  this  state  three  several  times.  The  first  time  it  lasted  fourteen 
hours,  the  second  time  twelve  hours,  and  the  third  time  nine  hours ;  with  waking 
intervals  of  two  days  after  the  first  fit,  and  one  day  after  the  second.  After  this  the 
disease  resumed  the  ordinary  form  of  melancholia ;  and  three  months  from  the  time 
of  her  delivery  she  was  well  enough  to  resume  her  domestic  duties." 

There  is  a  minor  form  of  this  affection  described,  in  which  the  patient  is  incapa- 
ble of  moving  or  speaking,  but  is  conscious  of  all  that  goes  on  around  him  at  the 
time.  I  saw  a  lady  last  year,  who  was  subject  to  these  attacks  of  imperfect  catalepsy ; 
which  have  been  whimsically,  but  very  expressively,  called  also  attacks  of  daymare. 
From  her  time  of  life,  her  habits,  and  some  other  points  in  the  history  of  the  diseasse, 
I  concluded  that  in  her  case  these  seizures  of  temporary  loss  of  muscular  power 
without  loss  of  consciousness  were  dependent  upon  a  diseased  state  of  the  blood- 
vessels of  the  brain.  She  afterwards  consulted  Dr.  Chambers ;  and  he  told  me  that 
he  had  formed  the  same  opinion  of  the  nature  and  cause  of  the  symptoms. 

In  what  is  called  ecstasy,  the  state  is  different.  The  patient  is  lost  to  all  external 
impressions  ;  but  wrapt  and  absorbed  in  some  object  of  the  imagination.  The  muscles 
are  sometimes  relaxed  ;  sometimes  rigid  as  in  slight  tetanus  :  but  the  loss  of  volun- 
tary power  over  them  is  not  complete  or  universal,  for  these  patients  often  speak  in 
a  very  earnest  manner,  or  sing.  They  are,  as  the  term  ixataai^  imports,  out  of  the 
body  at  the  time,  wholly  engrossed  in  some  high  contemplation.  This  state  is  not 
uncommon  as  forming  a  part  of  religious  insanity  :  and  sometintres  it  runs  into  ordi- 
nary hysteria.  Nervous  and  susceptible  persons  are  apt  to  be  thrown  into  these 
trances  under  the  influence  of  animal  magnetism :  and  grave  authors  assure  us  that 
the  intelligence  which  then  deserts  the  brain  concentrates  itself  in  the  epigastrium; 
or  at  the  tips  of  the  fingers :  that  people  in  that  state  read  letters  which  are  placed 
upon  their  stomach,  or  applied  to  the  soles  of  their  feet;  answer  oracularly,  enig- 
matical questions ;  describe  exactly  their  own  internal  organic  diseases ;  and  even 
foretell  future  events.  Credat  Judccus  Appella,  Non  ego.  I  take  for  granted  that 
they  who  were  in  the  habit  of  speaking,  a  few  years  since,  in  some  of  our  places  of 
worship,  in  what  they  called  unknown  tongues,  were  either  gross  impostors,  who 
deserved  to  be  publicly  w'hipped,  or  persons  labouring  under  this  disease,  and  want- 
ing physic.  Dr.  Copland  mentions  a  curious  fact  in  connection  with  this  subject. 
He  says  that  many  of  the  Italian  Improvisator!  are  in  possession  of  their  peculiar 
faculty  only  while  they  are  in  a  state  of  ecstatic  trance  ;  and  that  few  of  them  enjoy 
good  health,  or  consider  their  gift  as  otherwise  than  something  morbid. 

I  repeat  that  I  can  add  nothing  respecting  the  pathology  or  llie  managemens  of 

^l2 


426  NEURALGIA. 

these  diseases,  to  what  I  have  already  said  in  reference  to  the  whole  class  to  which 
they  belong. 

Leavinfj  these  nervous  disorders,  in  which  the  function  of  voluntary  motion  is  so 
curiously  modified  ;  and  in  which  there  sometimes  is  no  alte^ration  of  the  intellectual 
faculties,  and  sometimes  very  great  disturbance,  or  the  complete  suspension  of  them  : 
I  would  beg  to  turn  your  attention  to  another  class  of  complaints,  in  which  the  nerv- 
ous system  is  still  the  part  principally  interested,  but  in  which  the  deviation  from 
the  natural  state  is  manifested  chiefly  in  the  function  of  sensation  ;  the  powers  of 
thought  and  of  voluntary  motion,  being  scarcely  affected,  or  not  affected  at  all.  Com- 
plaints, I  mean,  in  which  the  sensibility  is  perverted,  and  augmented  ;  cases  of  nerv- 
ous pain.  We  have  considered  before  that  modification  of  sensation  which  consists 
in  numbness,  or  anaesthesia,  i.  e.,  in  the  diminution  of  the  natural  sensibility,  or  its 
total  privation.  We  have  noticed  also  incidentally  many  perversions  of  sensation ; 
such  as  giddiness,  nausea,  faintness,  and  the  hke  ;  and  in  the  same  incidental  way 
the  morbid  exaltation  of  the  sensibility  which  is  called  pain,  has  come  before  us,  as 
a  symptom  of  various  other  diseases  ;  of  inflammation,  and  of  hysteria.  But  there 
are  diseases  which  consist  of  pain,  and  of  nothing  else,  that  we  can  perceive.  They 
are  often  attended  bj'  no  inflammation,  no  detectable  change  of  structure  in  the  pain- 
ful part,  no  fever.  These  affections  are  included  under  the  general  term,  neuralgia. 
Now  pain  is  one  of  the  things  which  we  are  oftenest  consulted  about ;  and  these 
neuralgic  pains  are  apt  to  be  excessively  severe  and  troublesome ;  and  it  cannot  but 
be  of  importance  to  understand  what  has  been  ascertained  of  their  nature,  and  causes, 
and  capability  of  cure. 

That  pain  is  owing  to  some  morbid  condition,  or  to  some  irritation  of  a  particular 
nerve,  we  may  sometimes  know,  by  finding  that  it  occupies  exactly  the  course,  and 
follows  the  distribution  of  that  nerve.  But  when,  as  often  happens,  the  pain  is  con- 
fined to  a  certain  spot,  we  then  conclude  it  is  neuralgic,  if  and  because  we  can  find 
no  other  explanation  of  its  existence. 

What  increases  the  difficulty  of  making  out  the  cause  and  origin  of  these  nervous 
pains,  is  that  they  may  be  produced  by  some  source  of  irritation  situated  at  a  dis- 
tance from  the  part  in  which  the  pain  is  felt.  It  may  be  placed  in  the  brain  itself, 
or  in  the  spinal  cord  ;  or  in  the  trunk  of  the  nerve  that  supplies  the  aflected  part ; 
or  in  one  of  the  branches  of  the  same  trunk,  which  branch  is  distributed  to  another 
part.  If  you  strike  the  inside  of  the  elbow  in  a  certain  way,  so  that  the  blow  lights 
upon  the  ulnar  nerve,  a  peculiar  tingling  sensation  is  felt  in  the  little  finger  ;  that  is, 
not  in  the  part  struck,  but  in  the  sentient  extremity  of  the  same  nerve  ;  and  the  same 
thing  happens  continually  in  disease.  There  is  an  excellent  paper  on  this  subject, 
by  Sir  Benjamin  Brodie,  published  in  one  of  the  earlier  volumes  of  the  Medical 
Gazette,  in  which  he  has  collected  numerous  and  striking  illustrations  of  the  pro- 
duction of  nervous  pain  by  irritation  situated  in  a  distant  part.  Thus,  to  take  a  case 
in  point ;  a  man  was  admitted  into  St.  George's  Hospital  on  account  of  severe  pain 
on  the  inner  side  of  his  knee.  The  joint  was  carefully  examined,  but  no  mark  of 
disease  could  be  detected  in  it.  On  tracing  the  hnib  upwards,  however,  an  aneurism 
of  the  femoral  artery,  as  big  as  an  orange,  was  discovered  in  the  thigh.  This  nhe 
patient  thought  nothing  of;  his  only  concern  was  the  pain  in  his  knee.  Sir  E.  Honr^e 
performed  the  usual  operation  for  aneurism:  and  the  moment  the  ligature  was  drawn 
firmly  round  the  artery  in  the  upper  part  of  the  thigh,  the  tumour  ceased  to  pulsate, 
and  the  pain  in  the  knee  ceased  also.  This  man  died  four  or  five  days  after  the 
operation :  and  upon  inspection  of  the  limb  afier  his  death,  the  aneurism  was  found 
reduced  to  one-half  its  former  size  ;  and  some  branches  of  the  anterior  crural  nerve, 
which  passed  over  it,  and  which  musi  have  been  kept  on  the  stretch  previously  to 
the  operation,  were  seen  to  terminate  in  the  part  to  which  the  pain  had  been  referred 
on  the  inside  of  the  knee.  There  is  just  such  another  case  related  by  Dr.  Denmark, 
in  the  Medico-CJdrurgical  JVansaclions.  A  sailor  was  wounded  by  a  musket-ball 
in  the  arm.  The  wound  healed ;  but  the  patient  remained  affected  w'ith  agonizing 
pain,  beginning  in  the  extremities  of  the  thumb  and  fingers,  except  the  little  fii-ger, 
and  extending  up  the  fore-arm.     His  sufferings  were  so  great  that  he  willingly  sub- 


NEURALGIA.  427 

/I 
milled  to  have  the  limb  amputated :  and  the  operation  gave  him  complete  and  imme- 
diaie  relief.      AVhen  the  amputated  limb  was  dissected,  a  small  portion  of  lead 
which  seemed  to  have  been  detached  from  the  ball  when  it  struck  against  the  bone, 
was  found  imbedded  in  the  fibres  of  the  median  nerve. 

These  examples  teach  us,  when  we  receive  complaints  of  pain  in  any  part,  and 
can  discover  no  cause  of  pain  in  the  part  itself,  to  look  for  some  possible  source  ot 
irritation  in  the  trunk  of  the  nerve,  from  which  the  part  in  question  is  supplied  with 
nervous  librils. 

But  the  source  of  irritation  may  be  further  back  than  this  :  it  may  depend  upon  a 
diseased  stale  of  the  spinal  marrow,  or  of  the  brain.  Of  this  we  have  had  so 
many  examples  before  us  already,  that  I  need  not  seek  for  any  new  illustrations 
of  it. 

Sometimes,  again,  irritation  applied  in  the  course,  or  at  the  extremity  of  one  branch 
of  a  nerve,  will  give  rise  to  pain  at  the  extremity  of  another  branch  of  the  same 
nerve.  The  sensation  appears  to  be  reflected,  as  il  were,  along  the  branch  which  is 
not,  direcily,  the  subject  of  the  irritation.  Thus  hlaments  of  the  phrenic  nerve  pene- 
trate the  diaphragm  and  communicate  with  the  ganglia  that  lie  around  the  cceliac 
artery;  other  hlainents  are  distributed  to  some  of  the  muscles  about  the  shoulder; 
and  in  this  way  has  been  explained  the  well-known  fad,  that  disease  or  irritation  of 
the  liver  is  very  apt  to  be  accompanied  with  pain  in  the  shoulder. 

Thus  also  we  have  pain  in  the  glans  penis,  from  irritation  of  the  bladder,  produced 
by  a  stone  there  ;  ^ain  of  the  thigh  and  testicle,  from  irritation  of  the  kidney  :  pain 
in  the  left  arm,  from  disease  of  the  heart :  pain  in  the  feet,  from  stricture  and  irrita- 
tion of  the  urethra. 

I'here  are  many  pains  also,  plainly  enough  connected  with  irritation  of  distant 
parts,  although  no  olher  nervous  connection  can  be  traced  between  the  parts,  except 
that  which  is  afforded  by  the  nervous  centres.  In  such  cases  we  must  suppose  that 
the  morbid  impression  travels  to  the  brain,  and  then  the  sensation  is  referred  to  the 
part  affected  through  another  nervous  channel  of  communication.  Dr.  Wollastoa 
was  accustomed  to  relate  the  following  story  of  himself.  He  had  eaten  some  ice- 
cream after  dinner  one  day ;  and  his  stomach  did  not  seem  to  be  capable  of  digest- 
ing it.  Some  time  afterwards,  when  he  had  left  the  dinner  table  for  the  drawing 
room,  he  found  himself  rendered  lame  by  a  violent  pain  in  one  ankle.  Suddenly  he 
became  sick,  the  ice-cream  was  vomited,  and  instantaneous  relief  of  the  pain  fol- 
lowed its  ejection  from  the  stomach.  "  A  gentleman  (says  Sir  Benjamin  Brodie) 
awoke  in  the  middle  of  the  night,  labouring  under  a  severe  pain  in  one  foot.  At 
the  same  time  certain  other  sensations,  to  which  he  was  not  unaccustomed,  indi- 
cated the  existence  of  an  unusual  quantity  of  acid  in  the  stomach.  To  relieve  the 
latter  he  swallowed  a  large  dose  of  alkaline  medicine.  Immediately  on  the  acid  in 
the  stomach  having  been  thus  neutralized,  the  pain  in  the  foot  left  him." 

I'he  lesson  that  we  learn  from  all  these  facts  is  this :  that  when  we  can  find  no 
explanation  of  a  pain  in  the  very  spot  in  which  it  is  felt,  we  should  look  for  some 
condition  that  may  explain  it  in  the  trunk  of  the  nerve  supplying  that  part :  or  in 
the  pans  supplied  by  oilier  branches  of  the  same  nerve ;  or  (if  we  are  still  unsuc- 
cessful), we  look  for  other  indications  of  disease  in  the  brain  or  spinal  marrow :  and 
if  these  be  wanting,  we  should  extend  our  search,  and  inquire  whether  there  be  any 
intelligible  disorder  or  cause  of  irritation  elsewhere,  which,  operating  through  the 
medium  of  the  nervous  centres,  may  have  occasioned  the  sympathetic  pain  of  which 
our  patient  complains. 

I  say  we  should  institute  this  search,  because,  if  it  be  successful,  it  may  teach  us 
on  the  one  hand,  that  the  cause  of  the  pain  is  fixed  and  irremediable ;  or,  on  the 
other,  it  may  enable  us  by  some  simple  and  obvious  expedient  to  cure  the  pain. 
But  sometimes  we  shall  be  quite  disappointed  in  all  this  seeking.  We  shall  find 
nothing  either  in  the  living  patient,  or  in  the  dead  body,  which  throws  the  smallest 
light  upon  the  cause  of  the  neuralgia. 

Now  with  respect  to  those  neuralgic  pains,  for  which  we  can  discover  no  ade 
quale  cause,  either  in  any  diseased  structure,  or  in  any  morbid  action  of  the  blood 
vessels,  there  are  certair.  general  facts  observable  which  I  wiU  mention  bcfoie  [ 


428  NEURALGIA. 

specify  any  particular  forms  of  neuralgia.  They  occur  in  all  parts  of  the  body  ;  but 
they  are  more  frequent  about  the  head  than  in  any  other  part :  and  next  of  all,  pro- 
bably, in  the  abdomen.  In  the  head,  or  face,  the  branches  of  the  fifth  pair  of  nerves 
are  verj'  frequently  the  seat  of  neuralgia ;  and  to  such  pain,  in  that  situation,  the 
name  of  tic  douloureux  is  generally  given.  The  painful  affection  called  hemicru- 
nia  is  another  example  of  neuralgia  of  the  head.  Certain  forms  of  angina  pectoris, 
and  of  gastrodynia,  seem  to  belong  to  the  same  class  of  disorders ;  and  sciatica  — 
which  depends  on  different  causes  in  different  cases — is  often  rather  a  neuralgic  than 
a  rheumatic  pain.  I  have  stated  that  the  pains  sometimes  follow  the  track  of  cer- 
tain nerves ;  but  this  is  not,  I  think,  very  common.  Inflammation  of  the  nerve,  or 
of  its  investments,  generally  causes  pain  having  that  property  :  but  the  truly  nervous 
pains  are  much  better  characterized  by  the  suddenness  with  which  they  come  on, 
and  the  suddenness  with  which  they  sometimes  go  off  also;  by  their  intermittence 
in  many  cases,  and  the  regularity  of  the  period  at  which  they  often,  though  not 
always,  return ;  by  the  total  absence  (in  most  cases)  of  heat  and  swelling,  and  often 
of  tenderness  too,  when  they  are  external,  and  of  febrile  symptoms  when  they  are 
internal,  even  although  their  intensity  be  extreme ;  by  their  apparent  dependence, 
in  numerous  instances,  upon  sudden  changes  of  the  weather;  by  their  occurring 
chiefly  in  persons  of  a  nervous  temperament  in  whom  the  health  is  otherwise  disor- 
dered ;  and  by  their  frequently  abating  under  tonic  remedies,  or  what  are  called  spe- 
cifics, rather  than  under  antiphlogistic  treatment.  (Alison's  Outlines.)  There  is 
another  circumstance,  characteristic  of  these  pains,  which  has  been  mentioned  by  Sir 
Benjamin  Brodie,  and  I  do  not  know  that  the  same  thing  has  been  noticed  by  other 
writers.  These  pains  are  often  suspended  by  sleep.  "  A  person  suffering  from  tic 
douloureux  in  the  face  may  for  a  time  be  prevented  from  falling  asleep,  but  if  once 
asleep,  his  sleep  is  likely  to  be  sound  and  uninterrupted  for  many  hours."  He  says 
that  though  there  may  be  exceptions  to  this  rule,  they  are  comparatively  rare.  Now 
this,  you  will  observe,  is  quite  analogous  to  what  takes  place  in  certain  spasmodic 
affections  of  the  muscles  also.  The  jactitations  of  chorea  are  almost  always  sus- 
pended during  sleep.  It  is  the  same  with  the  spasmodic  wry  neck,  in  which  the 
involuntary  contraction  of  some  muscle,  commonly  the  sterno-cleido-masloideus, 
drags  the  chin  round,  and  the  head  awry.  Persons  affected  with  that  sort  of 
deformity  when  awake,  have  their  necks  flexible  enough,  I  beUeve,  while  they  are 
sleeping. 

I  mentioned  just  now  one  character  of  these  neuralgic  pains,  viz.,  the  total  ab- 
sence in  most  cases,  when  they  occupy  the  surface,  of  heat,  redness,  swelling,  or 
tenderness ;  and  I  said  in  most  cases,  because  there  are  unquestionably  exceptions 
to  this.  After  these  pains  have  been  long-continued  and  intense,  they  may  o-jve 
rise  even  to  a  moderate  degree  of  inflammation  of  the  part;  which  will  become 
tender  to  the  touch,  manifestly  vascular,  and  even  swollen  a  little.  "  In  a  gentle- 
man," mentioned  by  Sir  B.  "Brodie,  "  who  suffered  for  a  great  length  of  time  what 
was  regarded  as  a  most  severe  tic  douloureux  in  the  face,  at  first  the  parts  to  which 
the  pain  was  referred  retained  their  natural  appearance,  but  ultimately  they  be- 
came swollen,  from  an  effusion  of  scrum  into  the  cellular  texture,  and  so  exqui- 
sitely tender  that  they  could  not  bear  the  slightest  touch.  In  a  patient  who  had 
laboured  for  some  time  under  pain  in  the  testicle,  depending  on  a  calculus  passing 
down  the  ureter  into  the  bladder,  the  testicle  became  tender  and  considerably 
swelled." 

The  attacks  of  neuralgia  may  recur  at  intervals  of  a  few  seconds  onlj' :  or  they 
may  take  place  daily,  or  every  other  day  :  or  the)'-  may  be  separated  by  much  longer 
intervals,  regular  or  irregular.  Sometimes  there  is  continual  pain,  but  it  is  wonder- 
fully exalted  and  aggravated  by  fits.  It  is  described  as  being  sharp,  sudden, 
twinging,  fike  an  electric  shock  in  its  momentary  duration.  Sometimes  it  is  at- 
tended by  a  feeling  of  constriction  and  cramp,  although  no  muscular  contraction 
accompanies  it.  I  suppose  that  is  one  reason  why  such  pain  is  so  often  spoken  of 
even  by  medical  men,  and  almost  always  by  the  vulgar,  as  spasm.  AVhenever  a 
patient  tells  me  he  has  spasms  here  or  there,  I  am  obliged  to  request  that  he  wih 
explain  himself  further.     I  want  to  know  how  he  construes  spasm ;  and  nine  times 


TIC    DOULOUREUX.  429 

out  of  ten  I  find  that  he  intends  a  sudden  and  sharpish,  and  generally  a  transitory 
aitack  of  pain:  whereas  the  term  spasm  really  signifies,  and  ought  to  be  restricted 
to,  involuntary  muscular  contractions.  When  a  medical  man  prints  a  case  in  which 
he  states  that  spasms  occurred  in  suc-h  or  such  a  part,  it  is  impossible  to  tell 
what  he  means,  unless  that  term  is  explained  by  the  context.  Pray  avoid  this 
inexactness. 

The  most  common  of  these  neuralgic *pains,  as  I  have  said,  is  that  which  has  been 
called,  xav  i^oxf]v,  tic  douloiireicx,  and  which  is  situated  in  the  facial  branches  of  the 
fifth  pair  of  nerves ;  nerves,  as  you  know,  of  sensation ;  and  it  is  usually  restricted 
to  one  of  the  three  branches  that  emerge  severally  to  supply  the  parts  in  their  neigh- 
bourhood. Sometimes  two,  sometimes  all  of  them,  are  implicated.  The  middle  one 
of  these  branches,  the  infra-orbitary,  is,  I  believe,  the  most  commonly  affected  in  the 
severer  forms  of  the  complaint.  The  torture  occasioned  by  this  dreadful  malady  is 
sometimes  excessive.  The  sufferers  speak  of  it  as  anguish  that  is  scarcely  endura- 
ble ;  and  you  see,  in  their  quivering  features  and  restless  limbs,  that  the  acute  bodily 
pang  is,  indeed,  hard  to  bear. 

When  the  uppermost  branch  of  the  trifacial  nerve  is  the  seat  of  the  complaint,  the 
pain  generally  shoots  from  the  spot  where  the  nerve  issues  through  the  superciliary 
hole ;  and  it  involves  the  parts  adjacent,  upon  which  the  fibrils  of  the  nerve  are  dis- 
tributed ;  the  forehead,  the  brow,  the  upper  lid,  sometimes  the  eyeball  itself.  The 
eye  is  usually  closed  during  the  paroxysm,  and  the  skin  of  the  forehead  on  that  side 
corrugated.  The  neighbouring  arteries  throb,  and  a  copious  gush  of  tears  takes 
place.  In  some  instances  the  eye  becomes  blood-shotten  at  each  attack  ;  and  when 
the  attacks  are  frequently  repeated,  this  injection  of  the  conjunctiva  may  become 
permanent. 

When  the  pain  depends  upon  a  morbid  condition,  or  morbid  action,  of  the  middle 
branch  of  the  nerve,  it  is  sometimes  quite  sudden  in  its  accession,  and  sometimes 
comes  on  rather  more  gradually  ;  being  preceded  by  a  tickling  or  pricking  sensation 
of  the  cheek,  and  by  twitches  of  the  lower  eyelid.  These  symptoms  are  shortly 
followed  by  pain  at  the  infra-orbitary  foramen,  spreading  in  severe  flashes  (so  to 
speak)  over  the  cheek,  affecting  the  lower  eyelid,  ala  nasi,  and  upper  lip,  and  often 
terminating  abruptly  at  the  mesial  line  of  the  face.  Sometimes  it  extends  to  Ifte 
teeth,  the  antrum,  the  hard  and  soft  palate,  and  even  to  the  base  of  the  tongue,  and 
induces  spasmodic  contractions  of  the  neighbouring  muscles. 

When  the  pain  is  referable  to  the  inferior  or  maxillary  branch  of  the  fifth  pair  of 
nerves,  it  darts  from  the  mental  foramen,  radiating  to  the  lips,  the  alveolary  processes, 
the  teeth,  the  chin,  and  to  the  side  of  the  tongue.  It  often  stops  exactly  at  the  sym- 
physis of  the  chin.  Frequently  it  extends  in  the  other  direction  to  the  whole  cheek, 
and  to  the  ear.  During  the  paroxysm  the  features  are  liable  to  be  distorted  by  spas- 
modic action  of  the  muscles  of  the  face,  amounting  sometimes  to  tetanic  rigidity,  and 
holding  the  jaw  fixed  and  immovable. 

The  paroxysms  of  suffering  in  this  frightful  disease  are  apt  to  be  brought  on  by 
apparently  trivial  causes ;  by  a  slight  touch,  by  a  current  of  air  blowing  upon  the 
face,  by  a  sudden  jar  or  shake  of  the  bed  in  which  the  patient  is  lying,  by  a  knock 
at  the  door,  or  even  by  directing  the  patient's  attention  to  his  malady  by  speaking 
of  it,  and  asking  him  questions  about  it.  This  was  remarkably  manifest  in  a  patient 
who  came  into  the  hospital  under  my  care  for  another  complaint ;  but  who  had  for 
some  time  been  subject  to  tic  douloureux.  The  necessary  movements  of  the  face  in 
speaking,  or  eating,  are  often  sufficient  to  provoke  or  renew  the  paroxysm.  At  the 
same  time  firm  pressure  made  upon  the  painful  part  frequently  gives  relief,  and 
causes  a  sense  of  numbness  to  take  the  place  of  the  previous  agony. 

This  cruel  malady  occurs  most  commonly  in  persons  who  exhibit,  in  other  re- 
spects, the  signs  of  an  unsound,  or  deranged,  or  debilitated  system.  It  is  more  apt 
to  fasten  upon  those  who  are  pale,  and  asthenic,  and  upon  individuals  whose  powers 
have  been  broken  by  advancing  years.  It  is  not  unfrequently  attended  with  some 
obvious  disorder  of  the  digestive  organs,  and  ceases  or  is  mitigated  when  that  disor- 
der is  corrected.  Sometimes  it  is  clearly  connected  with  a  disposition  to  rheumatic 
affections ;  coming  on  in  persons  who  suffer  rheumatism  in  other  puts,  and  even 


430  TIC    DOULOUREUX. 

alternating  with  rheumatism  in  other  textures.  It  is  observed  to  be  common  among 
fishermen,  and  the  inhabitants  of  marshy  districts ;  and  in  some  of  these  sufferers  it 
maj-  be  attributable  to  their  habitual  exposure  to  cold  and  moisture ;  and  this  nerve, 
lying  superficially,  and  being  unprotected  by  any  artificial  covering,  is  more  likely, 
]>erhaps,  for  that  reason,  to  be  affected  by  vicissitudes  of  temperature ;  but  in  many 
of  these  cases  the  disease  seems  to  be  produced  by  the  malaria,  which  is  preA'alent 
in  those  situations.  The  paroxysms  are  then  not  only  intermittent,  but  periodical, 
and  they  will  frequently  yield  to  the  remedies  which  have  been  ascertained  to  be 
specific  against  ague  and  its  various  modifications.  Sometimes  the  facial  neuralgia 
is  evidently  dependent  upon  some  general  state  of  the  system :  for  it  will  cease  in 
the  face,  and  fix  itself  in  some  other  place ;  and  in  this  way  it  may  come  to  occupy 
several  distant  parts  of  the  body  in  succession.  There  are  other  cases  again  in 
which  the  disease  has  a  local  origin,  and  results  from  some  diseased  bone,  or  exosto- 
sis, in  the  neighbourhood  of  the  painful  spot.  The  late  Dr.  Pemberton  afforded  a 
well-known  example  of  this.  He  was  seized  with  tic  douloureux  in  the  very  zenith 
of  his  reputation,  and  when  he  was  in  the  fullest  practice  of  his  profession  in  this 
town.  It  completely  ruined  him :  compelled  him  to  give  up  business.  He  ulti- 
mately died  of  apoplexy.  When  his  head  was  examined  after  death,  the  os  frontia 
was  found  to  be  unusually  thick ;  and  on  the  falciform  process  of  the  dura  mater,  al 
a  little  distance  from  the  crista  galli,  a  small  osseous  substance  was  discovered,  nearly 
half  an  inch  long,  and  almost  as  broad.  Sir  Henry  Halford  has  recorded  severaJ 
other  instances  in  which  the  disease  was  connected  with  some  morbid  condition  of 
the  bones  of  the  head  or  face. 

Now  tic  douloureux  is  one  of  those  complaints  for  the  cure  of  which  there  exists 
a  number  of  specific  remedies.  But  what  I  have  been  stating  of  this  disease  will 
suffice  to  convince  you  that,  as  it  depends  upon  different  causes  and  different  per- 
sons, it  is  absurd  to  expect  that  any  single  drug — or  even  any  one  plan  of  treatment 
—  will  always  remove  it.  Our  first  care,  in  every  e.cample  of  it  that  comes  before 
lis,  must  be  to  investigate  all  the  particulars  of  the  case.  We  must  not  be  satisfied 
with  learnmg  that  the  complaint  is  tic  douloureux,  and  then  go  on  prescribing,  one 
after  another,  the  reputed  specifics  for  tic  douloureux.  It  may  happen  that  the  ori- 
gin of  the  disease  is  plain,  and  the  remedy  obvious.  We  must  endeavour  to  make 
out  Avhatever  is  amiss  in  the  system  at  large,  or  in  the  state  of  particular  functions. 
Very  rarely,  I  believe,  tic  douloureux  is  dependent  upon  a  condition  of  general  ple- 
thora. Mr.  John  Scott  gives  the  case  of  a  gentleman  who  suffered  severely  from  it 
for  some  time  ;  at  length  he  had  an  uttack  of  apoplexy,  and  for  this  last  disorder  he 
was  copiously  bled,  and  the  bleeding  seemed  to  cure  the  neuralgia.  Much  more 
frequently  we  find  evidence  of  a  feeble  or  a  shattered  state  of  the  system ;  debility 
and  paleness :  and  then  we  may  expect  to  do  good  by  the  treatment  so  strongly 
recommended  by  Mr.  Hutchinson,  viz.,  by  giving  the  carbonate  of  iron.  This 
remedy  has  been  put  largely  to  the  test,  since  Mr.  Hutchinson  wrote  in  commenda- 
tion of  it,  by  Dr.  Elliotson,  and  subsequently  by  others.  Dr.  Elliotson  states  it  as 
the  result  of  his  experience,  that,  "  in  all  cases  of  neuralgia,  whether  exquisite  or 
not^  unaccompanied  by  inflammation,  or  evident  existing  cause,  iron  is  the  best 
remedy."  I  have  already  explained  the  manner  of  administering  the  carbonate  of 
iron,  the  quantity  in  which  it  may  be  given,  and  the  limits  within  which  I  should  be 
inclined  to  restrict  the  doses.  Sir  Benjamin  Brodie  thinks  it  probable  that  the  car- 
bonate of  iron  proves  beneficial  by  its  mechanical  operation  on  the  internal  surface 
of  the  intestines :  but  I  should  rather  ascribe  its  good  effect  to  the  well-known  pro- 
perty of  preparations  of  iron,  to  give  firmness  to  the  nervous  system  ;  apparently  by 
increasing  the  quantity  of  red  blood  that  circulates  in  it.  However,  it  is  of  the  utmost 
consequence  that  the  state  of  the  digestive  organs  should  be  attended  to.  Mr.  Aber- 
nethy  used  to  relate,  in  his  lectures,  many  instances  of  tic  which  he  had  been  suc- 
cessful in  curing  by  measures  which  were  solely  directed  to  the  improvement  of  the 
stomach  and  bowels.  He  had  a  notion,  that  in  patients  who  suffer  under  this  disor- 
der, there  were  always  two  functions  wrong;  those  of  the  nervous  system  on  the 
one  hand,  those  of  the  digestive  system  on  the  other.  And  I  am  sure  you  will  com- 
monly find  mdications  of  a  faulty  state  of  both  these  systems.     "  The  two,"  he  used 


TIC    DOULOUREUX.  43" 

to  say,  "  were  the  common  parents  of  a  numerous  progeny  of  very  dissimilar  local 
diseases.  In  tic  douloureux,  you  must  seek  to  put  the  digestive  organs  right,  or  to 
soothe  the  nervous  system,  according  as  the  one  or  the  other  may  seem  to  be  the 
principal  and  primary  cause  of  the  disease.  Take  away  one  of  the  parents,  and  there 
will  be  no  more  propagation." 

In  these  cases  the  unheakhy  state  of  the  digestive  apparatus  may  be  marked  by 
obvious  signs ;  a  furred  tongue,  loss  of  appetite,  costive  bowels :  or  it  may  reveal 
itself  by  no  other  symptom  than  the  pain.  It  may  depend  upon  the  mere  presence 
of  acid  in  the  stomach.  Dr.  Rigby  tells  us  that  having  suffered  in  his  own  person 
an  intense  attack  of  tic  douloureux,  which  opium  did  not  assuage,  he  swallowed,  at 
the  suggestion  of  a  friend,  some  carbonate  of  soda  dissolved  in  water.  The  effect 
was  almost  immediate :  carbonic  acid  was  eructed,  and  the  pain  quickly  abated. 
More  often  the  cause  of  offence  appears  to  lie  in  some  part  of  the  intestines ;  and 
purgatives  do  good.  Sir  Charles  Bell — drawing  a  bow  at  a  venture — achieved  the 
cure  of  a  patient  upon  whom  much  previous  treatment  had  been  expended  in  vain, 
by  some  pills  composed  of  cathartic  extract,  croton  oil,  and  galbanum.  He  mixes 
one,  or  two,  drops  of  the  oleum  tiglii,  with  a  drachm  of  the  compound  extract  of  colo- 
cynth  ;  and  gives  five  grains  of  this  mass  with  ten  grains  of  the  compound  galbanum 
pill  at  bed-time.  I  mention  the  exact  proportions  and  dose,  because  other  cases  have 
been  since  reported,  both  by  Sir  Charles  and  by  others,  in  which  the  same  prescrip- 
tion was  followed  by  the  same  success. 

When  the  disease  occurs  in  a  rheumatic  individual,  and  especially  when,  as  is 
sometimes  the  case,  it  alternates  with  rheumatism  of  other  tissues,  the  remedies  which 
have  been  found  useful  in  rheumatism  deserve  a  fair  trial ;  guaiacum ;  colchicum ; 
calomel  and  opium. 

When  all  has  been  done  that  can  be  done  towards  restoring  or  improving  the 
general  health,  we  may  turn  our  thoughts  to  local  remedies.  It  is  plain  that  these 
must  be  inefficient  when  the  local  pain  results  from  constitutional  causes  that  are  un- 
redressed, or  perhaps  incurable.  Yet  even  then  topical  measures  may  soothe  the 
pain  for  a  while. 

One  of  these  topical  expedients,  which  promised  well  when  first  thought  of,  is  the 
division  of  the  trunk  of  the  painful  nerve,  so  as  to  cut  off  the  nervous  communica- 
tion, through  that  main  channel  at  least,  between  the  painful  part  and  the  brain. 
This  was  originally  proposed  by  Dr.  Haighton,  and  was  at  first  attended  with  some 
little  success  ;  but  in  a  great  number  of  instances  it  has  signally  failed,  as  indeed  might 
have  been  expected.  In  Dr.  Pemberton's  case  the  several  branches  of  the  filth  pair 
were  cut  by  Sir  Astley  Cooper :  but  in  vain.  When  there  is  any  reason  to  think 
that  the  disease  has  a  constitutional  origin,  or  a  local  distant  origin,  the  division,  or 
even  the  excision,  of  a  part  of  the  nerve  must  be  perfectly  useless.  It  would  be  as 
reasonable  (as  Mr.  Abernethy  has  observed)  to  expect  to  cure  gout  by  cutting  the 
nerve  that  goes  to  the  great  toe  :  or  to  perform  castration  with  the  view  of  remedying 
that  pain  in  the  testicle  which  is  apt  to  be  produced  by  the  passage  of  a  calculus 
through  the  ureter.  Nevertheless  there  are  cases,  in  which  the  division  of  the 
nerve,  or  some  other  surgical  operation,  is  required.  If  you  can  make  out  that  there 
is  any  tumour  pressing  upon  or  adherent  to  some  part  of  the  nerve — or  if  some 
foreign  body,  as  a  splinter,  or  a  shot,  should  be  ascertained  to  be  in  contact  with  the 
surface  of  the  nerve,  or  to  be  entangled  in  its  substance,  the  tumour  or  the  foreign 
body  may  be  removed  by  the  knife,  with  the  strong  expectation  that  a  cure  will  be 
llius  effected.  And  if  this  cannot  be  done,  or  if  the.  nerve  itself  be  altered  in  struc- 
ture, either  from  disease  or  injury,  (I  am  referring  now  to  neuralgia  in  general,  and 
not  merely  to  that  in  which  the  facial  branches  of  the  fifth  pair  of  nerves  are  impli- 
cated,) under  those  circumstances  it  will  become  a  very  proper  subject  of  delibera 
tion  whether  the  nerve  should  be  divided,  or  even  the  limb  amputated. 

In  the  Medical  and  Physical  Journal  there  is  a  case  described  by  Mr.  Jeffries,  of 
a  violent  facial  neuralgia,  cured  by  the  removal  of  a  small  fragment  of  china,  which 
had  been  lodging  in  the  cheek  for  fourteen  years.  And  Mr.  Descot  mentions  an 
instance  in  which  a  very  severe  affection,  of  ten  years'  standing,  was  removed  by 
the  extraction  of  a  carious  tooth.    I  saw,  not  many  days  ago,  a  young  woman  whoso 


432  -  TIC    DOULOUREUX. 

fing(?r  had  been  amputated  for  very  acute  neuralgic  pain  which  she  had  suffered  m 
jr.;  and  the  amputation  had  been  successful  in  liberating  her  from  that  pain. 

Sometimes  we  may  hope  to  afford  relief  to  the  suffering  patient  by  means  which 
tend  to  remove  or  lessen  the  exciting  cause  of  the  paroxj^sms.  Of  this  [  may  m,en- 
tion  one  remarkable  example,  Avhich  fell  in  part  under  my  own  observation  :  although 
I  had  nothing  to  do  with  the  treatment.  I  was  asked,  a  few  years  ago,  by  a  friend, 
to  go  with  him  to  call  upon  a  relation  of  his,  who  laboured,  he  said,  under  tic  dou 
loureux :  he  did  not  wish  me  to  see  her  professionally,  but  was  desirous  that  I 
should  witness  what  he  considered  an  extraordinary  complaint.  I  saw  a  young  girl, 
about  twelve  or  thirteen  years  old,  very  pale  and  dehcate,  lying  on  a  sofa ;  and  I 
learned  from  her  and  from  her  mother  that  she  was  subject  to  the  most  excruciating 
agony  in  one  side  of  her  face  and  neck.  The  pain  came  on  whenever  she  swallowed 
anything:  the  act  of  deglutition  proved  invariably  the  exciting  cause  of  the  torment. 
She  was  at  that  time  under  the  care  of  a  practitioner  who  had  desired  that  she  might 
eat  mutton-chops  three  or  four  times  of  a  day.  Of  course  this  was  a  sentence  full 
of  misery  to  her  ;  but  so  desirous  was  she  to  get  rid  of  her  disease,  that  she  resolved 
steadit)^  to  follow  the  directions  enjoined  her.  This  plan  was  to  be  tried  for  at  least 
a  month ;  after  that  time,  if  she  were  no  better,  her  mother  had  resolved  to  consult 
another  practitioner  who  had  been  much  recommended  to  her.  I  should  say  that 
she  had  already  consulted  a  great  number  of  medical  men  ;  for  the  malady  had 
existed  nearly  two  years.  At  the  end  of  the  month  she  was  worse  than  at  the 
beginning;  and  the  new  practitioner, Mr.  Pennington,  was  called  in.  He  acted,  hke 
a  man  of  sense  and  sagacity,  upon  the  fact  that  the  act  of  swallowing  always  gave 
rise  to  the  pain ;  and  he  advised  that  she  should  not  attempt  to  swallow  for  twenty- 
four  hours.  That  period  passed  without  any  return  of  the  pain  ;  but  it  immediately 
recurred  upon  her  eating  a  morsel  of  bread.  The  result  of  this  experiment,  how- 
ever, encouraged  him  to  hope  that  the  morbid  habit  might  be  broken  through' by  a 
sufficiently  long  abstinence  from  swallowing.  And  as  she  had  been  subjected  to  a 
great  variety  of  fruitless  treatment,  he  gave  her  no  medicine,  but  advised  that  she 
should  refrain  altogether  from  taking  food  or  drink  by  the  mouth.  Nourishing  injec- 
tions, composed  of  beef  tea  with  an  egg  beat  up  in  it,  or  of  milk,  were  thrown  into 
the  rectum,  two  or  three  times  a  day.  This  plan  was  persisted  in  for  a  longer  time 
than  I  should  have  supposed  she  could  have  endured  it.  No  nutriment  whatever 
was  taken  by  the  mouth  for  five  weeks  and  three  days,  and  no  paroxysm  of  pain 
occurred.  At  the  end  of  that  period  the  pulse  sank  suddenly,  from  between  seventy 
and  eighty,  to  thirty-five  beats  in  a  minute ;  and  thereupon  Mr.  Pennington  thought 
he  had  carried  his  experiment  far  enough  ;  and  deemed  it  advisable  to  administer  by 
the  mouth  a  dessert-spoonful  of  beef-tea  twice  a  day.  This  was  continued  for  four 
days  without  producing  any  return  of  the  pain.  A  small  piece  of  fish  was  then 
allowed,  and  afterwards  some  chicken  ;  and  proceeding  thus  cautiously,  in  the  course 
of  a  month  she  was  able  to  eat  and  drink  anything,  without  the  slightest  inconve- 
nience. 

1  should  state,  however,  that  some  time  afterwards,  the  neuralgia  returned  in 
another  situation,  affecting  the  left  knee  :  and  this  was  remedied  by  a  different  mode 
of  treatment.     She  is  since  dead. 

"When  other  means  fail,  or  in  conjunction  with  other  means,  local  applications  to 
the  affected  part  may  be  tried.  Belladonna  will  sometimes  materially  palliate  the 
pain  :  so  will  opium  :  but  within  the  last  few  years  a  new  anodyne  has  been  brought 
into  use ;  and  it  really  seems  to  have  been  of  essential  service  in  several  instances 
of  this  most  painful  disorder.  1  allude  to  aconitine:  the  active  principle  of  the 
monkshood.  The  property  belonging  to  this  plant,  of  benumbing  sensation,  has 
long  been  know'n.  Sir  Benjamin  Brodie  found  many  years  ago  that  after  chewing 
its  leaves,  a  remarkable  numbness  of  the  lips  was  left,  which  lasted  some  hours.  We 
may  understand  therefore  the  beneficial  operation  of  the  aconitine  upon  a  part  of 
which  the  sensibility  is  unduly  exalted.  It  is  only  very  recently  that  pure  aconitine 
has  been  procured  ;  and  consequently  it  has  not  yet  been  very  extensively  employed, 
and  the  less  so  on  account  of  its  very  high  price  :  but  what  experience  we  have  of 
;t,  as  a  benumber  of  pain,  is  highly  encouraging.     It  has  been  of  singular  benefit  to 


TIC    DOULOUREUX.  433 

a  surgeon  who  formerly  lived  in  Charterhouse  Square,  and  whose  case  is  well  known, 
1  believe,  to  the  profession.  Mr.  Spry  had  suffered  greatly,  for  eight  years,  under 
very  acute  neuralgia  affecting  the  parts  supplied  by  the  lowermost  or  mental  branch 
of  the  fifth  pair  of  nerves.  After  exhausting  almost  every  expedient  that  ever  has 
been  recommended  for  tic  douloureux,  except  that  of  dividing  the  nerve,  he  was 
induced  to  make  trial  of  the  aconitine.  It  was  mixed  with  cerate,  in  the  proportion 
of  one  grain  to  one  drachm,  and  a  small  portion  of  this  was  smeared  over  tlie  track 
of  the  painful  nerve  once  or  twice  a  day  for  six  days.  By  that  time  he  had  entirely 
lost  the  pain.  He  states,  I  understand,  that  the  appHcation  of  the  ointment  produced 
a  sense  of  numbness,  which  continued  for  twelve,  or  eighteen  hours.  Dr.  Hue,  who 
first  told  me  of  Mr.  Spry's  case,  told  me  at  the  same  time  that  he  knew  of  two  others 
in  which  the  same  apphcation  had  been  equally  successful.  This  encouraged  me  to 
try  it  upon  my  patient,  whom  I  mentioned  before,  and  who  happened  at  that  time  to 
be  in  the  hospital.  I  bought,  for  ten  shillings,  five  grains  of  the  aconitine  at  Mr. 
Morson's.  in  Southampton  Row,  where  I  knew  it  would  be  genuine.  One-third  of  a 
drachm  of  ointment,  containing  one-third  of  a  grain  of  the  alkaloid,  was  smeared 
two  or  three  limes  a  day  over  my  patient's  face,  and  the  attacks  presently  diminished 
in  intensity,  and  in  a  few  days  ceased  altogether.  He  soon  after  left  the  hospital,  so 
that  I  cannot  tell  whether  the  cure  was  permanent.  I  presume  it  was  so,  as  he  did 
not  return.  The  particulars  of  Mr.  Spry's  case  have  been  published  by  Mr.  Skey 
in  the  nineteenth  volume  of  the  Medical  Gazette.  Tt  is  now  (1841)  six  years  since 
the  aconitine  was  applied,  and  the  pain  (as  Mr.  Skey  has  recently  informed  me)  has 
never  recurred.  It  used  to  be  excited  by  gentle  friction  of  the  hand,  or  by  a  current 
of  cold  air,  but  Mr.  Spry  "can  now  face  any  wind  or  temperature  with  impunity."* 
In  the  same  paper  Mr.  Skey  relates  another  instance  of  the  utility  of  this  substance 
in  facial  neuralgia.    It  occurred  in  one  of  his  patients  at  St.  Bartholomew's  Hospital. 

This  is  a  remedy  therefore  which  is  not  to  be  neglected.  Even  if  it  only  allayed 
the  pain  for  a  time  it  would  be  highly  valuable.  But,  judging  from  the  instances 
now  referred  to,  we  may  hope  that,  in  some  forms  of  tic  douloureux,  the  aconitine 
may  be  found  equal  to  their  cure.  It  seems  probable  that  the  recurrence  of  the  pain 
is  sometimes  kept  up  by  the  influence  of  habit ;  and  will  cease  if  the  habit  can  for 
a  while  be  broken.  You  must  take  care,  however,  to  obtain  a  genuine  article.  The 
manufacture  of  aconitine  is  difficult,  and  therefore  the  cost  is  considerable.  Mr. 
Skey,  in  the  Bartholomew  case,  failed  with  some  aconitine  that  had  been  imported 
into  this  country,  but  succeeded  at  once  when  he  employed  the  same  quantity  of  Mr. 
Morson's  preparation. 

A  few  years  ago  Mr.  John  Scott  published  a  little  book  on  the  disease  we  are  now 
considering,  with  the  professed  object  of  introducing  to  general  notice  a  species  of 
local  treatment  which  he  had  found  successful  in  several  long-standing  and  previously 
obstinate  cases.  It  is  well  to  be  aware  of  these  things,  though  probably  the  aconitine 
ointment  will  beat  Mr.  Scott's.  Mr.  Spry  used  Mr.  Scott's  ointment,  but  withou-t 
benefit.  It  consists  of  the  iodide  of  mercury,  mixed  with  lard,  in  the  propoition  of 
two  scruples  to  the  ounce  :  and  it  is  rubbed  into,  or  placed  in  contact  with,  the  affected 
surface,  until  some  degree  of  irritation  is  produced. 

[In  several  cases  of  neuralgia,  of  different  parts  of  the  body,  w^liich,  for  a  number  of  years, 
had  resisted  a  variety  of  plans  of  treatment,  we  have  seen  almost  immediate  relief,  and  in  s 
few,  a  permanent  removal  of  the  disease  result  from  acupuncturation.  In  other  cases,  how 
ever,  no  benefit  has  resulted  from  the  operation.. — C] 

There  is  a  kind  of  hce-ache,  which  cannot  properly  be  reckoned  as  a  species  o( 
neuralgia,  for  it  does  not  occur  in  short  stabbing  paroxysms,  nor  is  the  pain  acute 
enough  to  entitle  it  to  the  name  of  tic  douloureux ;  but  which  is  very  common,  very 
distressing,  and  under  ordinary  treatment  sometimes  very  intractable.  It  is  called 
by  some  a  rheumatic  pain ;  it  occupies  the  lower  part  of  the  face,  the  jaw  princi- 
pally, and  the  patient  cannot  tell  you  exactly  whereabouts  it  is  most  intense.  It  is 
often  thought  to  proceed  from  toothache,  and  bad  or  suspected  teeth  are  extracted. 

•  This  gentleman  is  since  dead. 

38  2m 


•134  SCIATICA — HEMI  CRANIA. 

but  with  no  good  effect.  Now  I  allude  to  this  for  the  sake  of  saying  that  some  years 
ago  I  was  instructed  by  an  experienced  old  apothecary,  that  this  face-ache  might  be 
almost  always  and  speedil)'  cured  by  the  muriate  of  ammonia; — a  medicine  that  we 
seldom  give  internally  here,  although  it  so  much  used  in  Germany.  And  I  have 
again  and  aeain  availed  myself  of  this  hint,  and  been  much  thanked  by  the  patients 
for  the  good  I  did  them  with  this  muriate  of  ammonia.  It  does  not  always  succeed  ; 
but  it  often  does.  It  should  be  given  in  half-drachm  doses,  dissolved  in  water,  or  in 
almost  any  vehicle,  three  or  four  times  a-day.  if  the  pain  does  not  yield  after  four 
doses,  you  may  cease  to  expect  any  benefit  from  it.  In  two  or  three  instances  of  a 
similar  kind  that  I  have  recentlj^  had  to  treat,  I  have  found  the  iodide  of  potassium, 
in  doses  of  five  or  six  grains,  work  a  speedy  and  permanent  cure.  This  induces  me 
to  suppose  that  the  pain  in  some  of  these  cases  is  periosteal.  I  so  judge  from  the 
ascertained  efficacy  of  the  iodide  in  other  periosteal  affections  attended  with  pain. 

Tic  douloureux  is  the  principal  form  of  severe  neuralgia  which  you  may  expect 
to  meet  with,  in  regard  to  acuteness  of  suffering  and  difficulty  of  cure.  Two  other 
forms,  more  common,  and  luckily  more  tractable,  are  generally  spoken  of  under  the 
same  head :  sciatica,  namely,  and  hcmicrania.  I  have  very  little  to  say,  in  this 
place,  of  either  of  these.  Sciatica,  or  pain  radiating  from  the  sciatic  notch,  and  fol- 
lowing the  course  of  the  sciatic  nerve,  is  sometimes  an  inflammatory  complaint,  and 
yields  to  the  remedies  of  inflammation  —  bleeding  and  Mistering  :  sometimes  it  is 
plainly  a  part  of  rheumatism ;  and  then  may  often  be  relieved  by  calomel  and  opium, 
or  by  colchicum  :  sometimes,  again,  it  results  from  irritation  within  the  pelvis,  affect- 
ing the  nerve  before  it  emerges  externally ;  this  irritation  may  be  connected  with  a 
disordered  state  of  the  kidney,  and  I  suspect  that  it  is  in  such  cases  that  the  oil  of 
turpentine  is  of  so  much  use  :  lastly,  it  is  sometimes  a  purely  nervous  and  neuralgic 
pain  :  and  then  the  treatment  applicable  to  facial  neuralgia  will,  mutatis  mutandis, 
be  applicable  to  it.  I  had  some  time  ago  a  butler  under  my  care  at  tne  hospital, 
whom  I  am  afraid  I  did  not  manage  well.  He  suffered  severe  sciatica,  and  I  had 
him  cupped  and  blistered,  and  gave  him  a  variety  of  medicines,  for  some  time,  to 
httle  purpose  :  at  last  he  got  what  I  ought,  I  suppose,  to  have  given  him  at  first,  viz., 
the  carbonate  of  iron,  and  was  presently  well. 

Hemicrania  is  simply  headache,  confined  to  one  side,  and  occupying  generally 
the  brow  and  forehead,  but  sometimes  aflecting  very  exactly  one  moiety  of  the  head. 
It  is  the  migraine  of  the  French,  the  megrim  of  our  vernacular  language ;  each  of 
these  terms  being  obviously  traceable  to  the  same  Greek  root.  It  is  often  attended 
with  sickness ;  and  in  many  instances  it  is  periodical,  coming  on  every  day  at  a 
certain  hour,  lasting  a  certain  time,  and  then  subsiding.  Like  the  other  forms  of 
neuralgia,  hemicrania  may  be  produced  by  various  causes,  which  are,  however, 
almost  all  of  them  such  as  tend  to  debilitate  the  system  :  it  sometimes  occurs  in  con- 
nection with  hysteria ;  sometimes  it  plagues  women  who  have  suckled  their  infanta 
too  long;  sometimes  it  acknowledfres  the  same  cause  as  ague  ;  and  sometimes  also 
it  occurs  Independently  of  all  other  disease,  and  when  no  obvious  exciting  cause  can 
be  traced. 

Whatever  may  be  its  origin,  it  is  usually  a  very  manageable  complaint.  When 
it  is  associated  with  evident  antemia,  steel  and  the  shower-bath  may  be  expected  to 
cure  it.  When  its  visits  are  strictly  periodical,  it  will  yield  to  quina.  Arsenic  is 
considered  by  many  to  have  a  specific  power  over  the  complaint ;  and  I  believe  that 
four  or  six  drops  of  the  liquor  arsenicalis,  given  three  or  four  times  a  day,  with  due 
attention  to  the  state  of  the  bowels,  will  be  almost  sure  to  remove  hemicrania  in  nine 
castas  out  of  ten  in  which  it  occurs.  But  steel  or  bark,  being  milder  and  safer  drugs, 
are,  casteris  paribus,  to  be  preferred. 

I  say  this  disorder  often  acknowledges  the  same  cai(se  as  ague;  namely,  the 
miasm  of  marshes,  or  malaria :  and  as  that  cause,  mysterious  as  it  is  in  some  respects, 
".xerts  apparently  its  primary  or  chief  influence  upon  the  nervous  system,  and  as 
rtgue  has  no  definite  seat  in  the  human  body,  if  it  be  not  in  the  nervous  system,  I 
shall  not  find  a  more  convenient  place  in  these  lectures  for  the  consideration  of  ague 


INTERMITTENT    FEVER.  435 

than  here,  at  the  close  of  the  remarks  which  I  had  to  make  respecting  the  diseases 
of  the  brain  and  nerves.  In  the  next  lecture,  then,  I  shall  begin  to  speak  of  Inter- 
mittent Fever. 


LECTURE  XL. 

Intermittent  Fever.  Phenomena  of  an  Ague  Fit.  Species  and  varieties  of  Inter- 
mittents.  Predisposing  causes.  Exciting  cause.  Malaria ;  known  only  by  its 
effects  ;  places  which  it  chiefly  infests  ;  conditions  of  its  production  ;  its  ejects 
vpon  the  human  body;  injiuence  of  soils  in  evolving  it. 

I  AM  now  to  enter  upon  the  consideration  of  that  disorder  of  which  the  trivial 
English  name  is  ague,  and  which  is  called  by  nosologists  intermittent  fever.  This 
is  one  of  the  diseases  which  are  known  to  us  only  in  their  respective  group  of  symp- 
toms. Before  we  can  inquire  successfully  into  its  history,  it  is  necessary  that  we 
have  the  group  of  symptoms  which  identify  it  set  fairly  before  us.  I  must,  there- 
fore, describe  the  phenomena  of  ague. 

You  will  observe  that  ague  resembles  several  other  maladies  that  essentially 
belong  to  the  nervous  system,  in  being  paroxysmal.  A  certain  series  of  symptoms 
occurs,  and  then  the  patient  reverts  to  a  state  of  health :  but  this  alternation  com- 
monly happens  (or  would  happen  if  the  disease  were  left  to  itself)  a  great  many 
times.  You  may  therefore  look  upon  this  succession  of  attacks  as  so  many  repe- 
titions of  a  short  distemper;  or  you  may  regard  the  whole  period  during  which 
the  attacks  continue  to  recur  at  brief  intervals,  as  being  occupied  with  one  single 
disease. 

An  ague  fit  is  composed  of  three  distinct  stages ;  and  they  are  severally  named, 
from  the  phenomena  that  characterize  them,  the  cold,  the  hot,  and  the  sweating 
stages. 

A  person  who  is  on  the  brink  of  a  paroxysm  of  ague,  experiences  a  sensation  of 
debility  and  distress  about  his  epigastrium ;  becomes  weak,  languid,  listless,  and 
unable  to  make  any  bodily  or  mental  exertion.  He  begins  to  sigh,  and  yawn,  and 
sireich  himself;  and  he  sooa  feels  chilly,  particularly  in  the  back  along  the  course 
of  the  spine ;  the  blood  deserts  the  superficial  capillaries ;  he  grows  pale,  his  fea- 
tures shrink,  and  his  skin  is  rendered  dry  and  rough,  drawn  up  into  httle  promi- 
nences, such  as  may  at  any  time  be  produced  by  exposure  to  external  cold,  and 
presenting  an  appearance  somewhat  hke  the  skin  of  a  plucked  goose :  hence  it  is 
called  goose's  skin,  and  in  Latin  cutis  anserina.  Presently  the  slight  and  fleeting 
sensation  of  cold,  first  felt  creeping  along  the  back,  becomes  more  decided  and  more 
general ;  the  patient  yee/s  very  cold,  and  he  acts  and  looks  just  as  a  man  does  who 
is  exposed  to  intense  cold,  and  subdued  by  it;  he  trembles  and  shivers  all  over;  his 
teeth  chatter,  sometimes  so  violently  that  such  as  were  loose  have  been  shaken  out ; 
his  knees  knock  together ;  his  hair  bristles  shghtly  from  the  constricted  state  of  the 
integuments  of  the  scalp  ;  his  face,  lips,  ears,  and  nails  turn  blue  ;  rings  which  be- 
fore fitted  Closely  to  his  fingers  become  loose  ;  his  respiration  is  quick  and  anxious  ; 
his  pulse  frequent  sometimes,  but  feeble ;  and  he  complains  of  pains  in  his  head, 
back,  and  loins  :  all  the  secretions  are  usually  diminished  ;  he  may  make  water 
often,  though  g(^nerally  he  voids  but  httle,  and  it  is  pale  and  aqueous ;  his  bowels 
are  confined,  and  his  tongue  is  dry  and  white. 

After  this  state  of  general  distress  has  lasted  for  a  certain  time,  it  is  succeeded  by 
another  of  quite  an  opposite  kind.  The  cold  shivering  begins  to  alternate  with 
flushes  of  heat,  which  usually  commence  about  the  face  and  neck.  By  degrees  the 
coldness  ceases  entirely  ;  the  skin  recovers  its  natural  colour  and  smoothness ;  the 
collapsed  features  and  shrunken  extremities  resume  their  ordinary  condition  and  bulk. 
But  the  reaction  does  not  stop  here ;  it  goes  beyond  the  hedlthy  line.  The  face 
becomes  red  and  turgid  ;  the  general  surface  hot  and  pungent  and  dry  ;  the  templos 


436  INTERMITTENT    FEVER. 

throb;  a  new  kind  of  head-ache  is  induced  ;  the  pube  becomes  full  and  strong,  as 
well  as  rapid  ;  the  breathing  is  again  deep,  but  oppressed  ;  the  urine  is  still  scanty, 
but  it  is  now  high-coloured ;  the  patient  is  exceedingly  uncomfortable  and  restless. 
At  length  another  change  comes  over  him :  the  skin,  which,  from  being  pale  and 
rough  had  become  hot  and  level,  but  harsh,  now  recovers  its  natural  softness  ;  a 
moisture  appears  on  the  forehead  and  face  ;  presently  a  copious  and  universal  sweat 
breaks  forth,  with  great  relief  to  the  feelings  of  the  patient ;  the  thirst  ceases  ;  the 
tongue  becomes  moist ;  the  urine  plentiful  but  turbid  ;  the  pulse  regains  its  natural 
force  and  frequency  ;  the  pains  depart ;  and  by  and  by  the  sweating  also  terminates, 
and  the  patient  is  again  as  well,  or  nearly  as  well,  as  ever. 

This  is  surely  a  very  remarkable  sequence  of  phenomena :  and  it  would  appear 
still  more  remarkable  if  it  were  less  familiar  to  us.  The  earlier  symptoms  are  all 
indicative  of  debility,  and  of  a  depressed  state  of  the  nervous  system.  There  is  the 
same  sensation  of  exhaustion,  with  incapacity  of  exertion,  which  is  produced  by 
fatigue.  The  sighing,  yawning,  and  stretching,  all  notify  debihty.  The  paleness 
of  the  surface,  and  constriction  of  the  skin,  and  collapse  of  the  features,  are  all  owing 
to  the  retirement  of  the  blood  from  the  superficial  capillaries.  The  skin  shrinks, 
but  the  parts  containing  the  bulbs  of  the  hairs  cannot  contract  so  much  as  the  other 
parts,  and  therefore  the  surface  becomes  rough,  and  the  hairs  bristle  up,  or  become 
erected  in  some  degree.  HorrlpUatio  is  the  learned  term  for  this  state  of  the  surface. 
The  coldness  of  the  skin  is  another  consequence  of  the  emptiness  of  its  blood- 
vessels ;  and  the  tremors  which  are  always  indicative  of  debility,  seem  to  depend 
upon  the  coldness.  The  chattering  of  the  jaws  has  been  (it  is  said)  so  violent  as  to 
fracture  the  teeth.  This  you  may  believe  or  not  as  you  please,  but  certainly  the 
whole  bed  is  often  strongly  shaken  by  the  shivering  of  the  patient.  The  necessary 
accumulation  of  the  blood  in  the  larger  and  internal  vessels  offers  a  reasonable  expla- 
nation of  the  distressed  and  anxious  breathing. 

In  their  attempts  to  render  a  "  ratio  symptomatum,"  authors  have  sometimes  spoken 
of  the  hot  stage  as  though  it  were  a  necessary  consequence  of  the  cold.  But  if  the 
cold  fit  be  in  any  sense  or  degree  the  cause  of  the  hot  fit,  it  can  only  be  so  partially. 
There  must  be  some  other  cause  for  these  reasons.  The  cold  stage  may  occur  and 
never  be  followed  by  the  hot ;  or  the  hot  stage  may  come  on  without  any  previous 
cold  stage ;  and  when  they  do  both  happen,  they  are  not  by  any  means  proportioned 
to  each  other.  When  we  thus  see  that  a  supposed  cause  is  not  always  followed  by 
the  effect,  and  that  the  effect  is  sometimes  produced  without  the  agency  of  the  sup- 
posed cause,  and  also  that  the  supposed  cause  and  the  effect  are  not  proportioned  to 
each  other,  we  cannot  but  conclude  that  the  supposed  cause  is  at  most  but  a  partial 
and  accessory  cause.  We  can  more  easily  conceive  how  the  hot  fit  may  conduce 
to  bring  on  the  sweating  stage.  The  stronger  action  of  the  heart  and  the  more  forci- 
ble propulsion  of  the  blood  will  fill  the  superficial  vessels,  and  in  this  way  the  natural 
secretions  may  be  restored.  We  see  exactly  the  same  thing  happen  when  the  force 
of  the  circulation  is  increased  by  exercise  :  the  extreme  vessels  receive  a  larger  sup- 
ply of  blood,  and  sweat  ensues. 

There  are  many  curious  facts  to  be  observed  in  respect  to  the  paroxysm  of  an 
intermittent,  such  as  it  has  been  now,  in  general  terms,  described.  In  the  first  place 
the  paroxysm  returns.  Cullen  makes  this  a  part  of  his  definition  ;  and  quibbling 
objections  to  his  statement  have  been  made,  which  are  scarcely  deserving  of  men- 
tion. Thus  it  is  said  that  this  circumstance  should  not  have  been  introduced  into 
the  definition,  because  it  is  not  necessarily  or  iiuivcrsalh/  true  ;  that  the  patient  may 
die  in  the  very  first  paroxysm  ;  or  that  he  may  be  cured  by  the  proper  remedies  of 
ague,  before  a  second  paroxysm  has  time  to  show  itself.  But  all  this  is  captious  tri- 
fling. The  paroxysms,  if  the  disease  be  left  to  itself,  will  recur  for  a  certain  length 
of  time ;  and,  unlike  the  paroxysms  in  many  of  the  spasmodic  diseases  which  we 
have  lately  been  speaking  of,  they  recur  at  regular  periods,  and  often  with  singular 
punctuality.  This  is  a  circumstance  which  we  should  waste  our  time  in  attempting 
to  account  for.  Dr.  Cullen  has  tried  to  explain  it  on  the  principle  of  some  diurnal 
habit  of  thfe  body ;  but  the  truth  is,  that  no  satisfactory  explanation  of  it  has  ever 


INTERMITTENT   FEVER.  437 

been  given,  and  we  must  be  content,  for  the  present  at  least,  to  receive  it  as  an  ulti- 
mate fact ;  and,  doubtless,  a  very  strange  and  interesting  fact 

For  distinguishing  some  equally  curious  varieties  of  these  successions  and  alterna- 
tions of  disorder  and  health,  certain  terms  have,  by  common  consent,  been  adopted 
by  pathologists  ;  which  terms  it  is  necessary  that  I  should  explain.  The  period  that 
elapses  between  the  termination  of  one  paroxys.a  and  the  commencement  of  the 
next  is  called  an  intermission  ;  while  the  period  that  intervenes  between  the  begin- 
ning of  one  paroxysm  and  the  beginning  of  the  next,  is  called  an  interval.  As  the 
paroxysms  are  liable  to  vary  in  length,  the  intermissions  may  be  very  unequal,  even 
when  the  intervals  are  the  same.  When  the  intermissions  are  perfect  and  complete, 
the  patient  resuming  the  appearance  and  sensations  of  health,  the  disorder  is  an  in- 
termittent fever.  When  the  intermissions  are  imperfect,  the  patient  remaining  ill 
and  feverish,  and  uncomfortable  in  a  less  degree  than  during  the  paroxysm,  tlien  the 
complaint  is  said  to  be  a  remittent  fever. 

But,  confining  ourselves  for  the  present  to  intermittents,  it  is  another  curious  pro- 
perty of  this  complaint  that,  although  the  intervals  are  commonly  constant  in  each 
case,  and  quite  regular,  they  differ  in  duration  in  different  cases.  Upon  this  circum- 
stance is  founded  a  division  of  agues  into  species.  When  the  paroxysm  occurs  at 
the  same  hour  every  day,  the  patient  is  said  to  have  quotidian  ague.  When  it 
comes  on  at  the  same  hour  every  other  day,  appearing  and  remaining  absent  day  by 
day  alternately,  he  is  said  to  labour  under  tertian  ague.  The  paroxysm,  strictly 
speaking,  repeats  itself  every  second  day :  and  if  the  species  I  first  mentioned  be 
fitly  termed  quotidian,  that  in  which  the  fits  occur  on  alternate  days  ought  to  be 
styled  seciindan.  But  nosologists  have  chosen  to  reckon  the  day  on  which  the  pre- 
ceding fit  happens  as  the  first :  and  then  the  day  on  which  the  fit  next  to  it  will  hap- 
pen, in  the  species  now  under  consideration,  is  the  third.  In  the  same  way,  when 
a  paroxysm  absents  itself  for  two  whole  days,  and  then  recurs,  the  complaint  is 
called  a  quartan  ague.  These  are  the  three  principal  species  or  types  of  intermit- 
tent fever.  It  follows,  of  course,  from  wnat  I  have  been  stating,  that  in  the  quoti- 
dian type,  the  interval  is  twenty-four  hours ;  in  the  tertian,  forty-eight ;  and  in  the 
quartan,  seventy-two. 

Each  of  these  types  has  some  other  characters  peculiar  to  itself.  Thus,  the  parox- 
ysms of  the  quotidian  ague  begin  in  the  morning;  those  of  the  tertian,  at  noon; 
those  of  the  quartan,  in  the  afternoon.  These  are  the  rides.  You  are  not  to  expect 
to  find  them  always  or  rigidly  observed ;  for  the  most  part  you  will  find  that  they 
are  observed.  It  is  probable  that  quotidian  paroxysms,  occurring  at  noon  or  at  night, 
have  sometimes  been  ascribed  to  ague,  when  they  were  merely  symptoms  of  some 
local  disease  or  inflammation  ;  or  perhaps  accessions  of  hectic  fever.  It  is  observed 
also  of  the  paroxysms,  that  when  the  disease  is  about  to  yield,  they  often  occur  later 
day  after  daj%  before  they  take  their  final  departure.  This  is  caWedi  postponing : 
and  when  they  occur  earlier  than  their  stated  hour,  the  paroxysms  are  said  to  antici- 
pate. Now  a  postponing  quotidian  may  be  deferred  till  noon.  But  when  the  dis- 
ease is  pursuing  its  regular  undisturbed  course,  the  rule  is  such  as  I  have  men- 
tioned. 

The'  three  principal  types  differ  from  each  other,  not  only  in  their  respective  inter- 
vals, and  in  the  periods  of  the  day  at  which  the  paroxysms  severally  commence,  but 
also  in  the  duration  of  the  paroxysms ;  and  in  the  proportions  which  the  stages  of 
these  paroxysms  bear  to  each  other.  The  average  duration  of  the  paroxysm  in  the 
quotidian  is  ten  or  twelve  hours;  and  of  course  the  average  duration  of  the  intermis- 
sion is  nearly  the  same.  The  tertian  paroxysm  commonly  begins  at  noon,  and  is 
finished  the  same  evening ;  its  average  duration  may  be  estimated  at  six  or  eight 
hours.     And  that  of  the  quartan  does  not  exceed  four  or  six  hours. 

You  must  observe,  also,  that  while  the  quartan  has  the  longest  interval  and  thu 
shortest  paroxysm,  it  has  the  longest  cold  stage  ;  whereas  the  quotidian  has  the 
shortest  interval  and  the  shortest  cold  stage,  but  the  longest  paroxysm.  To  express 
these  facts  in  mathematical  language,  the  length  of  the  paroxysm  varies  inversely  as 
the  length  of  the  cold  stage ;  inversely  also  as  the  length  of  the  interval. 

Of  these  three  principal  types  or  species,  the  tertian  is  by  much  the  most  com- 

2m2 


138  INTERMITTENT    FEVER. 

mon :  but  the  quotidian  and  quartan  are  neither  of  them  unfrequent  wherever  ague 
is  rife. 

I  should  tell  you  that  there  are  other  types  also  spoken  of,  as  quintans  and  sextans  : 
but  they  are  scarcely  worth  our  attention.  It  is  probable  that  when  they  are  ob- 
served (and  that  is  very  rarely)  they  are  merely  irregular  quartans,  postponing  per- 
haps for  a  day  or  two.  They  never  prevail  epidemically.  Galen  describes  one  of 
these  ;  so  does  Van  Swieten.  Boerhaave  talks  of  a  septiman,  and  even  octavans  are 
mentioned  ;  or  if  you  want  still  more  of  the  marvellous,  PHny,  the  naturalist,  infonns 
us  that  a  certain  Improvisatori  was  in  the  habit  of  having  a  paroxysm  once  a  year, 
and  that  exactly  on  his  birth-day ;  yet  he  died  at  a  good  old  age. 

There  are,  however,  some  curious  modifications  of  the  three  principal  types ;  or 
rather  of  two  of  them,  the  tertian  and  the  quartan.  For  instance,  a  paroxysm  may 
occur  daily,  and  yet  the  ague  not  be  of  the  quotidian  type,  but  of  the  tertian.  The 
paroxysm  of  one  day  will  differ  from  the  paroxysm  of  the  next,  but  exactly  resemble 
that  of  the  third  day ;  while  the  paroxysm  of  the  second  day  will  be  like  that  of  the 
fourth  ;  and  so  on  alternately.  And  these  diflt;rences  will  be  decidedly  marked ; 
the  paroxysms  of  two  consecutive  days  will  come  on  at  different  hours,  and  will  differ 
in  duration  and  severity.  This  form  of  ague  is  called  the  double  tertian.  One  case 
of  this  kind,  very  distinctly  characterized,  was  some  time  ago  under  my  care  in  the 
hospital. 

There  is  another  form  of  double  tertian.  Two  fits  will  occur  on  the  same  day — 
Monday,  for  example,  one  in  the  morning,  the  other  in  the  evening;  on  Tuesday 
there  shall  be  no  fit ;  on  Wednesday  again  two ;  on  Thursday  none ;  and  so  on. 
The  Latin  nomenclature  is  more  precise  than  the  English  in  denoting  these  varia- 
tions. The  form  I  have  last  mentioned,  in  which  two  dissimilar  paroxysms  occur 
every  other  day,  is  called  tertiana  duplicafa,  while  the  other  form,  in  which  there  is 
a  fit  every  day,  but  those  on  the  alternate  days  resemble  each  other,  is  called  tertiana 
duplex. 

In  the  same  way  you  may  have  a  double  quartan.  In  that  case,  a  paroxysm 
occurs  on  two  days  in  succession,  and  leaves  the  third  day  free ;  then  it  returns 
on  the  fourth  day  as  it  was  on  the  first,  and  on  the  fifth  as  it  was  on  the  second,  and 
leaves  the  sixth  day  free  hke  the  third,  and  so  on.  This  is  the  quartana  duplex. 
But  two  fits  may  happen  in  one  day — say  on  Monday  ;  none  on  Tuesday  or  Wed- 
nesday ;  and  two  again  on  Thursday.  This  is  the  quartana  duplicata.  Nay,  the 
paroxysm  of  quartan  ague  may  recur  every  day,  and  so  far  resemble  a  quotidian; 
but  the  fit  of  the  first  day  will  differ  from  those  of  the  second  and  third,  and  resemble 
that  of  the  fourth  :  the  fit  of  the  second  day  will  be  dissimilar  from  that  of  the  first 
or  that  of  the  third,  and  like  that  of  the  fifth  ;  and  the  fit  of  the  third  will  be  unlike 
that  of  either  of  the  two  preceding  days,  and  find  its  counterpart  in  that  of  the  sixth. 
This  is  a  triple  quartan  ;  and  where  three  paroxysms  occur  on  the  first  day,  which 
we  will  again  suppose  to  be  Monday,  and  none  on  Tuesday  or  Wednesday,  but 
three  again  on  Thursday,  corresponding  respectively  to  the  first  three,  we  have  the 
quartana  triplicata.  And  there  are  other  complications  still,  with  which  I  need  not 
trouble  you.  In  Dr.  Cleghorn's  book  on  the  diseases  of  Minorca,  you  may  find  a 
very  good  and  authentic  account,  evidently  drawn  from  nature,  of  the  irregular  types 
and  varieties  of  ague.  They  are  well  worthy  of  the  attention  of  any  among  you  who 
may  be  liktly  to  practise  abroad. 

Some  physicians  have  used  the  words  doidAe  tertian,  and  so  on,  in  the  hteral  sense, 
and  have  supposed  that  two  or  more  distinct  agues  coexisted.  This  savonrs  a  good 
deal  of  the  error  that  I  formerly  warned  you  ajjainst,  of  looking  upon  diseases  as 
separate  entities,  and  not  merely  as  modes  of  being  and  of  acting  different  fiom  those 
whicr.  are  proper  to  the  state  of  health.  The  vulgar  always  regard  disorders  in  this 
light.  A  coachman  by  whose  side  I  sat  while  travelling  from  Broadstairs  to  Mar- 
gate, was  speaking  of  the  rarity  of  ague  in  that  part  of  the  Isle  of  Thanet.  His 
father,  he  said,  once  had  the  complaint,  and  when  he  was  on  a  visit  to  him,  the 
coachman,  at  Ramsgate,  a  fit  came  on.  The  son  administered  to  his  suffering  parent 
a  glass  of  brandy  :  whereupon  "  he  threw  the  agy  off  his  stomach  ;  and  ir  looked 


I 


INTERMITTENT    FEVER.  439 

for  all  the  world  like  a  lump  of  jelly."     Thai  was  the  only  occasion  on  which  he 
had  ever  "  aeen  the  agy." 

Besides  these  varieties  in  type,  some  other  deviations  from  the  normal  and  regular 
paroxysms  require  to  be  noticed. 

Sometimes  the  paroxysm  is  incomplete  :  it  is  shorn  of  one  or  more  of  its  stages  : 
the  heat  and  sweating  occur  without  any  previous  rigors  ;  or  the  patient  shaken,  but 
has  no  subsequent  heat ;  or  the  sweating  stage  is  the  only  one  of  the  three  that 
manifests  itself.  These  fragments  of  a  fit  are  often  noticeable  when  the  complaint  is 
about  to  take  its  departure ;  but  they  may  also  occur  at  other  periods  of  the  disease. 
Sometimes  there  is  no  distinct  stage  at  all:  but  the  patient  experiences  frequent  and 
irregular  chiUs,  is  languid  and  uneasy,  and  depressed.  This  state  is  commonly 
known  among  the  inhabitants  of  our  fenny  and  aguish  districts  as  the  dumb  ao-ue, 
or  dead  ague ;  the  patient  is  said  not  to  shake  out. 

Again,  there  is  often  observed  a  tendency  to  a  change  of  type  in  the  course  of  the 
same  disease  affecting  the  same  person.  The  quotidian  will  be  transformed  into  a 
tertian  ;  a  tertian  into  a  quartan  ;  or,  on  the  other  hand,  a  quartan  into  either  of  these. 
I  have  already  noticed  the  fact  that  the  paroxysms  will  also  alter  their  time  of  inva- 
sion, sometimes  coming  later  and  later  in  the  day,  at  each  recurrence,  sometimes 
earlier  and  earlier.  When  the  paroxysm  thus  postpones,  the  disease  is  growing 
milder :  when  it  anticipates  its  usual  period  of  attack,  the  disease  is  increasing  in 
severity.  The  postponement  or  anticipation,  therefore,  of  the  fit,  has  a  close  relation 
to  the  prognosis. 

There  are  yet  other  cases,  in  which  from  first  to  last  no  determinate  type  or  order 
of  succession  is  observed  by  the  paroxysms ;  and  these  cases  authors  speak  of  as 
erratic  forms  of  ague. 

There  are  also  many  modifications  or  complications  observable  in  the  symptoms 
which  constitute  the  fits.  Occasionally  each  paroxysm  is  attended  by  violent  deli- 
rium:  this  is  most  common,  I  believe,  in  the  hot  stage.  This  symptom  has  been 
known  to  be  almost  constant  throughout  an  epidemic.  Sometimes  the  patient  is 
convulsed  in  the  paroxysm;  or  syncope  comes  on;  or  tetanic  rigidity;  or  petechiae 
lakes  place  on  the  skin,  and  disappear  with  the  paroxysm.  These  deviations  from 
the  common  and  regular  kind  and  order  of  the  symptoms  may  sometimes  depend 
upon  the  constitutional  predispositions  of  the  person  affected ;  but  there  is  another 
way  also  in  which  they  may  be  explained.  1  shall  presently  have  a  good  deal  to 
say  upon  the  one  grand  —  1  may  say  sole  —  exciting  cause  of  intermittents.  Now 
exposure  to  that  cause,  a  residence  in  aguish  districts,  will  sometimes  impart  a  periodic 
character  to  other  diseases:  and  I  apprehend  that  this  explanation  will  apply  to 
many  of  the  instances  which  have  been  observed  of  hysterical,  tetanic,  or  other 
paroxysmal  complaints,  occurring  at  perfectly  regular  intervals. 

The  duration  of  ague — of  the  whole  disease,  and  not  merely  of  a  separate  pa- 
roxysm— it  is  not  easy  to  estimate.  If  persons  who  laboured  under  it  were  always 
removed  at  once  from  the  influence  of  the  exciting  cause,  and  were  always  suffered 
to  remain  without  treatment  calculated  to  check  the  malady,  we  might  then  find 
materials  for  determininn-  its  average  natural  duration.  But  we  have  not  these  data. 
In  point  of  fact,  ague  sometimes  consists  of  a  very  few  paroxysms  only,  half  a 
dozen,  or  four,  or  three,  or  even  of  one  fit ;  and  on  the  other  hand,  they  may  be  pro- 
tracted over  a  space  of  several  weeks,  or  months  ;  nay,  of  many  years. 

An  ague  may  attack  a  person  at  any  time ;  but  they  are  much  more  common  in 
spring,  and  in  autumn,  than  in  the  otlier  seasons  of  the  year:  so  that  you  will  hear 
and  read  a  good  deal  of  vernal  intermittents,  and  of  autumnal  intermittents.  The 
autumnal  agues  are,  cniteris  paribus,  the  more  severe  and  dangerous.  The  quotidian 
is  most  common  in  the  spring;  the  quartan  in  the  autumn;  and  the  tertian  is  Av- 
quenlly  met  with  both  as  a  vernal  and  as  an  autumnal  ague.  You  will  bi.'ar  in  mind 
ihat  in  all  this  I  am  stating  the  prevailing  rules ;  which  are  liable  lo  "umerous  ex- 
ceptions. 

Ague  is  one  of  those  disorders  of  which  (as  of  common  inflammation)  ah  pensons, 

at  all  periods  of  their  existence,  seem  to  be  susceptible,  when  submitted  to  the  influ 

nee  c^  the  specific  exciting  cause.     Individuals  of  all  'igcs,  from  sucking  infants  w. 


440  INTERMITTENT    FEVER. 

persons  of  four-score,  are  liable  to  it,  but  they  are  not  equally  subject  to  it.  It  is 
less  likely  {cxteris  paribus)  to  affect  the  very  young,  and  the  aged,  than  those  of 
middle  life.  However,  the  very  old  are  by  no  means  exempt  from  the  operation  of 
the  cause  of  ague :  and  with  respect  to  the  very  young,  some  extremely  curious 
statements  have  been  made.  It  is  said  that  persons  have  had  ague  before  they  were 
born.  We  know  that  the  period  of  intra-uterine  life  is  obnoxious  to  many  forms  of 
disease ;  for  we  trace  the  consequences  of  such  disease,  in  visible  changes  of  struc- 
ture, immediately  after  birth.  Pulmonary  tubercles  constitute  one  malady  to  which 
the  fcetus  in  utero  is  liable:  hydrocephalus  is  another:  acute  inflammation  of  the 
peritoneum  a  third.  And  there  can  be  no  doubt  that  various  specific  poisons  influ- 
ence, occasionally,  the  included  being,  even  although  they  may  have  no  sensible 
effect  upon  the  parent.  The  fcetus  may  thus  contract  small-pox,  which  sometimes 
proves  fatal  to  it,  sometimes  not.  The  daughter  of  my  bed-maker  at  Cambridge  had 
a  child  ill  of  hooping-cough  in  the  house  with  her  while  she  was  in  the  last  months 
of  pregnanc}'^ ;  and  the  infant  in  the  womb  must  have  caught  the  disease,  for  I  was 
assured  that  he  hooped  the  very  day  he  came  into  the  world.  The  sins  of  the  parent 
are  thus  visited  often  upon  the  child,  when,  before  its  first  breath  is  draAvn,  its  frame 
is  contaminated  by  the  virus  of  syphilis.  And  in  like  manner  unborn  infants  are 
capable  of  being  affected  by  the  poison  that  produces  ague.  One  case  in  proof  of 
this  is  recorded  by  Dr.  Russell,  in  his  History  of  Aleppo.  The  woman  had  tertian 
ague,  Avhich  attacked  her,  of  course,  every  other  day:  but  on  the  alternate  days, 
when  she  was  well  and  free,  she  felt  the  child  shake ;  so  that  they  both  had  tertian 
ague,  only  their  paroxysms  happened  on  alternate  days.  Bark  was  prescribed  for 
her ;  and  it  cured  the  little  one  first,  and  afterwards  it  cured  the  mother. 

One  probable  reason  why  ague  more  commonly  affects  persons  about  the  middle 
period  of  life,  than  those  near  its  extremes,  is  that  the  former  are  much  more  likely 
to  be  exposed  to  the  primary  exciting  cause.  And  the  same  reason  may  be  given,  I 
presume,  for  another  fact ;  viz.,  that  the  complaint  is  much  more  frequently  seen  in 
men  than  in  women. 

Among  the  circumstances  which  predispose  to  ague,  debility  has  a  powerful  in- 
fluence. It  is  important  to  be  aware  of  this,  as  it  concerns  the  prophylaxis,  and  the 
management  of  the  patient  after  the  disease  has  been  subdued.  Soldiers  have  been 
exposed  to  the  exciting  cause,  Avithout  becoming  affected  by  it,  while  strong  and  in 
good  health  ;  and  have  fallen  ill  of  intermittent  fever  upon  being  weakened  by  ex- 
ertion and  fatigue.  When  I  have  told  you  that  debility,  any  how  produced,  consti- 
tutes a  predisposition  to  intermittent  fever,  I  need  scarcely  add  that  all  the  multiform 
causes  of  debility  may  also  be  regarded  as  predisposing  causes'of  this  same  diease; 
as  they  are  of  so  many  others. 

But  the  strongest  predisposing  cause  of  all  is  an  actual  occurrence  of  the  disease 
itself.  The  effect  of  former  intermittents  upon  the  system  is  such  that  the  complaint 
may  be  reproduced  by  agencies  which  under  any  other  circumstances  would  be  quite 
inoperative  in  exciting  ague.  I  have  stated  already  my  persuasion  that,  strictly 
speaking,  there  is  but  one  exciting  cause  of  intermittent  fever:  but  in  making  that 
statement  I  refer  to  \\.s  first  production.  The  disease  leaves  the  body  in  a  condition 
in  which  other  injurious  influences  may,  of  themselves,  be  sufficient  to  renew  it. 
It  brings  into  play  a  new  order  of  exciting,  or  rather  of  re-exciting  causes.  If  a 
person  were  never  exposed  to  the  malaria,  he  would  never,  as  I  believe,  have  ague : 
but  having  once  had  ague,  he  may  many  times  have  it  again,  although  he  should 
never  again  be  subjected  to  the  direct  influence  of  the  malaria.  The  late  Dr.  James 
Gregory  of  Edinburgh,  had  a  brother-in-law  who  illustrated  well  in  his  own  person 
the  efffcls  of  predisposing  circumstances  in  respect  to  ac^ue.  This  gentleman  was  a 
strong,  active  man,  and  commanded  a  battalion  in  the  West  Indies ;  and  he  escaped 
for  a  long  time,  while  others  were  falling  down  around  him  in  remittent  fever.  At 
last  he  was  wounded  by  a  musket-ball  which  passed  through  his  shoulder.  He  in- 
sisted, much  asxainst  the  will  of  the  surgeon  of  the  regiment,  on  resuming  his  duties 
oe?ore  his  strength  was  completely  restored  ;  snd  the  consequence  was  that  he  was 
immediately  attacked  by  a  remittent  fever  of  such  violence,  that  his  hfe  was  for  some; 
ume  despaired  of.    Bu*:  this  was  not  all.    The  remittent  disease  assumed  by  degrees 


INTERMITTENT   FEVER.  441 

a  distinctly  intermittent  form,  and  became  a  tertian :  and  at  last  he  got  well,  and 
strong,  and  came  over  to  this  country.  But  for  a  long  while,  though  to  all  appear- 
ance his  health  was  re-established,  ague  fits  would  from  time  to  time  occur ;  and 
they  came  precisely  at  the  day  and  hour  on  which  they  would  have  happened  if  the 
tertian  had  continued  with  its  original  type  ;  and  shght  causes  were  sufficient  to  re- 
produce  them.  He  had  marked  in  an  almanack,  the  days  of  the  expected  accession, 
and  on  those  days  it  recurred,  for  some  time,  whenever  the  east  wind  blew.  This 
very  circumstance,  the  east  wind,  is  a  common  re-exciting  cause  in  such  cases ;  ex- 
posure to  cold  in  any  way  is  another. 

The  exciting  cause  of  intermittent  and  remittent  fevers — the  primary  exciting 
cause  I  mean,  that  without  which  ague  would  never  occur  at  all — deserves  a  some- 
what particular  consideration.  I  need  scarcely  say  that  it  consists  in  certain  invisible 
effluvia  or  emanations  from  the  surface  of  the  earth,  which  were  formerly  called 
marsh  miasmata,  but  to  which  it  has,  of  late  years,  become  fashionable  to  apply  the 
foreign  term  malaria.  In  some  respects  the  latter  designation  is  the  more  conve- 
nient of  the  two. 

The  malaria  is  a  specific  poison,  producing  specific  effects  upon  the  human  body. 
In  its  medical  sense,  it  is  not  simply  bad  air,  or  impure  air,  although  the  word  is 
loosely  employed  by  many  to  express  any  mixed  kind  of  contamination  of  the  at- 
mosphere. Thus  we  hear  of  the  malaria  of  London  :  but  ague,  even  when  it  occurs 
in  London,  is  very  seldom  indeed,  now-a-days,  of  London  growth.  The  impure  air 
incident  to  large  and  populous  cities  is  prejudicial  enough  to  health,  as  I  formerly 
took  occasion  to  show  you  :  but  it  does  not  generate  fever :  neither  continued  fever, 
nor  intermittent. 

[The  author  certainly  cannot  mean  to  assert,  as  his  language  would  seem  to  imply,  that  no 
form  of  fever  is  generated  by  "  the  impure  air  incident  to  large  and  populous  cities,"  but 
that  all  fevers  are  produced  by  a  "  specific  poison"  resulting  from  other  causes  than  those  by 
which  the  atmosphere  is  rendered  impure  in  the  crowded,  unventilated,  and  filthy  lanes, 
courts,  and  alleys,  which  abound  in  suburbs  of  most  large  cities.  That  typhus  and  typhoid, 
bilious,  and  yellow  fevers  are  generated  in  large  and  populous  cities,  no  one,  we  presume, 
will  pretend  to  deny,  but  of  their  dependence  upon  a  specific  aerial  poison  we  have  not  as 
yet  been  furnished  with  any  satisfactory  evidence. — C] 

The  emanations  which  cause  ague  have  been  called  marsh  miasmata,  because  they 
are  notoriously  common  in  marshy  places.  But  they  are  not  peculiar  to  marshy 
places.  For  this  reason,  and  for  brevity's  sake,  I  prefer  using  the  single  word  mal- 
aria. In  this  country,  thank  God,  we  witness  its  milder  evils  only,  and  those  not 
very  often  ;  but  it  is  the  bane  and  scourge  of  large  portions  of  the  world.  Whether 
you  practise  here  or  abroad,  it  is  very  fit  that  you  should  know  the  qualities,  habitats, 
and  habits,  of  this  wide-spread  poison.  The  mildest  form  of  fever  to  which  it  gives 
birth  is  the  intermittent  fever,  or  ague  ;  but  in  climates  and  places  where  it  exists  in 
greater  abundance  and  intensity,  the  fever  becomes  remittent,  or  even  assumes  the 
continued  form.  This  has  led  to  strange  errors,  and  proved  a  fertile  source  of  dif- 
ference and  controversy  amongst  medical  men :  not  a  few  of  whom  confound  the 
severe  continued  fevers  which  spring  from  the  malaria,  and  which  are  never  conta- 
gious, with  the  severe  continued  fevers  usually  called  typhous,  which  are  unques- 
tionably communicable  from  person  to  person. 

The  effluvia  which  thus  form  the  sole  exciting  cause  of  intermittent  and  remittent 
fevers  proceed  from  the  surface  of  the  earth,  and  are,  probably,  gaseous,  or  aeriform  : 
at  any  rate  they  are  involved  in  the  atmosphere.  But  i\\(  j  are  imperceptible  by 
any  of  our  senses.  Of  their  physical  or  chemical  qualities  we  really  know  nothing. 
We  are  made  aware  of  their  existence  only  by  their  noxious  effects ;  and  the 
inference  that  they  exist  was  not  made  till  within  the  last  century  and  a  half. — Time 
out  of  mind,  indeed,  it  had  been  matter  of  common  observation  that  the  inhabitants 
of  wet  and  marshy  situations  were  especially  subject  to  these  definite  and  unequi- 
vocal forms  of  disease.  But  the  Italian  physician,  Lancisi,  was  the  first,  so  far 
as  I  know,  to  put  forth  distinct  ideas  concerning  malaria,  in  his  book,  published 
about  lt!95,  De  noxiis  paludum  cjffluviis.  This  is  the  great  original  work  upon 
the  subject. 


442  IiNTERMITTENT    FEVER. 

To  the  production  of  this  deleterious  agent,  a  certain  degree  of  temperature  seems 
necessary.  It  does  not  appear  to  exist  witliin  the  arctic  circle  :  nor  does  it  manifest 
itself  during  the  colder  seasons  of  more  temperate  climates.  It  is  very  seldom 
traceable  beyond  the  56th  degree  of  north  latitude  ;  and  it  is  supposed  to  require  for 
its  development  a  continuous  temperature  higher  than  60°  of  Fahrenheit's  thermo- 
meter. The  nearer  we  approach  the  equator,  the  more  abundant,  virulent,  and  per- 
nicious does  the  poison  become,  wherever  it  is  evolved  at  all. — In  this  climate  it  gives 
rise  to  intermittonls,  and  principally  to  tertians.  As  we  go  south,  in  Spain,  and 
along  the  shores  of  the  Mediterranean,  the  remittent  becomes  the  predominant  form  ; 
and  (what  is  very  instructive)  remittents  there  contracted  often  improve  into  inter- 
inittents  upon  the  removal  of  the  patient  to  a  colder  climate.  Under  the  tropical 
heats,  in  the  West  Indies,  for  example,  the  fevers  very  frequently  assume  the  conti- 
nued form. 

And  another  condition  of  the  development  of  the  poison  soon  becomes  apparent 
It  requires  a  certain  degree  of  moisture.  Of  all  these  regions,  malaria,  showing 
itself  always  by  its  effects  alone,  infests  certain  parts  only ;  which  parts  are,  most 
generally,  remarkable  for  their  humid  and  swampy  character.  Thus,  in  this  island, 
intermittents  are  produced  chiefly,  I  may  say  almost  exclusively,  along  the  eastern 
coast ;  in  parts  of  Kent,  Essex,  Cambridgeshire,  Norfolk,  Lincolnshire,  and  the  East 
Riding  of  Yorkshire  :  and  in  each  of  these  counties  there  are  marshes,  or  fens,  or  low 
grounds  and  lands  that  are  occasionally  overfloAved.  Many  of  these  spots  have, 
within  the  last  fifty  years,  been  drained,  and  brought  under  cultivation ;  and  agues 
are  consequently  much  more  rare  in  England  than  they  formerly  were.  In  Syden- 
ham's lime  they  were  very  frequent,  and  very  fatal  indeed,  in  this  metropolis.  James 
I.  and  Oliver  Cromwell  both  died  of  ague  contracted  in  London.  At  present  (as  I 
said  before)  we  seldom  meet  with  them. — Except  in  the  year  1827,  I  have  never, 
since  I  have  been  in  practice,  known  ague  to  be  at  all  common  here.  This  compa- 
rative freedom  from  malaria  is  mainly  owing,  no  doubt,  to  the  improved  character  of 
the  draining  and  sewerage. 

Agues,  or  aguish  fevers,  are  endemic  along  every  part  of  the  low  and  level  coast 
of  Holland.  In  Italy,  the  Pontine  marshes,  near  Rome,  have  possessed  for  ages  an 
infamous  celebrity  of  the  same  kind.  The  whole  of  the  district  called  the  Marcmna, 
which  stretches  for  about  thirty  leagues  along  the  shores  of  the  Mediterranean,  and 
which  in  some  places  is  ten  or  twelve  leagues  broad,  is  rendered  dangerous,  and 
almost  uninhabitable,  by  the  vast  quantity  of  malaria  annually  evolved  from  its  soil. 
In  America  large  districts  are,  for  the  same  reason,  prohfic  of  disease.  The  late 
Bishop  Heber,  in  his  Narrative  of  a  Journey  through  the  Upper  Provinces  of  In- 
dia, gives  the  following  striking  picture  of  the  influence  of  the  malaria  in  that  part 
of  the  world.     It  seems  to  be  alike  pestiferous  to  man  and  beast. 

"I  asked  Mr.  Boulderson  if  it  were  true  that  the  monkeys  forsook  these  woods 
during  the  unwholesome  months.  He  answered  that  not  the  monkeys  onl\-,  but 
every  thing  which  has  the  breath  of  life,  instinctively  deserts  them  from  the  begin- 
ning of  April  to  October.  The  tigers  go  up  to  the  hills;  the  antelopes  and  wild 
hogs  make  incursions  into  the  cultivated  plain ;  and  those  persons,  such  as  dak- 
bearers,  or  military  officers,  who  are  obliged  to  traverse  the  forest  in  the  intervening 
months,  agree  that  not  so  much  as  a  bird  can  be  heard  or  seen  in  the  frightful  soli- 
tude. Yet  during  the  time  of  the  heaviest  rains,  while  the  water  falls  in  torrents, 
and  the  cloudy  sky  tends  to  prevent  evaporation  from  the  ground,  the  forest  may  be 
passed  with  tolerable  safety.  //  is  in  the  extreme  heat,  and  immediulehj  after  the 
.'xiins  have  ceased,  in  May,  the  latter  end  of  August,  and  the  early  part  of  Septem- 
ber, that  it  is  most  deadly.  In  October  the  animals  return.  By  the  latter  end  of 
that  month  the  wood-cuiters  and  the  cow-men  again  venture,  though  cautiously. 
From  the  middle  of  November  to  March  troops  pass  and  repass,  and  with  common 
precaution  no  risk  is  usually  apprehended." 

Peisons  who  live  in  England  might  perhaps  be  disposed  to  think  lightly  of  the 

malaria,  had  not  such  fearful  evidence  of  its  appalling  power  been  brought  home  to 

the  experience  of  our  countrymen,  in  the  early  part  of  the  present  century,  by  the 

esull  of  the  unfortunate  expedition  to  Walcheren.     Sir  Gilbert  Blane  has  given  an 


\ 


INTERMITTENT    FEVER.  443 

account  of  the  ravages  it  ihere  committed  among  our  troops.  You  may  see  his 
paper,  to  which  I  shall  presently  again  refer,  in  the  third  volume  of  the  Mcdico-Chi- 
riir sliced  I'ransuctions. 

Not  only  a  certain  degree  of  heat,  and  a  certain  quantity  of  moisture,  but  the  pre- 
sence of  all  the  four  elements  of  the  ancients,  would  appear  to  be  requisite  for  the 
production  of  this  poison.  Air  of  course  there  must  be  ;  and  earth  also  is  essential. 
If  heat  and  moisture  were  alone  adequate,  we  should  find  the  fever  prevailing  among 
sailors  when  out  at  sea:  but  it  is  not  so,  whatever  may  be  the  temperature  under 
which  they  cruise.  It  is  when  they  approach  the  coast,  or  land  upon  it,  that  they 
are  attacked.  The  water  of  marshes  has  been  examined  under  the  microscope,  and 
analyzed  again  and  again,  with  a  view  to  the  discovery  of  the  nature  of  this  pesti- 
lential agent ;  but  in  vain.  A  more  likely  Avay  to  detect  the  noxious  material  would 
seem  to  be  by  examining  the  air  of  malarious  districts ;  and  this  has  been  done 
carefully  and  repeatedly  by  expert  chemists ;  and  with  the  same  want  of  success. 
The  poisonous  princi})le  eludes  the  test  of  the  most  delicate  chemical  agents. 

Where  there  are  are  much  heat,  and  much  moisture,  there  we  usually  find  also 
much  and  rank  vegetation,  and  much  vegetable  dissolution  and  decay.  The  belief 
was  as  natural,  therefore,  as  it  has  been  general,  that  the  putrefaction  of  vegetable 
matters  was  somehow  or  other  requisite  to  the  formation  of  the  poison  that  exists  so 
commonly  in  swampy  situations.  This  belief  has  descended,  almost  unquestioned, 
from  the  time  of  Lancisi ;  and  it  obtains  almost  universal  acceptance,  I  fancy,  among 
phj'sicians  of  the  present  day.  Yet  very  strong  facts  have  been  adduced  to  show 
that  the  decomposition  of  vegetable  substances  is  only  an  accidental,  though  a  fre- 
quent, (iccompuniment  of  the  miasm ;  and  not  by  any  means  an  essential  condition  of 
its  evolution. 

In  the  first  place,  the  decomposition  of  vegetable  matter  goes  on  abundantly  vnth 
out  the  production  of  m.alaria.  The  rotting  cabbage-leaves  of  Covent  Garden,  and 
.hose  w'hich  taint  the  air  of  the  streets  from  the  neglected  dust-holes  of  London, 
during  the  hot  weather  of  summer  give  rise  to  no  ague.  The  same  may  be  said  of 
the  putrefying  and  offensive  sea-weed,  which  is  deposited  in  large  quantities  upon 
some  very  healthy  parts  of  our  sea-coast.  But  the  converse  facts  are  the  njo^t 
remarkable  and  conclusive.  I  have  stated  that  marshes  are  not  necessary  to  pro- 
duce malaria;  but  Dr.  William  Ferguson — a  physician  who  has  had,  and  who  has 
well  used,  very  suflicient  opportunities  of  investigating  the  question  —  shows  that 
vegetation  is  not  necessary :  that  the  peculiar  poison  may  abound  where  there  is  no 
decaying  vegetable  matter,  and  no  vegetable  matter  to  decay.  As  the  prevailing 
belief  is,  in  my  opinion,  an  erroneous  one,  and  as  it  is  really  of  great  importance  that 
correct  views  of  this  subject  should  be  taken  and  disseminated  by  medical  men,  I 
will  mention  a  few  of  the  most  striking  of  the  facts  detailed  by  Dr.  Fercjuson.  They 
are  contained  in  a  very  interesting  paper  "  On  the  Nature  and  History  of  the  Marsh 
Poison,''^  published  in  the  Edinburgh  Philosophical  Transactions. 

In  August,  1794,  after  a  very  hot  and  dry  summer,  our  army  in  Holland  encamped 
at  Rosendaal  and  Oosterhout.  The  soil,  in  both  places,  was  a  level  plain  of  sand, 
with  a  perfectly  dry  surface,  where  no  vegetation  existed,  or  could  exist,  but  stunted 
heath  plants.  It  was  universally  percolated  to  within  a  few  inches  of  the  surface, 
with  water  which,  so  far  from  being  putrid,  was  perfectly  potable.  Here  fevers  of 
the  intermittent  and  remittent  type  appeared  among  the  troops  in  great  abundance. 
It  is  interesting  to  observe  that  the  soil  in  Walcheren  is  precisely  similar.  Sir  Gil- 
bert Blane  describes  it  as  consisting  "  of  a  fine  white  sand,  known  in  the  eastern 
counties  of  England  by  the  name  of  silt,  and  about  a  third  part  of  clay."  It  was 
after  a  hot  and  dry  summer,  also,  that  the  British  army  suffered  in  that  island  from 
the  endemic  fever,  to  a  degree  which  Dr.  Ferguson  speaks  of  as  "being  almost  un- 
precedented in  the  annals  of  warfare." 

In  the  year  ISOO,  several  regiments  of  our  army  in  Spain  took  up  an  encamp- 
ment in  a  hilly  ravine  which  had  lately  been  a  water-course.  Pools  of  water  still 
remained  here  and  there  among  the  rocks,  so  pure  that  the  soldiers  were  anxious  to 
bivouack  near  them  for  the  sake  of  using  the  water.  Several  of  the  men  were  seized 
vvilh  violent  remitting  fever  before  they  could  move  from  the  bivouack  the  next  morn 


444  INTERMITTExXT    FEVER. 

ing.     "Till  tb^n  (says  Dr.  Ferguson)  it  had  always  been  believed  amongst  us  thsS 
vegetable  putrefaction  (the  humid  decay  of  vegetables)  was  essential  to  the  produc- 
tion of  pestiferous  miasmata ;  but  in  the  instance  of  the  half-dried  ravine  before  us,     ^  I 
from  the  stony  bed  of  which  (as  soil  never  could  lie  for  the  torrents)  the  very  exist-      M 
ence  even  of  vegetation  was  impossible;  it  proved  as  pestiferous  as  the  bed  of  a 
fen." 

After  the  battle  of  Talavera,  the  army  retreated  along  the  course  of  the  Guadiana 
river,  into  the  plains  of  Estremadura.  The  country  was  so  arid  and  dry  for  want 
of  rain,  that  the  Guadiana  itself,  and  all  the  smaller  streams,  had  in  fact  ceased  to  be 
streams,  and  were  no  more  than  lines  of  detached  pods  in  the  courses  that  had  for- 
merly been  rivers.  The  troops  there  "  suffered  from  remittent  fevers  of  such  destruc- 
tive malignity,  that  the  enemy,  and  all  Europe,  believed  that  the  British  host  was 
extirpated." 

Cividad  Rodrigo  is  situated  on  a  rocky  bank  of  the  river  Agueda,  a  remarkably 
clear  stream ;  but  the  approach  to  it  on  the  side  of  Portugal  is  through  a  bare,  open, 
hollow  country,  that  has  been  likened  to  the  dried-up  bed  of  an  extensive  lake;  and 
upon  more  than  one  occasion,  when  this  low  land,  after  having  been  flooded  in  the 
rainy  season,  had  become  as  dry  as  a  brick-ground,  with  the  vegetation  utterly 
burned  up,  there  arose  to  our  troops  fevers  which,  for  malignity  of  type,  could  only 
be  matched  by  those  before  mentioned  on  the  Guadiana. 

Many  more  facts  to  the  same  purpose  are  related  in  Dr.  Ferguson's  paper,  which 
is  in  every  way  well  \vorth  your  perusal.  He  tells  us  "  that  in  the  most  unhealthy 
parts  of  Spain,  we  may  in  vain,  towards  the  close  of  the  summer,  look  for  lakes, 
marshes,  ditches,  pools,  or  even  vegetation.  Spain,  generally  speaking,  is  then, 
though  as  prolific  of  endemic  fever  as  Walcheren,  beyond  all  doubt  one  of  the  driest 
countries  of  Europe ;  and  it  is  not  till  it  has  again  been  made  one  of  the  wettest,  by 
the  periodical  rains,  with  its  vegetation  and  aquatic  weeds  restored,  that  it  can  be 
called  healthy,  or  even  habitable  with  any  degree  of  safety." 

Our  time  will  not  allow  of  my  extracting  any  further  evidence  on  this  point ;  one 
circumstance  of  contrast,  however,  I  am  unwilling  to  omit. 

The  river  Tagus  is,  at  Lisbon,  about  two  miles  broad  ;  and  it  separates  a  healthy 
from  a  very  unheakhy  region.  On  the  one  side  is  a  bare  hilly  country;  the  founda- 
tion of  the  soil,  and  of  the  beds  of  the  streams,  being  rock,  with  free  open  water- 
courses among  the  hills.  This  is  the  healthy  side.  But  the  Alentejo  land,  on  the 
other  side,  though  as  dry  superficially,  being  perfectly  flat  and  sandy,  is  most  pesti- 
ferous. Moreover,  in  and  near  Lisbon  there  are  numerous  gardens,  where  they  keep 
water,  durino-  the  three  months'  absolute  drought  of  the  summer  season,  in  stone 
reservoirs.  These  reservoirs,  containing  water  in  the  most  concentrated  state  of  foul- 
ness and  putridity,  are  placed  close  to  the  houses  and  sleeping  rooms  :  the  inhabitants 
literally  live  and  breathe  in  their  atmosphere.  "  Yet  no  one  ever  heard  or  dreamt 
of  fever  being  generated  amongst  them  from  such  a  source  ;  though  the  most  igno- 
rant native  is  well  aware  that  were  he  only  to  cross  the  river,  and  sleep  on  the  sandy 
shores  of  the  Alentejo,  where  a  particle  of  water  at  that  season  had  not  been  seen 
for  months,  and  where  water,  being  absorbed  into  the  sand  as  soon  as  it  fell,  was 
7iever  known  to  be  putrid,  he  would  run  the  greatest  risk  of  being  seized  with  re- 
mittent fever." 

Now  these  facts,  and  facts  like  these,  ^eem  to  prove  that  the  malaria,  and  the  pro- 
duct of  vegetable  decomposition,  are  two  distinct  things.  They  are  often  in  company 
with  each  other,  but  they  have  no  necessary  connection.  "Whoever,  in  a  malarious 
country,  waits  for  the  evidence  of  putrefaction,  will  wait,  says  Dr.  Ferguson,  too  long. 
For  producing  malaria  it  appears  to  be  requisite  that  there  should  be  a  surface  capa- 
ble of  absorbing  moisture,  aiad  that  this  surface  should  be  flooded  and  soaked  with 
water,  and  then  dried :  and  the  higher  the  temperature,  and  the  quicker  the  drying 
process,  the  more  plentiful  and  the  more  virulent  (more  virulent  probably  because 
more  plentiful)  is  the  poison  that  is  evolved. 

The  putrefaction  o^  animal  matter  is  sometimes  spoken  of  as  an  element  in  the 
lormation  of  the  malarious  poison.  But  the  evidence  I  have  just  set  before  you  re- 
futes this  sup  position  as  completely  as  it  excludes  the  alleged  necessity  of  vegetable 


INTERMITTENT    FEVER.  445 

decay.  I  hoj^e  to  prove  to  you,  in  a  future  part  of  the  course,  that  neither  animal 
nor  vegetable  decomposition  is  sufficient  to  generate  fever  of  any  kind. 

Dr.  Ferguson's  facts  are  generally. in  accordance  with  the  observations  which 
others  have  made  upon  the  same  subject :  and  his  views  will  be  found  to  account  for 
some  phenomena  which  the  ordinary  theory  of  vegetable  putrefaction  did  not  cleverly 
explain. 

There  is  good  reason  for  believing  that  in  all  cases  the  poisonous  emanations  pro- 
ceed from  parts  ot  the  surface  that  have  been  flooded  and  then  dried,  rather  than 
from  parts  that  are  still  wet,  or  putrid.  And  this  elucidates  a  circumstance  very 
often  noticed,  viz.,  that  neighbouring  places — especially  high  and  low  lands  lying 
near  each  other — change  their  character  in  respect  to  salubrity  upon  the  occurrence 
of  rains.  The  low  grounds,  which  bad  previously  been  very  dangerous,  become 
healthy  when  they  are  flooded  over:  and  the  higher  lands,  which  are  made  wet, 
and  which  rapidly  dry  again,  produce  the  malaria  abundantly.  For  the  same  reason, 
the  edges  or  borders  of  swamps,  which  of  course  expand  or  contract  according  to 
the  wetness  or  dryness  of  the  season,  are  more  unsafe  than  their  centres.  The 
drying  and  half-dried  margins  of  the  purest  streams  may  be  prolific  of  the  evil,  when, 
from  the  want  of  confining  banks,  those  margins  have  been  flooded  by  the  rising  of 
the  waters. 

There  is  no  observation  more  general  than  that,  in  malarious  places,  agues  and 
remittent  fevers  abound  more  in  hot  and  dry  years  than  in  those  which  are  cold  and 
moist.  And  this  influence  of  temperature  it  is  which  mainly  determines  the  differ- 
ences observable  in  regard  to  these  fevers  at  different  elevations,  and  in  different 
seasons  of  the  year.  In  the  higher  grounds  of  the  West  Indies  agues  occur  as  in 
this  country  :  as  you  descend,  and  the  mean  atmospheric  temperature  increases, 
remittents  are  met  with  :  and  in  the  lowest  and  hottest  parts  the  fever  becomes  con- 
tinued. The  following  instructive  facts  are  stated  by  Dr.  Ferguson.  In  181<J,  the 
British  garrison  of  English  Harbour,  in  Antigua,  was  disposed  in  three  separate 
barracks,  on  fortified  hills  surrounding  the  dock-yard.  One  of  the  barracks  vi^as  on 
an  eminence  named  Monk's  Hill,  six  hundred  feet  above  the  level  of  the  marshes. 
The  other  two  were  situate  on  an  eminence  called  the  ridge,  one  at  the  height  of  five 
hundred,  and  the  other  at  the  height  of  three  hundred  feet.  So  pestiferous  were  the 
marshes  among  which  the  dock-yard  was  placed,  that  it  often  happened  to  a  well- 
seasoned  soldier,  coming  down  from  Monk's  Hill,  and  mounting  the  night-guard  in 
perfect  health,  to  be  seized  with  furious  delirium  while  standing  sentry,  and  to  ex- 
pire within  less  than  thirty  hours  after  being  carried  up  to  his  barracks,  with  a  yellow 
skin,  and  having  had  black  vomiting.  Those  in  the  barracks  on  Monk's  Hill  ivho 
did  not  come  doivn,  the  superior  officers,  the  women,  children,  and  drummers,  had 
no  fever  of  any  kind.  Seventeen  artillerymen,  in  the  barrack  at  the  height  of  three 
hundred  feet,  did  not  come  down  to  the  night-guards.  (We  shall  see  hereafter  that 
malarious  places  are  always  most  dangerous  at  night.)  Every  one  of  these  men 
was  attacked  with  remittent  fever,  of  which  one  of  them  died.  At  the  barrack  on 
the  top  of  the  ridge,  at  the  height  of  five  hundred  feet,  there  scarcely  occurred  any 
fever  worthy  of  notice.  Thus,  in  the  same  place,  the  malaria,  in  the  level  plain, 
caused  continued  fever,  resembling,  and  I  believe  identical  with,  yellow  fever  :  at  the 
elevation  of  three  hundred  feet  it  gave  rise  to  remittent  fever ;  and  at  the  height  of 
five  hundred  or  six  hundred  feet  its  influence  was  scarcely  felt  at  all.  In  the  neigh- 
bourhood of  the  Pontine  marshes  you  see  the  villages  perched  curiously  on  the  inter- 
vening hills  ;  the  Itahans  having  been  taught  by  experience  that  these  elevated  spots 
afforded  comparative  security  against  the  effects  of  the  miasmata. 

Wherever  the  malaria  prevails,  it  produces  its  peculiar  consequences  chiefly  in 
certain  seasons  :  and  it  is  in  the  autumn  especially  that  agues  and  aguish  fevers  occur; 
that  is  to  say,  after  the  heats  of  summer :  and  the  hoUer  and  drier  the  precedmg 
summer,  the  more  frequent  and  fatal  are  the  autumnal  fevers.  The  Pontine  marshes 
iie  to  the  southward  of  Rome ;  and  Horace,  you  know,  says  or  sings, 

Frustra  per  autumnos  nocentern 
Corporibus  metuemus  austrum. 

2n 


446  INTERMITTENT    FEVER. 

The  efft'Cts  of  these  morbific  effluvia  upon  the  human  body  vary  much  under  dif 
ferent  circumstances.  Where  ihey  are  most  concentrated  and  deadly,  their  opera- 
tion may  be  almost  immediate.  Witness  their  speedy  influence  upon  the  soldiers 
who  descended  at  night  from  Monk's  Hill.  So  also  sailors,  who  have  gone  on  shore 
for  a  single  night  only,  have  been  attacked  by  the  fever  before  they  could  return  to 
the  ship.  On  the  other  hand,  when  the  emanations  are  less  copious,  or  less  virulent, 
there  is  sometimes  a  long  and  uncertain  period  of  incubation.  The  disease  remains 
latent,  or  the  poison  lies  dormant,  for  a  considerable  space  of  time.  Many  of  the 
soldiers  who  were  exposed  to  the  malaria  at  Walcheren  did  not  experience  its  bad 
effects  until  after  they  had  returned,  and  had  even  resided  several  months  in  England. 
In  the  same  way,  labourers,  especially  the  itinerant  Irish,  will  go  down  in  the 
autumn  for  harvest  work  into  Lincolnshire,  and  bring  back  the  seeds  of  the  disorder 
within  them,  and  yet  may  not  be  attacked  with  ague  for  weeks  or  months  ;  upon 
the  occurrence  of  an  east  wind  perhaps,  or  after  unusual  exposure  to  cold  and  wet. 
We  trace  in  all  this  some  analogy  with,  the  animal  contagions ;  but  the  period  of 
incubation  is  more  irregular  and  accidental ;  and  it  is  probable  that  in  many  instances 
the  ague  would  not  happen  at  all,  but  for  the  concurrent  operation  of  some  other 
malign  influence. 

Another  fact  worthy  of  notice  in  respect  to  the  agency  of  the  malaria  upon  the 
human  frame,  is  that  it  affects  strangers  much  more  readily  and  decidedly  than  the 
natives  of  the  place.  In  other  words,  habit  mitigates  the  injurious  effects  of  the 
poison.  Persons  become  seasoned  to  it.  At  "Walcheren,  though  almost  every  adult 
among  the  lower  classes  had  laboured,  in  the  course  of  his  life,  under  the  endemic 
intermittent,  yet  they  were  infinitely  less  subject  to  it  than  strangers :  and  they  will 
not  believe  that  their  beloved  birth-place  is  unhealthy.  Sir  Gilbert  Blane  says  that 
persons  of  education,  and  even  medical  men,  denied  indignantly  that  their  country 
was  less  healthy  than  any  other ;  and  attributed  the  sickness  wliich  raged  among  our 
troops  to  some  trivial  circumstances  of  diet  or  habits,  and  not  to  any  insalubrity  of 
the  air.  This  is  a  curious  moral  feature  ;  but  a  very  general  one.  In  the  pestilen- 
tial plains  of  Estremadura  the  superstitious  natives,  unable  or  unwilling  to  ac(!:ount 
for  a  disease  of  a  type  so  uncommon,  among  the  soldiers,  Irom  any  unw'holesomeness 
of  the  air,  declared  that  they  had  all  been  poisoned  by  eating  mushrooms. 

It  was  found,  also,  at  Walcheren,  that  the  strangers  who  survived  the  first  attacks 
became  thereafter  much  less  liable  to  the  endemic  fevers.  The  French  general, 
Monnet,  who  had  held  the  command  at  Flushing  for  seven  years,  had  acquired  a 
knowledge  of  this  fact,  and  endeavoured  to  turn  it  to  practical  account.  He  recom- 
mended that  troops  should  not  be  frequently  changed  ;  for  when  it  was  the  custom 
to  send  battalions  from  Bergen  op  Zoom  every  fourth  night  in  succession,  to  work  on 
the  lines  of  Flushing,  these  men  never  failed,  upon  their  return,  to  be  taken  ill  in 
great  numbers.  General  Monnet  therefore  advised,  however  displeasing  it  might  be 
to  the  officers,  that  a  stationary  garrison  should  be  retained  at  Walcheren,  in  order 
that  the  men  might  be  habituated  or  seasoned  to  the  air  {acclimates,)  and  he  adduced 
the  instance  of  a  French  regiment  which  suffered  in  the  second  year  of  its  being 
stationed  there  only  one-half  the  sickness  and  mortahty  which  it  suffered  during  the 
first  year;  and  hardly  suffered  at  all  in  the  third  year. 

But  although  the  natives  and  residents  in  malarious  places  are  not  so  liable  as  new 
comers  to  the  violent  and  distinct  forms  of  fever,  they  are  chronically  affected  by 
the  insalubrity  of  the  atmosphere.  They  are  spoken  of  by  travellers  as  being  puny, 
sallow,  and  sickly ;  feeble  in  body  and  spiritless  in  mind  ;  as  having  yellow  faces, 
swelled  bellies,  and  wasted  hmbs ;  as  being  subject  to  dropsies  and  fluxes ;  phleg- 
matic, melancholy,  and  short-lived. 

One  remarkable  exception  is  mentioned  by  Dr.  Ferguson.  From  some  peculiarity 
or  idiosyncrasy  (which  he  conjectures  may  be  somehow  connected  with  the  texture 
of  the  skin)  the  negro  appears  to  be  proof  against  endemic  fevers.  "  To  him  marsh 
miasmata  are  in  fact  no  poison ;  and  hence  his  incalculable  value  as  a  soldier,  for 
field  service,  in  the  West  Indies.  The  warm,  moist,  low,  and  leeward  situations 
where  these  pernicious  exhalations  are  generated  and  concentrated,  prove  to  him 
congenial.     He  dehghts  in  them,  for  there  he  enjoys  hfe  and  health,  as  much  as  his 


INTERMITTENT   FEVER.  447 

feelings  are  abhorrent  to  the  currents  of  wind  that  sweep  the  mountain  tops,  where 
alone  the  whites  find  security  against  endemic  fevers." 

No  very  certain  or  extensive  observations  have  yet  been  made  in  respect  to  the 
kind  of  soil  from  which  the  miasmata  are  most  apt  to  be  extricated.  Such  as  is 
loose,  penetrable,  porous,  and  sandy,  appears  highly  favourable  to  their  formation. 
So  are  soils  which,  containing  much  clay,  are  very  retentive  of  moisture.  One 
curious  fact,  however,  bearing  upon  this  question,  seems  to  have  been  made  out : 
viz.,  that  what  is  termed  peat-bog,  or  peat-moss,  is  not  productive  of  malaria.  Many 
parts  of  Scotland  and  of  Ireland,  that  are  occupied  by  large  tracts  of  marsh  in  which 
the  peat-moss  abounds,  are  completely  free  from  these  fevers.  Dr.  BisseL  affirms 
that  the  exhalations  from  black  peat-moss  do  not  occasion  intermiltents,  "  at  least  in 
high  moors  under  a  clear  sharp  air."  Now  in  the  climate  of  Virginia,  this  counter- 
acting influence  of  a  sharp  air  can  scarcely  be  looked  for :  yet  it  is  a  remarkable  fact, 
that  though  the  provinces  of  North  America,  especially  North  and  South  Carolina 
and  Virginia,  are  full  of  ague,  that  disease  is  never  seen  among  the  inhabitants  near 
the  country  of  the  Dismal  Swamp,  a  moist  tract  of  150,000  acres  on  the  frontiers 
of  Virginia  and  North  Carolina.  Weld,  the  traveller,  informs  us,  that  this  immense 
tract  is  covered  with  trees  and 'abounds  with  water,  which  appears  the  moment  the 
shallowest  trench  is  dug.  The  water  is  brown,  hke  brandy,  but  quite  clear,  and  not 
unpalatable.  Its  colour  is  ascribed  by  the  inhabitants  to  the  roots  of  juniper  ;  and 
it  is  said  to  be  diuretic.     (Craigie.) 


LECTURE  XLI. 

Jigue,  continued.  Speculations  respecting  its  periodicity.  Habits  and  properties 
of  the  malaria;  most  noxious  at  night ;  lies  near  the  ground  ;  is  carried  along 
by  winds  ;  cannot  pass  across  water  ;  attaches  itself  to  trees  ;  is  diminished  by 
the  increase  of  cultivation  and  of  population.  Ultimate  effects  of  the  poison  on 
the  body.  Jigue  formerly  thought  salutary.  Prognosis.  Propriety  of  stopping 
the  disease. 

You  will  remember  the  progress  we  made,  at  our  last  meeting,  in  the  subject  of 
intermittent  fever.  I  described  the  ordinary  phenomena  of  a  paroxysm  of  ague ; 
and  afterwards  mentioned  certain  unusual  symptoms  with  which  it  is  sometimes 
complicated.  The  three  principal  types  of  ague  were  also  dehneated  ;  the  quotidian, 
the  tertian  and  the  quartan :  as  well  as  their  respective  characters,  and  intervals,  and 
varieties,  and  changes  of  type.  I  spoke,  too,  of  the  predisposing  causes  of  inter- 
'mittent  fever,  which  may  all  be  briefly  included  under  the  head  of  circumstances 
that  tend  to  debilitate  the  body:  the  strongest  predisposing  cause  of  all  be:ng  a 
former  attack  of  the  disease.  And  I  began  to  consider  the  great  exciting  cause  of 
agues  and  aguish  fevers — the  malaria.  I  first  directed  your  attention  to  the  circum 
stances  under  which  the  malaria  appears  to  be  evolved.  Since  the  time  of  Lancisi 
it  had  been  very  generally  supposed  that  the  humid  putrefaction  of  vegetable  sub- 
stances was  necessary  to  the  production  of  this  peculiar  and  wide-spread  poison  ;  and 
that  heat  accelerated  the  putrefactive  process.  That  was  Dr.  Bancroft's  opinion. 
That  also  is  (I  believe)  the  opinion  held,  and  stated  in  lectures,  by  many  pathologists 
at  the  present  time.  I  showed  you,  from  facts  which  rest  upon  Dr.  Ferguson  s 
authority,  that  this  notion  is  founded  in  mistake :  that  the  products  of  the  vegetable 
decay  and  decomposition  may  and  do  often  coexist  with  malaria,  but  are  distinct  and 
separable  from  it,  and  by  no  means  essential  to  its  formation.  There  is  reason  to 
believe  that  the  flooding  of  a  porous  earthy  surface  with  water,  and  a  subsequent 
drying  of  that  surface  under  a  certain  degree  of  heat,  constitute  the  sole  or  main 
con  litions  of  the  generation  of  the  poison.  We  found  that  the  efl^ects  of  the  malaria 
are  modified  by  the  temperature  of  the  place :  that  in  low  and  hot  situations  it  may 


\ 

448  INTERMITTENT    FEVER. 

give  rise  to  an  affection  not  distinguishable  in  its  symptoms  from  yellow  fever;  and 
that  in  proportion  as  the  locality  is  higher  and  cooler,  the  fever  tends  to  assume  first 
the  remittent,  and  then  the  intermittent  type :  that  the  period  of  incubation — the 

f)eriod  which  intervenes  between  exposure  to  the  malaria  and  the  invasion  of  the 
ever — is  extremely  variable  in  duration  :  that  the  poisonous  efiiuvia  affect  straiin-ers 
more  certainly  and  more  severely  than  natives  of  the  place :  that  persons  may  be- 
come in  some  sort  seasoned  to  the  malarious  districts  :  but  that,  with  the  exception 
of  the  negroes  in  the  West  Indies,  the  inhabitants  of  places  much  infested  with  the 
peculiar  miasmata,  are  feeble,  and  sickly,  and  short-lived 

There  was  one  point  which  I  briefly  adverted  to,  and  dismissed  perhaps  too  un- 
ceremoniously :  I  mean  the  very  curious  fact  of  the  regular  periodic  recurrence  of 
the  paroxysms  of  intermittent  fever.  I  ought,  I  think,  to  have  informed  you  of  the 
views  which  pathologists  have  entertained  respecting  the  explanation  of  that  singular 
circumstance ;  although  it  must  be  confessed  that  the  solution  of  the  phenomenon  is 
still  to  be  sought  for.  A  great  number  of  persons  have  tried  their  hands,  however, 
upon  this  question.  Many  of  the  earlier  attempts  at  explanation  are  either  quite  hy- 
pothetical, or  totally  insufficient  and  illogical.  Wilhs  ascribed  the  intermission  to  a 
periodic  development  of  the  fermentable  matter  in  the  blood.  But  if  any  such  de- 
velopment took  place  (of  which  we  have  no  evidence)  we  should  be  no  nearer  the 
mark  :  the  question  would  still  recur,  why  the  development  of  this  matter  should 
happen  periodically :  and  the  same  remarks  apply  to  various  other  so-called  expla- 
nations brought  forward  by  different  writers  of  considerable  reputation.  Reil  referred 
the  intermittence  of  fevers  to  some  general  law  of  the  universe  ;  by  which  he  meant, 
I  believe,  some  vague  generalization  of  such  facts  as  the  alternation  of  light  and 
darkness,  the  periodic  recurrence  of  the  seasons,  the  ebbing  and  flowing  of  the  tides, 
the  succession  of  appetite  and  satiety,  of  the  states  of  sleeping  and  waking,  and  so 
on :  but  this  evidently  is  no  explanation  at  all.  M.  Bailly  ofl^ers  a  very  singular 
conjecture  upon  the  subject :  he  attributes  the  periodic  phenomena  to  the  modifi- 
cation necessarily  induced  in  the  human  system,  and  particularly  in  the  function  of 
circulation,  by  the  alternate  change  of  position  from  the  upright  to  the  recumbent, 
and  from  the  recumbent  to  the  upright,  every  twenty-four  hours ;  and  he  adduces  in 
corroboration  of  this  notion  the  alleged  fact  that  animals,  which  undergo  no  such  os- 
cillation of  posture,  are  not  subject  to  intermittent  fevers ;  but  this  is  said  not  to  be  a 
fact.  Rodet  and  Charpentier  affirm  that  horses  are  liable  to  such  complaints.  Dr. 
Macculloch  refers  to  the  case  of  a  dog  which  laboured  under  a  regular  tertian  ague 
for  some  years ;  the  cold  paroxysms  taking  place  always  at  three  o'clock  in  the 
afternoon.  Even  if  this  were  not  so,  M.  Bailly's  theory  fails  to  account  for  the  oc- 
currence of  continued  fevers.  If  his  views  were  correct,  then  we  might  avoid 
having  ague  by  refraining  from  these  changes  of  position  from  the  vertical  to  the 
horizontal  during  sleep,  and  back  again  upon  awaking.  Recently  M,  Roche  has 
put  forth  the  opinion  that  the  attacks  of  ague  are  periodic,  because  the  causes  of 
them  are  periodic.  And  if  this  could  be  made  out,  the  conjecture  would  carry  with 
it  some  show  of  reason.  He  observes  that  the  spring  and  the  autumn  are  the 
seasons  in  which  intermittent  fevers  chiefly  break  out,  especially  the  autumn  :  and 
that  during  those  periods  there  is  a  very  sensible  difference  in  the  temperature  and 
humidity  of  the  atmosphere  by  day  and  by  night,  and  even  within  the  space  of  three 
or  four  hours  ;  that  a  consequent  alternation  of  action  and  reaction  is  thus  produced 
in  the  human  body,  and  soon  becomes  an  established  habit.  Throughout  a  part  of 
the  twenty-four  hours,  the  operation  of  the  miasmata  is  slight,  or  not  manifest  at  all ; 
while  during  another  part  of  that  period  it  is  in  full  energy,  and  at  about  the  same 
time  daily.  The  emenations  (which  he  conceives  to  proceed  from  putrefying  vege- 
ble  matter)  are  most  abundantly  disengaged  during  the  hottest  part  of  the  day  ;  these 
watery  effluvia  are  dissolved  by  the  warm  air  to  a  certain  amount ;  but  after  sunset, 
they  are  again  deposited,  and  deposited  the  more  copiously  in  proportion  to  the  cold- 
ness of  the  atmosphere  at  that  time  ;  and  coming  in  contact  with  the  surface  of  the 
body,  with  the  mucou«  membrane  of  the  air-passages,  and  perhaps  also  with  that  of 
the  digestive  organs,  and  being  absorbed  by  those  surfaces,  it  occasions  the  phe- 


MALARIA.  449 

nomena  which  constitute  an  ague  fit.  The  influence  of  the  miasmata  being  mter- 
mittent,  we  need  not  wonder,  he  says,  that  their  effects  should  be  intermittent  too: 
and  then  he  goes  on  to  ascribe  the  repetition  of  the  paroxysms,  after  the  cause  has 
ceased  to  be  applied,  to  that  tendency  observable  in  the  animal  system  to  reproduce 
certain  actions,  simply  because  they  have  been  produced  before ;  in  one  word,  to 
the  effect  of  habit.  At  length  the  habit  wears  out ;  which  accounts  for  the  sponta- 
neous recovery  of  those  who  are  removed  from  the  malarious  district. 

It  seems  to  be  a  very  serious  objection  to  M.  Roche's  theory,  that  the  disease  does 
not  show  itself,  sometimes,  for  weeks  or  months  after  the  patient  has  been  ex 
pased  to  the  miasmata.  His  theory  fails  altogether  also  to  account  for  the  dif- 
ferent types  of  intermittent  fever.  The  differences  of  type  are  indeed  opposed  to  the 
theory. 

After  all  it  is  most  probable  that  CuUen  had  discovered  a  part  though  not  the 
whole  of  the  truth  respecting  the  periodicity  of  intermittent  fevers,  when  he 
ascribed  it  to  some  law  of  the  animal  economy  whereby  it  is  subjected  in  many 
respects  to  a  diurnal  revolution.  "  Whether  this  depends,"  he  says,  "  upon  the 
original  conformation  of  the  body,  or  upon  certain  powers  constantly  applied  to  it, 
and  inducing  a  habit,  I  cannot  positively  determine  ;  but  the  returns  of  sleep  and 
watching,  of  appetites  and  excretions,  and  the  changes  which  regularly  occur  in  the 
state  of  the  pulse,  show  sufficiently  that  in  the  human  body  a  diurnal  revolution  takes 
place."  But  he  also  is  much  perplexed  with  the  differences  of  type  ;  and  all  that 
he  can  say  on  that  point  amounts  to  this — that  as  the  three  principal  types  observe, 
severally,  a  particular  time  of  day  for  their  accession,  and  as  quartans  and  tertians 
are  apt  to  become  quotidians,  these  to  pass  into  the  state  of  remittents,  and  these 
last  to  become  continued  ;  and  that  as  even  in  the  continued  form  daily  exacerba- 
tions and  remissions  are  generally  to  be  observed — all  this  marks  the  power  of  di- 
urnal revolution. 

A  most  interesting  experiment,  as  it  appears  to  me,  performed  by  M.  Brachet 
upon  himself,  shows  in  a  strong  hght  the  influence  of  acquired  habit  in  continuing 
cenain  unnatural  states  of  the  system  when  once  they  have  been  originated :  the  ex- 
periment connects  itself  also  with  the  pecufiar  phenomena  of  intermittent  fever. 
Towards  the  end  of  the  month  of  October,  in  the  year  1822,  M.  Brachet  took  a  cold 
bath  at  midnight,  for  seven  nights  in  succession,  in  the  river  Saone.  On  the  first  oc- 
casion he  remained  a  quarter  of  an  hour  in  the  river;  on  the  second,  half  an  hour; 
till  at  length  he  was  able  to  stay  in  the  water  a  full  hour  at  a  time.  After  each  bath 
he  betook  himself  to  a  warm  bed,  and  in  a  short  lime  became  affected  with  consider- 
able heat,  followed  by  copious  perspiration,  in  the  midst  of  which  he  fell  asleep. 
At  the  end  of  the  seven  days  M.  Brachet  ceased  to  repeat  this  experiment ;  but  what 
was  his  surprise  at  finding,  on  the  following  nights,  between  twelve  and  one 
o'clock,  that  all  the  phenomena  of  a  true  ague  fit  appeared  in  due  order  and  suc- 
cession !  As,  however,  this  ar'ificial  paroxysm  was  not  very  severe,  and  as  he  felt 
quite  well  during  the  day,  M.  Brachet  determined  not  to  interfere  with  it ;  but  to 
observe  the  result.  Six  times  it  recurred  with  great  regularity.  On  the  seventh 
night  after  he  had  omitted  the  baths,  he  was  summoned,  towards  midnight,  to  a 
woman  in  labour :  the  ride  to  her  house  heated  him,  and  on  his  arrival  he  kept  up 
the  heal  by  placing  himself  before  a  large  fire,  and  from  that  time  the  febrile  phe- 
nomena ceased  to  recur. 

The  facts  and  theories  which  I  have  thus  brought  roughly  together,  in  respect  to 
the  periodicity  of  agues,  are  not  without  interest,  but  they  show  that  we  have  yet 
much  to  learn  on  this  subject.  Granting  that  habit  may  have  its  share  m  coiuinuinir 
the  regular  recurrences,  we  want  some  explanation  of  the  return  of  the  second  and 
third  fit,  after  certain  determinate  intervals,  to  give  a  beginning  to  the  habit.  Ih 
respect  to  the  quotidian.  Dr.  Cullen's  diurnal  revolution  might  come  to  the  rescue . 
but  this  principle  evidently  will  not  apply  to  the  tertian  type.  I  know  of  no  two- 
day,  or  bidual  habit.  And  the  objection  holds  still  more  strongly  in  regard  to  quar- 
tans. Indeed  in  quotidians  themselves  there  is  much  ditficulty  in  applying  the  ex- 
planation, for  though  by  anticipating,  or  postponing,  they  mat/  come  on  at  differeui 
hours  of  the  day,  yet  their  usual  and  natural  paroxysms  occur,  nol  in  the  evening 
29  '  2  N  2 


450  INTERMITTENT    FEVER. 


T 


but  in  the  morning,  when,  on  the  principle  of  diurnal  habit,  there  should  be  the  least 
tendency  to  exacerbation  of  febrile  action.* 

In  yesterday's  lecture,  I  pointed  out  the  favourite  habitats,  if  I  may  so  speak,  of 
the  malarious  poison.  I  have  still  a  k\v  observations  to  make  respecting  its  ascer- 
tained habits  and  properties.  Some  of  the  laws  to  which  it  is  subject  are  of  great 
practical  importance,  and  ought  to  be  popularly  known";  much  more  ought  every 
medical  man  to  be  familiar  with  them. 

[n  the  first  place,  all  malarious  districts  are  (as  I  have  already  hinted)  much  more 
dangerous  at  night  than  in  the  day-time.  Whether  the  poison  be  then  more  copi- 
ously evolved,  or  whether  it  be  merely  condensed  and  concentrated  by  the  dimi- 
nished temperature,  or  whether  the  body  be  at  that  time  more  susceptible  of  its  influ- 
ence, it  certainly  is  most  active  and  pernicious  during  the  hours  of  darkness.  To 
sleep  at  night  in  the  open  air  in  such  places  is  almost  to  ensure  an  attack  of  the 
fever.  Lancisi  was  quite  aware  of  this,  and  devotes  a  chapter  to  the  question,  "Cur 
juxta  paludes  noctu  prgesertim  indormientes  magis  quam  vigilantes  Itedantur?"  It 
has  repeatedly  been  observed  among  the  crews  of  ships,  when  off  a  malarious  coast, 
that  the  sailors  could  go  on  shore  in  the  day  to  cut  wood,  or  for  other  purposes,  with 
impunity  ;  while  the  men  who  remained  on  shore  through  the  night,  guarding  the 
water-casks,  were  man}?-  or  all  of  them  seized  with  the  fever.  Take  one  instance  as 
a  sample  of  many.  It  is  recorded  by  Dr.  Lind.  In  176G  the  Phoenix  ship  of  war 
was  returning  from  the  coast  of  Guinea.  The  officers  and  ship's  company  were 
perfectly  healthy  till  they  touched  at  the  island  of  St.  Thomas.  Here  nearly  all  of 
them  went  on  shore.  Sixteen  of  the  number  remained  for  several  nights  on  the 
island.  Every  one  of  these  contracted  the  disorder,  and  thirteen  of  the  sixteen  died. 
The  rest  of  the  crew,  consisting  of  280  men,  went  in  parties  of  twenty  or  thirty  on 
shore  in  the  day,  and  rambled  about  the  island,  hunting,  shooting,  and  so  on :  but 
they  returned  to  the  ship  at  night ;  and  not  one  of  those  who  so  returned  suffered 
the  slightest  indisposition.  Exactly  similar  events  occurred  the  following  year,  with 
the  same  ship,  at  the  same  place,  where  "she  lost  eight  men  out  of  ten,  who  had 
imprudently  remained  all  the  flight  on  shore;"  while  the  rest  of  the  ship's  com- 
pany, "  who,  after  spending  the  greatest  part  of  the  day  on  shore,  always  returned 
to  their  vessel  before  night,  continued  in  perfect  health."  Many  more  examples  of 
the  same  kind  are  stated  or  referred  to  by  Dr.  Bancroft  in  his  book  on  the  Fellow 
Fever :  a  book  which  is  rich  in  information  respecting  the  malaria. 

The  reapers  in  the  "Campo  Morto" — a  well-named  part  of  the  Maremna  which 
1  yesterday  mentioned  —  are  permitted  to  sleep  for  two  hours  about  noon.  They 
do  so  at  that  time  without  danger :  but  when  the  dews  of  evening  have  fallen  down 
upon  the  earth,  which  serves  them  for  their  bed,  it  is  then  that  the  poison  puts  forth 
its  most  deadly  power.  Upon  this  principle  Lancisi  admonishes  those  who  in  sum 
mer  travel  through  the  Pontine  marshes,  not  to  do  so  by  night,  as  many  had  been 
accustomed  to  do,  in  order  to  avoid  the  greater  heat  of  the  day  :  and  similar  advice 
is  still  given  at  Rome  to  all  strangers.  Though  the  passage  requires  but  six  or  eight 
hours,  there  are  numerous  instances  of  travellers  who,  in  consequence  of  their  having 
crossed  these  fens  during  the  night,  have  been  attacked,  wath  violent  and  mortal 
fevers. 

The  practical  lesson  to  be  derived  from  a  knowledge  of  this  fact  is  too  obvious  to 
dwell  upon.  In  malarious  countries  the  open  air  at  night  must  be  avoided. — "  Early 
to  bed"  is  always  ?  good  and  wholesome  rule;  but  the  other  half  of  the  proverb, 
"  early  to  rise,"  becomes,  in  such  countries,  an  unsafe  precept.  At  least  it  is  hazard- 
ous to  leave  the  house  early. 

Secondly,  the  malaria  loves  the  ground.  It  tends  downwards.  Whether  this 
Jesuits  from  its  specific  gravity,  or  from  its  adhering  to  the  moisture  suspended  in 
the  lower  strata  of  the  atmosphere,  or  from  some  pecuhar  attraction  for  the  earth's 
surface,  I  cannot  tell  you.  There  is  reason  to  suppose  that  the  poison  combines 
bomehow,  or  becomes  entangled,  with  fog :  and  fogs  usually  brood  and  settle,  at 

•  I  would  beg  to  refer  the  reader  to  Dr.  Holland's  interesting  chapter  (in  his  Medical  Notes 
>*nd  Re/ledions,  published  since  these  lectures  were  delivered)  "  On  INIorbid  Actions  of  Inter- 
vijttent  kind." — T.  W. 


MALARIA.  451 

night  especially,  upon  the  surface.  This  may  be  one  reason  why  lying  down  to 
sleep  in  the  open  air  at  night  is  so  very  perilous.  The  lower  rooms  of  the  same 
house  may  contain  the  noxious  effluvia,  while  the  upper  are  free.  "  In  all  malari 
ous  seasons  and  countries,"  says  Dr.  Ferguson,  "the  inhabitants  of  ground  Jioors 
are  uniformly  affected  in  a  greater  proportion  than  those  of  the  upper  stories.  Ac- 
cording to  official  returns  during  the  last  sickly  season  at  Barbadoes,  the  proportion 
of  those  taken  ill  with  fever  in  the  lower  apartments  of  the  barracks  exceeded  that 
of  the  upper  by  one-third,  throughout  the  whole  course  of  the  epidemic.  At  the 
same  time  it  was  observed  that  the  deep  ditches  of  the  forts,  even  though  they  con- 
tained no  water  —  and  still  more  the  deep  ravines  of  rivers  and  water-courses  — 
abounded  with  the  malarious  poison."  Dr.  Hunter,  in  his  work  on  the  diseases  of 
the  army  in  Jamaica,  says,  "  The  barracks  of  Spanish  Town  consist  of  two  floors, 
the  first  upon  the  ground,  the  second  on  the  first.  The  difference  in  the  health  of 
the  men  on  the  two  floors  was  so  striking  as  to  engage  the  attention  of  the  Assembly 
of  the  island  :  and  upon  investigation  it  appeared  that  three  were  taken  ill  on  the 
ground  floor,  for  one  on  the  other.  The  ground  floor  was  not  therefore  used  as  a 
barrack  afterwards,"  Mr.  Ralph,  in  a  table  printed  as  an  appendix  to  a  paper  of 
Dr.  Ferguson's  in  the  eighth  volume  of  the  Medico-Chirurgical  Transactions,  states 
the  results  of  an  inquiry  into  the  comparative  healthfulness  of  the  upper  and  lower 
apartments  of  barracks  in  Barbadoes,  to  have  been  that  the  individuals  residing  in 
the  lower  apartments  were  attacked  in  the  proportion  of  two  to  one  of  those  living  in 
the'  upper :  and  with  certain  apparent  exceptions,  which  I  shall  notice  presently, 
experience  is  uniformly  in  favour  of  the  proposition  that  the  poison  is  most  preva- 
lent and  destructive  near  the  surface  of  the  earth,  and  does  not  rise  high  into  the 
atmosphere. 

To  specify  the  sanatory  precautions  dictated  by  an  acquaintance  with  this  pro- 
perty of  the  malaria,  must  be  quite  superfluous. 

Thirdly,  the  malaria  is  movable  by  the  wind.  It  is  capable,  therefore,  of  being 
carried  from  the  spot  where  it  was  generated,  and  to  other  places  which  might  else 
be  free  from  it  and  healthy.  In  this  respect  it  is  analogous  to  a  heavy  fog  or  vapour : 
and,  in  some  cases,  it  is  accompanied  by  a  palpable  mist ;  to  which,  perhaps,  it  may 
cling.  The  following  passage  relative  to  this  subject  occurs  in  Bishop  Heber's 
Journal.  "  From  Cheeta  Talao  our  road  lay  through  a  deep  and  close  forest,  in  the 
lower  parts  of  which,  even  in  the  present  season,  the  same  thick  milky  vapour  was 
hovering  as  that  which  I  saw  in  the  Terrai,  and  which  is  called  essence  of  owl." 
This  Terrai  is  the  region  which  I  mentioned  in  the  last  lecture  as  being  so  pestife- 
rous, that  it  is  deserted,  during  certain  parts  of  the  year,  by  every  living  creature. 

This  conveyance  of  the  poison,  like  a  cloud  or  fog,  from  one  part  of  the  surface 
of  the  ground  to  another,  it  is  very  important  to  attend  to  in  all  places ;  and  espe- 
cially so  in  tropical  climates,  where  the  wind  blows  for  a  long  time  together  from 
the  same  quarter.  We  are  thus  enabled  to  account  for  the  apparent  exceptions  to 
the  last-mentioned  property  of  the  malaria,  viz.,  its  preference  of  low  to  elevated 
situations.  You  will  readily  understand  how  the  miasmata  may  roll  up,  and  hang 
accumulated  upon,  the  side  of  a  hill  towards  which. a  current  of  air  sets  steadily  from 
or  across  a  neighbouring  marsh.  Nay,  the  poison  may  be  thus  blown  over  a  hill, 
and  deposited  on  the  other  side  of  it.  In  this  way,  I  presume,  are  to  be  explained 
the  following  curious  facts,  related  in  Dr.  Ferguson's  paper. 

The  beautiful  port  of  Prince  Rupert's,  in  the  island  of  Dominica,  is  a  peninsula 
which  comprehends  two  hills  of  a  remarkable  form,  joined  to  the  main  land  by  a  flat 
and  very  marshy  square  isthmus  to  windward,  of  about  three-quarters  of  a  mile  in 
extent.  The  two  hills  jut  right  out  on  the  same  line  into  the  sea,  by  which  they 
are  on  three  sides  encompassed.  The  inner  hill  of  a  slender  pyramidal  form,  rises 
from  a  narrow  base  nearly  perpendicular,  above  and  across  the  marsh  from  sea  to 
sea,  so  as  completely  to  shut  it  out  from  the  port.  The  outer  hill  is  a  round-backed 
bluff  promontory,  which  breaks  off  abruptly,  in  the  manner  of  a  precipice  above  the 
sea.  Between  the  hills  runs  a  very  narrow  clean  valley,  where  all  the  establish- 
ments of  the  garrison  were  originally  placed;  the  whole  space  within  the  peninsula 
being  the  driest,  the  cleanest,  and  the  healthiest  surface  conceivable.   It  was  speedily 


452  INTERMITTENT    FEVER. 

found  that  the  barracks  in  the  valley  were  very  unhealthy  ;  and  to  remedy  this  fault, 
advantage  was  taken  of  a  recess  or  platform  near  the  top  of  the  inner  hill,  to  con- 
struct a  barrack  which  was  completely  concealed  by  the  crest  of  the  hill  from  the 
view  of  the  marsh  on  the  outside,  and  at  least  three  hundred  feet  above  it :  but  it 
proved  to  be  pestiferous  beyond  belief.  In  fact  no  white  man  could  possibly  live 
there,  and  it  was  obliged  to  be  abandoned.  At  the  time  this  was  going  on,  it  was 
discovered  that  a  quarter  which  had  been  built  on  the  outer  hill,  on  nearly  the  same 
line  of  elevation,  and  exactly  five  hundred  yards  further  removed  from  the  swamp, 
was  perfectly  healthy  ;  not  a  single  case  of  fever  having  occurred  in  it  from  the  time 
it  was  built." 

There  is  a  striking  anecdote  given  by  Lancisi,  showing,  on  a  small  scale,  the  effect 
of  the  wind  in  carrying  the  malaria  with  it.  Thirty  ladies  and  gentlemen  had  sailed 
to  the  mouth  of  the  Tiber  on  an  excursion  of  pleasure.  Suddenly  the  breeze  shifted 
to  the  south,  and  began  to  blow  over  a  marshy  tract  of  land  situated  to  windward  of 
them.  Twenty-nine  of  the  thirty  were  immediately  after  attacked  with  tertian 
ague.  So  also  Humboldt  informs  us  that  the  town  of  Cariaco  is  afflicted  with  inter- 
mittents  by  the  north-west  wind  conveying  across  it  the  miasmatic  emanations  of  the 
Laguna  of  Campona. 

And  as  the  wind  may  thus  transport  the  malaria  to  a  distance,  and  thereby  render 
a  spot  unhealthy  which  naturally  would  not  be  so :  so  also  it  is  often  of  service  in 
clearing  the  poison  from  other  places,  and  preventing  its  concentration. 

A  knowledge  of  these  facts  ought  to  be  valuable  in  determining  the  choice  of 
encampments,  and  of  sites  for  dwelling-houses  in  aguish  districts.  Settlers  in  hot 
chmates,  especially  where  trade-winds  prevail,  would  do  well  to  avoid  founding  towns 
on  the  lee  side  of  any  swampy  or  suspicious  ground.  The  outlets  of  rivers  are 
commonly  selected,  for  the  convenience  of  commerce  :  and  there  is  often  a  right  and 
a  wrong  bank.  I  believe  that  most  of  the  principal  towns  in  the  West  Indies  are 
built,  for  the  advantage  of  the  outward-bound  vessels,  upon  the  western,  or  lee  side 
of  the  island. 

Fourthly,  it  is  a  singular,  but  well-ascertained  fact,  that  the  miasmata  lose  their 
noxious  properties  by  passing  over  even  a  small  surface  of  ivater.  Probably  they 
are  absorbed  by  it.  And  this  is  another  proof  of  their  tendency  downwards.  Many 
instances  have  already  been  referred  to,  where  some  of  the  crew  of  a  ship  have 
landed  on  a  malarious  coast,  and  have  all  been  attacked  by  the  fever ;  while  the  rest 
of  the  sailors,  who  remained  on  board,  continued  all  healthy  and  well,  though  the 
ship  was  close  to  the  shore.  You  could  not  have  a  better  or  more  striking  example 
of  this  than  what  took  place  at  Walcheren.  "Not  only  the  crews  of  the  ships  in 
the  road  of  Flushing  were  entirely  free  from  the  endemic ;  but  also  the  guard-ships 
which  were  stationed  in  the  narrow  channel  between  this  island  (Walcheren)  ai  1 
Beveland.  The  width  of  this  channel  is  about  six  thousand  feet,  yet,  though  some 
of  the  ships  lay  much  nearer  to  one  shore  than  to  the  other,  there  was  no  instance  of 
any  of  the  men  or  officers  being  taken  ill  with  the  same  disorder  as  that  with  which 
the  troops  on  shore  were  affected."  This  Sir  Gilbert  Blane  has  told  us  ;  and  it  is 
curious  that  Sir  John  Pringle  made  the  very  same  remark  in  the  very  same  place  in 
1747.  He  is  speaking  of  the  diseases  of  the  campaign  in  Dutch  Brabant ;  espe- 
cially in  reference  to  four  battalions  which  had  remained  for  some  time  in  Zealand: 
and  "he  says,  "  But  Commodore  Mitchell's  squadron,  which  lay  all  this  time  at  anchor 
in  the  channel  between  South  Beveland  and  the  island  of  Walcheren,  in  both  which 
places  the  distemper  raged,  was  neither  afflicted  with  the  fever  nor  the  flux,  but 
amidst  all  that  sickness  enjoyed  perfect  health ;  a  proof  that  the  moist  and  putrid  air 
of  the  marshes  was  dissipated,  or  corrected,  before  it  could  reach  them." 

It  is  probable  that  this  peculiarity  has  led  to  an  erroneous  and  contracted  estimate 
of  the  space  throucrh  which  the  poisonous  effluvia  can  be  carried  upon  land,  by  the 
wind.  Although  the  distance  to  which  they  are  capable  of  being  so  conveyed. 
A'ithout  losing  their  morbific  power,  has  never  been  precisely  defined,  there  can  be 
no  doubt  that  it  is  considerable.  In  Italy,  according  to  Dr.  Macculloch,  the  poisonous 
exhalations  of  the  lake  Agnano  have  been  ascertained  to  reach  as  far  as  the  convent 
of  CamaldoU,  situated  on  a  high  hill  three  miles  distant. 


MALARIA.  453 

Fifthly,  another  remarkable  property  of  the  marsh  poison,  is  its  attraction  towards, 
and  its  adherence  to,  the  foliage  of  lofty  umbrageous  trees:  so  that  it  is  very  danger- 
ous, in  malarious  places,  to  go  under  large  thick  trees,  and  still  more  dangerous 
to  sleep  under  them.  But  this  property,  thus  a  source  of  peril  to  those  who  are 
ignorant  of  it,  affords  when  known  and  rightly  made  use  of,  a  mode  of  protection 
and  remedy  against  the  influence  of  the  miasmata.  In  the  territory  of  Guiana, 
where  large  trees  abound,  the  settlers  live  fearlessly,  and  unhurt,  close  to  the  most 
pestiferous  marshes,  and  to  leeward  of  them,  provided  that  a  screen  or  beh  of  trees 
be  interposed.  New  Amsterdam,  in  Berbice,  hes  on  the  lee  side  of  an  immense 
swampy  forest,  in  the  direct  tract  of  a  strong  trade-wind  that  blows  night  and  day, 
and  pollutes  even  the  sleeping  apartments  of  the  town  with  the  stench  of  the  marshes; 
yet  it  brings  no  fevers.  The  inhabitants  are  well  aware  that  it  would  be  almost 
certain  death  for  an  European  to  sleep,  or  even  to  remain  after  nightfall,  within  the 
verge  of  the  forest.  To  cut  down  the  trees  would  not  only  be  a  perilous  operation 
in  itself;  but  would  let  in  pestilence  to  the  town. 

This  property  also  of  the  malaria,  as  well  as  the  use  to  which  it  may  be  turned, 
was  known  to  Lancisi.  He  describes  the  vast  increase  of  agues  and  remittent  fevers 
in  Rome  during  the  summer  of  1G95,  after  a  great  overflowing  of  the  Tiber,  by 
which  the  lower  part  of  the  city,  and  the  fields  adjacent,  had  been  inundated  in  the 
preceding  winter.  The  bad  effects  of  this  flood  were  felt  throughout  the  whole  of 
Rome,  with  the  exception  of  one  particular  quarter,  which  was  protected  by  a  belt 
of  trees  around  it.  Lancisi  even  addressed  a  remonstrance  to  the  Pope  against  a 
project  which  was  entertained  of  felling  some  wood  near  the  Pontine  marshes,  be- 
tween them  and  the  city.  He  endeavours  to  show  that  woods  and  groves  were  first 
made  sacred  on  account  of  their  conservative  influence  in  this  way,  to  prevent  their 
ever  being  cut  down. 

It  would  appear,  from  the  facts  I  have  just  been  detailing,  that  dwellings  unfortu- 
nately built  in  the  vicinity  of  marshes,  might  sometimes  be  rendered  safe  and  salu 
brious  by  encircling  them  at  a  little  distance  by  a  hedge  of  trees— or  (perhaps)  even 
by  drawing  round  them  a  broad  moat  of  water.  Such  experiments  deserve,  at  least, 
a  fair  trial. 

Sixthly,  the  production  and  consequently  the  efTects,  of  the  malaria  are  prevented, 
or  lessened,  by  cultivation.  It  is  to  this,  that  the  diminution  of  agues  in  this  country 
is  mainly  attributable.  The  fenny  lands  have  been  drained ;  and  many  of  them 
brought  under  the  plough.  Dr.  Craigie  states  that  East  Lothian,  in  Scotland,  was 
at  one  time  so  productive  of  malaria,  that  it  was  quite  an  expected  thing  that  the 
reapers  in  harvest  should  be  attacked  with  ague ;  but  that  now,  in  consequence  of 
the  perfect  tillage,  and  the  numerous  tracts  of  wood  with  which  the  country  is 
covered,  that  disorder  is  quite  unknown  there.  Converseljs  in  regions  which  have 
been  suffered  to  fall  out  of  cultivation,  intermittent  and  remittent  fevers  multiply. 
The  more  thoroughly  any  country  is  cultivated,  the  more  fully,  in  general,  it  is 
peopled  also :  and  in  many  places  the  prevalence  of  these  fevers  has  been  observed 
to  diminish  and  increase  with  the  increase  and  diminution  of  the  population.  Caeleris 
paribus,  agues  are  much  less  common  in  large  towns  than  in  country  villages.  This 
has  been  oddly  enough  accounted  for  by  saying  that  populous  cities  are  so  full  that 
there  is  no  room  for  the  malaria.  A  much  more  rational  and  probable  explanation  is 
that  which  ascribes  the  freedom  of  crowded  towns,  and  thickly  inhabited  districts,  to 
the  number  of  fires  burned  in  them. 

Many  instances  might  be  adduced  to  show  that  the  more  any  place  naturally  pro- 
ductive of  malaria,  is  depopulated,  the  more  evident  does  the  power  of  the  poison 
become.  The  Italians  date  the  introduction  of  the  malaria  into  the  Maremna,  from 
the  great  plague  in  the  sixteenth  century,  since  which  period  the  inhabitants  of  thai 
district  have  never  been  sufficiently  numerous  to  counteract  the  bad  air  which  in 
creases  as  population  and  agriculture  diminish. 

Bishop  Hcber,  in  the  narrative  I  quoted  before,  bears  testimony  to  facts  of  th« 
same  kind  with  those  I  have  now  been  stating.  He  says,  "  At  the  foot  of  the  lowest 
hills,  a  long  black  level  line  extends,  so  black  and  level,  that  it  might  seem  to  have, 
been  drawn  with  ink  and  a  ruler.     This  is  the  forest,  from  which  we  are  still  re- 


454  INTERMITTENT    FEVER.  ' 

moved  several  coss,  though  the  country  already  begins  to  partake  of  its  insalubrity. 
It  is  remarkable  that  this  insalubrity  is  said  to  have  gi'eatly  increased  in  the  last 
fifteen  years.  Before  that  time,  Ruderpoor,  where  now  the  soldiers  and  servants 
of  the  Police  Thanna  die  ofTso  fast  that  they  can  scarcely  keep  up  the  establishment, 
was  a  large  and  wealthy  place,  inhabited  all  the  year  through,  without  danger  or 
disease.  The  unfavourable  change  is  imputed  by  the  natives  themselves  to  depopu- 
lation. The  depopulation  of  these  countries  arose  from  the  invasion  of  Meer  Khan, 
in  1805.  He  then  laid  waste  all  these  Pergunnahs,  and  the  population,  once  sa 
checked,  has  never  recovered  itself." 

When  persons  having  intermittent  fever  are  unable  to  leave  the  unhealthy  situa 
tion  in  which  they  have  been  exposed  to  the  influence  of  the  malaria — and  espe- 
cially when  they  are  placed  under  unfavourable  circumstances  in  respect  to  food, 
and  clothing,  and  shelter — the  disease  is  apt  to  become  exceedingly  serious,  leading 
to  disorder  of  the  sensorium,  and  great  disturbance  of  the  abdominal  viscera,  even 
in  the  intermissions  ;  sickness,  diarrhoea,  dysentery,  diseases  of  the  liver. 

[Dr.  S.  A.  Cartwriglu,  of  Natchez,  asserts,  that  the  ptssieua  grandiflora,  or  floating  plant  of 
the  liayons  and  lakes  of  lower  Louisiana,  has  the  power  of  preventing  the  development  of 
malaria  in  regions  particularly  adapted  to  its  generation,  He  affirms,  also,  that  "it  purifies 
all  stagnant  water  in  which  it  grows — that  of  the  lakes  and  bayous  inhabited  by  it,  being  as 
pure  to  the  sight,  taste,  and  smell,  as  if  it  had  just  fallen  from  the  clouds."  He  ascribes  to 
the  presence  of  and  the  peculiar  "hygienic  or  health-preserving  properties  of  this  plant,''  the 
remarkable  exemption  of  the  inhabitants  of  lower  Louisiana  from  "  malarious  or  miasmatic 
diseases."  "The  fact,"  he  remarks,  "that  the  region  of  country  in  which  this  aquatic  plant 
abounds,  is  exceedingly  healthy,  can  be  established  beyond  cavil  or  dispute;  it  nevertheless 
contains  more  stagnant  water  and  swamps  than  any  other  inhabited  district,  of  the  same 
extent,  in  the  United  States." — C] 

In  Zealand,  the  biliary  functions  suffer  so  much  during  the  complaint,  that  it  is  com- 
monly known  among  the  inhabitants  of  that  country  under  the  name  of  the  gall  fever. 
The  frequent  unnatural  concentration  of  the  blood  in  the  internal  parts  may  afford 
a  reasonable  explanation  of  these  phenomena.  When  death  takes  place,  morbid 
appearances  present  themselves  such  as  might  he  expected :  hepatic  alterations  ; 
inflammation  and  ulceration  of  the  mucous  membrane  of  the  alimentary  canal :  but 
the  most  characteristic  morbid  condition  produced  by  repeated  attacks  of  intermittent 
fever  consists  in  enlargement  of  the  spleen  ;  Avith  or  without  induration  of  its  sub- 
stance. That  viscus  is  sometimes  enormously  increased  in  bulk,  so  as  to  be  felt, 
and  even  its  outline  seen  through  the  integuments  of  the  abdomen.  It  has  been 
known  to  weigh  nearly  eleven  pounds.  So  common  is  this  state  of  the  spleen,  that 
it  is  familiar  to  the  observation  of  the  vulgar,  who  have  even  given  it  a  name :  it  is 
called  among  the  inhabitants  of  the  fenny  parts  of  this  country,  the  ague  cake.  I 
beheve  that  whenever  the  abdominal  circulation  is  much  embarrassed,  and  the 
abdominal  veins  gorged,  as  they  must  be  during  the  cold  stage  of  an  intermittent, 
the  spleen  in  particular  becomes  distended  with  blood.  Constantly  we  see  this 
happen  when  the  passage  of  the  blood  through  the  portal  vessels  is  impeded  by 
disease  of  the  liver.  Now  this  distension  may  not  thoroughly  subside  perhaps  at 
once.  If  the  paroxysms  of  ague  be  frequently  repeated,  we  may  understand  how 
the  spleen  may  become  fuller  of  blood  on  each  successive  occasion.  It  may  be  that 
a  portion  of  the  blood  coagulates ;  or  that  inflammation  of  a  slow  kind  is  set  up  in 
the  stretched  covering  of  that  organ.  At  all  events,  this  is  a  veiy  common  sequel 
of  ague  ;  and  it  can  scarcely  be  doubted  that  the  repeated  congestions  of  the  internal 
vessels  and  viscera  are  the  determining  causes  of  the  ague  cake. 

Independently  of  the  paroxysm  of  ague,  there  is  ample  evidence  to  show  the 
mjurious  influence  of  the  malarious  districts  upon  the  general  health.  In  this 
country  suT:h  effects  are  not  much  seen ;  but  in  places  where  the  malaria  is  more 
constantly  and  abundantly  present,  the  race  of  inhabitants  deteriorates.  Their 
stature  is  small;  their  complexion  sallow  and  yellowish;  the)''  are  prematurely  old 
and  wrinkled  ;  even  the  children  early  acquire  an  aged  aspect ;  and  the  spirits  and 
intellects  of  those  who  dwell  in  these  unhealthy  spots  are  low  and  feeble,  and  par- 
take of  the  degeneration  of  the-'r  bodily  qualities. 


MALARIA.  455 

It  is  therefore  strange  that  a  notion  should  ever  have  prevailed,  of  the  salutifcrous 
eiTects  of  an  attack  of  ague.  But  such  a  notion  may  be  traced  from  very  nearly 
our  own  times  up  to  the  earliest  records  of  physic.  "  The  late  Dr.  James  Sims, 
who  was  a  physician  o!'  some  note  in  this  town,  felt  convinced,  at  the  commencement 
of  the  illness  which  terminated  his  life,  that  he  should  recover  if  he  could  catch  an 
ague  :  and  he  went  down  into  one  of  the  marshy  districts  expressly  for  that  purpose  ; 
but  returned  to  London  without  having  succeeded,  complaining  that  the  country  had 
been  spoiled  by  draining,  and  that  there  were  no  agues  to  catch.  The  superstitious 
Louis  XL  entertained  a  similar  opinion,  and  prayed  to  the  Lady  of  Selles  that  she 
would  confer  upon  him  a  quartan  ague.  Our  monarch,  James  the  First,  had  more 
sensible  notions  on  that  score.  There  is  an  old  English  proverb  which  says,  'An 
ague  in  the  spring,  is  physic  for  a  king;'  and  when  this  was  repeated  to  him  by  his 
courtiers,  he,  being  then  ill  of  that  disease,  answered  that  the  adage  might  be  appli- 
cable to  a  young  man,  but  that  it  would  not  do  for  an  old  one  like  him.  In  fact,  as 
I  mentioned  before,  he  died  of  his  ague.  The  same  doctrine  has,  hou'-ever,  been 
handed  down  to  us  by  the  father  of  physic  himself.  Hippocrates  says,  in  the  fifty- 
seventh  Aphorism  of  his  fourth  Section,  vno  oxa^^aov,  vi  -tita-vov  svoxfMi/j-svco,  ftvpsfo^ 
(Ttiysvoixsvoi  %vH  to  vov!;t;ua.  And  Celsus,  in  his  capital  digest  of  the  medical  know- 
ledge of  his  time,  preserves  the  same  opinion,  with  some  apparent  astonishment 
that  it  should  be  true.  '  Denique  ipsa  febris,  quod  maxime  mirum  videri  potest, 
saepe  prajsidio  est.'  I  recollect  hearing  Dr.  Graham,  the  professor  of  botany  in 
Edinburgh,  relate  the  following  anecdote  in  one  of  his  clinical  lectures, — His  brother 
was  intimate  with  the  professor  of  natural  history  at  Cremona ;  and  this  gentleman 
was  resolved  to  put  the  truth  of  the  aphorism  that  I  have  quoted  from  Hippocrates 
to  the  test.  Accordingly  he  sent  a  patient  afflicted  with  epilepsy,  to  pass  a  night  or 
two  in  a  marshy  place,  where  the  malaria  was  known  to  be  so  abundant  and  so 
powerful  that  (e\v  escaped  ague,  who  were  there  exposed  to  its  influence,  and  the 
twofold  design  succeeded  admirably.  The  patient  got  an  ague,  and  lost  his  epilepsy. 
The  worthy  professor  contented  himself  with  moderating  and  keeping  in  check  the 
new  complaint,  thus  intentionally  produced,  for  a  period  of  six  months,  when  he 
administered  its  coup  de  grace  in  a  few  doses  of  Peruvian  bark  ;  and  the  epilepsy 
never  returned.  If  I  had  believed  that  this  could  have  been  any  thing  more  than  a 
mere  coincidence,  I  should  have  told  you  of  it  before,  when  I  was  speaking  of  the 
treatment  of  epilepsy.  I  should  rather  imagine  the  notion  thus  prevalent  for  so  long 
a  time,  that  ague  had  a  salutary  tendency,  and  that  it  was  wrong  to  stop  it  too  soon, 
to  have  originated  in  the  difficulty  which  physicians  found  in  stopping  it,  before  its 
cause  was  so  well  understood,  and  the  specific  for  it  was  discovered.  They  found 
it  obstinate  under  the  feeble  and  inert  methods  then  employed,  and  therefore  they 
endeavoured  to  persuade  their  patients,  and  perhaps  themselves,  also,  that  the  disease 
had  better  proceed  a  certain  length. 

I  have  very  little  to  saj^  in  addition  to  what  you  must  have  inferred  from  what  I 
have  already  said,  as  to  ihe  prognosis  in  intermittent  fevers.  In  cold  countries,  such 
as  ours,  it  is  almost  always  favourable.  Of  course  it  will  be  modified  by  the  pre- 
vious condition  of  the  patient :  if  he  was  beforehand  the  subject  of  serious  organic 
visceral  disease,  or  if  he  be  very  old  or  infirm,  the  supervention  of  ague  may  destroy 
him.  But  to  persons  of  tolerable  heaUh  and  strength  prior  to  the  setting  in  of  the 
ague,  we  may  confidently  promise  a  acre.  In  warm  countries  intermittent  fevers 
are  much  more  dangerous:  and  are  sometimes  very  rapidly  fatal.  They  are  often 
accompanied  by  most  severe  affections  of  the  head,  stupor,  delirium,  convulsions  ; 
and  of  the  alimentary  canal,  diarrhoea,  sickness,  and  not  unfrequently  the  black 
vomit.  They  are  prone,  also,  in  those  climates,  to  run  into  the  remittent  or  conti 
nued  form;  and  this  tendency  is  shown  by  long  protracted  paroxysms,  or  by  the 
anticipation  or  doublincr  of  the  paroxysms.  In  all  countries  quartans  are  cured  with 
more  difficulty  than  either  tertians  or  quotidians.  And  quartans  are  most  common 
in  the  autumn  :  and  accordingly  autunmal  intermittents  are  more  pernicious  and  in- 
tractajiile  than  the  vernal.  This  fact  has  passed  into  a  proverb  in  Italy ;  which 
proverb  has  been  thus  translated  into  Latin,  "  Febris  autumnalis — vel  est  longa,  vel 
lelhulls.'''     The  longer  intermittents  have  lasted,  the  more  difficult  also  are  they  tf 


456  INTERMITTENT    FEVER. 

cure  :  and  certainlj^  there  is  much  more  danger  of  visceral  disease  in  those  that  are 
of  long  standing. 

It  is  probable  that  agues,  such  as  we  see  in  this  country,  would  generally,  under 
favourable  circumstances,  terminate  in  spontaneous  recovery,  provided  that  the 
patient  could  be  put  beyond  the  further  operation  of  the  malaria,  protected  from 
exposure  to  wet  and  cold,  and  suitably  nourished.  But  possessing  as  we  do  a  spe- 
cific cure  for  ao^ue,  if  there  be  such  a  thing  as  a  specific,  there  would  be  no  sense  in 
our  allowing  the  spontaneous  recovery  to  be  made  :  or  rather  Ave  should  be  inex- 
cusable, knowing  as  we  do  that  the  complaint  is  the  more  obstinate  the  longer  it  has 
lasted,  and  that  it  tends  to  the  establishment  of  organic  visceral  disease,  we  should 
be  inexcusable  if  we  did  not  stop  it  as  quickly  as  we  can.  The  disease  is  always 
distressing  to  the  patient,  and  always  debilitating.  It  may  be  dangerous,  even  in 
these  climates,  to  weak  or  old  persons :  and  it  is  dangerous  to  all  persons  in  hot  cli- 
mates. "  If  the  first  fit  (says  the  wise  and  observant  Heberden)  has  been  marked 
so  clearly  as  to  leave  no  doubt  of  its  being  a  genuine  intermittent,  the  remedy  should 
be  immediately  given  in  such  a  manner  as  to  prevent,  if  possible,  a  second."  There 
needs  very  little  preparation  of  the  patient  before  administering  the  specific  substance 
which  is  to  cure  him ;  and  which  every  one  here  knows  before  he  hears  me  say  so, 
is  the  celebrated  Peruvian  bark,  or  its  active  principle  as  presented  by  the  salts  of 
quina.  The  old  practice  was  to  wait  a  few  returns  of  the  fits,  either  till  some  hypo- 
thetical ferment  had  taken  place,  or  until  supposed  morbid  matter  had  been  expelled 
by  vomiting  or  purging.  There  is,  however,  one  very  simple  and  short  preparative 
which  I  am  in  the  habit  of  using,  and  which  I  learned  at  Cambridge.  You  are 
aware  that  Cambridge  is  situated  on  the  very  edge  of  the  fenny  country  which  ex- 
tends along  that  part  of  the  east  coast  of  the  island.  Numerous  patients  afflicted  with 
ague  come  in  from  the  surrounding  villages  ;  and  Dr.  Haviland  found  that  many  of 
these  had  taken  quina  before  they  applied  for  assistance  as  out-patients  at  the  hospi- 
tal ;  but  with  very  poor  success.  Now  these  cases  readily  gave  way  —  the  patient 
remaining  in  all  other  circumstances  as  before  —  after  the  operation  of  a  calomicl 
purge.  I  have  adopted  this  practice,  therefore,  upon  his  recommendation ;  but  it 
does  not  delay  the  specific  treatment.  I  generally  prescribe  three  grains  of  calomel 
with  six  or  eight  grains  of  rhubarb  at  bed-time,  and  commence  with  the  quina  the 
next  morning.  Very  lately,  in  perusing  the  late  Dr.  Baillie's  posthumous  volume,  I 
met  with  the  following  passage : — "  1  have  known  a  good  many  cases  in  which  bark 
alone  would  not  cure  an  ague.  In  all  these  cases,  as  far  as  I  now  recollect,  Avhen  a 
grain  of  calomel  was  given  every  night  for  eight  or  ten  nights,  bark  cured  the  ague 
in  the  course  of  a  few  days.  This  practice  I  learned  from  my  friend  Dr.  David 
Pitcairn." 

I  believe  that  calomel  given  once  in  a  purgative  dose  is  enough. 

But  first  of  all  what  is  to  be  done  for  the  patient  while  he  is  in  the  fit  ?  I  confess 
to  you  that  I  seldom  give  myself  much  concern  on  that  head.  In  ague,  as  we  see  it 
in  this  country,  nature  generally  prompts  the  patient  what  to  do  ;  to  cover  himself 
up  in  bed,  and  apply  warmth  to  his  feet,  and  to  take  some  hot  drink  during  the 
rigors  ;  to  adopt  a  cooler  regimen  during  the  hot  stage ;  to  Avipe  his  skin  dry,  if  the 
sweating  should  be  very  profuse  or  protracted.  But  in  hot  countries,  and  in  severer 
forms  of  intermiuent,  the  patient  really  requires  some  help ;  and  therefore  I  must 
consider  shortly  in  the  next  lecture  the  management  of  the  paroxysm ;  and  I  am  the 
more  jound  to  do  so,  because  certain  measures  which  I  do  not  think  necessary'  or 
judicious,  at  any  rate  for  the  complaint  as  we  see  it  here,  have  lately  been  stronorl 
"■ecommended  durins:  the  ague-fit. 


TREATMENT.  457 


LECTURE  XLII. 

Treatment  of  Intermittent  Fever ;  during  the  paroxysm ;  during  the  intermis 

sions.     Prophylaxis. 

I  WAS  about,  when  we  last  separated,  to  consider  the  treatment  of  ague :  first, 
during  the  paroxysm  ;  secondly,  during  the  intermissions. 

In  this  climate  we  need  not,  I  say,  encumber  a  patient  in  an  ague-fit  with  too 
much  help.  But  in  hot  countries,  where  the  disorder  is  apt  to  run  into  the  remit- 
tent, or  even  the  continu  d  form,  and  where,  during  its  violent  and  rapid  course, 
internal  organs  are  liable  lO  sustain  serious  damage,  the  best,  and  indeed  almost  the 
only  time  for  the  effectual  interference  of  the  physician  is  in  the  first  assault  or  pa- 
roxysm of  the  disease. 

The  objects  of  treatment  during  the  paroxysm  are,  to  alleviate  the  uneasy  sensa- 
tions of  the  patient :  to  abridge,  if  possible,  their  duration,  by  shortening  the  fit ;  and 
to  avert  the  danger  which,  under  certain  circumstances,  may  arise  from  intense  inter- 
nal congestion  long  continued,  or  from  the  severity  of  particular  symptoms. 

Now  in  the  cold  stage  of  ague,  diluent  drinks  have  been  recommended,  and  cor- 
dials, and  external  ivarmth,  and  opiitm,  and  emetics,  and  blood-letting.  One  would 
suppose  that  if  some  of  these  expedients  were  useful,  others  could  scarcely  be  so  too. 
The  diluent  drinks  are  very  proper :  and  1  should  allow  the  patient  to  use  his  own 
discretion  in  the  choice  of  them.  It  was  customary,  formerly,  to  prescribe  medicated 
drinks  of  this  kind  ;  and  one  pleasant,  but  neglected  ptisan  still  lingers  in  our  Phar- 
macopoeia, the  decoctum  hordei  compositum.  Now-a-days  we  are  contented  with 
the  simple  barley-water,  toast  and  water,  weak  tea,  gruel,  and  the  like.  These  dilu- 
ents should  be  taken  warm,  and  for  persons  who  are  very  feeble  or  exhausted,  they 
may  be  made  gently  cordial ;  weak  negus,  for  example,  or  white  wine  whey,  may 
be  given. 

External  warmth,  being  what  nature  and  common  sense  would  suggest,  is  cer- 
tainly advisable  and  beneficial  in  the  cold  fit ;  even  the  warm  bath,  if  it  can  be  pro- 
cured. In  some  places  it  is  the  custom  to  await  an  expected  fit  iii  the  warm  bath. 
When  this  cannot  so  conveniently  be  obtained,  the  pediluvium  may  be  employed  ; 
or  the  patient  may  be  put  into  a  warmed  bed,  and  have  bags  of  hot  salt  or  bran  ap- 
plied to  his  epigastrium;  and  a  hot  bottle,  or  a  hot  brick,  wrapped  up  in  flannel,  to 
his  feet.  Or,  what  perhaps  is  best  of  all,  he  may  have  a  hot  air  bath  applied  to  him, 
as  he  lies  in  bed.  This  may  be  very  easily  done,  by  means  of  a  semi-cylinder  or 
cradle  of  wicker  work,  closed  at  one  extremity  by  a  board.  This  is  laid  over  the 
patient,  and  then  covered  with  blankets.  Through  a  hole  in  the  centre  of  the  board 
one  end  of  a  curved  iron  tube  is  passed  ;  the  other  end,  expanded  into  a  bell,  looks 
downwards :  and  a  spirit  lamp  being  placed  beneath  it,  the  air  between  the  wicker 
work  and  the  sick  person  is  soon  made  very  hot.  This  apparatus  was  constructed 
many  years  ago,  by  Dr.  Gower,  when  he  was  physician  to  the  Middlesex  Hospital ; 
where  its  utility  has  been  fully  proved.  External  warmth  applied  in  some  one  of 
these  ways,  affords  singular  comfort  oftentimes,  and  contributes  to  shorten  the  cold 
stage.  And  the  same  may  be  said  of  friction,  with  stimulating  liniments,  along  the 
course  of  the  spine.  Lind  found  that,  in  children,  rubbing  the  spine  with  an  embro- 
cation composed  of  equal  parts  of  soap  liniment  and  laudanum,  at  the  approach  of 
the  cold  stage,  often  prevented  the  paroxysm. 

Opium  has  often  been  exhibited  in  the  cold  stage,  with  the  view  of  cutting  short 
the  fit ;  and  not  without  some  success.  The  strongest  evidence  of  its  usefulness  in 
that  stage  of  the  paroxysm  is  furnished  by  Dr.  Trotter,  in  his  Medicini  Nautica. 
Agues  being  very  frequent  among  the  crew  of  the  Vengeance,  he  resolved  to  try  the 
full  effect  of  opium  in  preventing  the  fit.  At  its  first  approach  a  dose  of  laudanum 
(never  less  than  thirty  drops)  was  given ;  if  this  did  not  bring  on  some  wanuth 
within  ten  or  fifteen  minutes,  from  twelve  to  twenty  drops  more  were  administered 
In  most  cases,  "in  a  few  minutes  an  exhilaration  of  spirits  was  perceived  ;  the  pvls** 

2o 


458  INTERMITTENT   FEVER. 

from  being  weak,  quick,  and  sometimes  irregular,  became  less  frequent,  full,  and 
equal ;  an  agreeable  warmth  was  diffused  over  the  whole  frame,  and  every  unplea- 
sant feeling  vanished,  sometimes  in  a  quarter  of  an  hour.  The  patients  were  them- 
selves surprised  at  the  sudden  change  in  their  sensations."  Dr.  Trotter  speaks  of 
these  as  being  the  completest  cures  that  ever  came  under  his  observation.  If,  at  the 
next  period,  the  paroxysm  threatened  to  recur,  the  opiate  was  repeated  always  with 
the  same  success.  "  Few  instances  were  met  with  where  any  indisposition  indi- 
cated a  third  attack,  at  the  expected  period  of  accession."  Notwithstanding  this 
testimony,  it  appears  that  opium  is  still  better  adapted  to  another  stage  of  the 
paroxjrsm. 

Emetics  were  formerly  much  prescribed  in  the  cold  stage,  at  its  earhest  approach. 
Cullen  recommends  them  ;  and  they  may  sometimes  be  useful,  in  spite  of  Chomel's 
assertion  that  they  are  always  hurtful.  That  they  have  gone  so  much  out  of  fashion 
is,  however,  a  proof  that  they  cannot  be  depended  upon  for  cutting  short  the  parox- 
ysm.  Vomiting  is  itself  no  small  distress  to  many  persons ;  and  for  my  own  part, 
I  should  not  think  of  giving  an  emetic  unless  some  indications  of  a  loaded  and  op- 
pressed state  of  the  stomach  weje  present ;  such  as  nausea,  an  ill  taste  in  the  mouth, 
a  coated  tongue,  and  foul  breath.  A  scruple  of  ipecacuanha  will,  even  then,  be 
sufficient.  The  object  is  to  empty  the  stomach  effectually,  but  mildly.  I  would  not 
give  antimony.  Irritability  of  the  stomach,  in  the  more  violent  of  these  fevers,  is 
too  apt  to  arise  spontaneously.  Sir  Gilbert  Blane  tells  us  that  the  greatest  impedi- 
ment to  the  cure  of  the  severer  intermittents  at  Walcheren,  in  their  early  stages, 
proceeded  from  the  extreme  irritability  of  stomach,  which  made  it  difficult  to  admi- 
nister the  requisite  medicines.  In  hotter  chmates  nausea  and  vomiting  are  still  more 
common  and  more  urgent ;  and  we  have  to  guard  against  the  risk  of  inducing  or 
aggravating  these  symptoms.  "  Emetics  (says  Dr.  Mackintosh,  in  his  Practice  of 
Physic)  have  been  often  extolled,  but  I  believe  eveiy  experienced  tropical  physician 
will  agree  with  me  in  cautioning  young  practitioners  against  their  indiscriminate  em- 
ployment. Irritability  of  the  stomach  is  one  of  the  most  frequent  and  troublesome 
symptoms ;  and  once  excited,  it  is  always  difficult,  and  in  many  cases  impossible  to 
restrain  it.  I  have  seen  emetics  exhibited,  and  the  vomiting  has  continued  till  death, 
in  spite  of  every  remedy." 

[We  have  repeatedly  prevented  the  accession  of  the  chill  by  administering  to  the  patient, 
just  before  the  period  when  it  was  expected,  an  emetic  of  ipecacuanha,  and  after  this  had 
ceased  operating,  immersing  his  feet  in  hot  water,  and,  as  soon  as  he  is  placed  in  bed,  giving 
him  from  30  to  40  drops  of  laudanum,  or  a  teaspoonful  of  the  camphorated  tincture  of  opium. 
By  this  treatment  not  only  is  the  chill  prevented  or  shortened,  but  the  whole  paroxysm  is 
often  rendered  milder. — C] 

Latel\^  the  practice  o[  blood-letting  m  the  cold  stage  has  been  revived  (for  it  is 
not  a  new  practice),  and  strongly  recommended  by  the  physician  whose  name  I  have 
just  mentioned ;  and  whose  opinion  carries  with  it  the  more  weight  from  its  having 
been  founded  on  much  personal  experience  in  the  treatment  of  these  fevers.  Dr. 
iVlackintosh  affirms  that  bleeding,  performed  in  the  cold  stage,  will  often  stop  at  once 
the  paroxysm,  and  with  it  the  disease  :  that  even  when  its  curative  effects  are  less 
decisive,  it  will  generally  stop  the  cold  stage  and  shorten  the  paroxysm,  and  mitigate 
its  severity,  and  afford  speedy  and  great  ease  to  the  distressful  sensations  of  the 
patient;  and  that  any  subsequent  paroxysms  which  may  occur  will  be  mild  and  few. 
One  bleeding,  he  says,  is  commonly  sufficient ;  sometimes  two  are  required  :  seldom 
more  than  two.  The  blood  is  to  be  suffered  to  flow  till  the  patient  feels  rehef :  wliich 
usually  consists  in  hberation  from  pain  of  the  head  and  loins;  freedom  of  respira- 
tion ;  the  departure  of  the  painful  sensation  of  cold  ;  and  the  cessation  of  the  tremors 
and  of  tiie  debility.  Most  of  the  patients  fall  asleep  after  the  operation.  These 
effects  have  been  pr  educed  by  the  abstraction  of  an  ounce  and  a  half  of  blood  ;  they 
ha?e  sometimes  (but  rarely)  required  for  their  production  twenty  ounces. 

Now  this  is  the  piece  of  practice  to  which  I  adverted  at  the  "close  of  yesterday's 
lecture,  as  being,  iU  my  humble  opinion,  inexpedient  and  not  to  be  recommended*  • 
9t  least  in  the  agues  of  this  country.     I  have  seen  a  good  many  cases,  first  and  last, 
und  certainly  I  have  never  seen  one  in  which  I  could  have  thought  such  an  heroic 


T 


TREATMENT.  459 

remedy  necessary,  in  the  cold  stage ;  if  indeed  it  be,  in  that  stage,  a  remedy  at  all. 
But  I  do  not  desire  to  oppose  my  experience  alone,  or  my  judgment,  to  that  of  Dr. 
xMaclcintosh.  His  method  has  been  tried,  since  he  first  made  it  public,  by  various 
practitioners  in  this  country.  Drs.  Townsend  and  Law,  of  DubHn,  found  it  fail  in 
the  majority  of  cases.  In  Dr.  Stokes's  hands,  the  most  usual  effect  of  blood-letting 
in  the  cold  stage  was,  to  check  the  shivering  ;  and,  next  to  this,  to  mitigate  iis  severity, 
without  abridging  its  duration.  In  most  instances,  no  modiiicalion  was  produced  ot 
the  hot  and  of  the  sweating  stages.  In  Dr.  Kelly's  experience,  the  general  effect 
was,  to  shorten  the  cold  stage,  and  to  render  the  hot  one  milder ;  but  in  some  cases 
it  seemed  to  aggravate  the  symptoms.  iVIr.  Gill  found  that,  although  the  blood-Jetting 
might  cut  short  the  cold  stage,  it  appeared  to  lengthen  the  period  of  febrile  disturb- 
ance. Confining  myself,  then,  to  intermittents,  as  they  show  themselves  in  this  cli- 
mate, I  cannot  advise  you  to  adopt  the  practice  introduced  by  Dr.  Mackintosh — of 
bleeding  in  the  cold  stage.  I  object  to  it  because  it  appears  to  me  quite  unnecessary; 
because  it  is  not  such  as  the  nature  of  the  symptoms  would  suggest ;  because  it 
tends  to  produce  subsequent  debility,  which  we  should  not  needlessly  inflict ;  and 
because  the  experience  of  other  sober-minded  men,  who  have  given  the  method  a 
fair  trial,  does  not  bear  out  the  statements  made  by  Dr.  Mackintosh  in  respect  to  its 
usefulness. 

At  the  same  time,  after  a  careful  perusal  of  nearly  a  hundred  cases  adduced  by 
Dr.  Mackintosh  to  illustrate  the  efficacy  of  this  measure,  I  think  it  highly  probable 
that  blood-letting  may  constitute  the  most  important  part  of  the  treatment,  in  the 
very  outset  of  the  severer  malarious  fevers  of  hot  climates ;  attended  as  they  are 
with  a  degree  of  internal  congestion  and  disturbance  which  is  dangerous  to  the  integ- 
rity of  vital  organs. 

[]\Ir.  Twining,  in  his  ^vork  on  the  Diseases  of  Bengal,  bears  strong  testimony  in  favour 
of  bleeding  in  the  cold  stage  of  intermittents.  In  the  greater  number  of  cases  he  lias  found 
it  to  arrest  the  paroxysm  ;  that  is,  the  occurrence  of  the  hot  and  sweating  stages  is  pre- 
vented. In  the  majority  of  patients,  when  the  bleeding  has  been  preceded  by  a  course  of 
niilu  purgatives,  there  will  be  no  return  of  the  disease,  provided  attention  is  paid  to  keep 
the  body  properly  clad  and  to  guard  against  exposure  to  atmospherical  vicissitudes.  In  this 
manner,  he  remarks,  we  cut  short  the  fever,  and  guard  against  those  ulterior  visceral  engorge- 
ments and  indurations,  by  which  it  is  too  often  prolonged,  until  the  constitution  is  completely 
ruined. 

The  only  period  of  the  cold  stage  at  which  bleeding  is  proper,  Mr.  Twining  states  to  be, 
at  the  very  commencement  of  the  rigor,  or  just  when  the  coldness  and  shivering  are  com- 
pletely established.  lie  has  found  that,  in  general,  it  is  sufficient  to  take  from  an  adult 
twelve  or  fifteen  ounces  of  blood,  and  in  the  most  robust  European  he  would  limit  the 
quantity  to  be  taken  at  one  bleeding  to  twenty  ounces.  After  the  arm  is  tied  up  the  patient 
should  be  permitted  to  lie  quiet  in  bed  for  an  hour  or  two — but  not  heated  by  being  covered 
with  too  many  bed-clothes ;  he  should  be  immediately  supplied  with  a  cup  of  warm  tea, 
gruel  or  thin  sago. 

According  to  Mr.  Twining,  "  the  requisites  to  ensure  success  from  bleeding  in  the  rigor, 
are,  1st,  the  preliminary  course  of  moderate  purging;  2d,  that  the  blood  be  taken,  from  a 
large  orifice,  quite  as  soon  as  the  coldness  and  rigor  are  fairly  established ;  and  3d,  that  the 
patient  be  bled  in  a  recumbent  posture,  and  no  more  blood  be  taken  than  is  suflicient  to 
arrest  the  paroxysm." 

In  robust  plethoric  patients,  who,  during  the  intervals  of  the  paroxysm,  complain  of  head- 
ache, and  morbid  tenderness  on  pressure  over  tlie  abdomen,  and  pain  or  uneasiness  in  the 
chest,  the  disease  will  seldom  be  arrested  by  the  first  bleeding;  in  many  cases,  they  will 
Lave  repeated  paroxysms  in  each  of  which  the  use  of  the  lancet  will  be  required.  Patients, 
also,  in  whom  the  jiaroxysm,  more  especially  the  cold  stage,  is  attended  with  vomiting,  Mr. 
Twining  has  found  to  require  the  repeated  abstractions  of  small  quantities  of  blood  during 
the  rigors. — C] 

If,  in  this  country,  bleeding  be  requisite  at  all,  it  is  in  the  hot  stage.  But  it  is  not 
requisite  at  all,  except  when  there  appears  to  be  danger  of  some  internal  inflatnma- 
tion.  The  best  remedy  of  the  hot  stage  is  undoubtedly  opium.  Dr.  Lind,  who 
wrote  after  large  experience,  says  that  he  never  saw  a  person  die  in  the  cold  fit,  but 
had  known  several  carried  off'  in  the  hot  one,  with  strong  convulsions  and  delirium. 
He  happened  to  notice  the  beneficial  effect  of  an  opiate  given  while  the  patient  was 
very  hot  and  feverish.     He  determined,  therefore,  to  make  further  trial  of  opium  'ii 


460  INTERMITTENT    FEVER. 

the  paroxysm.  "  Having  at  that  lime  (says  he)  twenty-five  patients  labouring  undei 
intermitting  fevers,  I  prescribed  an  opiate  for  each  of  them,  to  be  laken  immedial elij 
after  the  hot  fit,  provided  the  patient  had  then  any  inquietude,  headache,  or  anV 
such  symptom  usually  subsequent  to  the  fever.  The  consequence  was,  that  nine- 
teen in  twenty-two  received  immediate  relief;  the  other  three  had  no  occasion  to 
take  it. 

"  Encouraged  by  this  surprising  success,  I  next  day  ordered  the  opium  to  be  given 
during  the  hot  fit.  In  eleven  patients  out  of  twelve  to  whom  it  was  thus  adminis- 
tered it  removed  the  headache,  abated  the  fever,  and  produced  a  profuse  sweat ; 
which  was  soon  followed  by  a  perfect  intermission.  Since  that  time  1  have  pre- 
-jcribed  an  opiate  to  upwards  of  three  hundred  patients  labouring  under  this  disease: 
and  I  observed,  that  if  taken  during  the  intermission,  it  had  not  the  least  effect  either 
in  preventing  or  mitigating  the  succeeding  fit ;  when  given  in  the  cold  fit,  it  once  or 
twice  seemed  to  remove  it ;  but  when  given  half  an  hour  after  the  commencement 
of  the  hot  fit,  it  generally  gave  immediate  relief." 

Dr.  Lind  goes  on  to  state  that  he  found  the  influence  of  opium  more  uniform  and 
constant  in  intermitting  fever  than  in  any  other  disease  ;  and  more  quick  and.  sensible 
than  that  of  any  other  medicine. 

Very  little  need  be  said  in  regard  to  the  sweating  stage.  Up  to  a  certain  pomi  the 
perspiration  is  to  be  promoted  and  encouraged.  When  the  uneasy  feelings  of  the 
patient  have  abated,  it  should  be  restrained! ;  not  suddenly  but  with  caution.  Now 
the  sweating  may  be  promoted  by  diluents ;  by  keeping  the  patient  in  bed,  and 
covered  with  moderately  warm  clothes ;  by  sippings  of  hot  gruel  or  of  hot  chicken 
broth.  On  the  other  hand,  when  the  sweating  has  continued  long  enough,  it  may 
be  stopped  by  drying  the  patient  with  towels,  changing  his  linen,  and  getting  him  up 
out  of  bed. 

It  is  well  to  bear  all  this  in  mind  ;  but  I  repeat  once  more  that  in  agues,  such  as 
you  are  hkely  to  meet  with  in  this  country,  it  is  unnecessarj^  and  therefore  objection- 
able, to  be  over-busy  during  the  paroxysm.  Wherever  the  disorder  assumes  a  dis- 
tinctly intermittent  form,  the  most  important  part  of  the  practice  is  that  to  be  employed 
during  the  intermissions.  Now  there  are  certain  general  remedies  advised  lor 
adoption  in  this  period  ;  and  there  are  certain  specific  remedies.  The  general  reme- 
dies are  bleeding,  emetics,  and  purgatives.  They  need  not  detain  us  a  moment. 
Blood-letting  may  be  used  if  there  be  any  apparent  tendency  to  local  inflammation, 
or  any  marks  of  severe  topical  congestion  ;  especially  in  young  and  robust  subjects. 
Barring  such  circumstances,  there  can  be  no  occasion  to  bleed  your  patient  in  the 
intermissions. 

An  emetic  given  a  short  time  before  the  expected  paroxysm  has  been  known- to 
prevent  its  accession  ;  and  even  has  sometimes  cured  the  disease.  But  we  can  stop 
the  parox3'sms  by  gentler  and  better  means  ;  so  that  I  should  not  prescribe  an  emetic 
unless  1  saw  symptoms  of  a  foul  and  loaded  stomach. 

Purgatives  should  always  be  given  at  the  outset.  They  clear  the  stomach  and 
intestines  of  hurtful  accumulations,  which  are  apt  to  impede  the  beneficial  operation 
of  the  quina,  or  of  other  drugs  given  to  check  the  disorder.  I  mentioned  in  the  last 
lecture  my  own  custom  in  this  matter;  viz.,  to  give  a  couple  or  three  grains  of 
calomel  with  eight  or  ten  of  rhubarb  at  bed-time  ;  and  to  commence  with  the  specific 
remedies  the  next  Aviy. 

Of  these  specific  remedies,  bark  and  arsenic  are  by  far  the  most  certain  and  im- 
portant;  but  a  multitude  of  others  have  been  highly  praised  for  possessinof  similar 
virtues.  1  shall  by  and  by  say  a  word  or  two  about  some  of  these,  because  bark  is 
dear,  and  arsenic  is  scarcely  a  safe  drug  to  be  entrusted  to  the  hands  of  unprofessional 
persons ;  and  yet  it  is  often  expedient,  in  country  places,  where  ao-ues  are  rife,  to 
provide  the  poor  with  remedies  which  they  may  have  at  hand ;  and  which  should 
both  be  reasonably  cheap,  and  perfectly  safe. 

I  shall  not  detain  you  with  any  account  of  the  difficulties  and  objections  which 
were  thrown  in  the  way  of  the  Peruvian  bark,  upon  its  introduction  into  the  materia 
niedica  about  the  middle  of  the  seventeenth  century.  Its  use  met  with  the  most 
violent  opposition,  even  from  physicians  of  the  highest  authority.    It  was  resisted  by 


TREATMENT.  461 

Stahi  and  Hoffman ;  and  Boerhaave  was  never  quite  reconciled  to  it.  Sydenham, 
by  his  example  and  recommendation,  greatly  promoted  its  adoption  in  this  country. 
All  this  history  is  sufficiently  curious  and  interesting,  but  I  have  no  time  for  it :  and 
you  will  doubtless  hear  it  from  one  of  my  colleagues.  I  will  merely  say  that  in  the 
Peruvian  bark  we  have  one  of  the  very  few  specifics  that  we  can  boast  of  possessing; 
and  that,  unhke  most  other  highly  vaunted  substances,  so  far  from  falHng  off  from  the 
accounts  first  given  of  its  virtues,  it  has  acquired  in  the  lapse  of  time  an  increase  and 
stabihty  of  reputation. 

Neither  shall  I  enter  at  all  into  the  consideration  of  the  qualities  of  the  several 
species  of  cinchona ;  nor  of  the  several  principles  that  may  be  educed  from  them , 
nor  of  the  modes  in  which  the  quina  even  may  be  best  procured.  This  would  not 
belong  legitimately  to  my  province.  I  must  suppose  that  the  professors  of  chemistry 
and  of  materia  medica  have  furnished  you  with  the  sulphate  of  quina  which  is  the 
only  preparation  of  the  bark  I  intend  particularly  to  notice:  and  my  business  is  to 
tell  you  what  I  know  in  respect  to  its  employment  as  a  remedy  for  ague. 

I  may  observe,  however,  that  this  is  a  remedy  to  which  we  could  never  have  been 
led  by  any  process  of  reasoning.  It  is  a  matter  of  pure  empiricism.  We  know 
nothing  of  the  seat  or  of  the  essential  nature  of  the  disease ;  we  are  equally  in  the 
dark  as  to  the  modus  operandi  of  the  quina  in  curing  it ;  yet  our  knowledge  of  ague, 
upon  the  whole,  estimated  in  reference  to  its  precision  and  practical  bearing,  is  more 
satisfactory  than  of  many  other  complaints,  with  the  seat  and  nature  of  which  we 
are  much  better  acquainted.  The  group  of  symptoms  is  so  distinct,  that  we  have  no 
trouble  or  doubt  as  to  the  diagnosis ;  and  experience  has  taught  us  a  remedy  which 
is  all  but  infallible. 

The  discovery  of  quina  and  its  saks  formed  a  great  era  in  the  history  of  the  materia 
medica.  As  far  as  my  own  experience  goes,  the  sulphate  of  quina  has  quite  super- 
seded the  necessity  for  exhibiting  any  other  form  of  cinchona  for  the  cure  of  ague. 
Before  quina  was  unshrouded  by  the  chemist,  the  bark  in  substance  was  the  only 
form  in  which  the  remedy  could  be  confidently  relied  upon  :  and  I  am  old  enough 
to  be  aware  of  the  infinite  superiority  of  the  salt,  over  the  actual  bark.  To  obtain 
the  desired  effect,  it  was  often  necessary  to  give  it  in  such  quantities  as  almost  justi- 
fied x\Ir.  Abernethy's  sarcastic  way  of  speaking  of  it  and  of  physicians.  He  said  the 
doctors  talked  of  throwing  in  the  bark,  as  if  it  were  to  be  pitched  into  the  stomach 
with  a  shovel.  The  sulphate  of  quina  lies  in  a  much  smaller  compass,  and  a  more 
commodious  form  ;  and  it  does  not  cause  that  insupportable  nausea  which  the  woody 
mass  of  the  powdered  bark  was  so  apt  to  occasion. 

I  am  in  the  habit  of  giving  two,  and  sometimes  three,  grains  of  the  sulphate  of 
quina  every  four  or  six  hours  during  the  intermissions,  to  those  patients  v/hom  1  have 
occasion  to  treat  for  ague.  This  plan  has  succeeded  so  well,  that  1  have  never  been 
templed  to  try  any  other.  I  may,  indeed,  say  that  I  have  never  known  it  fail  to 
stop  an  ague  ;  and  to  stop  it  speedily :  so  that  very  few  parox3'sms  have  occurred 
after  the  patient  has  begun  to  take  the  medicine.  You  may  give  it  in  the  infusion 
of  roses,  which  contains  a  convenient  quantity  of  sulphuric  acid,  to  ensure  the  solu- 
tion of  the  sulphate  of  quina.  It  changes  the  colour  of  the  infusion,  however,  and 
renders  it  pinker  and  opaque.  Whether  the  draught  be  more  or  less  elegant  on  that 
account,  I  will  not  take  upon  me  to  say ;  I  know  that  the  virtue  of  the  quina  is  not 
much  interfered  with  by  the  change.  In  private  practice,  I  commonly  prescribe 
as  many  drops  of  dilute  sulphuric  acid  as  there  are  grains  of  the  quina,  with  a  drachm 
of  the  tincture  of  orange-peel,  and  a  drachm  of  the  syrup  of  the  same ;  completing 
the  draught  with  water.  This  I  find  my  patients  commonly  approve  of,  except  in  its 
bitterness,  which,  in  solution,  nothing  can  disguise.  Or  that  salt  may  be  administered 
in  the  shape  of  a  pill :  it  is  best,  however,  and  surest  in  solution. 

A  question  has  been  raised,  whether  this  remedy  should  be  given  in  repeated 
doses  during  the  intermissions,  or  whether  one  very  large  dose  should  be  given  a 
short  time  before  the  paroxysm  is  expected.  Dr.  Home  made  some  experiments 
on  that  point  in  the  clinical  wards  of  the  Edinburgh  Infirmary,  some  time  ago;  and 
he  thought  that  the  result  was  in  favour  of  the  plan  of  giving  the  bark  regularly  at 
short  intervals.     I  have  told  you  the  amount  of  my  own  experience,  which,  how 

2o2 


462  INTERMITTENT    FEVER. 

ever,  is  not  very  great ;  nor  have  I  had  any  severe  cases  to  deal  with.  I  think  it 
not  improbable  that  my  patients  would  have  been  cured  quite  as  soon  if  I  had  given 
the  remedy  in  half  the  strength.  Dr.  Barker,  of  Dublin,  has  found  small  doses 
equally  effectual  with  large  ones;  and  this  is  very  likely  to  be  the  case  with  specific 
remedies.  It  would  appear,  however,  that  in  some  quartans  it  is  better  to  give  large 
doses  before  the  return  of  the  paroxysm.  Dr.  EUiotson  gives  large  doses  just  after 
the  paroxysm ;  and  then  smaller  doses  during  the  remainder  of  the  intermission,  at 
regular  periods.  A  great  majority  of  those  who  suffer  ague  are  poor  persons.  Of 
course,  the  first  object  is  to  make  the  cure  as  speedy  as  possible ;  the  next  to  make  it 
as  cheap  as  possible.  So  that  it  is  not  a  matter  of  indifference,  or  mere  speculative 
curiositj',  to  ascertain  with  how  little  quina  you  may  cure  an  ague.  I  repeat  that  it 
has  not  happened  to  me  to  be  disappointed,  when  I  have  given  the  medicine  in  small 
doses,  as  already  described :  which  amount  to  abont  twelve  grains  in  twenty-four 
hours ;  but,  then,  I  suppose  my  cases  have  been  well  behaved  and  submissive. 
Dr.  EUiotson  states  that  he  is  continually  obliged  to  give  twenty  or  thirty  grains 
in  the  twenty-four  hours,  before  he  can  cure  the  complaint ;  sometimes  in  ob- 
stinate quartans,  forty-five  grains  ;  and  he  mentions  one  case  in  which  a  scruple 
of  the  sulphate  of  quina,  with  ten  minims  of  the  liquor  arsenicalis,  were  given  every 
eight  hours  in  vain,  but  succeeded  perfectly  when  given  every  six  hours. 

It  appears  also,  upon  the  testimony  of  careful  observers,  that  in  warm  climates 
larger  doses  are  required ;  and  that  it  takes  a  larger  quantity,  upon  the  whole,  to 
repel  the  complaint.  In  the  aguish  tracts  of  Italy,  in  the  Maremna,  small  doses  are 
said  to  be  inadequate  ;  and  the  physicians  there  are  in  the  habit  of  giving  twelve, 
twenty-four,  or  even  thirty  grains  at  a  time  :  and  in  one  recorded  instance,  the  dose,  in 
seven  days,  was  got  up  to  lOS  grains,  before  the  ague  was  arrested.  The  medium 
dose,  in  many  parts  of  America,  seems  to  be  eight  grains. 

It  sometimes  happens  that  the  irritability  of  the  stomach  is  so  great  as  to  make  it 
difficult  to  introduce  a  sufficient  quantity  of  the  remedy  into  the  system.  This  diffi- 
culty was  very  much  felt  at  Walcheren  :  it  is  in  a  great  measure  removed  since  the 
discovery  of  quina.  But  even  the  quina  sometimes  sits  ill  on  the  stomach  ;  and  it 
is  often  very  difficult  to  get  children  to  swallow  any  preparation  of  bark,  on  account 
of  its  bitter  taste.  It  is  an  important  thing  to  know,  therefore,  that  it  has  been  found 
scarcely  less  effectual,  in  curing  the  disease,  when  thrown  into  the  rectum.  The 
menstruum  in  which  it  is  dissolved  should  not  exceed  two  or  three  ounces,  lest  the 
bowel  should  reject  it.  Its  expulsion  may  sometimes  be  prevented  by  adding  a 
few  drops  of  laudanum  to  the  enema. 

[The  quinia  may  also  be  administered  endermically ;  from  4  to  10  grains  being  sprinkled 
upon  a  blistered  surface,  once,  twice  or  oftener,  according  to  circumstances,  in  the  course  of 
the  day.  That  the  remedy  will  produce  its  specific  effects  when  thus  exhibited  we  know 
from  experience. — C] 

It  is  said  that  bark  in  substance  will  sometimes  cure  the  disease  when  quina 
fails.  I  have  never  witnessed  this  :  but  in  obstinate  cases  I  would  give  the  quina  in 
the  decoction  of  bark. 

[It  is  very  certain  that  the  quinia,  even  when  given  freely  and  in  large  doses,  will  occa 
sionally  fail  in  arresting  the  disease,  and  that  the  majority  of  such  cases  will  be  promptlj 
cured  by  the  bark  in  substance.     This  we  have  seen  repeatedly  to  occur. — C] 

You  must  not  be  satisfied  with  merely  stopping  the  paroxysms.  Patients  will 
often  be  too  ready  to  give  up  their  medicine,  as  soon  as  the  paroxysm  has  once 
missed.  But  the  disease  is  very  apt  to  recur;  and  it  will  always  be  right  and  pru- 
dent to  go  on  with  the  quina  for  ten  days  or  a  fortnight  after  the  patient  seems  cured, 
gradually  diminishing,  after  the  first  week,  the  amount  and  the  frequency  of  the 
doses. 

There  have  been  some  curious  facts  observed  in  regard  to  the  relapses  that  are  apt 
to  take  place  after  the  bark  or  the  quina  has  been  omitted.  Clark,  of  Dominica, 
states  that  if  no  more  of  the  remedy  be  taken,  in  the  West  Indian  ague,  than  is 
barely  sufficient  to  stop  a  fit,  and  then  the  bark  is  suspended,  a  relapse  may  take 
place  on  the  eighth  day,  in  the  case  of  a  quotidian ;  on  the  fourteenth  or  fifteenth 


TREATMENT.  463 

in  the  case  of  a  tertian  or  double  tertian  ;  and  on  the  twenty-first  or  twenty-second 
in  the  case  of  a  quartan  :  thus  making  (you  see)  in  eacli  type,  seven  periodi- 
cal revolutions  from  the  time  the  fit  was  suppressed  to  the  next  attack ;  and  the 
fit  was  found  to  return  on  the  proper  day,  at  the  same  hour  at  which  it  would  have 
returned  if  its  course  had  not  been  interrupted  by  the  administration  of  the  remedy. 
All  this  is  very  curious,  and  inexplicable  :  but  it  points  clearly  to  the  propriety 
of  continuing  the  remedy  for  some  time  after  the  disease  appears  to  have  vanished. 

[The  Quini(B  Sulphas  Impurus  of  the  United  States  Pharmacopceia,  known  in  Philadelphia 
under  the  name  oi  Extract  of  Bark,  given  in  pills  of  from  3  to  5  grains  every  four  hours,  will 
seldom  fail  in  preventing  the  paroxysm  of  the  disease. — C] 

Arsenic  is  another  substance  which  has  great  and  unquestionable  power  over  ague. 
It  carries  Avith  it  these  marked  advantages  :  it  is  efficacious ;  it  is  cheap  ;  and  it  is 
tasteless.  It  is  well  adapted  by  these  qualities  for  the  poor,  and  for  children,  and  for 
patients  of  every  age  and  rank  in  whom  there  is  much  irritability  of  stomach  present; 
but  then  it  has  also  the  serious  disadvantage  of  being  an  active  poison.  One  over- 
dose may  be  fatal :  and  even  its  long-continued  use  in  minute  doses  leads  some- 
times to  evident  and  lasting  disorder  of  the  health.  Arsenic,  therefore,  is  an  unsafe 
remedy  to  be  trusted  in  the  hands  of  the  ignorant.  It  should  never  be  administered 
except  under  the  immediate  supervision  of  a  medical  eye ;  and  even  then  it  requires 
to  be  given  with  much  caution.  Its  bad  effects  may  be  very  certainly  prevented, 
however,  by  care  and  attention  :  and  it  becomes  a  valuable  instrument  of  cure,  and 
should  be  adopted  without  scruple,  in  cases  where  its  operation  can  be  watched,  and 
where  the  quina  does  not  agree  with  the  stomach,  or  fails  to  stop  the  disease.  I 
often  prescribe  arsenic  for  other  complaints  ;  but,  as  I  said  before,  I  do  not  recollect 
ever  having  been  foiled  in  removing  ague  by  the  sulphate  of  quina.  Some  persons 
are  of  opinion  that  relapses  are  less  frequent  after  the  cure  by  arsenic  than  after  the 
cure  by  bark.  It  would  require  a  large  induction  of  particular  facts  to  make  that 
point  clearly  out. 

When  substances,  which  even  in  small  quantities  prove  active  poisons,  are  used 
as  remedial  agents,  it  is  convenient  to  have  some  definite  form  in  which  they  may  be 
administered  at  all  times,  and  in  all  places.  The  liquor  potassse  arsenitis  of  the 
London  Pharmacopoeia  supplies  such  a  form.  This  is  the  form  in  which  arsenic 
was  recommended  to  the  public  by  Dr.  Fowler :  and  it  is  therefore  sometimes  called 
Fowler^s  solution.  It  was  founded  upon  an  analysis  of  the  tasteless  ague  drop, 
which  had  been  in  considerable  repute  in  some  parts  of  England.  The  pharmaco- 
po^ial  preparation  is  an  arsenite  of  potass  in  solution.  There  are  eighty  grains  of 
arsenic  in  the  new  or  imperial  pint,  and  therefore  four  grains  in  an  ounce  of  the  so- 
lution. Ten  minims  two  or  three  times  a  day  are  a  full  dose  for  an  adult :  and  you 
had  better  commence  with  not  more  than  five  minims.  Ten  minims  contain  one- 
twelfth  of  a  grain.  Twice  that  quantity  has  been  administered  at  once ;  but  this 
ought  not  to  be  done  except  when  the  system  has  been  gradually  inured  to  the 
arsenic,  and  thereby  enabled  to  bear  such  a  dose.  It  is  a  good  precaution  not  to  give 
this  corrosive  substance  on  an  empty  stomach. 

The  poisonous  or  hurtful  effects  that  we  have  to  look  out  for,  when  arsenic  has 
been  prescribed,  are  loss  of  appetite,  nausea,  and  sometimes  vomiting ;  griping  pain 
of  the  stomach  and  bowels,  and  diarrhcea ;  and  if  the  medicine  be  continued,  faint- 
ing is  often  added.  Other  symptoms,  less  constant,  perhaps,  and  less  important,  are 
painful  and  hot  tumefaction  and  stiffness  of  the  face  and  eyehds,  or  even  a  tingling 
eruption  something  like  nettle-rash.  These  effects  may,  I  believe,  be  controlled  by 
adding  a  few  drops  of  laudanum  to  each  dose  ;  but  I  would  rather  advise  you  to  sus- 
pend the  use  of  the  arsenic ;  or  to  leave  it  off  altogether.  When  this  is  done,  the 
unpleasant  symptoms  will  readily  yield  to  mild  laxatives,  followed  by  opiates. 

[The  arsenical  solution  is  a  remedy  admirably  adapted  for  the  cure  of  intermittent  feve» 
wlien  it  occurs  in  children,  to  induce  whom  to  take  the  quinia  in  any  form  will  be  found 
often  impossible.  When  cautiously  administered,  and  its  effects  are  carefully  watched,  wi" 
have  never  known  any  disagreeable  eflects  to  result  from  the  arsenic,  and  we  have  em 
ployed  it  somewhat  extensively. — C] 


464  INTERMITTENT    FEVER. 


T 


When  the  paroxysms  continue  to  recur  in  spite  of  the  bark,  it  has  been  recom- 
mended (and  I  think  the  plan  a  good  one),  to  try  to  stop  them  by  arsenic ;  and 
then,  the  })eriodic  recurrence  having  been  broken,  to  employ  sulphate  of  quina  to 
prevent  a  relapse. 

These,  then,  quina  and  arsenic,  are  the  two  sheet-anchors  to  which  we  trust  in 
the  cure,  of  ague.  A  host  of  other  remedies,  I  say,  have  had  their  praises  sung.  1 
do  not  intend  to  enumerate  them.  But  there  are  a  few  which  I  think  it  right  to 
mention,  for  reasons  already  assigned.  There  is  strong  evidence  of  the  efficacy  of 
some  of  them  ;  they  are  cheap,  and  easily  accessible,  and  above  all,  safe  ;  and,  there- 
fore, in  aguish  districts,  they  may  with  much  propriety  and  benefit  be  recommended 
to  the  poorer  classes,  or  distributed  by  Lady  Bountifuls. 

[The  ferrocyanuret  of  iron  is  certainly  a  very  valuable  remedy  in  cases  of  intermittent 
fever.  Stokes  places  it  in  efBcacy  after  qtiinia  and  the  arsenical  solution,  and  perhaps  he  is 
right  in  so  doing;  it  will,  however,  often  succeed  in  preventing  the  recurrence  of  the  pa 
roxysms,  given  in  the  dose  of  six  grains  every  three  hours. — C] 

One  of  these  is  willoiv-bark  ;  in  substance,  or  in  decoction.  If  this  does  cure 
agues,  as  it  is  affirmed  to  do,  it  w'ould  seem  as  if  Providence  had  placed  the  anti- 
dote alongside  of  the  poison  ;  for  these  trees,  as  you  know,  abound  and  flourish  in 
marshy  places.  The  bark  of  the  willow  furnishes  an  alkaloid  substance  called  saJi- 
cine,  in  which  the  febrifuge  property  is  believed  to  reside.  Holly-leaves,  and  ilicint  . 
derived  from  them,  stand  in  much  the  same  repute  in  France,  as  willow-bark  and 
salicine  here. 

Another  curious  remedy,  said  to  be  very  successful,  is  the  web  of  the  black  spider, 
which  inhabits  barns,  stables  and  cellars.  This  substance  has  been  tried  on  a  tolera- 
bly large  scale,  and  the  testimony  to  its  influence  in  curing  agues  is  very  strong. 
Dr.  Craige  has  given  this  account  of  it.  In  the  year  17G0,  a  number  of  prisoners 
from  the  vanquished  squadron  of  Thurot  having  been  landed  in  the  Isle  of  Man, 
Dr.  Gillespie,  who  was  practising  there,  found  that  many  of  the  agues  which  came 
to  prevail  both  among  these  prisoners  and  the  inhabitants  of  the  island,  obstinately 
resisted  bark  and  such  other  remedies  as  he  had  recourse  to.  He  was  informed,  by 
an  old  French  physician  belonging  to  the  squadron,  of  the  alleged  efficacy  of  cob- 
web, in  certain  forms  of  the  disease.  He  therefore  made  trial  of  cobweb,  and  founo 
it  to  answer  admirably.  He  was  successful  with  it  in  more  than  sixty  cases  of  dif 
ferent  types,  in  the  Isle  of  Man,  and  he  had  further  experience  of  its  utility  subse 
quently  in  Ayrshire. 

After  this,  the  same  remedy  was  tested  in  the  West  Indies,  by  Dr.  Jackson,  to 
whom  Dr.  Gillespie  had  recommended  it.  Dr.  Jackson's  observations  were  made 
in  the  hospital  of  the  army  depot,  in  the  West  Indies,  in  1801.  Several  cases  of 
ague,  on  which  bark,  arsenic,  or  mercury,  singly  or  alternately,  had  made  either  a 
very  temporary  impression  or  none  at  all,  were  selected  for  experiment.  In  four  of 
these  cases,  two  pills,  containing  each  five  grains  of  cobweb,  were  given  at  intervals 
of  two  hours,  commencing  six  hours  before  the  expected  time  of  recurrence  of  the 
paroxysm.     The  fit  did  not  return. 

[We  have  employed  the  spider's  web  in  this  manner  in  a  number  of  cases,  and  in  many 
of  them  found  it  very  promptly  to  suspend  the  paroxysms — as  effectually,  certainly,  as  th<» 
quinia ;  in  a  few  cases,  however,  it  failed. — C] 

On  subsequent  trials  it  was  found  not  only  to  arrest  the  course  of  agues,  but  to 
remove  various  symptoms,  such  as  pain,  delirium,  vomiting,  griping,  in  ague,  and 
VI  continued  fever,  when  these  symptoms  were  unconnected  with  inflammation. 

Charcoal  is  another  substance  which  has  been  found  effectual  for  the  cure  of 
intermittent  fevers.  You  may  find  an  account  of  it  in  the  tenth  volume  of  the  Edin- 
burgh Medical  and  Surgical  Journal.  It  would  seem  to  be  especially  useful  in 
those  cases  in  which  there  is  a  marked  disturbance  of  the  digestive  organs ;  nausea, 
flatulence,  hiccup,  diarrhcea,  or  dj^senter}'.  It  is  said  generally  to  cure  the  complaint 
by  the  time  two  drachms  of  it  have  been  taken.  It  may  be  given  in  doses  of  ten  or 
twenty  grains,  in  arrow-root ;  or  with  a  few  grains  of  rhubarb.  If  the  power  of  this 
sub&tance  should  be  confirmed  by  future  observations,  a  cheap  remedy  would  thus 


I 


TREATMENT.  465 

DC  open  to  the  poor.  A  clergyman  of  my  acquaintance  assures  me  that  he  seldom 
fails  to  cure  agues  among  his  parishioners  by  administering  to  them  the  snuffs  of 
candles,  which  he  takes  care  to  have  collected.  He  does  not  inform  them  of  what 
his  black  powder  consists.  I  presume  that  its  virtue  may  proceed  from  the  char- 
coal it  contains ;  unless  it  is  derived  from  the  confidence  his  flock  is  accustomed  to 
place  in  his  specific.  The  veiy  same  remedy,  the  snuff  of  a  candle,  is  mentioned 
by  Lind. 

Fiperine,  the  crystaUine  salt  of  pepper,  has  obtained  a  considerable  reputation,  of 
late  years,  as  a  remedy  for  intermittent  fever.  It  was  largely  tried  by  an  Italian 
physician,  Meli ;  and  Dr.  Gordini  has  repeated  Meli's  experiments  at  the  hospital 
at  Leghorn.  The  following  are  the  general  conclusions  at  which  these  physicians 
have  arrived  : — 1.  Piperine,  in  doses  of  six  or  eight  grains,  cures  intermittents.  2. 
It  is  more  efficient  in  powder  than  in  pills.  3.  It  succeeds  in  certain  cases  in  which 
the  sulphate  of  quina  fails.  And  4.  It  is  more  effectual  in  preventing  relapses.  I 
have  seen  letters  from  some  practitioners  in  this  country,  bearing  testimony  to  tlie 
power  of  the  piperine.  That  pepper  will  cure  ague,,  has  long  been  the  vulgar 
belief;  and  a  very  popular  remedy  for  the  disease  is  a  teaspoonful  of  pepper  in  a 
glass  of  gin. 

I  presume  that  the  efficacy  of  chamomile  flowers  in  the  removal  of  intermittent 
fever  is  to  be  attributed  to  the  piperine  which  they  have  been  asct-rtained  to  contain. 
These  flowers  had  been  long  in  use  for  the  treatment  of  ague,  before  the  Peruvian 
bark  was  discovered ;  and  they  are  said  to  have  accomplished  a  cure,  since  that 
lime,  after  the  bark  had  failed  ;  but  this  was  before  the  quina  had  been  educed  from 
it.  Fleberden  advises  us  to  have  recourse  to  chamomile  flowers,  if  the  bark  should 
disappoint  us.  I  am  always  willing  to  embrace  an  opportunity  of  referring  to  his 
commentaries,  for  the  exact  observations  they  contain,  but  above  all  for  the  beautiful 
Latinity  of  which  the  whole  book  is  an  example.  I  recommend  it  strongly  to  you, 
as  being,  next  to  C(,'lsus,  the  best  model  you  can  study  for  good  medical  Latin.  In 
reference  to  the  point  before  us  he  says,  "Cortex,  quanquam  rite  sumtus,  interdum 
parum  efficax  est;  quo  in  casu  suspicio  erit  ventriculum  sordibus  onustum  vin 
remedii  impedire.  Itaque  vomere  oportet ;  quo  facto,  febris  raro  non  cedit.  Gluod 
si  redire  perseveret,  confugiendum  est  ad  flores  chamsemeli,  quorum  contriorum  scru- 
pulus  dandus  est  loco  drachmae  cinchonoe,  et  ad  idem  proescriptum  repetendus.  Hos 
flores,  sic  sumtos,  semel  atque  iterum  profecisse  expertus  sum." 

Several  mineral  substitutes  for  the  bark,  or  for  arsenic,  have  been  tried  and  found 
useful.  Preparations  of  iron  and  of  zinc.  From  5  to  10  grains  of  the  sulphate pf 
zinc  have  been  given  several  times  a  day ;  or  3  grains  of  the  oxide  of  zinv"  every 
three  hours.  Sir  Gilbert  Blane  says  that  both  in  the  West  Indies  and  in  London, 
intermittents  have  been  cured  by  the  use  of  this  oxide,  when  they  had  previously 
resisted  the  bark.  Sir  James  Mac  Grigor  speaks  of  it  also  in  terms  of  praise  ;  from 
what  he  saw  of  its  effects  in  the  agues  of  the  Peninsula  during  the  war. 

Some  of  the  remedies  of  this  mysterious  disorder  operate  upon  the  mind,  or  lather 
upon  the  nervous  system,  through  the  mind.  Hence  it  becomes  probable  that  the 
drugs  which  have  such  power  over  the  disease,  act  also  on  the  nervous  system, 
throutjh  the  body.  And  hence  also  we  derive  a  confirmation  of  the  opinion,  that 
the  disease  itself  is  essentially  a  disease  of  the  same  nervous  system.  Ague  has 
ofien  been  cured  by  the  agency  of  strong  mental  emotion,  such  as  sudden  and  great 
ioy,  anger,  terror,  or  eager  expectation.  Thus  we  read  that  Quintus  Fabius  Maxi- 
mus  was  cured  of  an  old  quartan  on  the  day  of  a  great  battle.  Strong  iin])ressions 
upon  the  imagination,  producing  feelings  of  disgust  and  horror,  have  had  the  same 
effect:  such  as  those  caused  by  drinking  blood,  swallowing  a  spider  gently  bruised, 
and  wrapped  up  in  a  raisin,  or  spread  upon  bread  and  butter;  keeping  a  spider  sus- 
pended from  the  patieni's  neck  in  a  nutshell,  till  it  dies;  and  the  like.  The  un- 
doubted success,  in  many  cases,  of  charms,  must  be  referred  to  the  principle  oC  faif/i. 
The  patient  recovers,  because  he  firmly  believes  in  your  power  lo  cure  him.  Dr. 
Gregory  used  to  relate  the  case  of  a  patient  in  the  clinical  wards  in  Edinburgh, 
wno,  with  sundry  ceremonies,  swallowed  some  word,  written  on  a  slip  of  paper:  the 
result  was,  that  he  had  not  another  paroxysm  And  I  perfectly  recollect  hay-ng  a 
30 


4GC  INTERMITTENT    FEVER. 

great  awe,  when  I  was  quite  a  child,  of  my  maternal  grandmother,  because  she  was 
reputed  to  have  the  power  of  curing  agues  by  means  of  some  charm.  I  believe  all 
that  she  did  was  to  assure  the  poor  people  who  came  to  be  relieved  from  their  ague, 
that  they  should  have  no  more  of  it  offer  such  a  day;  and  their  implicit  reliance 
upon  this  prophecy  brought  about  its  fulfilment.  There  seems  to  be  this  general 
principle  obserA'able  in  respect  to  agues,  and  to  most  other  diseases  which  occur  in 
paroxysms,  viz.,  that  after  they  have  continued  for  some  time,  their  further  continu- 
ance depends  more  upon  the  efTect  o{  habit  than  any  thing  else:  and  this  habit 
may  be  broken  by  strong  impressions  made  upon  the  nervous  system ;  and  the  cure 
of  one  paroxysm  is  often  thus  the  cure  of  the  disease.  We  have  seen  examples  of 
the  existence  of  this  morbid  haoit  in  hysteria,  and  in  some  cases  of  epilepsy.  C'ft'leris 
paribus,  that  physician  will  be  the  most  successful  in  these  disorders,  who  is  best 
able  to  acquire  the  confidence  of  his  patient,  and  to  gain  a  powerful  influence  over 
his  mind. 

There  is  no  disease  in  which  the  prophylaxis  is  of  more  importance  ;  but  this  you 
v.'ill  have  gathered  from  the  facts  which  were  stated  in  the  two  preceding  lectures. 
The  disposition  to  relapse  is  strongest  soon  after  the  disease  has  been  removed ;  but 
it  generally  continues  long,  perhaps  even  for  fife.  The  late  Dr.  Macmichael  caught 
an  ague  many  years  before  his  death,  by  sleeping  on  a  rock  somewhere  in  Greece ; 
and  he  was  ever  after  subject  to  occasional  attacks  of  periodic  headache,  and  other 
aguish  symptoms,  for  which  he  was  obliged  to  have  recourse  to  bark  or  arsenic.  Of 
course  one  essential  point  in  the  prophylaxis  is  the  withdrawal  of  the  patient  from 
the  influence  of  the  exciting  cause ;  taking  him  away  from  the  malarious  locality. 
But  this  cannoi  always  be  done ;  and  when  it  cannot,  we  must  impress  upon  him 
those  cautions  which  arise  out  of  the  facts  ascertained  in  regard  to  the  operation  of 
the  malaria  upon  the  human  body.  Persons  who  have  been  exposed  to  the  exciting 
cause,  or  who  have  once  had  the  fever,  should,  in  whateATr  place  they  may  happen 
to  be,  avoid  over-fatigue,  and  exhaustion  of  all  kinds ;  sudden  exposure  to  cold  or 
heat ;  and  the  neglect  of  changing  wet  clothes  ;  wet  shoes  and  stockings,  for  instance. 
In  a  malarious  district  persons  should  bear  in  mind  the  facts,  that  the  miasmata  ar-e 
much  more  virulent  in  the  night-time  than  in  the  day  ;  and  close  to  the  surface  of 
the  earth,  than  in  a  higher  part  of  the  atmosphere.  They  should  refrain,  therefore, 
from  going  out  late  in  the  evening,  or  early  in  the  morning ;  and  they  should  rather 
select  the  attic  than  any  other  floor  for  their  bed-chamber.  They  who  are  obliged 
to  go  out  in  the  morning  in  countries  where  agues  are  rife,  should  take  care  not  to 
go  out  fasting;  a  good  hot  breakfast  should  be  first  taken,  or  at  any  rate  some  mode- 
rate stimulus.  A  crust  of  bread  and  a  glass  of  wine,  or  a  small  quantity  of  ardent 
spirit,  will  fortify  the  system  against  the  pestilential  miasma.  Measures  of  this  kind 
have  been  found  extremely  beneficial  in  the  navy  :  the  giving,  for  instance,  the  men 
a  warm  breakfast  before  going  out  in  the  morning  on  malarious  shores  in  boats, 
whatever  the  hour  of  starting  might  be.  Generous  diet,  and  a  fair  allowance  of  fer- 
mented liquor,  are  proper  also  for  all  persons  in  aguish  countries.  The  late  Dr. 
James  Gregory  used  to  mention  in  his  lectures  an  anecdote  in  point,  told  him  by  his 
father.  The  elder  Dr.  Gregory  studied  at  Leyden,  under  Boerhaave;  and  twenty- 
four  other  Enghsh  students  were  living  there  at  the  same  time  :  that  is,  they  were 
called  English,  on  account  of  their  common  language,  but  they  were  in  fact  composed 
of  Encrlish,  Irish,  Scotch,  West  Indians,  and  Americans.  The  celebrated  John 
Wilkes  and  Charles  Townsend  were  among  the  number.  These  twenty-five  students 
lived  a  good  deal  together ;  in  truth  they  were  cut,  as  the  phrase  is,  by  the  Dutch, 
for  some  raffish  behaviour  on  their  parts.  However,  of  the  twenty-five,  only  one 
was  a  water-drinker.  The  other  twenty-four  drank  each  a  bottle  of  claret  daily; 
and  the  water-drinker,  and  he  alone,  fell  ill  of  ague  there. 

Persons  who  have  recently  become  residents  in  aguish  districts,  or  who  even  hap- 
pen to  be  travelling  through  them,  would  do  well  to  take  moderate  doses  of  quina  by 
way  of  safeguard.  And  in  regulating  the  bowels,  which,  of  course,  is  of  much  im- 
portance, warm  stomachic  laxatives  should  be  made  use  of,  rather  than  cold  aperi* 
onts,  such  qs  the  neutral  salts. 


! 


EPISTAXIS.  467 

There  is  just  one  more  expedient  wliich  I  would  suggest  as  not  unlikely  to  affoil 
complete  protection  to  those  who  are  of  necessity  exposed  to  the  malaria ;  and  it  is, 
that  they  should  wear  an  orinasal  respirator.  It  is  impossible  that  as  a  breeze  is 
filtered  of  the  poison  which,  was  mingled  with  it,  by  passing  through  a  dense  mass 
of  foliage,  so,  on  a  smaller  scale,  the  air  inspired  in  breathing  may  be  strained  and 
purified,  and  rendered  harmless,  in  its  transit  through  the  sieve-like  structure  of  Mr. 
Jeffreys'  ingenious  instrument.  The  principle  of  the  suggestion  is  not  new  ;  but 
this  mode  of  applying  it  has  not,  so  far  as  I  know,  hitherto  been  tried.  It  is  said 
that  by  surrounding  the  head  with  a  gauze  veil,  or  conopeum,  the  action  of  malaria 
is  prevented  ;  and  that  thus  it  is  possible  even  to  sleep  in  the  most  pernicious  parts 
of  Italy  without  hazard  of  fever.  Dr.  MaccuUoch  says  that  in  Malta,  and  elsewhere, 
this  behef  is  universal :  and  hence  the  popular  practice  of  covering  the  mouth  and 
nose  with  a  handkerchief  in  the  morning  on  going  out,  or  in  other  suspicious  circum- 
stances :  a  practice  (he  observes)  the  efHcacy  of  which  is  attested,  as  far  as  popular 
belief  can  attest  any  thing.  Can  it  be  the  moisture  which  accumulates  upon  the 
handkerchief  from  the  breath,  that  confers  the  protection  ? 


LECTURE  XLIII. 

Epistaxis.     Bronchocele ;    Cretinism:   their  Phenomena  and  probable  Causes. 
Medical  and  Surgical  Treatment  of  Bronchocele. 

I  YESTERDAY  finished  what  I  had  to  say  respecting  intermittent  fever ;  its  symp- 
torns  ;  its  cause  ;  and  its  cure.  The  subtle  poison  which  produces  it  is  thickly  dis- 
tributed over  the  fairest  portions  of  the  habitable  globe  :  blighting  human  health,  and 
shortening  human  life,  more  often,  and  to  a  far  greater  numerical  amount  than  any 
other  single  cause  whatever.  Known  only  by  its  noxious  effects,  holding  out  no 
signal  of  its  presence,  this  unseen  and  treacherous  enemy  of  our  race  has  yet  been 
tracked  to  its  haunts  and  lurking  places,  and  detected  in  some  of  its  habits.  It  was 
necessary,  therefore,  that  I  should  enter  somewhat  fully  into  the  history  of  the  mal- 
aria, and  show  how  it  may  sometimes  be  shunned,  sometimes  be  averted ;  how,  also, 
in  this  climate  at  least,  the  effects  it  has  already  produced  upon  the  human  body 
may  be  successfully  combated.  But  I  shall  not  pursue  in  further  detail,  the  ravages 
committed  by  this  invisible  agent,  and  the  remedies  they  require,  in  hotter  and 
less  favoured  regions  than  our  own.  Of  these  personally,  I  know  nothing ;  and  I 
must  refer  you,  for  information  on  such  diseases,  to  authors  who  have  seen  and 
treated  them  :  particularly  to  Drs.  Lind,  Jackson,  Bancroft,  Johnson,  and  Sir  William 
Burnett. 

It  is  customary,  with  writers  and  lecturers,  to  pass  from  the  consideration  of  ague 
to  that  of  continued  fever.  A  paroxysm  of  ague  has  been  regarded  as  exhibiting  a 
paradigm  or  sample  of  fever  in  general.  But  this  has  always  appeared  to  me  rather 
an  ingenious  refinement  than  a  useful  matter  of  fact.  Practically,  I  see  nothing  to 
be  gained  by  the  association.  Intermittent  fever,  it  is  true,  does  often  run,  in  hot 
climates,  into  the  remittent,  and  the  remittent  into  the  continued  form.  But  these 
are  very  different  disorders  from  the  continued  fever  with  which,  in  these  climates, 
and  in  this  country,  we  have  to  do.  Intermittent  fever,  and  continued  fever,  as  we 
see  them,  differ  in  their  phenomena,  in  their  course,  and  in  their  treatment.  They 
are  alike,  inasmuch  as  they  are  both  called  fever,  and  both  are  attended,  in  some  part 
or  other  of  their  course,  with  pyrexia;  but,  in  essential  symptoms,  I  have  known 
many  a  compound  fracture  more  like  continued  fever  than  any  ague  we  are  likely 
to  witness.  I  shall  take  up  the  subject  of  continued  fever,  then,  in  connection  with 
the  eruptive  febrile  diseases,  with  which  it  has  many  strong  links  of  analogy ;  and 
I  resume  the  consideration  of  the  disorders  that  come  within  the  province  of  the 
physician,  according  to  their  anatomical  seat. 


468  EPISTAXIS. 

After  what  was  stated  0*"  .lemorrhafje  in  general,  in  an  earlier  part  of  the  course, 
I  hardly  know  whether  epistaxis  needs  or  deserves  any  formal  notice.  There  are, 
however,  some  points  relating  to  this  simple,  and  commonly  harmless  hemorrhage, 
which  it  may  be  worth  v^'hile  very  briefly  to  touch  upon.  Sometimes  it  is  a  remedy ; 
sometimes  a  warning;  sometimes  really  in  itself  a  disease.  The  readiness  with 
which  the  mucous  lining  of  the  nasal  passage  pours  forth  blood  is  familiar  toS.he 
experience  of  every  schoolboy,  who  "  often  wipes  a  bloody  nose."  A  slight  blow, 
brisk  exercise,  a  strong  bodily  effort,  a  fit  of  sneezing,  or  the  summer  heat,  is  suffi- 
cient, in  many  boys,  to  make  the  nose  bleed  ;  and  this  facility  of  hemorrhage  furnishes, 
often,  an  index  of  some  unnatural  state  of  the  circulation :  and  especially  of  undue 
fullness  of  the  vessels  of  the  head.  But  the  import  of  this  symptom  is  not  always 
the  same.  Epistaxis  may,  indeed,  be  taken  as  affording  an  epitome  of  the  various 
forms  of  hemorrhage  by  exhalation.  In  childhood  and  early  youth  it  is  idiopathic, 
dependent  upon  active  congestion,  and  probably  arterial.  It  is  nature's  favourite 
mode  of  blood-letting  at  that  period  of  life.  In  old  age  it  is  symptomatic,  the  result 
of  passive  or  mechanical  congestion,  and  probably  venous.  In  some  adult  persons 
it  happens  periodically,  and  is  habitual:  and  its  suspension,  rather  than  its  occur- 
rence, becomes  a  token  of  disease  or  of  danger.  In  young  women  it  is  not  seldom 
vicarious  of  suspended  menstruation :  in  men  it  is  apt  to  take  the  place  of  hemor- 
rhois.  Lastly,  it  may  proceed  from  disease  in  the  nares  themselves ;  or  form  a  part 
of  a  more  general  hemorrhagic  disorder. 

It  is  unnecessary  to  go  at  length  into  the  phenomena  of  epistaxis.  The  main 
phenomenon  becomes  obvious  at  once  both  to  the  patient  and  to  those  around  him  : 
and  the  accessory  and  incidental  circumstances  are  easily  discoverable  when  the 
attention  is  aroused  to  them  by  the  sight  of  the  blood.  Usually  the  blood  flows 
guflalim;  in  a  succession  of  drops:  but  these  may  follow  each  other  so  fast  as  to 
constitute  a  little  stream.  Sometimes  a  few  drops  only  fall ;  sometimes  several  pints 
are  lost.  A  moderate  hemorrhage  of  this  kind  is  generally  succeeded  by  a  sense  of 
relief  and  refreshment.  A  large  efflux  of  blood  may  cause  pallor,  faintness,  debility, 
exhaustion,  even  deatb. 

Active  idiopathic  epistaxis,  as  it  occurs  in  children,  is  almost  always  salutary,  and 
may  be  left  to  work  its  own  cure.  When  it  runs  into  excess,  or  is  too  often  repeated, 
it  may  be  checked  by  applying  cold  water  to  the  forehead  and  to  the  bridge  of  the 
nose.  The  sudden  contact  of  some  cold  substance  with  a  distant  part  of  the  surface 
of  the  body  will  often  have  the  effect  of  restraining  the  hemorrhage :  apparently  by 
producing  a  general  and  sympathetic  constriction  of  the  superficial  blood-vestels. 
This  is  doubtless  a  reflex  phenomenon.  The  nursery  remedy  is  to  slip  a  cold  key 
down  the  child's  neck,  between  its  back  and  its  clothes.  The  aspersion  of  cold  water 
is  iitill  better.  Besides  these  external  appliances,  cooling  laxatives  should  be  given  : 
and  if  the  bleeding  proves  obstinate,  some  astringent  internal  remedy  may  be  thought 
proper.  I  have,  myself,  hitherto  found  none  so  efficacious  as  the  acetate  of  lead. 
But  I  have  been  recently  informed  by  Dr.  Latham  that  his  experience  has  led  him 
to  trust  much  to  mercury  in  the  management  of  epistaxis ;  and  that  the  same  indica- 
tions have  governed  him,  in  adapting  its  use  to  this  form  of  hemorrhage,  as  serve  to 
guide  him  in  cases  of  inflammation.  Thus,  when  the  hemorrhage  has  been  profuse 
and  frequent,  and  moderate  depletion  by  blood-letting,  or  by  purgatives,  has  not 
arrested  it,  he  has  brought  the  constitution  rapidly  under  the  influence  of  mercury; 
and  as  soon  as  the  mouth  became  sore,  the  hemorrhage  has  ceased,  not  a  drop  more 
of  blood  has  been  lost.  Again,  when  the  epistaxis  has  been,  not  copious,  but  habitual 
or  frequently  recurring,  without  any  excess  of  vascular  action,  or  any  other  apparent 
ailmenc  in  the  constitution  at  large.  Dr.  Latham  has  often  cured  his  patient  by  a 
moderate  salivation,  gradually  induced,  and  continued  for  a  few  weeks. 

In  conversing  with  Dr.  Southey  on  the  same  subject,  I  find  that  he  also  has  been 
taught  by  experience  to  rely  upon  mercury  as  almost  a  specific  remedy  for  obstinate 
hemorrhage,  occurring  under  similar  conditions,  from  whatever  organ  of  the  body  it 
may  proceed. 

This  plan  of  treatment  it  is  therefore  my  purpose  to  prove,  as  future  opportunity 
Miay  permit. 


I 

H 


EPISTAXIS.  469 

When  epistaxis  begins  to  show  itself  in  advanced  life,  it  is  a  symptom  which 
cannot  safely  be  neglected  :  for  it  indicates  that  the  veins  of  the  head  are  loaded.  It 
implies  a  morbid  condition  that  requires  to  be  redressed.  You  will  look  for  disease 
of  the  heart — or  for  threatenings  of  apoplexy — and  take  your  measures  accordingly 
The  blood-vessels  which  ramify  upon  and  beneath  the  pituitary  membrane,  commu 
nicate  by  indirect  inosculation  with  the  veins  and  sinuses  of  the  skull,  as  well  as 
with  the  jugular  veins.  You  see,  therefore,  how  it  is  that  hemorrhage  from  this 
membrane  may  perform  the  office  of  a  safety-valve,  and  protect  the  important  organ 
within  the  cranium  from  impending  mischief. 

On  the  other  hand,  when  epistaxis,  which  is  known  to  have  been  habitual,  fails  to 
recur  at  or  about  the  usual  periods,  you  will  look,  with  a  jealous  care,  into  your 
patient's  state,  and  watch  for  and  obviate  any  tendency  to  plethora  capitis. 

When  epistaxis  forms  a  part  of  more  general  hemorrhagic  disease  —  as  when  it 
occurs  among  other  symptoms  of  purpura — its  treatment  merges  in  that  of  the  whole 
malady. 

In  any  case,  if  the  flow  of  blood  be  excessive,  and  cannot  be  restrained  by  the 
ordinary  remedies,  but  is  exhausting  the  patient's  strength,  it  becomes  an  absolute 
disease :  and  it  will  be  requisite  to  staunch  the  blood  by  manual  expedients. 

These  consist  in  stopping  the  bleeding  orifices  mechanically  :  which  is  most  effec- 
tually to  be  done  by  plugging  the  cavity.  A  dossil  of  lint  must  be  carefully  inserted 
into  the  bleeding  nostril.  Its  mechanical  effect,  which  is  pressure,  may  be  chemi- 
cally aided  by  first  wetting  the  lint  with  a  saturated  solution  of  alum.  The  mode 
of  introducing  these  plugs  it  is  the  business  of  the  surgeon — and  not  mine — to  teach. 
The  operation  is  not  a  very  comfortable  one  either  to  bear  or  to  perform. 

A  very  simple  mechanical  remedy  has  been  lately  announced  by  Dr.  Negrier,  of 
Anglers ;  who  discovered  it  (he  says)  by  mere  accident.  The  patient  is  to  raise  one 
or  both  of  his  arms  above  his  head,  and  to  hold  them  for  some  little  time  in  that 
position.  Dr.  Negrier  declares  that  during  an  experience  of  three  years  he  has 
never  known  this  method  fail  to  arrest  the  bleeding.  His  explanation  of  its  modus 
operandi  is  not  very  satisfactory.  The  expedient  itself  is  however  so  easy,  so  prompt, 
and  even  if  unsuccessful  so  harmless,  that  its  real  value  deserves  to  be  tested  — 
and  will  soon  probably  be  settled — by  an  ampler  trial. 

[In  cases  of  frequently  recurring  or  long-continued  epistaxis,  blisters  to  the  nape  of  the 
neck  will  be  found,  in  general,  a  very  etfectual  remedy. — C] 

Before  we  trace  this  mucous  membrane  downwards,  through  the  mouth,  to  the 
inside  of  the  throat,  let  me  turn  your  attention  to  a  singular  disorder  which  may  be 
deemed  external,  for  it  is  scarcely  more  than  skin-deep :  I  mean  that  enlarged  state 
of  the  thyreoid  gland  to  which  tlie  name  o(  bronchocele  has  been  given.  This  u  )rd 
is  not  merely  derived  from  the  Greek,  but  was  used  by  the  Greek  writers  in  the 
same  sense  in  which  we  now  employ  it.  In  Switzerland,  where  it  is  very  common, 
and  in  France,  the  complaint  is  called  goitre  ;  a  corruption,  it  is  believed,  of  the 
Latin  "guttur,"  the  throat.  It  is  known  in  England  as  the  Derbyshire  neck;  from 
its  frequent  occurrence  in  that  country. 

The  term  bronchocele  has  been  sometimes  applied  indiscriminately  to  all  protu- 
berances or  swellings  in  front  of  the  throat;  or  at  any  rate,  to  all  enlargements  of 
the  thyreoid  gland  ;  whereas  it  should  be  restricted  to  hypertrophy  of  that  part .  an 
exaggeration  of  its  natural  structure,  with  augmentation  of  its  volume.  The  texture 
of  the  gland  becomes  coarser;  its  blood-vessels  grow  larger  and  more  numerous  ;  us 
cells  are  magnified,  and  fdled  with  a  thick,  viscid  secretion.  It  usually  presents  a 
soft,  smooth,  elastic  tumour,  which  is  neither  painful,  nor  tender,  nor  discoloured. 
The  lobes  of  the  gland  become  more  obvious.  Sometimes  the  whole  tumour  ia 
irregularly  lobulated  :  sometimes  the  exact  form  and  relative  proportions  of  the  gland 
are  preserved,  each  lobe  and  portion  being  equally  increased  in  size.  Occasionally 
there  is  a  soft  uniform  or  irregular  swelling,  without  much  distinction  of  parts. 
Alibert  states  that  the  right  lobe  is  more  frequently  enlarged  than  the  left.  Mr, 
Rickwood  found  it  so  in  every  instance  of  bronchocele  that  came  under  his  notice 
in  the  neighbourhood  of  Horsham. 

2p 


470  BRONCHOCELE. 

Unless  the  tumour  be  very  large,  it  follows  all  the  motions  of  the  larynx  :  and  this 
IS  a  point  of  considerable  importance  whenever  the  diagnosis  is  at  all  doubtful.  It 
is  just  possible  that  an  enlarged  lymphatic  gland,  or  an  encysted  tumour  in  the 
neighbourhood  of  the  larynx,  or  even  a  collection  of  pus  thereabouts,  might,  in  some 
degree,  embarrass  the  diagnosis.  But,  by  placing  the  head  and  neck  in  different 
successive  positions,  swellings  of  this  accidental  kind  may,  in  general,  be  ascertained 
to  be  unconnected  \^-ith  the  larynx :  and  they  do  not  follow  its  up  and  down  move- 
ments when  the  act  of  deglutition  is  performed. 

It  is  of  importance  to  know,  also,  that  the  gland  itself  is  subject  to  different  kinds 
of  enlargement.  It  may  swell  from  inflammation,  chronic  or  acute  :  and  then  it 
will  be  hard,  and  tender,  and  painful.  But  it  does  not  seem  very  prone  to  inflame ; 
and  probably  Dr.  Copland  is  right  in  his  opinion  that  inflammation  occurs  sponta- 
neously in  this  organ  in  scrofulous  persons  only.  Baillie  and  Ahbert  speak  of  it  as 
being  occasionally  the  seat  of  cancer:  but  that  must  be  very  rare.  Sometimes  carti- 
laginous or  ossific  deposits  take  place  in  the  gland.  It  is  necessary,  I  say,  to  be 
aware  of  these  circumstances,  and  to  distinguish  one  kind  of  thyreoid  tumour  from 
another :  for  some  of  the  morbid  changes  just  referred  to  are  clearly  be3'ond  the 
power  of  any  medicine  to  remove ;  and  if  all  forms  of  enlargement  incidental  to  this 
part  are  lumped  together  under  one  common  name  of  bronchocele,  we  shall  be 
liable  to  arrive  at  false  conclusions  concerning  the  power  of  remedies  over  that 
disease. 

Bronchocele  is  not,  in  itself,  a  painful  disorder :  nor  does  it  taint  the  s)^stem,  or 
affect  the  constitution  in  any  way.  It  has  no  character  of  malignancy  about  it.  It 
is  always,  however,  a  deformity  ;  and,  by  its  mechanical  effects,  that  is,  by  its  weight 
when  large,  and  by  the  pressure  it  exercises  on  contiguous  parts,  it  may  occasion 
great  distress,  and  suffering,  and  even  death  itself.  The  size,  and  the  effects,  of  the 
tumour  both  vary  much  in  different  cases ;  but  its  injurious  effects  are  not  always, 
though  they  are  generally,  in  proportion  to  its  bulk.  Sometimes  there  is  no  more 
than  a  slight  fullness  of  the  throat,  which  some  persons,  I  beheve,  think  rather 
graceful  than  otherwise.  Now  and  then,  the  swelling,  after  its  first  commencement, 
develops  itself  with  great  rapidity;  but  its  ordinary  progress  is  slow.  It  often  con- 
tinues for  months,  or  years,  without  reaching  any  extreme  or  very  troublesome  mag- 
nitude. Sometimes  it  remains  stationary  for  a  considerable  time,  and  then  suddenly 
increases  without  any  apparent  cause.  The  worst  effects  of  bronchocele  are  its 
interference  with  the  circulation,  and  with  respiration.  By  its  pressure  it  may 
obstruct  the  free  descent  of  the  blood  through  the  veins  of  the  neck,  and  give  rise  to 
headache,  giddiness,  noises  in  the  ears,  confusion  of  thought,  and  a  turgid  condition 
of  the  head  and  face.  Or,  by  pressing  upon  the  wind-pipe,  it  may  cause  hoarse- 
ness, wheezing,  and  d3^spncea.  It  may  even  impede  deglutition.  But  these  effects, 
I  say,  do  not  depend  ahogether  on  the  actual  size  of  the  tumour.  A  very  large 
goitre  may  produce  no  other  inconvenience  than  what  results  from  its  weight  and 
i-ts  unseemly  appearance.  It  may  surround  all  the  front  and  sides  of  the  neck  like 
a  thick  collar,  and  rise  as  high  as  the  ears  ;  or  it  may  hang  down,  in  a  pendulous 
lump,  and  be  supported  upon  the  chest.  Nay,  the  tumour  is  said  to  descend,  in 
some  rare  instances,  so  low  as  to  be  in  contact  with  the  abdomen :  and  Alibert 
mentions  one  case  in  which  the  swelling  was  of  a  tapering  cylindrical  shape,  and 
reached  to  the  middle  of  the  thigh.  On  the  other  hand,  a  small  tumour,  not  bigger 
than  one's  fist,  especially  if  it  happens  to  occupy  the  ce.itral  portion,  or  what  is 
called  the  isthmus,  of  the  gland,  may  so  press  inwards  upon  the  trachea  as  mate- 
rially to  hinder  the  breathing,  and  even  to  threaten  suffocation.  A  pupil  now 
attending  the  hospital  has  informed  me  of  a  case,  which  he  himself  saw,  of  death 
produced  by  the  encroachment  of  a  bronchocele  ;  not  so  much,  however,  from  suffo- 
cation as  from  starvation :  for  the  swelling  encircled  the  trachea,  and  came  at  last  to 
press  so  much  upon  the  woman's  oesophagus,  that  she  could  not  get  food  into  her 
stomach.  I  suppose  that  the  reason  of  these  differences  may  be  sometimes  found  in 
the  manner  in  which  the  tumoui:  grows,  and  in  its  relative  situations.  When  it  is 
bound  down  by  the  muscles  of  the  neck,  it  presses,  as  it  continues  to  enlarge,  upon 


I 


BRONCHOCELE.  471 

the  parts  behind  it.     Wlien  it  is  not  so  confined,  the  skin  readily  yields,  and  the 
entire  growth  of  the  tumour  takes  place  anteriorly. 

This  disease  is  much  more  corgmon  in  women  than  in  men.  Indeed  we  seldom 
see  it,  in  this  country,  except  in  females.  Yet  I  happen  to  have  an  example  of  it 
now,  (December,  1S37)  in  a  male  among  my  patients  in  the  hospital.  Dr.  Andrew 
Crawford  states  that  forty-nine  cases  were  admitted  into  the  Hampshire  County 
Hospital,  in  ten  years,  and  forty-eight  of  these  were  in  women.  Of  seventy  patients 
treated  in  the  Chichester  Infirmary  in  nine  years,  two  only  were  males,  asd  they 
were  boys  of  a  very  feeble  and  feminine  habit,  and  backward  for  their  years. 
Among  one  hundred  and  sixteen  patients  of  Dr.  Manson,  fifteen  were  men.  Taking 
an  average  from  these  three  lists,  we  have  one  male  for  twelve  females.  It  is  well 
to  bear  in  mind  that  our  fashion  of  dress  renders  a  small  bronchocele  much  more 
noticeable,  much  less  easily  concealed,  in  women  than  in  men.  In  the  former  the 
swelling  has  been  knowm  to  come  on,  or  at  any  rate  to  increase  rapidly,  during  their 
confinement  in  child-bed  :  and  it  is  frequently  observed  to  undergo  a  temporary  en- 
largement at  the  menstrual  period.  Dr.  Copland  has  seldom  met  with  an  instance 
in  the  female,  unconnected  with  some  kind  of  irregularity  in  the  catamenial  discharge, 
or  disorder  of  the  uterine  functions ;  and  he  never  saw  a  case  in  which  the  disease 
made  its  appearance  before  the  period  of  coimmencing  puberty.  In  Switzerland, 
and  in  some  parts  of  India,  where  the  complaint  is  much  more  prevalent  than  here, 
the  proportion  of  males  affected  is  greater ;  and  it  begins,  often,  prior  to  the  age  of 
puberty,  in  both  sexes.  It  seldom  shows  itself  earlier  than  the  age  of  eight  or  ten. 
Dr.  EUiotson  states,  indeed,  that  he  himself,  when  in  Switzerland,  saw  goitre  in  a 
little  boy  only  four  years  old  ;  and  the  natives  told  him  that  it  rarely  made  its  appear- 
ance before  the  age  of  six.  But  children  have  been  born  goitrous.  M.  Godelle, 
physician  to  the  hospital  at  Soissons,  had  a  preparation  of  the  body  of  an  infant, 
which  only  hved  a  few  hours,  and  which  came  into  the  world  with  a  goitre ;  the 
mother  being  a.Tected  with  the  same  disease.  A  case  is  mentioned  in  the  London 
Medical  Repository  of  a  child  born  in  Derbyshire  with  bronchocele  of  considerable 
size.  The  disease,  therefore,  undoubtedly  may  be  congenital ;  and  one  of  the 
facts  I  have  just  mentioned  points  to  the  question  of  its  being  hereditary.  It  is  said 
to  be  so ;  and  there  is  much  probability  in  favour  of  that  opinion.  Children  born 
of  goitrous  parents  often  have  goitre.  But  that,  you  will  say,  may  depend  upon 
their  being  in  the  same  place,  and  exposed  to  the  same  causes,  which  produced  bron- 
chocele in  the  mother  or  father.  Dr.  Crawford  states,  however,  that  he  knew  a 
woman,  with  goitre,  whose  grandmother,  father,  paternal  aunt,  and  cousins,  also  had 
it,  although  they  did  not  all  live  in  the  same  place,  and  no  other  person  in  their 
respective  neighbourhoods  was  affected  by  the  disease. 

Admitting  what  seems  probable,  that  the  disease  may  sometimes  be  hereditary  in 
the  sense  in  which  I  formerly  explained  that  term,  there  can  be  no  doubt  that  it  is 
often  acquired. 

In  the  first  place,  bronchocele  is  endemic — prevalent  in  certain  localities,  and 
scarcely  occurring  elsewhere.  And  persons  who,  being  previously  well,  go  to  live 
in  those  localities,  often  become  affected  with  the  complaint :  and  persons  who  mi- 
grate/ro'm  those  localities,  having  the  complaint  upon  them,  sometimes  get  rid  of  it 
by  the  mere  change  of  residence.  The  physical  circumstances  of  the  places  thus 
selected  by  the  disease  have  been  studied  with  the  natural  hope  of  discovering  what 
the  cause  may  be  of  an  effect  so  singular.  Some  morbific  quality  of  the  air  v^'as  long 
suspected.  The  habitats  of  the  unknown  cause  of  bronchocele  appeared  at  first 
sight  to  be  very  much  like  those  of  the  mala/ia.  Goitre  abounds  in  the  hollows  of 
many  mountainous  districts  ;  among  the  Alps,  for  example,  and  in  the  Pyrenees 
This  was  notorious  to  the  ancients.     Juvenal  asks — 

Quis  tumidum  giittur  miratur  in  Alpibus? 

And  it  is  in  the  deep,  close,  and  humid  valleys  of  Switzerland,  which  lie  at  tnt 
feet  of,  and  between,  high  mountains,  that  bronchocele  is  most  common.  Several 
writers,  who  have  personally  investigated  this  subject  in  places  where  goitre  is  rife, 
concur  in  the  belief  that  it  depends  upon  insalubrity  of  the  air,  ari'^ing  from  the  pe 


472  CRETINISM. 

culiarities  of  the  situation.  They  affirm  that  it  is  most  frequent  in  low,  damp,  con- 
fined spots,  wliere  the  stagnant  atmosphere  Ls  seldom  stirred  by  wholesome  breezes ; 
and  where  the  sun,  in  summer,  has  great  power.  Dr.  James  Johnson  remarks,  "We 
find  in  the  Valais  (one  of  the  Swiss  cantons)  and  in  the  lower  gorges  or  ravines  that 
open  on  its  sides,  both  cretinism  and  bronchocele  in  the  most  intense  degrees.  As  we 
ascend  the  neighbouring  mountains,  cretinism  disappears,  and  goitre  only  is  observed. 
And  when  we  get  to  a  certain  altitude,  both  maladies  vanish."  Dr.  Reeve,  again, 
states  thai  all  the  cretins  he  saw  were  in  adjoining  houses  in  the  little  village  called 
La  Batia,  situated  in  a  narrow  corner  of  the  valley,  the  houses  being  built  up  under 
ledges  of  the  rocks,  and  rll  of  them  very  filthy,  very  close,  very  hot  and  miserable 
habitations.  In  villages  situated  higher  up  the  mountains,  no  cretins  are  to  be 
seen. 

The  cretinism  mentioned  in  these  quotations  is  a  strange  and  melancholy  disease: 
a  sort  of  idiocy,  accompanied  by  (and  doubtless  dependent  upon)  deformity  and  im- 
perfection of  the  bodily  organs.  The  mental  affection  exists  in  all  degrees,  from 
mere  obtuseness  of  thought  and  purpose,  to  the  complete  obliteration  of  intelligence. 
Many  of  the  cretins  are  incapable  of  articulate  speech;  some  are  blind,  some  deaf, 
and  others  labour  under  all  these  privations.  They  are  mostly  dwarfish  in  stature, 
with  large  heads,  wide  vacant  features,  and  goggle  eyes,  short  crooked  limbs,  flabby 
muscles,  and  tumid  bellies.  The  worst  of  them  are  insensible  to  the  decencies  of 
nature,  and  obey,  without  shame  or  self-restraint,  every  animal  impulse.  In  no 
other  class  of  mortals  is  the  impress  of  humanity  so  pitiably  defaced. 

More  recent  and  extensive  observation  of  the  localities  infested  b}^  goitre  have  ren- 
dered it  improbable  that  the  disease  derives  its  origin  from  any  deleterious  properties 
of  the  air.  Certainly  it  is  not  owing  to  any  thing  that  is  common  to  all  mountain- 
ous countries.  Some  parts  of  Switzerland  are  free  from  it.  So  are  the  Highlands 
of  Scotland.  It  is  met  with  also  in  flat  situations — as  in  Norfolk.  I  have  seen 
several  cases  of  it  in  Cambridgeshire,  which  is  a  venj  flat  country'.  Tn  one  village 
in  particular,  about  five  miles  from  Cambridge,  it  is  extremely  common.  There  are 
some  striking  facts  collected  by  the  celebrated  and  philosophic  Humboldt,  which  go 
to  show  that  the  prevalence  of  bronchocele  does  not  depend  on  any  particular 
configuration  of  the  surface  of  the  earth,  nor  on  any  peculiar  condition  of  the 
atmosphere.  He  tells  us  that  in  South  America  bronchocele  is  met  with,  both  in 
the  upper  and  the  lower  course  of  the  ^Magdalen  river  ;  and  in  the  flat  high  country 
of  Bogota,  6000  feet  above  the  bed  of  the  stream.  The  first  of  these  regions  is  a 
thick  forest ;  while  the  second  and  third  present  a  soil  destitute  of  vegetation.  The 
first  and  third  are  exceedingly  damp  ;  the  second  peculiarly  dry.  In  the  first  the 
air  is  stagnant :  in  the  second  and  third  the  winds  are  impetuous.  In  the  first  twd 
the  thermometer  keeps  up  all  the  year  at  22  or  23  degrees  of  the  Centrigrade  scale  : 
in  the  third  it  ranges  between  4  degrees  and  17. 

The  researches  of  Mr.  M'Clelland,  in  India,  lead  to  the  same  conclusion.  He  found 
goitre  extremely  frequent  in  one  portion  of  the  district  which  he  surveyed,  while  the 
other  portion  was  almost  exempt  from  the  complaint,  "although  an  equality  of 
moral  as  well  as  physical  circumstances  appeared  to  affect  the  whole.  The  external 
Alpine  characters  of  the  province  are  the  same  in  every  part ;  the  inhabitants  all 
belong  to  the  same  tribes  of  Hindoos,  and  are  subject  to  fevver  irregularities  in  their 
mode  of  life  than  any  other  people  in  the  world." 

The  dilFerent  localities  of  the  villages,  in  the  portion  where  goitre  was  not  preva- 
lent, he  describes  as  being  as  diverse  as  can  well  be  imagined.  "  Some  are  erected 
on  narrow  ridges,  others  in  deep  valleys,  surrounded  by  abrupt  and  lofty  mountains  ; 
others  on  rugged  declivities  between  lofty  peaks  on  one  side,  and  deep  ravines  on  the 
other,  into  some  of  which  the  sun  can  scarcely  penetrate.  The  different  altitudes  of 
these  villages  vary  from  2000  to  6000  feet." 

Facts  of  this  kind  have  turned  the  attention  of  scientific  inquirers  towards  the  only 
other  obvious  source  to  which  the  disorder  could,  with  probability,  be  attributed,  viz., 
[He  quality  of  the  ivater  used  for  drinking.  Wherever  goitre  prevails,  the  popular 
belief  assigns  it  to  the  water,  as  a  cause  :  and  the  more  accurately  the  search  is  pro- 
'S'Tuted,  the  more  strength  and  Hkelihood  does  this  supposition  acquire.     Its  very 


CRETINISM.  473 

universality  is  a  presumption  in  its  favour.  The  disease  was  formerly  ascribed  to 
the  use  of  snoiv  water :  a  notion  which  originated,  I  imagine,  in  its  frequent  occur- 
rence in  Alpine  regions.  But  the  people  in  almost  all  the  valleys  of  Switzerland 
drink  the  water  that  comes  from  the  Glaciers  ;  while  bronchocele  is  known  in  some 
of  the  valleys  only.  It  prevails  also  in  certain  spots  where  pump  water  is  used,  and 
there  the  people  accuse  the  pump  water  of  producing  it.  Besides,  goitre  occurs  in 
other  countries,  where  the  snow  never  lies  long,  as  in  Derbyshire  ;  and  even  in  Su- 
matra, where  there  is  no  snow.  Dr.  Bally,  a  native  of  a  goitrous  district  in  Switzer- 
land, beheves  that  bronchocele  is  caused  by  certain  zvaters,  which  issue  from  the 
hollows  of  rocks,  trickle  along  crevices  of  the  mountains,  or  rise  froia  the  bowels  of 
the  earth.  And  in  support  of  that  opinion  he  refers  to  some  fountains  in  his  own 
neighbourhood,  the  drinking  of  the  waters  of  which  will  produce,  or  augment,  goi- 
trous swellings,  in  eight  or  ten  days.  Such  of  the  inhabitants  as  avoid  these  waters 
are  free,  he  says,  from  goitre  and  cretinism.  In  Captain  Franklin's  narrative  of  his 
expedition  to  the  shores  of  the  Polar  sea,  there  is  the  following  statement,  made  by 
his  fellow-traveller  Dr.  Richardson : — "  Broncliocele  or  goitre  is  a  common  disorder 
at  Edmonton.  I  examined  several  of  the  inhabitants  afflicted  with  it,  and  endeavoured 
to  obtain  every  information  on  the  subject  from  the  most  authentic  sources.  The 
following  facts  may  be  depended  upon  : — The  disorder  attacks  those  only  who 
drink  from  the  water  of  the  (Saskatchanan)  river.  It  is,  indeed,  in  its  worst  state, 
confined  almost  entirely  to  the  half-bred  women  and  children  who  reside  constantly 
at  the  fort,  and  make  use  of  river  water,  drawn  in  winter,  through  a  hole  made  in 
the  ice.  The  men,  from  being  often  from  home  on  their  journeys  through  the  plain, 
where  their  drink  is  melted  snow,  are  less  affected  :  and  if  any  of  them  exhibit  during 
the  winter  some  incipient  symptoms  of  the  complaint,  the  annual  summer  voyage  to 
the  sea-coast  generally  effects  a  cure.  The  natives  who  confine  themselves  to  snow 
water  in  the  winter,  and  drink  of  the  small  rivulets  which  flow  through  the  plains 
it)  the  summer,  are  exempt  from  attacks  of  this  disease.  A  residence  of  a  single  year 
at  Edmonton  is  sufficient  to  render  a  family  bronchocelous.  Many  of  the  goitres 
acquire  great  size.  Burnt  sponge  has  been  tried,  and  found  to  remove  the  dis- 
ease :  but  an  exposure  to  the  same  cause  immediately  reproduces  it.  A  great 
proportion  of  the  children  of  the  women  who  have  goitres  are  born  idiots,  with 
large  heads,  and  the  other  distinguishing  marks  of  cretins.  I  could  not  learn 
whether  it  was  necessary  that  both  parents  should  have  goitres  to  produce  cretin 
children." 

We  are  able  even  to  go  a  step  further,  and  to  announce  a  probable  conjecture  as 
to  the  specific  quality  of  the  suspected  water.  Bronchocele  is  very  prevalent  in 
Nottingham  and  its  neighbourhood ;  and  the  vulgar  there  ascribe  it  (so  Dr.  Manson 
informs  us)  to  the  hardness  of  the  water.  You  know  that  the  rough  practical  dis- 
tinction between  soft  and  hard  water  is  that  the  former  dissolves  soap,  while  the 
latter  decomposes  it.  The  hardness  is  generally  occasioned  by  the  presence  either 
of  sulphate  of  lime,  or  of  carbonate  of  lime.  In  the  one  case  the  remedy  is  to  mix 
the  carbonate  of  an  alkali  with  the  water;  in  the  other  you  simply  boil  it.  Now  the 
well  water  in  and  about  Nottingham  is  more  or  less  hard,  and  unfit  for  the  purpose 
of  washing.  Dr.  Coindet,  of  Geneva,  declares  that  the  use  of  hard  or  pump  water 
in  the  lower  streets  of  that  town  brings  on  the  goitre  very  speedily.  At  Cluses,  on 
the  Arve,  numerous  cretins  and  goitrous  persons  are  seen  in  the  streets :  lofty  clifts 
of  limestone  tower  over  the  town,  and  through  its  caverns  copious  streams  of  water 
find  a  passage.  The  soil  in  the  neighbourhood  of  Edmonton  was  found  by  Dr. 
Richardson  to  be  calcareous,  and  to  contain  numerous  fragments  of  magnesian  lime- 
stone. In  a  Treatise  on  English  Bronchocele,  very  recently  published.  Dr.  Inglis 
states  his  belief  tliat  the  presence  of  magnesian  limestone  always  implies  the  co- 
existence of  the  disease.  "  Take  (he  says)  that  ridge  of  magnesian  limestone  run 
ning  from  north  to  south  through  the  centre  of  Yorkshire,  and  margining  the  shires 
of  Derby  and  Nottingham.  All  along  that  line  we  have  goitre  to  a  very  great 
extent;  whereas,  on  our  diverging  to  either  side,  the  disease  is  found  to  diminish." 

These  scattered  indications  that  the  hurtful  quaUty  of  the  water  is  somehow  de- 
rived froia  its  contact  with  limestone  rocks,  receive  a  powerful  corroboraliou  from  *.\uf 

2p3 


474  CRETINISM. 

result  of  Mr.  M'Clelland's  minute  and  valuable  inquiries,  which  were  carried  on  in 
the  province  of  Kemaon,  south  of  the  Himalayan  mountains.  I  have  not  been  able 
to  obtain  his  book  ;  what  I  am  about  to  tell  3'ou  I  take  from  a  full  and  instructive 
notice  of  it  in  the  fifteenth  number  of  the  British  and  Forcis^n  Medical  Review, 
Mr.  M'Clelland  finding  goitre  very  abundant  (as  I  mentioned  before)  in  one  great 
section  of  a  district,  and  almost  entirely  absent  from  another  section,  set  himself  to 
find  out  in  what  other  particulars  these  sections  were  distinguished  from  each  other. 
He  ascertained  that  they  completely  agreed  "  in  external  aspect,  altitude,  and  cli- 
matology," but  differed  remarkably  "  in  their  geognostic  relations  ;  and  this  distinc- 
tion was  even  traced  down  to  the  very  villages  in  which  the  disease  is  found,  with 
such  perfect  nicety,  as  to  enable  one  almost  to  predict,  «  priori,  on  examining  the 
rocks  of  a  neighbourhood,  whether  the  inhabitants  are  affected  with  goitre  or  not." 

It  would  be  impossible  for  me  to  give  you  even  an  abstract  of  Mr.  M'Clelland's 
numerous  observations ;  but  I  select  one  or  two  striking  instances  in  favour  of  his 
opinion  that  the  endemic  prevalence  of  goitre  is  connected  with  the  use  of  water  im- 
pregnated with  calcareous  salts. 

One  extremity  of  the  long  village  Deota,  which  occupies  half  a  mile  of  the  foot 
of  Durge  mountain,  is  inhabited  by  Brahmins  ;  the  other  by  Rajpoots  and  Domes. 
Of  the  first  caste  there  are  about  twenty  persons,  all  of  whom  are  free  from  goitre. 
There  are  forty  of  the  second,  and  two-thirds  are  affected,  more  or  less.  Of  the  third 
caste,  forty-six  in  number,  nearly  the  whole  are  goitrous.  "  To  what  cause  can  we 
ascribe  the  immunity  of  one  caste  of  the  inhabitants  of  this  village,  and  the  almost 
universal  affijction  of  the  other  two  castes?  They  are  all  alike  well  fed,  and  have 
little  toil ;  their  land  producing  the  requisites  of  life  almost  without  labour.  Differ- 
ence of  caste  does  not  here  imply  a  diflerence  of  pecuniary  circumstances,  and  con- 
sequently of  the  comforts  of  life.  In  these  respects  the  three  castes  in  this  village 
are  on  perfect. equality.  Nor  will  hereditary  predisposition  acquired  by  intermar- 
riages be  sufficient  to  explain  the  interesting  fact :  for  the  affected  parlies  are  con- 
fined to  the  Rajpoots  and  Domes,  who  cannot  intermarry,  while  the  Brahmins  and 
Rajpoots  may.  The  village  is  raised  about  one  hundred  feet  above  the  level  of  the 
valley  ;  and  the  mountain,  at  the  foot  of  which  it  is  situated,  rises  with  a  gentle 
slope,  and  is  not  in  this  vicinity  at  all  rugged.  It  is  chiefly  composed  of  transition 
limestone,  and  the  village  is  erected  on  a  conglomerated  rock,  composed  of  calcare- 
ous tuff,  inclosing  fragments  of  other  rocks.  There  is  a  spring  in  the  valley,  about 
one  hundred  yards  from  the  village,  bearing  on  its  first  appearance  the  character  of 
a  mineral  spring.  The  water  bursts  forth  with  strong  ebulhtion,  in  the  quantity  of 
at  least  forty  gallons  in  a  minute,  and  agglutinates  the  sand  and  gravel  by  which  it 
is  surrounded,  by  the  deposition  of  calcareous  tuff.  The  temperature  and  quantity 
of  the  water  are  the  same  at  all  seasons.  The  former  inhabitants  of  the  village, 
aware  perhaps  of  the  noxious  effects  of  this  spring,  had  an  aqueduct  formed,  by  which 
water  is  conveyed  into  the  Brahnn'n  portion  of  the  village  from  a  distant  source. 
The  aqueduct  having  been  suffered  to  get  out  of  repair,  the  quantity  of  water  it 
transmits  is  reserved  exclusively  for  the  Brahmins;  except  during  the  rainy  season, 
wdien,  the  water  being  plentiful,  the  Rajpoots  also  use  that  of  the  aqueduct ;  but  the 
Domes  have  no  alternative  at  any  season  but  to  use  the  water  from  the  spring." 

I'he  valley  of  Baribice  is  elevated  4000  feet  above  the  sea.  Its  eastern  extremity 
is  composed  of  c/nyslafe,  and  in  five  villages,  containing  152  inhabitants,  there  is 
not  one  goitre.  The  other  extremity  of  the  valley  is  partly  composed  of  limestone  ; 
and  of  lSi2  inhabitants,  distributed  in  six  villages,  70  are  affected  with  goitre:  but 
Duc3'gong,  one  of  these  villages,  supplied  with  water  from  clayslate,  has  not  a  single 
case  of  the  disease;  while  Agar,  only  half  a  mile  distant,  and  containing  .50  inha- 
bitants, has  no  less  than  40;  and  of  that  number  20  are  cretins.  They  use  the  v/ater 
wnich  issues  from  an  old  copper-mine  in  limestone,  and  which  contains  carbonate 
of  lime,  and  of  soda,  but  no  sulphate. 

Mr.  M'Clelland  affirms  that  in  the  course  of  his  personal  inquiries,  which  extended 
over  1000  square  miles,  and  which  were  prosecuted  without  regard  to  any  theory, 
no  instan/'e  occurred  in  which  goitre  prevailed  to  any  extent  where  the  ^illage.s 
were  not  situated  on  or  close  to  limestone  rock. 


CRETINISM.  475 

[In  the  United  States  the  disease  is  prevalent  in  many  of  the  valleys  siluuted  in  tlie  moun- 
tainous regions  of  New  Hampshire,  Vermont,  New  York,  Pennsylvania  and  Virginia ;  many 
of  these  regions  abound  in  limestone  rocks. — C] 

Cretinism  has  a  close,  but  an  ill-understood,  connection  with  goitre.  Wherever 
cretinism  is  endemic,  bronchocele  never  fails  to  be  abundant.  But  bronchocele  may- 
prevail  in  a  place  where  there  are  no  cretins.  With  but  few  exceptions,  cretins  are 
goitrous ;  whereas  many  of  those  who  have  bronchocele  are  not  affected  with  cre- 
tinism. The  two  disorders  either  spring  from  the  same  cause,  requiring  for  their 
joint  production  that  this  cause  should  be  in  active  operation :  or,  if  they  have  sepa- 
rate causes,  these  frequently  co-exist  and  act  in  combination.  It  is  said,  I  know  not 
with  what  accuracy,  that  when  both  parents  are  goitrous  for  two  generations  in  suc- 
cession, the  offspring,  being  in  the  third  generation,  are  sure  to  be  cretins.  Cer 
tainly  cretinism  is  most  common  where  bronchocele  is  most  common,  and  especially 
in  mountainous  places.  It  occurs  in  the  Pyrenees  as  well  as  in  the  Alps,  in  the 
mountains  of  Syria,  in  the  hilly  parts  of  China,  and  in  the  Himalayan  regions.  Yet 
cretinism  is  confined  within  much  more  Hniited  bounds  than  goitre.  Saussure,  Fo- 
dere,  and  Dr.  Reeve,  agree  entirely  as  to  the  circumstances  under  which  cretinism 
appears  to  be  most  commonly  engendered  in  Switzerland.  They  say  that  the  dis- 
ease is  usually  met  with  in  valleys  which  are  nearly  surrounded  by  high  and  steep 
rocks,  where  there  is  but  little  circulation  of  air,  and  where  the  inhabitants  are  ex- 
posed to  the  direct  rays  of  the  sun,  and  to  the  reflection  of  them  from  the  rocks  ;  and 
also  to  effluvia  from  marshes.  It  is  in  the  filthy  habitations  built  in  these  close,  hot 
and  humid  situations,  that  cretinism  abounds  most.  The  children  that  ate  taken 
away  from  the  low  valleys,  and  carried  up,  when  young,  into  the  high  grounds, 
escape  the  disease  ;  or  even  get  the  better  of  it  if  removed  soon  enough.  And  the 
amendment  is  said  to  be  perceptible  even  in  a  very  few  daj's.  These  facts  have  led 
many  persons  to  conclude  that  cretinism,  if  not  bronchocele,  depends  on  some  condi- 
tion of  the  uir.  It  appears  to  me  probable  that  the  exciting  cause  of  both  is  the 
same,  and  that  the  local  circumstances  just  now  mentioned  operate  as  predisposing 
causes  only.  Cretinism,  as  well  as  goitre,  was  observed,  by  Ramond,  in  the  "  open, 
well-watered,  and  well-ventilated  valleys  of  the  Pyrenees." 

There  are  some  difficulties  opposed  to  the  implicit  reception  of  the  opinions  formed 
by  Mr.  M'Clelland  and  by  others,  respecting  the  origin  of  these  diseases.  And  the 
facts  upon  which  those  opinions  are  grounded,  are  not  without  apparent  exceptions. 
Moreover,  the  actual  substance  which  exercises  or  confers  the  noxious  power,  has 
yet  to  be  ascertained.  This  etiological  problem,  so  fufl  of  interest,  is  not  solved. 
One  step  more,  and  probably  one  step  only,  remains  to  be  taken.  We  look  to  the 
medical  geologist,  for  its  complete  solution ;  and  I  trust  that,  now,  we  have  not  long 
to  look.  The  deleterious  agent  has  been  traced,  with  tolerable  certainty,  to  water : 
and  hence  to  some  element  of  the  soil  washed  by  that  water.  And  if  what  at  present 
is  probable  only,  shall  hereafter  be  proved, — namely,  that  the  hidden  cause  of  goitre 
and  of  cretinism  lurks  in  some  chemical  quality  of  man's  natural  beverage — it  can 
scarcely  be  doubled  that  chemistry  will  be  found  ready  to  supply  a  simple  and  effec- 
tual corrective  of  the  evil.  This  hope  it  is  which  makes  it  so  important  that  medical 
men  should  be  accurately  possessed  of  the  present  state  and  bearings  of  the  ques- 
tion;  and  prepared  to  take  advantage  of  every  opportunity  that  may  arise  from  its 
practical  determination.  For  surely  it  would  be  a  noble  achievement  of  our  art,  and 
a  signal  blessing  provided  for  hundreds  of  human  beings  yet  unborn,  thus  to  prevent 
the  deformity,  the  discomfort,  and  sometimes  the  danger,  of  bronchocele ;  and  to 
forbid,  in  its  very  source. and  fountain,  the  more  hideous  and  loathsome  disfigurement 
of  mind  as  well  as  of  body  that  distinguishes  the  wretched  cretin. 

i  ought,  perhaps,  to  tell  you,  that  other  causes,  many  of  them  very  vague  and  un 
satisfactory,  have,  at  different  times,  been  assigned.  Thus  Valentin  supposes  the 
disease  to  be  more  common  in  women  than  in  men,  simj)ly  because  women  more 
frequently  have  the  neck  uncovered.  It  has  been  affirmed  that  young  females  who 
have  taken  the  veil  in  Catholic  countries  have  lost  their  goitres  in  consequence  of  the 
change  then  made  in  their  costume ;  and  a  medical  man  in  Guatimala  asserts  that 


476  CRETINISM. 

the  same  infirmity  has  sensibly  diminished  among  the  men  in  that  part  of  the  world, 
since  cravats  became  fashionable  there.  These  views  of  the  matter  accord  with  some 
whimsical  notions  entertained  by  the  late  Sir  Anthony  Carlisle.  He  held  that  the 
chief  purpose  of  the  thyreoid  gland  was  to  protect  the  delicate  organ  of  the  voicu 
from  the  injurious  influence  of  cold ;  and  he  consequently  regarded  the  tumour  of 
bronchocele  as  being  rather  of  a  sanative  than  of  a  morbid  nature.  He  looked  upon  it 
as  an  additional  greatcoat  thrown  over  the  important  instrument  of  speech,  in  circum- 
stances of  extraordinary  need.  His  theory  agrees  with  some  of  the  facts  on  which 
other  theories,  not  perhaps  more  plausible,  have  been  founded.  Thus,  although 
snow  water  may  not  be,  indeed  I  may  say  certainly  is  not,  the  cause  of  bronchocele 
from  any  pecuhar  quality  that  belongs  to  it,  yet  the  disorder  is  confessedly  frequent 
in  many  places  where  snow  water  is  habitually  drunk ;  i.  e.,  as  Sir  Anthony  would 
have  reasoned,  where  very  cold  water  is  frequently  drunk ;  the  swelling  being  a 
provision  of  nature  to  obviate  the  hurtful  effects  which  might  else  be  produced  on 
the  larynx  by  these  cold  potations.  The  summer  change  for  the  better,  described 
by  Dr.  Richardson,  consists  also  with  the  same  theorj'^ ;  which  would  suggest  the 
covering  an  incipient  bronchocele  continually  with  warm  clothing,  such  as  flannel, 
to  check  its  growth,  to  obviate  its  necessity,  and  so  gradually  to  occasion  its  subsi- 
dence. And  this  plan  is  mentioned,  I  see,  by  Bouillaud,  among  the  curative  indi- 
cations. 

I  mention  these  theories,  not  because  I  have  any  faith  in  them  myself,  but  as  being 
curious  specimens  of  the  manner  in  which  the  human  mind  strives  to  account  for 
obscure  phenomena ;  and  as  showing  how  readily  facts  may  be  called  '»,nd  pressed 
into  the  service  of  very  slender  and  infirm  hypotheses. 

One  very  important  point  in  the  treatment  of  bronchocele  is  obvious  ;  the  removal 
of  the  patient,  if  that  can  be  done,  from  the  infected  locality.  When  this  has  been 
effected,  or  when  the  disorder  occurs  sporadically,  as  it  sometimes  does,  we  may 
administer  drugs  with  better  hope  and  advantage.  Now  a  great  variety  of  empirical 
remedies  have  been  recommended  for  the  cure  of  bronchocele,  concerning  most  of 
which  it  would  be  a  waste  of  time  for  me  to  speak  at  all.  The  remedy  which,  as 
an  internal  medicine,  has  of  late  years  superseded  all  others,  and  acquired  the  repu- 
tation of  a  specific  against  goitre,  is  iodine :  and  it  certainly  has  a  remarkable  influ- 
ence over  the  genuine  unmixed  form  of  the  disease,  whether  endemic  or  sporadic — 
the  hypertrophied  gland  ;  yet  it  does  not,  perhaps,  merit  the  title  of  specific  in  the 
same  absolute  sense  as  that  in  which  we  say  that  bark  is  a  specific  for  the  ague,  or 
sulphur  for  the  itch.  Dr.  Coindet,  of  Geneva,  was  the  first  who  made  this  remedy 
extensively  known.  Dr.  Slraub,  however,  of  Hofwyl,  has  laid  claim  to  the  priority 
of  its  use.  Probably  that  happened  in  this  matter,  which  has  often  happened  in 
others,  viz.,  that  the  slate  of  knowledge  was  ripe  for  such  a  discovery,  and  it  was 
made  by  each  of  these  physicians  independently  of  the  other.  Dr.  Coindet's  name, 
however,  has  been  inseparably  connected  with  the  application  of  iodine  to  the  cure 
of  bronchocele,  in  a  work  which,  if  he  had  no  other  claim  to  be  remembered,  would 
immortalize  his  lOcmory ; — I  mean  Sir  J.  Herschel's  profound  and  beautiful  Dis- 
course on  the  Study  of  Natural  Philosophy ; — a  book  which  I  should  advise  those 
among  you  who  have  not  already  read  it,  to  make  themselves  master  of  as  soon  as 
they  have  leisure  to  do  so.  He  thus  strikingly  illustrates  an  observation  of  his  own, 
that  mighty  benefits  often  accrue  to  science  from  the  casual  experience  of  even  un- 
scientific or  iUiterate  persons.  "A  soap  manufacturer  remarks  that  the  residuum  of 
his  ley,  when  exhausted  of  the  alkali  for  which  he  employs  it,  produces  a  corrosion 
of  the  copper  boiler,  for  which  he  cannot  account.  He  puts  it  into  the  hands  of  a 
scientific  chemist  for  analysis:  and  the  result  is  the  discovery  of  one  of  the  most 
singular  and  important  chemical  elements — iodine.  The  properties  of  this  being 
studied,  are  found  to  occur  most  appositely  in  illustration  and  support  of  a  variet}'  of 
new,  curious,  and  instructive  views  then  gaining  ground  in  chemistry;  and  thus 
exercise  a  marked  influence  over  the  whole  body  of  that  science.  Curiosity  is 
excited  ;  the  origin  of  the  new  substance  is  traced  to  the  sea  plants  from  whose 
ashes  the  principal  ingredient  of  soap  is  obtained ;  and  ultimately  to  the  sea-water 
Itself.     It  is  thence  hunted  through  nature,  discovered  in  salt-mines  and  springs,  and 


I 


TREATMENT.  477 

pursued  into  all  bodies  which  have  a  marine  origin  :  among  the  rest  into  sponge.  A 
raedical  practitioner,  Dr.  Coindet,  of  Geneva,  then  calls  to  mind  a  reputed  remedy 
for  the  cure  of  one  of  the  most  grievous  and  unsightly  disorders  to  which  the  human 
species  is  subject,  the  goitre ;  which  infests  the  inhabitants  of  mountainous  districts 
to  an  extent  that,  in  this  favoured  land,  we  liave  happily  no  experience  of,  and  which 
was  said  to  have  been  originally  cured  by  the  ashes  of  burnt  sponge.  Led  by  this 
indication,  he  tries  the  effect  of  iodine  on  that  complaint,  and  the  result  establishes 
the  extraordinary  fact  that  this  singular  substance,  taken  as  a  medicine,  acts  with  the 
utmost  promptitude  and  energy  on  goitre,  dissipating  the  largest  and  most  inveterate 
in  a  short  time,  and  acting  (of  course,  hke  all  medicines,  even  the  most  approved, 
with  occasional  failures)  as  a  specific,  or  natural  antagonist,  against  that  odious 
deformity." 

It  is  curious  enough,  and  marks  the  accuracy  with  which  the  effects  of  remedies 
may  be  observed,  that  not  only  had  burnt  sponge  been  found  efficacious  in  removing 
bronchocele,  but  the  bladdervvrack  also,  the  fucus  vesiculosus,  the  plant  that,  with 
others  of  the  same  family,  yields  the  soda  wherewith  the  iodine  was  found  combined. 
Dr.  Gairdner,  who  v^'as  the  first  I  believe  in  this  country  to  write  on  the  effects  of 
iodine,  accounts  for  the  frequent  failure  of  even  large  doses  of  the  burnt  sponge,  by 
showing  that  it  was  much  adulterated  with  charcoal.  Dr.  Manson,  of  Nottingham, 
has  published  the  following  tabular  statement  of  the  results  of  the  employment  of 
iodine  by  himself.  He  had  treated  one  hundred  and  sixteen  patients,  of  whom  fif- 
teen were  men,  and  the  rest  women.  Of  the  fifteen  men,  ten  were  cured,  three 
were  improving  and  under  treatment  at  the  time  of  his  publication,  one  was  dismissed 
for  irregular  attendance,  and  one  was  much  reheved.  Of  the  one  hundred  and  one 
women,  sixty-six  were  cured,  nine  much  relieved,  two  received  no  benefit,  ten  were 
discharged  for  irregular  attendance,  and  fourteen  were  improving  under  treatment. 
Of  the  whole  one  hundred  and  sixteen,  therefore,  there  were  seventy-six  positive 
cures,  or  two-thirds  of  the  entire  number;  and  only  two  positive  failures.  Dr.  Coin- 
det was  successful  in  about  the  same  proportion  of  cases.  This  is  strong  evidence 
of  the  power  of  the  remedy.  Dr.  Manson  found  that  in  some,  but  not  in  all  indivi- 
duals, after  the  preparations  of  iodine  had  been  given  internally  for  a  certain  time, 
they  were  apt  to  occasion  headache,  giddiness,  sickness  of  stomach,  with  some  degree 
of  languor,  and  inaptitude  for  exertion.  His  plan  in  such  cases  was  to  suspend  the 
use  of  the  medicine,  or  to  reduce  the  dose.  The  following  effects  of  the  iodine  are 
stated  by  Dr.  Coindet  as  having  occurred  in  his  practice : — Acceleration  of  the 
pulse,  palpitation,  dry  cough,  watchfulness,  marasmus,  and  prostration  of  strength. 
Sometimes  swelling  of  the  legs,  tremors,  painful  hardness  of  the  bronchocele,  dimi- 
nution of  the  breasts,  or  a  remarkable  increase  of  appetite  supervened ;  and  he  adds, 
that  in  almost  all  the  instances  which  he  had  observed,  a  very  rapid  diminution,  or  a 
disappearance  more  or  less  complete,  took  place,  during  these  symptoms,  of  even 
hard,  bulky,  and  old  bronchoceles.  His  doses  varied  I'rom  somewhat  less  than  a 
grain  to  somewhat  more  than  a  grain  and  a  half.  This  was  certainly,  as  Dr.  Manson 
has  suggested,  too  large  a  quantity  of  this  powerful  drug  for  the  generality  of  patients. 
The  management  of  the  remedy  is  now  belter  understood.  I  have  never  seen  any 
of  tlie  unpleasant  consequences  enumerated  by  Dr.  Coindet.  These  practitioners 
gave  the  iodine  in  the  form  of  a  tincture.  But  this  is  a  bad  mode  of  exhibiting  it  " 
for  the  tincture  is  decomposed  in  any  aqueous  menstruum,  and  the  vidine  thrown  down 
to  the  bottom.  Under  such  circumstances  the  patient  may  at  one  time  get  no  iodine 
at  all,  and  at  another  time  a  dangerous  dose :  for  you  are  aware  that  iodine  is  an  ac- 
tive irritant  poison.  But  if  you  mix  iodine  with  iodide  of  potassium,  it  is  then  held 
in  solution :  and  this  is  the  form  in  which  it  is  now  commonly  given.  In  the  last 
edition  of  the  Pharmafioposia  there  is  a  Liquor  Fotassii  lodidi  compositus,  made 
by  dissolving  five  grains  of  iodine,  and  ten  of  the  iodide  of  potassium,  in  a  pint  of 
distilled  water.  This  will  doubtless,  in  future,  be  much  prescribed.  It  is  a  dilute 
preparation.  There  is  one  grain  of  iodine  in  four  ounces  of  the  liquor.  An  ounce 
would,  therefore,  be  a  very  sufe  dose,  but  you  may  begin  with  a  couple  of  drachms, 
and  hxcrease  the  quantity,  if  need  be,  gradually  :  for  not  only  Dr.  Manson,  but  Dr 
Copland  also,  who  states  that  the  remedy  has  been  very  successful  in  his  hands 


478  BRONCHOCELE. 

adv^ocates  small,  unirritating,  what  are  sometimes  called  alterative  doses.  Simple 
friction  is  said  to  have  had  the  effect  of  diminishing  the  tumour;  and  friction  with 
some  ointment  or  Jiniment  containing  iodine  should  be  employed  whenever  the  inter- 
nal exhibition  of  the  remedy  is  contra-indicated:  or  in  addition  io  its  internal  use. 
There  is  an  authorized  form  for  that  purpose  also  in  the  Pharmacopoeia — the  Uru 
gucntinn  lodini  Composition.  A  small  portion  of  this  may  be  rubbed  upon  the 
tumour  night  and  morning.  I  need  not  add  that  besides  great  care  in  watching 
for  the  specific  ill  efft^cts  of  the  iodine  upon  the  system,  no  less  care  is  to  be  taken 
in  correcting  the  state  of  any  other  function  which  may  be  faulty,  and  in  improving 
the  general  health. 

Such  is  the  best  medical  treatment  of  bronchocele  ;  and  such  is  the  plan  which 
you  will  always  do  well  to  make  cautious  trial  of  in  the  first  instance :  and  with  re- 
spect to  surgical  treatment  I  may  observe,  that  so  long  as  the  disease  is  merely  a 
deformity,  so  long  as  it  does  not  interfere  with  any  of  the  important  functions  of  the 
body,  nor  produce  serious  discomfort — does  not  distress  the  respiration  by  pressing 
upon  the  trachea,  nor  impede  deglutition  by  pressing  upon  the  oesophagus,  nor  de- 
range to  any  great  degree  the  circulation  through  the  head  by  pressing  upon  the 
great  blood-vessels  of  the  neck,  nor  grievously  encumber  the  patient  by  its  weight — 
we  should  not  be  justified  (in  my  opinion)  in  performing  or  advising  any  surgical 
operation  for  the  removal  or  the  diminution  of  the  tumour.  Of  such  operations  the 
three  principal  are,  extirpation  of  the  whole  gland ;  the  passing  a  seton  through  the 
tumour,  and  so  exciting  suppuration  in  it,  whereby  its  substance  is  broken  down  and 
destroyed ;  and,  tying  the  arteries  which  supply  it  with  blood.  The  first  of  these 
methods,  extirpation,  has  been  performed  when  the  wen  was  small ;  but  few  patients 
imder  such  circumstances  would  consent  to  the  operation ;  and  few  surgeons  would 
now-a-days,  I  presume,  advise  or  undertake  it;  and  in  cases  where  it  might  seem 
more  expedient,  that  is,  where  the  swelling  is  large,  and  suffocation  is  threatened  by 
its  pressure  on  the  trachea,  the  execution  of  this  measure  would  be  exceedingly  diffi- 
cult and  dangerous  ;  for  the  arteries  are  so  much  dilated  in  these  cases  that  perilous 
hemorrhage  might  be  expected  from  their  division,  especially  when  their  close  vicinity 
to  the  carotids  is  considered.  Such  large  goitres  come  to  involve  also,  by  their  lateral 
extension,  very  important  nerves  there  situated.  In  one  case  where  excision  was 
attempted,  the  hemorrhage  was  so  alarming  that  the  surgeon  was  obliged  to  desist  in 
the  middle  of  his  task ;  and  the  patient  actually  died  of  hemorrhage  a  few  days 
afterwards.  I  believe  that  this  operation  may  be  considered  as  wholly  abandoned 
by  surgeons  in  the  present  day. 

The  introduction  of  a  seton  into  the  tumour  has  been  more  successful.  This  prac- 
tice was  revived  som.ewhat  more  than  twenty  years  ago  by  Dr.  Quadri,  of  Naples ; 
who  supposed,  indeed,  that  he  had  been  the  first  to  devise  it.  You  will  find  an 
account  of  his  mode  of  proceeding  in  the  tenth  volume  of  the  Medico-Chirurgical 
Transactions,  by  Dr.  Somerville.  The  seton  is  passed  through  the  substance  of  the 
gland,  and  retained  there  a  considerable  time ;  the  chief  caution  necessary  is  to 
avoid  the  enlarged  blood-vessels.  Dr.  Quadri  affirms  that  the  larger  trunks  of  the 
thyreoid  arteries  will  not  be  endangered  unless  the  seton  needle  be  passed  so  deeply 
as  almost  to  touch  the  thyreoid  cartilage ;  and  that  hemorrhage  from  any  of  the 
branches  of  those  arteries  that  may  be  wounded  when  the  seton  is  inserted  more 
superficially,  will  not  be  attended  with  hazard.  This  plan  was  followed  in  one  case 
by  ulceration  and  sloughing,  and  the  patient  died.  An  example  of  the  success  of 
this  treatment  occurred  in  the  practice  of  Mr.  James,  of  Exeter ;  the  tumour  was 
almost  entirely  removed,  and  the  patient  was  for  some  time  in  London  for  the  pur- 
pose of  showing  himself  to  the  medical  men  here.  But  he  also  had  passed  through 
a  good  deal  of  suffering  and  peril. 

The  expedient  of  tying  one  or  more  of  the  thyreoideal  arteries,  and  so  starving 
the  tumour,  has  been  attended  with  varied  success.  It  has  been  done  on  the  conti- 
nent ;  and  several  times  in  this  country :  there  is  a  case  of  it  by  Mr.  Coates,  of  Sahs- 
bury,  in  the  same  volume  of  the  Medico-Chirurgical  Transactions.  His  patient 
Wds  nmch  relieved  for  a  time,  and  supposed  herself  cured.  But  the  tumour  gradually 
returned,  and  caused  her  death  by  suffocation.     Sir  B.  Brodie  has  also  performed  a 


I 


CYNANCHE    PAROTID^A.  479 

«milar  operation  ;  and  I  have  myself  seen  one  very  satisfactory  instance  of  the  rame 
thing,  the  operation  having  been  done  by  the  late  Mr.  Earle,  in  St.  Bartholomew's 
Hospital.  The  patient  was  a  young  woman  with  an  immense  bronchocele,  which 
for  some  time  previously  had  obstructed  her  breathing,  and  of  which  the  effect  on 
the  trachea  seemed  to  be  every  day  increasing.  There  was  loud  wheezing,  and  great 
difficulty  of  respiration,  and  cough,  and  extreme  emaciation :  and  it  was  plain  that 
the  girl  must  soon  die  suffocated  if  nothing  were  done  for  her  relief.  One  of  the 
arteries,  I  think  the  superior  thyreoidal,  was  tied,  without  much  difficuhy,  on  one  side. 
After  the  operation,  the  tumour  on  that  side  shrunk  considerably ;  the  distress  of 
breathing  was  removed ;  and  the  patient  presently  recovered  so  much  of  her  former 
strength,  and  flesh,  and  comfort,  that  she  was  unwilling  to  have  any  thino-  more 
attempted,  and  left  the  hospital.  After  some  time,  however,  she  came  back  ao-ain  of 
her  own  accord,  and  requested  that  the  artery  on  the  other  side  might  be  tied  also. 
This  was  accordingly  done,  and  a  further  reduction  of  the  tumour  took  place.  The 
shrinking,  however,  if  I  remember  rightly,  was  not  so  striking  or  complete  after  the 
second  operation  as  after  the  first :  but  the  patient  was  certainly  rescued,  upon  the 
whole,  from  imminent  death,  and  put  into  a  condition  of  ease  and  at  least  temporary 
safety  ;  the  tumour  that  remained  constituting  merely  a  deformity.  I  never  heard 
of  her  afterwards.  In  a  case  very  similar  to  this,  related  by  Mr.  Crawford  in  the 
Cijdopsedia  of  Praclkal  Medicine,  Mr.  Wickham,  of  Winchester,  tied  one  of  the 
arteries,  with  much  immediate,  but  no  ultimate  benefit.  The  goitre  gradually  dimin- 
ished for  about  six  weeks,  and  then  (in  consequence,  I  presume,  of  the  establish- 
ment of  a  collateral  arterial  circulation)  it  as  gradually  enlarged  again  till  it  was  as 
big  as  ever. 

Of  these  surgical  expedients  there  is  not  one,  of  which  the  average  results  have 
been  sufficiently  prosperous  to  warrant  its  repetition,  except  in  cases  where  life  is 
put  in  jeopardy  or  made  miserable  by  the  swelling;  and  where  other  methods,  and 
particularly  the  treatment  by  iodine,  have  been  tried,  and  have  failed.  One  excep- 
tion, perhaps,  I  should  here  make.  The  tumour  sometimes  evidently  contains  a 
quantity  of  fluid,  either  in  one  of  its  enlarged  cells,  or  in  a  distinct  cyst.  Now  the 
cell,  or  cyst,  may  in  such  cases  be  punctured,  and  the  contained  fluid  let  out,  with- 
out much  risk.  This  was  done  in  one  instance  by.my  colleague,  Mr.  Arnott.  He 
kept  the  orifice  open  ;  and  the  cyst  shrank,  and  Avas  at  last  obliterated,  and  the  wo- 
man was  much  gratified  by  this  diminution  of  her  load. 


LECTURE  XLIV. 

Cynanche  Parotidxa.    Spontaneous  Salivation.    Aphthx.    Cynanche  Tonsillaris. 

The  Greek  writers  on  medicine  apply  the  terms  awwyxn  and  xway;^?;  to  inflamma- 
tory affections  occurring  about  the  throat,  and  more  or  less  interfering  with  the  func- 
tions of  respiration  and  deglutition :  and  the  Latins  employed  the  word  angina  in 
nearly  the  sanrie  sense.  CuUen,  in  his  Nosology,  has  made  a  genus  of  Cynanche, 
although  the  diseases  which  he  has  included  in  that  genus  have  but  little  connection, 
except  that  the  parts  they  occupy  lie  near  to  each  other.  Some  of  them,  indeed, 
have  their  seat  in  different,  though  almost  contiguous,  portions  of  the  same  mem- 
brane;  and  are  apt,  sometimes,  on  that  account,  to  pass  one  into  the  other.  In 
general  they  are  alHed  rather  by  proximity  of  situation  than  by  community  of 
symptoms. 

I  mention  these  things,  because  there  being  a  great  disposition  in  the  present  day 
to  rr-name  diseases,  and  to  affect  a  more  precise  and  scientific  nomenclature  than 
sufficed  for  Cullen,  if  I  adopted  the  more  modern  appellations  without  adverting  to 
the  old  ones,  which  have  been  current  so  many  years,  you  might  experience  some 
difficulty  in  your  reading,  in  determining  wha;  disease  was  intended,  when  it  was 
merely  namrd.     For  my  own  part,  I  think  there  i?  much  inconvenience  in  altering 


480  CYNANCHE    PAROTIDiEA. 

the  established  nomenclature ;  and  especially  in  changing  such  arbitrary  terms  as, 
though  they  may  not  be  scienlijic,  are  yet  definite,  and  convey  no  erroneous  notions 
respecting  the  nature  of  the  disorder.  I  shall  give  you,  however,  in  most  cases,  both 
the  old  and  the  new  denominations. 

Now  one  of  the  maladies  in  Dr.  Cullen's  genus  Cynanche  —  though  not  the  first 
in  the  order  he  follows  —  is  cynanche  purotidsca.  It  is  an  inflammatory  affection  of 
the  salivary  glands,  and  of  the  parotid  gland  in  particular.  Accordingly  it  is  called 
parotUis  now-a-days.  It  is  not,  however,  mere  inflammation  of  the  parotid,  arising 
from  any  cause  whatever;  and  therefore  parotitis,  unless  some  epithet  be  added,  is 
less  exact  than  cynanche  parotidsea.  The  vulgar  have  given  it  just  as  good  an  arbi- 
trary name  as  the  learned  ;  and  they  call  it,  in  this  country,  the  mumps.  AA'ith  the 
Scotch  it  is,  I  believe,  the  branJiS. 

The  disorder  need  not  detain  us  long.  The  parotid  swells ;  tumefaction  takes 
place  beneath  the  ear ;  and  if  the  submaxillary  and  sublingual  glands  are  not  impli- 
cated in  the  outset,  they  soon  participate  in  the  tumefaction,  in  most  instances ;  so 
that  the  swelling  extends  from  beneath  the  ear  along  the  neck,  towards  the  chin,  and 
the  swelled  parts  are  hot  and  painful,  and  very  tender  when  touched.  The  aspect 
of  the  patient  becomes  curiously  deformed.  Sometimes  one  side  only  is  afl^ected  ; 
sometimes  both  sides  at  once  ;  but  most  commonly  of  all,  first  one  side  and  then  the 
other.  These  local  symptoms  are  attended  with  slight  fever.  But  the  only  func 
tion  that  is  materially  affected  is  the  motion  of  the  lower  jaw,  which  is  impeded  by 
the  swelling.  The  inflammatory  condition  almost  always  terminates  after  a  few 
days,  in  resolution,  under  the  use  of  the  antiphlogistic  regimen,  and  the  application 
of  external  warmth.  The  disease  reaches  its  height  in  about  four  days,  and  then 
begins  to  decline  ;  and  its  whole  duration  may  be  stated,  on  an  average,  at  eight  or 
ten  days. 

This  complaint  often  prevails  epidemically  :  when  it  afTects  one  person  in  a  family. 
or  school,  it  usually  aflects  several  others,  simultaneously  or  in  succession,  ft  chiefly 
attacks  children  and  young  persons.  There  can  be  no  doubt  that  it  spreads  by  con- 
tagion ;  and  it  seldom  happens  that  the  same  person  is  twice  affected  by  the  mumps. 
These  are  remarkable  circumstances,  and  give  the  malady  a  peculiar  and  specific 
character.  I  do  not  dwell  upon  them  now,  because  they  beking  also  to  a  very 
interesting  group  of  diseases,  M-hich  will  require  to  be  particularly  considered 
hereafter. 

Another  curious  circumstance  connected  with  the  disease,  and  one  which  has 
some  bearing  upon  its  treatment,  is  that,  in  many  cases,  upon  the  subsidence  of  the 
swelling  of  the  neck  and  throat,  and  particularly  when  it  subsides  quickly,  the  testir 
cles,  in  the  male  sex,  become  swollen  and  tender,  and  the  inummx  in  the  female. 
It  is  said,  but  I  do  not  know  whether  the  observation  be  constantly  true,  that  the 
testicle,  or  the  breast,  of  tJie  same  side  Avith  the  inflamed  parotid,  suffers.  Some- 
times the  testicle  wastes  a-vay  after  the  swelling  recedes;  a  circumstance  which  is 
known  occasionally  to  happen  when  inflammation  of  that  part  arises  from  other 
causes.  This,  however,  is  not  usual.  In  general  the  inflammation  subsides  and 
ceases  in  the  one  gland  as  it  does  in  the  other;  the  swelling  is  neither  very  painful 
nor  long  continued.  But  sometimes  a  more  serious  transference  takes  place,  from 
the  testicle  to  the  brain  :  this  I  have  never  witnessed  ;  but  then,  to  say  the  truth,  I 
have  not  often  been  called  upon  to  treat  the  mumps,  and  my  personal  experience  of 
it  is  limited.  I  find  it  stated  that  the  metastasis  to  the  testicle  is  considered  as  rather 
a  fortunate  circumstance,  because  it  serves  as  a  sort  of  protection  against  metastasis 
to  ihe  brain  ;  but  I  suspect  this  to  be  a  mistake.  Inflammation  of  the  brain,  or  of 
its  membranes,  has  sometimes  occurred  on  the  disappearance  of  the  parotid  swell- 
incf :  but  it  has  much  oftener  supervened,  I  believe,  upon  the  retrocession  of  the 
inflammation  from  the  testicle  or  mamma.  It  is  said  also  that  the  inflammation 
sometimes  rtr-iurns  from  the  testicle  to  the  parotid,  and  back  again  ;  oscillating  thus 
two  or  three  times  between  the  two  glands.  Fortunately,  the  metastasis  to  the  brain 
iS  much  more  rare  than  that  to  the  testicle. 

The  treatment  of  the  mumps  is  simple.  It  consists  in  the  observance  of  the  anti- 
pnlogistic  regimen  ;  mild  diaphoretics ;  laxative  medicines,  if  the  head  aches,  or  the 


SPONTANEOUS    SALIVATION.  •^l' 

bowels  are  confined  ;  and  warm  fomentations,  or  dry  warm  flannel,  to  the  neck  and 
throat.  The  tendency  observed  in  this  complaint  to  a  change  of  place — to  metastasis 
to  more  important  organs — forbids  us  from  using  very  active  measures  to  check  or 
fiiibdue  the  inllammalion.  Nor  are  such  measures  necessary.  We  are  not  to  bleed, 
nor  violently  to  purge  such  patients,  nor  to  apply  cold  to  reduce  the  sweUing. 
Jjuckily,  hot  applications  are  not  only  the  most  safe  and  proper,  but  the  most  grateful 
also  to  the  feelings  of  the  patient.  If  suppuration  should  ensue — which  is  unusual 
and  unlikely,  but  which  sometimes  does  occur  from  extension  of  the  inflammation  to 
the  neighbouring  areolar  tissue — poultices  must  be  substituted  for  the  fomentation. 
Warm  apphcations,  and  rest  in  the  horizontal  posture  are  to  be  recommended  when 
the  inflammation  leaves  the  salivary  glands,  and  attacks  the  testicles ;  or  if  the  pa- 
tient will  not,  or  cannot,  lie  up,  the  testicle  must  be  supported  by  a  suspensory 
bandage — a  bag-truss.  If  the  inflammation  of  the  testicle  or  mammae  be  very  vio- 
lent, we  must  apj)ly  leeches,  and  afterwards  poultices ;  but  this  will  not  often  be 
required,  or  advisable.  Finally,  if  the  inflammation  should  fly  to  the  brain,  we  must 
lay  aside  our  previous  caution,  and  treat  the  disease  in  that  active  manner  which  the 
inflammation  of  so  important  a  part  of  the  body  demands.  No  worse  metastasis  can 
occur  on  the  cessation  of  the  phrenitis.  I  have  fully  spoken  heretofore  of  the  treat- 
ment to  be  pursued  in  that  disease,  and  I  have  nothing  to  add  respecting  it  now, 
except  that  it  may  be  right  as  an  auxiliary  expedient,  to  try  to  reproduce  the  inflam- 
mation in  the  parotid,  or  testicle,  or  mamma,  by  irritating  applications  —  mustard 
poultices,  for  example — in  the  hope  of  thus  producing  what  is  called  revulsion,  and 
of  diveriing  the  disease  from  the  brain  to  the  part  which  it  previously  occupied. 

You  know  that  there  is  another  specific  form  of  parotitis,  which  is  apt  to  be 
induced  by  mercury.  Of  this  I  have  already  spoken.  When  it  is  severe,  it  may 
be  treated  by  leeches,  without  any  dread  of  such  metastasis  as  occurs  in  the  mumps. 
It  is  usually,  though  not  always,  accompanied  by  a  profuse  discharge  of  the  secre- 
tion proper  to  the  glands  affected ;  and  it  is  attended  also  by  sponginess  and  swell- 
ing of  the  gums. 

1  presume  that  when  inflammation  of  these  salivary  glands  is  not  attended  with 
ptyalism,  the  parenchyma  of  the  gland,  or  the  areolar  tissue  which  enters  into  its 
composition,  is  principally  affected  ;  and  that  when  there  is  much  sahvation,  the 
membrane  lining  the  secretory  and  excretory  ducts  is  implicated.  We  see  the  same 
distillations  in  other  analogous  organs. 

Profuse  ptyalism  sometimes  occurs  without  any  obvious  cause,  and  is  then  said  to 
be  idiopathic,  or  spontaneous  :  and  this  is  a  circumstance  which  it  concerns  you  to 
be  aware  of,  both  as  practitioners  and  as  medical  jurists.  The  same  tenderness  and 
swellijig  of  the  salivary  glands,  the  same  copious  secretion  and  excretion  of  saliva, 
nay,  even  the  same  fetor,  or  a  smell  which  can  scarcely  be  distinguished  from  it — 
the  same  collection  of  symptoms  which  is  familiar  to  you  as  indicating  the  specific 
action  of  mercury  upon  the  human  system — will  arise  sometimes  (but  very  rarely) 
when  not  a  particle  of  mercury  has  been  administered.  Several  other  substances 
are  well  known  to  have  the  occasional  efftit  of  producing  an  increased,  and  even  a 
profuse  flow  of  saliva:  preparations,  for  example,  of  gold,  of  copper,  of  antimony, 
and  of  arsenic.  The  cttstor  oil  is  said  to  ha^e  sometimes  the  same  consequence 
Digit?  is  certainly  has ;  and  the  iodide  of  potassium ;  and  sometimes,  I  believe, 
opium.  Now  and  then  ptyalism  is  met  with  as  a  symptom  among  others,  of  preg- 
nancy. Occasionally  it  results  from  some  local  irritation  within  the  mouth  ;  from  a 
decayed  or  misplaced  tooth.  But  what  I  principally  wish  to  call  your  attention  to 
is  the  fact  that  salivation  may  occur  as  an  idiopathic  complaint.  In  the  twenty- 
sixth  volume  of  the  London  Medical  and  Physical  Journal,  there  is  an  instance  of 
it  described  by  Mr.  Davies,  in  which  two  or  three  pints  of  saliva  were  discharged 
daily  for  some  time.  This  flux  at  length  ceased  under  the  use  of  laxative  medicines 
In  the  second  volume  of  the  Transactions  of  the  College  of  Physicians  is  an  extra- 
ordinary example  of  the  same  thing,  related  by  Mr.  Power.  A  young  lady,  of  six- 
teen, spat  from  sixteen  to  forty  ounces  of  saliva  daily  for  upwards  of  two  years.  Mr. 
Power  believed  that  the  ptyalism  in  this  case  was  originally  excited  by  wool,  whicii 
he  found,  in  a  fetid  state,  in  her  ears.  In  the  Revue  Medicale  there  is  an  acccuni 
31  2q 


482  APHTHA. 

given  of  a  patient  who  was  cured  of  a  spontaneous  plyalism  after  spitting  nine  pints 
daily  for  nine  years  and  a  half.  You  may  see  another  instance,  as  related  by  Dr. 
Prout,  in  the  old  series  of  the  Jinnals  of  Philosophy.  Dr.  Pereira  states  that  he 
has  seen  a  dozen  such  cases;  and  he  describes  one  which  was  fatal,  not  from  the 
ptyalism,  however,  but  from  slouohintj  of  the  cheek:  and  this  is  no  uncommon  cir- 
cunistante.  In  certain  cases  of  idiopathic  inflammation  and  ulceration  of  ttie  gums 
or  cheeks,  from  some  constitutional  unsoundness,  there  may  be  extensive  sloughing 
ptyalism,  and  a  very  offensive  odour,  rnuch  resembling  that  which  mercury  pro- 
duces. I  have  met  Avith  one  example  only  of  well-marked  spontaneous  ptyalism ; 
and  some  of  its  circumstances  were  so  peculiar,  that  they  may  be  worth  relating.  1 
was  taken  out  to  Bayswater,  by  a  medical  friend,  in  the  beginning  of  the  year  1833, 
to  see  a  little  girl,  ten  years  old,  who  had  been  in  a  state  of  salivation  from  the  5th 
of  November  in  the  preceding  year.  Up  to  that  time  she  had  been  a  heakhy  lively 
child,  with  nothing  very  remarkable  about  her,  except  that  she  Avas  habitually  sub- 
ject to  profuse  perspirations,  which  had  a  very  acid  smell ;  so  that  the  washerwoman 
was  always  aware  which  were  her  clothes,  when  she  came  to  wash  them,  by  this 
smell.  She  then  sudden!}--  became  indisposed,  had  a  httle  headache,  and  began  to 
spit  a  good  deal.  This  was  noticed  by  her  mother,  and  pointed  out  to  her  medical 
attendant,  before  airy  medicine  was  given  her ;  and  mercury,  on  that  account,  was 
religiously  withheld.  But  in  spite  of  all  treatment  the  ptyalism  went  on  increasing. 
When  I  saw  her  she  was  spitting  three  pints  of  sahva  in  twelve  hours  :  transparent, 
rather  dark-coloured,  and  with  a  small  quantity  of  foam  on  its  surface.  There  was 
nothing  amiss  with  her  teeth,  or  her  gums,  and  no  fetor  of  the  breath.  She  was 
greatly  emaciated,  and  resembled,  in  some  respects,  a  person  worn  down  by  diabetes. 
From  the  very  commencement  of  the  spitting,  the  acid  perspiration  had  ceased,  and 
even  the  vapour  had  failed  to  make  her  sweat.  A  great  variety  of  remedies  were 
tried,  under  Dr.  Nevison's  superintendence,  but  without  the  least  good  effect.  At 
last  came  the  visitation  of  the  influenza,  in  April  of  that  year.  The  girl  became 
severely  affected  by  that  disorder;  and  thereupon  the  salivation  disappeared,  and 
has  not  returned.     I  heard  to-day  that  she  is  in  excellent  health. 

Should  you  meet  with  cases  of  the  same  kind,  you  will  search  for  some  cause  of 
irritation  in  the  neighbourhood  of  the  salivaiy  glands,  and  especially  in  the  state  of 
the  teeth  and  gums ;  and  finding  none,  you  will  seek  further  for  the  cause  of  the 
salivation  in  some  deviation  from  the  natural  condition  of  one  or  other  of  the  principal 
functions  of  the  system :  and  you  will  regulate  your  treatment  acce-dingly.  I  do 
not  know  of  any  specific  plan  of  cure  to  be  recommended  :  but  it  is  certainly  of  im- 
portance that  you  should  be  acquainted  with  the  fact,  that  ptyalism  sometimes  exists 
as  a  separable  and  independent  malady.  Astringent  washes  are  found,  sometimes, 
of  service ;  a  solution  of  alum,  or  the  infusion  of  catechu. 

Before  I  proceed  to  the  diseases  pertaining  to  the  interior  of  the  fauces  and  throat, 
let  me  take  this  opportunity  of  saying  a  few  words  in  respect  to  aphthse.  They 
form  the  characteristic  symptom  of  an  especial  disease  of  infancy:  and  they  are  apt 
to  occur  in  the  course  of  other  diseases  in  adult  age;  and  are  then  of  some  im 
portance  as  guides  in  forming  our  prognosis,  and  even  in  determining  our  plan  of 
treatment. 

AphthfB  consist  in  small,  irregular,  but  usually  roundish  white  specks,  or  patches, 
scattered  over  the  surface  of  the  tongue,  and  the  lining  membrane  of  the  cavity  of 
^he  mouth  and  fauces;  the  angles  of  the  lips,  the  cheeks,  the  palate,  the  pendulous 
velum,  the  tonsils,  the  pharynx.  They  look  like  little  drops  of  tallow,  or  morsels 
of  curd,  sprinkled  over  those  parts;  they  project  a  little  above  the  surrounding  sur- 
face ;  and,  in  fact,  they  are  mostly  formed  by  elevated  portions  of  the  mucous  epi- 
dermis, covering  a  small  quantity  of  a  serous  or  gelatinous  fluid,  which  separates  the 
epidermis  from  the  subjacent  corium.  These  portions  of  the  epidermis  detach 
Jiemselves,  and  fall  off;  leaving  behind  them  a  reddish  raw-looking  surface,  or 
sometimes  a  foul  and  ash-coloured  spot :  and  successive  crops  of  these  aphthae  are 
.ipt  to  be  formed. 

Noxv  children  in  arms  who  exhibit  these  aphthae,  are  said  to  have  the  thrush 


APHTHAE.  483 

This  occurs  at  an  early  age  ;  seldom,  or  never,  I  believe,  after  the  period  of  lacta- 
tion is  over.  The  spots  occasion  some  inconvenience  in  themselves — the  mouth  is 
rendered  hot  and  tender  by  them.  The  child  may  be  eager  enough  to  take  the 
breast,  but  is  observed  to  do  so  with  pain  and  wailing  whenever  the  mouth  is  applied 
to  the  nipple,  and  attempts  to  suck  or  to  swallow  are  made. 

But  these  aphthae,  thus  occurring  in  infants,  are  attended  with  other  symptoms  of 
disorder :  such  as  drowsiness,  sickness,  diarrhoea,  and  some  feverishness.  And  1 
believe,  a  general  notion  prevails,  that  the  same  aphthous  condition  which  is  visible 
in  the  tongue  and  mouth,  pervades,  in  such  cases,  the  whole  of  the  ahmentary  canal. 
But  this  must  be  a  mistake.  That  some  morbid  condition  exists  throughout  that 
tract  is  highly  probable,  but  true  aphthcE  can  only  form  on  those  mucous  surfaces 
which  are  provided  with  a  continuous  epidermis.  This  erroneous  notion  has  been 
strengthened,  perhaps,  by  the  observation  of  aphthous  spots  on  the  pharynx  and 
oesophagus.  The  complaint  sometimes  appears  to  be  the  result  of  improper  diet,  in 
children  brought  up  by  hand;  or  of  milk  of  a  bad  quahty,  from  an  unhealthy  or  in- 
temperate nurse.  It  generally  lasts  eight  or  ten  days.  It  is  not  attended  with  much 
danger,  except  in  certain  cases,  when  the  surface  is  left  brown  or  bluish  after  the 
loosening  and  separation  of  the  crusts.  In  such  cases,  the  local  affection  is  apt  to 
run  into  a  bad  kind  of  gangrenous  ulceration,  and  the  discharges  from  the  bowels 
become  slimy  and  shreddy. 

In  almost  all  instances  of  the  thrush  in  children,  there  is  acidity  of  stomach  present. 
Care,  of  course,  is  to  be  taken  to  discover  and  to  correct  any  error  of  diet ;  and  any 
unwholesomeness  in  the  quahty  of  the  food.  And  antacids  are  to  be  administered. 
I  know  of  no  form  of  medicine  better  adapted  to  remedy  the  diarrhoea  of  infants  than 
the  pulvis  sodse  cum  hi/drai'gijro  of  our  hospital  Pharmacopoeia  ;  composed  of  two 
parts  of  the  pulvis  cretae  compositus,  two  parts  of  the  dried  carbonate  of  soda,  and 
one  part  of  hydrargyrum  cum  creta.  From  three  to  five  grains  of  this  powder  may 
be  given  thrice  daily  :  and  for  the  local  affection  of  the  tongue  and  mouth,  the  mel 
boracis  is  a  capital  application.  It  may  be  painted  on  the  aphthous  parts  with  a 
camel's  hair  pencil. 

Aphthce  occurring  in  adults,  in  the  course  of  other  diseases,  are  often  the  har- 
bingers of  dissolution.  They  denote  considerable  debility  ;  and  they  point  out  the 
propriety  of  sustaining  the  patient's  strength,  by  bark,  wine,  and  nourishing  food.  It 
is  remarkable  how  treatment  of  this  kind  will  sometimes  tell.  I  had  a  patient  last 
summer  who  lived  for  some  months,  and  in  tolerable  comfort,  after  a  second  attack 
of  apoplexy.  Every  now  and  then  he  would  have  a  crop  of  aphthae  appear,  which 
was  always  an  admonition  to  us  that  he  not  only  would  bear,  but  that  he  required 
some  tonic.  A  more  generous  diet,  with  bark,  would  dissipate  them  in  a  day  or 
two. 

Borax  is  an  excellent  application  for  aphthse,  whether  they  occur  in  adults  or  in 
infants.  I  have  known  it  afford  great  comfort  to  patients  who  were  in  the  last  stage 
of  plithisis,  and  to  whom  the  aphthous  state  of  the  mouth  was  a  source  of  consider- 
able distress.  Equal  parts  of  mel  boracis,  and  syrup  of  poppies,  make  a  good  form. 
Or  an  agreeable  as  well  as  useful  gargle  may  be  made  by  mixing  two  drachms  of 
borax,  with  an  ounce  of  mel  rosae,  three  ounces  of  decoction  of  quince  seeds,  and  four 
ounces  of  water. 

Aphthae  seem  sometimes  to  depend  upon  mere  derangement  of  the  stomach.  A 
nobleman  who  is  well  known' as  a  bon  vivant,  can  never  eat  shell-fish  (so  I  am  told 
by  his  physician)  without  finding,  within  two  hours,  that  his  mouth  is  full  of  aphthae. 
Even  lobster-sauce  will  serve  him  thus.  I  look  upon  this  as  a  sort  of  internal 
urticaria. 

[The  disease  of  the  mouth  occurring  in  infants  duririgj  the  period  of  suckling,  in  wliich  the 
tongue,  and  the  inner  surface  of  the  lips  and  cheeks  are  covered,  to  a  greater  or  less  extent, 
with  minute  portions  of  a  white  matter  resembling  curd  —  and  which  constitutes  the  tnugttel 
of  tlie  French  writers,  the  thrush  or  children's  sore  mouth  of  nurses,  and  the  aphthcB  lactumiiixi 
and  aphtha  infantiles  of  the  older  physicians,  is  evidently  a  very  distinct  affection  from  the 
aphtha  which  occurs  in  the  adult  as  well  as  in  the  infant.  The  first  depends  upon  an  ery 
thematic  inflammation  of  the  mucous  membrane  of  tlie  mouth,  in  which  an  altered  seoro 


484  APHTHAE. 

lion,  in  the  form  of  small  and  curd-like  particles  or  flocculi,  or,  as  in  other  diphtheritic 
inflammations,  of  large  patches  of  a  soft  pseudo-membranous  matter,  takes  place  upon  the 
surface  of  the  inflamed  membrane.  Upon  the  separation  of  these  morbid  exudations,  the 
membrane  beneath  is  found  to  be  smooth,  and  without  any  solution  of  continuity.  According 
to  Guersent,  the  curd-like  exudation  is  deposited  beneath  the  epithelium,  and  its  separation 
is  consequent  upon  the  rupture  of  the  latter;  Plumbe  is  of  a  similar  opinion  ;  Guyot  and  Bil 
lard,  however,  never  saw  it,  excepting  upon  the  surface  of  tlie  epithelium,  and  this  accords 
Avith  our  own  experience. 

In  mild  cases,  the  inflammation  of  the  mouth  quickly  disappears,  the  particles  of  curdy 
matter  becoming  detached,  fall  oiT,  and  leave  the  membrane  beneath  of  a  smooth  and  healthy 
appearance.  In  other  cases  the  inflammation  continues  for  a  greater  length  of  time  with 
little  abatement:  the  spots  of  curd-like  matter  increase  in  number,  and,  occasionally,  form 
by  their  union  large  patches,  often  of  considerable  thickness — these  patches,  sooner  or  later, 
become  detached  and  fall  off,  and  their  place  is  quickly  supplied  by  a  new  exudation :  and 
this  separation  and  renewal  of  the  patches  continue  as  long  as  the  inflammation  lasts.  In 
some  instances,  the  patches  upon  the  tongue,  lips,  and  cheeks,  coalesce,  and  the  whole  of 
these  parts  become  coated  with  a  whitish,  granulated  crust,  which  not  unfrequently  extends 
into  the  fauces,  pharynx,  and,  occasionally,  into  the  larynx. 

In  situations  where  a  number  of  children  are  crowded  together,  in  ill-ventilated  apart- 
ments, the  patches  of  exudation  acquire  often  a  dark  colour,  the  breath  of  the  infant  becomes 
fetid  —  the  submaxillary  glands  enlarged  and  painful,  the  face  sM-oUen  and  of  a  dusky-red 
hjie  —  the  lips  and  gums  become  tumid,  and  bleed  upon  the  slightest  touch,  vhile  a  fetid 
sanious  saliva  flows  constantly  from  the  mouth.  Diarrhcea  often  attends,  the  discharges  being 
dark-coloured  and  highly  offensive.  The  disease,  in  its  milder  forms,  is  rather  troublesome 
than  dangerous  —  and  it  may  be  removed  very  speedily  by  an  appropriate  treatment;  but 
when  it  is  attended  by  the  symptoms  last  described,  it  is  very  apt  to  terminate  fatally,  death 
being  occasionally  preceded  by  a  deep  comatose  condition. 

There  exists  some  difierence  of  opinion  among  medical  writers  as  to  how  far  the  morbid 
exudation  characteristic  of  this  affection  extends  beyond  the  mouth  and  favices.  It  is  gene- 
rally admitted  that,  in  severe  cases,  it  has  been  found  in  the  oesophagus,  as  far  down  as  its 
cardiac  orifice  :  but,  while  some,  including  Billard,  have  asserted  that  it  has  been  observed 
throughout  the  whole  tract  of  the  alimentary  canal,  others,  with  Veron,  maintain  that,  in  no 
instance  has  it  been  met  with  beyond  the  cesophagus  —  the  curd-like  crusts,  occasionally 
found  in  the  stomach  being,  as  they  suppose,  conveyed  thither  from  the  mouth  by  degluti- 
tion. Guyot  gives  a  case,  in  which  the  disease  was  detected,  after  death,  throughout  nearly 
the  whole  tract  of  the  intestines.  In  the  few  opportunities  we  have  had  of  examining  the 
state  of  the  alimentary  canal  in  infants  who  have  died  whilst  labouring  under  this  disease, 
we  were  unable  to  trace  the  exudation  beyond  the  oesophagus — a  similar  statement  is  made 
by  Dewees  and  Eberle. 

We  are  to  recollect  that  the  disease  just  described  is  the  result  of  an  erythematic  inflam- 
mation of  the  mucous  membrane  of  the  mouth;  aphtha,  however,  are  produced  by  a  follicu- 
lar inflammation  of  the  same  membrane.  This  aflection  is  more  commonly  observed  about 
the  period  of  dentition  than  at  an  earlier  age  —  it  is  particularly  liable  to  occur  in  children 
of  a  lymphatic  temperament,  or  in  whom  htematosis  has  been  rendered  imperfect,  by  impro- 
per or  innutritions  food,  a  damp  and  cold,  or  impure  and  stagnant  atmosphere,  exclusion 
from  the  light,  and  neglect  of  cleanliness.  It  is,  also,  of  very  common  occurrence  during 
most  of  the  chronic  aflections,  especially  of  the  intestinal  canal,  in  persons  of  all  ages. 

In  the  commencement  of  the  disease  the  mucous  membrane  of  the  mouth  becomes  in- 
creased in  redness,  and  upon  the  inner  surface  of  the  lips  and  cheeks,  on  the  sides  and  infe- 
rior surface  of  the  tongue,  and,  occasionally,  over  the  greater  part  of  the  soft  palate,  there 
soon  appear  a  number  of  distinct  white  specks,  M-hicli,  upon  examination,  are  found  to  be 
small  transparent  vesicles,  of  a  grayish  or  whitish  colour,  each  being  surrounded  at  its  base 
by  a  raised,  hard  ring  of  a  red  colour  more  or  less  decided.  These  vesicles  often  occur  in 
groups,  or  they  may  cover  the  whole  of  the  lining  membrane  of  the  mouth  and  fauces;  ex- 
tending, in  some  cases,  into  the  cesophagus,  and  throughout  the  alimentary  canal ;  while  in 
other  cases  they  penetrate  into  the  pharynx,  and,  according  to  some  writers,  into  the  larynx 
and  even  the  trachea.  The  follicular  inflamiuation  will  often  continue  for  some  time,  as 
just  described,  without  making  any  further  progress,  and  it  may  often  be  arrested  before 
ulceration  ensues.  Usually,  however,  the  vesicles  enlarge  in  size,  rupture,  and  give  discharge 
.0  a  whitish  matter;  a  superficial  idcer  now  occurs,  witii  slightly  elevated  edges,  and  sur ' 
rounded  by  a  circle  of  inflammation.  These  ulcers  often  secrete  a  white,  curdy  matter, 
which  adheres,  at  first,  to  their  surface,  but  becomes  subsequently  detached,  and  is  either 
swallowe.!  or  ejected  with  the  saliva.  It  is  often  succeeded  by  a  new  exudation  of  a  simi 
lar  matter,  and  thus,  in  protracted  cases,  the  crusts  of  curdy  matter  are  repeatedly  detached 
and  renewed;  or  only  a  portion  of  the  crusts  are  detached,  while  the  general  layer  of  curdy 
Miatter  remains  adherent,  often  for  weeks.  When  the  aphthous  ulcerations  are  numerous, 
axid  in  close  contact,  this  curd-like  exudation  may  spread  from  one  to  the  other,  and  form  a 


CYNANCHE    TOxNSILLARIS.  485 

'ayor,  often  of  considerable  thickness  and  extent.  Occasionally,  the  exudation  from  the 
ulcers  is  mixed  with  a  small  portion  of  blood  ;  it  then  forms  dark-coloured-crusts,  which  have, 
act  unfreqiiently,  been  mistalcen  for  gangrenous  sloughs. 

Upon  the  subsidence  of  the  inflammation  the  ulcerated  follicles  readily  cicatrize  without 
leaving  any  permanent  scar. 

Occasionally,  particularly  in  children  of  debilitated  habits,  and  who  are  deprived  of  pro- 
per hygienic  influences,  the  aphthous  ulcerations  become  gangrenous,  their  edges  shrink,  and 
assume  a  ragged,  flabby  appearance  ;  a  brownish  slough  forms  in  their  centre,  which,  on 
separating,  leaves  a  granulated  surface  of  a  vermilion  hue  ;  or,  in  place  of  a  slough,  the 
ulcers  become  covered  w^ith  a  brown,  creamy  fluid,  that  exhales  a  very  decided  gangrenous 
odour.  The  parts  surrounding  the  ulcers  become  tumid,  soft,  and  of  a  violet  hue.  From  the 
half-open  mouth  of  the  child  is  discharged  a  ropy,  often  fetid,  saliva.  The  countenance 
becomes  pale  and  puffy;  the  pulse  feeble;  and  the  entire  surface  of  the  body  pallid,  and 
deficient  in  sensibility: — repeated  vomiting,  profuse  diarrhoea,  and  a  tympanitic  condition  of 
the  abdomen,  generally  occur ;  and  occasionally,  hiccup  with  frequent  eructations,  and  the 
patient  finally  dies,  according  to  Billard,  without  febrile  reaction  or  cerebral  excitement. — 
(See  Condie  on  Diseases  of  Children,  page  126  et  seq.) 

Recently,  M.  Gruby  has  attempted  to  show  that,  aphthae  and  muguet  are  invariably  pro- 
duced by  the  development  of  a  cryptogamic  vegetable. 

According  to  tire  researclies  of  this  gentleman,  the  affection  consists,  at  first,  of  small,  coni- 
cal, whitish  elevations,  tv/enty-five  millimetres  in  diameter,  dispersed  over  the  mucous  mem- 
brane of  the  mouth.  These  elevations  quickly  augment  in  size,  and  extend  rapidly  over  the 
adjacent  surface,  until,  finally,  the  whole  of  the  mouth,  fauces,  and  sometimes  the  entire  ex- 
tent of  the  alimentary  canal,  appear  to  be  covered  with  a  pseudo-membranous  layer,  from 
two  to  three  millimetres  thick,  and  strongly  adherent  to  the  subjacent  tissue.  When  a  por- 
tion of  this  substance  was  examined  under  a  microscope,  M.  Gruby  found  it  to  be  composed 
entirely  of  a  collection  of  cryptogamic  plants,  the  roots  of  which,  of  a  cylindrical  form,  trans- 
parent, and  about  one-four  hundred  and  eightieth  part  of  a  millimetre  in  diameter,  are  im- 
planted in  the  cellules  of  the  epithelium.  During  their  development,  projections  from  these 
roots  penetrate  the  entire  series  of  cellules  of  which  the  epithelium  is  composed,  to  arrive  at 
the  free  surface  of  the  mucous  membrane. 

According  to  M.  Gruby,  these  cryptogamic  plants  have  considerable  analogy  with  the  spo- 
rotrichiura  described  by  some  botanists.  Being  very  fragile,  they  become  detached  by  the 
movements  of  the  tongue  and  lips,  and  mixing  with  the  food,  are  carried  into  the  alimentary 
canal,  a  considerable  portion  of  the  mucous  coat  of  which  they  subsequently  cover.  Those 
children  in  whom  this  extension  of  the  disease  takes  jilace  to  any  great  extent,  fall  into  a 
state  of  marasmus,  and  soon  die. 

M.  Gruby,  having  never  detected  in  the  white  substance  of  aphthce  or  muguet  any  thing 
else  than  the  cryptogami  just  described,  and  the  cellules  of  the  epithelium, — there  being,  in 
no  instance,  any  product  of  inflammation  present, — considers  himself  authorized  to  conclude 
that  aphthae  are  neither  more  nor  less  than  a  vegetation  occurring  upon  the  living  mucous 
membrane.  Views  precisely  similar  to  those  of  JNI.  Gruby  have  been  advanced  by  Dr.  Berg, 
of  Stockholm. 

Dr.  Oestorlein  has  also  submitted  the  matter  of  aphtha3  and  muguet  to  microscopic  exami- 
nation, and  has  been  able  to  detect  in  it  a  vegetation  similar  to  that  described  by  the  ob- 
servers just  named.  This  vegetation  he  has  met  with,  however,  only  at  the  period  of  the 
fullest  development  of  the  aphthie  or  muguet,  which  latter  he  considers  to  be  the  product  of 
an  exudation  resulting  from  an  inflammatory  condition  of  the  mucous  nrembrane ;  the  pro- 
duction of  the  confervas  being  purely  accidental.  He  attempted,  repeatedly,  to  transplant 
them  to  other  animal  tissues  or  fluids,  but  without  success. — C.] 

Hard  by  the  salivary  glands  lie  the  tonsils  :  and  one  of  CuUen's  species  of 
cynanche  is  the  cynanche  tonsillaris  ;  in  more  modern  language,  tonsillitis,  or  amyg- 
dalatis  :  or,  in  the  vernacular,  quinsy,  common  inflammatory  sore  throat :  a  disease 
which,  though  internal,  is  yet  within  the  reach  of  our  sight,  and  easily  recognized. 

The  popular  term  quinsy  is  in  truth,  traceable — through  the  French  csqidnancie 
— to  the  scientific  term  cynanche. 

This  common  and  troublesome  disorder  occurs  with  very  unequal  severity  in  dif- 
ferent cases.  The  differences  depend  upon  the  extent  of  the  disease,  and  upon  the 
number  and  variety  of  the  parts  which  it  involves  :  for  it  is  seldom  limited  entirely  to 
the  tonsils,  but  spreads  to  the  uvula,  the  velum  palati,  the  salivary  glands,  the  pha- 
rynx, and  even  to  the  root  of  the  tongue,  and  the  neighbouring  areolar  tissue.  When 
the  inflammation  is  superficial  it  does  not  produce  any  great  distress,  even  though  it 
may  be  diffused.  When  it  penetrates  through  and  beyond  the  mucous  membrane, 
it  is  apt  to  end  in  suppuration,  and  to  harass  the  patient  much  :  the  tonsils  sweJJ  to 

2<i3 


486  CYNAxNCHE    TONSILLARIS. 

an  enormous  size,  and  at  length  deep  abscesses  form  in  them.  The  disease  is  worsl 
of  all  when  the  back  part  of  the  tongue,  and  the  muscular  and  areolar  tissue  there- 
abouts, become  implicated  :  it  may  chance  to  reach  even  the  larynx,  and  then  it 
is  always  and  extremely  perilous. 

Under  its  more  ordinary  forms,  cynanche  tonsillaris  generally  manifests  itself,  at 
first,  by  a  slight  degree  of  uneasiness  and  difficulty  in  swallowing ;  with  a  constant 
dryness  and  sense  of  constriction  in  the  fauces,  and  a  feeling  as  if  some  foreign  sub- 
stance were  sticking  there.  Upon  inspecting  the  throat,  more  or  less  of  inflamma- 
tory redness  and  swelling  is  seen  of  one  or  both  of  the  tonsils.  Sometimes  both  of 
them  are  affected  at  once.  Very  frequently  one  only  is  first  attacked  :  and  the 
swelling  begins  in  the  other  as  it  ceases  in  the  first.  This  is  just  what  occurs  in 
manj^  instances  also  of  cynanche  parotidsea.  The  uvula  is  commonly  enlarged  and 
elongated,  and  of  a  scarlet  colour.  Sometimes  it  drags  upon  the  back  part  of  the 
tongue,  or  dangles  into  the  pharynx,  causing  the  disagreeable  sensation  of  a  foreign 
body  continually  present,  and  provoking,  by  its  mere  contact,  painful  and  fatiguing 
acts  of  deglutition.  More  frequently  the  uvula  may  be  seen  to  be  adherent  to  that 
tonsil  which  is  most  swollen.  The  dryness  of  the  fauces  soon  gives  place  to  a  copi- 
ous secretion  of  transparent  mucus,  which  is  frothy  and  viscid,  and  sticks  to  the  in- 
flamed surface  so  as  to  be  detached  with  difficulty  ;  and  the  patient  is  tormented  by 
continual  and  painful  efforts  to  hawk  up,  or  to  swallow,  this  mucus.  In  an  early 
stage  of  the  disease  opaque  whitish  spots  appear  upon  the  red  tonsil.  They  are  ex- 
udations from  its  surface,  or  the  discharged  contents  of  the  mucous  crypts  there 
situate.  It  is  important  that  you  should  be  aware  of  this,  lest  you  mistake  such 
specks  for  ulcerating  or  sloughing  points,  such  as  occur  in  some  other  affections  of 
the  throat,  but  which  are  not  common  in  the  outset  at  least  of  this. 

When  the  inflammation  is  violent,  the  submaxillary  and  parotid  glands  sometimes 
swell,  and  become  tender  on  pressure  :  and,  less  frequently,  the  patient  is  troubled 
by  profuse  ptyalism.  In  other  words,  the  inflammation  spreads  from  the  tonsils  to 
the  salivary  glands,  and  secondary  parotitis  occurs  ;  sometimes  with  and  sometimes 
without  an  augmentation  of  their  natural  secretion.  Unable,  or  unwilling,  to  swal- 
low the  abundant  saliva,  the  patient  allows  it  to  dribble  from  his  mouth. 

Now  and  then,  although  the  act  of  swallowing  is  difficult  and  painful,  you  per- 
ceive on  looking  into  the  fauces,  no  appearance  which  can  account  for  these  symp- 
toms. The  inflammation  is  seated  lower  down  in  the  throat ;  out  of  sight.  This 
cannot  with  propriety  be  called  cynanche  tonsillaris  ;  indeed,  it  forms  a  distinct  spe- 
cies, the  cynanche  p/utrijngca  of  CuUen.  I  mention  it  here  because  it  really  does 
not  require  any  separate  consideration. 

The  pain  in  cynanche  tonsillaris  is  felt  almost  solely  during  the  act  of  deglutition; 
which  is  difficult  also  from  the  mechanical  narrowing  of  the  passage  by  the  enlarged 
glands.  When  both  tonsils  are  afl^cted  at  once,  and  much  swollen,  they  push  for- 
wards the  anterior  pillars  of  the  velum  palati,  and  project  in  the  shape  of  two  great 
balls  of  flesh,  into  the  arch  of  the  fauces,  so  as  to  leave  a  very  small  space  only  be- 
tw^een  them ;  and  they  sometimes  even  meet  and  touch  each  other,  and  cause  ul- 
ceration by  their  mutual  pressure.  When  attempts  are  made  to  swallow  hquids, 
they  are  apt  to  return  through  the  nose ;  the  backward  passage  can  no  longer  be 
shut  in  consequence  of  the  tumid  and  fixed  condition  of  the  velum  palati.  The  pa- 
tients are  unable  to  swallow  even  soft  solids  ;  indeed  the  pain  of  swallowing  is  so 
great,  that  they  are  not  easily  persuaded  to  try.  In  severe  cases  pain  shoots  from 
the  throat  to  the  ear  along  the  course  of  the  eustachian  tube  ;  and  this  is  considered 
important,  as  being  indicative  of  suppuration.  I  believe  that  suppuration  does  occui 
111  the  majority  of  the  cases  which  are  attended  with  this  symptom.  Sometimes 
there  is  tinnitus  aurium,  and  partial  deafness,  from  the  obstruction  produced  to  the 
passage  of  air  through  the  eustachian  tube  :  either  by  closure  of  its  extremity  in  con- 
.sequence  of  the  swollen  state  of  the  parts  about  it,  or  by  some  thickening  of  its  lining 
membrane  from  an  extension  of  the  inflammation  along  its  channel. 

When  the  inflammation  is  intense,  and  involves  the  root  of  the  tongue,  the  patient 
becomes  unable  to  open  his  mouth  sufficiently  to  allow  the  fauces  to  be  seen ;  and 
the  inflamed  parts  can  be  examined  only  by  means  of  one's  finger.  In  some  instances 


CYNANCHE    TONSILLARIS.  487 

the  power  of  separating  the  jaws  is  so  limited,  as  not  to  admit  the  introduction  of 
the  finger :  and  the  tongue  is  incapable  of  any  motion. 

In  ordinary  cases,  however  severe  the  disease  may  be,  there  is  scarcely  any 
affection  of  the  breathing.  But  the  throat  is  so  blocked  up,  and  the  free  play  of  the 
velum  palati  so  impeded,  that  the  speech  is  altered  ;  becoming  thick,  guttural,  and 
inarticulate.  You  may  often  recognize  the  disease  by  the  peculiar  sound  of  the 
patient's  voice,  without  looking  into  his  throat.  When  the  swelling  of  the  tonsils  is 
very  great,  the  breathing  does  sometimes  become  impaired  ;  and  it  is  in  such  cases 
alone,  or  nearly  in  such  cases  alone,  that  this  disease  is  at  all  alarming. 

Cynanche  tonsillaris  is  commonly  attended,  from  the  very  outset  of  the  inflam- 
mation, by  smart  inflammatory  fever  :  severe  headache  often,  and  a  rapid  pulse,  rising 
to  120  beats  in  the  minute,  or  more.  The  constitutional  disturbance  runs  higher 
than  we  might  have  expected,  considering  the  limited  extent  of  the  local  inflammation, 
and  the  comparatively  small  importance  of  the  part  inflamed.  At  the  same  time 
there  is  very  little  of  that  debility  and  anxiety  which  are  observed,  as  we  shall  see 
hereafter,  in  common  continued  fever. 

The  inflammation  crften  terminates  by  resolution ;  but  when  it  is  violent  or  long- 
continued,  it  very  frequently  leads  to  the  formation  of  pus.  When  the  mucous 
secretion  increases  in  quantity,  and  becomes  less  viscid,  while  the  difliculty  of 
swallowing  diminishes,  and  the  febrile  symptoms  decline,  resolution  may  be  expected. 
Suppuration,  on  the  other  hand,  may  be  looked  for  when  the  inflammation  is  un- 
usually intense,  when,  by  the  swelling  of  the  tonsils,  the  breathing  is  impeded,  when 
a  pulsating  pain  is  felt,  shooting  to  the  ear,  when  the  patient  can  scarcely  open  his 
mouth,  or  protrude  or  move  his  tongue,  when  there  is  more  than  usual  external 
swelling,  and  when  the  symptoms  increase,  or  even  fail  to  remit,  after  five  or  six 
days  have  elapsed.  Rigors  sometimes  accompany  and  announce  the  suppuration  : 
and  afterwards  the  pus  may  be  often  seen  shining  through  the  membrane  covering 
the  tonsils.  In  many  cases,  however,  it  lies  so  deep  that  it  cannot  be  detected  by 
the  most  careful  examination.  At  length  the  little  abscess  bursts ;  and  the  relief 
thereupon  experienced  by  the  patient  is  sudden  and  striking.  All  at  once  the  pain 
ceases:  he  can  swallow,  and  he  feels  himself  well;  and  often  indeed  he  is  well,  or 
nearly  so.  The  matter  discharged  has  always  a  nauseous  taste  and  a  remarkably 
fetid  smell :  and  sometimes  the  fetor,  or  the  ill  taste,  is  the  only  sign,  besides  the 
improvement  in  the  symptoms,  that  indicates  the  rupture  of  the  abscess ;  the  pus 
being  so  small  in  quantity  as  when  mixed  up  with  other  matters,  easily  to  escape 
notice,  or  (what  frequently  happens),  passing  backwards  into  the  stomach  by  an  in- 
voluntary movement  of  deglutition.  Suppuration  sometimes,  but  rarely,  takes  place 
externally,  in  the  areolar  tissue  of  the  neck,  as  well  as  internally. 

The  termination  in  gangrene  is  spoken  of  in  books :  and  it  is  just  possible  :  but  it 
never  happens,  I  imagine,  except  in  unhealthy  constitutions  ;  or  when  tonsiUitis 
occurs  as  a  compUcation  of  more  general  disease,  such  as  scarlet  fever.  It  is  much 
more  common  to  see  repeated  attacks  of  cynanche  tonsillaris  produce  what  used  to 
be  absurdly  called  scirrhus,  a  permanent  enlargement  and  hardening  of  the  tonsils. 
While  they  are  in  this  state,  a  low  kind  of  inflammation  is  very  readily  re-excited  in 
them.  The  enlarged  tonsils  are  generally  irregular,  and  notched ;  something  like 
the  surface  of  a  walnut  shell;  and  a  white  or  yellow  secretion  is  often  to  be  seen 
lying  in  the  hollows.  This  appearance  may  be  easily  mistaken,  by  an  inexperienced 
eye,  for  ulceration. 

There  is  not  much  risk  of  your  confounding  cynanche  tonsillaris  with  any  other 
complaint.  The  various  species  of  cynanche  enumerated  by  CuUen  are  separated 
each  from  the  others  by  certain  broad  lines  of  distinction  :  all  derived,  however,  from 
different  combinations  of  two  symptoms; — dyspnoea  and  dysphagia.  Thus,  in 
cynanche  tonsillaris,  deglutition  alone  is  difHcult ;  and  when  you  look  into  the  ^Jiroar 
you  see  at  once  why  it  is  difficult.  There  is  equal  difficulty  of  swallowing,  and 
equal  freedom  of  respiration,  in  cynanche  pharyngea  ;  but  the  cause  of  the  dysphagia 
is  not  visible.  In  cynanche  trachcalis,  the  respiration  is  much  afl^ected  ;  the  facility 
ot  swallowing  not  affected  at  all.  In  cynanche  laryngea  both  these  functions  are 
implicated;   there  is  difficulty  of  swallowing  as  well  as  difliculty  of  breathing. 


488  CYNANCHE    TONSILLARIS. 

Cynanche  paro/idcca  is  distinguished  by  tlie  absence  of  both  the  symptoms  ;  its  title 
to  the  name  of  cynanche  is  therefore  equivocal.  Many  of  these  points  will  soon 
come  under  our  notice  again. 

Cynanche  tonsillaris  is  supposed  to  be  most  frequent  among  the  young  and 
plethoric.  But  it  certainly  occurs  very  often  also  in  persons  who  are  pale,  and  spare, 
and  feeble;  and  in  those  of  middle  age.  Some  individuals  appear  to  have,  by 
nature,  a  strong  predisposition  to  the  disease  ;  and  in  them  its  attacks  are  more  or 
less  periodical ;  recurring  at  particular  seasons,  and  commonly  during  the  variable 
weather  of  spring  and  autumn.  This  peculiarity  runs  sometimes  in  families. 
The  liability  to  the  complaint  is  also  very  much  increased  by  repetitions  of  the 
attacks. 

The  only  exciting  cause  worth  mentioning,  almost  the  sole  cause  indeed,  is  expo- 
sure to  cold.  Not  unfrequently  it  assails  so  many  persons  at  the  same  time  as  to  be 
epidemic ;  and  for  that  reason  it  has  sometimes  been  thought  contagious.  But  it 
has  no  contagious  property  whatever.  Although  we  often  see  several  members  of 
the  same  family  affected  by  it  at  once,  yet  we  may  learn,  upon  careful  inquiry,  that 
its  commencement  in  the  different  cases  has  been  too  nearly  simultaneous  to  admit 
the  supposition  of  its  having  been  communicated  from  one  to  another.  The  patients 
have  all  been  exposed  to  the  same  unwholesome  influences,  which  operating  upon 
similar  constitutions,  such  as  those  who  are  sprung  from  the  same  parents  may  be 
expected  to  possess,  have  produced  similar  effects.  This  prevalence  of  the  disorder 
at  certain  times  and  places,  is  connected,  no  doubt,  with  some  peculiar  conditions  of 
the  atmosphere. 

The  prognosis  is  almost  always  favourable.  Not  but  what  death  may  be  produced 
by  this  disease,  under  pecuHar  circumstances,  and  when  the  inflammation  is  un- 
usually violent  and  extensive.  The  late  Dr.  Gregory,  of  Edinburgh,  used  to  men- 
tion in  his  lectures  one  instance,  the  only  one  he  had  met  with  among  many  hundred 
cases,  of  death  from  cynanche  tonsillaris.  He  did  not  see  the  patient  till  he  was 
moribund:  and  he  suspected  that  it  was  combined  with  typhus  fever.  The  only 
fatal  case  that  I  ever  witnessed  occurred  some  years  ago  at  the  Middlesex  Hospital, 
in  one  of  my  own  patients.  He  was  a  stout  young  man,  20  years  old,  a  private 
coachman.  The  complaint  was  clearly  traced  to  his  having  got  wet  through,  more 
than  once,  a  day  or  two  before  it  came  on.  Besides  the  ordinary  symptoms  of 
cynanche  tonsillaris,  there  was  great  external  swelling  on  both  sides  of  the  throat, 
and  the  patient  was  unable  either  to  open  his  mouth,  or  to  move  his  tongue.  The 
inflammation  involved  not  the  tonsils  merely,  but  the  base  of  the  tongue,  the  saHvary 
glands,  and  the  surrounding  areolar  tissue.  At  length  suppuration  took  place.  The 
abscess  broke  internally,  and  pointed  also  externally,  just  below  the  symphysis  of 
the  chin,  where  it  was  opened  with  a  lancet.  Two  days  after,  there  was  a  sudden 
gusli  of  blood  from  the  mouth.  So  immovable  were  his  jaws  that  it  was  impossible 
to  determine  from  which  side  the  hemorrhage  proceeded  ;  it  was  stopped,  however, 
apparently  by  the  treatment  adopted.  A  fortnight  later,  the  bleeding  recurred  pro- 
fusely. It  was  now  evident  that  the  blood  was  arterial,  and  that  it  came  from  the 
left  side  of  the  throat.  Preparations  were  made  for  tying  the  common  carotid  on 
the  left  side  ;  but  just  as  the  operation  was  about  to  be  begun,  the  j)atient  expired  in 
our  presence.  His  death  was  shocking,  but  full  of  pathological  interest.  He  did 
not  sink,  as  you  ma}'  have  supposed,  in  the  way  of  syncope,  from  loss  of  blood  ; 
but  by  suffocation.  The  blood  passed  down  the  trachea  and  into  the  lunjjs;  and  he 
had  been  so  weakened  l>y  the  previous  hemorrhage,  that  he  could  not  expel  the 
blood  so  introduced,  which  actually  choked  him.  A  large  clot  was  afterwards  found, 
filling  up  the  wind-pipe.  I  felt  this  man's  pulse  beat  firmly  and  regularly,  for  a 
mmule  perhaps,  after  his  last  effort  to  breathe.  On  examining  the  body  it  was  dis- 
covered that  the  abscess  had  opened  internally  behind  and  below  the  left  tonsil. 
The  lingual  branch  of  the  carotid  artery  crossed  the  site  of  the  abscess;  and  had 
been  severed  and  laid  open  b}''  ulceration.  From  this  vessel  the  fatal  hemorrhage 
had  come. 

It  should  be  borne  in  mind  also,  that  cynanche  tonsillaris  does  sometimes,  by  ex- 
.t'lision  of  the  inflammation  to  the  neighbouring  parts,  superinduce  that  very  formi- 


CYNANCHE    TONSILLARIS. 


489 


(lable  species  of  cynanche,  of  which  I  am  soon  to  speak,  the  cynanche  laryngea. 
All  cases  in  which  the  breathing  is  in  any  degree  affected,  should  excite  suspicion, 
and  strict  scrutiny  ;  although  the  dyspnoea  may  be  produced  by  the  mere  sweUing  of 
the  tonsils. 

You  will  understand,  then,  that  cynanche  tonsillaris  may,  under  unusual  and 
untoward  circumstances,  prove  a  fatal  disease;  but  that  it  is  so  very  rarely  indeed. 
In  almost  all  cases  we  may  say  that  the  life  of  the  patient  is  not  in  danger. 

In  the  uncomplicated  and  milder  form  of  the  disease,  when  the  inflammation  is 
superficial  and  the  fever  slight,  no  great  activity  of  treatment  is  requisite.  The 
patient  should  be  kept  within  doors,  and  even  in  bed:  for  a  troublesome  tendency 
to  a  recurrence  of  the  disorder  may  be  fostered  by  neglect  or  imprudence.  Cooling 
sahne  purgatives  will  be  proper,  and  the  antiphlogistic  regimen.  A  strip  of  flannel 
may  be  put  round  the  neck,  and  some  stimulating  embrocation  applied  to  the  exte- 
rior of  the  throat,  beneath  the  ramus  of  the  jaw  :  the  compound  camphor  liniment  is 
well  adapted  to  this  purpose.  Some  such  plan  as  this  will  generally  suffice,  not 
indeed  to  stop  the  inflammation  of  a  sudden,  nor  to  put  an  end  at  once  to  the  fever, 
but  to  cause  the  complaint  to  run  its  course  evenly,  arid  to  go  on  to  resolution  in  a 
few  days.  Commonly  it  is  not  completely  over  until  both  the  tonsils  have  been 
attacked  in  succession. 

When  you  catch  the  disorder  in  its  very  outset,  I  believe  you  may  sometimes 
succeed  in  cutting  it  short  by  an  emetic:  a  scruple  of  ipecacuanha,  for  example, 
with  a  grain  of  tartarized  antimony.  In  all  cases  it  is  right  to  administer  a  brisk 
purgative. 

A  great  variety  of  astringent,  acid,  and  other  gargles,  have  been  employed  in  this 
disease  ;  and  their  good  elfects  have,  I  apprehend,  been  much  over-rated.  Many 
cases  would  do  quite  as  well,  or  belter,  without  them ;  for  in  the  early  stages  strong 
astringents,  and  the  straining  and  movements  of  the  throat  that  accompany  their  use, 
may  even  be  hurtful,  and  increase  the  pain  and  the  inflammation.  The  only  gargle 
which  I  should  consider  admissible  in  the  commencement  of  the  malady  is  a  gargle 
of  warm  milk  and  water.  I  have  known  of  one  instance  in  which  quinsy  suddenly 
attacked  a  gentleman  who  was  extremely  anxious  to  use  his  throat,  in  public  speak- 
ing, the  next  day.  He  occupied  himself  perpetually,  for  some  hours,  in  this  sort  of 
fomentation  of  the  tonsils  with  hot  water ;  and  with  such  good  effect  that  on  the  day 
following  he  was  able  to  accomplish  his  object.  Still  there  are  cases  in  which,  at 
certain  stages  of  the  disease,  detergent  gargles  are  serviceable,  by  assisting  the  excre- 
tion of  the  mucus  that  collects  in  the  fauces,  and  by  correcting  fetor.  A  weak  solu- 
tion of  chlorine  in  water  answers  well.  In  more  chronic  sore-throats,  stimulatinor 
gargles  may  often  be  employed  with  advantage.  When  the  inflammation  is  violent 
a  slightly  stimulant  linctus  is  preferable;  it  cuts  the  phlegm  as  they  say,  i.  e.,  it 
promotes  its  detachment  and  removal.  Of  this  kind,  currant-jelly  is  one  of  the  best- 
But  far  better  than  any  thing  else,  as  a  local  application  to  the  inflamed  fauces,  is 
the  steam  of  hot  water;  whether  we  are  hoping  for  resolution  of  the  inflammation 
or  whether  we  desire  to  promote  and  hasten  the  process  of  suppuration  already  begun 
The  inhaler  introduced  by  myself  into  the  Mid- 
dlesex Hospital,  and  elsewhere,  though  somewhat 
clumsy  in  appearance,  is  the  most  convenient  and 
effectual  that  I  am  acquainted  with.  I  show  it  to 
you.  It  was  invented  in  Edinburgh  by  a  friend 
of  mine  long  since  dead,  Mr.  Hercy.  It  will  stand 
upon  a  table,  or  lie  upon  a  pillow;  and  a  large 
volume  of  steam  is  carried  inwards  against  the 
fauces  by  the  mere  natural  breathings  of  the  pa- 
tient. Most  of  the  inhaling  machines  that  I  have  1 
seen  require  a  sucking  effort,  like  that  made  in 
smoking  a  pipe  :  an  effort  that  is  apt  to  be  irksome 
and  fatiguing,  especially  in  pulmonary  diseases  ; 

for  some  of  which  this  method  of  applying  vapour  directly  to  the  suffering  part  is  a» 
useful  as  it  is  for  sore-throats. 


490  CYNANCHE    TONSILLARIS. 

Blistering  the  outsidt  of  the  throat  is  a  fa  vol  rite  remedy  with  many.  When 
early  applied,  a  blister  often  does  much  good,  and  probably  prevents  suppuration  in 
some  cases.  But  I  have  found  blisters  of  uncertain  efficacy ;  they  leave  a  mark 
which  lasts  for  some  time,  and  which  patients  of  the  other  sex  are  apt  to  complain 
of.  For  these  reasons  I  prefer  mere  rubefacients  ;  the  liniment  I  mentioned  before, 
or  the  compound  soap  liniment,  or  a  mustard  poultice  folded  between  two  layers  of 
.hin  hnen. 

In  more  severe  cases  leeches  applied  to  the  upper  part  of  the  throat,  just  below 
the  angles  of  the  jaw,  have  been  found  to  give  sensible  relief:  and  in  the  VA'orst 
degrees  of  the  disorder,  when  there  is  much  outward  swelhng,  and  the  jaws  and 
tongue  are  fixed,  leeches  are  absolutely  requisite.  It  may  be  proper  to  take  blood 
from  the  arm  also.  The  necessity  for  active  depletion  must  be  measured  by  the 
severity  of  the  local  symptoms,  the  intensity  of  the  fever,  and  the  general  strength 
and  condition  of  the  patient :  and  of  these  things  a  little  experience  will  teach  you 
to  judge. 

It  is  not  to  be  expected  that  either  leeches  or  blisters  will  be  of  much  use  afier  the 
process  of  suppuration  has  commenced  ;  nay  they  may  sometimes  be  injurious  by 
retarding  it.  it  is  frequently  a  difficult  matter  to  determine  whether  pus  has  yet 
formed  or  not. 

I  have  already  admonished  you  to  make  a  careful  examination  of  the  throat,  and 
to  watch  your  patient  narrowly,  whenever  he  experiences  any  difficulty  of  breathing. 
Dyspnoea  may  be  produced  by  the  mere  swelling  of  the  inflamed  part ;  and  when  it 
concurs  with  much  enlargement  of  the  tonsils  you  had  better  pierce  them  with  the 
lancet.  If  they  contain  matter,  it  will  be  evacuated  ;  and  if  not,  the  bleeding  pro- 
duced by  the  puncture  will  generally  reduce  the  swelling  somewhat,  and  relieve  the 
patient.  There  is  an  instrument  made  on  purpose  for  this  small  operation,  consisting 
of  a  lancet  enclosed  in  a  flat  silver  sheath,  from  the  end  of  which  it  is  made  to  pro- 
trude, to  a  certain  extent  only,  by  pressing  upon  a  spring.  The  instrument  should 
be  directed  towards  the  centre  of  the  fauces,  and  not  outwards,  in  order  to  avoid 
wounding  important  vessels  or  nerves.  Dr.  Cullen  indeed  says,  "this  does  not 
require  much  caution  :"  but  notwithstanding  this  high  authority,  I  must  warn  you 
that  puncturing  or  scarifying  the  tonsils  is  an  operation  not  to  be  carelessly,  or  rashly, 
or  wantonly  performed.  Portal  mentions  a  case  in  which  a  skilful  surgeon,  in  scari- 
fying the  tonsils  of  his  patient,  wounded  as  he  supposes  some  ramification  of  the 
internal  carotid,  and  the  patient  was  presently  dead.  That  artery  lies,  as  you  know, 
very  near  the  tonsil ;  and  only  a  few  years  ago,  in  Ireland,  it  was  struck  by  a  sur- 
jreon  while  scarifying  a  gentleman's  tonsil;  and  the  gentleman  died  in  three  minutes. 
This  I  was  told  by  the  late  Dr.  Barclay.  The  case  I  related  just  now  of  faial  hemor- 
rhage from  the  lingual  artery  points  to  the  same  danger :  and  since  that  case  occurred 
two  others  involving  similar  hazard  have  fallen  under  my  own  notice,  and  impressed 
me  with  a  strong  feeling  of  the  necessity  of  caution.  A  man  was  brought  into  the 
hospital  with  profuse  hemorrhage  from  the  right  tonsil  or  its  immediate  neighbour- 
hood, the  consequence  of  syphilitic  ulceration  of  those  parts.  He  had  lost  ihree  or 
four  quarts  of  blood,  and  was  nearly  dead.  His  life  was  saved  by  Mr.  Mayo,  who 
tied  the  common  carotid  on  that  side. 

Last  February  (1838)  a  boy  from  Harrow  School  was  placed  under  my  care,  in 
whom  cynanche  tonsillaris  came  on  during  convalescence  from  scarlet  fever.  So 
much  swelling  was  there  of  both  tonsils  that  they  met,  and  pushed  the  uvula  out- 
wards before  them,  and  the  breathing  was  much  impeded.  A  surgeon  who  was  in 
attendance  with  me  punctured  the  tonsils.  The  next  day  a  good  deal  of  hemor- 
rhage took  place ;  and  this  recurred,  several  times,  to  a  considerable  and  even  an 
alarming  amount.  When  the  clots  that  formed  were  wiped  away  with  a  sponge, 
he  blood  could  be  seen  welling  out  in  a  little  stream,  wiih  a  pulsating  motion,  from 
a  small  incision  in  the  left  tonsil.  The  hemorrhage  was  ultimately,  after  much  trouble 
and  anxiety,  arrested,  by  applying  a  pencil  of  lunar  caustic  freely,  within  the  bleed- 
ing orifice.  Lint,  wetted  with  the  muriated  tincture  of  iron,  or  with  a  saturated 
Kolution  01  alum,  is  a  fit  application  in  similar  accidenis. 


ACUTE    LARYNGITIS.  491 

Mr.  Lawrence,  who  saw  this  case,  told  me  that  he  once  knew  a  patient  die  of 
Jiemorrhage  from  the  tonsillar  artery. 

1  ought,  perhaps,  here  to  add,  that  very  recently,  Mr.  Joseph  Bell,  of  Barrhead, 
has  strongly  recommended  the  internal  administration  of  powdered  guaiacum,  in 
large  doses,  as  being  almost  specific  in  the  cure  of  cynanche  tonsillaris.  He  gives 
as  much  as  half  a  drachm,  suspended  by  means  of  mucilage,  in  a  draught,  every  six 
lOurs.  Mr.  Bell  has  no  doubt  that  this  remedy,  if  timely  administered,  will  cut  the 
disease  short  in  ninety-nine  cases  out  of  a  hundred.  It  has  been  found  successful  in 
othpr  hands  also.     I  have  never  had  an  opportunity  of  trying  it. 

The  chronic  enlargement  of  the  tonsils,  to  which  I  have  s'l-eady  adverted,  is  some- 
times productive  of  great  inconvenience  and  distress,  and  ev^n  of  danger.  Its  occa- 
sional consequences  are — an  habitual  trouble  in  swallowing;  confused  and  inarticu- 
late speech ;  deafness  in  various  degrees,  from  occlusion  of  the  eustachian  tubes; 
more  or  less  impediment  of  breathing;  and  even  spasm  of  the  glottis,  and  impending 
suffocation.  The  enlargement  may,  in  such  cases,  be  somewhat  reduced,  I  believe, 
by  repeatedly  passing  a  stick  of  lunar  caustic  over  the  surface  of  the  tonsils ;  but  a 
much  readier  and  better  plan  is  to  amputate  them,  in  part  at  least.  This  may  be 
done  by  a  ligature  ;  or  still  better  by  scissors,  or  by  a  sort  of  small  guillotine  invented 
for  that  purpose.  It  is  not  a  very  painful  operation.  Mr.  Arnott  removed  one  lately 
from  one  of  my  hospital  patients;  and  a  very  few  days  ago  (December,  1838)  Mr. 
Mayo  brought  two,  in  a  piece  of  paper,  to  the  hospital.  He  had  just  before  cut 
them  ofT  for  a  patient  whose  respiration  they  had  much  embarrassed. 

[Recently  the  application  to  the  enlarged  tonsils  of  the  iodide  of  zinc,  is  said  to  have  the 
effect  of  causing  their  rapid  absorption.  The  article  is  prepared  by  placing  a  clean  plate 
of  zinc  over  a  jar  or  vial,  and  sprinkling  iodine  over  it.  In  a  short  time  the  iodine  is 
deposited  in  the  vessel,  in  the  form  of  a  semi-fluid  deliquescent  substance.  This  is  to  be 
applied  pure,  to  the  surface  of  the  enlarged  tonsil,  by  means  of  a  earners  hair  pencil,  or  a 
piece  of  sponge,  secured  to  a  suitable  handle.  It  is  to  be  held  on  for  a  short  time,  and  re- 
peated every  two  or  three  days,  until  the  object  is  accomplished.  The  application  is  fol- 
lowed by  a  pimgent  smarting,  which  lasts  for  twenty  or  thirty  minutes,  but  by  no  other 
inconvenience.  Dr.  Goddard,  of  this  city,  we  are  informed  by  Dr.  Parrish,  in  his  annual 
Report  on  Surgery,  read  to  the  College  of  Physicians,  has  used  the  remedy  extensively,  and 
speaks  very  favourably  of  its  effects.  He  has  found  it  to  possess  the  property  of  inducing 
a  rapid  absorption  of  the  enlarged  tonsil,  by  a  sort  of  shrivelling  process,  without  the  forma- 
tion of  a  slough.  It  does  not,  like  the  chloride  of  zinc,  spread  to  the  surrounding  healthy 
structure,  and  hence,  may  be  used  without  the  fear  of  injury  from  being  swallowed.  (Sit»»- 
mary  of  the  Trans,  of  the  College  of  Phijs.,  of  Philadelphia,  No.  vii,  page  191.) — C] 


LECTURE  XLV 

^cute  Laryngitis.     Symptoms.     Treatment ;  Blood-letting.     Tracheotomy,  Mer-' 
cury,  Antimony.     Anatomical  Characters  of  the  Disease.    ^Causes.     Secondary 
Laryngitis.     Oedema  of  the  Glottis.     Chronic  affections  of  the  lAirynx. 

The  disease  of  which  I  have  next  to  speak  is  of  far  more  serious  character  than 
those  which  were  considered  in  the  last  lecture.  Cynanche  laryngea,  or  acute 
laryngitis,  has  proved  rapidly  fatal  in  a  large  proportion  of  the  instances  in  which  it 
has  been  known  to  occur.  Yet,  when  the  patient  is  seen  tolerably  early,  and  the 
nature  of  the  malady  is  clearly  perceived,  and  the  source  of  peril  thoroughly  under- 
stood, I  believe  that  our  art  is  sufficient,  in  most  cases,  to  rescue  the  sufTerer  from 
the  fate  that  hangs  over  him.  It  is  of  the  greatest  importance,  therefore,  that  you 
should  be  able  to  recognize  laryngitis  when  you  meet  with  it,  and  that  you  should 
comprehend  the  principles  according  to  which  it  requires  to  be  treated. 

What  is  laryngitis  ?  It  consists,  as  that  term  implies,  in  inflammation  oi  the  pans 
composing  the  larynx :  and  especially  of  the  mucous  membrane  that  covers  tho 


492  ACUTE    LARYNGITIS. 

laryngeal  cartilages,  including  the  epiglottis.  The  inflammation  may  be,  and  some- 
times is,  exactly  limited  to  the  larynx  ;  but  frequently  it  extends  also  to  the  posterior 
fauces,  the  velum  palati,  and  the  tonsils. 

The  symptoms  of  acute  inflammation  of  the  larynx  are  these.  The  patient  com- 
plains of  sore-throat.  If  you  look  into  his  throat  you  Avill  commonly  perceive  some 
redness  of  the  velum  and  uvula,  and  of  the  fauces  generally.  But  there  is  a  degree 
of  restlessness  and  anxiety  about  tlie  patient  more  than  proportionate  to  the  apparent 
inflammation.  Among  the  earliest  of  the  symptoms  that  bespeak  danger,  and  ought 
to  excite  alarm,  is  difficulty  of  des:httition,  for  Avhich  no  adequate  cause  is  visible  in 
the  fauces;  and  to  this  is  presently  added  difficulty  of  breathing,  for  which  no  ade- 
quate cause  can  be  discovered  in  the  thorax.  The  mode  and  character  of  the  respi- 
ration are  peculiar;  it  is  attended  with  a  throttling  noise;  the  act  of  inspiring  is 
protracted  and  wheezing,  as  though  the  air  was  drawn  in  through  a  dry  narrow  reed. 
If  you  ask  the  patient  what  is  the  seat  of  his  distress,  ivhere  the  disease  is  situated, 
he  points  with  his  finger  to  the  pomum  Adami.  If  he  coughs,  he  coughs  whh  a 
peculiarly  harsh,  stridulous,  husky,  abortive  sound.  He  either  speaks  quite  hoarsely, 
or  (what  is  more  common)  all  power  of  audible  voice  in  the  larynx  is  lost,  and  he 
speaks  by  means  of  his  lips  and  tongue  only,  in  a  whisper.  There  is  tenderness  of 
the  larj'ngeal  cartilages ;  they  are  painful  when  pressed  externally.  The  face  is 
flushed  ;  the  skin  hot  and  dry  ;  the  pulse  hard.  As  the  disorder  advances,  the  pa- 
tient's general  distress  increases ;  but  some  of  the  symptoms  alter;  his  countenance 
becomes  pale  or  livid,  anxious  and  ghastly ;  his  eyes  protrude ;  he  is  miserably  un- 
quiet, impatient  for  some  relief,  declares  or  makes  signs  that  he  wants  air,  and  begs 
that  the  windows  may  be  opened :  and  if  he  does  not  obtain  timely  relief,  he  pe- 
rishes— he  dies  strangled. 

The  pathology  of  this  terrible  disease  is  extremely  simple.  The  membrane 
covering  the  interior  surface  of  the  instrument  of  the  voice  suffers  inflammation. 
One  effect  of  inflammation  in  mucous  membranes  is  a  thickening  of  those  membranes; 
they  become  turgid  and  swollen.  Another  frequent  effect  is  the  effusion  of  serous 
fluid  in  the  subjacent  areolar  tissue.  B}'  such  tumid  thickening  of  its  lining  mem- 
brane, the  chink  called  the  rima  glottidis  is  narrowed  :  it  is  still  further  diminished 
in  breadth  whenever  the  membrane  is  lifted  and  protruded  by  infiltration  of  the  tissue 
beneath  it:  it  is  so  nearly  closed  up,  that  air  cannot  pass  inwards  in  sufficient 
quantity  to  sustain  the  vital  functions:  a  small  portion  only  of  the  blood  returned  to 
the  lungs  from  the  right  side  of  the  heart  undergoes  the  requisite  change  from  venous 
to  arterial.  The  miserable  patient  grows  drowsy  and  delirious,  and  dies  b}^  a  slow 
process  of  strangulation.  If  the  rima  glottidis  becomes  quite  closed  up,  his  suffer- 
ings and  his  life  are  quickly  at  an  end. 

This  disease  affords  a  good  instance  of  a  truth  which  was  announced  in  a  former 
part  of  this  course  of  lectures ;  viz.,  that  the  danger  of  a  morbid  change  may  de- 
pend entirely  upon  its  situation.  It  is  so,  eminently,  with  laryngitis.  The  inflam- 
mation is  sometimes  limited  to  a  spot  of  membrane  not  bigger  than  a  square  inch. 
If  a  square  inch  and  no  more  of  the  same  membrane,  a  little  lower  down,  in  the 
trachea,  were  inflamed  in  the  same  manner  and  degree,  the  complaint  would  be  quite 
unimportant.  Cynanche  laryngea  derives  all  its  peril  from  the  circumstance  that  the 
inflammation  tends  to  shut  up  what  may  well  be  called  the  jamtu  vitsc.  The  part 
afll^cted  subserves  two  purposes :  it  is  the  organ  of  speech  ;  and  it  forms  a  portion 
of  the  channel  through  which  air  is  conveyed  from  without  into  the  lungs.  Both  of 
these  purposes  are  impeded  in  laryngitis.  Now  the  animal  function  of  speech  may 
be  entirely  and  permanently  suspended  without  any  danger  to  life.  The  function  of 
••espiration,  which,  though  under  the  influence  of  the  will,  is  an  organic  function, 
will  not  bear  to  be  suspemled,  even  for  a  few  minutes  ;  and  life  cannot  be  long  sus- 
tained when  it  is  inuch  impeded. 

The  difficulty  of  swallowing  is  a  remarkable  symptom,  and  almost  always  present. 
Yet  it  is  not  absolutely  universal ;  for  Mr.  Lawrence  describes  a  case  in  Avhich  it  did 
not  occur.  It  appears  to  depend,  in  some  measure,  upon  the  tumid  and  tender  con- 
dition of  the  whole  membrane  which  is  common  to  the  larynx  and  pharynx,  and 
■which  is  pressed  upon  as  the  larjmx  rises  in  the  act  of  deglutition  :  but  this  symptom 


ACUTE    LARYNGITIS.  493 

depends  also,  and  in  a  greater  measure,  upon  the  state  of  the  epiglottis,  which  is  often 
enlarged,  and  fixed  by  the  swelling  in  an  erect  position,  and  unable  to  execute  its 
natural  valvular  office ;  so  that  when  the  patient  makes  efforts  to  swallow,  a  portion 
of  the  food  or  drink  gets  into  the  larynx,  and  a  paroxysm  of  choking  dyspnoea  ensues. 
By  pressing  down  the  back  part  of  the  patient's  tongue,  and  getting  him  at  the  same 
moment  to  make  a  coughing  effort,  you  may  sometimes  obtain  a  sight  of  the  tumid, 
red,  and  upright  valve. 

The  dyspnoea  is  constant :  yet  there  are  pauses  of  comparative  ease  and  quiet ; 
and  thert  are,  commonly,  periods  of  severe  aggravation  and  urgent  distress.  It  is 
probable  taat  the  permanent  narrowing  of  the  chink  by  the  inflammation  and  its  con- 
sequences is  from  time  to  time  increased  by  spasmodic  contraction  of  the  muscles 
that  close  the  glottis. 

This  is  the  first  disease  that  has  come  before  us,  in  which  the  respiration  has  been 
primarihj  impeded.  If  you  call  to  mind  what  was  stated  in  one  of  the  early  lectures 
respecting  death  by  apncea,  you  will  be  at  no  loss  to  understand  the  manner  in  which 
life  is  destroyed  in  laryngitis. 

This  formidable  malady  has  always  existed ;  for  you  may  trace  examples  of  it, 
under  various  names,  even  in  the  writings  of  the  ancients.  But  it  is  only  in  recent 
times  that  it  has  been  singled  out  from  the  rest  of  the  angiuce,  and  made  a  separate 
object  of  study.  It  has  numbered  some  distinguished  medical  men  among  its  victims : 
Dr.  David  Pitcairn,  Sir  John  Macnamara  Hayes,  Sir  George  Tuthill.  The  cele- 
orated  General  Washington  died  of  it.  When  it  has  caused  death  it  has  generally 
run  a  rapid  course,  and  proved  fatal  before  the  fifth  day.  It  has  carried  the  patient 
ofT  in  less  than  twelve  hours. 

It  is  of  the  utmost  consequence  to  make  an  accurate  diagnosis.  Laryngitis  is 
easily  distinguished  from  cynanche  tonsillaris  by  the  extreme  and  peculiar  dyspnoea 
which  attends  it.  There  may  be  difficulty  of  breathing  in  the  latter  disease,  from 
enormous  sweUing  of  the  tonsils  ;  but  then  such  swelling  will  mostly  be  visible.  In 
laryngitis  the  marks  of  inflammation  to  be  seen  on  inspection  of  the  fauces  are  gene- 
rally slight  and  trifling,  and  quite  inadequate  to  explain  the  difficulty  of  swallowing. 
Do  not,  however,  forget  that  laryngitis  may  supervene  upon  cynanche  tonsillaris. 
Again,  cynanche  laryngea  is  readily  discriminated  from  cynanche  pharyngea ;  in 
which  complaint  there  is  great  pain  and  difficulty  in  deglutition ;  but  the  breathing 
is  quite  free.  In  cynanche  tracheahs,  or  croup,  which  I  shall  next  describe,  the 
breathing  is  afTected,  and  the  swallowing  is  not. 

What  is  to  be  done  for  a  patient  labouring  under  acute  laryngitis  ?  How  and  when 
tire  we  to  employ  the  great  remedy  for  acute  inflammation— blood-letting  ?  or  are 
we  to  employ  it  at  all  ?  These  are  points  concerning  which  it  is  quite  necessary  that 
your  minds  should  be  prepared  and  prompt  to  decide.  If  you  look  merely  to  the 
results  in  the  recorded  cases  of  this  fearful  complaint,  you  will  scarcely  find  an 
answer  to  the  question.  In  some  of  them  copious  bleeding  appeared  to  save  the 
patients ;  in  others,  it  was  of  no  service,  but  rather  seemed  to  accelerate  their  death. 
Sir  John  Macnamara  Hayes  suffered  two  attacks  of  cynanche  laryngea.  In  the  first 
he  was  freely  bled.  Dr.  Roberts,  of  Bishop  Stortford,  informs  us  that  the  first  bleed 
ing  was  attended  with  considerable  relief;  the  second  also  with  manifest  advantage, 
and  by  the  third,  his  safety  appeared  to  be  ensured.  Fifteen  years  afterwards  he 
died  of  the  same  disorder,  for  which  he  was  again  bled  and  leeched,  under  the  care 
of  the  late  Dr.  Baillie.  Washington  was  largely  bled,  and  died.  Again,  a  Dr. 
Francis,  of  New  York,  recovered  from  acute  laryngitis  after  copious  venaesection. 
It  is  evidently  needful  to  consider  and  determine  the  circumstances  under  which  we 
are  to  use,  or  to  withhold,  the  lancet. 

Bleeding,  to  be  serviceable,  or  safe,  must  be  performed  early.  There  is,  perhaps, 
no  disease  in  wl>ich  the  xatpoj  o|v;,  the  fleeting  opportunity,  is  more  conspicuous  than 
m  this.  When  I  say  that  you  must  bleed  early,  if  at  all,  I  do  not  mean  that  you 
are  to  reckon  so  many  days  or  hours  from  the  commencement  of  the  disorder;  but 
you  must  ascertain  what  progress  it  has  made ;  for  it  travels  sometimes  at  a  railroad- 
pace.  You  must  look  to  your  patient's  actual  condition ;  and  I  apprehend  that  your 
practice,  in  respect  to  blood-letting,  may  be  safely  guided  by  the  following  rules.    If 

2r 


494  ACUTE    LARY.NGITIS. 

there  bo  high  inflammatory  fever  present,  and  the  skin  is  hot,  the  pulse  firm  and 
full,  and  the  cheeks  are  red,  and  the  lips  florid,  you  may  bleed  your  patient  with 
decision  and  advantage.  But  if  his  powers  are  beginning  to  sink  under  the  poison- 
ous influence  of  imperfectly  aerated  blood,  if  his  skin  be  cold,  or  even  cool,  his  face 
pale  or  leaden,  his  lips  blue,  his  pulse  small  and  feeble,  his  mind  wavering — you 
will  do  no  good  by  blood-letting:  nay,  you  will  increase  the  debility  which  already-' 
exists,  and  hasten  the  fatal  catastrophe. 

With  regard  to  local  blood-letting,  and  to  counter-irritation,  there  is  one  remark 
made  by  Dr.  Farre  of  much  practical  importance.  It  is  a  common  practice,  in  affec- 
tions of  the  throat,  to  appl}^  leeches  over  or  near  the  laryngeal  cartilages,  and  after- 
wards to  place  a  blister  there.  Now  serous  infiltration  of  the  neighbouring  parts 
often  follows  leech-bites ;  and  the  effect  of  a  bhster  in  producing  serous  effusion  often 
extends  beyond  the  skin :  and  the  cartilages  of  the  throat  he  very  near  the  surface  ; 
and  it  is  possible  that  cedema  of  the  glottis  might  be  produced,  or  augmented,  in 
consequence  of  these  topical  remedies.  It  will  be  better,  therefore,  when  we  wish 
to  take  blood  locally,  to  take  it  by  cupping  from  the  back  part  of  the  neck  :  and  when 
we  desire  to  produce  counter-irritation,  it  will  be  prudent  to  lay  a  blister  on  the  upper 
part  of  the  sternum,  rather  than  to  the  front  of  the  throat. 

In  the  advanced  stage  of  the  disease,  medicine,  I  fear,  can  effect  but  little. 

But  surgery  may  be  more  successful. 

The  danger  arises  from  the  mechanical  obstacle  to  the  entrance  and  exit  of  air  into 
and  from  the  lungs ;  and  this  state  of  peril  admits  of  a  mechanical  remedy.  If  an 
artificial  opening  be  made  between  the  obstructed  part  and  the  lungs,  the  air  is  again 
freely  inhaled  and  freely  expelled;  the  blood  undergoes  the  vital  change  from  pur- 
ple to  scarlet ;  and  the  patient  is  placed  in  a  condition  of  safety.  He  continues  to 
respire  through  the  hole  thus  drilled  in  the  trachea,  until  the  inflammation  of  the 
larynx  has  subsided  ;  the  thickening  of  the  membrane  disappeared  ;  the  submucous 
infiltration  been  re-absorbed  ;  and  the  vocal  instrument  restored  to  its  natural  integ- 
rity ;  and  then  the  aperture  in  the  wind-pipe  may  be  suffered  to  heal,  and  the  patient 
will  again  draw  his  breath  through  its  natural  channels. 

This  is  one  of  the  triumphs  of  the  healing  art.  It  requires  a  knowledge  of  the 
general  pathology  of  the  disease,  i.  e.,  an  acquaintance  with  the  facts  that  acute  in- 
flammation may  aff'ect  the  larj-nx  almost  exclusively,  and  that  its  tendency  is  to  nar- 
row the  fissure  of  the  glottis,  and  destroy  life  by  suffocation.  It  requires  a  knowledge 
of  the  symptoms  of  such  inflammation :  and  it  requires  an  accurate  knowledge  of 
all  the  essential  circumstances  of  the  particular  case.  For  it  is  not  every  case  in 
which  the  transit  of  air  through  the  slit  in  the  larynx  is  hindered,  that  is  a  fit  case 
for  the  operation  of  tracheotomy.  Some  years  ago  there  was  brought  to  me  by  a 
surgeon  a  man  breathing  with  considerable  labour  and  constraint,  the  air  passing 
through  the  larynx  with  an  audible  hissing  noise.  The  surgeon  wished  to  know  my 
opinion  of  the  propriety  of  opening  the  patient's  wind-pipe.  He  had  come  to  the 
conclusion  that  there  was  ulceration  of  the  membrane  lining  the  larynx,  with  thicken- 
ing; that  the  cause  of  the  sibilous  respiration  was  partly  mechanical,  partly  spasmo- 
dic ;  the  little  muscles  that  close  the  glottis  acting  with  injurious  energy  in  conse- 
quence of  the  neighbouring  irritation :  and  he  thought  that  this  mischief  in  the 
larynx  would  have  a  better  chance  of  being  repaired,  if  the  functions  of  the  organ 
could  be  for  a  lime  suspended.  He  was  aware,  however,  of  the  necessity  of  ascer- 
taining what  was  the  condition  of  the  lungs  ;  and  he  had  not  studied  auscultation 
long  enough  to  trust  his  own  ear  in  that  matter.  The  patient  was  pale  and  thin,  and 
emaciated  ;  and  three  minutes  sufficed  to  convince  me  that  his  lungs  were  exten- 
sively disorganized.  His  respiration  was  not  so  difficult  as  to  threaten  suffocation  ;  he 
was  not  dying  of  the  laryngeal  obstruction  ;  and  I  recommended  that  he  should  not 
be  subjected  to  an  operation  which  might  curtail  his  existence,  but  could  not  effect  a 
■;ure.  The  man  died  soon  after ;  and  we  examined  his  body  together.  There  was, 
as  my  friend  had  supposed,  ulceration  of  the  membrane  near  the  chordce  vocales, 
and  the  lungs  were  full  of  suppurating  or  softening  tubercles.  I  mention  this  case 
to  show  you  that  it  is  necessary  to  ascertain  the  condition  of  the  thorax  generally, 
before  we  perform  or  sanction  such  an  operation  as  tracheotomy.     Not  that  there  is 


ACUTE    LARYNGITIS.  495 

anything  very  formidable,  or  painful,  or  dangerous,  in  the  operation  itself.  But  if 
we  cut  a  hole  in-  a  patient's  throat,  who  is  sure  to  die  soon  after  of  some  other 
incurable  complaint,  we  shall  incur  the  risk  of  being  charged  with  having  killed 
him.  Do  not  misunderstand  me,  however.  If  a  patient's  life  be  threatened  by  acute 
laryngitis,  or  by  laryngeal  oedema,  and  we  are  sure  of  that,  and  if  at  the  same  time 
we  are  sure  that  he  carries  another  mortal  disease  about  him,  we  are  not  for  that 
reason  to  let  him  die,  if  we  can  help  it,  of  the  laryngitis  ;  any  more  than  it  would 
be  'lawful  for  us  to  administer  a  drachm  of  prussic  acid  to  a  man  condemned  to  bo 
hanged  the  next  morning.  But  we  must  state  the  whole  of  the  case  plainly  to  the 
patient's  friends,  and  propose  the  operation  as  a  mode,  not  of  effecting  an  absolute 
cure,  but  of  staving  off  the  immediate  danger. 

And  here  let  me  repair  an  omission  of  which  I  was  guilty  when  speaking  just 
now  of  the  diagnosis.  My  object  was  to  guard  you  against  mistaking  laryngitis  for 
some  other  malady :  but  I  must  also  warn  you  against  the  converse  error,  that  of 
mistaking  some  other  malady  for  acute  laryngitis.  I  can  assure  you  that  such  a 
mistake  has  been  made  ;  and  tracheotomy  has  been  performed,  too,  when  there  was 
no  disease  in  the  larynx ,  and  the  practitioners  by  whose  authority  it  ivas  performed 
have  been  ungenerously  reproached  for  their  error,  although  no  harm  beyond  the 
slight  pain  and  inconvenience  of  the  operation  resulted  from  it.  The  cases  in  which 
this  blunder  has  been  committed  have  nearly  all,  I  believe,  been  cases  of  aneurism 
of  the  thoracic  aorta,  which  by  its  pressure  on  the  first  divisions  of  the  air-passages, 
or  on  the  nerves  thereabouts  distributed,  had  caused  that  kind  of  laboured  andstridu- 
lous  breathing  which  is  characteristic  of  laryngitis.  I  may  venture  to  say  that  no 
person  who  has  had  opportunities  of  educating  his  ear  for  the  purposes  of  ausculta- 
tion, and  has  made  a  proper  use  of  those  opportunities,  could  ever  overlook  such  a 
comphcation  as  this.  I  have  myself  seen  a  woman  (I  mentioned  her  case  before) 
whose  trachea  was  laid  open  by  a  surgeon  while  she  was  suffering  under  mere  hys- 
teria;  so  closely  did  that  disease  mimic  laryngitis. 

When  you  have  good  evidence  that  a  mechanical  obstruction  to  the  passage  of  the 
air  exists  in  the  larynx,  and  that  the  tubes  beyond  the  larynx  are  pervious  and  free ; 
there  are  two  things  which  I  would  urge  upon  you.  First,  I  would  most  earnestly 
advise  you  not  to  wait  too  long  before  you  propose  or  perform  tracheotomy  ;  and 
secondly,  never  to  omit  performing  it  merely  because  it  may  appear  to  be  then  too 
late.  If,  in  the  acute  and  limited  disease,  an  artificial  opening  be  made  while  the 
patient's  strength  is  yet  entire,  and  before  his  whole  system  is  poisoned  with  venous 
blood,  or  his  lungs  are  overwhelmed  with  sanguine  congestion  and  serous  effusion,  it 
will  almost  infalhbly  save  his  hfe.  But  if  the  sinking  of  the  vital  power  has  got 
beyond  a  certain  point,  tracheotomy  will  not,  in  that  case,  rescue  him.  It  is  bad  and 
foolish  practice  to  wait,  and  try  other  methods,  and  postpone  the  operation  as  a  last 
resource,  when  the  circulation  is  evidently  loaded  with  unarteriaHzed  blood.  In  my 
own  case  I  should  choose  to  be  operated  on  early ;  the  moment  that  1  found  early 
blood-letting  was  not  telling  upon  the  local  distress,  and  that  any  shade  of  duskiness 
became  perceptible  in  the  skin  ;  just  as  I  should  choose  to  be  operated  on  at  once 
for  strangulated  hernia,  after  one  fair  attempt  had  been  made  by  a  skilful  hand  to 
return  the  bowel ;  without  waiting  till  inflammation  set  in,  or  had  been  caused  by 
the  taxis.  On  the  other  hand,  if  you  do  not  see  your  patient  until  his  powers  are 
nearly  exhausted,  do  not  abstain  from  the  operation  even  though  you  may  feel  con- 
vinced that  it  will  be  unsuccessful ;  for  if  it  does  not  save  life,  it  will  disarm  death 
of  its  agony.  A  patient  will  lie  sometimes  for  hours,  painfully  labouring  for  breath 
in  deep  and  strong  catches,  at  considerable  intervals  from  each  other :  in  fact,  he  is 
just  in  the  condition  of  a  man  with  a  cord  round  his  neck,  not  pulled  quite  tight 
enough  to  suffocate  him  at  once.  Besides,  it  is  not  always  easy  to  say  whether  the 
period  of  possible  recovery  is  yet  gone  by.  I  had  a  female  patient  in  the  hospital 
who  had  suffered  one  or  two  attacks  of  frightful  dyspnoea,  in  which  the  main  dilR- 
cuhy  was  referred  to  the  larynx;  but  she  had  rallied  from  them  before  any  steps 
could  be  taken  for  performing  tracheotomy.  On  the  next  occasion,  however,  the 
seizure  was  so  sudden  and  rapid,  that  although  Mr.  Arnott  was  luckily  in  the  hospital 
at  the  time,  the  woman  was,  to  all  appearance,  dead,  before  he  could  "re  found  and 


496  ACUTE    LARYNGITIS 

brought  to  her  bedside.  Respiration  had  entirely  ceased.  This  quietude  of  the 
larynx  rendered  the  operation  more  easy.  Mr.  Arnott  speedily  made  an  opening 
into  the  trachea ;  some  air  was  blown  in  through  the  aperture,  and  then  pressed  out 
again  ;  and  presently  the  natural  respiration  was  renewed.  The  woman  recovered: 
the  orifice  healed  up,  and  she  left  the  hospital.  Three  or  four  months  afterwards 
word  was  brought  that  she  had  died  at  her  own  home  after  a  short  attack,  and  when 
there  was  no  one  at  hand  to  open  her  windpipe.  We  got  permission  to  examine 
the  body,  and  found  a  large  ulcer  in  the  trachea,  near  the  larynx ;  which  ulcer  by 
its  irritation  had  occasioned,  as  we  presumed,  the  spasmodic  closure  of  the  glottis. 
A  preparation  exhibiting  the  diseased  parts  is  on  the  table  before  you.  You  see  that 
there  was  an  enlargement  of  the  thyreoid  gland.  This  had  probably  nothing  to  do 
with  the  symptoms.     There  was  also  a  large  ulcer  in  the  left  bronchus. 

Mr.  Goodeve,  surgeon  to  the  Clifton  Dispensary,  operated  on  a  patient  in  whom 
"no  pulse  could  be  found  at  the  wrist;  his  face  was  suffused  with  blood,  and  his 
lips  hvid ;  and  it  was  hard  to  say  whether  he  breathed  or  not :"  yet  he  recovered. 

It  so  happens  that  there  is  at  present  (December  1838)  under  Dr.  Wilson's  care, 
in  the  hospital,  a  woman  named  Slack,  who  was  rescued  when  almost  in  articulo 
mortis,  by  the  same  expedient.  She  had  chronic  disease  of  the  larynx  ;  but  a  sud- 
den aggravation  of  the  symptoms  occurred ;  she  became  stupid  and  comatose,  her 
countenance  was  cadaverous,  her  skin  covered  with  a  cold  clammy  sweat,  and  her 
breathing,  which  had  been  stridulous  and  laryngeal,  had  almost,  if  not  quite  stopped. 
She  was  making  short,  gasping  efforts  to  respire,  not  oftener  than  twice  in  a  minute. 
Her  pulse  was  intermittent,  and  extremely  feeble.  In  this  state  the  house-surgeon 
(Dr.  William  Merriman)  made  a  small  incision  in  the  skin  over  the  cricoid  cartilage, 
and  then  thrust  a  large  trocar  into  the  windpipe.  Air  rushed  through  the  opening, 
the  respiration  returned,  the  pulse  revived,  and  the  stupor  passed  away.  This  hap- 
pened on  the  1 0th  of  October.  She  is  still  in  the  ward  ;  the  aperture  has  closed  up  ; 
and  though  she  is  not  well,  she  is  living;. 

What  is  the  reason,  you  may  ask,  of  these  different  and  inconsistent  results  ?  How 
is  it  that  tracheotomy  shall  reanimate  one  patient,  whose  last  breath,  but  for  its  help 
was  already  drawn,  who  was  already  motionless  in  apparent  death;  and  yet  shalJ 
fail  to  save  another  patient,  who  is  still  alive,  and  sensible  of  his  danger,  and  strug- 
gling with  his  disease  ?  The  difference  depends,  I  make  no  doubt,  upon  the  timt? 
that  elapses  between  the  commencement  of  extreme  dyspnosa,  and  the  performance 
of  the  operation  ;  upon  the  slow  or  the  speedy  completion  of  the  stranghng  process 
And  this,  again,  obviously  depends  upon  the  manner  and  degree  in  which  the  pas- 
sage is  narrowed.  When  the  obstruction,  though  considerable,  is  incomplete,  and 
does  not  rapidly  augment,  the  respiration  continues  to  be  performed,  however,  im- 
perfectly. Meanwhile  the  brain  gets  oppressed,  the  circulation  tends  to  stagnate, 
and,  above  all,  the  lungs  become  gorged  with  black  blood,  and  clogged  up  by  effu- 
sion into  their  cells  and  substance.  Secondary  causes  of  apnosa  are  thus  established, 
which  do  not  cease  when  the  primary  cause  is  at  length  removed,  by  the  unbarring 
of  the  main  channel  for  the  admission  of  air.  Whereas  when  the  access  of  the 
atmosphere  is  suddenly  or  soon  shut  out,  the  lungs  are  not  thus  mortally  injured, 
but  remain  capable  of  resuming  their  functions  when  they  are  again  supplied 
with  air. 

Tracheotomy,  then,  will  be  the  most  likely  to  succeed,  while  the  patient  is  still 
lively  and  strong  ;  and  after  that  the  chance  of  success  will  be  worse  in  those  cases 
in  which  the  apnoea  has  been  slow  in  its  progress,  than  in  those  in  which  it  has 
been  rapid.  I  repeat  that,  in  threatening  circumstances,  the  operation  should  be  done 
earhj ;  but  that  it  should  not  be  withheld,  through  despair,  at  any  period  of  the 
disease. 

The  effect  produced  upon  the  condition  of  the  patient  by  the  timely  formation  of 
in  artificial  gbttis  is  very  striking.  The  moment  that  the  scalpel  penetrates  the 
rings  of  the  trachea,  air  begins  to  hiss  through  the  incision  ;  and  when  a  fair  opening 
is  established,  and  a  full  inspiration  is  drawn  in  through  the  wound,  several  forcible 
expirations  generally  succeed,  whereby  a  considerable  quantity  of  niwcus  is  expelled, 
which  could   not  pass  the  contracted  apertu'-e  of  the  natural  glatis.     Then  the 


ACUTE    LARYNGITIS.  497 

bi*eathing  soon  becomes  easy,  the  anxiety  and  distress  are  followed  by  a  perfect  calm, 
and  usually  the  exhausted  sufferer  sinks  into  a  tranquil  slumber.  This  sleep  is  apt 
to  be  from  time  to  time  interrupted  by  the  clooging  up  of  the  orifice  with  frothy 
mucus.  It  is  requisite  that  some  intelligent  person  should  remain  by  the  patient, 
to  assist  him  in  these  emergencies,  or  he  may  still  be  throttled,  notwithstanding  the 
apparent  prosperity  of  the  operation. 

When  a  sufficient  hole  has  been  made  in  the  instrument  of  the  voice,  belovv  the 
glottis,  the  voice  of  course  becomes  extinct,  or  nearly  so  ;  and  the  patient  is  as  unable 
to  utter  a  cough  as  he  is  to  use  vocal  language.  Now  this  it  is  of  some  importance 
to  notice,  for  he  often  wants  to  cough,  in  order  to  clear  the  air-passages  of  mucus,  or 
of  blood,  by  which  they  may  be  embarrassed  ;  and  he  may  be  helped  to  do  so,  or 
taught  to  help  himself.  First  he  should  draw  in  a  full  breath,  and  then  stop  the  ori- 
Itce  for  a  moment  with  his  finger,  while  he  makes  the  expiratory  effort.  And  as  the 
parts  within  the  larynx  recover,  the  patient,  by  a  similar  manoeuvre,  may  enable 
himself  to  speak  aloud. 

As  actual  examples  are  more  interesting  and  often  more  instructive  than  an  ab- 
stract of  results,  I  will  tell  you  in  a  summary  manner  the  history  of  a  case  of  laryn- 
gitis, which  occurred  in  one  of  my  hospital  patients,  in  the  latter  part  of  the  year 
18;i2.  He  was  an  old  man,  about  sixty.  His  name  was  Kent.  He  was  brought 
to  the  hospital  bloated  with  anasarca,  which  was  most  conspicuous  in  his  legs  and 
thighs.  His  breathing  was  laborious  and  difficult,  and  attended  with  a  wheezing 
noise,  audible  at  some  distance.  He  could  not  lie  down  :  he  had  a  hard,  but  not  full 
pulse.  The  dropsical  swelling  had  come  on  suddenly  five  or  six  days  before  ;  and 
in  the  outset  his  face  (he  said)  was  so  pufl^ed  up  that  he  could  scarcely  see.  He 
had  been  bled  to  the  amount  of  a  pint  and  a  half,  according  to  his  own  account,  on  the 
previous  evening.  I  had  a  vein  opened  immediately,  and  twenty-four  ounces  of 
blood  were  drawn  ;  and  eight  ounces  more  were  taken  from  the  chest  by  cupping. 
He  was  thoroughly  purged  with  calomel  and  senna.  The  bleeding  gave  him  very 
little  relief,  so  far  as  the  respiration  was  concerned  ;  but  the  next  morning  the  ana- 
sarca had  totally  disappeared.  I  found  him  sitting  up  in  bed,  breathing  with  much 
effort,  and  with  a  loud  stridulous  noise  which  accompanied  both  inspiration  and  ex- 
piration. He  referred  all  this  uneasiness  to  two  points;  one  of  these  was  the 
larynx,  the  other  the  ensiform  cartilage.  He  swalloAved  with  great  pain  and  diffi- 
culty ;  and  every  attempt  to  do  so  excited  a  fit  of  choking  cough.  There  was  no 
morbid  appearance  visible  in  the  fauces  :  every  part  of  his  chest  sounded  well  on 
percussion,  and  the  murmur  of  healthy  respiration  could  everywhere  be  heard  in  the 
lungs,  almost  drowned,  however,  in  the  louder  laryngeal  noise.  As  his  strength  was 
entire,  I  had  him  again  cupped,  to  twelve  ounces,  at  the  back  of  the  neck ;  and  pre- 
scribed three  grains  of  calomel  every  three  hours.  He  also  inhaled  the  steam  of  hot 
water. 

Upon  visiting  him  again  the  same  evening,  I  found  the  dyspnG3a  increased.  Each 
act  of  respiration  was  attended  with  a  loud  croupy  noise.  His  countenance  was  be- 
ginning to  be  anxious  and  ghastly.  He  was  restless  ;  and  his  pulse  was  less  firm. 
Being  now  firmly  convinced  that  the  operation  of  tracheotomy  was  the  only  thing 
that  could  save  him,  and  that  it  could  not  be  safely  delayed,  I  sent  to  request  that  Sir 
Charles  Bell  would  come  and  perform  it.  By  the  time  he  arrived  the  restlessness 
had  increased.  The  patient  was  shifting  perpetually  from  one  side  of  the  bed  to  the 
other,  as  if  seeking  some  new  point  of  support :  his  face  had  become  pale  ;  and  his 
lips  were  turning  livid.  He  spoke  with  sudden,  and  as  it  were  with  convulsive 
eflbrts;  stating  earnestly  how  thankful  he  should  be  to  have  the  obstacle  to  his 
breathing  removed ;  and  pointing  to  the  larynx  as  the  seat  of  his  distress. 

The  ordinary  operation,  under  such  circumstances,  is  by  no  means  an  easy  one  to 
perform.  Its  difficulties  were  well  exemplified  in  this  patient.  In  the  first  place  he 
was  sitting  up ;  he  could  not  bear  to  be  placed  in  the  recumbent  position.  Then  the 
dyspnoea  caused  him  instinctively  to  elevate  his  shoulders,  and  sternum,  and  clavi- 
cles, to  the  utmost,  so  that  the  trachea  was  sunk  deeply  into  the  thorax ;  and  the 
larynx  was  in  constant  and  rapid  movement  up  and  down  with  a  plunging  motion, 
like  that  of  the  piston  of  a  steam  engine.  Sir  Charles,  after  some  trouble,  succeeded 
33  2r2 


498  ACUTE    LARYNGITIS. 

in  cutting  out  a  piece  of  the  cartilage  ;  for  a  mere  slit  did  not  suffice  :  it  closed  tightly 
during  every  inspiration,  although  it  was  open  enough  during  expiration.  At  length, 
when  ihe  air  was  freely  admitted,  the  breathing  became  gradually  easy.  I  shall 
never  forget  the  whole  spectacle  :  there  sat  the  poor  man  gasping  and  fighting  for 
breath  ;  his  face  covered  with  sweat,  and  wearing  the  most  anxious  expression.  By 
and  by  what  I  have  called  an  artificial  glottis  is  opened  for  him  ;  and  presently  after- 
wards, though  half  a  dozen  candles  (as  Sir  Charles  has  himself  painted  the  scene) 
are  held  close  to  his  face,  to  throw  light  upon  ihe  wound,  and  though  the  surgeons, 
their  hands  smeared  with  blood,  are  still  busy  about  his  throat,  making  arrangements 
to  ensure  the  patency  of  the  orifice,  the  patient  falls  fast  asleep.  It  was  necessary 
to  place  an  assistant  behind  him  to  prevent  his  head  from  nodding  forwards,  and 
deranging  the  apparatus  in  the  wound.  Nothing  can  express  more  strongly  than 
this  fact  the  great  distress  and  fatigue  which  had  previously  existed,  and  the  perfect 
relief  afforded  by  the  operation. 

This  man  ultimately  got  quite  well;  and  he  has  since  shown  himself  occasionally 
at  the  hospital,  in  excellent  health.  There  were  two  or  three  points  about  the  case 
which  I  am  unwilling  to  pass  over  without  notice.  It  was  evident  that  after  the 
opening  was  made  in  his  windpipe,  he  still  breathed  in  part  through  the  rima  glot- 
tidis  also;  for  the  stridulous  sound  did  not  wholly  cease.  The  aperture  was  formed 
as  low  as  the  circumstances  of  the  case  appeared  to  permit :  the  tube  was  perforated 
in  the  membranous  space  between  the  thyreoid  and  cricoid  cartilages.  Strictly 
speaking,  laryngotomy  was  the  operation  performed.  I  do  not  enter  into  the  con- 
sideration of  the  best  place  for  making  the  opening;  that  point  you  will  be  taught 
by  the  professor  of  surgery :  but  it  was  observed  in  the  case  in  question,  that  the 
slightest  touch  of  the  irritable  mucous  membrane,  with  a  hook  or  a  probe — especially 
if  the  touching  instrument  was  turned  vpicords  towards  the  glottis — produced  a  fit 
of  coughing,  and  a  paroxysm  of  still  more  laborious  breathing.  For  some  days  after 
the  operation,  it  was  noticed  that  a  part  of  whatever  liquid  he  swallowed  appeared 
immediately  at  ihe  wound.  Now  this  proved  as  plainly  as  if  we  could  have  seen 
the  parts,  that  the  epiglottis  was  thickened,  and  erected,  and  incapable  of  performing 
its  protective  function  to  the  larynx :  and  it  accounted  for  the  paroxysm  of  choking 
cough  produced  by  each  act  of  deglutition.  At  first  the  lining  membrane  of  the, 
larynx  and  trachea  was  so  irritable,  that  the  patient  could  not  bear  to  have  a  metal- 
lic tube  inserted  ;  and  an  ingenious  contrivance  was  adopted  for  keeping  the  orifice 
from  being  covered  over  by  the  lips  of  the  wound.  They  were  held  apart  by  two 
bent  wires,  which  were  tied  together  at  the  back  of  his  neck.  After  twenty-four 
hours  had  elapsed,  the  irritability  of  the  mucous  membrane  had  so  far  abated  that  he 
was  able  to  breathe  through  a  canula. 

There  cannot  be  a  doubt  that  this  man  was  snatched  from  the  very  jaws  of  death 
by  the  intervention  of  the  surgeon.  A  function  indispensable  to  life  was  nearly  sus- 
pended ;  and  a  substitute  for  the  faulty  organ  was  provided  by  art,  until  the  inter- 
rupting cause  was  removed.  Scarcely  a  year  passes  over  our  heads  without  the 
occurrence  of  one  or  two  such  events  in  the  hospital.  When  lecturing  upon  this 
subject  last  season,  I  was  able  to  show  you  a  female  patient  whose  life  had  been 
saved  in  a  similar  way.  And  there  is  now  also  (December  11,  1839),  in  Pepys' 
ward,  a  rescued  man,  with  the  tube  still  in  his  windpipe.  The  operation  was  done 
on  the  spur  of  necessity  by  Mr.  Tomes,  the  present  house-surgeon,  with  a  trocar. 
The  patient,  who  was  previously  in  a  state  of  extreme  distress,  said,  in  a  faint  whis- 
per, as  soon  as  the  opening  was  effected,  "It's  all  right  now." 

He  had  been  exposed  to  rain  and  cold  about  a  week  before ;  and  had  suffered 
pain  and  tenderness  of  the  larynx.  Prior  to  his  admission  he  had  been  bled,  and 
sahvatcd,  and  had  a  blister  on  the  throat  ivhich  embarrasacd  the  operation. 

Within  the  last  eight  years  the  operation  of  tracheotomy  has  been  performed  in 
me  Middlesex  Hospital  fourteen  times.  Seven  of  the  patients  recovered ;  seven 
died.  In  two  of  the  seven  fatal  cases,  the  condition  of  the  patients  was.  hopeless  at 
the  time  of  the  operation.  In  four  at  least  of  the  five  others  much  relief  from  suffer- 
ing was  afforded  by  it,  and  life  apparently  prolonged.  One  of  the  patients  was  a 
young  child  :  the  opening  was  made  by  a  trocar ;  much  blood  got  into  the  air-pas- 


ACUTE   LARYNGITIS.  49& 

sages,  and  the  cLild,  which  seemed  to  be  sinking  previously,  died  within  the  hour. 
Life  might,  I  think,  have  been  preserved  in  this  case,  by  a  timely  operation,  pro- 
perly done.  For  a  trachea  so  small,  the  scalpel  is  preferable  to  the  trocar.  But  in 
the  adult  subject  I  haA^e  seen  the  larynx  penetrated  so  neatly,  easily,  and  speedily, 
both  by  Mr.  Arnott  and  by  Mr.  Shaw,  with  a  small  curved  trocar,  tliat  I  am  per- 
suaded of  the  general  superiority  of  that  method  over  the  common  operation  with 
the  knife  or  scissors.  If  this  be  granted,  the  fit  place  for  the  opening  must  be  the 
membranous  space  between  the  thyreoid  and  the  cricoid  cartilages.  The  superja- 
cent skin  is  first  nicked  with  a  scalpel :  the  larynx  is  then  fixed  for  a  moment  by 
the  operator's  left  hand,  while  with  his  right  he  thrusts  the  instrument  steadily 
inwards  and  downwards. 

I  have  said  nothing  hitherto  about  the  use  of  mercury  in  this  acute  disorder,  be- 
cause I  hold  it  to  be  of  very  secondary  importance,  and  because  I  have  been  anxious 
not  to  divert  your  attention  from  the  two  great  practical  points,  bleeding  and  trache- 
otomy. Mercury  may  very  fitly  be  given  in  those  cases  and  circumstances  m  which 
blood-letting  appears  proper ;  but  we  cannot  depend  upon  it ;  we  cannot  reckon  upon 
its  influencing  the  system  in  time;  nor  upon  any  marked  improvement  of  the  symp- 
toms when  it  does  produce  its  specific  effects.  After  the  operation  it  is,  for  the  most 
part,  unnecessary. 

Nor  do  I  recommend  the  employment  of  tartar-emetic,  powerful  as  that  drug  is 
known  to  be  in  subduing  inflammation  of  the  mucous  tissues.  In  the  swollen  and 
unpliant  state  of  the  epiglottis  it  would  not  be  prudent  to  excite,  or  to  hazard,  vomit- 
ing. The  contents  of  the  stomach  passing  upwards  would  be  apt  to  enter  the  un- 
protected larynx,  and  to  cause  hurtful,  distressing,  and  even  perilous  attacks  of  suffo- 
cative cough. 

In  the  examination  of  fatal  cases,  sometimes  the  thickened  membrane  forming  the 
edges  of  the  rima  glottidis  is  found  covered  with  viscid  mucus,  which  had  formed 
an  additional  impediment  to  the  passage  of  air  towards  and  from  the  lungs :  some- 
times pus  is  discovered,  lying  in  the  sacculi  laryngis,  or  scattered  among  the  carti- 
lages and  surrounding  muscles :  and  sometimes  the  chief  morbid  condition  is  the 
infiltration  of  the  submucous  areolar  tissue.  The  effect  in  all  cases  is  the  sam.e,  that 
of  closing  up,  wholly  or  partially,  the  narrow  fissure  between  the  arytenoid  carti- 
lages.    The  state  of  the  epiglottis  I  have  several  times  described. 

This  very  serious  disease  is  a  disease  of  adult  age ;  it  is  not  often  known  to  occur 
in  children.  They  again  are  almost  as  exclusively  liable  to  croup:  and  cynanche 
laryngea  has  been  called  the  croup  of  adults.  But  as  the  part  occupied  by  croup, 
and  the  event  of  the  inflammation,  are  both  difl^erent  from  those  of  laryngitis,  this 
name,  croup  of  adults,  is  objectionable.  I  may  remark,  however,  that  sometimes  in 
rue  croup,  the  inflammation,  besides  specially  affecting  the  membrane  of  the  trachea, 
extends  to  that  of  the  larynx  also. 

[Children  are  very  liable  to  a  mild  form  of  laryngitis  accompanied  unth  a  spasmodic 
affection  of  the  glottis.  The  disease  is  marked  by  many  of  the  symptoms  of  gennine  croupv 
and  is  probably  the  most  common  form  of  croupal  disease  met  with  in  this  country.- -C] 

The  main  exciting  cause  of  laryngitis  is  exposure  to  cold,  or  to  cold  and  wtt.  My 
hospital  patient,  Kent,  was  a  seller  of  small  wares  in  the  streets,  and  must,  therefore, 
have  been  habitually  in  the  way  of  such  causes.  The  first  attack  of  the  disease  in 
Sir  J.  M.  Hayes  was  brought  on  by  exposure  at  an  open  window  to  the  night  air 
for  some  time,  while  he  was  undressed,  and  in  a  profuse  state  of  perspiration,  with 
a  strong  breeze  blowing  upon  him.  Dr.  Craigie  states  that  young  persons  from  tro- 
pical climates,  from  the  West  Indies  for  example,  are  apt  to  be  attacked  by  laryn- 
gitis soon  after  their  arrival  in  Europe. 

The  disease  is  liable  to  be  produced  also  by  mechanical  violence,  or  chemical 
injury  done  to  the  larynx.  It  has  been  caused,  on  several  occasions,  in  children,  by 
their  atteinpting  to  swallow  boiling  water  from  the  spout  of  a  tea-kettle  ;  and  life  ha-* 
been  saved  in  such  cases  by  the  performance  of  tracheotomy.  The  mineral  acids, 
taken  as  poisons,  have  excited  the  disease.  Fatal  laryngitis  has  followed  the  incau- 
tious application  of  ammonia  to  the  nostrils,  in  cases  of  hysteria,  and  of  suspended 
animation :  and  I  once  knew  a  man  nearly  killed  by  the  inhalation  of  the  fumes 


500  ACUTE    LARYNGITIS. 

evolved  from  cinnabar  thrown  upon  a  hot  iron,  in  what  is  called  fumigafion  of  th« 
throat  for  venereal  ulceration  of  that  part.  I  am  afraid  that  I  must  confess  also  to 
have  once  seen  acute  laryngitis  produced  by  a  bungling  attempt  to  introduce  the 
stomach-pump,  in  a  case  of  poisoning.  i. 

In  all  these  cases  the  lar}mgitis  is  primitive.  But  laryngeal  inflammation,  and  « 
especially  laryngeal  oedema,  not  unfrequently  take  place,  and  prove  suddenly  fatal, 
in  the  course  of  other  diseases.  I  have  apprised  you  that  in  cynanche  tonsillaris,  the 
inflammation  sometimes  steals  onward  to  the  larynx.  I  have  seen  two  or  three  cases 
of  erysipelas  of  the  head,  attended,  as  it  almost  always  is,  with  sore  throat,  wherein 
death  took  place  suddenly  and  unexpectedly,  and  where  the  epiglottis,  and  the 
edges  of  the  fissure  of  the  glottis,  were  found  to  be  oedematous  :  the  inflammation  of 
the  throat  had  extended  to  the  areolar  tissue  beneath  the  mucous  membrane  of  those 
parts,  and  had  led  to  the  effusion  of  serous  fluid  there.  The  very  same  thing  is  apt 
to  happen  in  other  forms  of  exanthematous  disease  attended  with  sore  throat,  and 
especially  in  small-pox,  measles  and  scarlet  fever.  I  have  known  a  similar  condi- 
tion of  inflammatory  oedema  arise  from  a  mercurial  sore  throat  in  a  broken-down 
constitution,  Tn  these  cases  the  laryngeal  affection  is  consecutive,  and  secondary; 
and  in  all  of  them  the  great  remedy  is  the  formation  of  a  sufficient  aperture  beneath 
the  obstructed  glottis.  In  all  of  them,  also,  the  essential  symptoms,  warranting  and 
demanding  the  operation  of  tracheotomy,  are  the  same. 

A  distinction  has  been  made  between  laryngitis  and  oedema  of  the  glottis  ;  and 
it  is  a  just  and  real  distinction.  Qildema  of  the  loose  areolar  tissue  subjacent  to  the 
mucous  membrane  of  the  glottis,  is,  indeed,  one  common  consequence  of  inflammation 
of  that  membrane :  but  it  may  occur  independently  of  inflammation.  The  hps  of 
the  glottis  become  tumid  and  dropsical ;  sometimes,  (as  I  have  just  pointed  out,) 
in  consequence  of  a  low  inflammatory  action  in  the  throat,  but  sometimes  also 
from  obstruction  of  the  veins  leading  from  that  part.  When  laryngeal  dyspnoea 
accompanies  aneurism  of  the  thoracic  aorta,  it  may,  in  some  instances,  result  from 
local  dropsy  tlius  produced  ;  and  then  tracheotomy  is  fully  justifiable,  and  indeed 
demanded. 

The  main  practical  difTerence  between  mere  oedema  glottidis  and  acute  laryngitis, 
is  this :  that  in  the  former,  there  being  no  fever  or  inflammation,  blood-letting  is  not 
requisite ;  and  the  operation  of  tracheotomy  becomes  the  sole  resource  to  which,  in 
the  extremity  of  danger,  we  can  look  for  help.  Mere  oedema  glottidis  is  seldomer 
attended  with  dysphagia,  too,  than  is  laryngitis :  yet  if  the  epiglottis  be  involved  in 
the  oedematous  swelling,  and  unable  to  shut  over  the  glottis,  the  act  of  swallowing 
will  be  followed  by  strangling  cough,  and  increased  dyspncEa. 

Besides  the  afTcctions  which  I  have  now  described  or  referred  to,  the  larynx  is 
Fiable  to  chronic  disease  :  to  chronic  injlammation  ;  chronic  thickening  of  the  mem- 
brane ;  slow  idceralion  :  necrosis  of  its  cartilages.  Chronic  inflammation  and  ulce- 
ration of  that  part  are  very  common  in  consumptive  patients.  It  is  attended  first 
with  hoarseness,  then  with  aphonia,  a  barking  or  stridulous  cough,  and  all  the  melan- 
choly accompaniments  of  tubercular  phthisis.  There  has  accordingly  been  a  species 
of  phthisis  spoken  of  as  phthisis  lurijngea.  But  in  most,  if  not  in  all  cases,  this 
laryngeal  afTection  is  only  a  part  of  the  complaint  under  which  the  patient  labours ; 
and  what  I  have  further  to  observe  respecting  it,  I  shall  postpone  until  we  come  to 
the  consideration  of  tubercular  consumption, 

Acain,  the  membrane  lining  the  laryngeal  cartilages  is  not  unfrequently  thickened 
and  ulcerated  in  secondary  syphilis  ;  giving  rise  to  a  hoarse  croaking  voice,  and  a 
noisy  and  painful  breathing.  In  such  cases,  or  in  chronic  thickening  of  the  same 
parts  from  common  inflammation,  you  may  do  great  good  by  gently  introducing  mer- 
cury into  the  system,  until  the  gums  rise.  I  have  again  and  again  seen  the  uneasi- 
ness about  the  throat,  the  noisy  respiration,  the  rough  or  whispering  voice,  all  cease, 
as  if  by  enchantment,  so  soon  as  the  specific  influence  of  the  mercury  became 
manifest.  There  was  a  woman  Avho  used  to  apply  at  the  Middlesex  Hospital  for  an 
affection  of  this  kind  :  whether  it  was  syphilitic  or  not  I  could  not  well  determine, 
but  she  lost  it  under  the  employment  of  mercury,  two  or  three  times  :  the  complain* 


CHRONIC    AFFECTIONS.  501 

returning  again  after  the  interval  of  a  few  months,  upon  the  re-application  of  some 
irritating  cause.  In  another  female  patient,  who  was  long  under  my  care  in  the 
hospital  with  similar  symptoms,  every  thing  failed  to  give  permanent  relief,  till  I 
began  to  leech  the  neighbourhood  of  the  larynx  repeatedly.  She  had  four  leeches 
applied,  I  think,  every  night,  and  then  every  other  night,  for  a  fortnight  or  three 
weeks ;  the  hoarseness  and  difficulty  of  respiration  gradually  diminishing  all  the 
time,  until  at  length  the  perfect  use  of  the  instrument  of  the  voice  was  restored.  In 
these  cases,  while  using  local  depletion,  or  mercury,  it  is  often  necessary  to  uphold 
the  strength  of  the  patient  by  nourishing  but  unstimulating  diet :  and  it  is  always 
expedient  that  the  organ  should  be  kept,  as  much  as  possible,  in  a  state  of  repose. 

It  is  said  that  a  little  practice  will  enable  a  person  to  pass  his  finger  into  a  patient's 
throat,  and  to  familiarize  his  sense  of  touch  with  the  ordinary  condition  of  the  upper 
part  of  the  respiratory  apparatus,  so  as  to  be  able  to  detect  swelling,  or  irregularity, 
or  thickening  about  the  chink  of  the  glottis.  And  great  advantage  is  said  to  have 
been  obtained  from  applying  remedies  directly  to  the  diseased  or  irritable  part.  This 
practice  was  much  followed  by  the  late  Mr.  Vance,  who  had  been  for  many  years  a 
naval  surgeon ;  and  he  called  it,  in  naval  phrase,  swabbing  the  affected  organ.  A 
small  piece  of  sponge,  secured  with  a  string,  or  fastened  to  the  end  of  the  finger  of 
a  glove,  is  dipped  in  a  strong  solution  of  nitrate  of  silver,  and  then  carried  down  into 
the  throat,  as  far  as  that  spasmodic  state  of  the  muscles  which  the  attempt  induces 
will  permit,  and  pressed  downwards  against  the  superior  surface  of  the  larynx.  I 
believe  other  stimulating  applications  are  sometimes  employed  in  the  place  of  the 
nitrate  of  silver.  Now  of  this  method  of  cure  I  do  not  know  much,  except  by  report. 
I  have  heard  that  many  cases  of  chronic  hoarseness  and  cough  have  speedily  been 
cured  by  it.  But  I  have  more  than  once  had  what  seemed  satisfactory  evidence  of 
the  beneficial  effect  of  this  expedient.  The  man  Kent,  whose  case  I  have  related, 
gradually  regained  the  power  of  easy  breathing  through  the  natural  passage ;  and 
the  opening,  which  Sir  Charles  Bell  had  made,  closed  up  perfectly.  About  a  week 
after  this  took  place,  he  began  again  to  respire  with  a  wheeze  almost  as  audible  as 
that  which  existed  at  the  time  of  his  admission :  and  to  speak  in  a  hoarse  voice ;  and 
a  night  or  two  after  the  return  of  the  wheezing,  he  had  a  paroxysm  of  extreme 
dyspnoea.  I  began  to  be  afraid  that  the  whole  process  of  laryngotomy  and  the 
metallic  tube  would  be  again  requisite.  However  I  got  Sir  Charles  Bell  to  examine 
the  interior  of  the  throat,  and  we  agreed  that  it  would  be  advisable  to  swab  the 
epiglottis  and  upper  part  of  the  air-passages  with  a  strong  solution  of  lunar  caustic. 
For  he  had  no  fever,  and  we  thought  it  probable  that  the  membrane  might  have 
been  left  lax,  and  in  a  state  to  be  benefited  by  astringents.  Sir  Charles  applied  the 
sponge  with  very  little  difficulty  ;  and  the  next  day  the  breathing  was  greatly  im- 
proved, and  the  hoarseness  almost  gone :  and  he  never  had,  from  that  time,  any 
recurrence  of  troublesome  dyspnoea. 

Mr.  Arnott  has  twice  or  thrice,  at  my  request,  swabbed  the  upper  part  of  the 
larynx  for  intractable  hoarseness  and  aphonia  :  but  with  no  good,  nor  any  bad  con- 
sequence. 

The  lining  membrane  of  the  larynx  is  liable  also  to  warty  growths,  which  impede 
the  entrance  and  exit  of  air,  and  ultimately  destroy  life.  There  are  several  examples 
of  that  kind  on  record.     I  extract  the  following  from  my  note  book : — 

George  Tenon  la  Font,  aged  11,  admitted  March  4,  1828.  He  speaks  in  a 
whisper;  complains  of  difficult  breathing,  and  of  cough.  Inspires  with  a  loud 
wheeze.  Coughs  with  a  sort  of  whistling  sound,  as  through  a  narrow  tube. — The 
cough  is  most  troublesome  at  night.  Expectoration  mucous,  and  inconsiderable  in 
quantity. 

H?is  been  ill,  in  this  way,  all  the  winter — having  had  hooping-cough  in  the  pre- 
ceding autumn.  There  are  marks  of  cupping  on  his  throat.  Little  can  be  heara 
in  the  chest,  the  loud  wheeze  of  his  respiration  obscuring  all  other  sounds.  In  about 
a  fortnight  his  gums  were  brought  under  the  influence  of  mercury.  No  perceptible 
improvement  ensued.  A  careful  examination  was  again  made  of  the  thorax,  and 
the  conclusion  arrived  at  was,  that  the  obstacle  to  his  respiration  lay  in  the  larynx 
or  upper  part  of  the  trachea,  and  that  the  lungs  themselves  were  not  concerned 


502  CYNANCHE    TRACHEALIS. 

After  this,  a  blister  to  the  throat,  a  seton  near  the  thyreoid  cartilage,  smaL  doses  of 
ipecacuanha,  emetics,  and  iodine  were  successively  tried — but  in  vain.  Towards 
the  end  of  the  month  he  began  to  suffer  occasional,  very  violent,  and  apparently- 
spasmodic  attacks  of  extreme  dyspnoea.  He  died  during  the  night,  two  months  after 
his  admission.  For  some  days  before  he  had  been  manifest!)^  worse  than  usual, 
was  more  feeble,  wandered  somewhat,  and  complained  that  his  vision  was  imperfect. 
No  noticeable  increase  had  taken  place  in  the  difficult}'-  of  breathing,  except  during 
the  paroxysms  of  aggravation  already  mentioned.  His  death  was  sudden,  and  pro- 
bably took  place  in  one  of  these  paroxysms. 

When  the  body  was  examined,  the  lungs  were  found  sound  as  to  structure,  but 
copiously  infiliered,  especially  on  the  left  side  of  the  thorax,  with  serous  fluid.  At 
the  very  top  of  the  larynx,  involving  the  base  of  the  epiglottis  and  the  vocal  cords, 
was  a  considerable  warty  growth,  closing  the  rima  glottidis  almost  entirely.  The 
excrescences  sj^rang  chifjly  from  one  continuous  base,  and  branched  out  precisely 
after  the  manner  of  what  is  vulgarly  called  a  seedy  wart.  There  were,  however, 
several  distinct  smaller  growths  or  warts.  The  main  excrescence,  having  several 
heads,  passed  upwards  from  and  through  the  rima,  and  so  came  to  act  partly  as  a 
valve  during  inspiration,  which  was  always  sensibly  more  difficult  than  expiration. 

Ought  tracheotomy  to  have  been  performed  in  this  case  ?  I  now  think  so.  But 
supposing  it  to  have  been  done,  and  to  have  been  successful,  the  boy  would  have 
been  under  the  necessity  of  breathing  through  an  artificial  tube  for  the  remainder  of 
his  fife. 

There  are  two  excellent  specimens  of  warty  growths  in  the  larynx  upon  the  table 
before  you. 

I  might  have  referred,  when  speaking  of  chronic  enlargement  of  the  tonsils,  in  the 
last  lecture,  to  the  case  of  a  little  boy  at  present  under  the  care  of  one  of  my  col- 
leagues. He  was  brought  to  the  hospital  on  account  of  great  dyspnoea,  and  a  hissing 
respiration,  produced  apparendy  by  two  enormous  tonsils.  With  some  difficulty 
(arising  from  his  unmanageable  age)  a  large  part  of  one  of  the  tonsils  was  cut  off 
with  scissors  :  but  after  the  operation  (either  from  some  fresh  swelHng  of  the  parts, 
or  from  pressure  made  by  the  remaining  tonsil,  which  grew  downwards,  I  under- 
stand, into  the  throat),  his  difficulty  of  breathing  became  extreme  ;  and  it  was  thought 
necessary  to  perform  tracheotomy,  which  afforded  him  signal  relief.  He  breathed 
for  some  time  through  the  artificial  opening  in  his  windpipe.  At  length  the  other 
tonsil  was  partly  removed :  and  the  child  is  now  well,  and  about  to  be  discharged. 


LECTURE  XLVI. 


Cynanche  Trachealis ;  Symptoms;  Pathology;  Prognosis;  Treattnent      Child' 
crowing,  or  Spurious  Croup, 

I  PROCEED  this  afternoon  to  another  of  Dr.  Cullen's  species  of  cynanche ;  the  last 
that  I  propose  to  consider  in  this  part  of  the  course :  viz.,  cynanche  trachealis — 
tracheitis — croup. 

The  essence  of  this  complaint  is  violent  inflammation,  affecting  the  mucous  mem 
brane  of  that  portion  of  the  air-passages  which  lies  between  the  laryngeal  cartilages 
and  the  primary  bronchi;  in  one  word,  of  trachea,  or  wind-pipe.  That  is  the 
genuine  seat  of  the  disease  ;  but  the  inflammation  sometimes  ascends  into  the  larynx; 
and  not  unfrequently  it  dives  into  the  bronchi  and  into  their  ramifications. 

[In  perhaps  tne  majority  of  cases,  the  inflammation  in  croup  commences  in  the  mucous 
iiiembrine  of  the  larynx,  and  from  thence  extends  into  the  trachea — the  disease  is  there- 
fore, strictly  speaking,  a  laryngeo-tracheitis.  In  many  instances,  however,  -we  have  reason  to 
believe  that  the  inflammation  commences  in  the  bronclii,  and  from  thence  exter.ds  to  the 
tiach'ia;  but  there  are   ii'e  suspect,  very  few  cases  indeed,  if  any,  in  which  the  disease  ia 


CYNANCHE    TRACHEALIS.  503 

confined  to  the  %rach^a.  In  cases  of  croup  that  have  terminated  rapidly  in  death,  the  in- 
flammation and  pseudo-membranous  exudation  which  form  so  striking  a  feature  in  this  dis- 
ease are  found  only  in  the  larynx  and  upper  portion  of  the  trachea — when  death  occurs  at 
a  later  period  the  exudation  is  often  present  in  the  trachea  alone,  or  in  the  trachea  and 
bronchi ;  it  is  never  /ound  to  exist  in  the  latter  tubes  alone.  It  has  been  attempted  to  be 
shown  by  Jurin  and  others,  that,  in  the  ordinary  form  of  croup,  tlie  disease  is,  in  its  first 
stages  at  least,  simply  a  tracheitis,  and  that  in  the  more  violent  and  rapid  form,  (suflbcating 
croup,)  the  inflammation  is  confined  to  the  larynx.  Although  this  is  not  true,  as  is  shown 
by  tlie  result  of  numerous  dissections,  yet  our  observations  have  shown  us,  that  in  cases 
marked  by  symptoms  of  great  violence,  which  are  sudden  in  their  onset  and  rapid  in  their 
progress,  tlie  indications  of  inflammation  are  to  a  mucli  greater  extent,  and  the  pseudo-mem- 
branous exudation  more  cojjious  about  the  larynx,  glottis,  and  upper  portion  of  the  trachea, 
than  in  cases  in  which  the  disease  succeeds  to  bronchitis,  runs  a  more  protracted  course,  and 
is  attended  by  symptoms  of  less  violence.  For  a  more  detailed  account  of  the  pathology 
of  croup,  the  reader  is  referred  to  the  Editor's  Treatise  on  Diseases  of  Cliildren,  page  301 
et  scq. — C] 

Cullen  makes  no  distinction  between  cynanche  trachealis  and  cynanche  laryngea. 
Yet  they  are  separated  from  each  other  by  very  definite  boundaries.  They  differ  in 
anatomical  position  :  tliey  differ  in  gravity.  Both  indeed  are  serious  diseases;  but 
croup  is  the  more  serious,  because  it  seldom  admits  of  that  mechanical  relief  whicn, 
when  rendered  in  time,  deprives  cynanche  laryngea  of  its  dangerous  character. 
The  two  disorders  differ  also  in  respect  to  the  period  of  life  at  which  they  occur. 
Idiopathic  laryngitis  is  seldom  met  with  except  in  adults;  croup  seldom  after  the 
age  of  puberty.  Cynanche  trachealis  is  indeed  a  very  remarkable  disease,  for  it 
exhibits  an  event  of  inflammation  which  does  not  usually  belong  to  that  process  when 
it  affects  the  mucous  tissues.     In  this,  too,  it  differs  from  larj^ngitis. 

I  say  that  croup  is  peculiarly  a  disease  of  early  life.  The  interval  that  lies  be- 
tween the  two  periods  of  loeaning  and  puberty,  is  the  time  during  which  its  visitation 
is  chiefly  to  be  apprehended.  Comparatively  few  cases  of  it  occur  during  the  first 
year  of  infantile  life.  There  are  more  in  the  second  year  than  in  any  other.  This, 
in  all  probability,  is  connected  with  the  change  that  ensues  in  regard  to  diet,  upon 
the  child's  being  weaned.  Dr.  Cheyne,  whose  experience  of  croup  was  very  ex- 
tensive, says,  that  the  younger  children  are  when  weaned,  the  more  liable  are  they, 
cxteris  paribus,  to  this  malady.  From  the  second  year  onwards  the  number  of 
children  affected  with  croup  gradually  decreases.  Of  ninety-one  instances  referred 
to  by  Jurin,  one  only  was  after  the  tenth  year.  But  it  does  occasionally  happen 
subsequently  to  the  period  of  puberty,  and  up  to  the  twenty-first  year ;  and  even 
later.  A  girl  of  nineteen,  one  of  my  hospital  patients,  died  of  it.  Some  of  the  cases 
recorded  of  croup  in  the  adult,  were  probably,  in  reality,  cases  of  laryngitis. 

[We  Iiave  met  with  the  disease  most  frequently  in  children  between  ten  months  and  five 
years  old.  By  numerous  writers  the  occurrence  of  croup  previous  to  the  seventh  months 
has  been  denied  ;  others,  however,  declare  that  they  have  seen  it  to  occur,  as  a  primary 
disease,  repeatedly,  at  an  earlier  period. — C] 

It  is  curious  that  inflammation  should  thus,  at  different  epochs  of  life,  fix  itself  upon 
limited  portions  of  the  same  continuous  surface,  and  lead  to  consequences  so  diverse. 
We  are  unable  to  give  any  account  of  this. 

Cynanche  trachealis  is  frequently  preceded  by  a  slighter  and  more  diffused  affec- 
tion of  the  membrane  lining  the  air-passages.  The  child  has  what  is  popularly 
called  a  cold  ;  sneezes,  coughs,  and  is  hoarse.  Now  with  respect  to  this  last  symp- 
tom. Dr.  Cheyne  makes  the  following  practical  remark.  Hoarseness  (he  says)  in 
very  young  children,  does  not  usually  attend  common  catarrh.  When  noticed  in  a 
district  where  croup  is  not  unfrequent,  it  ought  to  put  the  parents  or  the  medical 
attendant  of  the  child  upon  their  guard  ;  especially  as  much  depends  upon  the  early 
treatment  of  the  disorder.  With  these  symptoms  the  child  is  feverish  and  fretfui, 
and  does  not  sleep  well.  In  the  course  of  a  day  or  two  the  signs  peculiar  to  croup 
begin  to  show  themselves :  they  are  well  stated  by  Cullen,  in  his  definition  of  the 
complaint.  "  Cynanche,  respiratione  difficili,  inspiratione  strepente,  voce  rauca, 
tussi  clangosa,  tumore  fere  nullo  in  faucibus  apparente,  deglutilione  parum  difficili, 
cum  febre  synocha."     These  are  the  phenomena  that  characterize  croup.     Di/fi- 


504  CYNANCHE   TRACHEALIS. 

culty  of  breathintr,  and  sonorous  inspiration.  The  last  is  often  almost  enough,  of 
itself,  to  identify  the  disease.  Hoarseness;  a  gruff  voice;  sometimes  a  total  loss  of 
the  power  of  vocal  speech.  A  very  peculiar  and  distinctive  cough,  to  which  the 
epithet  "brassy"  has  been  justly  applied  ;  the  noise  resembling  that  which  would  be 
occasioned  by  coughing  through  a  brazen  trumpet.  This  remarkable  sound  is 
always  easily  recognized  when  it  has  once  been  heard.  It  is  a  ringing  cough ;  and 
'.he  expiration  has  a  ringing  character ;  and  either  of  these,  the  cough  or  the  expira- 
tion, is  followed  by  a  loud  crotcing  inspiration.  Then  there  is  the  negative  symp- 
tom ;  the  absence  of  nny  difficulty  of  swallowing;  and  with  all  this,  inflammatory 
fever  ;  a  flushed  face,  hot  ."^kin,  a  frequent  hard  pulse,  thirst. 

However,  it  is  by  taking  the  symptoms  collectively,  that  we  judge  of  the  existence 
of  croup,  and  by  the  rapid  progress  of  the  disease,  rather  than  by  any  particular  or 
pathognomic  sign.  Some  of  the  symptoms  may  occur,  separately,  when  there  is  no 
croup.  The  brassy  or  metallic  cough,  for  instance,  has  been  known  to  accompany 
some  chronic  affections  of  the  larynx.  Dr.  Gregory — the  late  Edinburgh  Professor 
of  Physic  —  knew  a  man  with  a  venereal  disease  of  the  throat  who  coughed  so 
exactly  the  cough  of  croup,  that  he  was  admitted  into  the  clinical  wards  of  the 
infirmary  every  session  for  some  years,  that  the  students  might  have  an  opportunity 
of  hearing  this  peculiar  sound.  So  also  the  remarkable  crowing  inspiration  may 
take  place,  as  we  shall  soon  see,  without  croup. 

In  the  outset  the  fever  generally  runs  high ;  and  it  is  of  importance,  as  respects 
the  diagnosis,  to  mark  the  presence  or  the  absence  of  pyrexia.  As  the  obstruction 
to  the  passage  of  air  increases,  the  blood  ceases  to  be  duly  arterialized :  and  then, 
of  course,  the  skin  grows  dusky,  the  pulse  feeble  and  irregular,  the  extremities  cold. 
The  cough,  also,  as  the  malady  thus  goes  on  from  bad  to  worse,  ceases  to  be  loud 
and  clanging,  becomes  husky,  and  inaudible  at  a  short  distance,  and  the  voice  sinks 
into  a  whisper ;  the  head  is  thrown  back ;  the  nostrils,  in  perpetual  motion,  dilate 
widely ;  the  face  is  pale  and  livid,  and  sometimes  bloated ;  the  pupils  often  expand. 
When  these  indications  of  sinking  have  come  on,  the  case  usually  terminates  ill  : 
the  bottoms  of  the  feet  turn  black  and  hard ;  drowsiness  supervenes ;  some  tossing 
of  the  arms  perhaps ;  the  breathing  becomes  gasping  and  interrupted,  and  the  child 
dies  after  an  inspiration. 

In  other  cases  the  croupy  symptoms  make  their  attack  very  suddenly.  A  child 
shall  go  to  bed  apparently  well,  and  in  the  course  of  the  night  have  all  the  worst 
signs  of  the  disease.  And  it  is  observable,  that  whether  the  attack  be  altogether 
unexpected  or  whether  it  has  been  preceded  by  hoarseness,  sore-throat,  and  catarrh, 
it  usually  comes  on  in  the  night. 

[These  will  be  generally  found,  however,  to  be  cases  of  spasmodic  laryngitis  or  false  croup, 
and  to  be  unattended  witli  the  formation  of  false  membrane  in  the  larynx  or  trachea. — C] 

Croup  resembles  laryngitis  in  this  respect,  that  it  runs  its  course  rapidly,  proving 
fatal  sometimes  within  twenty-four,  and  often  within  forty-eight  hours.  It  may, 
however,  continue  for  five  or  six  days  before  it  terminates,  whether  death  or  recovery 
be  the  result.  Dr.  Craigie  affirms  that  it  is  never  protracted  beyond  the  eleventh  day  ; 
the  fatal  or  the  favourable  issue  having  always  taken  place  by  that  time.  Life  is  de- 
stroyed, in  pure  circumscribed  tracheitis,  by  the  accumulation  in  the  windpipe  of  a 
concrete  membrane-like  substance,  which  so  frequently  attends  this  disease,  and  is 
so  peculiar  to  it,  that  it  is  called  the  membrane  of  eroiip.  In  cases  of  recover}^  this 
substance  has  been  expectorated  in  the  form  of  a  nearly  perfect  tube,  representing  a 
cast  of  the  trachea;  at  other  times  it  is  coughed  up  in  flat  or  tubular  fragments.  In 
fatal  cases  it  is  found  sometimes  lying  in  close  contact  with  the  mucous  membrane, 
and  sometimes  quite  detached  from  it ;  so  that  it  might  have  been  expelled  without 
much  forcing  or  diflicultv,  if  the  child  could  have  sufficiently  inflated  its  lungs;,  and 
the  requisite  muscular  power  had  remained,  and  spasmodic  irritabihty  of  the  glottis 
had  not  op])osed. 

But,  in  many  instances,  this  albuminous  exudation  is  not  confined  to  the  trachea. 
It  often  stretches  down  to,  and  enters  the  ramifications  of  the  bronchi,  and  reaches 
••ven  to  their  termination  in  the  pulmonary  vesicles.     Sometimes  also  it  is  found 


CYNANCHE    TRACHEALIS.  505 

clothing  the  mucous  membrane  belonging  to  the  laryngeal  cartilages.  This  Dr. 
Craigie  denies.  But  I  show  you  two  specimens  in  which  the  false  membrane,  besides 
filling  the  trachea,  evidently  extends  into  the  larynx.  One  of  these  comes  from  the 
museum  up  stairs  ;  the  other  I  have  borrowed  from  the  Middlesex  Hospital  Museum: 
it  is  the  larynx  and  trachea  of  the  young  woman  whom  I  mentioned  just  now  as 
having  died  there  of  croup,  at  the  age  of  nineteen.  The  false  membrane  reached 
from  the  tip  of  the  epiglottis  to  the  bifurcation  of  the  trachea.  You  see  the  same 
thing  represented  in  this  excellent  plate  of  Dr.  Carswell's,  pictured  from  nature. 
Usually  the  adventitious  membrane  commences  just  below  the  larynx,  where  it  is 
thin  and  soft :  about  the  middle  of  the  windpipe  it  is  more  dense  and  firm ;  lower 
down  in  the  trachea,  and  in  the  bronchi,  it  is  generally  looser  again,  pulpy,  and 
broken:  it  sometimes,  I  repeat,  penetrates  to  the  very  air-cells.  What  are  called 
(absurdh'^  enough)  bronchial  polypi,  branch-like  casts  of  the  smaller  ramifications  of 
the  air-tubes,  are  then  apt  to  be  coughed  up.  And  even  when  this  concrete  substance 
is  not  formed,  we  have  other  evidence,  often,  of  the  extension  of  the  inflammation 
throughout  the  whole  downward  course  of  the  membrane. 

On  the  other  hand,  there  are  a  few  cases  in  which  this  adventitious  membrane  is 
not  formed  at  all ;  the  inner  surface  of  the  windpipe  is  seen  to  be  merely  reddened 
and  tumid,  and  covered  with  viscid  mucus ;  or  perhaps  with  a  shred  or  two  of  con- 
crete albumen  here  and  there. 

The  difficult}'-  of  breathing,  and  the  characteristic  sounds  that  accompany  it, 
depend,  in  part,  I  believe,  upon  spasmodic  contractions. of  the  small  muscles  of  the 
lar3nix ;  for  remarkable  aggravations  of  the  dyspnoea  are  apt  to  occur,  and  to  subside 
again  ;  and  these  aggravations  are  sometimes  brought  on  by  sudden  causes — by  the 
movements  of  deglutition,  for  example. 

I  shall  have  to  recur  to  this  spasmodic  constriction  of  the  glottis :  but  I  may  here 
remark,  that  because  it  has  not  been  (and  cannot  be)  seen,  doubts  have  been  expressed 
by  some  about  its  having  any  thing  to  do  with  the  dyspnoea.  Such  doubts  seem 
scarcely  reasonable.  It  is  easy,  at  any  time,  by  an  effort  of  the  will,  to  close  the 
glottis,  and  to  prevent  the  passage  of  air  to  and  from  the  lungs.  This  is  mainly 
effected  by  the  action  of  the  little  muscles  that  bring  together  the  arytenoid  cartilages. 
But  those  muscles,  like  the  other  muscles  concerned  in  respiration,  act  also  inde- 
pendently of  the  will,  spasmodically  therefore,  through  the  reflex  function  of  the 
spinal  cord.  And  it  is  by  a  providential  and  conservative  appointment  that  they  do 
so  act,  as  janitors,  admitting,  in  the  healthy  state,  the  vivifying  air,  but  barring  the 
door  against  certain  hurtful  gases,  and  against  solids  and  liquids  which  would  be 
injurious  to  the  respiratory  apparatus.  We  know  that  if  a  drop  of  water,  or  a  crumb 
of  bread,  or  a  whiff  of  carbonic  acid  gas,  gets  past  the  outer  defence,  the  epiglottis, 
and  into  the  larynx,  spasmodic  action  of  the  little  muscles  in  question  is  instantly 
excited.  We  cannot  see  these  intruders,  and  voluntarily  resist  their  entrance,  but 
the  unsleeping  sentinel  is  there  to  guard  the  passage.  We  may  well  conceive,  there- 
fore (and  I  know  not  how  the  supposition  can  be  disproved),  that  the  noisy  and  diffi- 
cult respiration  of  croup  may  be  caused,  in  part,  by  spasm. 

[As  further  evidence  of  the  correctness  of  this  remark  may  be  adduced  those  cases  in 
which  all  the  diagnostic  symptoms  of  croup  are  suddenly  in<Uiced  by  an  irritation  seated  in 
the  stomach,  as  from  indigestible  food,  &c.,  and  are  as  suddenly  removed  the  moment  the 
cause  of  irritation  is  expelled.  A  medical  friend  has  informed  us,  that  in  one  of  his  own 
children,  symptoms  resembling  croup  are  produced  by  eating  fish,  and  are  immediately  re- 
moved upon  the  operation  of  an  emetic. — C] 

The  presence  of  the  adventitious  tubular  membrane  in  the  trachea  affords  a 
plausible  explanation  of  one  of  the  symptoms  observed  in  these  little  patients ;  the 
tendency  they  show  to  throw  the  hea"d  back.  The  cylinder  of  the  membrane  is  kept 
open  in  that  position ;  whereas,  if  the  head  were  inclined  at  all  towards  the  chest, 
the  membrane  would  be  bent  upon  itself,  and  the  passage  through  it  obstructed. 

This  concrete  exudation  is  often  adduced  to  prove  that  the  mucous  membranes 
may  exhibit,  under  certain  circumstances,  the  phenomena  of  adhesive  inflammation. 
Similar  films  sometimes  form  upon,  or  are  thrown  off  by,  the  mucous  surfaces  of 
the  intestines,  and  of  the  uterus.     \Fhether  they  are  to  be  regarded  as  essentially 

2s 


506  CYNANCHE    IRACHEALIS. 

identical  with  the  layers  of  coagulable  lymph  poured  forth  in  inflammation  of  the 
serous  and  areolar  tissues,  may  be  made  a  question.  There  are  certainly  some  strong 
points  of  distinction  between  them.  The  concrete  membrane  of  croup  is  more 
brittle,  less  fibrous,  more  decidedly  albuminous,  than  the  false  membranes  that  cover 
the  inflamed  pleura,  pericardium,  or  peritoneum.  A  still  more  remarkable  difference 
is  this,  that  it  is  not  plastic,  in  the  sense  in  which  that  term  was  formerly  explained  ; 
it  never  becomes  organized,  never  connects  itself  by  blood-vessels  with  the  surface 
from  which  it  proceeds.  On  the  contrary,  it  is  partially  detached  ;  and  by  degrees, 
if  the  patient  live  long  enough,  it  is  completely  separated  from  the  subjacent  parts. 

Hypotheses  have  been  framed  to  account  for  the  limitation  of  this  product  of 
tracheal  inflammation  to  the  early  periods  of  life  ;  and  for  its  variation  from  the  usual 
products  of  inflammation  of  the  same  part.  Dr.  Stokes  thinks  that  the  predominance 
of  the  white  tissues  in  young  subjects  may  explain  the  greater  frequency  of  croup, 
with  its  peculiar  membrane,  in  infants.  Dr.  C.  B.  Williams  starts  the  very  reason- 
able supposition  that  the  inflammation  involves  the  submucous  areolar  tissue,  which 
is  abundant  during  youth ;  and  that  the  natural  product  of  this  phlegmonous  inflam- 
mation transudes  readily  through  the  thin,  simple,  and  delicate  mucous  membrane 
proper  to  that  age. 

The  formation  of  this  adventitious  membrane,  and  even  its  renewal,  appears  to  be 
sometimes  very  rapid.  1  have  here  a  preparation  made  by  the  late  Dr.  Sweatman, 
iflustrative  of  this.  It  now  belongs  to  the  Middlesex  Hospital  Museum.  Upon  a 
child,  on  the  very  brink  of  suflbcaiion  from  croup,  the  operation  of  tracheotomy  was 
performed,  at  one  o'clock  in  the  morning,  by  Mr.  Chevaher.  A  tubular  portion  of 
membrane,  of  the  shape  and  size  of  the  trachea,  was  presently  forced  through  the 
artificial  opening.  Immediately  the  child's  respiration  became  easy,  and  it  fell  asleep. 
In  the  course  of  the  same  morning,  Dr.  Sweatman  was  hastily  summoned,  and  arriv- 
ing at  eight  o'clock,  found  the  child  dead.  It  had  slept  six  hours,  and  upwards ;  and 
then  the  distress  of  the  breathing  had  returned,  and  was  soon  fatal.  The  trachea 
was  found  to  contain  a  new  tube  of  lymph,  or  of  concrete  albumen.  The  prepara- 
tion shows  that  such  a  membrane  may  re-form  in  that  short  space  of  time  ;  namely, 
in  from  six  to  seven  hours. 

The  croup  is  not  contagious ;  although,  like  cynanche  tonsillaris,  and  for  the  same 
reasons,  it  is  found  sometimes  existing  at  the  same  time,  or  in  quick  succession,  in 
more  than  one  child  of  the  same  famil\\  Thus  two  twin  children  of  Dr.  Gregory's 
were  seized  with  croup  on  the  same  night.  They  had  both  been  walking  in  the 
evening  on  the  sea-shore  during  a  cold  wind.  This  is  in  accordance  with  what  Dr. 
Cheyne  has  stated,  that  the  attack  is  almost  always  noctural,  and  often  when  the 
child  has  during  the  preceeding  day  been  exposed  to  the  weather.  It  frequently 
occurs  sporadically  ;  but  there  are  places  in  which  the  disease  appears  to  be  endemic. 
Dr.  Cheyne  found  it  so  on  the  coast  of  the  Frith  of  Forth.  Indeed,  the  first  distinct 
account  of  it  that  we  possess  was  drawn  up  by  Dr.  Home,  of  Edinburgh,  in  1705, 
from  much  personal  observation  of  its  ravages  in  Leilh  and  Musselburgh.  Cold  situ- 
ations— and  damp  places,  more  than  such  as  are  merely  cold — are  subject  to  the 
prevalence  of  this  disease,  it  is  accordingly  frequent  in  the  seasons  of  winter  and 
spring.  It  is  said  to  be  most  common  near  the  sea-shore,  and  in  the  neighbourhood 
of  large  bodies  of  water  generally.  It  occurs  in  low,  moist,  what  are  called  in  Scot- 
land came  districts,  more  than  in  upland  situations  that  are  more  exposed  to  cold 
winds.  It  is  more  common  at  Leith  than  it  is  in  Edinburgh  ;  and  in  Edinburgh,  it 
is  most  frequent  in  the  lowest  parts  of  the  town.  This  I  learned  from  Dr.  Alison, 
who,  having  long  been  physician  to  a  dispensary  there,  had  had  ample  means  of 
observing  the  disease.  Canal  Street  and  the  Cowgate,  both  low  spots,  as  some  of 
you  may  know,  have  long  been  famous,  or  rather  infamous,  for  cases  of  croup. 
Towns  situated  on  the  banks  of  rivers  are  more  than  commonly  visited  by  it;  and  it 
has  been  observed  to  be  particularly  frequent  among  the  children  of  washer-women 
in  such  places ;  and  thus  evidently  connected  with  exposure  to  moisture.  It  has 
been  known  to  prevail  epidemically  in  towns  so  situated  after  an  inundation.  And 
r)r.  Alison  has  made  a  very  curious  remark  respecting  it.  He  says  that  it  seems 
*x>  bi"  often  produced  by  the  child's  silling,  or  sleeping,  in  a  room  newly  washed: 


CYNANCHE    TRACHEALIS.  507 

and  that  he  has  noticed  its  frequent  occurrence  on  a  Saturday  night — ihe  only  day 
in  the  week  on  which  it  is  customary  for  the  lower  orders  in  Edinburgh  to  wash 
their  houses. 

Like  cynanche  tonsillaris,  and  unlike  cynanche  parotidcea,  the  croup  is  exceeding 
apt  to  recur.  Relapses  may  happen  within  a  few  days  after  apparent  recovery ;  and 
these  are  very  perilous.  But  besides  this  tendency  to  a  renewal  of  the  severer  symp- 
toms, the  little  patients  are  often  affected  with  cough,  and  hoarseness,  and  even  with 
aphonia,  for  a  long  lime.  And  Avhile  these  relics  of  the  acute  attack  continue,  it  is 
eajily  brought  back  again.  The  first  seizure  is  generally,  I  beheve,  the  worst :  but 
to  this  rule  there  are  numerous  exceptions. 

[The  remarks  contained  in  the  foregoing  paragraph  are  applicable  rather  to  Spasmodic  La- 
ryngitis than  genuine  croup. — C] 

Croup  is  a  disorder  which  justly  excites  extreme  alarm  in  the  friends  and  parents 
of  the  patient :  for  the  prognosis  can  never  be  better  than  doubtful.  It  is  said  that 
four  children  out  of  five  attacked  by  it  used  to  die  :  but  that  now,  the  treatment  being 
better  understood  than  formerly,  the  number  of  deaths  and  the  number  of  recoveries 
are  nearly  equal.  We  judge  of  the  probable  issue,  in  a  given  case,  by  the  apparent 
circumstances  and  progress  of  the  malady.  If  we  could  see  the  interior  of  the  air- 
tubes,  we  should  know  that  the  chance  of  escape  was  small,  in  proportion  as  the 
inflammation,  and  its  albuminous  product,  descended  along  the  ramifications  of  the 
bronchi.  But  in  these  little  patients,  and  amid  the  tracheal  noises,  it  is  difficult  to 
ascertain  the  physical  state  of  the  lungs.  The  prognosis  is  chiefly  to  be  collected 
from  the  general  condition  of  the  child.  If  the  distress  of  breathing  seems  to  remit, 
And  free  expectoration  to  come  on,  while  the  strength  is  yet  entire,  we  venture  to 
hope.  On  the  other  hand,  we  begin  to  despair  when  the  lips  are  becoming  blue,  the 
skin  is  losing  its  heat,  the  pulse  is  already  feeble  and  intermitting,  and  the  little  pa- 
tient is  drowsy  or  comatose :  in  other  words,  when  we  perceive  the  final  symptoms 
of  death  in  the  way  of  apnoea.  Some  few  patients  die  suddenly  and  unexpectedly 
without  any  previous  coma. 

The  mortality  will  differ  according  as  the  disease  is  detected  early,  and  treated 
vigorously, — or  otherwise.  And  with  respect  to  treatment,  there  is  no  specific  re- 
medy for  this,  any  more  than  for  any  other  inflammation.  We  must  put  in  force 
the  general  principles  upon  which  the  treatment  of  inflammation  is  founded ;  adapt- 
ing them,  however,  to  the  malady  in  question  by  those  particular  rules  which  the 
experience  of  the  best  observers  has  collected  for  our  guidance. 

I  need  scarcely  say  that  where  cough  and  catarrh,  and  especially  hoarseness  or  loss 
of  voice,  are  noticed  in  a  young  child,  he  should  be  narrowly  watched,  and  protected 
against  all  circumstances  likely  to  excite  or  to  aggravate;  inflammation  :  he  should 
be  kept  in  the  house,  and  put  upon  farinaceous  diet ;  and  the  functions  of  the  bowels 
and  of  the  skin  should  be  attended  to. 

The  three  remedies  that  most  require  consideration  are  blood-letting,  tartarized 
antimony,  and  calomel. 

Bleeding  is  to  be  unhesitatingly  employed  when  the  patient  is  strong,  and  ple- 
thoric, and  seen  in  the  outset  of  the  disease.  In  judging  of  its  mode,  and  of  its 
amount,  we  must  recollect  that  what  is  no  more  than  a  topical  bleeding  in  an  adult, 
becomes  equivalent,  in  its  effects  upon  the  system,  to  general  bleeding,  when  it  Is 
used  for  a  very  young  child.  Abstraction  of  blood,  by  venesection  or  cupping  in  the 
case  of  older  children,  and  by  leeches  in  the  case  of  infants,  should  be  practised 
whenever  the  symptoms  are  violent,  and  there  is  much  fever,  and  the  patient  is  seen 
within  a  few  hours  after  the  commencement  of  the  symptoms.  The  relief  that  is 
given  by  this  measure,  under  such  circumstances,  is  often  so  decided,  that  no  doubt 
can  remain  of  its  usefulness  and  propriety. 

It  is  impossible  to  lay  down  any  fixed  rules  for  the  quantity  of  blood  that  shoulo 
be  taken  in  this  complaint.  Under  two  years  of  age,  it  should  not,  sa3's  Dr.  Cheyne, 
exceed  five  ounces.  I  should  esteem  that  a  large  bleeding,  at  that  age.  Upon  an 
average,  a  moderate  bleeding  will  be  produced  by  the  application  of  a  couple  of 
leeches  to  an  infant  in  its  first  year:  and  an  additional  leech  may  be  employed  for 


508  CYNANCHE    TRACHEALTS. 

every  additional  year  :  so  that  six  may  be  put  to  a  child  five  years  old  ;  or  eight  if 
he  be  stout.  Dr.  Copland  estimates  the  amount  of  blood  which  these  patients  may, 
with  safety,  bear,  to  be  somewhat  more  than  an  ounce,  or  as  much  as  an  ounce  and 
a  half,  for  everj^  year  of  their  age.  Much,  however,  must  depend  upon  the  special 
circumstances  of  the  case:  the  quantity  of  blood  extracted  by  a  given  number  of 
leeches  is  less  in  one  instance  than  in  another;  and  then,  of  course,  the  number 
must  be  increased.  They  should  be  applied  at  the  upper  part  of  the  sternum,  and 
not  upon  the  throat  itself;  for  this  reason  : — that  the  pressure  which  may  be  neces- 
sary to  stop  the  bleeding,  or  to  regulate  its  quantity,  cannot  well  be  borne  upon  the 
throat  in  these  cases. 

After  one  sufficient  evacuation  of  blood,  whether  by  means  of  the  lancet,  or  of 
leeches,  or  of  cupping-glasses  applied  between  the  shoulders,  it  will  always  be  right, 
before  repeating  it,  to  ascertain  the  effects  of  other  measures  ;  such  as  emetics  and 
purgatives,  the  beneficial  operation  of  which,  in  this  disorder,  is  often  very  re- 
markable. 

Full  vomiting  sometimes  affords  relief  so  sudden  and  complete,  as  to  lead  to  the 
persuasion  that  the  symptoms  had  been  principally  owing  to  spasm.  And  eyen 
when  the  disease  is  unequivocally  inflammation — sometimes  even  late,  but  particu- 
larly in  the  early  part  of  its  course — the  effect  of  a  vomit  is  often  very  striking.  It 
promotes  expectoration  ;  and  is  not  unfrequently  followed  by  the  expulsion  of  shreds 
of  the  adventitious  membrane.  When  blood-letting  is  employed,  it  sliould  precede 
the  emetic ;  or,  at  any  rate,  it  should  precede  the  act  of  vomiting.  Dr.  Cheyne 
recommends  that  the  bleeding  should  be  practised  ten  minutes  after  the  emetic  has 
been  swallowed.  The  loss  of  blood  assists  the  operation  of  the  emetic,  and  lessens 
the  risk  (which  is  not  a  fanciful  one)  of  injurious  congestion  of  the  vessels  of  the 
head  during  the  straining  efforts  of  vomiting. 

It  is  desirable,  not  simply  to  excite  the  act  of  vomiting,  but  to  produce  and  to  pro- 
long a  state  of  nausea  and  faintness :  and  so  to  depress  and  to  keep  down  the  in- 
creased action  of  the  heart,  and  to  keep  empty  the  capillary  vessels  of  the  inflamed 
part.  Now  the  substance  best  adapted  to  this  purpose  is  tartarized  antimony.  This 
medicine,  as  I  have  often  mentioned  before,  has  great  power  over  inflammation  of 
the  mucous  tissues :  and  there  is  one  very  great  advantage  belonging  to  it  in  cases 
of  croup;  namely,  that  children  may  be  induced  to  take  it  without  their  knowing 
that  they  are  taking  medicine  ;  for  the  solution  of  it  has  little  or  no  taste  :  whereas 
the  struggling  which  is  often  occasioned  by  the  administration  of  other  emetics  may 
be  the  cause  of  much  inconvenience,  and  even  of  much  injury  to  the  patient.  It 
should  be  dissolved  in  boiling  water,  in  the  proportion  of  a  grain  to  an  ounce  ;  and 
the  cold  solution  given,  A  tea  or  a  dessert-spoonful  may  be  repeated  every  quarter 
of  an  hour,  till  some  efl^ect  is  produced.  When  vomiting  is  thus  excited  on  the  very 
first  appearance  of  the  symptoms,  and  before  the  disease  seems  thoroughly  formed, 
it  sometimes  puts  it  off:  so  that  no  other  treatment  remains  necessary  beyond  the 
exhibition  of  some  purgative  medicine.  But  if  this  perfect  relief  does  not  ensue 
upon  the  operation  of  the  emetic.  Dr.  Cheyne  advises  (and  this  is  in  conformity  with 
the  practice  of  many  other  persons),  that  a  powder,  consisting  of  two,  three,  or  foui 
grains  of  calomel,  with  two  or  three  grains  of  James's  powder,  should  be  given  at 
short  intervals;  every  two  or  three  hours,  for  example.  A  dose  of  castor-oil  is  to 
be  admmistered  occasionally,  to  clear  the  bowels.  And  another  expedient,  of  great 
efficacy  sometimes,  and  therefore  never  to  be  omitted,  is  the  warm  bath.  This  is 
often  properly  resorted  to  just  after  the  act  of  vomiting,  particularly  if  any  tendency 
to  perspiration  is  apparent.  The  temperature  of  the  water  should  not  be  lower  than 
98°  Fahrenheit;  and  the  child  should  remain  in  the  bath  for  ten  minutes  at  least. 
W'iien  taken  out,  he  should  be  wiped  dry,  and  put  immediately  into  bed  again. 
The  change  for  the  better  produced  by  the  bath  is  sometimes  so  marked  and  so 
speedy  as  to  strengthen  the  conclusion  that  the  most  distressing  of  the  symptoms  had 
•esulted  from  spasm. 

The  usual  efiect  of  calomel  thus  frequently  repeated  is  not,  as  in  adults,  that  of 
causing  salivation,  but  the  discharge  of  a  quantity  of  green  fecal  matter,  resembling 
chopped  spinach :  and  when  stools  of  this  kind  begin  to  make  their  appearance. 


CYNANCHE   TRACHEALIS.  509 

there  is  often  a  sensible  mitigation  of  the  symptoms.  The  green  colour  is  a  common 
consequence  of  mercury  given  to  young  children  ;  and  will  occur,  I  believe,  Avhat- 
ever  be  the  disease,  when  the  full  effect  of  calomel  as  a  purgative  is  obtained.  The 
green  matter  has  been  found,  after  death,  in  all  the  intestines,  small  as  well  as  large, 
up  to  the  duodenum.  I  presume  that  the  colour  is  owing  to  some  chemical  action 
that  takes  place  between  the  calomel  and  the  bile.  We  know  that  calomel  does 
tinge  bile  green  when  mixed  with  it  out  of  the  body.  It  may  be,  however,  that  the 
calomel  provokes  a  flow  of  altered  bile. 

Calomel,  thus  administered,  is  the  purgative  that  has  received  the  strongest  recom- 
mendations. Its  usefulness  appears  to  have  been  fully  borne  out  by  the  test  of  ex- 
perience :  and  the  well-known  virtue  belonging  to  mercury,  of  preventing  or  arrest- 
ing the  effusion  of  coagulable  lymph  in  other  textures,  has  formed  (I  conceive)  one 
cogent  reason  for  its  adoption  in  this  disorder,  of  which  the  chief  peril  results  from 
the  pouring  forth  of  the  albuminous  part  of  the  blood.  But  whether  mercury  really 
has  the  same  power  of  controlHng  adhesive  inflammation,  when  that  process  is  set 
up  in  mucous  tissues,  which  are  so  commonly  exempt  from  it,  may  be  questioned. 
On  the  other  hand,  the  effect  of  full  doses  of  tartar  emetic  in  restraining  active  inflam- 
mation of  those  tissues  is  well  ascertained :  and  I  should  certainly  make  use  of  it  in 
the  early  stages  of  this  dangerous  malady.  The  system  can  be  brought  to  feel  its 
decided  influence  with  much  more  certainty,  and  in  a  much  shorter  space  of  time, 
than  that  of  calomel :  and  if  it  fails  to  make  a  beneficial  impression,  it  need  not  long 
interfere  with  the  mercurial  treatment.  Let  me  quote  to  you  the  statement  of  Dr. 
Cheyne  (whose  experience  of  this  disease  was  far  ampler  than  mine  has  been,)  re- 
specting the  efficacy  of  tartarized  antimony  in  what  he  calls  the  second  stage  of 
croup.  He  recommends  that  half  a  grain,  dissolved  in  a  tablespoonful  of  water, 
should  be  given  to  a  child  two  or  three  years  old,  every  half  hour,  till  sickness  and 
vomiting  ensue.  In  two  hours  after  the  last  effort  of  vomiting,  the  same  process  is 
to  be  recommenced  ;  and  so  repeated  while  the  symptoms  require  it,  and  the  strength 
will  permit.  This  mode  of  treatment  was  suggested  to  him  by  the  accidental  ob- 
servation of  a  particular  case,  in  which  it  was  remarkably  successful.  From  that 
time  he  placed  his  whole  reliance  on  that  remedy  in  the  second  stage  of  croup ; 
especially  as  he  had  found  that  blood-letting  in  that  stage  only  accelerated  the  death 
of  the  patient.  He  noticed  that  the  cases  were  few  in  which  he  had  known  children 
survive  the  second  stage,  but  in  all  of  these  few,  they  recovered  while  using  a  solu- 
tion of  tartarized  antimony.  He  held  that  no  other  medicine  was,  at  that  stage  of 
the  disorder,  entitled  to  confidence.  In  short,  he  declared  that  tartar  emetic,  so  given 
as  to  produce  continued  nausea,  had  been  his  sheet-anchor,  in  the  treatment  of  croup, 
since  the  year  1799.  This  was  written  in  1801,  in  a  separate  work  on  the  patho- 
logy of  the  larynx  and  bronchi ;  and  Dr.  Cheyne  recently  has  affirmed,  in  the  Cy- 
clopfedia  of  Practical  Medicine,  that  he  still  found  reason  to  adhere  to  the  same 
opinions,  and  the  same  practice. 

Now  what  is  good  for  the  second  stage,  would,  a  fortiori,  I  think,  be  likely  to  save 
life,  if  employed  during  the  earlier  stage  of  the  disease.  I  therefore  should  say,  take 
blood  in  the  very  outset,  as  largely  as  may  seem  prudent :  then  give  the  tartar 
emetic  solution  in  the  way  already  described.  As  soon  as  it  causes  vomiting,  and 
pallor,  and  a  sinking  of  the  pulse,  stop  ;  and  suffer  the  heart  to  recover  itself.  And 
if,  with  the  rallying  circulation,  the  difficulty  of  breathing  returns,  have  recourse 
again  to  the  same  remedy.  The  faintness  and  collapse  are  sometimes  so  great  as  to 
threaten  the  extinction  of  life:  the  child,  with  a  flying  pulse,  and  a  clay-cold  sur- 
face, seems  gasping  its  last.  When  this  happens,  a  few  drops  of  sal  volatile,  or  of 
brandy,  mixed  with  water,  will  presently  bring  the  little  patient  round  again.  If  no 
ground  is  gained  after  two  or  three  repetitions  of  the  nauseating  treatment,  then  it 
will  be  well  to  make  trial  of  the  calomel  plan. 

Sometimes  the  tartar  emetic  acts  severely  on  the  bowels :  it  may  occasionally, 
therefore,  be  necessary  to  combine  with  it  a  small  quantity  of  syrup  of  poppies,  or 
of  laudanum. 

Blisters  are  often  applied  in  this  disease ;  but  with  very  questionable  propriety. 
In  the  outset  thev  are  likely  to  do  harm ;  in  the  advanced  periods  thev  are  not  likely 

2s2 


510  CYiNANCHE    TRACHEALIS. 

to  do  good.     If  used  at  all,  they  should  be  placed,  not  on  the  throat,  but  across  the 
upper  part  of  the  sternum. 

[We  do  not  approve  of  the  u«e  of  blisters  in  this  disease;  but  if  applied,  they  should  onlj 
be  kepi  on  for  a  few  hours,  so  as  to  tender  the  skin. — C] 

When  signs  of  approaching  death  have  come  on — lividity  of  the  lips,  coldness  of 
the  skin,  and  a  tendency  to  stupor,  the  question  ivill  obtrude  itself,  whether  there 
may  not  still  be  a  chance  of  saving  the  patient  by  performing  tracheotomy.  In  the 
first  place  you  will  consider  that  the  operation  is  much  more  difficult  to  execute  upon 
children  than  upon  adults ;  and  is  attended  with  more  perplexing  hemorrhaoe.  But 
there  is  a  greater  objection  than  this  to  tracheotomy  in  such  cases ;  an  objection 
which  you  will  have  anticipated,  namely,  the  existence  of  the  preternatural  membrane  ; 
which  often  extends  so  far  down,  that  air  would  not  be  admitted  into  the  lungs,  even 
if  an  aperture  in  the  windpipe  were  made  at  the  lowest  possible  point.  Another 
consideration,  forbidding  much  hope  of  success  from  this  expedient  at  any  period  of 
the  disease,  is  that  the  ramifications  of  the  bronchi  and  the  ultimate  air-cells  get  filled 
up  with  serous,  or  mucous,  or  puriform  matter,  or  even  sometimes  with  a  mem- 
branous exudation,  whereby  suffocation  is  effected  in  the  lungs  themselves.  The 
membrane  in  the  trachea,  being  tubular,  does  not  entirely  exclude  the  air  from  those 
organs  ;  but  it  does  not  admit  it  in  sufficient  quantity.  Tracheotomy  has  attain  and 
again  been  practised  in  this  complaint  to  no  purpose :  and  I  should  be  inclined  to 
look  upon  it  as  absolutely  hopeless,  but  for  two  instances  of  its  successful  perform- 
ance, recorded  in  the  Medico-Chirurgical  Transactions :  the  one  achieved  by  Mr. 
Andre,  and  related  by  Dr.  Farre,  in  the  third  volume  ;  and  the  other  by  iVlr.  Che- 
valier, in  the  sixth  volume.  These  were  both  apparently  desperate  cases.  Immediate 
relief  followed  the  operation  in  both,  and  the  patients  recovered  perfectly. 

There  seem  to  be  just  two  predicaments  in  which  there  is  a  chance  that  tracheo- 
tomy may  be  useful.  They  are  perhaps  rare  :  yet  they  have  been  noticed  by  several 
observers.  The  one  is  where  the  preternatural  membrane  extends  but  a  very  little 
way  down  the  trachea,  and  is  chiefly  confined  to  the  larynx ;  and  the  other  is  where 
there  is  no  preternatural  membrane  at  all,  or  only  a  very  slight  coating  in  some  part 
of  the  trachea,  the  impediment  to  the  breathing  having  arisen  mainly  from  the 
thickening  of  the  mucous  membrane.  And  you  will  observe  that  an  impediment 
from  this  cause  will  always  be  the  greatest  at  the  narrowest  part  of  the  canal:  and 
therefore  incision  of  the  windpipe  in  such  a  case  may  be  expected  to  bring  relief. 
The  effect  produced  by  the  tracheotomy  in  Mr.  Chevalier's  case  was  very  instruc 
tive.  Air  was  fully  inspired  through  the  opening,  then  a  strong  cough  took  place, 
by  which  a  large  quantity  of  viscid  reddish  mucus  was  forced  out  by  the  natural 
channel,  through  the  glottis.  It  was  evident  that  the  child  could  not  expectorate  before, 
simply  because  it  could  not  sufficiently  fill  its  lungs  with  air  to  drive  the  collected 
mucus  out.  Dr.  Farre  gives  a  circumstantial  account  of  a  case  in  which  the  adven- 
titious membrane  did  not  reach  more  than  a  finger's  breadth  below  the  cricoid  car- 
tilage ;  and  the  rest  of  the  tube  was  so  free  that  he  was  convinced  the  child's  fife 
might  have  been  saved  by  a  timely  opening  into  the  trachea.  Unfortunatelj',  we 
cannot  tell,  before  death,  to  what  degree  or  extent  the  preternatural  membrane  exists. 
All  that  can  be  said,  I  think,  is,  that  when  dyspnoea  and  much  croup  come  on  sud- 
denly or  quickly,  the  disease  is  probably  limited  to  the  larynx  and  upper  part  of 
the  windpipe :  but  that  when  the  progress  of  the  disorder  is  slower,  and  the  croupy 
symptoms  are  not  so  well  marked,  it  is  more  likely  that  a  greater  extent  of  the  tra- 
chea, below  the  larynx,  participates  in  the  mischief.  Our  expectations  of  success 
from  tracheotomy  will  vary  accordingly.  It  affords  a  bad  chance  at  the  best ;  but  it 
affords  also,  in  many  cases,  the  only  chance. 

[The  subject  of  tracheotomy  in  croup  is  one  of  considerable  interest. — That  it  may,  in 
many  cases,  •when  timely  performed,  save  the  life  of  the  patient,  we  have  the  most  unques- 
tionable evidence.  In  a  statement  by  M.  Trousseau  of  the  result  of  the  operation,  as  per- 
formed by  himself,  and  by  others,  according  to  his  method,  in  one  hvmdred  and  fifty  cases, 
the  patients  were  saved  in  thirty-nine.  In  the  case  of  his  own  child,  three  weeks  old,  re- 
cently published  by  Dr.  Scoutetten,  the  operation  was  performed  on  the  thi^  day  of  the 
ilisease,  under  circumstances  apparently  the  most  desperate,  with  complete  success — the 


I 


CYNANCHE    TRACHEALIS.  511 

infant  recovering  in  a  short  time  from  the  effects  of  the  operation  as  well  as  from  every 
symptom  of  the  croup.  The  class  of  cases,  the  period  and  particular  circumstances  of  the 
disease  in  which  the  operation  is  most  likely  to  atford  relief,  are  questions  of  no  little  im- 
portance, and  we  believe  that  much  of  the  want  of  success,  which  many  practitioners  have 
experienced  in  performing  the  operation,  is  to  be  attributed  to  its  having  been  resorted  to 
under  improper  circumstances.  M.  Trousseau,  whose  experience  on  this  subject  has  been 
somewhat  extensive,  has  presented  the  following  as  a  summary  of  the  prognosis  of  tracheo- 
tomy in  croup — 

"  1st.  If  the  commencement  of  the  attack  dates  several  days  back,  if,  consequently,  the 
disease  has  advanced  slowly,  whatever  may  be  the  extent  of  the  false  membranes  in  the 
trachea  and  bronchi,  the  children  either  recover,  or  live  at  least  several  days  after  the  ope- 
ration. 

"  2d.  But  if  the  disease  has  been  very  rapid,  even  although  at  the  time  of  the  operation, 
we  ascertain  that  the  false  membranes  do  not  extend  beyond  the  larynx,  the  children  die 
very  quickly. 

"3d.  If  previous  to  the  operation,  the  false  membranes  have  extended  to  the  nares,  or  if 
they  cover  the  blistered  surfaces ;  if  the  child  is  pale  and  somewhat  bloated,  without  hav- 
ing taken  mercury  or  been  bled,  or  if  he  has  lost  much  blood,  there  is  little  chance  of  tha 
operation  succeeding. 

"  -Itli.  If  previous  to  the  operation,  the  pulse  is  moderately  frequent,  and  if,  after  it,  the 
pulse  remains  calm,  hopes  may  be  entertained. 

"  5th.  It  is  a  bad  sign,  if,  immediately  after  the  operation,  the  respiration  becomes  very 
frequent,  without  any  cough  or  with  very  little. 
"  Otli.  More  boys  than  girls  are  cured. 

*^  7tli.  Children  under  two,  and  over  six  years  of  age,  rarely  recover. 

"  Stli.  The  more  deeply  the  false  membranes  have  extended,  the  greater,  ccBteris  paribus^ 
the  danger. 

"  9th.  If  the  child  has  been  subject  to  chronic  catarrlis,  and  if  he  had  been  suffering  from 
a  cold  for  some  time  when  he  was  attacked  with  the  croup,  tracheotomy  is  rfiore  successful. 
"  10th.  Even  when  all  is  going  on  favourably,  very  great  frequency  of  respiration  is  a  bad 
sign. 

'  1 1th.  The  more  rapid  and  energetic  the  inflammation  which  attacks  the  wound  in  the 
trachea,  the  better  are  the  chances  of  success — a  sudden  sinking  of  the  wound  is  a  mortal 
sign. 

"  r2th.  So  long  as  the  respiration  is  silent  or  the  noise  is  only  occasioned  by  the  displace- 
ment of  inucosity,  there  is  nothing  to  fear;  but  when  the  respiration  becomes  saw-like  (ser- 
ratiquc),  in  other  words,  when  it  is  attended  with  a  sound  like  that  produced  by  a  saw  cut- 
ting stone,  death  is  certain. 

'•13th.  Tliere  is  no  reason  to  despair  of  the  patient,  even  if  a  pneumonic  or  pleuritic 
attack  should  supervene. 

"  14th.  Agitation  and  sleeplessness  are  bad  signs. 

"  15tli.  Should  the  wound  become  covered  with  false  membranes;  if,  after  withdrawing 
the  canula,  it  remains  gaping  for  a  long  time,  or,  if  after  having  become  entirely  cicatrized 
it  reopens  largely,  the  child  is  in  danger. 

"  IGth.  The  sooner  after  the  operation  the  larynx  is  disembarrassed,  the  sooner  may  we 
remove  the  canula,  and  the  more  rapid  and  certain  is  the  cure. 

"  17th.  If  the  croup  supervened  upon  rubeola,  scarlatina,  variola  or  pertussis,  although 
tliere  is  not  ordinarily  any  connection  between  the  malignant  angina  and  these  pyrexia, 
tracheotomy  does  not  succeed. 

"  ISth.  If  the  expectoration  becomes  mucous  and  catarrhal  by  the  third  day  after  the  ope- 
ration, the  children  will  recover.  If  there  is  no  expectoration,  or  it  is  serous,  or  like  half- 
dried  portions  of  gum  Arabic,  they  will  die. 

"  19th.  If  the  patients  react  vigorously  under  tlie  injections  into  the  trachea  of  water  or 
nitrate  of  silver,  and  under  the  sponging  out  of  the  trachea,  we  should  not  despair,  how- 
ever unfavourable  may  be  the  other  signs. 

"  20th.  Children  attacked  with  convulsions  after  the  operation  die,  and  the  younger  the 
patients  and  the  more  blood  they  have  lost  before  or  during  the  operation,  the  more  often 
convulsions  supervene. 

"  21st.  When,  after  the  tenth  day,  the  drinks  pass  almost  entirely  from  the  pharynx  into 
tlie  larynx  and  trachea,  even  if  they  are  readily  rejected,  the  children  most  generally  die. 

"  22il.  The  increase  of  the  lever  after  the  fourth  day,  agitation,  sinking  of  the  wound,  and 
dryness  of  the  trachea,  frequency  of  the  respiratory  movements,  and  attempts  to  cough, 
announce  the  invasion  of  pneumonia,  which,  at  first  lobular,  becomes  sometimes  pseudo- 
Icbar,  and  is  to  be  treated  by  the  same  means  as  are  usually  employed  in  the  pneumonia 
of  chilflren  ;  we  should,  however,  exclude  blisters,  because  they  too  often  become  covereil 
with  false  membranes."     (See  Rilliet  and  Barthez,  Traiti  des  Mai.  des  Enfans,  t.  i  365-'' 


512  CHILD-CROWING,  OR 

There  is  a  sort  of  bastard  croup,  with  which  it  is  quite  necessarj'^  that  you  should 
be  acquainted,  for  it  is  not  at  all  uncommon ;  nay,  it  is  far  more  common  in  this 
place  at  least,  than  the  real  disease.  It  has  received  a  variety  of  names,  which 
shows  that  it  has  been  recognized,  as  a  distinct  maladj%  by  various  observers.  Yet 
no  doubt  can  be  entertained  that  it  has  very  often  indeed  been  confounded, — and  is 
still  continuall)'  confounded, — with  the  true  croup,  with  cynanche  trachealis.  In 
their  most  obvious  symptoms  the  two  affections  are  much  alike.  The  broad  and 
essential  distinction  between  them,  is  the  absence,  in  the  spurious  disorder,  of  inflam- 
mation and  of  fever — and  consequently  of  any  concrete  or  other  effusion  from  the 
mucous  membrane  of  the  air-passages.  The  child  is  seized  all  of  a  sudden,  roused 
perhaps  from  its  sleep  by  a  catch,  or  interruption  of  its  breathing,  more  or  less  com- 
plete. It  strives  and  struggles  to  inspire,  but  is  apparently  unable  to  do  so ;  at 
length  the  effort  is  successful,  and  the  breath  is  drawn  in  with  a  shrill  whistling  or 
crowing  sound,  like  that  which  characterizes  the  inspirations  of  croup,  or  of  hooping- 
cough,  and  depending,  no  doubt,  upon  the  same  cause — a  narrowing  (in  this  com- 
plaint temporary)  of  the  fissure  of  the  glottis.  Spasmodic  croup  is  the  most  com- 
mon of  its  names.  It  is  the  thymic  asthma  of  the  Germans.  My  late  colleague. 
Dr.  Ley,  in  a  volume  upon  this  curious  disorder,  published  a  short  time  before  his 
death,  adopts  from  Dr.  Mason  Good  the  appellation  oi  laryngismus  stridulus.  Dr. 
Gooch  called  it  child-crowing,  a  homespun  term,  which  I  must  prefer  to  the  some- 
what pedantic  and  cacophonous  title  bestowed  upon  it  by  Dr.  Good.  The  crowing 
noise,  and  its  concomitant  phenomena,  take  place  in  paroxysms,  which  vary  in  re- 
spect to  frequency  and  severity,  and  which  are  separated  by  intervals  of  easy  and 
natural  breathing. 

"When  the  closure  of  the  chink  of  the  glottis  is  not  perfect,  the  child  struggles 
for  its  breath  :  the  respiration  is  hurried  ;  the  countenance  generally  bluish  or  livid  ; 
the  ej'es  staring ;  and  each  inspiration  is  attended  with  a  crowing  noise.  When 
the  closure  is  more  complete  (and  this  state  was  found  by  Dr.  Ley,  whose  words  I 
am  now  quoting,  to  be  much  the  most  frequent  at  the  commencement  of  the  pa- 
roxysm), the  function  of  respiration  is  entirely  suspended  for  a  while  ;  there  is  an 
effectual  obstacle  to  the  admission  of  air.  The  child  makes  vehement  struggles,  by 
some  termed  convulsive,  to  recover  its  breath.  At  varied  intervals,  from  a  few 
seconds  up  to  a  mmute,  or  upon  some  occasions  nearly  two  minutes,  air  is  at  length 
admitted  through  the  glottis,  now^  partially  open ;  and  this  rush  of  air,  passing 
through  a  very  narrow  chink,  produces  the  peculiar  sound.  To  these  symptoms  not 
unfrcquently  succeed  a  fit  of  coughing  or  crying,  which  terminates  the  scene  :  or,  if 
the  glottis  be  not  thus  partially  open,  the  child,  at  the  end  of  from  two  to  three 
minutes  at  the  utmost,  w^ill  die  suffocated.  Pallid  and  exhausted,  it  falls  lifeless 
upon  its  nurse's  arms ;  and  it  is  then  that  the  child  is  generally  said  to  have  died  in 
a  fit." 

Sometimes,  but  not  always,  with  the  symptoms  now  described  there  is  a  con- 
tracted state  of  the  flexor  muscles  of  the  thumb,  fingers,  wrist,  ankle,  and  toes ; 
giving  to  the  foot  an  appearance  approaching  to  that  of  club-foot. 

Now  till  very  lately  most  of  those  persons  who  had  learned  not  to  confound  this 
child-crowing  with  true  croup,  were  of  opinion  that  it  depended  upon  cerebral  disease 
or  disorder.  This  was  the  doctrine  of  Dr.  John  Clarke,  who  has  left  a  very  good 
description  of  the  complaint,  which  he  called  "a  peculiar  species  of  convulsions." 
Dr.  Ley  doubted  the  correctness  of  that  notion,  and  believed  that  the  bending  of  the 
limbs  results  rather  from  feebleness  or  paralysis  of  the  extensor  muscles,  than  from 
spasmodic  contraction  of  the  flexors.  It  was  obviously  a  great  point  to  make  out, 
whether  the  disorder  depends  upon  pressure  within  the  head  or  not.  Our  treatment 
will  be  regulated  by  what  we  know,  or  believe,  in  that  respect.  But  what  is  chiefly 
original,  and  very  interesting,  in  Dr.  Ley's  views  concerning  this  bastard  sort  of 
croup  is  this,  that  he  attributes  the  temporary  closure  of  the  glottis  to  pressure  made 
by  enlarged  glands  in  the  neck  or  chest  upon  the  recurrent  nerve,  or  upon  some  part 
of  the  eighth  pair ;  "  subverting  the  exact  antagonism  by  which  the  glottis  is  automa- 
tically and  involuntarily  kept  open,  and  allowing  its  margins  to  come  together,  and 
to  occasion  the  peculiar  kind  of  inspiration  so  much  hke  that  of  croup."     Dr.  Lev 


SPURIOUS    CROUP.  513 

looks  upon  the  aflection  altogether  as  more  allied  to  paralysis  than  to  convulsive 
movements.  This  certainly  is  a  very  original,  but,  I  think,  a  mistaken  view  of  the 
matter ;  1  must  refer  you,  however,  to  his  book  for  the  facts  and  reasonings  upon 
which  it  is  founded.  The  important  practical  fact  is,  the  connection  of  the  child- 
crowing  with  tumefaction  of  the  glands  in  the  neck  and  chest,  and  with  the  entangle- 
ment of  the  pneumogastric  nerve  or  its  branches  among  these  glands.  "  Scarcely 
an  instance  (says  he)  has  occurred  to  me  since  my  attention  has  been  very  much 
directed  to  the  subject,  in  which  there  has  not  been  the  strongest  foundation  for  the 
belief  that  either  the  glandulte  concatenatae  of  the  neck,  or  the  thoracic  absorbent 
glands,  had  become  morbidly  enlarged." 

Even  in  the  short  period  that  has  elapsed  since  Dr.  Ley  wrote,  this  curious  and 
intricate  knot  has  been  somewhat  further  (though  perhaps  it  is  not  yet  completely) 
untwisted.  Dr.  J.  Reid  has  ascertained,  by  a  well-contrived  set  of  experiments,  that 
the  inferior  laryngeal  (or  recurrent)  nerve,  is  an  efferent  or  motor  nerve,  by  which 
nearly  all  the  movements  of  the  larynx  are  regulated  ;  and  that  the  superior  laryn- 
geal is  an  afferent  or  incident  nerve.  We  may  easily  conceive,  therefore,  how 
pressure  upon,  or  irritation  of  either  of  these  nerves,  may  affect  the  aperture  of  the 
glottis.  If  the  superior  laryngeal  nerve  be  implicated,  the  impression  is  communi- 
cated to  the  spinal  cord,  and  thence  reflected,  through  the  recurrent,  upon  the  laryn- 
geal muscles.  Irritation  of  the  gastric  ramifications  of  the  par  vagum  may  have 
the  same  result.  It  is  an  observation  of  Dr.  John  Clarke's,  that  the  attacks  "  very 
commonly  take  place  after  a  full  meal."  Nay,  it  seems  probable  that  not  only  any 
of  the  afferent  fibrils  of  the  eighth  pair  of  nerves,  but  those  of  the  fifth  pair  also  may 
have  a  similar  exciting  power;  for  a  transient  crowing  is  readily  produced  in  some 
children,  by  exposure  of  the  surface  of  the  face  and  chest  to  a  breeze  of  wind,  or 
by  their  being  suddenly  tossed  in  the  arms  of  a  nurse.  We  must  even  suppose  that 
the  effect  produced  upon  the  central  cord  may,  by  reflexion,  influence  other  muscles, 
and  cause  the  contractions  that  are  sometimes  observed  in  the  flexors  of  the  feet  and 
hands.  Again,  if  the  recurrent  nerve  itself  be  pressed  upon,  or  interfered  with, 
undue  contraction  or  paralysis,  according  to  the  kind  and  degree  of  interference,  will 
be  likely  to  ensue  of  the  muscles  belonging  to  the  glottis.  Spasm  of  those  muscles 
would  close  the  chink,  and  stop  the  breath.  And  Dr.  Reid  has  shown  that  their 
palsy,  except  while  tlie  breathing  is  perfectly  quiet  and  tranquil,  sensibly  impedes 
inspiration,  and  alters  its  character. 

It  appears,  therefore,  that  the  ingenious  view  taken  by  Dr.  Ley  of  the  special 
pathology  of  this  child-crowing  disorder,  or  croup-hke  convulsion,  merges  in  the 
more  general  principles  of  reflex  function  advanced  by  Dr.  Marshall  Hall. 

At  the  same  time  it  is  interestiug  to  observe  how  Dr.  Ley's  theory  harmonizes 
with  what  has  been  noticed  of  the  predisposing  causes  of  this  crowing  inspiration. 
In  the  first  place,  it  is  often  manifestly  connected  with  dentition.  Now  one  effect 
of  dentition  is  the  production  of  glandular  swellings  of  the  neck,  which  happen  even 
in  the  absence  of  all  strumous  taint,  but  with  still  more  certainty  if  any  such  taint 
exists.  And  thus  he  explains  the  feet,  that  the  disorder  has  appeared  in  the  most 
robust  as  well  as  in  the  most  delicate  infants.  Thus,  also,  he  explains  another  well- 
known  fact,  viz.,  that,  when  child-crowing  accompanies  painful  dentition,  the  sj^mp- 
toms  do  not  vanish  instantaneously,  as  if  by  magic,  the  moment  that  the  tooth  starts 
through  the  gum,  but  pass  off  by  degrees.  Dr.  Ley  remarks  that,  "  after  the  gum 
and  enveloping  membrane  of  the  tooth  have  been  relieved  from  swelling  and  inflam- 
mation, by  the  free  use  of  the  gum-lance,  some  time  is  still  required  for  the  irritation 
and  tumid  state  of  the  cervical  glands  to  subside."  It  is  not  improbable  that  the 
gingival  irritation  alone  may  sometimes  suffice,  through  the  channel  of  the  trifacial 
nerve,  to  determine  the  reflex  spasm. 

Again,  this  child-crowing  is  found  to  occur  in  connection  with  excoriations  behind 
the  ears,  and  with  inflamed  and  irritable  scalp ;  and  these  complaints  very  frequently 
lead  to  enlargement  of  the  absorbent  glands  of  the  neck,  which  enlargement  may 
thus  form  an  intermediate  link  in  the  chain  of  events.  And  upon  some  occasionV 
Dr.  Ley  has  had  strong  reason  to  suspect  that  bronchitis,  or  other  disease  of  thr 
33 


514  CIIILD-CROWING,    OR 

kings,  has  occasioned  enlargement  of  the  bronchial  glands,  and  so  given  rise  to  the 
crowing  inspiration. 

I  think  that  Dr.  Ley  has  made  out  fair  grounds  for  his  view  of  the  patholog}'  of 
what  is  called  spasmodic  croup.  But  it  is  too  partial  and  limited  a  view.  Again, 
the  alleged  connection  between  child-growing  and  cerebral  disturbance  is  not  a  mere 
fancy  although  its  bearing  may  have  been  sometimes  misapprehended.  The  cere- 
bral disturbance  is  mostlj'  the  consequence,  and  not  the  cause,  of  the  impediment  to 
the  function  of  respiration. 

[We  doubt  the  correctness  of  Dr.  Ley's  views,  as  well  as  the  views  of  those  who  refer 
ihe  disease  to  enlargement  of  the  thymus  gland. — For  an  examination  of  the  facts  connected 
with  the  pathology  o(  laryngismus  stridulus,  the  reader  is  referred  to  the  Editor's  Treatise  on 
the  Diseases  of  Children,  page  311,  et  seq. — C] 

The  practical  fact  which  you  have  to  remember  is,  that  croupy  breathing  may 
occur,  and  return  in  paroxysms,  when  there  is  no  croup.  And  the  practical  lesson 
which  you  have  to  learn  is,  how  to  discriminate  between  these  two  similar,  yet  dif- 
ferent disorders.  I  have  already  specified  the  distinctive  characters  of  cynanche 
trachealis.  The  complaint  that  copies  it  may  be  known  by  its  sudden  accession  and 
its  sudden  departure ;  by  the  freedom  of  breathing  in  the  intervals  between  the  pa- 
roxysms ;  by  the  absence  of  fever,  of  preceding  or  present  catarrh,  of  hoarseness, 
and  of  any  abiding  cough.  The  diagnosis,  easily  enough  reached  when  these  points 
are  sufficiently  attended  to,  will  be  still  more  sure,  if  you  discover  enlarged  glands  in 
the  neck  ;  or  hot,  tense,  and  tender  gums. 

According  to  Dr.  Clarke,  "  convulsions  of  this  description  seldom,  if  ever,  occur 
after  the  expiration  of  the  third  year  of  a  child's  life." 

It  must  be  necessary  for  me  to  urge  the  importance  of  the  diagnosis.  Those 
active  measures  which  befit  the  outset  of  the  inflammatory  disease,  would  be  mis- 
placed and  mischievous  in  the  other.  It  was  the  result  of  Dr.  Ley's  experience  that 
"those  children  have,  upon  the  whole,  a  much  better  chance  of  being  preserved, 
who  are  not  subjected  to  very  sev'ere  discipline,  than  those  who,  in  compliance  with 
the  prevailing  doctrine,  have  been  treated  by  very  copious  bleeding,  large  doses  of 
calomel,  and  such  other  remedies  as  the  supposition  of  the  invariable  dependence 
of  the  disease  upon  cerebral  turgescence,  or  excitement,  has  suggested." 

Do  not,  however,  imagine,  from  vvhat  I  have  just  been  saying,  that  this  disorder, 
child-crowing,  is  a  trifling  disorder,  and  unattended  with  danger.  It  is  really  a 
perilous,  as  well  as  a  terrifying  condition.  The  respiration  is  sometimes  so  long 
suspended  that  death  takes  place  in  the  paroxysm.  And  each  paroxysm  is  accom- 
panied by  a  tendency  to  stagnation  and  congestion  of  blood  in  the  brain,  lungs,  and 
heart :  a  tendency  which,  by  its  frequent  repetition,  may  lay  the  foundation  of  serious 
and  fatal  disease  in  one  or  other  of  those  vital  organs. 

The  treatment  of  this  affection  must  depend  a  good  deal  upon  the  nature  of  the 
predisposing  and  exciting  causes.  To  go  into  it  fully  would  require  that  I  should 
speak  of  the  mode  of  cure  in  painful  dentition,  in  eruptive  complaints  about  the  head, 
in  ceitain  pulmonary  and  cardiac  diseases,  and  in  all  those  conditions  which  are  apt 
to  cause  enlargement  of  the  catenated  or  bronchial  glands  ;  or  to  fret  in  some  other 
way  the  pneumogastric  nerves. 

In  addition  to  the  special  methods  of  treatment  which  these  disorders  may  severally 
need,  great  care  must  be  taken,  in  all  cases,  to  regulate  the  state  of  the  bowels,  and 
of  the  skin.  Fresh  air  also  is  a  powerful  adjuvant ;  and  sometimes  of  itself  a  suffi- 
cient remedy.  Change  of  place,  therefore,  and  especially  a  removal  from  the  air 
of  a  city  or  town  to  the  pure  atmosphere  of  the  country,  should  be  urged  whenever 
it  is  practicable. 

In  the  paroxysm  itself  the  warm  bath  might  be  useful,  if  it  could  be  got  ready  in 
time.  The  application  to  the  throat  of  a  large  sponge  from  which  hot  water  has  just 
been  squeezed,  is  a  more  accessible,  and  often  a  very  effecfual  expedient.  Sprinkling 
ihe  face  and  chest  freely  with  cold  water  will  sometimes  unlock  the  spasm,  and  set 
Jne  little  sufferer  free. 
1  sbouldjiave  stated,  that  Dr.  Ley's  views  were  amply  supported  by  the  researches 


SPURIOUS    CROUP.  515 

that  he  had  made  in.to  the  morbid  anatomy  of  this  affection.  Had  he  lived,  I  should 
have  had  it  in  my  power  to  show  you  some  very  beautiful  and  interesting  prepara- 
tions, illustrative  of  the  connection  of  the  disorder  with  enlarged  glands,  which  had 
come  to  press  upon,  or  stretch,  the  par  vagum,  or  its  branches.  As  it  is,  I  can  only 
show  you  the  published  engraving  from  some  of  them,  appended  to  his  book. 

[Spasmodic  Laryngitis  or  False  Croup  is  a  disease  bearing  many  of  the  characteristics 
of  genuine  croup,  and  has  no  doubt  been  frequently  confounded  with  it.  It  diliers  from  it, 
however,  in  the  absence  of  any  tendency  to  the  formation  of  false  membranes  in  the  larynx 
or  trachea,  and  in  being  a  far  more  manageable  and  less  fatal  disease. 

The  attack  of  spasmodic  laryngitis  is  usually  preceded  by  slight  catarrhal  symptoms ; 
coryza,  watering  of  the  eyes,  a  sense  of  chilliness  followed  by  flushes  of  heat;  slight  hoarse- 
ness and  some  cough.  Th&se  symptoms  may  continue  for  twenty-four  or  forty-eight  hours  before 
a  paroxysm  of  the  disease  is  observed.  In  general  this  occurs  at  night ;  the  child  being  sud- 
denly awoke  from  its  sleep  by  a  sense  of  impending  suffocation.  He  starts  up  in  a  sitting 
posture,  or  throws  himself  forwards  on  his  knees.  He  cries  out  that  he  is  choking,  seems 
anxious  for  air,  tears  off  every  covering  from  his  throat,  and  pushes  away  all  who  sur- 
round or  offer  to  assist  him.  The  face  becomes  swollen  and  of  a  dark  red  or  violet  hue  , 
the  eyes  projecting  and  humid,  and  the  expression  of  the  countenance  extremely  anxious. 
The  inspiration  is  long  and  hissing ;  and  so  loud  as  occasionally  to  be  heard  in  an  adjoining 
apartment.  There  is  also,  at  intervals,  a  frequent  hoarse  cough.  The  voice  is  constrained, 
but  seldom  whispering  or  abolished.  The  pulse  is  quick,  and  the  skin  hot.  In  a  short  time 
the  paroxysm  ceases,  and  the  patient  falls  asleep.  The  disease  may  be  confined  to  a  single 
paroxysm.  2More  commonly,  however,  the  child  continues  during  the  ensuing  day  tolerably 
well,  excepting  perViaps  that  he  is  somewhat  hoarse  and  has  an  occasional  short  barking 
cough,  with  or  without  expectoration;  and  on  the  succeeding  night  is  again  attacked  with  a 
paroxysm  as  on  the  night  previous.  The  disease  may  continue  thus,  with  one  or  two 
paroxysms  each  night,  for  several  days,  when  the  paroxysms  will  cease  to  recur,  and  the 
cough  and  other  symptoms  speedily  disappear.  In  some  cases,  however,  the  paroxysms  con- 
tinue to  recur  at  shorter  intervals,  and  gradually  augmenting  in  intensity,  the  patient  dies 
from  asphyxia,  or,  in  other  cases,  after  one  or  more  paroxysms,  he  becomes  affected  with 
the  utmost  inquietude,  with  almost  constant  nausea  and  repeated  vomiting,  with  symp- 
toms of  great  exhaustion,  cold  extremities,  and  a  small  frequent  pulse,  and  soon  dms. 
Usually,  however,  the  disease  is  one  very  readily  controlled,  and  has  seldom  a  fatal  um 
mination. 

Spasmodic  laryngitis  is  very  liable  to  recur  after  three,  six,  nine  months  or  a  year,  or 
whenever  the  child  is  exposed  to  cold  and  damp,  or  during  seasons  marked  by  sudden 
vicissitudes  of  temperature. 

Barthez  and  Rilliet,  by  whom  the  term  spasmodic  laryngitis  has  been  given  to  the  disease, 
believe  it  to  be  dependent  upon  an  actual  but  slight  inflammation  of  the  larynx.  This  opinion 
is  based  upon  the  fact  that  its  attacks  generally  follow  sudden  exposure  to  cold,  and  by  its 
being  preceded  by  catafrhal  symptoms,  and  being  attended  by  some  degree  of  febrile  excite- 
ment. In  connection  with  this  mild  bronchitis  there  occurs  also  a  spasmodic  affection  of  the 
glottis,  to  which  they  attribute  the  paroxysms  of  suffocation.  That  the  disease  is  attended 
with  some  degree  of  laryngeal  inflammation  is  evident  from  the  result  of  post-mortem  exa- 
minations. In  the  few  instances  in  which  an  opportunity  has  been  afforded  for  an  examina 
tion  after  death,  traces  more  or  less  decided  of  inflammation  of  the  mucous  membrane  of 
the  larynx  have  generally  been  detected — even  when  no  traces  of  increased  redness  are  pre- 
sent, the  secretion  of  the  membrane  is  usually  found  to  be  augmented,  and  of  an  opaque, 
yellowish  or  reddish  colour.  When,  as  sometimes  happens,  death  takes  place  suddenly 
during  a  paroxysm,  it  is  probably  the  result  of  asphyxia,  caused  by  a  complete  spasmodic 
closure  of  the  glottis. 

The  disease  usually  occurs  in  children  from  ten  months  to  eight  years  of  age,  but  more 
frequently  between  two  and  five  years.     It  occurs  more  often  in  boys  than  in  girls. 

There  is  in  some  families  a  peculiar  predisposition  to  the  attacks  of  spasmodic  laryngitis 
— nearly  all  the  children  becoming  affected  with  it  as  they  attain  the  age  of  between  two 
and  three  years.     Though  generally  sporadic,  it  occasionally  prevails  as  an  epidemic. 

Its  occasional  cause  is  almost  exclusively  exposure  to  cold  and  damp,  or  sudden  alterna 
tions  of  temperature.  After  an  attack  has  occurred,  the  paroxysms  may  be  excited  by  any 
sudden  or  violent  mental  emotion. 

The  prognosis  in  this  disease  is  generally  favourable — but  when  the  occurrence  of  the 
paroxysms  is  prolonged  beyond  the  third  day,  and  constantly  augments  in  intensity — espe- 
cially when  they  are  succeeded  by  great  restlessness,  nausea  and  vomiting,  when  the  pulse 
becomes  soft  and  feeble,  when  a  frequent  suffocative  cough  remains,  and  the  patient's  strengtr: 
gradually  diminishes,  an  unfavourable  termination  is  to  be  apprehended. 

The  disease  with  which  spasmodic  laryngitis  is  most  liable  to  be  confounded,  is  pseudo 
membranous  or  genuine  croup. 


516  CHILD-CROWING,    OR 

Tlie  following  comparative  diagnostic  peculiarities,  borrowed  partly  from  M.  Valleix 
and  partly  from  MM.  Rilliet  and  Barthez,  will  enable  us  very  readily  to  distinguish  the  two 
diseases — • 

In  Croup.  In  Spasmodic  Laryngitis. 

There    is    fever    of    variable    intensity —  The   symptoms   of  invasion    are   slight — . 
pseudfHnembramms  angina,  and  slight  hoarse-  there  are  a  slight  catarrh,  and  a  cough  some- 
ness.  what  hoarse — the  throat  is  unaffected — some- 
There  is  a  gradual  increase  of  the  hoarse-  times  there  are  no  prodroma. 
ness,  and  sooner  or  later  a  hoarse  cough.  The  attack  is  sudden — usually  at  night. 

The  fever  does  not  remit;  the  cough  be-  Between    the    paroxysms   the    patient  ap- 

comes  hollow  and  feeble,  and  the  voice  faint  pears  well — the  fever  disappears  or  declines 

or  extinct.  — the  voice  is  rarely  extinct. 

The  disease  is  sometimes  attended  with  an  There  is  an  expectoration  of  mucus, 

expectoration  of  false  membrane.  The  paroxysms  of  the  disease  decrease  in 

The    dyspnoea    constantly    increases,    the  violence, 
croupal   sound   continues   during    the   parox- 
ysms—  finally  the  voice  and  cough  become 
extinct 

The  proper  treatment  of  a  case  of  spasmodic  laryngitis  will  depend  in  a  great  measure 
upon  the  violence  of  tlie  attack  and  the  age  of  the  patient. 

When  there  are  decided  indications  of  laryngeal  inflammation,  and  the  spasmodic  parox* 
ysms  are  intense  and  prolonged,  the  application  of  leeches  to  the  throat,  in  numbers  pro- 
portioned to  the  violence  of  the  symptoms,  and  the  age  and  strength  of  the  child,  will  be 
proper.  In  robust  children  of  five  years  and  upwards,  bleeding  from  the  arm  will  often  be 
productive  of  the  best  effects.  In  no  case,  however,  will  it  be  proper  to  draw  much  blood 
either  from  the  arm  or  by  leeches ;  nor  should  the  operation  be  repeated  at  short  intervals, 
or  too  late  in  the  disease — and  in  the  milder  cases  the  abstraction  of  blood  will  not  be 
demanded. 

On  the  first  accession  of  the  disease  it  has  been  advised  by  Lehmann  to  apply  a  sponge, 
dipped  in  very  hot  water,  and  then  carefully  squeezed  out,  upon  the  anterior  part  of  the 
neck,  and  leave  it  a  moment  in  contact  with  the  skin — the  application  being  repeated  at 
short  intervals.  This  will  produce  a  redness  of  the  surface,  and  a  general  perspiration, 
which  is  to  be  promoted  by  giving  some  mild  tepid  d.iluent.  By  this  simple  procedure  the 
paroxysm,  we  are  told,  together  with  all  the  leading  symptoms  of  the  disease  may  be  cut 
short. 

An  emetic  given  at  the  commencement  of  the  attack,  when  followed  by  the  warm  bath 
and  sinapisms  to  the  extremities,  will  generally  abate  the  violence  of  the  paroxysm,  and 
shorten  its  duration.  The  exhibition  of  an  emetic,  or  of  small  nauseating  doses  of  ipeca- 
cuanlia,  in  the  intervals  of  the  paroxysms,  when  considerable  hoarseness  of  the  voice,  and  a 
frequent  short  barking  cough  continue,  will  generally  be  found  to  remove  very  promptly 
these  symptoms,  and  prevent  tlieir  recurrence. 

The  bowels  should  always  be  attended  to,  and  if  not  freely  and  regularly  open,  a  dose  ol 
calomel,  followed  by  castor  oil  or  magnesia,  will  be  proper. 

Blisters  to  the  neck  or  chest,  or  between  the  shoulders,  are  recommended  by  some  writers. 
We  have  seldom  seen  much  benefit  to  result  from  their  application.  When  employed  they 
should  be  allowed  to  remain  on  only  for  an  hour  or  two ;  and  when  removed  the  part  occu 
pied  by  them  should  be  covered  with  a  soft  emollient  poultice. 

In  violent  cases,  subsequent  to  depletion  and  the  use  of  the  warm  bath,  much  benefit  has 
been  derived  from  the  administration  of  assafcEtida,  cither  by  the  mouth  or  by  enema,  a 
few  hours  after  the  paroxysm  has  terminated.  Covering  the  breast  with  an  assafcetida  plas- 
ter we  have,  also,  found  to  be  decidedly  beneficial. 

Several  of  the  German  physicians  recommend  in  the  highest  terms  the  use  of  musk  in 
this  disease.     Wendt  gave  it  in  the  dose  of  a  grain  every  hour. 

When  the  paroxysm,  from  its  length  and  violence,  threatens  the  destruction  of  the  child 
by  asphyxia,  the  operation  of  tracheotomy  should  be  performed  without  delay. 

During  the  entire  continuance  of  the  disease  the  child  should  be  warmly  clad,  and  kept 
1  I  a  warm,  well  ventilated  room.  His  diet  should  be  light,  and  of  easy  digestion,  and  hi? 
drinks  should  consist  of  weak,  lukewarm  lemonade,  barley  or  toast  water.  The  utmost  caro 
should  be  taken  to  preserve  the  patient  in  a  state  of  perfect  tranquillity.  During  the  parox- 
ysms he  should  be  supported  in  an  erect  position  ;  all  covering  or  ligatures  being  removed 
liom  about  the  neck. 

Tnere  is  anotner  affection  of  not  unfrequent  occurrence,  to  which  attention  has  been  re- 
cently directed  by  Dr.  Behrend  of  Berlin  (^Journ.  der  Kinderkrankheiten),  that  has  no  doubt 
been  frequently  mistaken  for  spasmodic  laryngitis.  It  is  a  spasmodic  cough  of  a  peculiar 
character,  to  which  children  are  liable,  and  which  occurs  only  during  the  night. 


SPURIOUS    CROUP.  517 

This  affection  is  most  generally  observed  in  spring  and  winter;  it,  however,  also  frequenl/ 
•jfcurs  during  the  autumn,  and  but  rarely  in  summer.  It  is  seldom,  if  ever,  observed  lu 
infants  at  the  breast,  but  occurs  at  every  subsequent  period  of  cliildhood,  and  more  fre- 
quently in  boys  tliau  girls.  There  is  no  cough  whatever  during  the  day,  not  the  slightest 
catarrhal  symptom,  and,  when  put  to  bed,  the  child  falls  into  a  sound  quiet  sleep  at  the 
usual  hour.  lu  the  course  of  a  few  minutes,  however,  it  becomes  restless,  and  before  awak- 
ing, coughs  violently.  It  now  commences  to  cry,  and  the  cough  becomes  more  and  more 
severe,  until,  in  some  cases,  it  produces  vomiting;  after  one  or  two  hours  of  suffering,  the 
child  again  falls  asleep,  and  passes  the  remainder  of  the  night  quietly.  The  cough  returns 
at  the  same  hour  the  following  night,  and  continues  sometimes  for  weeks  and  even  months ; 
finally,  it  begins  to  diminish  in  violence,  tlie  fits  beconu  of  shorter  duration,  and  occur  at  a 
more  advanced  period  of  the  night,  so  that  the  length  of  the  sleep  enjoyed  previously  to  its 
coming  on,  is  gradually  prolonged : — at  length  the  cough  disappears  entirely  and  sponta- 
neously. The  subjects  of  this  affection  are  pale,  readily  fatigued,  and  troubled  with  a  cold- 
ness of  the  feet  towards  evening;  they  eat  and  play,  however,  as  usual,  and  appear  other- 
wise to  enjoy  good  health.  The  nocturnal  cough  has  frequently  a  catarrhal  character,  and 
is  generally  accompanied  with  a  mucous  rattle;  sometimes,  the  cough  is  dry,  croupy,  and 
whistling :  the  kinks  are  short,  isolated,  and  uniform,  and  may  recur  every  five  minutes,  or 
extend  only  to  one  or  two. 

This  nocturnal  periodic  cough  cannot  be  mistaken  for  genuine  croup — which  has  well 
marked  symptoms ;  and  it  may  be  distinguished  from  spasmodic  laryngitis  by  the  complete 
intermission  which  follows  the  paroxysms,  by  its  not  being  preceded  by  any  catarrhal  symp- 
toms, and  by  the  entire  freedom  from  fever  throughout  the  attack.  It  may  be  distinguished 
from  hooping-cough  from  the  latter  being  almost  always  epidemic,  and  occurring  as  well  during 
tlie  day  as  during  the  night,  and  always  accompanied  with  a  peculiar  dyspnoea.  In  the  noc- 
turnal periodic  cough  there  is  no  true  appearance  of  suffocation ;  the  children  do  not  awake 
suddenly,  as  in  a  fit  of  asthma  or  spasm  of  the  glottis,  but  they  awake  slowly,  after  having 
coughed  several  times  during  sleep.  It  most  nearly  resembles  the  cough  of  catarrh  or  bron- 
chitis, but  it  is  distinguished  from  those  by  the  entire  absence  of  the  j)hysical  signs,  and  by 
the  nocturnal  periodicity  of  the  fits,  which  arc  followed  by  complete  remission. 

Dr.  Behrend  considers  this  cough  to  depend  on  an  affection  of  the  nerves,  and  bases  this 
opinion  chiefly  on  the  symptoms,  and  on  the  circumstance  of  its  having  frequently  appeared 
after  an  epidemic  of  hooping-cough,  and  whilst  intermittent  fevers  were  very  prevalent  among 
adults.  This  latter  remark  has  been  made  by  several  physicians  whose  attention  was  drawn 
to  this  cough  by  Dr.  Behrend. 

The  prognosis,  we  are  told,  is  always  favourable.  In  one  case  the  periodic  cough  was 
followed  by  bronchitis,  but  this  was  probably  merely  accidental.  In  another  case  there  was 
repeated  epistaxis. 

The  disease,  upon  the  whole,  is  generally  more  troublesome  than  serious,  and  demands 
no  active  treatment.  Gentle  purgatives,  as  manna  with  the  tincture  of  rhubarb,  given  in 
the  evening,  with  attention  to  diet  and  regimen,  are  recommended.  A  drachm  or  two  of  the 
liq.  acctatis  ammonite,  in  a  little  sugar,  may  also  be  given,  before  putting  the  child  to  bed. 
One  physician  found  small  doses  of  quinia,  given  at  bed-time,  of  great  service ;  another 
found  slight  irritation  of  the  skin,  chiefly  by  means  of  pediluvia,  and  friction  of  the  soles  of 
the  feet  with  roasted  onions,  and  even  enveloping  the  limbs,  after  the  manner  of  Preissnitz, 
beneficial. — C] 


LECTURE  XLVII. 

Diseases  of  the  Thorax.  General  observations.  Dyspnoea.  Coitgh.  Methods 
of  exploring  the  physical  conditions  of  the  chest,  by  the  senses  of  sight,  touch 
and  hearing. 

From  the  throat — and  especially  from  that  part  of  it  with  which  we  were  last 
occupied — the  transition  is  natural  and  immediate  to  the  thorax.  Now  the  interior 
of  the  chest  is  the  theatre  of  numerous  and  most  important  morbid  changes.  Within 
that  cavity  are  lodged  two  of  the  three  organs  most  essential  to  life.  The  heart, 
lungs,  and  brain,  have  been  said,  by  a  bold  figure  of  speech,  to  constitute  the  tripod 
of  life :  and  the  two  former  are  planted  in  the  thorax.  In  the  same  division  of  the 
body  lie  also  the  greater  blood-vessels,  and  many  other  parts  of  scarcely  less  conse- 
quence.    With  respect  to  the  heart,  its  alternate  swinging  movement  cannot  long 

2t 


5]  8  DISEASES    OF    THE    THORAX. 

stop,  and  the  patient  continue  to  live :  while  three  minutes'  total  interruption  to  the 
play  of  the  lungs  would  in  most  cases  be  irremediably  fatal.  And  lesser  impedi- 
ments to  the  free  working  of  either  of  these  two  vital  organs  are  productive  of  much 
danger  and  distress ;  and  lead  often  to  consecutive  changes  of  a  very  serious  kind, 
in  various  other  portions  of  the  body. 

These  parts,  of  which  the  function  is  so  indispensable,  and  of  which  the  disorders 
are  so  grave  and  perilous,  are  encased  in  such  a  manner  by  the  ribs  and  other 
boundaries  of  the  chest,  that  they  can  neither  be  seen  nor  handled.  And  until  i 
very  late  period  in  the  history  of  medicine — until  our  own  times,  in  fact — the  diag- 
nosis of  the  formidable  maladies  that  befal  the  viscera  of  the  thorax  was  exceedingly 
uncertain  and  imperfect.  Physicians  were  able,  indeed,  by  the  observation  of  indi- 
rect S3'mptoms,  manifested  through  the  general  system — by  remarking  the  presence 
of  inflammatory  fever,  I  mean  —  to  infer  that  inflammation  had  been  somewhere 
lighted  up  :  and'  symptoms  that  denoted  disturbed  functions  of  the  respiratory  appa- 
ratus— cough,  difficult  breathing,  or  local  pain — might  suffice  to  apprize  them  that 
the  inflammation  Avas  situated  in  the  chest.  But  what  tissue  it  affected,  where" 
was  its  exact  place,  what  was  its  extent,  or  what  were  its  physical  consequences — 
these  were  points  concerning  which  they  had  no  means  of  obtaining  any  precise 
Knowledge.  "Under  the  title  of  pneumonia,  or  pneumonic  inflammation,"  says 
Cullen,  "I  mean  to  comprehend  the  whole  of  the  inflammations  affecting  either  the 
viscera  of  the  thorax,  or  the  membrane  lining  the  interior  surface  of  that  cavity  :  for 
neither  do  our  diagnostics  serve  to  ascertain  exactly  the  seat  of  the  disease,  nor  does 
the  difference  in  the  seat  of  the  disease  exhibit  any  considerable  variation  in  the  state 
of  the  symptoms,  nor  lead  to  any  difference  in  the  method  of  cure."  You  will  see, 
as  we  proceed,  how  very  inaccurate  this  last  statement  would  be,  if  it  were  made 
under  our  present  mode  of  investigating  these  diseases.  "  Pneumonic  inflammation 
(he  continues),  however  various  in  its  scat,  seems  to  me  to  be  always  known  and 
distinguished  by  the  following  symptoms : — Pyrexia,  difficult'breathing,  cough,  and 
pain  in  some  part  of  the  thorax." 

I  state  these  things  to  you — who  do  not  recollect  the  time,  as  I  do,  when  no  medi- 
cal man  in  this  country  could,  with  truth  and  candour,  say  more  of  his  knowledge 
of  diseases  of  the  chest  than  Cullen  said — that  you  maj'  the  better  estimate  the  ex- 
ceeding value  of  the  discovery  of  what  is  called  the  method  of  auscultation,  in  the 
detection  and  discrimination  of  disease;  and  most  particularly  of  thoracic  disease. 
In  the  present  day,  we  are  able  to  obtain  more  exact  information  respecting  the  dis- 
orders of  the  parts  contained  within  the  chest,  than  of  any  other  internal,  and  there- 
fore invisible  parts  of  the  body.  Indeed,  in  a  vast  number  of  instances,  we  can  tell, 
as  accurately  as  if  we  saw  them,  the  actual  condition  of  the  thoracic  viscera :  can 
follow,  step  by  step,  the  successive  processes  of  disease,  or  of  repair,  in  which  they 
are  involved.  We  can  penetrate  beyond  the  symptoms  Avhich  denote  deranged 
function,  and  detect  and  understand  those  much  less  fallible  symptoms  which  arise 
from  alterations  of  structure.  And  this  vast  addition  to  our  pathological  knowledge 
has  been  given  us  by  the  simple  application  of  one  of  our  five  senses  to  the  investi- 
gation of  disease,  the  sense  of  hearing,  which  for  so  many  centuries  had  been 
(strangely  as  it  now  seems)  neglected,  or  but  little  used.  By  the  assistance  of  the 
ear  it  has  come  to  pass  that  those  diseases  which,  besides  being  the  most  common  and 
the  most  destructive,  were  also  the  most  obscure,  are  now  better  understood  than  the 
diseases  of  any  other  internal  part  whatever. 

The  direct  symptoms  which  arise  out  of  the  changed  conditions  of  the  parts  affected 
in  thoracic  complaints,  are  so  mixed  up  with  all  that  we  know  or  can  learn  of  such 
complaints,  that  what  in  other  cases  is  called  the  morbid  anatomy  of  disease,  becomes 
here  a  part  of  its  descriptive  history.  I  shall  not  say,  therefore, — as  in  regard  to 
many  other  maladies  I  am  obliged  or  I  find  it  convenient  to  sa}^ — so  and  so  are  the 
symptoms  ;  and  afterwards,  so  and  so  are  the  morbid  appearances :  but  I  shall  de- 
scribe the  morbid  conditions  in  the  outset,  as  the  only  way  of  rendering  the  symptoms 
which  result  from  them  intelligible. 

But  before  I  enter  upon  the  subject  of  auscultation,  it  may  be  useful  to  make  a 


PHYSICAL    SIGNS.  519 

few  remarks  upon  those  symptoms  of  thoracic  disease  which  were  previously  known, 
and  which  depend  upon,  or  rather  which  express,  derangement  of  the  pulmonary 
functions. 

One  of  the  most  constant,  and  obvious,  and  distressing,  and  instructive  of  these 
symptoms,  is  embarrassed  or  laborious  breathing :  what  is  technically  called  dysp- 
noea. You  know  that  by  a  heahhy  adult,  under  ordinary  circumstances,  the  act  of 
respiration  is  performed,  unconsciously  almost,  about  eighteen  times  in  a  minute. 
There  is  about  one  act  of  respiration  for  every  four  beats  of  the  heart.  In  various 
diseases  this  proportion  is  materially  altered.  The  reciprocal  movements,  by  means 
of  which,  in  measured  succession,  air  is  drawn  into  and  again  let  out  of  the  lungs, 
are  performed  with  hurry,  or  effort,  or  unusual  slowness.  Dyspnoea  implies  some 
deviation  from  the  natural  manner  or  rate  of  alternately  expanding  the  thorax,  and 
suffering  it  to  collapse  again  :  of  inspiring  and  expiring :  in  one  word,  of  breathing. 
The  patient  himself  may,  or  may  not,  be  conscious  of  this  deviation.  In  most  of  the 
cases  in  which  dyspnoea  claims  to  be  regarded  as  a  symptom,  he  is  conscious  of  it. 
Now,  upon  what  does  this  symptom  depend  ?  It  may  ultimately  be  referred  to  an 
altered  proportion  between  the  quantity  of  atmospheric  air  that  reaches  the  lungs, 
and  the  quantity  of  blood  that  is  sent  into  them,  from  the  right  side  of  the  heart,  to 
be  converted  from  venous  to  arterial.  That,  doubtless,  is  at  the  bottom  of  almost 
every  case  of  dyspnoea.  Let  me  remind  you  that  respiration  is  an  automatic  move- 
ment ;  subject,  nevertheless,  to  the  occasional  control  of  the  will.  The  pulmonary 
branches  of  the  par  vagum  constitute  the  principal  and  constant  cxcitor,as  the  nerves 
that  supply  the  muscles  of  respiration  are  the  inotor  links  of  the  nervous  chain  by 
which  the  automatic  movements  are  governed.  It  is  believed  that  the  presence  of 
venous  blood  in  the  capillary  vessels  of  the  lungs  forms  the  natural  stimulus  to  the 
pulmonary  part  of  the  par  vagum.  In  the  ordinary  breathing  of  a  healthy  person, 
this  stimulus  or  imprt^ssion  is  not  feU ;  perhaps  because,  being  slight  and  habitual, 
and  exactly  apportioned  to  the  need  of  the  individual,  it  is  not  attended  to ;  or,  it  is 
at  once  appeased  by  the  admission  of  air,  and  the  corresponding  change  in  the  blood. 
But  when  that  change  is  not  immediately  or  perfectly  accomplished,  then  arises  the 
distressful  sensation  which  everybody  has  felt,  but  which  our  own  language  has  no 
one  word  to  express.  The  French  call  it  the  besoin  tie  respirer.  The  English 
phrase,  ward  of  breath,  denotes  the  peculiar  sensation  equally  well.  It  calls  into 
exercise,  frequently,  the  voluntary  power  of  performing  the  mechanical  act  of  breath- 
ing— a  power  which  is  superadded  to  the  automatic  process. 

Various  are  the  ways  in  which  the  natural  manner  and  frequency  of  the  respira- 
tory movement  may  be  deranged.  They  were  fully  considered  when  I  was  on  the 
subject  of  death  by  apncca.  They  all  operate,  ultimately,  by  destroying  the  just 
equilibrium  between  the  blood  and  air  which  meet  to  undergo  chemical  changes  in 
the  lungs.  We  have  lately  been  considering  certain  diseases  in  which  the  dilliculty 
and  distress  of  breathing  is  often  extreme.  In  croup  and  laryngitis,  the  only  inlet 
for  the  air  is  narrowed  at  its  very  entrance  :  there  is  more  blood  passing  through  the 
lungs  than  can  be  arterialized  under  the  ordinary  motions  of  respiration :  instinctive 
eflijrts  take  place  to  increase  the  quantity  of  air :  to  make  up  by  more  numerous 
acts  of  inspiration  for  the  diminished  amount  of  air  introduced  by  each  single  act. 
For  a  time  these  compensatory  efforts  may  suffice.  But  if  the  access  of  air  be  still 
impeded,  blood  begins  to  circulate  through  the  arteries  but  half  decarbonized,  and  to 
linoer  and  stagnate  in  the  lungs :  the  lips  become  livid,  and  the  skin  grows  dusky. 
Make,  however,  a  free  opening  in  the  pipe  that  should  conduct  air  to  the  lungs,  and 
the  balance  being  restored  between  the  blood  in  those  organs  and  the  air  that  reaches 
them,  the  dyspna-a  is  soon  at  an  end.  The  quantity  of  blood  being  the  same  tlien, 
but  the  air  inspired  too  little,  there  will  be  dyspnoea.  The  very  same  thing  occurs 
whenever  a  portion  of  lung,  from  being  spongy,  is  rapidly  rendered  solid.  No  ai; 
can  then  penetrate  it,  nor  perhaps  any  blood;  but  the  same  quantity  of  olood  ai 
before  arrives  at  the  right  side  of  the  heart,  and  is  transmitted  thence  through  the 
pulmonary  artery  ;  and  consequently  those  portions  of  the  lungs  which  are  pervious 
M  blood  and  air,  are  supplied  with  blood  in  excess,  and  require  air  in  excess:  i.  e.i 
dyspnoea  i&  necessitated.     And  you  will  perceive  that  similar  consequences  nay 


520  '  DISEASES    OF    THE    THORAX. 

arise  from  any  pressure  made  upon  the  lung,  obliterating  in  a  certain  degree  its  cel- 
lular structure  ;  as  b}'  fluid  collected  in  the  pleura  ;  by  enlargement  of  the  heart ;  by 
aneurism  of  the  great  vessels  ;  by  tXjmours,  of  whatever  kind,  within  the  chest ;  or 
jy  pressure  upwards  against  the  diaphragm  by  reason  of  a  distended  abdomen,  whe- 
ther the  distension  be  occasioned  by  disease,  such  as  ascites,  or  by  obesit}',  or  by  a 
,  full  stomach,  or  by  a  gravid  uterus.  A  like  disproportion  will  ensue,  if  the  free 
expansion  of  the  thorpcic  cavitj'  be  prevented  by  pain,  b}'  disease  or  rigidity  of  its 
boundaries,  or  by  palsy  of  its  muscles  through  interruption  of  the  nervous  circle 
whereon  their  contractions  depend. 

But  on  the  other  hand  the  balance  may  be  destroyed  from  the  opposite  quarter: 
the  air  admitted  during  a  single  ordinary  inspiration  being  the  same,  the  quantity 
of  blood  requiring  to  be  converted  from  purple  to  scarlet  may  be  augmented  ;  and 
in  that  case  also,  in  order  to  maintain  the  due  equilibrium,  more  numerous  acts  of 
respiration  must  be  performed :  in  other  words,  d3-spncea  will  arise.  This  is  the 
case  under  brisk  exercise :  the  pressure  of  the  muscles  upon  the  veins  propels  their 
contents  with  greater  velocity  towards  the  right  side  of  the  heart ;  the  heart  contracts 
more  frequently  in  proportion  as  it  is  more  rapidly  filled  with  blood;  a  greater  quan- 
tity than  usual  is  sent  through  the  pulmonary  artery  to  the  lungs ;  and  the  individual 
breathes  more  quickly,  to  supplj'  this  augmented  quantity  of  blood  with  air :  he  is 
out  of  breath,  in  a  state  of  dyspncea.  But  this  is  not  disease.  Disease,  however, 
will  often  have  the  same  effect.  The  quickened  circulation  in  fevers,  any  obstacle 
to  the  free  passage  of  the  blood  from  the  heart  into  the  arteries,  will  tend  to  gorge 
the  lungs  with  blood,  to  destroy  the  requisite  equilibrium  between  the  air  and  the 
blood  in  those  organs,  and  so  give  rise  to  dyspntsa. 

Other  conditions  still  may  be  mentioned,  as  predisposing  to  hurry  of  the  breathing 
— a  peculiar  state  of  the  nervous  system  ;  certain  qualities  of  the  blood  ; — but  I  need 
not  dwell  on  these  at  present. 

There  are  two  important  corollaries  derivable  from  what  I  have  now  been  statinor. 
In  the  first  place,  you  must  perceive  how  intimately  the  functions  of  the  heart  and 
lungs  are  dependent  upon  each  other;  and  that  disease  originating  in  either  of  these 
vital  organs  may  readily  be  the  cause  of  consecutive  disease  in  the  other.  We  shall 
have  many  examples  of  this  before  us  as  we  proceed.  It  would  afford  materials  for 
an  interesting  essay,  this  mutual  relation  between  cardiac  and  pulmonary  disease. 
At  present  I  merely  glance  at  it  in  passing. 

In  the  second  place,  what  I  have  said  of  dyspnoea  must  have  sufficed  to  show  you 
that,  taken  by  itself,  it  has  not  much  value  as  a  diagnostic  symptom.  All  that  it 
tells  us  is,  that  the  healthy  and  natural  relation  between  the  quantities  of  blood  and 
of  air  in  the  lungs  is  disturbed  :  but  to  determine  the  cause  of  that  disturbance  —  to 
decide  whether  the  heart  be  in  fault,  or  the  lungs,  or  both,  or  neither — we  must  have 
recourse  to  other  sources  of  information. 

Cough  is  another  of  the  symptoms,  mentioned  by  Cullen,  as  denoting  disordered 
function  of  the  breathing  apparatus.  I  need  scarcely  tell  you  that  it  is  produced  by 
closing  the  glottis,  and  then  making  a  sudden  and  strong  expiration.  Its  purpose  is 
the  disiodgement  of  mucus  which  may  have  collected  in  excess  in  the  air-passages, 
or  of  any  other  source  of  irritation  to  the  membrane  lining  those  parts.  To  be  effectual 
it  requires  the  admission  of  a  certain  quantity  of  air,  and  the  possession  of  a  certain 
degree  of  muscular  strength.  I  pointed  out  to  you,  in  the  last  lecture,  a  remarkable 
exemplification  of  this :  the  boy  whose  case  is  described  by  Mr.  Chevalier  in  the 
Medico-CJdrurgical  Transactions,  was  dying  of  croup;  was  on  the  brink  of  being 
suffocated  by  the  collection  of  mucus  in  his  wind-pipe  and  bronchi,  which  mucus  he 
was  unable  to  expel:  and  he  was  unable,  not  from  defect  of  muscular  strength,  but 
because  he  could  not  sufficiently  inflate  his  lungs  beyond  \he  collected  mucus.  When 
an  ample  opening  was  made  in  his  trachea,  he  drew  in  a  strong  breath,  and  coughed 
the  mucus  up  through  the  rhna  gtotlidis.  In  old  and  feeble  persons  labouring  under 
chronic  bronchitis  with  profuse  secretion  from  the  mucous  surface,  strength  is  often 
wanting  to  cough  the  phlegm  up ;  and  they  die  suffocated. 

But  the  sensation  which  prompts  to  the  acts  of  coughing  may  arise  from  various 
;jth'r  causes  besides  the  accumulation  of  mucus  in  the  air-passages.     Any  slight 


PHYSICAL   SIGNS.  521 

f  ,  1.       . 

irritation  about  the  glottis ;  a  long,  trailing  and  tickling  uvula  ,*  the  inspiration  of 

irritating  vapours;  pressure  of  any  kind  upon  the  respiratory  organs ;  may  any  of 
them  produce  cough.  Nay,  it  sometimes  is  provoked  by  sympathy  with  other  parts  ; 
an  instance  of  which  we  have  in  what  is  cfJled  a  stomach-cough.  Some  morbid 
condition,  some  irritation  of  the  stomach  exists,  which  being  appeased,  the  cough 
ceases.  You  will  recollect  the  name  and  the  functions  of  the  pneumo gastric  nerves. 
We  have,  in  the  fact  just  mentioned,  another  example,  in  addition  to  those  which  I 
glanced  at  in  a  former  lecture,  of  irritation  of  the  sentient  extremities  of  one  branch 
of  a  nerve,  declaring  itself  by  uneasy  sensations  referred  to  other  branches  of  the 
same  nerve.  For  these  reasons,  therefore,  cough  is  not  more  diagnostic  of  particular 
diseases  situated  in  the  thorax,  than  is  dyspncea.  There  are,  indeed,  certain  varieties 
of  cough,  as  there  are  certain  modifications  of  the  breathing,  from  which  we  may 
obtain  very  useful  information  even  in  respect  to  the  nature  and  seat  of  some  diseases: 
and  these  varieties  and  modifications  I  will  point  out  as  I  go  along. 

Let  me  admbnish  you,  also,  before  we  come  to  auscultation,  not  to  fall  into  an 
error  which  has  been  too  common :  that  of  trusting  entirely  to  the  ear  in  the  investi- 
gation of  thoracic  disease,  to  the  exclusion  or  neglect  of  those  phenomena  which  are 
perceptible  by  the  eye,  or  by  the  hand  ;  or  of  those  indirect  revelations  which  are 
furnished  by  the  condition  of  other  parts  and  functions,  or  by  the  previous  history 
of  the  patient.  Even  before  the  discoveries  of  Avenbrugger  and  Laennec,  physicians 
were  too  remiss  (if  we  may  judge  from  their  writings)  in  what  may  be  called  the 
mechanical  exploration  and  notice  of  the  actions  of  respiration.  A  good  deal  may 
be  learned,  sometimes,  by  merely  placing  one's  hand  upon  the  chest,  or  belly,  as  I 
shall  explain  more  particularly  by  and  by :  and  a  great  deal,  also,  may  be  made  out, 
in  some  cases,  by  the  simple  inspection  of  those  parts,  when  they  are  uncovered. 
You  may  see,  for  example,  that  the  ribs,  in  respiration,  scarcely  move  at  all,  while 
the  belly  rises  and  falls  alternately  with  the  descent  and  ascent  of  the  diaphragm. 
This  is  called  abdominal  respiration.  It  may  arise  from  a  painful  condition  of  the 
intercostal  niuscles,  or  of  the  plurse,  rendering  the  patient  unwilling  to  elevate  his 
ribs ;  or  it  may  arise  from  disease  of  the  spinal  cord,  between  the  origins  of  the 
phrenic  nerve  and  of  the  intercostal  nerves,  rendering  the  patient  unable  to  raise 
them ;  or  the  same  inability  may  result  from  disease  of  the  lungs  themselves.  The 
symptom  may  guide  us  at  once  to  the  seat  of  the  malady.  Again,  the  breathing 
may  be  entirely  thoracic,  no  motion  of  the  abdomen  taking  place ;  and  this  may  de- 
pend upon  an  affection  of  the  diaphragm,  or  of  the  pleura  which  is  reflected  over  it ; 
or  upon  disease,  accompanied  with  tenderness,  within  the  abdomen  —  upon  perito- 
nitis, for  example ;  or  upon  mere  distension  of  the  abdomen.  Or  by  looking  at  the 
naked  chest,  you  may  see  that  one  side  of  it  moves,  and  that  the  other  moves  less, 
or  does  not  move  at  all :  and  the  motionless  side  may  be  of  the  natural  size  as  com- 
pared with  the  other,  or  it  may  be  flattened  and  contracted,  or  it  may  be  round  and 
bulging;  and  most  important  conclusions,  and  most  important  indications  of  treat- 
ment, will  flow  from  a  knowledge  of  these  circumstances.  The  general  form  of  the 
chest  is  also  instructive.  Never  neglect,  then,  to  examine  the  thorax,  in  cases  where 
it  is  supposable  that  the  disease  may  be  seated  in  that  part  of  the  body,  by  your  et/e, 
as  well  as  by  your  ear.  The  eye  needs  but  httle  training  to  enable  it  to  perceive 
and  comprehend  those  signs  which  are  within  its  sphere :  the  ear,  unfortunately, 
requires  to  be  carefully  educated.  I  will  just  remark,  further,  that  in  the  case  of 
females,  no  indelicate  exposure  of  the  person  need  be  made.  In  most  instances  the 
morbid  conditions  I  have  been  adverting  to  may  be  recognized  through  a  thin  lineu 
covering. 

Auscultation  signifies  the  investigation  of  internal  diseases  through  the  sense  of 
hearing:  and  it  is  especially  applicable,  for  reasons  which  I  either  have  stated  or 
will  state,  to  the  study  of  thoracic  diseases.  In  its  full  meaning  it  includes  all  that 
we  learn  by  listening  to  a  cough,  and  all  that  we  gather  by  striking  the  chest,  and 
attending  to  the  resulting  sound.  But  in  general,  the  term  percussion  is  used  to 
express  this  last  mode  of  eliciting  information,  although  the  information  is  conveyed 
through  the  medium  of  the  ear:  and  the  word  auscultation  is  applied  to  the  art  of 
distinguishing  diseases  by  listening  to  internal  sounds,  by  "^leans  of  the  ear  piaced 

2x3 


T  ^ 


522  DISEASES    OF    THE    THORAX. 

in  apposition  with  the  surface  of  the  body  ;  or  by  means  of  some  conductor  of  sound 
interposed  between  the  ear  of  the  listener  and  the  person  of  the  patient.  In  the  first 
of  these  two  modes  the  auscultation  is  said  to  be  immediate;  in  the  second,  ??je(/m/e. 
By  percussion  we  ascertain  the  degree  of  resonance,  or  want  of  resonance,  of  the 
part  struck  :  by  auscultation  we  learn  the  qualities  and  modifications  of  the  voice,  as 
reflected  through  the  chest;  and  of  the  breathing;  and  of  the  sounds  of  the  heart. 
The  invention  of  the  method  of  percussion  we  owe  to  a  C4erman,  Avenbrugger,  who 
wrote  an  excellent  treatise  upon  it,  which  was  brought  into  notice  by  Corvisart,  who 
translated  it.  For  the  more  brilliant  discovery  of  auscultation  we  are  indebted,  as 
every  body  knows,  to  Laennec. 

Now  it  will  save  us  much  trouble,  and  conduce,  I  hope,  to  your  future  progress  as 
practical  auscultators,  if,  before  I  speak  of  any  of  the  diseases  of  the  chest,  I  pre- 
mise some  general  observations  respecting  these  modern  methods  of  examining  the 
human  body,  with  the  view  of  detecting  and  discriminating  its  diseases.  Indeed,  I 
could  not  make  myself  intelligible  unless  I  did  so. 

And  first,  with  respect  to  percussion,  which  you  will  please  to  recollect  is  nothing 
else  than  auscultation  of,  or  listening  to,  sounds  which  we  ourselves  artificially  and 
purposely  produce. 

You  know,  every  child  knows,  by  daily  experience,  that  difl^erent  substances, 
when  struck,  give  out  very  different  modifications  of  sound.  If  you  strike  a  drum, 
you  get  one  kind  of  sound ;  if  you  strike  a  brick  wall,  you  get  another.  The  one 
is  loud,  trembling  as  it  were,  and  prolonged  ;  the  other  dull,  short,  and  flat.  But 
why  should  I  attempt  to  describe  in  words  things  which  are  familiar  to  you  already? 
Bodies  that  are  solid,  or  inelastic,  give  the  dull  flat  sound  in  proportion  to  their  solid 
thickness,  or  their  want  of  elasticity.  On  the  other  hand,  hollow  vessels,  i.  e„  ves- 
sels containing  air,  with  thin,  firm,  elastic  boundaries,  give  out  a  sound  more  or  less 
approaching  in  its  qualities  to  that  of  a  drum. :  the  sound  is  called  a  hollow  sound 
from  that  circumstance.  If  you  have  a  wooden  cask  containing  air  only,  it  is  resonant 
when  struck :  fill  it  half  full  of  water,  and  the  lower  part  will  render  a  flat  sound, 
the  upper  empty  portion  a  hollow  sound ;  less  hollow,  however,  than  when  the 
vessel  contained  no  water;  fill  it  up  with  water,  and  the  whole  is  dull  on  percussion; 
pour  out  the  water,  and  fill  it  loosely  with  wool — it  will  still  be  resonant,  though  in 
a  different  and  less  clear  note  than  when  it  held  air  alone. 

Now  this  experiment  may  be  transferred  to  the  human  chest,  which  is  a  cavity, 
bounded  by  firm,  thin,  tense,  and  elastic  walls,  and  containing,  in  its  natural  state, 
the  spongy  lungs,  which  are  full  of  air ;  and  other  parts  that  are  solid,  whereof  the 
heart  is  the  chief.  If  you  strike  the  surface  of  the  chest  (it  requires  a  little  knack 
to  do  it  properly),  and  if  the  blow  falls  over  a  portion  of  healthy  lung,  you  Avill 
produce  a  resonant  or  hollow  sound.  If  the  lung  be  not  there,  if  it  be  pushed  aside, 
and  its  place  supplied  by  some  more  solid  or  inelastic  substance,  by  fluid  for  example, 
you  will  hear  a  dead  sound.  So  you  will  if  the  lung  be  there,  but  has  lost  its  spongy 
character,  is  void  of  air,  and  somehow  or  other  solidified.  But  you  may  have  a 
resonant  sound,  though  the  lung  is  in  a  state  of  disease ;  nay  though  the  lung  is  not 
there  :  so  that  percussion  alone  cannot  always  be  depended  upon.  I  shall  tell  you, 
hereafter,  how  to  guard  against  being  misled  by  it  in  such  cases.  Again,  if  you 
strike  over  the  region  of  the  heart,  you  will  get  a  positively  dull  sound,  or  at  any 
rate  a  much  duller  sound  than  in  most  other  parts  of  the  chest. 

It  is  really  a  singular  thing,  that  this  method  of  searching  for  indications  of  disease, 
and  of  health,  should  have  been  so  long  neglected  or  overlooked  in  .'»ur  profession. 
I  am  sure  that  I  had  a  practical  acquaintance  with  the  princijile  of  percussion  long 
before  I  knew  any  thing  of  physic;  and  so,  I  make  no  doubt,  have  most  of  you. 
■Vlany  a  time,  when  wishing  to  know  whereabouts  I  might  drive  a  nail  firmly  into  a 
wall,  I  have  tried  with  the  hammer  to  find  which  was  brickwork,  and  which  was 
wooden  joist;  and  percussion  is  an  art  in  daily  use  for  similar  purposes,  with  car- 
penters and  bricklayers.  Yet  it  does  not  appear  to  have  been  thought  of  by  physi- 
cians till  the  middle  of  the  last  century,  when  Avenbrugger,  after  studying' its  results 
for  seven  years,  as  he  tells  us  inter  tcedia  et  laborc.s,  published  at  Vienna  his  "  In- 
ventum  novum,  ex  percussione  thoracis  humani,  ut  signo,  abstrusos  interni  pectoris 


t 


PHYS  CAL    SIGNS.  523 

morbos  detegendi."  This  ivas  almost  totallj'  neglected  however,  until,  as  I  stated 
before,  Corvisart's  work  on  diseases  of  the  heart  brought  it  into  general  notice. 

Avenbrugger  and  Corvisart,  and  indeed  every  body  who  used  percussion  at  all, 
until  a  very  few  years  ago,  employed  direct  percussion  :  that  is,  they  struck  the  chest 
with  the  extremities  of  the  fingers.  More  recently,  mediate  percussion  has  been 
introduced  into  practice,  by  JM.  Piorry.  In  mediate  percussion  some  solid  substance 
is  placed  upon  the  spot,  the  resonance  of  which  is  about  to  be  explored,  and  the 
blow  is  made  upon  that  substance,  which  is  called  a  pleximeter — a  stroke-measurer. 
A  round  thin  plate  of  ivory,  laid  flat  upon  the  surface,  is  the  most  common  sort  of 
pleximeter ;  or  metal,  or  wood,  or  leather,  or  India  rubber,  may  be  employed.  Many 
persons,  and  I  am  one  of  them,  use  no  other  pleximeter  than  the  fingers  of  the  left 
hand. 

I  shall  explain,  as  briefly  as  T  can,  the  method  of  employing  percussion,  and  the 
cautions  requisite  to  render  it  an  effectual  and  a  true  interpreter  of  the  state  of  the 
parts  beneath  the  stricken  surface. 

The  position  of  the  patient  is  of  some  consequence.  It  should  be  one  that  is  con- 
venient to  the  examiner,  and  not  inconvenient  to  himself;  and  it  should  be  one 
calculated  to  render  the  part  struck  as  firm  and  tense  as  possible.  1  he  best  position 
of  all  is  a  sitting  position,  on  a  firm  chair.  But  you  may  percuss  a  patient  very 
effectually  as  he  siis  up  in  bed,  or  while  he  stands,  or  some  parts  even  when  he  is 
lying  down.  A  good  deal  is  said, — more,  in  my  opinion,  than  is  necessary, — about 
the  effect  of  curtains,  and  so  forth,  in  deadening  the  sound.  I  do  not  believe  they 
will  ever  interfere  with  your  conclusions,  especially  as  we  learn  more  from  com- 
paring the  sounds  given  out  upon  percussing  the  corresponding  parts  of  the  opposite 
sides  of  the  chest,  than  from  the  absolute  resonance  or  want  of  resonance  of  any 
single  part.  But  there  are  some  exceptions  to  this  ;  and  if  your  patient  can  be  made 
to  sit  on  a  chair  in  the  middle  of  the  room,  so  much  the  better. 

Then,  if  you  are  about  to  percuss  the  front  of  his  chest,  make  him  hook  his  arms 
over  the  corners  of  the  back  of  the  chair,  and  throw  his  head  back.  If  you  des.re 
to  explore  in  this  way  the  lateral  portion  of  the  thorax,  he  must  place  the  hand  of 
that  side  upon  his  head,  and  lean  a  hltle  to  the  opposite  side.  If  you  would  know 
how  the  posterior  part  of  the  chest  sounds,  he  must  lean  forwards,  fold  his  arms 
across  his  breast,  and  bend  down  his  head. 

Next  as  to  the  mode  of  percussing.  For  direct  percussion,  the  ends  of  the  fingers 
of  the  right  hand  should  be  brought  together,  and  into  a  line  with  each  oiher,  so  that 
no  one  of  them  may  project  beyond  the  rest ;  and  care  should  be  taken,  first,  to 
compare  the  sound  produced  by  striking  any  part  of  the  chest  on  one  side,  with  that 
produced  by  striking  the  corresponding  part  on  the  other  side.  It  follows  from  this 
rule  that  we  should  not  examine  all  the  points  on  one  side  before  passing  to  the  other, 
because  we  should  thus  lose  the  remembrance  of,  and  the  power  of  accurately  com- 
paring, the  sounds  obtained  from  corresponding  points.  It  is  best  to  strike  first  on 
one  side  of  the  body,  and  then  on  the  corresponding  spot  of  the  other.  It  follows 
also  that  we  are  not  to  compare  the  result  of  percussion  on  one  of  the  I'ibs,  with  the 
result  of  percussion  on  one  of  the  intercostal  spaces.  The  blow  should  fall  upon 
the  rib,  and  parallel  to  it. 

A  second  point  requiring  attention,  is  the  state  of  the  chest  in  respect  to  the  act 
of  breathing.  If  one  side  be  percussed  after  the  movement  of  inspiration,  and  the 
other  after  that  of  expiration,  some  little  difference  in  the  resulting  sounds  will  be 
manifest,  even  in  the  healthy  condition  of  the  thorax.  And  this  might  mislead. 
Let  corresponding  spots  on  the  two  sides  be  therefore  both  struck,  either  while  the 
chest  is  expanded,  or  while  it  is  collapsed,  or  while  the  patient  holds  his  breath. 

Thirdly,  you  must  take  care  to  strike  the  corresponding  parts  at  the  same  angle, 
and  not  with  the  fingers  perpendicular  to  the  surface  on  one  side,  and  inclined 
obliquely  to  it  on  the  other:  also  to  strike  corresponding  parts  with  the  same  degreu 
of  force.  And  the  blow  should  not  be  hard  enough  to  give  the  patient  pain  ;  indeed 
such  a  blow  would  not  produce  a  good  sound,  it  should  be  smart  and  quick  ;  the 
ends  of  the  fingers  should  not  remain  on  the  chest.  Under  some  circumstances, 
however,  the  patient  cannot  bear  to  be  percussed  at  all. 


T   '■^ 


524  DISEASES   OF    THE    THORAX. 

The  latter  cautions  are  most  necessary  when  direct  percussion  is  employed  ;  over 
which  mediate  percussion  has,  however,  many  advantages.  Some  of  these  are  ob- 
vious. In  the  first  place,  the  space  examined  by  mediate  percussion  is  very  exactly 
defined  and  limited.  Secondly,  you  may  strike  the  pleximeter  much  more  forcibly 
than  you  could  strike  the  unprotected  body,  and  so  produce  a  more  decided  sound. 
Even  when  the  surface  is  morbidly  sensible,  or  the  patient  unusually  irritable,  so 
that  percussion  in  the  ordinary  way  cannot  be  performed  at  all,  it  may  generally  be 
done  through  the  pleximeter.  A  third  and  very  great  advantage  is,  that  mediate 
percussion  is  available  when  made  over  certain  parts  where,  even  although  there 
may  be  no  pain  occasioned  by  i',  ordinary  immediate  percussion  is  attended  with 
no  useful  result.  Parts,  I  mean,  where  there  is  much  fat,  and  parts  which  are  fleshy, 
or  oedematous.  If  the  pleximeter  be  pressed  firmly  upon  these  parts,  even  upon  the 
mamma  in  females,  the  hollow  sound  is  attainable  ;  whereas,  if  they  were  struck  by 
the  fingers,  the  sound  would  be  perfectly  dull.  Mediate  percussion  may  be  apphed 
also,  with  effect,  through  the  clothes. 

I  say  that  a  convenient  way,  and  one  which  I  find  quite  sufficient,  of  employing 
mediate  percussion,  is  by  making  a  pleximeter  of  the  finger  or  fingers,  of  the  left 
hand  ;  taking  care  that  they  are  closely  in  contact  with  the  subjacent  parts,  and  si77ii- 
larly  applied  to  corresponding  spots  ;  and  that  the  backs  of  the  fingers  be  outwards. 
Piorry  declares,  indeed,  that  the  resonance  produced  by  this  mode  is  scarcely  one- 
tenth  part  so  great  as  that  elicited  by  using  a  thin,  solid  and  elastic  plate.  For  all 
practical  purposes,  however,  I  am  certain  that  the  finger,  as  it  is  the  readiest,  so  also 
it  is  a  very  satisfactory  and  sufficient  pleximeter.  It  has,  moreover,  this  positive 
advantage,  that  the  sound  made  by  striking  it  is  not  loud,  and  does  not  obscure  or 
interfere  with  that  which  depends  upon  the  condition  of  the  chest. 

Ft  is  right  that  you  should  be  aware  of  differences  of  sound  which  belong  to  the 
individual.  Cseteris  paribus,  the  sound  given  out  on  percussion  is  more  resonant 
during  inspiration  than  during  expiration ;  in  childhood  and  youth  than  in  middle 
age :  in  middle  age  than  in  old  age  ;  in  females  than  in  males  ;  in  thin  persons  than 
in  fat :  and,  they  say,  in  nervous,  irritable  people,  than  in  those  of  a  contrary  tem- 
perament. 

And  it  is  still  more  necessary  that  you  should  be  aware  of  differences  of  sound 
given  out  in  health,  by  different  parts  of  the  surface  of  the  thorax,  in  the  same  indi- 
vidua!.  And  in  order  to  explain  this  more  distinctly,  and  for  the  sake  of  refc'  nee 
hereafter,  let  me  here  exhibit  to  you  the  regions  of  the  thorax,  as  they  havr  !'een 
artificially  mapped  out  for  the  purposes  of  auscultation. 

It  is  unnecessary  for  me  to  describe  particularly  the  method  followed  in  this  arbi- 
trary division  of  the  thorax  into  regions.  I  will  state  the  names  that  have  been  com- 
monly applied  to  them,  and  the  sounds  which  in  health  they  respectively  yield,  ac- 
cording to  their  number  in  the  diagram  before  you. 

T\\c  first  region  is  that  of  the  clavicles  ;  one,  of  course,  on  each  side.  Upon  these 
bones  it  is  immaterial  whether  direct  or  mediate  percussion  be  made.  The  sound 
given  out  should  be  very  clear  at  their  sternal  extremities,  dull  at  their  humeral  ex- 
tremities, and  clear  at  their  middles.  The  resonance  diminishes  from  the  sternal 
towards  the  acromial  end  of  the  clavicle.  These  parts  correspond  to  the  summits 
of  the  lungs. 

The  second  region  is  the  stibclavian.  It  lies  between  the  clavicle  and  the  fourth 
rib  on  each  side.  Beneath  this  superficial  region  hes  the  upper  lobe  of  the  lung; 
and  towards  the  sternum  large  bronchi  are  situated.  You  will  understand,  there- 
fore, that  the  sound  educed  by  striking  this  part  ought  to  be  very  clear, 

A  little  lower  down,  number  three,  is  the  'mammary  region,  extending  from  the 
fourth  to  the  seventh  rib  on  each  side,  and  answering  to  the  middle  lobe  of  the  lungs. 
Here  also  the  resonance  afforded  by  percussion  is  clear;  but  in  the  lower  part  of 
this  region,  on  the  left  side,  we  find  the  heart,  which  is  more  or  less  covered  by 
lung:  and  on  the  right  side  the  liver  begins  to  mount.  The  sound  is  somewhat 
modified  and  deadened  by  these  deeper-seated  viscera.  In  women  we  can  deter- 
mine the  degree  of  resonance  of  this  region  through  the  mammae,  by  mediate  per 
cussion  only. 


PHYSICAL   SIGNS. 


525 


The  fourth  is  the  infra-mammary  region.     It  comprehends  that  part  of  the  bony 
compages  of  the  thorax  on  each  side,  which  Hes  between  the  seventh  rib  and  the 


edge  of  the  cartilages  of  the  false  nbs.  Into  this  region,  on  either  side,  may  descend 
the  thin  anterior  margins  of  the  lower  lobes  of  the  lungs ;  but  in  the  same  region,  on 
the  right  side,  lies  the  liver,  over  which  the  sound  of  percussion  is  dull ;  and  on  the 
left  side  is  placed  the  stomach.  Hence,  when  the  stomach  is  tympanitic,  a  preter- 
naturally  resonant  sound  will  proceed  from  this  part ;  and  when  the  stomach  con- 
tains no  gas,  the  sound  will  be  irregularly  dull. 

All  the  regions  hitherto  described  are  double.  There  is  still  the  mesial  part  of 
the  front  of  the  chest  to  be  subdivided,  and  we  may  call  the  three  regions  there  situ- 
ated, and  numbered  5,  6,  7,  the  upper  sternal  region,  the  middle  sternal,  and  the 
lower  sternal.  In  all  these  the  sound  on  percussion  ought  to  be  clear,  except,  per- 
haps, in  the  inferior  portion  of  the  last,  which  may  be  rather  dull,  or  which,  from  its 
vicinity  to  the  stomach,  may  be  tympanitic. 

The  eighth  region  is  the  axillary  ;  the  axilla  above  the  fourth  rib  on  each  side. 
The  ninth  is  the  lateral  region,  between  the  fourth  and  seventh  ribs.  In  both  these 
regions  the  resonance  should  be  distinct  and  clear.  The  tenth,  which  may  be  called 
the  lower  lateral  region,  below  the  seventh  rib  at  the  sides,  gives  the  same  sounds 
as  the  infra-mammary,  namely,  on  the  right  side  a  dull  sound,  on  the  left  a  sound 
which  at  times  is  preternaturally  hollow  :  on  account  of  the  presence  of  the  hver  in 
the  former  case,  and  of  the  stomach  in  the  latter. 

But  we  have  yet  to  look  at  the  hind  part  of  the  thorax.  Here  we  have  the  space 
(region  eleven)  which  forms  the  top  of  the  shoulder,  and  lies  between  the  clavicle  in 
front,  and  the  superior  spine  of  the  scapula  behind ;  the  acromial  region.  Very 
little  can  be  made  out  by  percussion  in  this  spot ;  the  sound  is  dull.  But  the  depres- 
sion immediately  above  the  scapula,  the  supra-spinal  fossa,  as  it  is  called,  is  a  space 
which  affords  valuable  information  to  the  ear  applied  over  it. 

The  twelfth  region  is  the  scapular.  It  comprises  the  part  covered  by  the  scapula 
on  either  side.  It  corresponds  to  the  posterior  part  of  the  middle  lobe  of  the  lungs, 
but  yields  a  dead  sound,  unless  a  pleximeter  be  used. 

The  thirteenth  region  is  the  intra-scapular.  It  lies  between  the  inner  edge  ot 
the  scapula  and  the  spine  on  each  side.  It  corresponds  to  the  roots  of  the  lungs, 
and  to  the  middle  parts  of  their  lower  lobes.  You  may  get  a  good  clear  sound  here, 
if  the  patient's  arms  be  crossed,  and  his  head  bent  forwards,  and  his  back  arched, 
60  as  to  stretch  and  tighten,  and  make  as  thin  as  possible,  the  superincumbent 
muscles  ;  you  will  find  also  that  the  ridge  of  the  spinal  column  in  this  part  gives  a 
hollow  sound. 


526  DISEASES    OF    THE    THORAX. 

The  last  region  to  be  mentioned,  number /owr/ecn,  the  (Zorsa/,  is  the  loweiinost 
part  of  the  ribs  behind.  It  answers  to  the  base  of  the  lungs,  and  gives  a  clear  sound* 
but  the  liver  on  the  right  side  is  apt  to  render  its  inferior  portion  dull ;  and  the 
stomach  on  the  left  to  make  it  undulj'  resonant. 

Now,  knowmg  these  circumstances,  if  you  find  that  a  dull  sound  is  yielded  on 
percussing  a  part  that  should  render  a  hollow  sound,  you  conclude  that  beneath  the 
pan  struck  there  is  not  the  natural  quantity  of  air.  But  whether  this  arises  from 
consolidation  of  the  lung  itself,  and  the  obhteration  of  its  cells,  or  from  fluid  effused 
into  the  cavity  of  the  pleura,  you  cannot,  by  mere  percussion,  determine.  So,  again, 
f  the  sound  be  unnaturally  tympanitic,  you  cannot  say  whether  that  results  from 
what  is  called  pneumothonLx,  or  from  emphysema  of  the  lung.  Percussion  testifies 
that  air  is  there  ;  but  further  this  deponent  sayeth  not. 

The  information  which  the  exercise  of  percussion  may  leave  thus  imperfect,  aus- 
cultation of  the  sounds  produced  by  the  acts  of  breathing,  speaking,  or  coughing, 
vn]\  in  most  cases  supply. 

If  the  ear  be  laid  close  to  the  surface  of  a  healthy  thorax  (or  if  the  instrument 
called  the  stethoscope  be  interposed  between  that  surface  and  the  ear),  the  ear  will 
hear  the  air  enter  and  fill  the  lungs,  and  then  withdraw  and  leave  them  again,  in 
perpetual  succession.  The  sound  produced  by  this  ingress  and  egress  of  air  has 
been  called  the  respiratory  77nirinur.  I  might  tell  you  that  this  sound,  to  my  mind, 
is  rather  a  rustle  than  a  murmur ;  that  it  is  hke  the  sighing  of  the  wind  in  the 
branches  of  a  tree.  I  might  say,  with  Laennec,  that  it  resembles  the  sound  made  in 
the  deep  inspiration  of  a  sleeping  person  ;  or,  with  Dr.  Davies,  that  it  reminds  one 
of  the  soft  murmur  of  a  pair  of  bellows,  of  which  the  valve  does  not  click.  But 
one  minute's  appliance  of  your  ear  to  the  subclavian  region  in  a  child,  or  even  in 
an  adult,  will  give  you  a  clearer  notion  of  the  nature  and  character  of  this  sound 
than  any  verbal  description  could  convey.  Yet,  respecting  this  natural  respiratory 
murmur,  there  are  some  things  of  which  it  is  desirable  that  you  should  be  previously 
informed. 

In  the  first  place,  the  entrance  of  the  air  is  much  more  noisy  than  the  exit:  which, 
sometimes  can  scarcely  be  heard.  You  will  see,  by  and  by,  the  importance  of 
noticing  this  fact. 

In  the  next  place,  the  murmur  of  respiration  is  not  equally  audible  in  all  persons. 
It  may  differ  much  in  intensity,  though  not  in  kind,  in  two  persons,  each  of  whom  is 
in  perfect  health.  Thus  it  is  much  more  loud  and  distinct  in  children  than  in  grown 
persons.  So  remarkably  is  this  the  case,  that  when  we  meet  with  an  unusually  noisy 
respiratory  murmur  in  an  adult,  we  say  that  his  breathing  is  puerile  ;  it  has  the  cha- 
racter of  the  respiration  of  a  child.  Now,  I  tell  you  before  hand,  that  puerile  respi- 
ration in  the  lung  of  an  adult  is  generally  a  sign  of  disease  ;  and  it  is  mostly  partial ; 
heard  in  certain  parts  only  of  the  chest. 

Again,  ca^teris  paribus,  the  natural  murmur  of  respiration  is  more  clearly  audible 
in  lean  and  spare  persons  than  in  such  as  are  muscular  and  fat.  Fat  and  muscle 
are  bad  conductors  of  sound,  and  act  as  dampers.  Listening  to  the  breathing  through 
a  thick  layer  of  adipous  tissue,  is  like  hstening  (as  Dr.  Latham  says)  to  the  respira- 
tion of  a  person  through  his  clothes. 

But  if  you  take  two  healthy  men  who  are  alike  in  respect  to  leaness  and  fatness, 
you  may  often  find  that  the  respiratory  murmur  is  very  loud  in  the  one,  and  very 
feeble,  or  almost  inaudible,  in  the  other :  but  in  this  last  it  becomes  audible  when  he 
'akes  a  deep  and  forced  inspiration. 

The  reason  of  this  difference  is  not  very  well  understood.  The  breathing  may 
be  very  indistinct,  though  the  thorax  be  capacious,  and  well  formed,  and'heaUhy. 
Some  persons  seem  to  require  less  effort  than  others  to  maintain  the  due  equilibrium 
between  the  air  in  the  lungs,  and  the  blood  in  the  lungs :  as  if  they  had  not  only 
pulmonary  space  enough,  but  to  spare.  So  that  the  difference  in  the  manner  of 
breathing,  and  in  the  sound  occasioned  by  the  passage  of  the  air  in  and  out,  depends, 
m  all  probability,  upon  individual  pecuharities  of  the  circulation.  At  any  rate,  it  is 
Tery  important  that  you  should  be  aware  of  the  existence  of  these  differences. 
But  the  sounds  which  reach  the  ear  applied  to  the  chest  of  a  breathing  person  will 


PHYSICAL    SIGNS.  527 

differ  in  different  parts,  and  under  different  circumstances.  The  sound  given  out  by 
rtie  air  as  it  passes  through  the  trachea  and  larger  bronchi,  differs  from  that  which 
results  from  its  passage  into  and  out  of  the  smaller  bronchi  and  air-passages.  I  am 
anxious  not  to  refine  too  much  in  these  matters  :  and,  therefore,  I  pass  by  mmuter 
points  of  diff(?rence.  Place  the  stethoscope  over  the  trachea,  and  you  will  hear  just 
such  a  sound  as  you  might  expect  to  hear:  the  sound  of  air  rushing  tluough  a  tube 
of  considerable  size,  a  blowing  noise.  We  will  call  that  sound,  which  you  will  re- 
cognize again  when  you  have  once  heard  it,  bronchial  breathing.  It  accompanies 
the  outward  as  well  as  the  inward  passage  of  the  breath.  Again,  place  your  ear 
or  your  stethoscope  upon  the  right  mammary  region  ;  there  you  shall  hear  that  rust- 
ling sound,  which  I  propose  to  call  vesicular  breathing,  and  which  is  chiefly  audible 
during  inspiration.  We  shall  find  these  distinctions  of  much  use  in  the  discrimina- 
tion of  disease.  We  shall  find,  for  example,  that  the  breathing  sometimes  is  bron- 
chial, where  it  ought  to  be  vesicular. 

.  Now  if  any  part  of  the  chest  where  we  should  hear  breathing,  we  can  hear  none, 
this  may  result  from  solidification  of  the  subjacent  portion  of  lung;  or  from  some 
obstacle  in  a  large  bronchus,  preventing  the  air  from  entering  that  part ;  or  from  air 
being  in  any  way  shut  up  and  stagnant  in  that  part ;  or  from  an  effusion  of  liquid 
into  the  pleura  at  that  part.  And  here  again  percussion  comes  into  play,  and  de- 
termines  for  us  which  of  these  possible  circumstances  is  the  one  really  present.  If 
the  part  when  struck  emits  a  hollow  sound,  there  is  stagnant  air  beneath  it,  either  in 
the  heakhy  lung,  or  in  the  lung  altered  by  disease,  or  in  the  cavity  of  the  pleura. 
If  a  flat  solid  sound  be  given  out,  there  is  sohd  lung  beneath,  or  liquid  in  the  pleura, 
between  the  ear  and  the  lung.  All  these  points,  and  the  conclusions  to  be  deduced 
from  them,  will  become  clear  to  you,  I  trust,  as  we  proceed.  iVIinuter  analysis  of 
the  diagnostic  signs  would  be  premature. 

A  word  or  two  preliminary  I  must  say  about  the  voice. 

The  voice  passes  outwardly  through  the  mouth  and  nostrils  into  the  surroundino" 
air;  it  passes  also  inwardly  through  the  trachea  and  bronchi  into  the  lungs,  and  it 
may  be  heard  through  the  lungs,  by  the  ear  laid  flat  against  the  chest.  Bui  it  gives 
quite  a  different  sensation  to  the  ear  in  different  places.  If  you  place  the  stethoscope 
on  the  trachea,  the  voice  will  articulate  itself  into  your  ear  as  if  it  came  from  and 
through  the  instrument.  This  sound,  which  is  natural  here,  would  be  unnatural,  and 
a  mark  of  disease,  if  heard  beneath  the  clavicles.  When  heard  beyond  its  natural 
situation,  it  is  called  pectoriloquy.  A  less  degree  of  this,  a  sound  like  that  of  a 
person  talking  into  a  tube,  and  whose  words,  for  that  reason,  are  muffled  and  indis- 
tinct, is  called  bronchial  voice,  or  bronchophony.  When  to  this  modification  of  the 
voice  there  is  added  a  twanging  vibration,  a  cracked  discordant  tremor,  resembling 
the  squeak  of  Punchinello,  or  (as  some  think)  the  bleating  of  a  goat,  oegophony 
is  said  to  exist.  All  these  unnatural  modifications  of  the  voice  are  indicative  of 
most  important  changes  within  the  thorax.  I  merely  introduce  them  to  you  now: 
you  will  become  better  acquainted  with  them  in  due  time. 

What  is  true  of  the  natural  voice,  is  true,  mutatis  mutandis,  of  that  unnatural 
vocal  sound,  cough.  The  cough  may  be  so  modified  by  the  condition  of  the  internal 
parts,  as  to  reveal  that  condition. 

There  are  yet  other  ways  in  which  some  information  can  be  gathered  respecting 
the  interior  of  the  chest.  If  you  give  certain  patients  a  sudden  smart  jog  while  your 
ear  is  applied  to  their  thorax,  you  may  hear  a  splashing  sound,  like  that  produced 
by  shaking  a  barrel  or  a  bottle  partly  full  of  water.  From  this  expedient  you  in  fact 
determine  that  the  cavity  of  the  pleura,  or  perhaps  a  large  excavation  in  the  lung, 
does  contain  both  air  and  a  liquid.  This  is  called  the  method  of  succussio7i.  It  was 
employed  long  before  the  other  forms  of  auscultation  were  thought  of.  Hippocrates 
mentions  it. 

Again  (but  that  is  not  auscultation),  you  may  sometimes  collect  useful  information 
respecting  the  state  of  the  chest  by  simply  laying  your  open  hand  upon  it.  In  most 
persons  there  is  a  distinct  vibration  or  thrill  produced  by  their  speaking,  which  thril' 


528  CATARRH. — BRONCHITIS. 

is  very  sensiblj'  felt  by  the  hand.  Now,  this  thrill  may  be  felt  on  one  side  of  the 
chest,  and  not  on  the  other.  And  such  a  difference  is  an  unequivocal  sign  of 
disease. 

The  positions  which  I  described  before  as  being  the  most  convenient  for  the  per- 
'brmance  of  percussion,  are  the  most  convenient  also  for  the  purposes  of  auscultation. 
You  may  listen  with  the  unassisted  ear,  or  you  may  listen  through  the  stethoscope. 
This,  as  you  know,  is  a  soUd  or  perforated  piece  of  wood,  of  which  one  end  is  adapted 
to  the  ear ;  and  the  other,  which  is  to  be  applied  to  the  chest,  is  hollowed  out,  or 
expanded,  into  the  shape  of  a  bell,  or  funnel.  The  object  of  the  instrument  is  to 
collect  and  convey  to  the  ear  of  the  observer  the  vibrating  impulse  of  the  air,  or  of 
the  solid  walls  of  the  thorax,  occasioned  by  the  motions  within.  The  stethoscope  is 
sometimes  useful  for  examining  a  circumscribed  spot  in  the  thoracic  cavity.  With 
it  we  o-aujie,  more  nicely  than  we  could  do  with  the  naked  ear,  the  signs  furnished 
by  the  patient's  voice.  We  must  use  it  also  when  we  would  investigate  the  breath- 
ing in  parts  to  which  the  ear  itself  cannot  easily  be  applied ;  and  in  cases  where, 
from  the  filth  of  the  patient,  or  because  he  has  some  infectious  disorder,  we  desire  tc 
avoid  any  immediate  contact  with  his  clothes  or  person  ;  and  in  cases  of  young  or 
old  ladies,  to  whose  breasts  it  might  not  be  seemly  or  delicate  to  be  putting  our  faces. 
But,  with  these  exceptions,  the  stethoscope,  in  my  experience,  is  rather  a  hindrance 
than  a  help.  Much,  however,  depends  upon  custom.  I  can  best  distinguish  most 
of  the  sounds  to  be  heard  within  the  thorax  by  my  unassisted — perhaps  I  should  say 
my  unimpeded — ear;  and  I  therefore  employ  the  stethoscope  or  cyhnder  in  such 
cases  only  as  I  have  just  adverted  to.  I  cannot  do  without  the  instrument ;  but  I  do 
without  it  as  much  as  1  can.  Care  should  be  taken  that  the  end  of  the  stethoscope 
next  to  the  ear  be  closely  and  comfortably  fitted  to  that  organ ;  and  that  its  other 
extremity  be  blunt,  so  as  not  to  hurt  the  patient;  and  further,  that  it  be  uniformly 
and  evenly  applied  to  the  surface  of  his  chest.  If  these  precautions  be  attended,  to, 
the  shape  and  fashion  of  the  instrument  are  very  unimportant. 


LECTURE  XLVIII. 


Catarrh  ;  its  Varieties.  Jicute  Bronchitis.  Dry  Sounds  attending  the  Respira- 
tion ;  Ehonchvs,  and  Sibilus ;  Moist  Sounds;  Large  and  Small  Crepitation; 
how  these  are  produced,  and  what  they  denote.  Treatment  of  Jlcute  Bronchitis. 
Peripneumonia  Notha.     Sudden  Infraction  of  a  large  Bronchus. 

In  the  last  lecture  I  described  to  you,  in  a  general  manner,  the  method  of  ausculta- 
tion, or  the  employment  of  the  sense  of  hearing  in  the  investigation  of  disease ;  and 
particularly  of  thoracic  disease.  I  explained,  as  Avell  as  I  could,  the  different  sounds 
which  result  from  percussing  various  parts  of  the  chest ;  and  from  the  entrance  and 
exit  of  air  during  the  several  acts  of  breathing,  speaking,  and  coughing.  I  men- 
tioned certain  conditions  in  which  those  natural  sounds  are  abolished;  but  I  did  not 
speak,  except  incidentally  and  very  cursorily,  of  the  altered  and  new  sounds  to 
which  the  presence  of  disease  within  the  thorax  has  been  found  to  give  rise.  Nor 
do  I  propose  to  enter  now  upon  any  formal  account  of  these  morbid  sounds.  I  shall 
endeavour  to  make  you  acquainted  with  their  characters,  and  causes,  and  significa- 
tion, as  they  arise  in  the  progress  of  the  separate  thoracic  diseases  which  I  am  about 
to  consider. 

Before  you  can  possibly  appreciate  the  morbid  sounds,  you  must  make  yourselves 
familiar  with  the  natural  and  healthy.  You  must  have  a  standard,  by  which  you 
may  measure  the  numerous  deviations  from  the  natural  sound  that  will  meet  your 
ear  in  disease.  Listen  to  the  voice  and  the  breathing  of  healthy  children,  or  of  some 
of  your  friends  and  fellow-students  ;  and  you  will  soon  recognise  those  respiratory 
sounds  which  accompany  the  perfect  state  and  working  of  the  breath-machine. 


PHYSICAL   SIGNS.  529 

I  intend  to  commence  with  those  diseases  of  the  lungs  in  which  the  imicous  7nem- 
hrane  lining  the  air-passages  is  primarily  or  principally  involved.  This  membrane 
is  often  affected  alone.  It  is  much  exposed  to  known  causes  of  disease  :  to  alterna- 
tions of  temperature  in  the  air  which  is  constantly  passing  over  it ;  to  the  irritation 
produced  by  acrid  or  noxious  matters,  solid  or  gaseous,  which  are  mixed  and  inhaled 
with  the  air.  And  when  disease  commences  in  other  parts  of  the  lungs,  it  seldom 
fails  to  reach,  sooner  or  later,  the  mucous  membrane.  In  diseases  also  of  the  heart, 
the  same  mucous  membrane  is  very  liable  to  be  consecutively  affected,  by  reason  of 
those  alterations  in  the  condition  of  its  capillary  vessels  which  the  disorder  of  the 
circulation  produces. 

Now  I  shall  first  point  out  the  changes  to  which  this  mucous  membrane  is  liable ; 
and  then  describe  the  modifications  of  the  natural  sounds  that  result  from  such 
changes ;  and,  lastly,  consider  the  different  forms  of  disease  which  these  changes 
constitute,  and  these  altered  sounds  denote. 

In  a  former  part  of  the  course,  I  gave  you  some  account  of  the  peculiarities  which 
differences  of  texture  impress  upon  the  phenomena  and  process  of  inflammation ; 
and,  among  the  rest,  I  spoke  of  the  behaviour  of  the  mucous  tissue  when  inflamed. 

The  mucous  membranes,  in  the  state  of  health,  are  perpetually  moist.  The 
exhalation  of  this  moisture,  to  a  certain  amount,  and  not  berjond  a  certain  amount, 
jonstitutes  an  essential  part  of  their  healthy  functions.  Now,  their  biflam,mation 
(for  I  am  atout  to  consider  first  the  inflammatory  affections  of  the  membrane  of  the 
nir-passages  ;  some  of  them  indeed  I  have  already  discussed),  I  say  the  inflammation 
of  these  mucous  surfaces  alters  their  ordinary  secretion.  An  inflamed  mucous  mem- 
brane is  in  the  first  instance  dry ;  its  secretion  is  suspended.  But  this  is  not  the 
only  change  that  takes  place  in  it;  it  becomes  tumid  also,  swollen,  thicker  than 
before;  it  is  redder  than  natural,  and  its  sensibility  undergoes  a  perceptible  modifi- 
cation. Pain,  in  mucous  membranes,  is  7iot  a  common  phenomenon  ;  for  their  text- 
ure enables  them  to  expand  or  dilate  freely,  so  that  they  escape  much  tension,  and 
the  pain  which  is  produced  by  tension  ;  but  their  natural  sensations  are  blunted,  and 
new  and  uneasy  sensations  arise  in  them:  sensations  of  heat,  fullness,  itching.  It 
happens  that  we  can  see  a  portion  of  the  mucous  membrane  that  belongs  to  the  air- 
passages  ;  and  by  noticing  the  changes  produced  in  it  by  inflammation,  we  infer 
those  which  are  apt  to  take  place  in  the  parts  we  cannot  see.  We  have  all  often 
experienced  in  our  own  persons  an  inflammatory  state  of  the  membrane  lining  the 
nasal  cavities ;  the  Schneiderian  membrane.  At  first  the  nostril  is  preternaturally 
dry ;  yet,  though  it  is  dry,  you  cannot  breathe  through  it :  it  is  stuffed  up,  not  with 
accumulated  mucus,  but  by  the  mere  swelling  of  the  membrane  :  the  sense  of  smell 
is  perverted  or  lost ;  the  part  is  evidently  red ;  it  is  tender,  also,  and  irritable ;  the 
contact  of  atmospheric  air  a  little  colder  or  a  little  less  pure  than  common,  provokes 
sneezing.  The  affection  extends  often  into  the  frontal  sinuses,  and  headach  and 
oppression  ensue ;  or  it  passes  into  and  through  the  lachrymal  sac,  the  conjunctiva 
participates  in  the  inflammation,  the  puncta  lachrymalia  become  impervious,  and  the 
tears  flow  over  the  cheek.  And  with  all  this  there  is  sometimes  shivering  or  chilli- 
ness;  and  the  pulse,  especially  in  ihe  evening,  becomes  a  little  more  frequent  than 
common.  There  is  slight  fever.  After  the  unusual  dryness,  the  membrane  begins 
to  secrete  a  thin  serous  fluid,  having  acrid  properties ;  for  it  reddens  and  frets  the 
al?e  nasi  and  upper  lip,  over  which  it  flows.  By  degrees  this  thin  serous  fluid  be- 
comes thicker,  and  as  it  becomes  thicker  it  becomes  less  irritating  also,  more  viscid, 
opaque  and  yellow:  the  swelling  of  the  membrane  diminishes;  it  is  less  raw  and 
sensitive:  at  length  the  secretion  resumes  its  natural  ^'Urt/tVy,  and  is  reduced  to  its 
natural  cpumtilii  again  ;  and  the  tumefaction  of  the  membrane  entirely  disappears. 
This  i-s  the  course  of  what  is  properly  called  a  cold  in  the  head.  When  the  defiuxiou 
from  the  nasal  membrane  is  considerable,  systematic  writers  call  the  complaint  cory- 
za  ;  when  it  is  attended  with  much  pain  and  weight  about  the  frontal  sinuses,  it  is 
named  gravedo.  It  is  a  variety  of  catarrh.  Iri  catarrh,  sometimes  one  part,  and 
sometimes  the  whole,  of  the  mucous  membrane  of  the  air-passages  suff'ers  inflamma- 
tion. If  the  disorder  goes  down  into  the  lungs,  it  is  said  to  be  a  cold  in  the  chest : 
jX,  from  one  of  the  most  prominent  of  its  symptoms,  a  cough;  in  medical  language, 
iU  2  u 


530  CATARRH. — BRONCHITIS. 

broncliilis.  It  sometimes  travels  from  one  part  of  the  membrane  tc  another.  Be 
ginning,  for  example,  in  the  nose,  it  oradually  creeps  down  into  the  windpipe  and 
lun^^s.  Sometimes  the  inflammatory  condition  passes  from  the  throat  into  the  Eusta 
ch.un  tubes,  and  produces  deafness ;  or  down  the  gullet  and  to  the  stomach,  causing 
qualmish  or  other  uneasy  sensations,  and  loss  of  appetite.  And  occasionally  this 
order  appears  to  be  reversed.  There  are  some  persons  who  will  tell  you  that  when- 
ever anything  disagrees  with  their  stomachs,  whenever  dyspepsia  is  produced  by 
some  error  in  diet,  they  are  sure  to  have  catarrh. 

Now  I  have  adverted  to  this  cold  in  the  head,  or  coryza,  because  the  phenomena 
which  are  open  to  our  inspection  in  the  Schneiderian  membrane  take  place  also,  no 
doubt,  in  the  bronchial.  The  membrane  is  first  dry,  and  tumid,  and  irritable;  fhe 
uneasy  sensations  of  which  it  is  the  seat  prompt  to  the  action  of  coughing.  The 
chest  feels  tight,  stuffed,  constricted.  There  is  some  hoarseness,  and  a  sense  of 
roughness  and  soreness  in  the  windpipe ;  and  a  dry  cough,  which  seems  to  arise 
from  some  irritation  about  the  glottis.  Sometimes,  with  these  symptoms,  pains  in 
the  limbs,  like  the  pains  of  rheumatism,  occur;  the  appetite  is  impaired ;  the  patient 
IS  thirsty ;  and  a  general  lassitude  is  felt  all  over  the  bod)'. 

But  what  effect  has  the  altered  state  of  the  membrane  upon  the  sounds  elicited  by 
percussion;  or  heard  within  the  chest,  by  the  ear,  during  respiration?  AVhy  it 
brino;s  us  acquainted  at  once  with  two  remarkable  modifications  of  the  natural  sound 
of  breathing;  and  these  I  must  describe  and  explain. 

I  will  take  this  opportunity  of  again  recommending  you  to  read  and  study  the 
httle  book  of  lectures  recently  published  by  Dr.  Latham.  It  contains  a  very  plain 
and  clear  account  of  the  auscultatory  signs  of  disease  Avithint  he  chest ;  and  he  speaks 
of  these  signs  in  more  easy  and  popular  language,  with  less  of  over-refinement,  and 
a  less  subservient  adoption  of  the  French  mode  of  thinking  and  writing  on  these 
subjects,  than  any  other  English  author  that  I  know  of.  I  recommend  his  little 
volume  the  rather  also,  because  he  uses  the  nomenclature  which  is  the  most  familiar 
to  myself:  in  fact,  as  we  some  years  ago  saw  and  talked  of  these  matters  together  in 
the  wards  of  St.  Bartholomew's,  we  were  likely  to  employ  the  same  terms. 

When  you  listen,  I  repeat,  to  the  breathing  of  a  healthy  person,  you  hear,  as  the 
breath  goes  in  and  out,  but  especially  as  it  goes  in,  a  smooth  and  gentle  rustle — the 
respiratory  murmur,  or  the  vesicular  breathing.  But  when  the  inner  surface  of 
the  bronchial  tubes,  and  of  their  ramifications,  is  preternatural ly  dry,  and  tumid,  this 
sound  is  altered :  you  hear  a  hissing,  or  wheezing,  or  whistling,  as  the  breath  goes 
in  and  out ;  and  this  is  technically  called  sibilus :  or  you  hear  a  deeper  note,  a  snoring 
noise,  as  I  he  patient  inspires  or  expires — a  sound  like  the  cooing  of  a  pigeon,  or  the 
bass  no'.e  of  a  violin,  or  the  droning  hum  of  an  insect  in  its  flight ;  and  this  is  called 
rhonchus.  These  two,  in  their  various  modifications,  constitute  the  dry  sounds  of 
respiration  ;  and  it  will  be  worth  while,  once  for  all,  to  reflect  upon  their  cause  and 
natuje,  and  the  manner  in  which  they  are  combined,  and  what  they  denote.  You 
are  aware  that  when  air  is  propelled  through  a  cylindrical  tube  of  a  certain  size,  and 
when  that  tube  is  narrowed  in  a  particular  way  at  one  or  more  points,  a  musical 
note  is  produced.  Now  this  is  what  often  happens  in  the  larger  bronchi ;  this  is 
what  always  happens  in  them  when  rhonchus  is  present.  Rhonchus  belongs  to  the 
larjrer  divisions  of  the  bronchi  exclusively;  and  as  these  are  often,  for  a  time  exclu- 
sively affected,  so  rhonchus  may  exist  alone.  It  will  be  grave  or  deep  in  proportion 
to  the  length  and  diameter  of  the  tube  in  which  it  is  produced.  When  the  sound  is 
grave  and  deep,  the  hand  placed  upon  the  chest  may  frequently  perceive  a  trem- 
bling or  thrill  communicated  to  its  parietes.  I  believe  that  rhonchus  is  mostly  occa- 
sioned by  portions  of  viscid  half  solid  mucus,  which  adhere  to  the  membrane  and 
cause  a  virtual  constriction  of  the  air-tubes,  and  act  as  vibrating  tongues  while  the 
air  passes  by  them.  I  conclude  such  to  be  the  case,  because  it  seldom  happens  that 
the  rhonchus  cannot  be  got  rid  of  by  a  vigorous  cough.  It  will  soon  begin  again, 
perhaps,  or  it  will  commence  in  some  other  part,  but  the  effort  of  coughing,  which 
detaches  and  removes  the  adhering  tough  mucus,  dislodges  also,  for  the  time,  the 
ihonchus.  Yet,  rhonchus  in  a  given  spot  may  be  permanent :  a  tumour,  or  a  tubercle, 
may  flatten  one  of  the  air-tubes,  and  convert  it  into  a  musical  instrument.     For  the  mosi 


PHYSICAL   SIGNS.  531 

part,  you  will  find  what  I  have  told  you  holds  true  :  you  may  suspend  tne  rhonchus  by 
getting  the  patient  to  make  a  hearty  cough.  Now  in  the  natural  state  of  the  chest, 
we  do  not,  except  in  particular  spots,  hear  the  transit  of  the  air  through  the  larger 
bronchi.  Whatever  sound  it  makes  is  damped  by  the  spongy  lung,  or  covered  by  the 
vesicular  breathing.  But  rhonchus,  in  its  turn,  may  overpower  the  vesicular  murmur, 
and  render  it  inaudible.  It  does  not  prevent  it,  but  it  outroars  it,  as  it  were.  Yet 
this  is  seldom  the  case :  you  hear  the  rhonchus,  and,  if  you  listen  attentively,  you 
may  in  general  hear,  mingling  with  it,  the  vesicular  murmur  also.  Recollect,  then, 
that  rhonchus  belongs  to  the  larger  divisions  of  the  air-tubes ;  that  it  denotes  their 
partial  narrowing ;  that  it  is  a  dry  sound  ;  and  that  the  condition  of  which  it  is  ex- 
pressive implies  usually  no  danger :  there  is  no  rhaterial  obstacle  to  the  passage  of 
the  air  through  these  larger  tubes  to  the  vesicular  structure  beyond  them. 

I  must  further  admonish  you,  that  in  your  earlier  essays  in  auscultation  you  will 
De  apt  to  deceive  yourselves  in  respect  to  the  exact  place  in  the  lung  in  which  the 
rhonchus  which  you  hear  is  produced.  It  is  so  loud  a  sound,  that  when  it  proceeds 
from  a  single  bronchial  tube  it  may  be  plainly  audible  over  the  whole  of  that  side  of 
the  chest ;  and  sometimes,  more  obscurely,  over  the  other  side  too. 

When  air  is  driven  with  a  certain  degree  of  velocity  through  a  small  pipe,  it 
gives  rise  to  a  hissing  noise.  It  is  by  forcing  air  through  a  cylinder  perforated  by  a 
slender  tube,  that  Professor  Wheatstone  obtains  the  sound  of  the  letter  S  in  the 
talking  machine  which  he  has  constructed,  after  Kempelon's  model.  Precisely  this 
condition  we  have  in  the  smaller  bronchial  ramifications,  when  the  inflammation  in 
catarrh  or  bronchitis  has  reached  ihe?7i,  and  rendered  the  membrane  hning  them 
tumid.  And  sibilus  is  the  result  of  this  change.  Now  sibilus,  like  rhonchus,  may 
exist  alone  ;  and,  inasmuch  as  the  sibilus  proceeds  from  the  smaller  air-tubes,  adjacent 
to  the  pulmonary  vesicles,  it  abolishes  the  natural  respiratory  murmur.  It  does  not, 
like  simple  rhonchus,  merely  drown  it,  but  it  takes  its  place.  If  you  hear  the  res- 
piratory murmur  mingling  with  sibilus,  you  may  be  sure  that  some  of  the  lesser  air- 
tubes  are  narrowed,  and  some  free :  you  cannot  have  both  sounds  at  once  from  the 
same  ramifications  of  the  bronchi.  Sibilus  is  a  sound  of  more  serious  import,  there- 
fore, than  rhonchus ;  it  bespeaks  a  condition  of  greater  danger.  It  belongs  to  the 
smaller  air-tubes  and  vesicles,  and  denotes  that  they  are  in  the  first  stage  of  inflam- 
mation, which  has  diminished  their  natural  cahbre,  by  rendering  the  membrane 
tumid.     It  is  a  dry  sound,  but  you  cannot  cough  it  away. 

I  say  rhonchus  may  occur  alone,  and  sibilus  may  occur  alone ;  but  very  often 
indeed  they  both  occur  together;  and  maybe  heard  in  various  parts  in  different 
degrees  :  causing  a  strange  medley  of  groaning,  and  cooing,  and  chirping,  and  whist- 
ling, and  hissing,  mixed,  it  may  be,  here  and  there,  with  the  natural  respiratory 
murmur.  When  you  hear  sibilus  over  the  entire  surface  of  the  chest,  the  mucous 
membrane  is  universally  affected,  and  the  case  is  a  severe  one,  and  attended  with 
considerable  hazard. 

It  is  just  possible  that  a  sibilant  sound  may  proceed  from  a  large  air-tube,  when 
its  bore  has  been  narrowed  to  a  very  minute  slit  or  orifice  ;  but  this  possibility 
does  not  interfere  with  the  general  distinctions  that  I  have  been  endeavouring  to 
point  out. 

Now  in  these  cases  we  neither  obtain  nor  require  any  information  from  percus- 
sion, except  of  a  negative  kind.  Supposing  the  inflammation  confined  to  the  mu- 
cous membrane,  the  resonance  on  percussion  will  not  be  sensibly  diminished  ;  the 
lung  is  everywhere  spongy  still,  and  air  reaches  every  part  of  it,  though  not  with  the 
«isual  freedom. 

There  is  one  exception  to  this.  Occasionally,  though  rarely,  a  piece  of  tough 
phlegm  may  seal  up,  as  it  were,  the  very  entrance  of  one  of  the  principal  bronchial 
tubes,  and  so  prevent  the  air  from  passing  to  or  from  the  portion  of  lung  to  which 
that  tube  conducts.  When  this  happens,  it  is  very  likely  to  puzzle  the  auscuitator 
for  a  time.  There  is  air  in  the  sealed-up  portion  of  lung,  therefore  percussion  gives 
a  natural  sound  ;  but  the  air  is  at  rest,  therefore  no  sound  of  respiration  is  audible. 
An  effort  of  coughing  unstops,  perhaps,  the  bronchial  tube  ;  and  *hen  the  air  is  ao^iu 


532  CATARRH. 

heard  to  enter  and  to  depart  from  that  portion  of  lung.  I  shall  advert  to  this  sort 
of  accident  again. 

Finally,  I  may  remark,  that  these  dry  sounds,  rhonchus  and  sibilus.,  are  heard 
during  the  breathing:  they  have  no  relation  to  the  voice  or  to  the  cough. 

After  a  while,  the  inflamed  membrane  begins  again  to  pour  out  fluid ;  but  it  is 
not  the  thin,  bland,  moderate  exhalation  of  health ;  it  is  a  glairy,  saltish,  transparent 
liquid,  like  white  of  esg  somewhat ;  and  if  it  be  expectorated  only  after  much  cough- 
ing, it  will  be  frothy  also,  i.  e.,  it  will  contain  many  bubbles  of  air  entangled  in  it. 
It  is  a  stringy,  tenacious  fluid,  and  the  more  so  in  proportion  to  the  intensity  of  the 
inflammation.  With  this  new  condition  of  the  membrane,  we  have  new  sounds  — 
sounds  which  result  from  the  passage  of  air  through  a  hquid ;  sounds  which  are 
occasioned  by  the  formation  and  bursting,  in  rapid  succession,  of  numerous  little  air- 
bubbles.  These  sounds  are  called  crepitations.  This  process  may  take  place  in 
the  larger  air-tubes,  or  it  may  take  place  in  the  smaller,  or  in  both.  In  the  larger 
tubes  the  bubbles  will  be  larger,  and  the  ear  can  readily  distinguish  this ;  we  have 
large  crepitation.  In  the  smaller  air-tubes,  we  have,  in  the  same  way,  small  crepi- 
tation. There  is  no  difference  between  these  sounds,  except  in  degree ;  and  they 
graduate  insensibly  into  each  other.  But  there  is  a  considerable  difference  in  the 
nature  of  the  intimations  which  their  well-marked  varieties  convey.  If  there  be 
merely  large  crepitation,  without  any  other  morbid  sound,  it  is  produced  in  the 
larger  tubes.  Air  passes,  notwithstanding,  into  the  vesicular  structure  beyond  the 
accumulated  liquid  ;  and  vesicular  breathing  exists,  though  perhaps  it  cannot  be 
heard,  on  account  of  the  crepitation.  But  the  state  of  the  patient  is  not  a  state  of 
peril.  On  the  other  hand,  small  crepitation  has  its  seat  in  the  smaller  air-tubes  and 
cells  ;  it  supersedes  the  vesicular  breathing,  and,  if  extensive,  it  bespeaks  considem- 
ble  danger.     .. 

Rhonchus  and  large  crepitation  are  respectively  the  dry  and  moist  sounds  that 
belong  to  the  larger  bronchi ;  sibikis  and  small  crepitation  the  dry  and  moist  sounds 
of  the  smaller  branches.  When  the  latter  sounds  are  heard  over  a  considerable  part 
of  the  chest,  there  is,  I  say,  usually  a  good  deal  of  distress,  dyspnoea,  and  cough ; 
and  the  fever  which  attends  the  local  inflammation  is  at  its  height.  By  and  by  the 
expectoration  becomes  opaque,  and  more  consistent,  and  of  a  greenish  or  yellowish 
colour;  it  is  brought  up  with  more  ease;  the  crepitation,  great  and  small,  dimi- 
nishes ;  perhaps  rhonchus  reappears :  but  at  last  the  parts  return  to  their  original 
condition ;  and  the  natural,  smooth,  equable  rustle  of  the  breathing  is  again  every- 
where audible. 

These  are  all  the  morbid  sounds  to  which  active  and  recent  inflammation  of  the 
mucous  membrane  of  the  air-passages  ever  gives  rise  :  rhonchus  and  sibilus  ;  large 
and  small  crepitation.  Having  once  described  their  nature  and  causes,  I  need  not 
repeat  the  description  if  we  find  them  accompanying  other  diseases  :  but  their  im- 
port may  be  different.  I  may  mention  here,  that  as  crepitation  results  from  the 
passage  of  air  amongst  and  through  liquid,  from  the  rupture  of  the  little  air-bubbles 
so  produced,  the  kind  of  liquid  may  vary.  If  the  air,  in  going  and  returning,  meets 
with  serum,  or  with  pus,  or  with  blood,  it  will  occasion  exactly  the  same  bubbling 
noise.  Hence  the  French  term  for  what  I  have  been  calling  crepitation,  viz.,  mu- 
cous rattle,  is  very  objectionable.  From  the  sound  itself,  we  cannot  tell  whether  it 
proceeds  from  mucus  or  from  some  other  liquid  present  in  the  air-passages ;  and 
from  this  objection  the  word  crepitation,  whatever  exception  may  be  taken  against 
it  on  other  accounts,  is  free. 

Having  thus  embraced  the  occasion  of  explaining  these  auscultatory  signs,  I  will 
novv  resume  the  history  of  catarrh.  It  implies  inflammation  of  the  mucous  mem- 
brane of  the  air-passages; 'and  it  receives  different  appellations,  according  to  the  dis- 
trict of  that  membrane  which  it  chiefly  plagued :  gravedo,  in  the  frontal  sinuses ; 
coryza,  in  the  Schneiderian  membrane  of  the  nose ;  bronchitis  in  the  trachea  and 
••ungs. 

Catarrh  is  the  commonest  of  all  disorders : — not  one  man  in  ten  thousand  passes 
a  winter  without  having  a  cold  of  some  sort.  And  this  name  points  to  its  ordinary 
vause :  cold  somehow  applied  to  the  body.     It  does  not  always  or  often  result,  I 


CATARRH.  533 

apprehend,  from  cold  air  brought  into  contact  with  the  membrane  iiself,  in  the  pro- 
cess of  breathing  ;  but  from  cold,  and  especially  from  cold  and  wet,  applied  to  the 
external  integument.  It  is  unnecessary  for  me  again  to  go  over  the  circumstances 
under  which  the  application  of  cold  is  most  likely  to  prove  injurious.  Catarrh  is 
usually  a  trivial  disorder,  and  runs  its  course  in  a  few  days,  if  abstinence  be  observed 
with  respect  to  animal  food  and  stimulating  liquor,  and  if  the  patient  remains  in  an 
equable  temperature,  and  avoids  re-exposure  to  the  cause  of  his  malady.  I  am  now 
speaking  of  the  milder  forms  of  catarrh.  We  are  not  often  consulted  for  this  com- 
plaint. Every  man,  in  regard  to  a  cold,  thinks  himself  quahfied  to  be  his  own  doc- 
tor. But  if  you  are  consulted,  keep  your  patient  in  the  house,  or  even  in  bed ;  let 
him  live  upon  slops ;  give  him  a  gentle  aperient,  and  then  some  of  those  medicines 
•w^hich  are  esteemed  to  be  diaphoretic:  small  doses  of  James's  powder;  three  drachms 
of  the  liquor  ammonise  acetatis,  with  a  drachm  of  the  spiritus  aetheris  nitrici,  and  an 
ounce  of  camphor  mixture  ;  or  a  saline  draught  with  an  excess  of  alkali,  and  a  few 
grains  of  nitre,  or  a  little  antimonial  wine  ;  three  or  four  times  a  day :  and  let  him 
take  four  or  five  grains  of  Dover's  powder,  and  put  his  feet  and  legs  into  a  warm 
bath,  just  before  he  goes  to  bed.  In  this  way  you  may  conduce  to  his  recovery  ; 
and  he  may  be  simple  enough  to  believe  that  you  have  cured  him. 

Yet  I  believe  catarrhs  may  sometimes  be  cured;  and  the  natural  recovery  from 
them  may  be,  sometimes,  accelerated.  If  you  practise  the  old  maxim,  which  says, 
"  venienti  occurite  morbo,"  you  may  occasionally  stop  a  cold  on  the  threshold,  as  it 
were,  by  an  opiate.  And  to  persons  who  are  habitually  troubled  with  slight  catarrhs, 
this  piece  of  practice  may  prove  of  the  greatest  value.  A  medical  man  who  resides 
in  this  neighbourhood,  and  with  whom  I  was  a  fellow-student,  is  exceedingly  subject 
to  what  he  calls  a  snivelling  cold.  For  many  years  he  used  to  bear  this  as  he  best 
might ;  and  that,  to  say  the  truth,  was  very  ill  and  impatiently.  On  one  occasion, 
almost  by  accident,  he  took  twenty  drops  of  laudanum  just  as  one  of  his  colds  was 
beginning  to  torment  him,  and  he  found  that  the  initiatory  symptoms  ceased.  Since 
that  time  he  has  constantly  had  recourse  to  the  opiate  under  similar  circumstances  ; 
and  whereas  he  used  formerly  to  be  very  miserable  for  three  or  four  days,  he  now  is 
quite  well  and  comfortable  in  the  course  of  half  an  hour.  And  this  is  not  a  solitary 
case.  It  is  worth  trying,  if  you  experience  the  feelings  of  an  incipient  catarrh,  to  go 
to  bed,  and  to  take  a  beaker  of  hot  wine  negus,  with  a  tablespoonful  of  the  syrup  of 
poppies  in  it.  This  will  not  suit  every  person;  but  if  it  fails  on  the  first  trial,  it 
need  not  be  repeated,  and  no  great  harm,  beyond  an  increase  of  headache,  will  be 
done  by  it.  I  would  not  recommend  this  plan,  however,  to  a  plethoric  person  ;  nor 
to  any  one  having  a  tendency  to  inflammatory  disease  ;  for  when  it  does  not  cure,  it 
makes  the  complaint  worse. 

There  is  also  a  period  in  catarrh  which  has  gone  on  unchecked,  when  you  may 
accelerate  its  departure — "speed  the  going  guest" — by  a  good  dinner,  and  an  extra 
glass  or  two  of  wine.  But  this  pleasant  method  is  scarcely  to  be  advised  for  persons 
of  delicate  habits  ;  or  in  whom  any  pthistical  tendency  is  suspected  to  exist ;  or  who 
are  prone  to  inflammation.  And  it  is  not  to  be  tried  with  any  one  till  the  fever  is 
over,  and  the  expectoration  thick  and  loose. 

t  must  not  omit  to  mention  the  dry  plan  of  cure  ;  although  (I  confess  it  with  some 
shame)  I  have  never  yet  tried  it  either  upon  myself  or  upon  others.  Dr.  C.  J.  B. 
Williams,  who  invented  it,  I  believe,  has  a  high  opinion  of  its  efficacy.  It  certainly 
has  the  merit  of  simplicity,  for  it  consists  merely  in  abstinence  from  every  kind  of 
drink.  No  hquid,  or  next  to  none,  is  to  be  swallowed  until  the  disorder  is  gone. 
The  principle  here  concerned  is  that  of  cutting  off  the  supply  of  watery  materials  to 
the  blood.  The  wants  of  the  system  exhaust,  from  the  circulating  fluid,  all  that  can 
be  spared  for  the  natural  evacuations ;  and  there  is  nothing  left  to  feed  the  unnatural 
secretion  from  the  inflamed  mucous  membrane.  Its  capillary  vessels  cease  to  be 
congested  ;  the  morbid  flux  is  diverted,  and  the  inflammation  starved  away.  Such 
is  the  theory.  Habitual  topers  might  hold  the  remedy  to  be  worse  than  the  disease  ; 
but  Dr.  Williams  assures  \is  that  the  necessary  privation  is  not  very  hard  to  bear ; 
and  that  it  achieves  a  cure,  upon  an  average,  in  forty-eight  hours.     He  allov.-s,  wiib- 

2u2 


534  ACUTE  BRONCHI  ris. 

out  recommending,  a  tablespoonful  of  tea  or  milk  for  the  morning  and  evening  meals 
and  a  wine-glass  of  water  at  bed-time. 

One  o-reat  advantage  of  this  plan  is,  that  it  does  not  require  confinement  to  bed,  or 
to  the  house.  The  man  whose  business  calls  him  abroad,  ma)-,  with  appropriate 
clothing,  pursue  his  customary  employment,  and  his  cure  is  all  the  while  going  on. 
fn  fact,  exercise,  inasmuch  as  it  promotes  perspiration,  helps  the  recovery;  whereas 
the  system  of  warm  drinks  and  diaphoretics  renders  the  body  more  susceptible  to 
atmospheric  vicissitudes ;  and,  to  be  effectual,  implies  restrictions  which  are  often- 
times extremely  inconvenient. 

Dr.  Williams  observes,  that  while  this  dry  treatment  is  serviceable  in  catarrhal 
bronchitis,  it  is  most  successful  in  coryza,  the  snivelling  cold  in  the  head.  It  must 
be  put  in  force  in  the  very  commencement  of  the  disorder. 

You  may  often  do  much  by  way  of  prevention,  for  persons  who  are  unusually 
liable  to  take  colds.  I  have  remarked  before  upon  the  great  value  of  the  shower- 
bath  for  that  purpose.  I  could  mention  several  instances  in  which  persons  have  got 
rid  of  the  tendency  to  catch  cold  by  the  habitual  use  of  this  aspersion.  It  should  be 
begun  in  the  summer,  and  made  tepid  at  first ;  but  in  a  short  time  quite  cold  water 
may  be  employed  ;  and  being  once  begun,  the  practice  may  be  continued  through 
the  Avinter.  I  stated  formerly,  that  the  efTect  of  exposure  to  cold  was,  caetcris  pari- 
bus, in  proportion  to  the  intensity  and  the  duration  of  the  sensation  of  cold  that  it 
produced.  The  intensity  of  the  sensation  of  cold  under  the  shower-bath  is  consider- 
able, but  the  duration  of  it  is  momentary.  It  operates  as  a  prophylactic  in  this  way  : 
it  inures  the  surface  to  a  lower  temperature  than  it  is  likely  to  be  subjected  to  at  any 
other  part  of  the  day.  The  lesser  degrees  of  cold  have  then  no  injurious  effect,  un- 
less they  are  long  protracted.  For  those  who  cannot  procure  a  shower-bath,  or  who 
cannot  bear  its  shock,  cold  sponging  Avill  be  found  exceedingly  salutary. 

But  inflammation  of  the  membrane  lining  the  air-passages  may  be,  and  often  is,  a 
very  acute  and  dangerous  disorder,  i.  e.,  the  inflammation  may  be  both  intense  and 
diffused ;  it  may  descend  into  the  vesicular  texture,  and  occupy  the  whole  surface 
of  the  membratie  on  one  side  of  the  chest,  and  then  it  may  prove  a  very  grave  dis- 
ease ;  or  it  may  involve  the  whole  lining  membrane  of  both  lungs,  and  then  it  is 
always  attended  with  considerable  peril. 

This  inflammation  will  sometimes,  when  it  is  thus  general  over  the  whole  mem- 
brane, linger  for  a  considerable  period  in  its  first  stage ;  and  it  may  even,  after  so 
hntrering,  subside  asain  without  ever  passing  beyond  the  first  stage.  By  the  first 
Etaee,  I  mean  the  stage  of  dryness.  Very  little  notice  of  this  modification  of  bron- 
chitis has  been  taken  by  authors.  Dr.  Latham  has  given  a  distinct  and  graphic 
description  of  it,  to  the  accuracy  of  which  I  can  testify  from  my  own  experience. 
You  will  find  cases  of  it  detailed  in  his  book.  Since  they  were  published,  some 
striking  instances  of  this  form  of  the  disease  have  occurred  to  myself.  One,  which 
happened  lately,  I  will  relate  by  way  of  example.  I  was  asked  by  an  old  pupil  of 
the  hospital  to  see  a  lady,  his  patient,  in  Gordon  Square.  I  found  her  feverish  and 
in  a  state  of  extreme  dyspnoea,  sitting  up  in  bed  from  inability  to  lie  down,  labouring 
for  her  breath  ;  her  face  turgid  and  rather  livid,  her  nostrils  working,  her  shoulders 
elevated.  She  could  scarcely  speak,  but  expressed,  in  what  she  did  say,  a  dread  of 
imm.ediate  suffocation.  She  had  been  in  nearly  the  same  state  for  a  day  or  two. 
On  listening  at  her  back  I  could  hear  the  air  slowly  wheezing  and  whistling  into  her 
lungs  everywhere,  and  then  leaving  them  still  more  slowly,  with  a  prolonged  growi, 
something  hke  that  of  an  angry  cat.  There  was  no  true  vesicular  breathing  ;  there 
was  no  crepitation ;  and  there  was  no  part  into  which  the  air  did  not,  although  with 
ditficulty,  find  its  way.  The  chest  was  everywhere  resonant  on  percussion.  There 
could  be  no  doubt  that  the  membrane  throughout  was  tumid  and  dry,  and  in  the 
earliest  stajre  of  inflammation.  Depletion  had  already  been  employed  in  this  case, 
and  we  had  recourse  to  the  tartar  emetic.  This  was  given  in  free  and  repeated 
doses,  till  it  produced  nausea  and  sickness.  Whenever  it  did  so,  the  pulse  dimin- 
ished in  force,  the  face  became  blanched,  and  the  breathing  much  easier  ;  and  the 
medicine  was  then  suspended  until  these  effects  had  gone  off,  when  it  was  repeated 
•V  the  same  manner      The  disease  was  not,  however,  brought  at  once  to  an  end  by 


ACUTE    BRONCHITIS.  53o 

this  treatment ;  it  was  kept  at  bay  for  a  day  or  two  longer,  and  then  a  copious 
secretion  from  the  membrane  took  place,  with  great  relief  to  all  the  distressing 
symptoms.  7^hen,  of  coarse,  crepitation  became  universally  audible.  Except 
the  debihty  which  it  left  behind,  the  patient  soon  recovered  of  the  bronchial  inflam- 
mation. 

But  in  the  great  majority  of  instances  the  inflammation  does  not  thus  linger  in  its 
first  stage  ;  the  membrane  soon  begins  to  pour  forth  glairy  mucus ;  so  that  we  do  not 
often  meet  with  sibllus,  without  finding  at  the  same  time,  in  some  part  of  the  same 
lung,  that  there  is  also  small  and  large  crepitation.  It  is  of  some  importance  to 
attend  to  the  characters  of  the  mucus  that  is  expectorated.  It  is  transparent  and 
adhesive.  If  you  pour  it  from  one  vessel  into  another,  it  flows  out  in  one  mass  of 
extreme  tenacity ;  it  will  draw  out  sometimes  hke  melted  glass  ;  and  the  degree  of 
viscosity  is  a  tolerably  accurate  measure  of  the  degree  of  the  existing  inflammation. 
Upon  the  surface  of  the  viscid  mucus  there  is  usually  more  or  less  froth,  the  quantity 
of  it  depending  on  the  facility  or  the  difliculty  with  which  the  sputa  are  brought  up. 
If  the  patient  does  not  expectorate  till  after  a  long  fit  of  coughing,  during  which  air 
has  been  many  times  inspired  and  expired,  and  has  thus  got  intimately  mingled  with 
the  mucus  that  fills  the  air-passages,  the  expectoration  will  contain  numerous  little 
air-bubbles ;  will  be  very  frothy.  Sometimes  also,  during  this  stage  of  the  com- 
plaint, the  sputa  are  marked  Avith  streaks  of  blood. 

While  the  expectoration  possesses  the  characters  I  have  been  describing,  the 
inflammation  is  still  intense,  and  the  fever  and  dyspnoea  considerable.  This  cor- 
respondence between  the  general  symptoms  and  the  matters  spat  up  was  well  known 
to  the  ancients,  who  said  that  such  expectoration  was  still  crude.  But  in  proportion 
as  the  inflammation  approaches  to  resolution,  the  appearance  and  qualities  of  the 
sputa  are  changed ;  the  mucus  loses  by  degrees  its  transparency,  is  mixed  with 
masses  that  are  opaque,  and  of  a  yellow,  white  or  greenish  colour :  and  these  masses, 
few  at  first,  increase  more  and  more  in  number,  until  they  constitute  the  whole  of 
the  sputa.  Such  expectoration  as  this  is  commonly  accompanied  by'  a  marked  re- 
mission in  the  different  symptoms  of  the  bronchial  inflammation ;  it  announces  that 
the  inflammation  is  terminating  in  resolution.  It  is  such  as  the  ancients  spoke  of  as 
being  concocted,  or  ripe.  However,  the  characters  of  the  opaque  sputa  expecto- 
rated towards  the  end  of  an  attack  of  acute  bronchitis  are  subject  to  much  variety. 

It  will  often  happen  that  the  expectoration,  after  having  thus  become  opaque,  and 
parti-coloured,  will  go  back  again  to  its  former  condition  of  transparency,  and  sticki- 
ness, and  froth  :  and  that  is  a  very  certain  index  of  a  return  or  increase  or  extension 
of  the  inflammation  ;  so  that  the  character  of  the  matter  expectorated  exhibits,  in  a 
certain  degree,  the  progress  of  the  inflammation ;  and  consequently  constitutes  one 
point  of  guidance  to  our  treatment.  The  nature  of  the  expectoration  forms  also  an 
important  particular  in  our  means  of  distinguishing  bronchitis  from  pneumonia;  as  I 
shall  further  explain  when  I  speak  of  the  latter  disease. 

I  have  described  acute  bronchitis  as  it  appears  when  it  terminates  favourably :  in 
such  cases  the  inflammation  generally  begins  to  abate,  somewhere  from  the  fourth  to 
the  eighth  day  of  the  disease.  But  acute  bronchitis  may  terminate  wxfavoKrably. 
When  the  inflammation  is  universal  and  intense,  the  fever  high,  and  the  labour  of 
respiration  great — if  the  symptoms  do  not  yield  to  the  treatment  employed,  or  if  judi- 
cious treatment  has  not  been  adopted,  or  has  been  too  long  delayed,  signs  of  im- 
pending suflxjcation  begin  to  show  themselves :  the  lips  and  cheeks,  and  tongue, 
assume  a  purplish  colour;  a  livid  paleness  takes  the  place  of  the  former  red  flush; 
the  expression  becomes  more  and  more  anxious :  delirium  comes  on,  and  rapid  sinking. 
These  indicate,  you  know,  the  circulation  of  blood  that  is  in  a  great  measure  venous 
through  the  arteries ;  and  the  venous  blood  acts  as  a  poison  when  it  so  circulates 
Profuse,  cold,  clammy  sweats  ensue  ;  and  the  patient  dies  of  apnoc.  His  breathm- 
is  choked  by  the  morbid  secretion  which  occupies  the  bronchial  tubes,  small  as  wel! 
as  large,  and  which  he  has  not  strength  enough  left  to  cough  up. 

Accordingly,  when  we  examine  the  thorax  after  death  so  produced,  we  find,  ni 
the  first  place,  that  the  lungs  do  not  collapse  upon  the  admission  of  the  pressure  of 
the  rttmosphere  to  their  external  surface.     We  next  find  the  trachea,  and  bronchi,  and 


536  ACUTE   BRONCHITIS. 

their  ramifications,  blocked  up  by  a  frothy  adhesive  mucus,  resembling  that  which 
during  life  had  been  expectorated ;  and  the  membrane  which  lines  them  is  red  and 
thickened. 

The  treatment  proper  for  these  acute  and  dangerous  forms  of  bronchitis  is  a  matter 
of  some  nicety.  Blood-letting,  as  I  formerly  stated  to  you,  has  not  that  decided 
power  over  inflammation  of  the  mucous  tissues  which  it  possesses  over  the  adhesive 
inflammation  that  takes  place  in  the  serous  membranes.  If  there  be  much  fever,  a 
hard  pulse,  and  great  oppression  of  the  breathing,  and  particularly  if  these  symptoms 
present  themselves  in  a  young,  strong,  and  robust  individual,  we  must  bleed  him 
from  the  arm.  And  you  will  always  find  blood-letting  relieve  the  symptoms ;  even 
when  its  ultimate  effect  may  be  injurious.  The  patient's  distress  arises  from  his 
inability  to  supply  air  enough  to  arlerialize  the  venous  blood  which  is  transmitted  to 
his  lungs ;  and  by  diminishing  the  quantity  of  blood  sent  to  those  organs,  you  will, 
pro  (anto,  mitigate  his  uneasiness.  But  a  great  part  of  the  danger  to  be  apprehended 
in  the  advanced  periods  of  the  disease,  is  that  the  patient  may  not  have  muscular 
power  enough  to  disembarrass  his  air-passages  of  the  phlegm  that  overloads  them ; 
to  draw  a  strong  breath,  and  to  achieve  a  vigorous  cough.  We  must  not  bleed 
therefore  to  syncope,  and  again  and  again,  as  we  are  often  justified  in  doing  in  cases 
of  pneumonia.  Sixteen  ounces  will  be  a  moderate  bleeding  at  first  for  an  adult,  but 
more  or  less  than  that  must  be  taken,  and  the  bleeding  must  be  repeated  or  not, 
according  to  the  condition  of  the  pulse :  for  the  pulse  affords  a  better  measure  of  the 
propriety  of  pushing  the  abstraction  of  blood,  than  is  furnished  by  the  local  symp- 
toms. 

Great  relief  is  often  obtainable  by  topical  blood-letting;  by  cupping  over  the  sur- 
face of  the  chest,  or  between  the  scapulae.  If  you  distinguish  sibilus  in  one  portion 
of  the  lung  more  than  in  another,  take  the  blood  rather  from  that  part  of  the  surface 
which  corresponds  to  the  place  of  the  sibilus. 

After  the  bowels  have  been  cleared  by  a  mercurial  purgative,  calomel  and  jalap, 
for  example,  you  will  find  the  tartar  emetic  a  very  valuable  medicine  in  these  acute 
cases  of  bronchitis.  It  should  be  given  in  such  doses  as  will  excite  nausea:  and  if 
vomiting  be  occasioned,  you  may  still  go  on  with  the  medicine  after  the  sickness  has 
subsided.  The  depression  which  this  substance  produces  is  great,  but  it  is  tempo- 
rary, and  it  is  effi'Cted  without  expending  blood.  With  the  antimony  —  I  mean 
during  the  same  period—  mercury  may  and  ought  to  be  given  :  to  this  combination  I 
should  be  inclined  to  trust  more  than  to  any  other  internal  treatment. 

If  syraptf'iiis  of  sinking  and  debility  have  begun  to  show  themselves,  it  \\i\l  be 
necessary  to  administer  stimulating  expectorants.  I  presume  that  the  carbonate  of 
ammonia,  which  is  often  extremely  useful  in  such  cases,  acts  as  an  expectorant,  by 
giving  a  fillip  to  the  muscular  power.  But  it  is  supposed  by  some  persons  to  exer- 
cise some  specific  influence  upon  the  bronchial  membrane.  However  this  may  be, 
five  or  six  grains  of  it,  given  in  solution  every  four  or  six  hours,  are  often  followed 
by  free  expectoration  and  a  marked  improvement. 

One  of  the  circumstances  of  which  patients  are  much  disposed  to  complain,  is 
the  violent  or  importunate  cough;  and  another  is,  the  want  of  sleep  and  of  rest; 
indeed,  the  one  of  these  is  often,  in  a  great  measure,  the  cause  of  the  other ; — the 
urgency  or  frequency  of  the  cough  prevents  the  patient  from  sleeping.  Now  there 
is  nothing  so  well  calculated  to  allay  cough,  and  to  procure  sleep,  as  opium  ;  and 
you  will  be  strongly  tempted  to  give  these  patients  opiates,  and  you  will  probably 
be  encouraged  to  do  so  by  the  success  which  will  follow  that  practice  in  many 
cases.  The  good  efft'cts  of  a  full  narcotic  at  bed-time  are  sometimes  very  striking. 
Patients  who  for  previous  nights  have  been  perpetually  harassed  by  cough,  and 
who  are  worn  out  by  the  disturbance  of  their  rest,  will  sleep  tranquilly,  and  in  the 
morning  expectorate  largely  and  freely,  and  declare  themselves  wonderfully  the 
better  for  their  opiate.  Yet  opium  is  a  ticklish  remedy  in  these  cases.  Many  a 
patient — some  within  my  own  knowledge — labouring  under  general  or  extensive 
broncnitis,  have  been  put  so  soundly  to  sleep  by  a  dose  of  opium  on  going  to  bed, 
that  they  have  not  waked  again.  I  believe  you  may  receive  it  as  a  golden  rule  in 
ih'^se  case.s  not  to  give  opium — I  mean  in  a  full  dose,  so  as  to  force  sleep — if  you  see 


1 


PERIPNEUMONIA   NOTHA.  537 

any  venous  blood  mingling  in  the  general  circulation, — if  the  complexion  be  dusky, 
and  the  lips  in  any  degree  blue.  The  circulation  of  half-arterialized  blood  through 
the  brain  is  in  itself  a  powerful  cause  of  coma ;  and  if  you  add  the  influence  of  an 
opiate,  the  coma  may  easily  be  made  fatal.  While  the  cheeks  and  lips  remain  florid, 
and  when  the  first  violence  of  the  disease  has  abated,  an  opiate  will  do  capital  ser- 
vice. It  is  a  common  practice  to  combine  it  with  antimony  or  some  other  expecto- 
rant. Twenty  minims  of  laudanum,  with  the  same  quantity  of  the  liquor  antimonii 
tartarizati ;  or  a  third  of  a  grain  of  the  acetate  of  morphia,  with  a  drachm  of  oxymel 
of  squills  ;  are  convenient  forms. 

Counter-irritation  is  frequently  of  great  use,  as  an  auxiliary  measure,  in  the  treat- 
ment of  acute  bronchitis.  Sensible  rehef  of  the  cough,  and  of  the  oppressed  breath- 
ing, often  follows  the  rising  of  a  large  blister  laid  across  the  front  of  the  chest.  When 
the  dyspncea  is  extreme,  and  a  more  speedy  counter-irritant  is  required,  you  may 
have  recourse  to  the  mustard  poultice.  Inhalation  of  the  steam  of  hot  water  is  also 
very  soothing  and  useful.  It  is  one  of  the  best  expectorants  I  know  of  when  it 
answers  at  all ;  but  to  some  persons  it  proves  irritating,  and  they  derive  no  comfort 
from  it. 

I  have  been  speaking  of  acute  bronchitis,  uncombined  with  any  other  pulmonary 
disease ;  and  it  is  curious  how  little  disposed  the  inflammation  often  seems  to  be  to 
extend  itself  from  the  mucous  membrane  to  the  neighbouring  tissues.  The  reason, 
doubtless,  is,  that  this  membrane  is  furnished  with  a  distinct  set  of  blood-vessels, 
the  bronchial  arteries,  and  veins :  while  the  substance  of  the  lungs  is  supplied  by 
the  pulmonary.  We  could  not  tell,  merely  by  attending  to  the  general  symptoms, 
whether  the  inflammation  was  hmited  to  the  inner  membrane  or  not ;  but  by  making 
use  of  the  sense  of  hearing,  we  are  able  to  determine  this.  If  the  inflammation 
should  spread  to  the  parenchymatous  texture  of  the  lungs, — i.  e.,  if  the  bronchitis 
should  pass  into  pneumonia,  —  this  circumstance  would  be  disclosed  by  physical 
signs,  which  I  shall  in  due  time  prescribe  and  explain  ;  and  it  would  demand  certain 
modifications  of  our  plan  of  treatment. 

I  shall  have  to  speak  of  some  varieties  of  chronic  bronchitis  ;  but  there  is  a  mixed 
form  of  pulmonary  disease  that  requires  to  be  noticed,  in  which  acute  or  subacute 
inflammation  engrafts  itself  upon  changes  that  are  chronic  and  abiding.  Sydenham 
calls  the  disorder  to  which  I  now  refer  peripneumonia  notha — bastard  peripneumony. 
■  Calarrhiis  senilis  is  another  of  its  names.  It  may  be  considered  as  chronic  bron- 
chitis, occurring  in  old  persons,  and  very  apt  to  be  converted  into  pneumonia,  or  to 
be  greatly  aggravated  in  degree  during  winter,  or  upon  any  accidental  exposure. 
This  is  the  common  complaint  of  persons  advanced  in  life.  I  mention  it  here  in 
compliance  with  the  usual  custom,  and  because  this  is  as  convenient  a  place  for  its 
introduction  as  any.  But  it  would  be  an  error  to  regard  it  as  exclusively  a  disease 
of  the  mucous  membrane  of  the  lungs.  An  habitually  congested  state  of  that  mem- 
brane, marked  by  some  shortness  of  breath,  and  some  expectoration,  and  by  the 
constant  presence  of  some  degree  of  crepitation  in  the  lower  parts  of  the  lungs, — 
these  are  circumstances  which  are  of  daily  occurrence  as  consequences  of  disease 
of  the  heart  ^  and  it  is  in  persons  whose  habitual  health  is  of  this  kind,  that  what  is 
called  peripneumonia  notha,  which  implies  a  diffused  inflammation  of  the  pulmonary 
mucous  membrane,  with  sometimes  an  enormous  secretion  from  its  surface,  is  most 
apt  to  supervene.  Almost  all  such  persons  will  tell  you  that  there  are  periods  at 
which  they  experience  slight  febrile  attacks,  and  exacerbations  of  their  complaints  : 
they  have  pain  in  the  breast  or  side,  headache,  heat,  and  thirst ;  and  at  these  periods 
the  cough  and  expectoration  are  always  aggravated,  and  continue  for  some  time  to 
be  more  than  commonly  severe.  "The  disease  (says  CuUen,  who,  following  Syden- 
ham, has  given  a  good  description  of  its  general  symptoms)  has  often  ihe  appearance 
only  of  a  more  violent  catarrh  ;  and  after  the  employment  of  some  remedies,  .s 
entirely  relieved  by  a  free  and  copious  expectoration.  In  other  cases,  however,  the 
feverish  and  catarrhal  symptoms  are  at  first  very  moderate,  and  even  slight ;  buf 
after  a  few  days  these  symptoms  suddenly  become  considerable,  and  put  an  end  to 
the  patient's  Hie,  when  the  indications  of  "danger  were  before  very  little  evident.' 


538  PERIPNEUMONIA    NOTIIA. 

The  truth  is,  (and  we  learn  the  truth  by  the  evidence  of  auscultation,)  that  ia 
these  cases  pneumonic  inflammation  is  often  suddenly  set  up.  There  is  no  security, 
as  Dr.  Latham  observes,  that  the  portions  of  lung  which  yield  small  crepitation  to- 
day may  not  be  solid  and  impervious  to-morrow.  Dr.  Latham  is  of  opinion  that  in 
this  disease  the  inflammation  is  apt  to  travel  over  the  bronchial  membrane  from  place 
to  place,  as  erysipelas  is  seen  sometimes  to  wander  over  the  surface  of  the  body.  I 
know  not  how  this  may  be ;  but  certainly  death  is  often  produced  in  these  persons 
by  the  sudden  spoiling  of  even  a  moderate  portion  of  lung.  In  their  ordinary  con- 
dition, the  patients  have  just  enough,  and  no  more,  of  the  respiratory  apparatus  in 
an  effective  stale,  whereby  to  subsist ;  and  when  a  fresh  part  of  it  is  rapidly  rendered 
solid,  they  quickly  perish.  But  they  die  also  from  another  cause.  The  nicety  of 
treatment  which  I  spoke  of  as  being  required  in  certain  stages  of  acute  bronchitis,  ia 
still  more  apparent  and  necessary  here.  We  are  placed  in  this  dilemma.  If  we  do 
not  take  biood  in  these  attacks,  we  run  a  risk  of  losing  our  patient  from  the  effects 
of  the  unchecked  inflammation ;  and  if  we  do  bleed,  we  are  in  danger  of  losing 
him  by  producing  a  degree  of  weakness  which  will  render  him  unable  to  expecto- 
rate the  effused  mucus,  and  so  liable  to  perish  by  suffocation.  Leeches  and  blisters, 
and  what  are  called  expectorants,  are  the  remedies  to  which  we  must  chiefly  trust. 
Medicines,  which  are  at  the  same  time  diuretic  are  also  serviceable  —  the  spiritus 
aslheris  nitrici,  the  preparations  of  squill,  and  of  digitalis. 

Even  in  younger  patients,  in  whom  the  bronchitis  is  idiopathic,  not  engrafted  upon 
any  previous  disease  of  the  chest,  and  in  whom  the  disorder  had  not  appeared  severe, 
extreme  difficulty  of  breathing  will  sometimes  most  imexpectedly  arise,  and  some- 
times it  will  rapidly  lead  to  the  extinction  of  life.  Now  both  Andral  and  Laennec 
have  pointed  out  one  cause  (to  which,  indeed,  I  have  already  adverted  in  the  pre- 
sent lecture)  of  this  sudden  change  for  the  worse.  It  is  a  cause  which  was  not 
likely  to  be  even  guessed  at  before  the  discovery  of  the  method  of  auscultation. 
Occasionally  it  happens,  they  say,  that  during  the  course  of  an  attack  of  bronchitis, 
we  cease  altogether  to  hear,  in  a  certain  extent  of  the  lung,  either  the  natural  respira- 
tory murmur,  or  any  of  the  modifications  of  rhonchus,  sibilus,  or  crepitation,  that 
have  been  mentioned  ;  yet  over  this  same  portion  of  lung,  in  which  no  sound, 
healthy  or  morbid,  is  heard  by  the  ear  apphed  to  the  thorax,  percussion  gives  the 
natural  hollow  sound.  At  the  same  time  the  patient  becomes  affected  with  urgent 
dyspnoea.  This  sudden  suspension  of  all  sound  of  respiration  they  attribute  to  the 
temporary,  or,  in  some  cases,  the  permanent,  obstruction  of  one  of  the  bronchi,  the 
ramifications  whereof  are  distributed  to  that  portion  of  lung  in  which  the  respiration 
is  no  longer  audible.  In  such  cases  it  generally  happens  that  at  the  end  of  a  strong 
fit  of  coifo-hing — the  effect  of  which  is  to  expel,  or  at  least  to  displace  the  tenacious 
plug  of  mucus  obstructing  the  bronchus — the  sound  of  respiration  is  re-established 
as  suddenly  as  it  had  previously  disappeared ;  and  the  dyspnoea  also  ceases.  In 
some  rarer  cases,  however,  the  noise  of  the  pulmonary  expansion  does  not  return, 
the  difficulty  of  breathing  increases,  suffocation  becomes  imminent,  and  death  by 
apncea  rapidly  takes  place.  The  slightest  attack  of  bronchitis  may  in  this  way  be 
suddenly  transformed  into  a  most  serious  and  quickly  fatal  malady. 

Andral  relates  two  instances  of  death  from  this  cause  ;  one  of  which  was  the  fol- 
lowiuij.  A  coachman,  fifty  years  old,  had  been  several  times  a  patient  in  La  Charite, 
for  obstinate  pulmonary  catarrh,  with  slight  dyspnma,  and  puriform  expectoration. 
Every  time  he  went  away  relieved,  but  not  cured.  On  both  sides  of  his  chest  could 
be  heard  all  the  varieties  of  rhonchus.  In  one  spot  the  column  of  air  which  pene- 
trated the  bronchi  imitated  the  snoring  of  one  in  a  deep  sleep  ;  in  another  spot  it 
was  like  a  duU  and  prolonged  groan  ;  in  a  third,  a  sound  resembling  that  made  by 
bellows  ;  and  in  a  fourth  the  cooing  of  a  turtle-dove  was  exactly  simulated.  On  the 
last  occas.on  of  his  entering  the  hospital,  his  respiration  was  still  tolerably  free.  One 
iTiorning  he  was  found  in  a  state" of  unusual  anxiety.  In  the  middle  of  the  night, 
after  a  violent  paroxysm  of  cough,  his  breathing  (he  said)  had  suddenly  become  very 
much  oppressed.  It  was  discovered,  on  auscultation  of  his  chest,  that  no  air  pene- 
trated into  the  upper  lobe  of  the  right  lung;  yet  that  part  sounded  well  on  percus- 
sioi..  even  louder  than  the  corresponding  part  of  the  other  side,  which  was  morbidly 


INFLUENZA.  539 

dull.  The  difficulty  of  breathing  went  on  augmenting,  and  the  man  was  soon 
dead. 

Besides  other  marks  of  disease  in  the  lungs,  the  primary  bronchus  leading  to  the 
upper  lobe  on  the  right  side  was  closed  up  completely  by  tough  mucus,  and  exhi- 
bited the  appearance  of  a  full  cylinder. 

In  the  other  case,  also,  the  obstructed  bronchial  tube  supplied  the  upper  lobe  of 
the  right  lung. 

It  may  seem  strange  that  the  interruption  of  the  access  of  air  to  so  small  a  portion 
of  the  lungs  should  be  attended  with  such  serious  consequences,  when  we  know  that 
the  greater  part  of  each  lung  may  be  impermeable  by  air,  and  yet  the  patient  liv^e  a 
long  time,  and  often  without  any  great  dyspnoea.  The  explanation  of  the  apparent 
difficulty  seems  to  be,  that  in  the  one  case  the  prevention  of  the  arrival  of  air  in  the 
part  afffcted  is  sudden,  in  the  other  gradual.  Moreover,  the  remaining  portions  of 
the  lungs  are  performing  their  functions  imperfectly. 

When  once  attention  has  been  awakened  to  the  kind  of  accident  just  mentioned, 
the  diagnosis  would  not  seem  to  be  difficult.  We  may  suspect  obstruction  of  one  of 
the  bronchi  when  considerable  dyspnoea  comes  on  suddenly  during  the  continuance 
of  simple  bronchitis:  and  our  suspicion  will  be  confirmed  if  at  the  same  time  respi- 
ration ceases  to  be  audible  in  a  certain  portion  of  the  lung,  while  the  sound  given  by 
])ercussion  over  the  same  part  remains  unaltered.  Emphysema  of  the  lung  (which 
I  shall  explain  hereafter)  is  the  only  other  condition  which  could  give  rise  to  a  similar 
set  of  symptoms. 

Andral  judiciously  suggests  the  employment  of  emetics,  and  the  inhalation  of 
steam,  in  such  cases. 


LECTURE  XLIX. 

Injliienza.  Symptoms  and  progress.  Conjectures  as  to  its  cause.  Treatment. 
Hay  asthma.  Chronic  Bronchitis.  Its  varieties.  Morbid  anatomy  of  these 
affections. 

Catarrh,  which  was  the  principal  subject  of  the  last  lecture,  occasionally  prevails 
far  and  wide  as  an  epidemic  disease.  I  speak,  indeed,  (February  4,  1837,)  during 
the  immediate  presence  of  one  such  visitation,  although  the  extreme  violence  of  the 
complaint  that  has  been  raging  among  us  is  now  fast  subsiding.  You  can  hardly 
be  without  curiosity  to  know  what  has  been  learned  respecting  an  influence  which 
has  thus,  on  a  sudden,  before  your  eyes,  disturbed  and  sickened  a  whole  community. 

I  have  here  used,  without  thinking  of  it,  the  very  word  by  which,  in  a  foreign 
version,  the  disorder  is  denominated.  It  has  received,  however,  various  names ;  for 
it  has  been  known  and  noticed  from  remote  antiquity.  Cullen  calls  it  catarrhus  e 
contagio:  and  under  that  head,  in  his  Nosology,  you  will  find  a  copious  reference 
to  recorded  accounts  of  epidemic  catarrh,  as  it  has  been  observed  to  spread  over 
great  portions  of  the  world.  In  France  the  disorder  thus  prevailing  is  styled  the 
grippe.  The  Italians,  putting  the  cause  for  the  effect,  called  it  influenza,  the  injlu- 
ence:  and  this  last  term,  influenza,  has  now  become  naturalized  in  our  language. 
Since  Cullen  wrote  there  have  been  four  or  five  more  of  these  epidemics.  One  in 
1782,  which  extended  over  all  Europe,  visiting  every  country  therein,  affecting  more 
than  one  half  of  its  inhabitants,  and  proving  fatal  to  very  many  of  them.  You  will 
find,  in  the  third  volume  of  the  Transactions  of  the  College  of  Physicians,  a  good 
account  of  the  disease  as  it  then  showed  itself  in  this  country.  In  the  spring  of  1803 
another  instance  of  it  occurred ;  and  of  this  the  history,  as  compiled  from  the  testi- 
mony of  a  hundred  and  twenty-four  observers,  is  preserved  in  the  ninth  and  tenth 
volumes  of  the  London  Medical  and  Physical  Journal.  In  the  month  of  April,  in 
the  year  1833,  the  influenza  arrain  made  its  appearance,  and  prevailed  extensively, 
both  here  and  elsewhere :  and  of  the  influenza  of  1837  you  have  had,  and  you  still 
have,  the  opportunity  of  being  observers.     A  very  good  and  instructive  sketch  of 


540  INFLUENZA. 

this  epidemic  malady,  compiled  by  Dr.  Hancock,  is  to  be  found  in  the  Cyclopxdia 
of  Practical  Medicine.  To  that  article,  to  the  publications  I  just  now  mentioned, 
and  to  the  works  enumerated  by  Cullen,  I  may  refer  you  for  much  which  is  curious 
and  interesting  in  the  history  of  the  disease  ;  but  which  would  not  be  so  well  adapted 
to  our  immediate  purpose  in  this  place — namely,  that  of  seizing  upon  the  practical 
facts  which  have  been  ascertained  respecting  influenza. 

One  characteristic  feature  of  this  species  of  catarrh,  as  distinguished  from  the  ordi- 
nary sporadic  disorder,  is  the  sudden  occurrence,  in  the  outset,  of  more  decided 
febrile  disturbance.  The  first  two  patients  whom  I  saw  in  the  epidemic  of  1S33  had 
just  the  symptoms  which  frequently  mark  the  commencement  of  an  attack  of  conti- 
nued fever ;  and  I  did  not  know,  at  my  first  visit,  what  was  about  to  happen  to  them. 
The  symptoms,  taking  them  altogether,  are  somewhat  as  follows.  The  patient  is 
chilly,  and  perhaps  shivers ;  presently  headache  occurs,  and  a  sense  of  tightness 
across  the  forehead,  in  the  situation  of  the  frontal  sinuses ;  the  eyes  become  tender 
and  watery ;  and  sneezing  and  a  copious  defluxion  from  the  nose  ensue,  followed  or 
accompanied  by  heat  and  uneasiness  about  the  throat,  hoarseness,  a  troublesome 
cough,  and  oppression  of  the  breathing.  In  short,  the  symptoms  are  the  symptoms 
of  catarrh ;  including  in  that  term  all  the  varieties  thereof  that  are  sometimes  met 
with  separately — gravedo,  cor}'za,  bronchitis  :  and  with  these  symptoms  a  sudden, 
early  and  extraordinary  subdual  of  the  strength;  and,  most  commonly,  great  depres- 
sion of  spirits.  The  debility  which  comes  on  at  the  very  outset  of  the  complaint,  is 
one  of  its  most  singular  phenomena,  taking  place,  in  some  cases,  almost  instantly, 
and  in  a  much  greater  degree  than  would  seem  proportioned  to  the  other  symptoms 
of  the  malady  which  it  thus  ushers  in.  Indeed,  this  rapid  and  remarkable  prostra- 
tion of  strength  is  more  essentially  a  part  of  the  disorder  than  the  catarrhal  affection, 
which  sometimes  (though  rarely)  is  absent,  or  imperceptible.  It  is  upon  the  mucous 
membranes,  however,  that  the  stress  of  the  disease  generally  falls  ;  especially  upon 
the  internal  lining  of  the  air-passages.  Those  of  the  alimentary  canal  seldom  escape 
entirely ;  but  they  suffer  in  a  less  degree.  The  tongue  is  white  and  creamy,  the 
palate  loses  its  sensibihty,  the  appetite  fails,  nausea  and  vomiting  are  not  uncommon, 
and  sometimes  there  is  diarrhoga.  The  pulse,  in  the  uncomplicated  disease,  is  soft, 
and  generally  weak.  The  patients  complain  also  of  pains  in  the  limbs  and  back, 
and  of  much  soreness,  a  bruised,  fatigued,  or  tender  feel,  along  the  edges  of  the  ribs 
and  in  various  parts  of  the  body. 

In  its  simple  form  and  ordinary  course,  the  disease  abates  of  its  violence  after  two, 
three,  or  four  days,  and  the  patient  is  usually  convalescent  before  the  termination  of 
the  week :  but  cough  and  much  debilitj'-  are  apt  to  survive  the  other  symptoms,  and 
while  these  continue,  the  complaint  is  very  easily  renewed.  Pre-existing  disease, 
and  peculiar  constitutional  habits  and  tendencies,  modify  considerably  the  character 
of  the  influenza,  as  it  affects  different  persons.  I  do  not  attempt  to  represent  its  va- 
rious phases  ;  they  are  fit  subjects  of  study  for  yourselves. 

I  have  remarked  that  Cullen  makes  this  species  of  catarrh  to  proceed  from  conta- 
gion. But  the  visitation  is  a  great  deal  too  sudden  and  too  widely  spread  to  be 
capable  of  explanation  in  that  way.  I  will  not  say  that  the  disease  may  not  be  iri 
some  degree  infectious ;  for  there  is  reason  to  believe  that  other  epidemic  disorders, 
having  many  points  of  analogy  with  the  influenza,  are  somehow  imparted  from  one 
individual  to  another,  akhough  they  are  mainly  produced  by  some  influence  which 
resides  in  the  aunosphere.  There  are  points  in  the  history  of  influenza  which  fur 
nish  a  strong  presumption  that  the  exciting  cause  of  the  disorder  is  material,  not  a 
mere  quality  of  the  atmosphere  ;  and  that  it  is  at  least  portable.  The  instances  are 
very  numerous,  too  numerous  to  be  attributed  to  mere  chance,  in  which  the  com- 
plaint has  first  broken  out  in  those  particular  houses  of  a  town  at  which  travellers 
have  recently  arrived  from  infected  places.  But  this  great  and  important  question 
of  contagion  I  hope  to  examine  with  you  more  rigorously  on  a  future  occasion. 
What  I  wish  to  point  out  now  is  the  fact  that  the  influenza  pervades  large  tracts  of 
country  in  a  manner  much  too  sudden  and  simultaneous  to  be  consistent  with  the 
notion  that  its  prevalence  depends  exclusively  upon  any  contagious  properties  that 
it  may  possess.     You  are  aware  that  it  has  recently  seized  upon  all  parts  of  this 


INFLUENZA.  541 

metropolis — and  I  believe  I  may  say  of  nearly  the  whole  kingdom — within  the  space 
of  a  very  few  days.  It  has  been  observed  to  occur  also,  at  the  same  time,  on  land, 
and  on  board  different  ships  which  have  had  no  communication  with  the  shore,  nor 
with  each  other.  Thus  it  is  stated  in  the  Transactions  of  the  College  of  Physi- 
cians, that  on  the  2d  of  May,  1782,  Admiral  Kempenfelt  sailed  from  Spithead  with 
a  squadron,  of  which  the  Goliah  was  one.  The  crew  of  that  vessel  were  attacked 
with  influenza  on  the  29th  of  JVlay  ;  and  the  rest  were  at  different  times  affected,  and 
so  many  of  the  men  were  rendered  incapable  of  duty  by  this  prevailing  sickness 
that  the  whole  squadron  was  obliged  to  return  into  port  about  the  second  week  in 
June,  not  having  had  communication  with  any  shore,  but  having  cruised  solely  be- 
tween Brest  and  the  Lizard.  This  happened  in  one  part  of  the  fleet.  In  the  begin- 
ning of  the  same  month,  another  large  squadron  sailed,  all  in  perfect  health,  under 
Lord  Howe's  command,  for  the  Dutch  coast.  Towards  the  end  of  the  month,  just 
at  the  time,  therefore,  when  the  Goliah  became  full  of  the  disease,  it  appeared  in  the 
Rippon,  the  Princess  Ameha,  and  other  ships  of  the  last-mentioned  fleet,  although 
there  had  been  no  intercourse  with  the  land.  Similar  events  were  noticed  in  the 
epidemic  of  1833.  One  or  two  curious  instances  of  the  sudden  sickening  of  consi- 
derable bodies  of  men  in  different  places  at  the  same  time,  were  related  to  me  on 
good  authority.  On  the  3d  of  April  in  that  year — the  very  day  on  which  I  saw  the 
first  two  cases  that  I  did  see  of  the  influenza,  all  London  being  smitten  with  it  on 
ihat  and  the  following  day — on  that  same  day  the  Stag  was  coming  up  the  channel, 
and  arrived  at  two  o'clock  off"  Berry  Head,  on  the  Devonshire  coast,  all  on  board 
being  at  that  time  well.  In  half  an  hour  afterwards,  the  breeze  being  easterly  and 
blowing  off"  the  land,  40  men  were  down  with  the  influenza ;  by  six  o'clock  the 
number  was  increased  to  GO,  and  by  two  o'clock  the  next  day  to  160.  On  the  self- 
same evening  a  regiment  on  duty  at  Portsmouth  was  in  a  perfectly  healthy  state, 
but  by  the  next  morning  so  many  of  the  soldiers  of  that  regiment  were  affected  by 
the  influenza,  that  the  garrison  duty  could  not  be  performed  by  it.  I  make  no  doubt 
that  facts  of  a  like  nature  have  occurred  during  the  present  epidemic,  and  will  be 
made  known  in  due  time.  They  illustrate  several  important  points  in  respect  to  the 
disease  :  viz.,  the  impossibility  of  accounting  for  its  prevalence  upon  the  principle 
of  mere  contagion — the  suddenness  of  its  invasion — and  the  early  and  extreme  pros- 
tration of  strength  with  which  it  is  attended. 

The  occurrence  of  epidemic  catarrh,  as  well  as  of  most  other  epidemics,  is  un- 
questionably connected  with  some  particular  state  or  contamination  of  the  atmosphere. 
What  that  state  is,  or  what  may  be  the  kind  of  contamination,  no  one  knows.  The 
present  epidemic  followed  hard  upon  the  sudden  thaw  that  succeeded  the  remarka- 
ble snow-storm  of  the  last  week  of  the  last  year.  A  similar  coincidence  between 
the  breaking  out  of  the  same  disorder,  and  a  sudden  elevation  of  the  temperature 
of  the  atmosphere,  happened  at  St.  Petersburgh  in  the  epidemic  of  1782.  "  On  a 
cold  night  (Maertens  says),  the  thermometer  rose  30°  of  Fahrenheit ;  the  next  morn- 
ing 40,000  people  were  taken  ill  with  the  influenza."  Now  if  every  epidemic  had 
been  preceded  by  similar  changes  in  the  weather,  we  might  resolve  the  universal 
prevalence  and  sudden  accession  of  the  complaint,  into  the  effect  of  the  cold  and 
damp  state  of  the  air,  produced  by  the  thaw.  But  it  is  not  so ;  for,  as  Dr.  Hancock 
observes,  there  has  not  been  any  uniform  connection  between  any  one  sensible  quality 
of  the  atmosphere  as  to  the  heat  or  cold,  rain  or  drought,  wind  or  calm — and  the 
mvasion  of  the  epidemic.  "  Et  tempore  frigidiori  et  calidiori,  et  flante  tarn  Austro 
quam  Borea,  et  pluvioso  et  sereno  caelo,  peragravit  haSce  omnes  Europa}  regiones, 
et  omnia  loca  indiscriminatim."  Irregularities  and  great  vicissitudes  of  weather 
have,  however,  gone  before  the  disease  in  very  many  instances :  but  sometimes  one 
condition  of  the  atmosphere,  and  sometimes  another,  has  been  its  immediate  fore- 
runner: and  the  epidemic  has  frequently  been  observed  to  fall  partially  and  caprici- 
ously :  as  a  blight  falls  upon  a  field  or  district.  Short,  in  his  chronological  history 
of  the  weather,  says  that  thick  ill-smelling  fogs  preceded,  some  days,  the  epidemic 
catarrh  of  1557.  Jussieu  states  that  the  grippe  of  the  spring  of  1733  appeared  m 
France  immediately  after  offensive  fogs,  "  more  dense  than  the  darkness  of  Egypt." 
So  also  in  1775,  Petit  informs  us  that  in  France  the  disease  was  ushered  in  by  thick 

2v 


542  INFLUENZA. 

noisome  fogs.  In  the  same  year  it  visited  the  shire  of  Galloway  in  Scotland,  where, 
we  are  told,  "  a  continual  dark  fog  and  particularly  smoky  smell  prevailed  in  the 
atmosphere  for  five  weeks,  the  sun  being  seldom  seen."  Dr.  Darwin  has  recorded 
that,  in  1783,  "the  sun  was  for  many  weeks  obscured  by  a  dry  fog,  and  appeared 
red  as  liirough  a  common  mist :"  and  he  supposes  that  "  the  materia]  which  thus 
rendered  the  air  muddy,  probably  caused  the  epidemic  catarrh  which  prevailed  in 
that  year."  You  will  call  to  mind  here  the  dark  fog  which  brooded  over  this  city  in 
the  midst  of  the  raging  of  the  distemper  about  ten  days  ago,  and  which  was  repeated 
in  a  less  degree,  on  Wednesday  last  (Feb.  1). 

It  has  been  observed  also,  that  shortly  before,  or  during,  or  soon  after,  the  preva- 
lence of  these  epidemic  catarrhs — epizootic  diseases  have  raged  ;  various  species 
of  brutes,  and  of  birds,  have  been  extensive!}'-  affected  with  sickness :  while  on 
some  occasions  prodigious  swarms  of  insects  have  made  their  appearance.  In 
short,  a  great  variet)'-  of  facts  concur  to  render  it  probable  that  some  pecuhar  con- 
dition of  the  air  existed,  which,  though  it  might  be  favourable  to  the  multiplication 
of  some  species  of  living  creatures,  such  as  the  insects  just  referred  to,  operated 
as  a  poison  upon  the  human  body,  and  upon  the  bodies  of  many  of  the  brute 
creation. 

It  is  a  very  curious  circumstance  in  the  history  of  epidemic  catarrhs,  and  worthy 
of  your  reflection,  that  they  travel ;  migrate  as  it  were  from  one  place  to  another: 
and  moreover,  that  they  hold,  for  the  most  part,  to  certain  courses,  in  spite  even  of 
opposite  winds,  and  of  variations  of  temperature.  It  has  been  noticed  that  the  influ- 
enza generally  follows  a  westerly  direction,  or  one  from  the  south  towards  the  north- 
west. In  this  remarkable  properly  it  resembles,  as  you  may  perhaps  be  aware,  the 
epidemic  cholera. 

AUhough  the  general  descent  of  the  malady  is,  as  I  have  said,  very  sudden  and 
diffused,  scattered  cases  of  it,  like  the  first  droppings  of  a  thunder-shower,  have 
usually  been  remembered  as  having  preceded  it.  The  disorder  is  most  violent  at 
the  commencement  of  the  visitation  ;  then  its  severity  abates  ;  and  the  epidemic  is 
mostly  over  in  about  six  weeks.  Yet  the  morbific  influence  would  seem  to  have  a 
longer  duration.  In  a  given  place  nearly  all  the  inhabitants  who  are  susceptibb  of 
the  distemper  suffer  it  within  that  period,  or  become  proof  against  its  power.  But 
strangers  who,  after  that  period,  arrive  from  uninfected  places,  have  not,  apparently, 
the  same  immunity. 

The  locality  does  not  appear  to  be  thoroughly  cleared  of  the  poison  for  some  time  : 
or  perhaps  a  more  cautious  statement  of  the  fact  Avould  be,  that  the  disorder  generally 
shows  itself  again  in  succeeding  years,  but  in  a  milder  and  less  general  form.  This 
must  depend  either  upon  some  remaining  dregs,  or  possibly  some  revival,  of  the  mju- 
rious  influence  ;  or  else  upon  some  abiding  predisposition  impressed  upon  the  bodies 
of  men  by  its  former  visit.  You  may  hear,  every  year,  of  Mr.  So-and-so  having 
the  influenza.  In  many  instances,  no  doubt,  common  si)oradic  catarrh  is  dignified 
by  that  name  ;  but  it  is  certain  also  that  many  of  the  colds,  and  bronchial  disorders, 
of  the  seasons  which  immediately  follow  a  period  of  genuine  influenza,  are  attended 
with  much  more  languor,  debihty,  muscular  aching,  and  distress,  than  belong  to  an 
ordinary  attack  of  catarrh. 

All  this  is  very  curious ;  and  very  mysterious.  All  this,  or  much  of  it,  is  true 
also  of  all  the  diseases  which  are  known  to  prevail  occasionally  as  epidemics.  The 
facts  that  have  now  been  mentioned  respecting  the  influenza,  warrant,  I  think,  the 
conclusion  that  it  does  not  depend  upon  any  mutations  in  the  ordinary  qualities  of 
the  atmospere ;  upon  any  degrees  or  variations,  I  mean,  of  its  temperature,  its 
motions,  or  its  moisture  ;  upon  what  is  expressed  in  the  single  word  weather.  Con- 
cernmg  a  calamity  so  generafly  felt,  and  so  obscure  in  its  origin,  conjecture,  you  may 
well  believe,  has  not  been  idle.  One  hypothesis  assigns  the  complaint  to  some  change 
in  the  electrical  condition  of  the  air :  to  its  becoming  negatively  electric :  or  to  its 
being  such  as  to  cause  an  excessive  accumulation  of  electricity  in  the  animal  econo- 
my. The  facts  adduced  in  support  of  these  views  are  of  this  kind.  Meat,  sent  up 
t»y  means  of  a  kite,  high  into  the  atmosphere,  during  the  prevalence  of  the  disease, 
has  returned  putrid.     Large  heavy  separate  clouds,  in  a  state  of  negative  electricity, 


INFLUENZA.  543 

have  been  observed  just  before  the  setting  in  of  an  epidemic.  Thunder-storms,  and 
tumults  of  the  atmosphere,  have  occurred  at  the  same  periods.  During  the  raging 
^f  one  epidemic,  300  women  engaged  in  coal-dredging  at  Newcastle,  and  wading  al. 
day  in  the  sea,  escaped  the  complaint.  It  has  been  thought  that  this  exemption 
might  be  accounted  for  by  supposing  that  the  almost  constant  immersion  of  the  body 
in  a  conducting  medium  prevented  any  undue  collection  of  electricity. 

Again,  it  has  been  fancied  that  the  tolerably  definite  course  of  the  epidemic,  in  its 
migrations,  might  be  somehow  connected  with  magnetic  currents. 

Another  hypothesis,  more  fanciful,  perhaps,  at  first  sight,  than  these,  yet  more 
easily  accommodated  to  the  known  phenomena  of  the  distemper,  attributes  it  to  the 
presence  of  innumerable  minute  substances,  endowed  with  vegetable  or  with  animal 
life,  and  developed  in  unusual  abundance  under  specific  states  of  the  atmosphere,  in 
which  they  float,  and  by  which  they  are  carried  hither  and  thither.  Myriads  of 
these  animalcules,  or  of  these  vegetable  germs,  coming  in  contact  with  the  mucous 
membranes,  and  especially  with  that  of  the  air-passages,  irritate  (it  is  imagined)  these 
surfaces,  and  exercise  a  poisonous  influence  upon  the  system.  Now,  the  sporules 
of  certain  fungi,  which  ruin  the  health,  and  destroy  the  vitality  of  larger  plants,  on 
which  they  prey,  are  inconceivably  small.  I  shall  prove  to  you,  presently,  that 
vegetable  effluvia  are  capable  of  producing,  in  the  human  body,  symptoms  not  very 
dissimilar  from  those  of  influenza.  Again,  that  the  waters  of  this  globe  swarm  with 
living  creatures,  which  are  invisible  by  our  unaided  eyes,  the  microscope  has  tauo^ht 
us.  Others,  too  small  even  to  be  estimated  by  that  wonder-showing  instrument,  in 
all  probability  exist.  We  cannot  doubt  that  the  gaseous  fluid  which  surrounds  this 
planet,  equally  teems  with  living  atoms.  We  know  that  multitudes  of  insects,  and 
of  cryptogamous  plants,  infinite  in  number  in  respect  to  our  finite  powers  of  compu- 
tation, are  sometimes  suddenly  hatched  or  developed,  in  places  which  were  pre- 
viously free  from  them.  It  is  easy  to  conceive  that  atmospheric  infusoria  (so  to 
speak)  may  rapidly  congregate,  or  vivify,  in  masses  sufficient  to  render  deleterious 
the  very  air  we  breathe.  If  this  be  so,  we  can  understand  how  such  a  cause  of  dis- 
ease may  first  act  here  and  there,  and  presently  overspread  large  districts ;  how  it 
may  move,  or  be  wafted  from  place  to  place,  or  be  carried  about  by  persons ;  how 
its  course  and  operation  may  be  circumscribed  and  definite ;  and  how  some  germs 
or  ova  may  remain  after  the  visit,  retaining  their  vitality,  and  ready  in  future  seasons 
again  to  start  into  life  and  activity  under  favouring  circumstances.  Taking  the 
insect  hypothesis,  and  knowing  as  we  do  that  some  animal  poisons  (that  of  small-pox, 
for  example),  have  the  singular  property  of  multiplying  themselves  in  the  human 
body,  like  yeast  in  beer,  we  may  conceive  that  diseases,  produced  by  animalcules, 
may  thus  infect  the  fluids  of  the  body,  and  become  contagious  in  the  fullest  sense  of 
that  term.  Lastly,  the  uniform  duration  of  these  epidemics  has  been  supposed  to 
add  probability  to  the  hypothesis  that  they  result  from  the  operation  of  some  organic 
principle,  which  has  its  definite  periods  of  growth  and  of  decay.  All  this  is  sheer 
hypothesis ;  but  it  is  as  good  an  hypothesis  as  I  am  able  to  offer  you ;  and  you 
must  be  content  to  conceive  of  it  as  being  possibly  the  true  one,  until  a  better  shall 
be  proposed. 

The  character  of  debility  which  is  so  conspicuously  impressed  upon  this  disease, 
boars  closely  upon  the  treatment  required  for  its  cure,  or  its  safe  conduct.  As  in  all 
other  epidemics,  the  severity  of  the  complaint  is  extremely  variable  in  different  per- 
sons. In  some  it  proves  a  very  trifling  malady,  Avhich  soon  passes  off,  and  requires 
httle  or  no  assistance  from  medicine.  In  others  it  is  a  very  distressing  affection,  and 
lays  the  foundation  for  other  and  still  more  serious,  though  more  chvonic  diseases ; 
and  in  some,  and  more  especially  in  the  old  and  the  unsound,  it  shows  itself  a  very 
fatal  disorder.  The  absolute  mortality  under  the  recent  epidemic  has  been  immense  ; 
the  daily  newspaper  obituaries  have  been  unusually  long;  and  you  may  have  re- 
marked, that  the  ages  of  the  persons  whose  deaths  they  announced  were  in  almost 
all  cases  great.  The  funerals  have  been  so  frequent,  that  difficulty  has  been  found 
m  performing  them  without  indecent  hurry  and  confusion.  One  undertaker  of  whom 
I  was  informed  had  at  one  time  seventy-five  dead  bodies  to  inter — above  ground,  a* 
he  expressed  it ;  and  mourning  coaches  and  black  horse*  could  not  be  procured  in 


544  INFLUENZA. 

sufficient  numbers  to  meet  the  demand  for  them.  The  absolute  mortahty,  therefore, 
I  say,  has  been  enormous  ;  yet  the  relative  mortahty  has  been  smalL  You  will  hear 
people  comparing  the  ravages  of  the  influenza  with  those  of  the  cholera,  and  infer- 
ring that  the  latter  is  the  less  dangerous  complaint  of  the  two  ;  but  this  is  plainly  a 
great  misapprehension.  Less  dangerous  to  the  community  at  large  (in  this  country 
at  least)  it  certainly  has  been;  but  infinitely  more  dangerous  to  the  individuals 
attacked  by  it.  More  persons  have  died  of  the  influenza  in  the  present  year  than 
died  of  the  cholera  when  it  raged  in  1S32;  but  then  a  vastly  greater  number  have 
been  affected  with  the  one  disease  than  with  the  other.  I  suppose  that  nearly  one- 
half  of  those  who  were  seized  with  the  cholera  perished ;  while  but  a  very  small 
fraction  indeed  of  those  who  suffered,  influenza  have  sunk  under  it.  The  only  fatal 
cases  that  I  have  seen  have  been  in  persons  advanced  in  life,  or  in  persons  whose 
lungs  were  previously  known  to  be  unsound. 

Now,  the  treatment  of  the  influenza  is  pretty  well  understood.  The  chief  risk 
of  mistake  is  that  of  being  too  busy  with  the  lancet.  Certainly  those  affected  by  this 
disorder  do  not  well  bear  active  depletion.  Of  course  no  one  would  think  of  blood- 
letting except  the  symptoms  were  severe,  and  the  distress  great;  but,  even  in  such 
cases,  much  caution  is  requisite  in  adopting  that  remedy.  If  you  find  that  the  in- 
flammation has  extended  to  the  pleura,  or  to  the  substance  of  the  lungs,  it  may  be 
necessary  to  open  a  vein,  or  to  apply  cupping-glasses  over  the  chest ;  but  this  is  a 
very  unpleasant  necessity.  Such  is  the  result  of  all  that  I  have  seen,  and  heard 
from  others,  of  the  present  epidemic ;  and  such  is  the  result  of  the  recorded  expe- 
rience of  nearly  all  previous  epidemics.  You  will  find  abundant  evidence  of  this  col- 
lected into  a  summary  view  by  Dr.  Hancock.  In  1510,  Dr.  Short  says  bleeding  and 
purging  did  harm.  In  1557,  bleeding  was  said  to  be  so  fatal,  that  in  a  small  town 
near  Madrid,  two  thousand  persons  died  after  it  in  the  month  of  September.  In 
1580,  Sennertus,  after  stating  that,  where  blood-letting  was  omitted,  the  mortality 
was  not  greater  than  one  in  one  thousand,  adds,  "  Experientia  enim  lioc  comprobavit, 
omnes  fere  mortuos  esse  quibus  vena  aperiebatur."  Dr.  Ash  observes  that,  in  1775, 
it  was  never  necessary  to  bleed  at  Birmingham  ;  and  that,  in  a  neighbouring  town, 
three  died  who  were  bled,  and  all  recovered  who  were  not  bled.  And  a  great  deal 
more  evidence  to  the  same  purpose  you  may  find  in  the  article  I  have  referred  to. 

I  believe  the  best  plan  of  management — as  far  as  any  general  plan  can  be  laid 
down — is  to  keep  the  patient  in  bed,  and,  after  clearing  the  bowels  by  a  mild  ape- 
rient, to  give  a  couple  of  grains  of  James's  powder  every  six  hours,  with  a  saline 
draught,  and  slops,  till  the  first  brunt  of  the  disorder  is  over ;  and  then,  if  the  cough 
be  troublesome,  and  the  breathing  laborious,  and  much  rhonchus,  or  sibilus,  or  crepi- 
tation, is  audible  in  the  chest,  to  apply  a  blister,  and  to  give  expectorants  and  diure- 
tics. What  I  prescribed  a  great  many  times  was  something  of  this  kind :  half  a 
drachm  of  oxymel  of  squills,  a  drachm  of  the  sweet  spirit  of  nitre,  and  sometimes 
another  drachm  of  paregoric,  in  almond  emulsion.  With  respect  to  full  doses  of 
opium,  when  the  feverishness  is  abated  and  the  headache  gone,  I  should  recommend 
the  same  practice  which  I  described  in  the  last  lecture.  If  there  be  any  lividity  of 
the  skin,  or  of  the  mucous  membranes,  it  is  dangerous  to  give  a  full  dose  of  opium. 
On  the  other  hand,  if  there  be  no  visible  indication  in  the  complexion  that  venous 
blood  is  circulating  in  the  arteries,  opium  given  at  bed-time  wall  sometimes  have  a 
magical  effect  in  relieving  distress,  and  (by  giving  rest  and  refreshing  sleep)  in 
recruiting  the  strength  also.  In  cases  in  which  the  powers  of  the  system  are  pros- 
trate, and  the  face  and  lips  are  livid,  and  the  patient  is  tugging  to  expectorate  the 
mucus  that  is  filling  up  his  air-passages,  you  should  have  recourse  to  ammonia,  to 
nourishing  broths,  and  it  may  be  to  wine  and  water :  and  when  all  danger  from  the 
disease  is  over,  but  the  patient  remains  feeble,  languid,  and  out  of  spirits,  then  is  the 
fit  time  to  administer  tonic  medicines;  and  ahhough  snake-root  and  cascarilla  are 
well-spoken  of  by  many  practitioners,  I  know  no  tonics  so  good  as  the  sulphate  of 
quina,  or  of  iron,  for  such  patients. 

As  to  external  applications,  mustard  poultices,  blisters,  and  the  like  —  and  to  the 
mhalation  of  the  steam  of  hot  water, — these  may  each  and  all  be  very  useful ;  but  I 


HAY-ASTHxMA.  545 

have  nothing  to  add  concerning  the  time  and  manner  of  their  employment  lo  whcit  I 
said  upon  the  same  subject  in  the  last  lecture. 

There  is  one  pomt  in  the  treatment  which  I  must  not  omit  to  notice,  although  I 
cannot  tell  you  much  about  it  from  my  own  experience.  Dr.  Thomas  Davies,  an 
accurate  observer,  and  one  well  qualified  to  form  a  judgment  in  the  matter,  slates 
that  he  found  a  mercurial  treatment  answer  well  in  severe  cases,  in  the  epidemic 
of  1833.  He  perceived  that  active  depletion  was  not  well  borne,  and  discovering 
that  in  the  bad  cases  there  was  always  crepitation  in  the  lower  lobes  of  the  lungs, 
he  thought  mercury  was  one  of  the  most  proper  remedies  to  subdue  the  inflamma- 
tion, and  to  occasion  absorption  of  the  fluid  eflbsed  into  the  air-cells.  He  had  severe 
cases  to  deal  with.  He  says  that  it  happened  to  be  his  duty  to  admit  the  patients 
into  the  London  Flospiiai  during  the  week  the  epidemic  was  at  its  height,  and  that 
thirty-two  beds  which  were  placed  at  his  disposal  were  all  soon  filled  with  individuals 
labouring  under  the  severe  forms  of  influenza ;  so  severe,  that  he  believed  the  greater 
number  of  them  would  have  perished  if  they  had  been  allowed  to  wander  about  the 
streets,  or  even  to  have  remained  at  their  own  homes,  with  the  insuflicient  attention 
they  could  there  have  obtained.  Onlytjue  or  two  of  these  patients  were  bled,  but 
they  were  all  put  under  the  influence  of  mercury.  This  treatment  commenced  on 
Thursday,  and  all  who,  by  Saturday  night,  were  affected  in  the  usual  way  by  the 
remedy,  safely  and  gradually  recovered,  with  the  exception  of  two  ;  and  one  of  these 
had  hypertrophy  of  the  heart,  and  diseased  aortic  valves.  His  object  was  not  to 
salivate,  but  merely  to  make  the  gums  tender.  It  was  of  course  necessary  that  the 
action  of  mercury  should  be  prompt;  and  he  found  that  the  most  quick  and  effica- 
cious way  of  obtaining  it  was  by  rubbing  in  the  llnimentum  hydrargyri. 

There  is  another  kind  of  catarrh  described  as  depending  upon  a  peculiar  local 
cause,  and  therefore  requiring  to  be  briefly  noticed.     1  have  seen  only  one  instance 
of  it ;  but  it  has  b.'en  observed  and  described  by  several  medical  men.    Dr.  Bostock, 
in  the  Medico-Chirurglcal  Transactions,  gives  an  account  of  this  complaint  as  it  is 
tipt  to  attack  himself.    It  is  called  the  calarrhiis  xstivm,  and  by  some  the  hay-fever, 
or  the  hay-asthma.     In  Dr.  Elliotson's  lectures,  also,  as  published  in  the  Medical 
Gazette,  there  is  a  good  deal  of  curious  information  upon  this  malady,  contained  in 
letters  addressed  lo  him  from  practitioners  in  various  parts  of  the  country,  in  conse- 
quence of  some  previous  remarks  he  had  made  upon  it  in  a  clinical  lecture,  which 
had  also  been  printed.     Dr.  Elliotson  speaks  of  it  as  a  combination  of  catarrh  and 
asthma.     It  consists  in  excessive  irritation  of  the  eyes,  nose,  and  the  whole  of  the 
air-passages ;  producing,  in  succession,  itching  of  the  eyes  and  nose,  much  sneezing 
occurring  in  paroxysms,  with  a  copious  defluxion  from  the  nostrils ;  pricking  sensa- 
tions in  the  throat ;  cough,  tightness  of  the  chest,  and  difficulty  of  breathing,  with  or 
without  considerable  mucous  expectoration.     This  complaint  afl:ects  certain  persons 
only,  and  in  them  it  always  takes  place  at  ihe  same  period  of  the  year,  in  the  latter 
end  of  May,  or  in  June,  when  the  grass  comes  into  blossom,  or  when  the  hay-making 
is  going  on.     It  seems,  in  fact,  to  be  produced  by  some  kind  of  emanation  from  cer- 
tain of  the  grasses  that  are  in  flower  at  that  season,  of  the  irritating  qualities  of  which 
emanation  some  persons  only, — and  a  very  few  persons  in  comparison  with  the  en- 
tire population, — are  susceptible.     The  disorder  happens  only  at  that  one  particulai 
season  ;  and  it  then  attacks  persons  who  are  not  remarkably  subject  to  catarrh  at 
other  times,  nor  from  the  ordinary  causes  of  catarrh  ;  and  if  they  avoid  meadows  and 
hay-fields,  and  the  neighbourhood  of  hay-stacks,  they  escape  the  malady.     Hence 
going  to  the  sea-coast,  and  especially  to  those  parls  of  the  coast  that  are  barren  of 
gia.';s,  ofllers  a  means  of  protection ;  and  when  this  cannot  be  done,  such  persons  ob- 
tain refuge,  in  some  measure,  from  the  cause  of  the  irritation,  by  remaining  wiihui 
doors,  and  shutting  out  as  much  as  possible  the  external  air,  during  the  hay-crop. 
One  lady,  who  suffered  annually  from  this  strange  aflection,  states  that  a  paroxysm 
has  been  brought  on  by  the  approach  of  her  children,  who  had  been  in  a  hay-field; 
and  once  this  happened  when  the  hay-season  had  been  for  some  time  ovt-r,  upon 
iheir  joining  her  at  tea,  after  playing  in  a  barn  in  which  the  hay  of  that  yi?ar  had 
been  deposited.     She  was  in  the  habit  of  flying  to  Harwich,  or  some  other  pan  of 
35  2  v  3 


546  HAY-ASTHMA. 

the  coast,  as  the  dangerous  season  came  on.  On  one  occasion,  \vhile  walkino-  on  the 
shore  at  Harwich,  she  was  suddenly  attacked  by  the  complaint,  to  her  great  surprise, 
as  she  was  not  aware  of  any  grass  being  in  the  neighbourhood ;  but  the  next  day 
she  discovered  that  hay-making  was  in  progress  upon  the  top  of  the  cliff  at  the  time 
she  was  walking  under  it.  In  another  year,  she  being  at  Cromer,  and  an  attack  that 
she  had  suffered  having  quite  subsided,  and  all  the  hay-making  thereabouts  being 
over,  she  was  suddenly  visited  by  the  well-known  symptoms,  and  on  going  into  her 
bed-chamber,  perceived  that  they  were  building  a  large  stack  of  hay  in  a  yard  near 
the  house,  having  transferred  it  from  a  field  five  miles  distant. 

Very  lately  I  was  asked  by  Mr.  Cheyne  to  see  with  him  the  wife  of  a  stable-keeper 
near  Regent  street.  I  found  her  suffering  under  what  is  popularly  called  "a  crying 
cold  :"  pain  in  the  situation  of  the  frontal  sinuses,  streaming  eyes,  sneezing  and  de- 
fluxion  from  the  nostrils,  and  very  urgent  dyspnoea,  which  was  accompanied  by  loud 
wheezing.  Symptoms  of  this  kind  had  come  on,  suddenly,  some  days  before  :  and 
her  distress  was  then  so  great,  that  her  husband  proposed  to  drive  her  in  a  gig  to 
consult  a  medical  friend  of  his  who  hved  at  Islington.  On  their  way  thither,  every 
symptom  disappeared,  and  she  felt  at  once^quite  well.  She  subsequently  stayed  a 
night  or  two,  in  comfort,  with  some  relations  in  the  city.  Immediately  upon  her  re- 
turn homf  *he  same  symptoms  recurred,  with  all  their  former  severity,  and  resisted 
the  means,  adopted  for  their  relief  by  JMr.  Cheyne,  who  had  now  been  called  in.  He 
was  soon  led  to  suspect  the  cause  of  the  attack,  and  of  its  obstinac}'.  There  was  a 
strong  odour  of  hay  in  the  house.  The  husband  told  him  that  his  lofts  were  filled 
with  a  lot  of  hay  which  had  recently  arrived,  and  which  had  an  unusually  powerful 
smell.  We  learned  that  our  patient  was  always  worse  at  night,  when  the  house  was 
shut  up ;  and  better  in  the  morning,  when  a  free  current  of  air  blew  through  the 
open  windows.  We  advised  a  temporary  change  of  residence  :  but  our  advice  was 
not  followed  until  two  days  afterwards,  the  disorder  meanwhile  continuing,  and  in- 
creasing in  intensity.  Then  the  patient  removed  to  lodgings  not  one  hundred  yards 
distant ;  and  immediately  all  the  catarrh  and  distress  again  ceased,  and  she  passed  a 
perfectly  tranquil  night.  Afterwards  she  went  into  the  country,  and  did  not  return 
till  the  odoriferous  parcel  of  hay  had  been  consumed,  and  a  new  stock  laid  in.  She 
was  however  revisited  by  some  slight  cough,  and  occasional  dyspnoea  —  neither  of 
which  troubled  her  much  or  long. 

Avoidance,  then,  of  the  ascertained  source  of  the  complaint  is  the  best  thing  that 
can  be  recommended  to  these  persons.  You  may  read  almost  every  year  in  the 
newspapers  that  one  of  our  English  dukes  has  gone  to  Brighton  to  escape  the  hay- 
fever.  But  it  is  not  in  the  power  of  every  one  to  leave  home  for  that  purpose ;  and 
it  has  been  found  that  the  system  is  capable  of  being  fortified  in  some  degree  against 
the  pernicious  effects  of  these  vegetable  effluvia.  Mr.  Gordon  of  Welton,  in  York- 
shire, had  communicated  some  interesting  observations  to  the  profession  on  this 
subject,  before  those  of  Dr.  Elliotson  were  published.  You  may  find  Mr.  Gordon's 
paper  in  the  fourth  volume  of  the  JMedical  Gazette.  He  supposes  that  the  aroma 
of  the  sweet-scented  vernal  grass,  the  anthoxanthinn  odoratiim,  is  the  principal 
exciting  cause  of  the  complaint.  He  found  the  symptoms  more  speedily  and  effectu- 
ally removed  by  the  tincture  of  lobelia  inflata,  than  by  anything  else  that  he  had  tried 
at  that  time;  and  he  recommended  the  cold  shower-bath  as  the  best  preservative 
against  the  attack.  But  in  a  subsequent  communication  to  Dr.  Elliotson,  he  states 
that  the  sulphates  of  quina  and  of  iron  given  in  combination,  had  proved  completely 
successful  in  emancipating  from  their  tormenting  disorder  the  two  patients,  from 
whose  cases  he  had  principally  drawn  up  his  account;  although  they  had,  in  spite 
of  all  previous  treatment,  suffered  an  annual  return  of  it  for  fifteen  or  twenty  years. 

The  susceptibility  of  this  troublesome  affection  of  the  mucous  membrane,  from  a 
peculiar  cause,  which,  to  most  people,  occasions  no  uneasiness,  app-ears  sometimes 
to  run  in  families  :  and  this  is  nothing  more  than  one  might  expect. 

Dr.  Elliotson,  thinking  it  possible  that  the  chlorides  which  have  the  power  of 
decomposing,  and  disarming  of  their  noxious  qualities,  certain  anj??Jo/ effluvia,  might 
exert  a  similar  control  over  the  vegetable  emanations  that  excite  the  hay-catarrh, 
■•ug^gebted  to  one  of  the  sufferers  a  trial  of  the  chloride  of  lime  or  of  soda.     He 


CHRONIC   BRONCHITIS.  547 

desired  him  to  have  it  placed  in  saucers  about  his  bed-chamber  :  to  have  rags  dipped 
in  it  and  hung  about  the  rooms  of  the  house;  to  wash  his  hands  and  face  witii  it 
night  and  morning ;  and  to  carry  a  small  bottle  of  it  with  him  to  smell  repeatedly  in 
the  course  of  the  day ;  and  this  plan  gave  so  much  relief, — either  by  destroying  the 
emanations,  or  by  lessening  the  irritability  of  the  mucous  membranes,  —  that  it  was 
tried  in  other  cases;  and,  though  it  did  not  succeed  in  all,  it  did  in  most  of  them. 
Three  patients  out  of  four  derived  advantage  from  it.  This  expedient,  therefore,  is 
worth  carrying  in  mind. 

There  is  another  vegetable  substance,  better  known  to  us,  which  produces  in  some 
few  individuals  symptoms  like  those  of  the  hay-asthma ;  I  mean  the  powder  of  ipe- 
cacuanha. I  recollect  a  servant  employed  in  the  laboratory  of  St.  Bartholomew's 
Hospital,  when  I  was  a  pupil  there,  who  had  the  peculiar  ill  luck  to  be  liable  to  this 
affection.  Whenever  that  drug  was  under  preparation,  he  was  obliged  to  fly  the 
place.  This  idiosyncrasy  is  not  very  uncommon.  A  very  small  quantity  of  the 
ipecacuanha  dust  is  sufficient  in  such  persons  to  bring  on  a  paroxysm  of  extreme 
dyspnoea,  wheezing,  and  cough,  with  singular  anxiety  and  great  weakness.  The 
distress  usually  terminates  by  a  copious  expectoration  of  mucus. 

These  effects  of  a  powdered  root,  and  of  certain  emanations  from  grass  or  hay,  lend 
weight  to  the  hypothesis  which  ascribes  the  influenza  to  subtle  vegetable  matter 
floating  in  the  atmosphere. 

I  would  suggest  a  trial  of  the  Respirator,  as  a  defence  against  the  particles  of 
ipecacuanha,  and  against  the  volatile  exciting  cause  (whatever  it  may  be)  of  hay 
asthma. 

Catarrh  is  very  often  met  with  in  a  chronic  form ;  in  other  words,  the  mucous 
membrane  of  the  air-passages  is  very  liable  to  be  affected  with  chronic  inflammation. 
The  accounts  which  you  may  read  of  this  are  exceedingly  puzzling.  Authors  have 
endeavoured  to  draw  nice  distinctions  between  different  species  of  chronic  catarrh  ; 
sometimes  according  to  varying  qualities  in  the  matter  expectorated  :  thus  you  have 
chronic  mucous  catarrh — /nVinVous  catarrh  —  chronic  pituitous  catarrh — and  dry 
catarrh,  which,  after  all,  is  not  dry,  but  only  accompanied  by  less  expectoration  than 
some  of  the  others  ;  and  then  again  there  is  symptomatic  catarrh.  You  will  find  all 
these  enumerated  by  Laennec ;  and  the  majority  of  writers  since  his  time  have  trod- 
den with  too  submissive  reverence  in  his  footsteps.  There  are  by  no  means  such 
differences  in  the  symptoms  or  in  the  proper  treatment  of  the  several  varieties  of 
chronic  inflammation  of  the  membrane  in  question,  as  to  make  these  numerous  sub- 
divisions of  any  practical  utility.  Chronic  or  moderate  catarrh  is  often  a  sequel  of 
acute  bronchitis  ;  it  is  a  very  common  accompaniment  of  disease  of  the  heart ;  it  fre. 
quently  arises  during  the  course  of  the  febrile  exanthemata;  it  is  seldom  entirely 
absent  in  cases  of  continued  fever ;  and  it  is  a  form  of  complaint  that  is  full  of 
interest  on  this  account,  if  on  no  other,  that  it  has  so  often  been  mistaken,  and  is  so 
liable  to  be  mistaken  still  for  tubercular  consumption  ;  of  which  indeed  it  is  very  fre- 
quently the  companion. 

The  constant  symptoms  of  chronic  catarrh,  or  bronchitis,  are  cough,  some  short- 
ness of  breath,  expectoration  of  altered  mucus.  The  t^an'rti/e  symptoms,  those  which 
are  oftentimes  of  the  most  importance,  as  determining  the  slight  or  the  serious  character 
of  the  disorder,  consist  in  the  quantity  and  quality  of  the  matters  expectorated,  and 
the  presence  or  absence  of  wasting,  and  of  hectic  "fever. 

You  will  continually  be  meeting  with  cases  of  tliis  kind.  A  person  advanced  in 
years  has  what  he  calls  a  slight  cold,  in  the  winter.  He  coughs,  and  expectorates  a 
certain  quantity  of  gray  or  transparent  mucus.  In  the  summer  his  cough  diminishes, 
or  ceases  altogether.  The  next  winter  the  same  thing  happens  again  ;  and  each  suc- 
cessive return  of  the  colder  seasons  of  the  year  brings  back  in  increasing  seventy 
the  cough  and  the  expectoration  :  and  if  you  hsten  to  the  breathing  of  such  persons, 
while  the  cough  is  on  them,  you  will  find  crepitation  at  the  lower  part  of  their  lungs. 
Now  these  are  examples,  I  beheve,  of  a  chronic  state  of  slight  inflammation  of  the 
membrane,— or  it  maybe  of  passive  congestion  and  effusion,  —  depending  upon 


1 


548  CHRONIC    BRONCHITIS. 

slowly  advancing  cardiac  alterations.     Peripneumonia  nolha  is  very  apt  to  super 
vene  on  this  condition. 

But  chronic  bronchitis  may  take  place  at  any  age,  as  a  sequel  to  the  acute  ;  just 
as  active  inflammation  of  other  parts  of  the  body  is  liable  lo  degenerate  into  the 
chronic  form  ;  and  such  cases  are  sometimes  very  equivocal  and  deceptive.  Several 
years  ago,  a  lady  became  my  patient,  having  cough,  expectoration  of  puriform 
matter,  night-sweats,  and  diarrhoea.  She  had  had  hooping-cough  a  short  time 
before ;  but  though  the  hooping,  and  other  symptoms  proper  to  that  disease  had 
ceased,  she  continued  to  cough,  and  to  waste.  Gradually  she  got  thinner  and 
weaker,  her  pulse  became  like  a  thread,  and  beat  120  times  in  a  minute ;  she  took 
to  her  bed,  the  diarrhoea  was  scarcely  restrained  b}'  astringents  and  opiates,  and  I 
thought  she  could  not  live  a  week.  And,  upon  being  pressed  by  her  brother  for  my 
opinion,  I  said  so.  She  had  scarcely  allowed  me  to  listen  to  the  s'ounds  in  the 
thorax :  but  I  had  once  done  so  fairly,  and  I  could  find  no  morbid  sounds,  except  at 
the  lower  part  of  the  lungs.  If  I  had  trusted  to  that  circumstance  alone,  I  should 
have  said  that  she  had  not  tubercular  consumption  ;  but  I  had  not  then  so  much  faith 
in  the  indications  afforded  by  auscultation,  nor  in  my  accuracy  of  ear  in  such  matters, 
as  I  might  have  now;  and  I  concluded  that  she  teas  dying  of  tubercular  phthisis. 
Almost  on  the  day,  however,  on  which  I  ventured  to  give  this  prognosis,  some  slight 
amendment  began  :  and  she  did  gradually  recover,  and  is  alive  and  quite  well  at  this 
time.  Now  it  is  in  cases  of  this  kind  that  cures  are  performed  by  those  who  boast 
of  curing  consumption. 

In  truth,  chronic  bronchitis  is,  in  some  cases,  as  incapable  of  recovery,  and  as 
surely  and  progressively  fatal,  as  tubercular  phthisis  itself;  and  even  more  so  than 
some  of  the  forms  of  phthisis.  So  long,  however,  as  no  organic  change  has  taken 
place  in  the  air-tubes,  or  in  the  mucous  membrane  lining  them,  these  chronic  forms 
of  bronchitis  that  simulate  phthisis  in  their  general  symptoms,  are  within  the  reach 
of  cure.  They  are  to  be  treated  by  counter-irritants  to  the  chest  —  and  by  such 
measures  as  are  calculated  to  relieve  the  most  urgent  symptoms.  Opiates  for  cough, 
or  for  diarrhoea.  Sometimes  the  patients  bear  steel  well,  and  then  it  is  almost  sure 
to  have  a  beneficial  effect.  Sometimes  sarsaparilla  appears  to  do  good  ;  but,  as  far 
as  I  have  observed,  one  of  the  most  effectual  restoratives  in  these  cases  is  to  be  found 
when  the  weather  and  the  strength  permit,  in  frequent  change  of  air  and  place  ;  in 
gentle  gestation  in  a  carriage,  or  in  a  boat ;  and  in  a  nourishing  but  bland  and  un- 
stimulating  diet.  When  the  membrane,  and  the  tubes  which  it  lines,  become  alterca 
in  structure,  and  pour  forth  a  fluid  which  has  all  the  qualities  of  pus,  hectic  fever 
generally  is  present,  and  the  chronic  disease  tends,  slowly  perhaps,  but  surely,  to 
death. 

There  are  certain  cases  af  chronic  bronchitis  which  are  especially  remarkable,  on 
account  of  the  great  abundance  of  the  bronchial  secretion :  so  great  that  the  patients 
appear  to  die  principally  from  the  daily  exhausting  drain  thus  made  upon  the  sys- 
tem. There  are  sometimes  no  other  evident  signs  of  inflammation;  so  that,  as 
Andral  observes,  one  might  be  led  to  separate  these  fluxes  from  the  truly  inflamma- 
tory afflictions.  They  differ  from  them,  apparently,  in  their  nature,  and  certainly  in 
the  treatment  which  they  require.  Andral  has  detailed  two  or  three  instances  of  this 
kind  in  his  C/inique  Medicale.  The  patients  expectorated  every  day  large  quanti- 
ties— a  pint  or  more — of  frothy  fluid,  resembling  weak  gum-water  in  colour  and  con- 
sistence. They  had  no  fever ;  neither  frequency  of  pulse  nor  heat  of  skin  ;  but  they 
were  exceedingly  pale,  like  persons  blanched  by  hemorrhage,  and  their  emaciation 
and  weakness  were  also  extreme.  Ver}^  little  appreciable  deviation  from  the  healthy 
state  was  detectible  when  the  lungs  and  heart  were  examined  after  death. 

It  does  occasionally  happen  that  even  larger  quantities — three  or  four  pints  daily — 
are,  for  a  considerable  period,  spat  up,  without  much  wasting. 

Andral  asks,  whether,  in  such  cases  as  these,  which  certainly  occur,  though  they 
are  not  very  common,  the  first  indication  of  treatment  should  not  be  to  check  and 
diminish  the  excessive  bronchial  secretion  ;  to  treat  it  as  you  might  treat  a  gleet  of 
the  other  mucous  membranes,  with  balsams,  administered  either  by  the  stomach,  or 
;n  the  shape  of  vapour.     He  conjectures  that  it  might  have  been  in  cases  of  this 


CHRONIC    BRONCHITIS.  549 

nature  that  the  vapour  of  tar,  and  tar-water,  were  once  thought  to  be  so  useful. 
Probably  the  creasote  would  be  well  adapted  to  such  cases.  Certainly  I  have 
seen  the  excessive  expectoration  diminish,  and  the  patients  gain  strength,  under  the 
use  of  the  balsams ;  the  compound  tincture  of  benzoes,  for  example ;  a  form  of 
medicine  much  emploj'ed  formerly,  and  too  much  neglected,  I  apprehend,  at  present. 

[Balsam  Copaiba  will  be  found  a  very  valuable  remedy  in  these  cases. — C] 

Another  remedy,  from  which  I  have  derived  great  advantage  in  some  cases  of  the 
same  kind,  is  the  sulphate  of  iron,  given  in  two  or  three-grain  doses,  in  the  compound 
infusion  of  roses,  thrice  daily.  When  there  is  any  fever  present,  these  remedies  are 
apt  to  augment  it :  but  when  the  pulse  is  quiet,  and  the  skin  cool,  1  am  quite  sure 
that  they  are  often  of  the  greatest  service  ;  and  this  you  will  find  to  be  the  opinion 
also  of  various  practical  authors. 

There  is  another  very  remarkable  condition  of  the  pulmonary  mucous  membrane, 
constituting  also,  I  imagine,  a  species  of  chronic  inflammation,  and  characterized 
chiefly,  Hke  the  last,  by  the  matters  expectorated.  I  mean  that  state  in  which  a  firm 
substance,  resembling  a  false  membrane,  forms  in  the  smaller  bronchi  and  their  rami- 
fications, and  is  coughed  up,  from  time  to  time,  in  fragments.  I  mentioned  in  a 
former  lecture  that  the  false  membrane  of  croup  sometimes  descends  a  long  way  into 
the  bronchi ;  even  to  their  extremities.  But  I  am  speaking  now  of  a  different  and 
less  acute  form  of  disease,  in  which,  the  trachea  being  unaffected,  concrete  masses, 
evidently  moulded  in  parts  of  the  hollow  bronchial  tree,  are  ^pat  up ;  somewhat  like 
bunches  of  worms,  or  the  roots  of  a  small  plant.  This  I  presume  to  be  uncommon  ; 
for  I  have  met  with  it  twice  only  in  my  life.  It  has  been  described,  however,  by 
several  observers.  The  first,  Dr.  Warren,  has  a  paper  upon  it  in  the  first  volume 
of  the  Medical  Transactions,  where  he  gives  representations  of  the  substances 
coughed  up,  which  he  calls  bronchial  polypi.  Dr.  Paris  has  told  me  that  a  patient 
of  his  coughed  up  considerable  qiaantities  of  these  branching  casts  of  the  ultimate  air- 
tubes,  now  and  then,  for  a  long  period.  An  interesting  paper  of  Mr.  North's,  on  the 
same  subject,  was  read  at  one  of  the  evening  meetings  of  the  College  of  Phj'sicians. 
That  gendeman  possesses  some  beautiful  specimens  of  these  miscalled  polypi.  Dr. 
Carswell  gives  a  figure  representing  them.  When  the  affection  is  extensive,  it  is 
attended  with  great  distress,  and  dyspnoea,  and  violent  fits  of  coughing;  and  the 
symptoms  are  wonderfully  calmed  upon  each  expulsion  of  the  solid  matter.  The 
surprise  is  that  such  patients  should  ever  recover ;  but  I  have  never  heard  of  an 
instance  in  which  the  complaint  proved  fatal. 

The  two  examples  of  it  which  have  fallen  under  my  own  observation,  were 
invested,  bj''  the  circumstances  attending  them,  with  a  peculiar  interest.  They 
occurred,  within  less  ?han  a  twelvemonth  of  each  other,  in  the  persons  of  two  brothers, 
of  middle  age,  the  one  a  barrister,  the  other  well  known  to  you  all  as  one  of  my  most 
valued  colleagues  in  this  place.  Both  of  them  were,  and  are,  remarkably  stout, 
strong,  and  healthy  men.  In  both  cases  the  expulsion  of  the  so-called  polypi  was 
preceded  by  haemoptysis,  which  came  in  considerable  gushes,  and  was  repeated  at 
intervals  of  a  few  days,  until  the  sohd  matters  began  also  to  be  expelled,  and  then 
hemorrhage  soon  subsided. 

The  barrister,  after  having  been  annoyed  for  nearly  a  year  by  some  huskiness  of 
the  voice,  spat  up,  all  of  a  sudden,  a  small  quantity  of  bright  blood ;  and  soon  after- 
wards expectorated  several  ramifying  masses  of  tolerably  firm  consistence,  resembling 
fibrinous  coagula  of  blood,  deprived  of  most  of  its  colouring  matter.  Some  of  them, 
which  I  saw  and  examined,  were  solid  ;  others,  I  understood,  were  hollow.  I  found 
slight  circumscribed  crepitation  in  the  lower  and  posterior  part  of  his  left  lung.  This 
trivial  degree  of  hoemoptysis,  with  the  expulsion  of  what  looked  like  casts  of  the  inte- 
rior of  a  bronchial  tube,  was  once  or  twice  repeated  within  a  few  days.  He  had  no 
fever — no  dyspnoea.  Mercury,  inter  alia,  was  prescribed;  but  as  the  patient  did 
not  feel  in  any  way  ill,  I  befieve  he  soon  became  tired  of  physic,  and  of  medical 
restraint.  Whenever  I  have  since  seen  him,  he  has  appeared  to  be  in  perfect 
health. 

Of  the  professor's  illness  I  saw  more.     In  the  midst  of  health  which  had  been 


^ 


550  CHRONIC    BRONCHITIS 

uninterrupted,  save  by  a  solitary  fit  of  the  gout  some  years  before,  he  also  sj/at  some 
mouthfuls  of  florid  blocd.  He  had  no  cough,  but  the  haemoptysis  was  accompanied 
by  a  rattling  sensation  in  the  right  side  of  his  chest. 

For  about  three  weeks  he  continued,  at  intervals  varying  from  three  to  six  days, 
to  expectorate  blood  in  gushes.  The  smallest  quantity  brought  up  on  any  one 
occasion  \vas  two  ounces  ;  the  largest,  eight.  Just  above  the  right  nipple,  the  respi- 
ratory murmur  was  mingled  with  large  crepitation,  Avhich  was  always  sensiblj- 
increased,  and  quite  perceptible  by  the  patient  himself,  during  the  attacks  of  he- 
morrhage. In  the  intervals  between  them  his  breathing  and  his  pulse  were  per- 
fectly tranquil  and  regular. 

With  the  florid  blood  came  up,  in  general,  some  black  coagula :  and  at  the  end 
of  three  weeks,  or  thereabouts,  in  these  black  masses,  ragged  shreds  of  a  difleren*. 
and  firmer  material  began  to  be  visible  :  and  presently  afterwards,  complete  branch- 
hke  casts  of  the  ramifying  air-tubes  were  expelled ;  and  the  bleeding  ceased. 

Of  these  casts  tiiere'were  two  kinds;  the  one  solid,  somewhat  coloured,  evidently 
fibrinous,  and  resembling  the  branching  coagula  that  may  sometimes  be  drawn  out 
of  the  arteries  in  the  dead  body  ;  the  other  white,  membranous,  tubular,  but  rami- 
fying also.     None  of  them  were  of  very  firm  consistence. 

Till  these  substances  made  their  appearance,  our  anxiety  about  the  patient  was 
extreme,  and  he  underwent  some  rigorous  discipUne  at  our  hands.  He  was  con- 
fined to  bed,  forbidden  to  speak,  kept  strictly  to  the  slenderest  slop  diet,  several 
times  bled,  and  extensively  blistered.  Lumps  of  ice  were  given  him  to  swallow,  and 
pounded  ice  was  applied  to  his  chest  whenever  the  blood  broke  forth  afresh.  He 
took  mercury  till  his  gums  were  tender,  and  afterwards  the  acetate  of  lead,  and  other 
reputed  styptics. 

To  most  of  this  I  was  a  consenting  party ;  but,  looking  back  upon  the  case  now 
that  its  nature  and  resuk  are  known,  I  must  confess  that  the  treatment,  though  fairly 
justifiable  at  the  time,  was  unnecessarily  active. 

Mr.  North,  in  the  paper  to  which  I  have  alluded  (you  may  see  it  in  the  twenty- 
second  volume  of  the  Medical  Gazelle),  draws  a  distinction,  of  which  he  gives  the 
credit  to  Dr.  Cheyne,  between  the  hollow,  membranous  concretions,  expelled  without 
any  blood  ;  and  the  sohd  branching  masses  which  accompany  or  succeed  haemopty- 
sis, and  are  obviously  mere  coagula  of  blood  moulded  in  the  smaller  air-tubes,  where 
it  had  stagnated.  He  points  out  the  comparatively  harmless  character  of  the  cases 
in  which  the  first  occur;  and  the  far  more  serious  import  of  the  second :  the  hemor 
rhage  denoting  the  presence  of  some  organic  mischief  within  the  thorax,  and  the 
"  polypous  concretions"  being  simply  an  accident  of  the  hemorrhage. 

I  doubt  the  accuracy  of  this  distinction.  The  brothers  of  whom  I  have  spoken 
continue  to  be,  as  they  were  before,  free  from  any  symptom  or  suspicion,  either  of 
cardiac  or  of  pulmonary  disease.  Moreover,  in  hasmoptysis  depending  upon  tuber- 
cles in  the  lungs,  or  upon  organic  disease  of  the  heart,  these  concretions  are  very 
rarely  observed.  I  have  never  seen  them  in  such  cases,  conimon  as  such  cases  are. 
The  barrister  had  a  husky  voice,  and  the  professor  was  noticed  to  have  been  often 
"  clearing  his  throat"  for  some  time  before  the  first  eruption  of  blood :  from  which 
cnxumstance  I  infer  a  previous  unhealthy  state  of  the  mucous  membrane.  Upon  the 
whole  I  incline  to  the  "iews  expressed  by  Dr.  Todd,  with  whom  I  had  the  advantage 
of  consulting  in  the  latter  case — that  a  chronic  and  limited  inflammation  of  certain 
of  the  bronchial  tubes  first  occurred  ;  disclosing  itself  by  no  marked  symptoms,  but 
leading  to  the  formation  of  tubular  membranes  :  that,  after  awhile,  these  membranes 
began  to  be  detached :  that  hemorrhage  resulted,  and  continued  till  the  separation 
was  complete  :  and  that,  at  the  same  time,  some  of  the  extra vasated  blood  coagulated 
in,  and  took  the  shape  of,  the  air-tubes,  and  was  afterwards  expectorated. 

I  understand  that  the  barrister  has  since  had  a  recurrence  of  this  strange  complaint, 
which  he  treated  very  lightly,  and  soon  got  rid  of. 

He  entertained  a  fixed  belief  that  his  attacks  were  attributable  to  the  presence  of 
v»ne  of  Dr.  Arnott's  stoves,  in  his  chambers ;  the  heated  atmosphere  of  which  always 
produced  a  slight  feeling  of  constriction  and  distress  within  his  chest.  Whether 
this  notion  be  well  or  ill  founded  I  cannot  pretend  to  say :  but  it  is  curious  that  the 


MORBID  ANATOMY  OF  THESE  AFFECTIONS.  551 

j>rofessor  also  had  been  using  a  similar  stove,  which,  placed  in  his  siLling-ioom, 
warmed  both  it  and  his  bed-room  adjoining. 

A  word  or  two,  before  we  separate,  as  to  the  morbid  anatomy  of  these  tissues. 

Chronic  inflammation  of  the  aerial  mucous  membrane  may  lead  to  changes  in  its 
colour;  or  to  thickening  of  the  membrane;  or  to  ulceration;  or  to  dilatation  of  the 
bronchi,  and  their  ramilications.  And  it  is  proper  that  you  should  be  informed  re- 
specting these  morbid  conditions. 

In  general,  when  chronic  inflammation  has  existed  during  life,  the  mucous  mem- 
brane is  found  to  be  red  :  but  it  is  not  a  bright  redness ;  it  is  rather  a  livid,  or  violet, 
or  brownish  tint.  And  what  is  very  curious,  in  some  instances  in  which  all  the 
symptoms  of  inveterate  bronchitis,  with  pwiform  expectoration,  had  been  present, 
the  inner  membrane  of  the  air-passages  has  been  found  scarcely  rosy — or  even  per- 
fectly white — throughout  its  whole  extent.  Of  course  we  are  not  to  infer  from  this 
that  there  has  not  been  injlummation  ;  for  the  same  thing  is  known  to  occur  in  the 
intestinal  mucous  membrane,  in  that  of  the  bladder,  and  even  in  serous  membranes. 
Where  pus  is  poured  forth  there  must  have  been  inflammation. 

One  effect  of  inflammation,  as  I  formerly  showed  you,  is  a  softening  of  the  mem- 
brane ;  but  this  is  a  much  less  common  result  of  inflammation  in  the  mucous  mem- 
brane of  the  bronchi,  than  in  that  of  the  digestive  organs.  In  regard  to  ulceration 
likewise  there  is  a  great  difference  between  the  two  mucous  surfaces  :  in  that  of  the 
air-passages  it  is  comparatively  rare. 

■  Thickening  of  the  mucous  tissue  occurs  also  in  various  degrees :  but  the  most 
remarkable  change  undergone  by  the  membrane,  and  the  tubes  which  it  lines,  is  the 
dilatation  of  those  tubes,  and  the  consequent  alteration  of  the  membrane,  which 
expands  with  them. 

There  are  two  or  three  varieties  of  this  dilatation.  In  the  first  of  them,  one  or 
more  of  the  bronchi  present,  throughout  the  whole  or  the  greater  part  of  their  extent, 
an  increase  of  capacity  more  or  less  considerable  :  so  that  tubes  which  result  from  the 
fourth  or  fifth,  or  even  sixth  division  of  the  principal  bronchus  of  each  lung,  may 
equal  or  exceed  in  diameter  that  bronchus  itself.  Tubes  that  ought  not  to  be  bigger 
than  a  crow-quill  may  become  as  large  as  the  finger  of  one's  glove.  Sometimes  this 
kind  of  dilatation  is  seen  in  a  single  branch  only,  sometimes  in  many.  It  may  affect 
the  bronchial  ramifications  of  an  entire  lobe.  It  is  more  common  in  the  branches  of 
a  bronchus  than  in  the  bronchus  itself. 

It  is  not  very  easy  to  explain  the  manner  in  which  this  sort  of  dilatation  is  pro- 
duced. We  might  attribute  it  to  simple  distension  of  the  bronchial  parietes,  were  it 
not  that  these  parietes  are  at  the  same  time  thickened,  and  the  circular  fibres  hyper- 
trophied,  as  you  may  see  in  this  preparation,  and  in  Dr.  Carswell's  plate.  But  there 
is  another  form  of  bronchial  dilatation  to  which  the  explanation  just  adverted  to  is 
easily  applicable.  Instead  of  the  uniform  dilatation  of  one  or  more  bronchial  lubes, 
throughout  their  whole  extent,  we  find  a  bellying,  or  globular  expansion,  at  the  ex- 
tremity of  one  of  them  ;  and  the  walls  of  the  tube,  instead  of  being  thick  and  hyper- 
irophied,  are  wasted,  and  in  a  state  of  atrophy.  The  tissues  composing  the  tube  are 
often  so  thin,  that  when  the  cavity,  for  such  it  must  be  called,  is  laid  open,  the  colour 
and  structure  of  the  pulmonary  tissue  may  be  seen  through  them.  These  cavities 
are  generally  found  filled  with  a  thick,  tenacious,  straw-coloured,  muco-purulent  fluid. 
Now  it  is  easy  to  conceive  how  "  the  straining  influence  of  repeated  paroxysms  of 
coughing"  may  cause  dilatation  of  this  kind.  The  primary  branches  are  more  easily 
cleared  of  the  mucus  that  fills  them:  but  the  pressure  which  the  lung  undergoes 
under  a  forced  expiration,  operating  on  a  portion  of  the  same  kind  of  nmcus  detained 
in  the  smaller  branches,  may  be  more  than  the  elasticity  of  the  tube  is  capable  of 
resisting.  And,  in  fact,  all  dilatations  of  the  bronchial  tubes  must  be,  in  part  at  leasl, 
owing  to  the  same  influence  of  centrifugal  pressure  by  imprisoned  mucus.  The) 
are  seldom  met  with  except  after  those  affections  which  are  characterized  Oy  con 
siderable  secretion  from  the  membrane,  and  by  much  and  repeated  cough :  as  after 
some  forms  of  chronic  bronchitis,  and  after  hooping-cough. 

A  third  variety  of  dilatation  is  that  in  which  the  same  bronchus  bellies  out  in  dif 


552  HOOPING-COUGH. 

ferent  plucjs  ;  is  dilated  at  intervals  ;  so  as  to  present  in  its  course  a  series  of  sutccw- 
sive  enlargements  and  contractions.  Here,  again,  the  walls  of  the  bronchi,  thouo-h 
they  may  be  traced  in  the  parts  dilated,  do  not  appear  to  be  thickened,  but  rather 
are  diminished  in  thickness.  We  may  suppose,  therefore,  that  these  small  partial 
dilatations  of  the  bronchi  may  result  from  mechanical  distension,  by  mucus,  in  those 
places  which  offer  the  least  resistance  ;  either  on  account  of  diminished  elasticity,  or 
of  actual  thinning.  This  variety  of  dilatation  is  more  frequent  in  children  than  ia 
aduks. 

In  whatever  way  the  dihtation  may  take  place,  one  of  its  obvious  and  necessary 
consequences  is,  the  condensation  of  the  pulmonary  substance  around  the  dilated 
tube,  the  obliteration  of  some  of  the  cells,  and  a  proportional  abridgement  of  the  func- 
tion of  the  lung.  According!}^,  when  it  is  extensive,  dilatation  of  the  bronchi  is 
attended  with  habitual  dyspnosa. 

But  the  most  important  consideration  arising  out  of  this  state  of  the  bronchi,  is 
this ;  that  the  signs,  both  general  and  physical,  by  which  it  is  accompanied,  are 
apt  to  be  exactly  those  which  are  most  distinctive  of  phthisis.  And  it  is  on  that 
account  that  I  have  now  described  these  changes.  I  shall  revert  to  them  ao-ain 
when  I  come  to  the  symptoms,  revealed  by  auscukation,  of  tubercular  disease  of  the 
lungfs. 


LECTURE  L 


Hooping-covgh:   symptoms;   duration;   complications;    pafhology ;    treatment. 
Fnewnonia :  its  stages  and  morbid  anatomy  ;  auscidtatory  signs. 

I  HAVE  yet  to  consider  one  very  important  disorder,  which  is  usually  classed  among 
the  catarrhal  aflections,  but  which  is  marked  by  features  so  peculiarly  its  own,  as  to 
distinguish  it  effectually  from  every  other  form  of  disease.  I  allude  to  hooping- 
cough ;  a  remarkable  complaint,  well  known  everywhere,  I  believe,  and  much 
dreaded  by  parents.  It  has  received  a  variety  of  names  :  chin-cough  ;  kinkhoast ; 
coqueluche  ;  tussis  convulsiva  ;  tussis  ferina  ;  and  pertussis.  This  last  name,  which 
Sydenham  bestowed  upon  it,  and  which  was  adopted  by  Cullen,  is  the  technical 
appellation  of  the  disease  in  this  country,  as  hooping-cough  is  the  popular. 

The  phenomena  that  characterize  hooping-cough  are,  I  say,  remarkable.  It  begins 
with  the  symptoms  of  an  ordinarj'  catarrh  arising  from  cold.  The  child  (for  it  is 
most  especially  a  disease  of  children)  has  coryza,  and  coughs ;  and  mothers  and 
nurses  are  aware  that  the  disease  commences  in  this  way,  and  express  their  appre 
hensions  lest  it  may  turn  to  the  hooping-cough.  After  this,  the  catarrhal  stage,  has 
lasted  eight  or  ten  days,  or  a  fortnight,  or  sometimes  a  day  or  two  longer,  that  kind 
of  cough  begins  to  be  heard  which  is  so  distinctive.  It  comes  on  in  paroxysms,  in 
which  a  number  of  the  crpiratory  motions  belonging  to  the  act  of  coughing  are  made 
in  rapid  succession,  and  with  much  violence,  without  any  intervening  inspirations; 
till  thi  little  patii'nt  turns  black  in  the  face,  and  seems  on  the  point  of  being  suffo- 
cated. Then  one  long-drawn  act  of  i;jspiration  takes  place,  attended  with  that  pecu- 
liar crowing  or  l)t)()[;ing  noise,  which  denotes  that  the  rima  glottidis  is  partially  closed, 
and  which  gives  tin;  disease  its  name.  As  soon  as  this  protracted  inspiration  has 
been  coinpleted,  ilic  ^^cries  of  short  expiratory  coughs,  repeated  one  innnediaiely 
after  the  other  till  all  the  air  appears  to  be  expelled  from  the  lungs,  is  renewed  ;  and 
then  a  second  sonorous  L:'.rk-draught  occurs;  and  this  alternation  of  a  number  of 
expiratory  coughs,  with  one  shrill  inspiration,  goes  on,  until  a  quantity  of  glairy 
nuicus  is  forced  up  from  the  lungs,  or  until  the  child  vomits,  or  until  expectoration 
vnd  vomiting  both  take  place  at  once.  During  the  urgency  of  the  paroxysms,  the 
face  becomes  swelled,  and  red  or  livid,  the  eyes  start,  the  httle  suffi^rer  stamps  some- 
times with  impatience,  and  generally  clings  to  the  person  who  is  nursing  him  for 
support,  or  lays  hold  of  a  chair  or  table,  or  of  whatever  object  may  be  near  him.  to 


HOOPING-COUGH.  553 

diminish  (as  it  would  seem)  the  shock  and  jar  by  which  his  whole  frame  is  shaken. 
As  soon  as  expectoration  or  vomiting  have  happened,  the  paroxysm  is  over.  The 
child  may  pant  a  little  while,  and  appear  fatigued ;  but  commonly  the  relief  is  so 
complete,  that  he  returns  immediately  to  the  amusements,  or  the  occupation,  which 
the  fit  of  coughing  had  interrupted,  and  is  as  gay  and  lively  as  if  nothing  had  been 
the  matter  with  him.  When  the  fit  terminates  by  vomiting,  the  patient  is  in  general 
seized  immediately  after  with  a  craving  for  food,  asks  for  something  to  eat,  and  takes 
it  with  some  greediness. 

Each  paroxysm  may  consist  of  several  alternations  of  the  gasping  coughs,  and  the 
characteristic  hoop  or  kink;  but  CuUen  remarks,  that  the  expectoration  or  vomiting 
usually  takes  place  after  the  second  coughing,  and  puts  an  end  to  the  fit. 

The  number  of  paroxysms  that  occur  in  the  twenty-four  hours  is  variable  also; 
and  they  come  on  at  irregular  intervals.  When  the  complaint  is  uncomplicated,  the 
child,  during  the  intermissions,  appears  to  be  quite  well.  This  is  another  striking 
feature  of  the  disorder.  In  the  earlier  paroxysms  the  mucus  expelled  is  scanty  and 
thin  ;  and  in  proportion  as  this  is  the  case,  the  fits  are  the  longer  and  the  more  violent. 
By  degrees  the  expectoration  becomes  more  abundant ;  and  sometimes  it  is  very 
copious :  at  the  same  time  it  is  thicker,  and  more  easily  brought  up ;  and  on  that 
account  the  fits  of  coughing  are  less  protracted. 

The  ordinary  duration  of  the  disease  is  from  six  weeks  to  three  months;  but  it 
ma}^  run  its  course,  I  believe,  in  three  weeks  ;  and  it  may  continue  for  six  months, 
or  more. 

In  an  uncomplicated  case,  if  3'ou  listen  at  the  chest  during  the  intermissions,  you 
will  probably  hear  the  sounds  that  are  proper  to  catarrh — some  degree  of  rhonchus 
or  sibilus  :  and  in  many  parts  there  may  be  puerile  respiration  ;  and  if  you  percuss 
the  thorax,  you  get  the  natural  hollow  sounds.  But  what  happens  when  you  apply 
your  ear  to  the  chest  during  the  paroxysms  of  coughing?  Why,  the  information 
given  us  in  this  case  by  auscultation  is  very  curious.  You  may  perhaps  hear,  be- 
tween the  short  explosive  shocks  of  the  cough,  some  snatches  of  wheezing,  or  of 
vesicular  breathing ;  but  during  the  long-drawn  noisy  inspiration  that  succeeds,  all 
wllhin  the  chest  is  silent.  This  is  supposed  to  result  from  the  slow  and  niggardly 
manner  in  which  the  air  passes  towards  the  lungs  through  the  chink  of  the  glottis, 
which  is  spasmodically  narrov/ed.  It  may  also  depend,  in  part,  as  Laennec  sup- 
posed, upon  a  spasmodic  condition  of  the  muscular  or  contractile  fibres  of  the  bronchi 
and  their  branches.  When  the  fit  is  at  an  end,  the  ordinary  sounds  of  healthy,  or 
of  catarrhal  respiration,  are  resumed. 

Children  are  very  susceptible  of  this  complaint ;  and  it  is  a  complaint  which 
spreads  by  contagion.  Hence  it  follows  that  kw  children  escape  an  attack  of  it. 
It  is  also  one  of  those  contagious  maladies  which  do  not  in  general  affect  the  same 
individual  twice  ;  and  hence  again  it  follows  that  it  is  rarely  met  with  in  adults.  Such 
is  the  fact ;  and  such,  I  apprehend,  is  the  explanation  of  it.  It  is  not  that  adults  are 
insusceptible  of  hooping-cough;  for  adults  that  have  not  had  it  during  their  child* 
hood  are  readily  afii^cted  when  exposed  to  the  contagion.  But  it  is  that  the  disorder, 
with  very  few  exceptions,  protects  the  system  somehow  from  its  future  recurrence ; 
and  that  most  adults  have  had  it  when  they  were  young,  and  for  that  reason  do  not 
take  it  afterwards. 

During  the  very  early  periods  of  infancy,  i.  e.,  within  the  first  two  or  three  months, 
hooping-cough  is  said  to  be  rare :  I  mentioned  a  case,  however,  before — and  I  have 
read  of  others — in  which  the  disorder  appeared  to  have  been  contracted  before  the 
patient  was  born.  My  bed  maker's  daughter  in  Cambridge  had  a  child  ill  with 
hooping-cough  in  the  house  with  her  during  the  last  weeks  of  another  pregnancy, 
and  the  new-comer  hooped  the  first  day  he  came  into  the  world. 

As  long  as  this  disease  is  uncompHcated — unmixed  with  inflammation,  and  there- 
fore unattended  with  fever,  or  only  with  that  slight  inflammatory  condition  proper  to 
mild  catarrh — it  is  not  at  all  a  dangerous  disease.  Probably  it  will,  under  the  most 
favourable  circumstances,  run  a  certain  course.  By  degrees  the  violence  and  the 
frequency  of  the  paroxysms  diminish  ;  they  occur  only  in  the  morning  and  the  eve- 
ning, then  in  the  evening  alone,  and  at  length  they  cease  altogether.     But  for  ?orrve 

2  vv 


554  HOOPI.XG-COJGH. 

time  after  the  disorder  has  apparently  come  to  an  end,  if  the  child  takes  cold,  and 
gets  a  cough,  it  is  apt  to  assume  a  spasmodic  character,  and  to  be  attended  with  a 
hooping  noise  in  inspiration. 

Unfortunately  hooping-cough  is,  in  a  great  many  cases,  not  simple — not  uncom- 
plicated. It  becomes  mixed  up  with  other  kinds  of  disease  in  the  chest,  or  in  the 
head.  In  the  chest,  severe  bronchitis  supervenes  upon  it,  or  inflammation  of  the 
substance  of  the  lungs  ;  and  then  fever  is  lighted  up,  and  permanent  dyspnoea  is  pre- 
sent. When  the  disorder  has  been  long  drawn  out,  and  has  at  last  terminated  fatally, 
dilatation  of  the  bronchi,  such  as  I  described  in  the  last  lecture,  is  often  found  upon 
dissection ;  or,  still  more  commonly,  I  beheve,  what  is  called  emphyzema  of  the 
lungs — a  change  which  I  have  yet  to  bring  before  you. 

That  such  effects  should  follow  such  violent  and  continued  efforts  of  coughing,  is 
no  o-reat  matter  for  wonder.  Neither  can  we  be  surprised  that  the  disease  frequently 
leads  to  cerebral  disorder.  During  the  fits,  there  is  a  great  and  visible  determination 
of  blood  towards  the  head,  or  rather  a  detention  of  the  blood  in  the  veins  that  pro- 
ceed from  the  head  ; — passive  mechanical  congestion  :  the  transmission  of  the  blood 
throun-h  the  lungs  being  obstructed,  and  its  return  from  the  head  being  interrupted. 
Hence,  the  face  becomes  turgid,  the  eyes  are  prominent,  the  superficial  veins  full 
and  projecting,  the  lips  and  cheeks  turn  livid ;  sometimes  hemorrhage  takes  place 
from  the  nose  or  ears,  or  the  eyes  become  blood-shotten,  or  the  patient  actually  falls 
into  convulsions  ;  nay,  apoplexy  is  occasionally  the  result  of  the  straining ;  and  when 
life  is  not  thus  suddenly  cut  short,  chronic  mischief  is  apt  to  be  set  up  in  the  brain, 
and  the  child  ultimately  dies  hydrocephalic. 

All  this  is  the  more  to  be  feared  in  proportion  as  the  child  is  the  younger.  Head 
affections  are  particularly  to  be  dreaded  in  scrofulous  children ;  and  in  any  children 
during  the  first  dentition.  When  the  disease  occurs  within  the  first  two  years  of  life, 
it  is  usually  attended  with  convulsions :  and  many  more  die  within  that  period  than 
afterwards.  And  CuUen's  remark  is  undoubtedly  true,  that  the  older  children  are, 
the  more  secure  they  are,  cscteris  paribus,  against  an  unhappy  event. 

Hooping-cough  may  be  complicated  also  with  a  disordered  condition  of  the  bowels ; 
and  with  infantile  remittent  fever.  This  complication  is  more  accidental,  and  less  a 
consequence  of  the  hooping-cough  than  the  former ;  but  it  may  very  materially  add 
to  its  peril. 

Dr.  CuUen  was  of  opinion  that  the  complaint  may  exist  in  even  a  milder  forn?. 
than  that  which  I  have  called  simple  hooping-cough.  He  thought  he  had  seen  "  in- 
stances of  a  disease,  which,  though  evidently  arising  from  the  chin-cough  contagion 
never  put  on  any  other  form  than  that  of  a  common  catarrh."  Others  again  believe 
that  adulLs  may  have  it  without  hooping.  But  all  this  seems  to  me  very  doubtful 
Catarrh  is  an  exceedingly  common  malady  ;  and  I  should  be  slow  to  consider  any 
case  a  genuine  case  of  pertussis,  unless  the  characteristic  paroxysms  of  coughing, 
and  the  stridulous  inspiration,  were  present. 

Divers  opinions  have  been  held  respecting  the  seat,  and  respecting  the  nature,  of 
hooping-cough.  Some  supj)ose  it  to  have  its  seat  in  the  brain  ;  and  that  it  is  essen- 
tially a  spasmodic  disease.  Others  maintain  that  it  is  situated  in  the  air-passages  of 
the  lungs,  and  that  it  is  always  an  inflammatory  disorder.  I  do  not  pretend  to  strike 
the  balance  between  these  conflicting  judgments.  Certainly  the  simple  form  of  the 
disease  is  often  unattended  with  any  appreciable  fever:  and  that  is  a  strong  ground 
lor  believing  that  its  peculiar  phenomena  are  not  necessarily  connected  with  inflam- 
mation. They  who  have  ascribed  the  complaint  to  a  morbid  condition  of  the  brain 
have  deduced  that  opinion,  I  presume,  from  the  cerebral  symptoms  that  are  some- 
times so  plainly  marked  in  hooping-cough.  But  these  symptoms  are  oftener,  to  all 
appearance,  the  consequence,  than  the  cause,  of  the  paroxysms  of  coughing.  I  would 
suggest  it  as  an  interesting  point  for  your  future  inquiry,  whether  the  pathology  of 
hooping-cough  may  not  receive  some  elucidation  from  the  researches  of  the  late  Dr. 
Ley,  respecting  the  crowing  inspiration  of  infants.  You  remember  his  suggestion, 
that  mere  inflammation  of  the  mucous  membrane  of  the  air-passages  might  cause 
swelling  of  the  absorben"  glands  of  the  bronchi  or  of  the  neck.  This  is  a  circum- 
iiance  which  I  have  myself  long  thought  probable,  from  having  found  enlargement 


PATHOLOGY.  555 

of  the  cervical  glands  springing  up  during  the  existence  of  pulmonary  irritation. 
Take  notice  that  the  spasmodic  fits  of  hooping-cough  are  always  preceded  for  some 
days  by  mere  catarrhal  symptoms.  Observe  further  how  the  parts  supplied  by  the 
pneumogastric  nerve  are  affected  in  these  paroxysms :  the  larynx,  the  lungs,  the 
stomach.  This  conjecture,  that  the  crowing  inspiration  of  infants,  and  the  crowing 
inspiration  of  hooping-cough  —  though  quite  distinct  affections  —  may  both  depend 
upon  irritation  of  the  recurrent  nerve,  or  of  the  pneumogastric  nerve  generally;  and 
that  even  the  irritation  might  in  both  cases  arise  out  of  enlargement  of  the  glands 
that  lie  in  the  course  of  that  nerve:  this  natural  conjecture  had  presented  itself  to 
Dr.  Ley's  mind  ;  for,  towards  the  end  of  his  book,  1  hnd  this  note  : — "Recently  foui 
children  have  been  brought  to  my  house,  labouring  under  hooping-cough.  In  all, 
ths;  glandulcB  concatenatas  near  the  trachea  were  very  considerably  enlarged.  Is  this 
(he  says)  merely  an  accidental  combination  ?  or  is  there  any  essential  connection 
between  the  two  ?  May  it  not  be  that  an  enlargement  of  these  glands,  from  a  specific 
animal  poison,  similar  to  that  of  the  parotid  glands  in  mumps,  is,  after  all,  the  essence 
of  hooping-cough  ?  The  subject  at  least  deserves  inquiry,  and  further  observation." 
In  corroboration  of  this  conjectural  view  of  what  may  ultimately  prove  to  be  the 
true  pathologj'  of  hooping-cough,  I  may  remark  that  among  the  morbid  appearances 
described  as  being  met  with  after  death  from  that  disease,  "an  unusual  swelling  of 
the  bronchial  glands"  is  set  down.  It  is  also  stated,  by  some  of  the  Germans,  that 
that  portion  of  the  pneumogastric  nerve  which  lies  in  the  cavity  of  the  chest  has  been 
sometimes  found  red.  Yet  I  should  lay  no  stress  upon  this ;  for  others  have  asserted 
that  they  have  looked  in  vain  for  this  redness :  and  even  supposing  it  to  exist,  it  is 
no  sure  or  safe  token  that  there  had  been  inflammation  of  the  nerve.  The  nerve,  all 
things  considered,  would  be  likely  to  become  tinged  of  that  colour  soon  before,  or 
even  after,  death,  from  the  gorged  condition  of  the  lungs.  In  some  cases,  as  you 
may  well  believe,  serous  fluid  is  met  with  in  the  ventricles  of  the  brain,  or  in  the 
meshes  of  the  pia  mater:  in  others  the  consequences  of  inflammation  are  traceable 
in  the  bronchi,  the  lungs,  or  the  pleura.  Portions  of  what  is  called  hepatized  lung 
are  not  unfrequently  seen  in  the  fatal  cases. 

[The  leading  opinions  in  relation  to  the  pathoIog:y  of  hooping-cough,  may  be  referred  to 
one  or  other  of  the  following  heads. 

1st.  With  some  the  disease  is  essentially  a  spasmodic  affection  of  the  air-passages,  arising 
from  a  primary  irritation,  inllammatory  or  nervous,  of  the  brain,  or  of  one  or  oth'er  set  of  the 
respiratory  nerves.  This  theory,  variously  modified,  is  that  advocated  by  Hoffmann,  Cullen, 
Hufcland,  Jalin,  Lobel,  Holzhansen.  Leroy,  Coitcr,  Guibert,  Breschet,  Gardien,  Bauer,  Albers, 
Clarus,  Webster  and  Copland.  Dr.  Webster  considers  the  affection  of  the  respiratory  organs 
as  secondary,  and  dependent  on  a  primary  inflammatory  irritation  of  the  brain  or  of  its 
membranes,  or  of  both.  JMost  of  the  ailvocates  of  the  nervous  theory  regard  the  pneumo- 
gastric nerves  as  the  primary  seat  of  the  aflection ;  others,  however,  locate  the  irritation  in 
tbe  phrenic  nerves — the  principal  of  these  are  Jiiger,  Lobensteiii,  Lobel  and  Leroy;  others 
again,  as  Albers,  of  Bremen,  Pinel,  Laennec,  Blache  and  Roe,  refer  the  irritation  to  both  the 
mucous  membrane  of  the  bronchi  and  the  pneumogastric  nerves. 

2d.  Others  consider  the  disease  as  an  inflammatory  affection  of  some  part  of  the  mucous 
membrane  of  the  air-passages  ;  this  opinion  numbers  among  its  advocates,  Darwin,  Watt,  Mar- 
cus Alcock,  Dewees,  Dawson,  Pearson,  Guersent,  Fourcade-Prunet,  Boisseau,  Brpussais, 
Rostan,  and  Dug^s.  Dr.  Watt  believed  it  to  be  "in  all  cases,  an  inflammatory,  whose  chief 
seat  is  in  the  mucous  membrane  of  the  larynx,  trachea,  bronchi,  and  air-cells,  jjossibly  at- 
tended with  a  minute  exanthematous  eruption  there.'  He  considers  that,  when  mild,  '-this 
inflammation  runs  its  course  witboat  materially  disturbing  the  other  functions  of  the  body, 
or  even  the  functions  of  that  very  membrane  in  which  it  is  seated,  and  that  whenever 
hooping-cough  proves  dangerous  or  fatal,  it  becomes  so  by  the  degree  of  inflammation  in  the 
natural  seat  of  the  disease,  or  by  that  inflammation  extending  or  being  translated  to  other 
parts.'  Most  advocates,  however,  of  the  inflammatory  origin  of  the  disease,  limit  the  in- 
flammation to  the  trachea  and  bronchi — Dawson  confines  it,  at  first,  to  the  larynx,  or.  strictly- 
speaking,  to  the  glottis — an  opinion,  by  the  way,  not  widely  differing  from  that  of  Astrue, 
who  of  old  describes  the  disease  as  an  "  inflammation  of  the  superior  part  of  the  larynx  nnd 
I'harynx." 

3d.  Many  view  the  complaint  as  at  first  inflammatory,  and  afterwards  spasmodic,  or  a-, 
a  specific  inflammation  of  the  respiratory  mucous  membrane  combined  with  irritation  of  th« 
respiratory  nerves,  in  consequence  of  which  the  muscles  to  which  these  are  distributed  are 
thrown  into  spasmodic  action,  which  irritation  continues  after  the  inflammation  lias  ceased. 


556  HOOPING-COUGH. 

This  (loctiinp,  vavionsly  modified,  is  a  favourite  one  with  the  writers  on  hooping-cough.— 
Desrnelles  makes  the  di.-^ease  to  consist  in  a  primary  inflammation  of  the  bronchi,  compli 
cated  with  a  consecutive  cerebral  irritation,  vhicli  by  its  influence  over  the  diaphragm  and 
other  res})iratory  muscles,  and  over  those  of  tne  larynx  and  glottis,  changes  the  simple  cough 
of  broncliiiis  into  one  of  a  convulsive  character.  This  opinion  is  the  one  adopted,  also,  by 
Dr.  C.  Johnson  in  his  able  article  on  hooping-cough  in  the  Cyclopxdia  of  Practical  Medicine, 
(^Philadelphia  Editio7i,  vol.  2,  page  453 :)  other  writers  who  admit  the  occasional  presence  of 
cerebral  disease,  consider  them  to  be  invariably  secondary  to  the  bronchial  aflxjction:  of  thi? 
opinion  are  Boisseau,  Begin,  Otto,  and  Vondembush. 

4th.  By  not  a  few,  especially  of  the  older  medical  writers,  hooping-cough  is  referred  to  an 
irritation  of  the  stomach  and  lungs. — Rosen,  who  supposed  the  disease  to  be  produced  by 
either  an  insect  or  a  morbid  poison,  partly  inhaled  into  the  lungs  and  partly  swallowed  with 
the  patient's  saliva,  considered  that  the  stomach  suffered  more  from  the  irritation  than  the 
lungs.  Daiiz  believed  that  the  irritation  is  seated  primarily  in  the  stomach  and  bowels,  the 
ofi'ection  of  the  respiratory  organs  being  secondary — this  ojjinion  had  been  previously  ad- 
vanced by  StoU,  and  is  also  that  advocated  by  Chambon  in  his  work  ^^  Des  Maladies  del 
E7ifans.'"  Tourtelle  likewise  describes  the  disease  as  a  catarrhal  aflection  of  the  limgs  and 
stomach  (ajjhlion  piieumogastrique  pituiteuse).  Millot  entertains  a  somewhat  similar  opinion; 
he  supposes,  however,  that  the  irritation  of  the  stomach  is  secondary,  and  not  so  intense  as 
that  of  the  lungs  and  larynx.  Opinions  somewhat  similar  are  maintained  by  Mel.zer,  Hoi 
defreund.  Butler,  Klinge  and  Strack. 

0th.  The  peculiar  phenomena  of  the  hooping-cough  have  been  ascribed,  by  a  few,  to  a 
physical  or  chemical  irritant  introduced  into  the  larynx,  either  from  without  or  after  it  has 
been  engendered  in  the  blood,  or  in  the  secretions  of  the  respiratory  organs.  Under  this 
head  may  be  arranged  the  opinion  of  Linnaeus,  who  referred  it  to  the  presence  of  minute 
insects;  that  of  Sydenham,  who  imputed  it  to  a  subtle  and  irritating  vapour  in  the  blood 
which  affected  the  lungs, — that  of  Bohme,  and  Klinge,  and  also,  partially,  that  of  Rosen, 
who  ascribed  it  to  a  peculiar  miasm,  acting  chiefly  on  the  nerves.  Dr.  Bland,  of  the  Hos- 
pital Beaucaire  (Revue  Medicale.  March,  1S31),  considers  the  primary  cause  of  hooping-cough 
to  consist  in  an  irritation,  not  inflammatory,  of  the  mucous  membrane  of  the  bronchi,  vmder 
which  the  glands  and  follicles  of  the  membrane  pour  forth  a  specific  secretion  saturated 
with  hydrochlorate  of  soda,  the  irritation  caused  by  which,  when  it  reaches  the  upper  part 
of  the  trachea  and  larynx,  throws  the  muscles  of  the  glottis  and  of  respiration  into  spas- 
modic action  for  its  expulsion,  in  a  manner  exactly  similar  to  any  foreign  body  which  acci- 
dentally enters  the  larynx.  This  theory  of  the  disease  Jlr.  Streeter.  of  London,  in  a  paper 
read  before  the  Physical  Society  of  Guy's  Hospital,  November,  1844,  has  adopted  and  zeal- 
ously advocated,  "as  the  one  most  consistent  with  the  i^henomena  observable  in  the  symp- 
toms, pathology,  and  successful  treatment  of  the  disease," 

Mr.  Streeter  regards,  however,  the  primary  affection  of  the  bronchial  membranes  as  in- 
flammatory, and  believes  that  it  will  be  found,  on  careful  observation,  to  be  attended  by 
more  or  less  fever  of  an  analogous  character  to  that  which  attends  the  influenza. 

The  evidences  of  the  truth  of  this  theory  upon  which  this  gentleman  places  reliane  are 
— "  the  testimony  of  adults,  who  have  been  attacked  by  the  disease,  to  the  unusual  and  ex- 
cessive saline  taste  of  the  expectoration  so  long  as  the  paroxysms  are  severe — the  resem- 
blance of  the  expiratory  eflbrts  in  the  hooping-cough  to  those  made  by  the  excito-motory 
system  for  the  expulsion  of  a  foreign  body  from  the  larynx — the  very  adequate  explanation 
it  affords,  both  of  the  extraordinary  and  spasmodic  muscular  actions  which  accompany  the 
cough,  and  of  its  occurrence  in  paroxysms  after  intervals  of  uncertain  duration — and,  lastly, 
the  key  which  it  furnishes  to  the  chaotic  host  of  apparently  opposite  remedies  that  have  ob- 
tained professional  or  popular  reputation  in  its  treatment.  Of  these  remedies,  we  find  one 
group  jidapted  to  lessen  the  original  bronchial  aflections,  and  favour  the  expulsion  of  the 
offending  mucus — as  emetics,  antimnnials,  and  counter-irritants  applied  over  the  chest;  an- 
other which  acts  by  altering  the  quality  of  the  secretion,  as  the  alkaline  carbonates,  ammo- 
nia, and  sulphurct  of  potass,  so  strongly  recommended  by  Dr.  Blaud  himself;  another,  by 
exciting  a  new  action  in  the  bronchial  membrane,  and,  by  constringing  the  vessels,  to  put  a 
sto[)  to  the  secretion,  in  a  manner  perfectly  familiar  to  the  physician  in  chronic  bronchitis, 
and  to  the  surgeon  in  purulent  ophthalmia — as  the  super-acetate  of  lead,  alum,  common 
resin,  tine,  cantliarid.,  bals.  copaiba,  tar  vapour,  and  even  the  inhalation  of  nitrous  vapours, 
&.O.  Other?,  again,  as  musk,  both  native  and  artificial,  camphor,  arsenic,  conium,  belladonna, 
ojnum,  and  hydrocyanic  acid,  are  more  especially  adapted  for  the  nervous,  lesions ;  while 
antiphlogistic  measures  meet  the  inflammatory  lesions  of  the  third  or  complicated  stage. 

"When,  he  remarks,  the  convulsive  hooping  is  fully  established,  it  very  commonly  hap 
pens  that  sympioms  which  mark  the  third,  or  what  may  be  appropriately  termed  the  com. 
plicated  stage,  are  developed,  and  continue  to  mark  the  varying  and  formidable  phases  of 
the  disease  which  mostly  attract  attention  in  practice."  These  tertiary  phenomena  usually 
nianifest  themselves  "  1st — as  special  lesions  of  the  nervous  and  muscular  systems — An 
rxalted  sensibility  and  morbidly  susceptible  state  of  the  membrane  of  the  larynx  the  pha 


HOOPIKG-COUGII.  557 

rynx,  the  epiglottis,  under  which  death  from  asphyxia  may  suddenly  occur — Slorbid  associa- 
tion of  the  action  of  the  muscles  of  the  glottis  and  respiration,  in  consequence  of  which  the 
cough  continues  from  mere  habit,  or  is  reproduced  by  the  most  trivial  irritation  of  the  air 
pas.'^ages  —  reflex  irritation  often  passing  into  inflammation  of  the  nervous  centres  of  the 
pneumogastric  nerves,  involving  those  of  the  phrenic  nerves  also ;  and,  finally,  these  reflex 
afii-'ctions  may  extend  to  the  whole  of  the  brain,  or  to  the  medulla  oblongata  and  theil 
meninges,  and  prove  fatal  by  inducing  general  convulsions  or  hydrocephalus.  All  these,  h^ 
it  observed,  are  pathological  conditions  of  the  nervous  system  which  have  been  so  constantly 
put  forward  in  high  relief,  by  the  advocates  of  the  nervous  theory,  as  proximate  causes  of 
the  disease  itself"  A  second  class  of  tertiary  phenomena  include  "the  various  congestive 
and  inflammatory  affections  that  result  from  the  mechanical  disturbance  of  respiration  and 
circulation,  and  the  extension  of  the  primary  bronchial  inflammation  to  the  trachea,  larynx 
and  pharynx,  and  to  the  tissues  of  the  lungs  themselves.  Epistaxis,  hasmoptysis,  and  fatal 
emphysema  from  extensive  rupture  of  the  air-cells,  have  occurred  within  my  own  expe- 
rience, and  have  apparently  resulted  from  the  mechanical  Ariolence  of  the  cough  acting  upon 
tissues  previously  weakened  by  disease."  A  third  class  of  tertiary  phenomena  "  include 
fever  and  cachexia,"  which  are  "present  in  individual  cases  in  every  conceivable  variety  of 
combination." — "  In  the  absence  of  cerebral  or  pulmonary  inflammation,  the  fever  of  the 
third  stage  is  always  asthenic,  and  oilen  assumes  a  remittent  type  when  the  cachexia  is  of  a 
marasmic  character." 

For  an  account  of  tlie  various  lesions  met  with  in  the  bodies  of  those  who  die  of  hooping- 
cough,  the  reader  is  referred  to  Coiidie  on  Diseases  of  Children,  page  327. — C] 

The  object  of  rational  treatment  in  hooping-cough,  supposing  the  disease  to  be 
simple,  is  to  kef!])  it  simple :  to  keep  it  mere  hooping-cough :  to  obviate  serious 
inflammation  or  mischief  in  the  chest  and  head  :  and,  if  possible,  to  mitigate  the 
severity  and  shorten  the  duration  of  the  fits  of  couohing.  I  have  no  notion  that 
anything  we  can  do  in  the  beginning  will  materially  abridge  the  duration  of  the  com- 
plaint as  it  appears  in  its  unmixed  form.  It  tvi/l,  I  say,  in  all  probability,  run  a 
certain  course  ;  and  our  business  is  to  conduct  it  evenly  and  safely  to  the  end  of  its 
course.  For  this  purpose  the  diet  must,  in  the  first  place,  be  regulated  and  reduced. 
The  child  should  not  be  allowed  to  eat  meat:  the  bowels  should  be  kept  moderately 
open  ;  and  the  patient  in  cold  weather  should  be  confined  to  the  equable  tempera- 
ture of  the  house,  or  protected  by  warm  clothing.  You  will  find  different  persons 
employing  and  praising  different  plans  of  treatment;  the  object  in  all  cases,  how- 
ever, being  the  same,  viz.,  to  ward  cjf  injlumviation  and  to  quiet  irritation.  One 
very  good  plan,  as  I  believe,  is  that  of  giving  a  grain,  or  a  grain  and  a  half,  of  ipeca- 
cuan,  three  or  four  times  a  day.  This  generally  keeps  the  bowels  sufficiently  open, 
and  seems  to  have  a  beneficial  operation  on  the  mucous  membrane  of  the  air-pas- 
sages also.  Or  a  few  grains  of  rhubarb  and  ipecacuan  may  be  given  every  night : 
and  if  the  cough  be  very  troublesome  and  urgent,  small  opiates  may  be  administered  : 
syrup  of  poppies  :  or  the  extract  of  hyoscyamus ;  as  many  grains  per  diem  as  the 
child  has  years.  There  is  a  method  recommended  many  years  ago  by  a  namesake 
of  mine,  which  some  people  swear  by.  Sir  William  Watson's  prescription  was  one 
grain  of  tariarized  antimony  and  twenty  drops  of  laudanum  in  an  ounce  of  water. 
A.  teaspoonful,  or  a  dessertspoonful,  of  that  mixture  was  given  every  evening,  or 
every  other  evening.  I  have  heard  the  late  Dr.  Gooch  say  that  his  mother  became 
famous  as  a  village  doclress  by  the  help  of  that  prescription.  Fothergill's  method 
was  to  give  an  emetic  every  day  ;  or  three  or  four  times  a  week :  and  this  j^lan 
answers  best,  I  believe,  when  the  expectoration  is  scanty,  and  brought  up  with  diffi- 
culty, and  after  much  coughing.  The  best  emetic  substance  in  such  cases  is,  doubt- 
less, i])ecacuan.  Mr.  Pearson — who  has  had,  I  fancy,  many  imitators — used  to  give, 
after  the  operation  of  an  emetic,  one  drop  of  laudanum,  five  drops  of  ipecacuan 
wine,  and  two  grains  of  carbonate  of  soda,  in  a  draught,  every  fourth  hour,  for 
several  days.  Under  some  such  treatment  as  this,  the  disease  will  reach  its  termina- 
tion in  from  six  to  twelve  weeks :  and  it  frequently  happens  that  when  the  child  is 
quite  well  in  all  other  respects,  it  still  continues  to  cough.  The  cough  would  almost 
seem  to  be  kept  up  by  the  mere  influence  of  habit.  Now,  under  these  circum- 
stances, change  of  air  will  often  remove  the  cough,  as  if  by  magic :  and  'he  shower- 
bath,  and  iron  in  some  shape,  will  sometimes  succeed,  if  change  of  air  be  not 
practicable. 

2vv2 


558  HOOPING-COUGH. 

Tliere  is  a  great  variet}'  of  medicines  lauded  as  specifics  against  hooping-cough : 
but  they  are  not  to  be  trusted  to.  Many  persons  tliink  highly  of  the  prussic  acid,  as 
a  remedy  for  the  paroxysms  of  coughing.  Others  employ  and  laud  the  extract  of 
belladonna.  But  these  are  gigantic  remedies  to  employ  in  such  young  subjects.  If 
you  give  them  at  all,  you  must  give  them  in  very  small  quantities,  and  watch  their 
efTects.  The  artificial  tincture  of  musk  is  another  substance  which  some  have  found 
useful.  Three  or  four  minims  of  it  may  be  given  in  the  outset,  and  the  dose  in- 
creased till  some  sensible  effect  is  produced ;  and  then  the  dose  that  has  been  so 
reached  should  be  persisted  in  without  further  augmentation.  I  have  been  assured, 
by  a  most  intelligent  practitioner,  that  he  had  got  considerable  credit  by  prescribing 
this  medicine,  after  other  persons,  with  other  modes  of  management,  had  failed. 
Digitalis,  and  cantharipes,  are  other,  and  I  think,  hazardous  remedies.  Safer  drugs 
recommended,  and,  for  aught  I  know,  equally  efhcacious  with  these  poisons,  are 
cochineal,  oil  of  amber,  musk,  camphor,  and  the  meadow  narcissus.  Of  late  the 
carbonate  of  iron  has  been  greatly  praised  by  some  of  the  continental  physicians. 

[Horst  recommends  the  flowers  of  sulphur  as'  ahnost  a  specific  in  hooping-cough.  He 
gives  it  throughout  the  disease,  from  its  onset  until  its  termination.  Schneider,  Roffy,  Rand- 
han,  Riecken,  and  others,  confine  its  use  to  the  more  advanced  periods  of  the  attack.  Jade- 
lot  is  said  by  Barthez  and  Rilliet  to  have  derived  the  best  effects  from  the  sulphur  as  a 
remedy  in  hooping-cough,  as  well  as  in  bronchitis  unattended  with  fever.  The  sulphur  is 
given  to  children  between  two  and  four  years  of  age  in  the  dose  of  from  6  to  8  grains,  two 
or  three  times  a  day,  and  to  older  children  in  doses  of  from  15  to  20  grains, — in  both  cases 
the  dose  being  gradually  augmented. 

Assafostida  will  \.^  lound  a  very  excellent  remedy  in- the  spasmodic  stage  of  hooping- 
cough.  Dr.  Lombard  states  that  he  has  often  known  frictions  to  the  spine  with  the  tincture 
of  assafcetida  of  great  service,  and  we  have  found  a  plaster  of  assafcetida  applied  to  the 
chest  promptly  to  relieve  the  cough,  which  is  liable  to  remain  after  the  more  acute  symp- 
toms have  subsided. 

It  is  stated  that  M.  Berger  has  found  the  following  plan  of  treating  hooping-cough  particu- 
larly successful.  In  the  first  stage,  a  moderate  course  of  antijihlogistic  remedies,  purgatives, 
and  repeated  emetics  of  ipecacuanha  in  combination  with  tartar  emetic.  In  the  spasmodic 
stage,  in  which  the  indication  is  to  quell  the  existing  nervous  irritation,  being  dissatisfied 
with  the  remedies  ordinarily  employed,  he  was  induced  to  administer  the  nitrate  of  silver, 
from  which  lie  has  obtained  results  singularly  beneficial.  He  administers  it  in  doses 
of  from  a  sixteenth  to  a  twelfth  of  a  grain,  at  first  three  times,  and  afterwards  four  times  a 
day.  Of  course  the  remedy  should  not  be  administered  in  cases  where  the  state  of  the  diges- 
tive organs  contra-indicates  its  employment  (Annuaire  de  Therapeutique,  1S46). 

Dr.  Golding  Bird  remarks  (^Guy's  Hospital  Reports,  April,  1845),  that,  in  the  second  or  ner- 
vous stage  of  pertussis,'  after  all  infiamniatory  symptoms  have  subsided — and  when,  with  a 
tolerably  cool  skin  and  clean  tongue,  the  patient  is  still  severely  distressed  by  the  more  or 
less  copious  secretion  of  viscid  mucus  from  the  bronchi — each  attempt  to  get  rid  of  which 
produces  the  exhausting  and  characteristic  cough — no  remedy  will  be  found  to  act  so  satis- 
factorily, or  to  give  such  marked  and  often  rapid  relief  to  the  child  as  alum.  He  has  not  yet 
met  with  any  other  remedy  which  is  equally  efficacious.  Dr.  Bird  generally  gives  the  alum 
in  doses  of  from  two  to  six  grains  to  children  of  from  one  to  tjn  years  of  age,  repeated  every 
four  or  six  hours.  For  a  child  of  two  or  three  hours  he  employs  generally  the  folloM'ing 
formula : — 

K  Aluminis  gr.  xxv;  extr.  conii  gr.  xij ;  syrup,  rhsedos.  ^ij ;  aq.  anethi  ^iij.  m.  Dose  a 
medium  sized  spoonful,  every  sixth  hour.  Dr.  B.  has  never  met  with  any  inconvenient 
stringent  effects  on  the  bowels  during  its  exhibition ;  on  the  contrary,  in  more  than  one  in- 
stance it  produced,  he  says,  diarrhcea.  The  only  obvious  effects  resulting  from  its  use  were, 
diminished  secrection,  and  of  a  less  viscid  mucus,  with  a  marked  diminution  in  the  fre- 
quency and  severity  of  the  spasmodic  paroxysms. — C] 

External  applications  are  also  much  in  fashion  in  the  treatment  of  hooping-cough. 
Frictions  to  the  spine  and  to  the  chest ;  and  as  counter-irritants,  they  probably  are  of 
some  service.  The  tartarized  antimony  is  the  least  innocent  of  these  applications. 
It  will  often  cause  foul  and  very  troublesome  sores  upon  an  adult  skin  :  and  till  I  am 
better  advised  than  1  am  at  present  of  its  certain  efficacy  as  a  remedy  for  hooping- 
cough,  no  one  (however  authorized  professionally  liidere  corio  hianano),  should  rub 
it  upon  a  child  of  mine.  Mothers  are  many  of  them  fond  of  using  Roche's  Embro- 
cation for  the  hooping-cough.  This  (Dr.  Paris  tells  us)  consists  of  ohve  oil,  mixed 
■with  half  its  quantity  of  the  oils  of  cloves  and  of  amber. 


Ii 


PNEUMONIA.  559 

Such  is  tht  plan  of  management  which  you  will  do  well  to  enforce — and  such  are 
the  expedients  which  you  may,  if  you  please,  make  use  of  as  auxiliaries  to  that 
plan — when  the  disease  is  inere  hooping-cough.  But  when  it  becomes  complicated 
with  symptoms  of  inflammation  within  the  chest,  or  with  head  symptoms — (and  for 
such  symptoms  you  must  jealously  watch) — then  you  must  employ  antiphlogistic 
remedies  (in  addiiion  to  the  antiphlogistic  regimen)  adapted  to  the  circumstances  of 
the  case.  Now  we  know  that  the  bronchi,  or  the  lungs,  are  affected  with  inflamma- 
tion, when  we  find  that  the  child  has  fever,  and  that  there  is  permanent  dyspnoea 
between  the  paroxysms  of  spasmodic  cough.  In  such  a  case  we  must  have  recourse 
to  the  treatment  required  in  such  inflammation :  leeches  to  the  surface  of  the  chest, 
bleeding  even  from  the  arm,  if  the  child's  age  and  strength  should  warrant  it,  tartar 
emetic,  small  doses  of  nitre,  the  warm  bath,  and  blistering;  and  to  these  measures, 
modified  and  combined  according  to  the  particular  emergency,  it  will  be  w^ell  to  add 
small  and  repeated  doses  of  mercury  :  of  the  hydrargyrum  cum  creta,  or  of  calomel; 
the  state  of  the  bowels  determining  which.  Some  have  recommended  friction  with 
the  tartar  emetic  ointment  to  the  chest  in  such  cases :  but  I  have  the  same  objection 
to  it  there,  in  such  young  patients,  as  to  the  spine. 

When  any  head  symptoms  come  on,  threatening  hydrocephalus — such  as  squint- 
ing, convulsions,  stupor — those  remedies  must  be  adopted  which  1  endeavoured  to 
describe  to  you  when  I  spoke  of  that  disease ;  leeches  to  the  head,  cold  applied 
there,  purgatives,  the  w'arm  bath  :  but  except  in  very  young  children,  I  believe  there 
is  more  danger  of  fatal  pulmonary  changes  in  this  disagreeable,  and  sometimes  in- 
tractable disorder,  than  of  cerebral  mischief. 

I  might  pass,  by  a  very  natural  transition,  from  the  consideration  of  hOoping-cough, 
to  that  of  spasmodic  asthma.  But  this  last  complaint  is  found  to  exist  in  connection 
with  various  organic  changes  within  the  chest,  few  of  which  have  yet  been  treated 
of  in  these  lectures.  I  shall,  therefore,  postpone  what  I  have  to  say  respecting 
asthma,  till  I  have  gone  through  some  other  thoracic  diseases.  And  I  now  proceed 
to  pneumonia,  or  inflammation  of  the  substance  of  the  lungs.  Questions  have  been 
raised  as  to  the  precise  part  and  texture  in  which  the  inflammation  begins  ;  and  to 
these  questions  I  may  briefly  advert  as  w^e  go  on:  but  I  hold  that  in  pneumonia  all 
the  textures  composing  the  pulmonary  substance  in  the  part  inflamed  are  involved  in 
the  inflammatory  process. 

Now  of  pneumonia  it  is  especially  true,  that  we  ascertain  its  extent,  its  situation, 
and  every  step  of  its  progress,  by  means  of  the  ear.  All  the  symptoms  that  give  us 
the  most  sure  information  respecting  the  nature  of  the  disease,  the  event  to  which  it 
tends,  and  the  remedial  treatment  which  it  requires,  spring  out  of  the  actual  changes 
wrought  in  the  pulmonary  substance  itself;  and  these  changes  are  disclosed  to  us  by 
the  method  of  auscultation.  It  is  necessary,  therefore,  that  you  should  understand, 
first  of  all,  what  those  changes  are  which  are  produced  by  inflammation  of  the  sub- 
stance of  the  lungs :  that  you  should  know  the  morbid  anatomy  of  pneumonia,  as 
an  indispensable  groundwork  for  a  knowledge  of  its  pathology. 

There  are  three  well-marked,  and  very  constant  conditions  of  the  lung,  correspond- 
ing to  different  degrees  and  periods  of  its  inflammation.  I  will  describe  them  in 
succession,  in  the  order  in  which  they  take  place. 

The  first  stage  or  condition  is  that  of  engorgement :  all  modern  observers  agree, 
I  believe,  both  as  to  the  nature  and  as  to  the  name  of  this  condition.  The  substance 
of  the  lung  is  gorged  with  blood,  or  bloody  serum.  It  is  of  a  dark  red  colour  ex- 
ternally, and  crepitates  less  under  pressure  than  sound  lung  does.  We  feel  thai 
there  is  more  liquid  than  air  in  its  cells.  It  is  heavier  also  than  natural,  and  inelastic, 
and  retains,  in  some  degree,  the  impression  of  the  finger.  When  the  engorged  por 
tion  is  cut,  we  find  it  red,  and  we  see  a  great  quantity  of  a  reddish  and  frothy  serum 
flow  from  it.  Its  cohesion  is  at  the  same  time  diminished ;  it  is  more  easily  torn  ; 
more,  in  that  respect,  like  the  spleen ;  and  accordingly  the  term  splenization  of  the 
lung  has  been  given  to  this  stage  of  its  inflammation,  as  hepatization  has  to  that 
which  succeeds  it.  In  this  state  of  engorgement  the  mucous  membrane  of  the 
small  bronchial  ramifications  is  of  a  deep  red  colour.     The  portions  most  engorged. 


560  PiNEUMOxMA. 

although  their  specific  gravity  is  increased,  will  nevertheless  almost  ahvaj's  float  on 
water. 

Now  it  is  necessary  to  caution  you,  in  the  outset,  against  a  very  frequent  source 
of  fallacy  in  respect  to  this  condition  of  inflammatory  engorgement.  Such  a  state 
of  the  pulmonary  substance  as  I  have  been  describing,  you  will  meet  with  in  half, 
at  least,  of  the  dead  bodies  which  you  may  have  to  examine ;  and  you  must  not 
necessarily  infer  therefrom  that  the  persons  deceased  had  in/lamrnation  of  the  lungs. 
There  is  almost  always  some  degree  of  mediunic.al  engorgement  of  the  back  part  of 
the  kings  ;  or  of  that  part  which  has  been  undermost  during  the  last  hours  of  life,  or 
after  death  ;  and  the  two  kinds  of  engorgements  can  scarcely  be  distinguished  from 
each  other  by  their  anatomical  characters  alone.  Andral  at  one  time  held,  indeed, 
that  if  the  engorged  part  were  more  friable,  more  easily  torn  or  broken  down  under 
pressure  than  natural,  that  was  a  sufficient  evidence  of  its  inflammation ;  but  he 
afterwards  saw  reason  to  change  that  opinion.  We  judge  by  the  situalion  of  the 
engorgement  sometimes :  if  it  be  not  in  a  depending  part  of  the  lungs,  it  is  surely 
inflammatory.     We  judge  also  by  the  antecedent  symptoms. 

If  the  inflammation  continues,  the  lung  undergoes  a  further  alteration,  and  presents 
the  following  characters.  It  is  still  red — externally  and  within  :  but  it  crepitates  no 
longer  under  pressure ;  and  it  sinks  in  water :  it  contains  in  fact  no  air.  Its  cut 
surface  presents  sometimes  a  uniform  red  colour;  sometimes  a  slightly  mottled  or 
variegated  appearance,  produced  by  intermixture  of  specks  of  the  black  matter  of  tne 
lung,  and  of  the  interlobular  areolar  tissue,  which  is  less  red  than  the  other  parts,  and 
more  than  naturally  obvious  to  the  sight ;  but  the  spongy  character  of  the  organ  is 
lost;  it  is  evidently  solid  ;  and  the  cut  surface  very  much  resembles  the  cut  surface 
of  the  liver.  Hence  Laennec,  and  after  him  most  other  writers,  have  applied  to 
this  altered  condition  of  the  lung  the  term  lupa'ization.  There  still  flows  out, 
under  pressure,  from  the  surface,  when  a  fresh  incision  is  made,  some  red  fluid,  but 
it  is  much  less  in  quantity  than  in  the  former  degree  ;  and  it  is  not  foamy  ;  and  if 
the  surface  be  gently  scraped  with  a  scalpel,  you  may  often  perceive  in  the  red  fluid 
so  collected,  some  traces  of  a  thicker  and  yellower  matter,  the  first  indication  of 
commencing  suppuration.  The  hepalized  lung  is  denser  and  more  solid  than  before, 
but  it  is  also  more  friable ;  more  easily  crushed  and  broken  :  and  this  results  from 
the  softening  of  the  areolar  tissue  which  holds  its  component  parts  together. 

If  you  tear  a  portion  of  hepatized  lung,  and  examine  the  torn  surface  with  a  mag- 
nifying glass,  the  pulmonary  tissue  will  appear  to  be  composed  of  a  crowd  of  small 
red  granulations,  lying  close  to  each  other.  These  are,  1  presume,  the  air-vesicles, 
clogged  up,  thickened,  and  made  red,  by  the  inflammation.  As  no  air  is  contained 
in  the  lung  in  this  stage  of  the  inflammation,  it  follows  that  if  the  entire  organ  be 
involved  in  the  disease,  it  vvill  not  collapse  when  the  thorax  is  laid  open  ;  and  will 
therefore  appear  to  be  increased  in  bulk.  It  is  swelled,  in  fact — ^just  as  other  in- 
flamed parts  are  swelled  —  by  the  congestion  of  its  vessels,  and  by  the  effusion  of 
blood,  or  of  some  of  the  constituent  parts  of  the  blood,  into  its  hollows  and  inter- 
stices. The  marks  of  the  ribs  are  frequently  visible  on  the  surface  of  the  distended 
lung.  The  texture  of  the  lung  in  this  condition  is  sometimes  so  rotten,  that  a  mode- 
rate degree  of  pressure  between  the  fingers  will  suffice  to  reduce  it  to  a  state  of 
pulp;  and  this  diminution  of  consistence  has  made  Andral  quarrel  with  the  term 
hepatization  :  and  he  proposes  to  call  this  second  stage  of  pneumonia,  red  softening, 
runiol/hseiyient  rouge.  All  this  is  very  unimportant,  provided  that  you  recollect  the 
sense  in  which  either  nomenclature  is  employed.  But  as  Laennec  and  Andral  are 
both  great  authorities,  and  both  have  their  disciples  in  this  country,  it  is  weU  thai 
you  should  understand  their  language. 

I  have  been  speaking  of  pneumonia  as  it  is  apt  to  attack  the  whole,  or  the  larger 
portion,  or  a  considerable  portion,  of  the  lung  on  one  side  :  but  it  is  a  curious  cir- 
f-umstance  that  the  changes  I  have  been  describing  are  sometimes  exactly  limited 
to  certain  of  the  pulmonary  lobules ;  and  this  slate  is  called,  accordingly,  lobular 
pneumonia. 

In  a  degree  still  further  advanced,  the  pulmonary  tissue,  dense,  solid,  and  imper- 
vious to  air,  as  in  the  last  stage,  undergoes  an  alteration  of  colour ;  it  presents  -i  red- 


PNEUMONIA.  561 

dish  yellow,  or  straw,  or  drab,  or  stone  colour;  or  it  is  of  a  grayish  hue,  sometimes 
mottled  with  red,  or  with  the  black  pulmonary  matter.  The  little  granulation?  which 
I  just  now  mentioned  are  whitish  or  gray,  instead  of  being  red ;  and  the  texture  of 
the  lung  is  still  more  rotten  and  friable  than  before.  It  is  full,"  in  fact,  of  puriform 
matter,  which  is  ^metimes  so  abundant  that  it  oozes  out  plentifully  when  incisions 
are  made  into  the  lung :  or  it  may  be  made  to  exude  by  gentle  pressure.  The  gray 
pus  shows  itself  upon  the  cut  surface  in  the  form  of  minute  drops.  The  more  the 
pulmonary  texture  is  soaked  or  drenched  with  this  fluid,  the  softer  and  more  friable 
it  becomes.  When  crushed  between  the  thumb  and  fingers,  it  is  reduced  to  a  yel- 
lowish gray  pulp,  exactly  hke  the  fluid  itself,  only  rather  more  consistent.  And  by 
gently  forcing  the  finger  into  any  part  of  the  parenchyma  in  this  state,  a  small  cavity 
may  be  made  which  soon  fills  with  pus,  and  which  might  readily  be  mistaken  for  a 
recently  formed  abscess. 

Laennec  has  called  this  third  stage  of  the  process  of  inflammation  in  the  lung, 
gray  hepatization,  ox  purulent  injiltration.  Andral  denominates  it  gray  softening 
— rumolHssement  gj'is.  In  fact,  it  consists  in  diffused  suppuration  of  the  pulmo- 
nary texture.  And  it  is  a  very  remarkable  circumstance,  and  one  which  the  re- 
searches of  modern  times  have  brought  to  light,  that,  in  the  lung,  inflammation  going 
on  to  suppuration  does  not  lead  to  the  formation  of  a  circumscribed  abscess,  as  it 
does  when  it  affects  the  areolar  tissue,  or  the  parenchymatous  tissue,  in  other  parts 
of  the  body.  Abscess  of  the  lung  used  to  be  spoken  of  as  a  very  common  thing; 
but  it  is  a  very  rare  thing.  In  several  hundred  dissections  of  persons  dead  of  pneu- 
monia, made  by  Laennec  during  a  space  of  more  than  twenty  years,  he  only  met 
with  five  or  six  collections  of  pus  in  the  inflamed  lung.  Once  only  did  he  find  -i 
large  abscess  of  that  sort.  Once  only  has  Andral  seen  a  real  abscess  of  the  lung 
form  as  a  consequence  of  pneumonia.  You  may  find  collections  of  pus  in  the  lungs, 
sometimes,  occurring  in  connection  with  the  inflammation  of  veins.  Several  in- 
stances of  that  kind  have  happened  very  recently  in  patients  who  have  died  in  the 
Middlesex  Hospital.  But  these  are  not  ordinary  cases  of  pneumonia.  I  need 
scarcely  caution  you  not  to  take  tubercular  vomicae  and  cavities,  containing  pus,  for 
genuine  abscesses  of  the  lung.  These,  and  the  phlebitic  deposits  of  pus,  are  not 
exceptions  to  the  general  statement:  they  arise  from  different  forms  of  disease  :  and 
you  will  find  a  circumscribed  collection  of  pus,  surrounded  by  hepatized  lung,  as  a 
consequence  of  common  pneumonia,  to  be  an  exceedingly  rare  event. 

Can  we  account  for  this  in  any  way  ?  I  do  not  know  that  any  satisfactory  expla- 
nation of  the  fact  has  ever  been  offered.  But  I  would  submit  to  your  consideration 
what  has  occurred  to  my  mind  on  this  subject.  When  I  was  speaking  of  inflamma- 
tion in  general,  I  pointed  out  to  you  the  remarkable  influence  which  the  presence 
of  atmospheric  air  in  contact  with  the  inflamed  part  has  in  accelerating,  or  deter- 
mining, the  event  of  suppuration.  In  a  recent  cut,  the  admission  or  exclusion  of 
the  air  to  the  cut  surface  will  make  all  the  difTerence  between  the  adhesive  and  the 
suppurative  inflammation  ;  and  so  in  other  cases  which  I  then  mentioned,  and  will 
not  now  trouble  you  by  repeating.  Now  it  seems  to  me  that  the  same  principle 
obtains  in  inflammation  of  the  lung.  First,  there  is  an  effusion  of  serum  and  blood, 
then  of  lymph  and  blood  ;  but  the  air  passing  into  the  surrounding  sounder  tissue, 
and  mingling  for  a  time  even  with  the  inflamed  portion  itself,  causes  the  suppurative 
process  to  supersede  the  adhesive ;  and  so  no  wall  of  circumvallation  is  formed  by 
the  coagulable  lymph,  as  is  the  case  in  areolar  tissue  which  is  not  accessible  by  the 
air.  Whether  this  be  a  sufficient  explanation  of  the/rtc/  (all  explanations  being  the 
resolving  a  given  fact  into  a  certain  class  of  other  facts  more  general  and  compre- 
hensive); I  say  whether  it  be  a  reasonable  and  satisfactory  explanation,  you  will 
judge :  at  any  rate  it  may  serve  to  impress  upon  your  memory  that  fact  which  it 
enJeaTours  to  elucidate. 

Gangrene  is  sometimes,  but  very  seldom,  the  result  of  acute  inflammation  of  the 
lUng.  It  is  almost  as  uncommon  as  the  formation  of  an  abscess.  Yet  it  certainly 
does  now  and  then  occur,  as  a  consequence  of  acute  inflammation  of  the  pulmonary 
substance.  It  is  somewhat  more  common  (though  under  any  shape  rare)  as  an  inde- 
pendent and  primitive  afTection.  Sometimes  it  occupies  a  large  portion  of  the  lung, 
36 


562  PNEUMONIA. 

and  is  uncircumscrlbed  ;  and  sometimes  it  is  more  limited.  Tlie  colour  of  the  part 
which  has  thus  perished  under  inflammation  is  dark,  of  a  dirty  olive,  or  greenish-brown 
colour.  The  gangrenous  portion  is  moist  and  wet;  sometimes  of  the  consistence  of 
the  engorged  lung ;  more  commonly  softer,  and  even  diffluent ;  and  it  stinks  most 
abominably.  This  horrible  odour  is  in  truth,  during  hfe,  the  most  distinctive  cha- 
racter of  gangrene  of  the  lung.  It  sometimes  renders  the  room  in  which  the  un- 
happy patient  is  lying,  scarcely  endurable.  I  should  have  stated  before  that  the 
puriform  infiltration  of  the  third  stage  of  pneumonia  is  attended  with  no  fetor. 

There  are  some  other  points,  connected  with,  or  learned  from  investigating,  the 
morbid  anatomy  of  pneumonia,  which  I  may  as  well  take  this  opportunity  of  tell- 
ing you,  before  we  go  on  to  consider  the  symptoms,  ph3'sical  and  general,  of  that 
disease. 

There  are  two  lungs,  just  as  there  are  two  tonsils,  and  two  eyes ;  and  in  the  one 
case  as  well  as  in  the  other,  inflammation  may  affect  both  organs  at  once,  or  it  may 
affect  one  of  them  alone.  Technically  speaking,  pneumonia  may  be  either  double 
or  single.  Acain,  the  inflammation  may  occupy  a  part  of  one  lung,  or  the  whole 
of  it :  in  other  words,  it  may  be  partial  or  general ;  but  it  does  not  affect  all  parts, 
or  both  sides,  indifferently  or  capriciously.  In  the  first  place,  it  is  (why  I  know  not) 
greatly  more  common  on  the  right  side  of  the  body  than  on  the  left.  I  will  give 
you  some  statistical  statements  collected  by  Andral,  in  respect  to  this  point.  Of  one 
hundred  and  fifty-one  cases  of  pneumonia,  noticed  at  La  Charite,  ninety  were  of  the 
right  lung  alone  ;  thirty-eight  only  of  the  left  alone  ;  seventeen  of  both  sides  at  once  ; 
and  in  six  the  situation  was  uncertain.  He  was  at  the  pains  of  collecting  the  parti- 
culars of  fifty-nine  other  examples  of  pneumonia,  from  different  authors,  so  fully  de- 
scribed as  to  leave  no  doubt  about  the  nature  and  situation  of  the  disease.  Among 
these,  the  inflammation  existed  in  the  right  lung  alone  in  thirty-one  patients ;  in  the 
left  alone  in  twenty;  and  in  both  sides  at  once  in  eight.  Hence,  taking  both  series 
of  observations  together,  we  have  two  hundred  and  ten  cases  of  pneumonia;  and 
there  were  one  hundred  and  twenty-one  in  which  the  right  side  was  solely  the  seat 
of  the  disease ;  fifty-eight  in  which  the  left ;  twenty-five  in  which  the  pneumonia 
was  double ;  and  six  in  which  the  seat  was  uncertain.  So  that,  at  this  rate,  pneu- 
monia is  more  than  twice  as  common  on  the  right  side  as  on  the  left ;  and  does  not 
occur  on  both  sides  together  so  often  as  once  in  eight  times. 

Again,  with  regard  to  the  part  of  the  lung  which  is  most  obnoxious  to  inflamma- 
tion, there  are  remarkable  differences.  It  is  well  known,  and  it  is  a  very  important 
fact  in  respect  to  diagnosis  in  some  cases,  that  the  lower  lobes  are  more  liable  to 
inflammation  than  the  upper.  I  speak,  of  course,  of  active  idiopathic  inflammation. 
But  this  circumstance,  much  insisted  on  by  Laennec,  and  quite  true  in  the  main,  has 
perhaps  been  somewhat  exaggerated.  I  have  not  had  leisure  to  frame  any  numeri- 
cal statement  of  the  cases  that  have  come  under  my  own  observation,  but  the  general 
impression  which  they  have  left  upon  my  mind  is  in  favour  of  the  correctness  of 
Laennec's  statement — that  pneumonia  generally  commences  in  the  lower  lobes,  and 
spreads  upwards  frequently  to  the  superior  lobes.  But  I  may  adduce  Andral's  sta- 
tistical representation  in  respect  to  this  question  also.  Of  eightj''-eight  cases  of  pneu- 
monia, he  found  that  the  inflammation  affected  the  inferior  lobe  forty-seven  times,  the 
superior  lobe  thirty,  and  the  whole  lung  at  once,  eleven. 

Inflammation  of  the  bronchi  constantly  accompanies  inflammation  of  the  paren- 
chyina.  The  mucous  membrane  presents  a  red  colour,  both  in  the  large  and  in  the 
small  branches  of  the  air-passages.  And  when  a  single  lobe  is  inflamed,  it  has 
been  observed  that  the  redness  of  the  mucous  membrane  existed  in  those  bronchial 
tubes  alone  which  were  distributed  to  that  lobe.  You  may  have  bronchitis  without 
pneumonia ;  but  pneumonia  without  a  corresponding  extent  of  bronchitis  is  perhaps 
riever  seen. 

The  majority  of  cases  of  pneumonia  are  attended  also  with  a  degree  of  inflam- 
mation of  the  investing  membrane  of  the  lung:  there  is  some  pleurisy.  So  fre- 
quently indeed  is  this  the  case,  that  certain  writers,  Andral  among  others,  call  the. 
disease  by  the  compound  name  of  pleuro-pneumonia.  However,  pneumonia  may 
and  does  sometimes  occur  without  any  concurrent  pleurisy.    Of  the  latter  complaint 


PNEUMONIA  563 

I  must  speak  by  itself;  and  I  merely  notice  now  the  frequent  combination  of 
the  two — the  occurrence  of  a  slight  degree  and  extent  of  pleuritis  in  most  cases  of 
pneumonia — that  you  may  the  better  understand  some  of  the  general  symptoms  of 
pneumonia. 

Now  such  being  the  changes  which  the  lungs  undergo  when  inflammation  affects 
the  pulmonary  texture,  we  may  next  inquire  what  signals  of  its  existence  the  inflam- 
mation holds  out ;  and  how  far  we,  not  having  the  power  of  seeing  what  is  going  on 
within  the  cavity  of  the  thorax,  may  nevertheless  ascertain  the  important  processes 
which  are  there  transacted. 

If  the  ear  be  applied  to  the  surface  of  the  chest,  with  or  without  the  intervention 
of  the  stethoscope,  and  the  portion  of  lung  subjacent  to  that  surface  happen  to  be  in 
the  first  stage  of  inflammation,  that  of  engorgement,  what  does  the  lung,  so  sufl^er- 
ing,  say?  what  audible  notice  does  it  give  of  its  morbid  condition?  Why,  it  speaks 
very  plainly.  You  hear  a  pecuHar  crackling  sound  ;  the  smallest  and  finest-possible 
kind  of  crepitation  :  which  has  been  happily  illustrated  by  saying  that  it  re&emblt-s 
the  multitudinous  httle  crackling  explosions  made  by  salt  when  it  is  scattered  over 
red-hot  coals.  Andral  has  another  resemblance  for  it,  and  not  a  bad  one  ;  he  says 
the  noise  is  often  like  that  which  is  produced  by  rumpling  a  very  fine  piece  of  parch- 
ment. Dr.  Williams  observes  that  a  pretty  correct  idea  of  this  sound  may  be 
obtained  in  a  ready  way,  by  rubbing  between  the  finger  and  thumb  a  lock  of  one's 
own  hair,  close  to  the  ear.  Laennec  calls  this  crepitant  rhonchiis :  I  would  speak 
of  it  as  minute  crepitation ;  or  the  crackling  of  pneumonia.  This  may  be  heard 
in  a  very  limited  spot  in  the  beginning.  And  what  an  important  sound  it  is  !  "  It 
is  a  direct  symptom,  having  immediate  reference  to  the  structure  of  the  part.  And 
(says  Dr.  Latliam)  if  we  consider  what  the  part  is,  and  what  the  disease;  the  part 
the  lungs,  and  the  disease  inflammation :  we  cannot  too  highly  value  this  single 
symptom  (simple  and  mean  as  it  may  seem),  which  gives  the  earliest  and  surest  inti- 
mation that  such  a  disease  has  begun,  as  tends  to  disorganization,  and  the  inevitable 
loss  of  life,  unless  quickly  arrested  by  its  counteracting  remedy." 

At  first,  when  you  catch  the  inflammation  in  its  earliest  stage,  this  minute  crepita- 
tion, which  announces  commencing  engorgement  of  the  part,  is  heard  mingled  with 
the  ordinary  vesicular  breathing.  This  obscures  the  natural  sound,  though  it  does 
not  yet  entirely  cover  it — but  as  the  inflammation  advances,  the  crackHng  becomes 
more  and  more  pronounced,  until  at  length  it  totally  supersedes  it.  So  long  as  the 
natural  vesicular  breathing  prevails  over  the  crackling,  we  may  conclude  that  the 
inflammation  is  slight:  and  if  the  crackling  should,  in  its  turn,  become  predominant 
if  it  should  ultimately  mask  the  murmur  of  respiration  entirely,  that  infallibly  de 
notes  the  progress  of  the  pneumonia,  and  teaches  us  that  it  tends  to  pass  from  the 
first  into  the  second  degree.  But  the  crackling  sound  does  not  long  remain  in  any 
part.  As  the  case  proceeds,  the  sound  is  less  and  less  heard,  and  at  length  is  not 
heard  at  all,  in  that  spot ;  and  it  may  be  succeeded  by  one  of  two  very  different 
things.  Its  place  may  be  taken  by  the  natural  respiratory  murmur  again.  When 
this  is  so,  it  denotes  the  resolution  of  the  inflammation.  But  the  crackling  may 
cease,  and  either  no  sound  at  all  be  heard  in  its  stead,  or  another  morbid  sound 
which  I  shall  presently  describe  :  and  this  teaches  us  with  absolute  certainty,  that  the 
disease  is  growing  more  severe  and  serious ;  that  the  lung  is  becoming,  or  has  be- 
come, hepatized. 

Let  us  inquire,  for  a  moment,  before  we  go  any  further,  what  is  the  nature  and 
the  seat  of  this  minute  crepitation,  so  characteristic  of  the  commencement  of  pul- 
monic inflammation.  With  respect  to  its  scat,  I  apprehend,  there  can  be  no  question. 
It  proceeds  from  the  very  smallest  ramifications  of  the  bronchi,  and  the  air-vesicles 
themselves.  The  common  opinion  is,  and  such,  I  confess,  is  mine,  that  the  sound  is 
the  same  in  cause  and  kind,  only  dilTerent  in  degree,  with  the  large  and  small  crepi- 
tation described  in  a  previous  lecture  :  that  it  results  from  the  passage  of  a^r  through 
liquid  ;  from  the  formation  and  bursting  in  quick  succession  of  a  multitude  of  little 
air-bubbles.  The  bubbles  are  necessarily  minute,  for  they  are  formed,  and  they  ex- 
plode, in  very  slender  tubes.  This  is  Andral's  view  of  the  matter.  Laennec  doe.s 
pot  appear  to  have  formed  very  clear  notions  on  the  subject.     But  a  different  expla 


564  PNEUMONIA 

nation  has  been  offered  by  a  well-known  and  able  writer  on  the  auscultatory  signs 
of  disease,  in  this  country  :  I  mean  Dr.  Williams.  He  holds  t^at  the  distended 
blood-vessels,  and  the  interstitial  serous  effusion,  press  upon  the  minutest  bronchial 
ramifications,  and  obstruct,  without  wholly  preventing,  the  passage  of  the  air  through 
them :  that  these  small  tubes  are  lined  by  a  viscid  secretion,  such  as  is  expectoratt-d, 
and  such  as  I  shall  have  to  describe  :  that  the  sides  of  the  tubes  stick  together  in 
consequence  of  the  presence  of  this  viscid  matter  ;  and  that  it  is  the  separation  of 
these  adhering  sides  by  httle  portions  of  air  which  successively  pass  in  and  out,  that 
gives  rise  to  the  characteristic  sound.  However,  what  it  is  important  to  remember 
is,  that  the  crackling  sound  proceeds  from  the  minutest  divisions  of  the  air-tubes,  and 
from  the  ultimate  vesicles  of  the  lungs. 

Sometimes,  I  say,  when  this  crackling  ceases,  the  ear  apphed  to  the  corresponding 
surface  of  the  chest,  feels  it  heave  up  in  inspiration,  but  catches  no  sound  at  all. 
Much  more  commonly,  however,  a  neio  sound  reaches  the  ear.  It  is  not  the  vesi- 
cular rustle  ;  it  is  not  the  minute  crepitation :  but  a  whiffing  sound  is  audible,  like 
that  produced  by  blowing  through  a  quill.  Little  gusts  of  air  are  puffed  in  and  out ; 
most  distinct,  often,  at  the  termination  of  a  slight  cough  or  hem.  This  is  the  sound 
to  which  the  term  bronchial  respiration  has  been  given :  and  the  name  expresses 
well  the  fact.  I  mentioned  before  that  in  the  healthy  state  we  do  not  hear  the  air 
pass  through  the  larger  bronchi  during  inspiration  and  expiration  :  the  sound  doubt- 
less is  made,  but  it  is  obscured  and  hidden  by  the  smooth  rustle  of  the  vesicular 
breathing,  which  comes  from  the  spongy  lung  surrounding  the  large  divisions  of  the 
bronchi,  and  intervening  between  them  and  the  ear.  But  that  spongy  structure  is 
now  filled  up.  The  hepatized  lung  admits  air  to  pass  through  the  larger  bronchi, 
which  are  still  patent,  but  it  admits  none  into  the  vesicles  and  smaller  tubes.  It  cre- 
pitates not  when  pressed  between  the  thumb  and  finger:  in  fact,  it  is  converted  into 
a  solid  substance,  and  conducts  the  sound,  in  the  living  body,  as  any  other  solid  sub- 
stance might  do:  and  therefore  the  whiffing,  blowing,  gusty  sound  of  the  breath, 
as  it  enters  and  departs  from  the  larger  bronchial  tubes,  which  still  remain  open,  is 
conveyed  to  the  ear,  and  bronchial  respiration  is  heard.  At  the  same  time,  and  in 
the  same  place,  another  auscultatory  phenomenon  generally  arises,  and  admits  of  a 
similar  explanation.  The  voice  of  the  patient  descends  into  the  pervious  bronchi, 
and  is  conveyed  to  the  ear  of  the  listener  through  the  solid  lung :  and  it  is  quite 
altered  by  that  circumstance.  The  tone  of  it  is  modified  ;  it  sounds  hke  the  voice 
of  one  speaking  through  a  tube.  It  is  totally  different  from  the  same  voice  heard 
through  the  healthy  lung  at  the  corresponding  point  on  the  other  side.  It  approaches 
in  distinctness  and  qualitj%  but  it  does  not  reach,  the  sound  heard  in  speaking,  when 
the  stethoscope  is  placed  over  the  trachea.  A  humming  and  muttering  are  audible, 
but  the  words  are  not  distinctly  articulated  into  the  ear.  It  is  hard  to  describe  these 
things  in  words.  Three  minutes,  at  the  bedside  of  a  patient  in  whom  the  bronchial 
breathing  and  the  bronchial  voice  were  tolerably  well  marked,  would  put  you  in 
possession  of  them  for  ever.  They  are  striking  sounds :  requiring  no  fine  tact  to 
distinguish :  and  exceedingly  informing  sounds.  But  I  must  resume  this  subject 
when  we  meet  again. 


LECTURE  LI. 

Pnaimonia  continued;  its  general  symptoms;  pain,  dyspnoea,  cough,  erpectoror 
tion.     Course  of  the  disease.     Prognosis.     Treatment. 

1  svAS  describing,  at  the  close  of  the  last  lecture,  the  auscultatory  signs  which  lead 
us  to  the  knowledge  that  the  inflamed  lung,  in  a  case  of  pneumonia,  has  passed  from 
the  first  into  the  second  stage  of  inflammation,  and  become  solid,  or  hepatized.  The 
pltered  condition  of  the  organ  gives  rise  to  altered  sounds.     Instead  of  the  vesicular 


PNEUMONIA.  565 

breathing,  which  is  the  natural  sound,  or  of  the  minute  crepitation,  which  is  the 
sound  belonging  to  the  first  stage  of  the  inflammation,  we  either  hear  no  sound  at 
all,  although  we  feel  the  chest  heave  up  against  our  ear,  or  we  hear  what  I  described 
under  the  denomination  of  bronchial  respiration;  that  is  to  say,  a  puffing  sound 
which  is  conveyed  to  the  ear  from  the  larger  and  still  pervious  branches  of  the  bron- 
chi, through  the  solid  portion  of  the  lung  around  them,  and  through  the  solid  walls 
of  the  chest.  This  is  what  the  listener  hears  when  the  patient  breathes.  And  when 
he  speaks,  his  voice  is  heard,  much  more  resonant  than  is  natural,  much  more  reso- 
nant than  in  the  corresponding  spot  on  the  opposite  side  of  the  chest,  entering  the 
same  open  air-tubes,  and  conducted  to  the  ear  by  the  dense  and  sohd  lung.  We  thus 
become  acquainted  with  two  entirely  new  sounds ;  sounds  which  are  never  heard  in 
the  healthy  state  of  the  lungs  ;  bronchial  respiration,  and  bronchial  voice,  or  bron- 
chophony ;  and  you  will  do  well  to  remember  these  two  sounds,  and  to  famiHarize 
your  ear  to  them  ;  for  they  speak  a  most  significant  language  in  other  pulmonary 
diseases,  as  well  as  in  pneumonia. 

But  I  say,  sometimes  we  hear  these  morbid  sounds,  in  the  case  in  question,  and 
sometimes  we  hear  no  sound  at  all  during  the  breathing.  How  is  that?  Why,  the 
existence  and  degree  of  the  bronchial  respiration,  and  bronchial  voice,  vary  accord- 
ing to  the  place  and  extent  of  the  inflammation.  These  morbid  sounds  are  most 
plainly  marked,  where  the  number  and  size  of  the  bronchial  tubes  involved  in  the 
hepatization  are  the  greater.  They  are  most  distinct,  therefore,  when  the  inflamma- 
tion occupies  the  upper  part  of  the  lung ;  or  the  central  parts,  what  are  called  the 
roots  of  the  lungs  :  and  when  it  extends  thence  to  the  surface :  but  when  the  lower 
portions  alone  are  inflamed,  or  the  inflammation  is  merely  superficial  or  partial,  they 
may  not  be  heard  at  all.  Again,  if  the  hepatization  should  be  so  general  and  com- 
plete as  to  prevent  the  chest,  on  the  affected  side,  from  expanding,  you  will,  in  that 
case,  hear  no  bronchial  respiration  ;  for  the  air  in  the  large  bronchi  must  be  stagnant. 
Bronchophony,  however,  may  remain. 

When  we  have  the  bronchial  respiration,  usually  also  we  have  dullness  on  per- 
cussion. The  degree  in  which  this  is  present  will  depend  upon  the  circumstances 
of  the  case.  If  a  portion  of  crepitant  and  permeable  lung,  even  a  thin  portion,  should 
intervene  between  the  inflamed  parts  and  the  walls  of  the  chest,  there  will  still  be 
resonance,  though  it  will  not  be  exactly  the  natural  resonance,  on  percussion.  If  the 
hepatized  part  come  close  up  to  the  ribs,  the  sound  elicited  by  mediate  percussion 
will  be  flat,  or  dead.  With  all  this,  you  will  generally  hear,  in  the  sound  lung,  if 
the  whole  of  the  other  be  engaged  in  the  inflammation — or  in  those  parts  of  the 
inflamed  lung  that  arc  healthy — you  will  hear,  I  say,  puerile  respiration  ;  and  this 
is  a  strong  confirming  symptom  that  a  part  of  the  breathing  apparatus  is  spoiled,  and 
that  the  remaining  part  is  endeavouring  to  compensate  for  its  deficiency. 

Now,  this  period  in  pneumonia,  when  no  sound  but  bronchial  breathing  is  audible 
during  respiration,  is  a  period  of  anxious  and  painful  interest.  We  cannot  tell  whe- 
ther the  lung  will  revert  gradually  to  its  healthy  state,  or  whether  it  is  passing  into 
the  third  stage ;  that  of  purulent  infiltration.  But  taking  first  the  most  favourable 
of  these  two  suppositions — what  happens  ?  Why,  there,  where  for  a  while  we  heard 
nothing  but  bronchial  respiration,  a  slight  crepitation  begins  again  to  be  distinguish- 
able, especially  at  the  end  of  each  act  of  inspiration :  gradually  this  increases  in  ex- 
tent and  intensity,  and,  as  it  increases,  the  bronchial  breathing  and  the  bronchial 
voice  become  proportionably  less  distinct,  in  consequence  of  the  texture  of  the  lungs 
becoming  again  permeable  by  air,  and  therefore  a  worse  conductor  of  sound.  By 
degrees,  the  bronchial  breathinof  and  the  voice  disappear  altogether ;  the  vesicular 
murmur  begins  again  to  mix  with  the  crepitation,  and  at  length  supersedes  it ;  and 
the  lung  is  restored  to  its  previous  fitness  for  the  purposes  of  respiration.  The  same 
symptoms  therefore  recur,  over  again,  but  in  a  reversed  order;  the  returning  crepi 
tation  is,  however,  coarser  and  larger,  and  less  regularly  diffused,  than  that  of  the 
advancing  pneumonia:  and  even  when  nothing  is  heard  in  the  ordinary  condition 
ef  the  breathing  but  the  natural  vesicular  rustle,  some  crepitation  is  found  for  some 
little  while  to  mingle  with  it,  towards  the  end  of  a  full  inspiration.  This  is  believea 
to  depend  upon  an  oedematous  state  of  the  pulmonary  texture,  left  after  'he  active 

2x 


566  PNEUMONIA. 

inflammation  has  been  displaced.*  Next,  let  us  take  the  worst  of  the  two  supposi- 
tions. Auscultation  has  traced  the  disease  through  its  stage  of  engorgement,  and 
into  its  stage  of  hepatization.  Can  it  trace  it  further?  I  believe  not,  with  any  cer- 
tainty. We  cannot  say  whether  the  lung  remains  in  the  state  of  hepatization  (as  it 
may  remain),  or  whether  it  has  passed  into  the  third  stage.  But  at  last,  if  the  struc- 
ture of  the  lung  breaks  down,  and  a  portion  of  it  is  expectorated,  air  finds  its  Avay 
into  the  vacant  spot,  and  gives  rise  to  large  gurgling  crepitation.  But  the  other  signs 
sometimes  come  to  our  aid  when  this  state  has  been  reached. 

We  often  find,  after  death,  the  three  degrees  of  pneumonia  existing  in  difTerent 
parts  of  the  same  lung;  and  therefore  it  is  not  to  be  wondered  at  that  the  different 
parts  of  the  chest  should  during  life  yield  sounds  indicative  of  each  of  those  degrees, 
or  at  least  of  the  first  two ;  minute  crepitation  here,  bronchial  breathing,  and  bron- 
chophony, and  dullness  on  percussion  tlicre,  and  in  another  spot  no  sound  at  all,  or, 
on  the  other  hand,  puerile  respiration. 

Again,  it  must  be  confessed — and  I  am  desirous  jf  confessing  it,  for  I  am  sure  that 
the  method  of  auscultation  is  brought  into  undeseived  suspicion  and  disrepute  by 
attempts  made  to  assert  its  all-sufficiency  in  all  cases — it  must  be  confessed  that,  in 
some  instances,  although  pneumonia  exists,  the  ear  is  able  to  collect  nothing  of  it; 
nothing  indicative  of  its  situation,  or  of  its  extent,  or  even  of  its  existence.  The 
pulmonary  expansion  is  clear,  all  over  the  thorax ;  nay,  much  more  strong  than  is 
natural:  and  this  circumstance  justifies  the  belief  that,  from  some  cause  or  other, 
not  necessarily  from  pneumonia,  a  portion  of  the  lung  has  ceased  to  discharge  its 
function,  and  the  other  portions  have  taken  it  up.  This  failure  on  the  part  of  aus- 
cultation happens  when  the  inflammation  occupies  only  a  small  portion  of  the  lung, 
and  that  portion  central,  or  deeply  situated — at  a  distance  from  the  walls  of  the  chest. 
For  this  reason,  auscultation  may  give  little  or  no  account  of  lobular  pneumonia. 

Such  are,  then,  the  physical  signs  that  accompany  and  reveal  the  successive 
changes  of  texture,  destructive  and  reparatory,  which  take  place  in  inflammation  of 
the  lungs.  I  do  not  know  whether  I  have  made  them  clear  to  you ;  but  I  know  that 
no  very  long  apprenticeship,  if  I  may  so  speak,  in  the  wards  of  a  hospital,  will  be 
sufficient,  Avith  a  little  guidance,  to  render  you  master  of  them.  There  are  indeed 
varieties,  and  modifications,  and  exceptions,  which  nothing  but  such  an  apprentice- 
ship can  ever  teach  you.  Of  these  it  would  be  idle  and  unprofitable  for  me  here  to 
speak:  and  I  go  on  to  consider  the  general  SAgns  of  pneumonia;  some  of  which, 
either  in  themselves,  or  in  combination  with  the  physical  signs,  are  of  no  less  im 
portance  than  these. 

In  the  majority  of  cases  the  commencement  of  inflammation  of  the  lung  is  marked 
b)''  shivering,  followed  by  heat  and  increased  frequency  of  pulse ;  in  one  word,  by 
inflammatory  fever ;  and  at  the  same  time,  or  presently  after,  a  stitch  in  the  side 
comes  on,  with  cough,  and  a  sense  of  oppression  in  the  chest.  In  other  instances 
the  disease  steals  on  more  insidiously,  and  succeeds  to  bronchitis ;  the  inflammation 
appearing  to  propagate  itself  by  httle  and  little  from  the  larger  to  the  smaller 
bronchi,  and  ultimately  to  reach  the  air  vesicles  themselves,  and  the  interstitial  tex- 
tures ;  and  this  may  be  accomplished  with  or  without  the  sharp  pain  or  stitch  in  the 
side.  At  first  the  cough  may  be  dry,  but  it  soon  is  attended  with  a  verj''  characteristic 
sort  of  expectoration.  The  dyspnoea  is  sometimes  but  slight  in  the  outset ;  some- 
times severe. 

Apart,  therefore,  from  the  physical  signs,  we  may  say  that  the  usual  symptoms 
of  pneumonia  are  pain,  more  or  less  severe,  on  one  side  of  the  chest ;  dyspnoea ; 
cough  ;  a  peculiar  expectoration  ;  and  fever. 

The  pain  in  pneumonia  appears  to  exist  only  in  those  cases  in  which  the  inflam- 
mation of  the  lung  is  accompanied  by  some  degree  of  pleurisy.  But  these  are  the 
most  numerous  cases.  It  is  most  commonly  experienced  on  a  level  with,  or  a  little 
be.ow,  one  or  other  breast ;  but  it  may  exist  in  almost  any  other  part  of  the  thoracic 
parictes.  Generally  it  is  most  severe  at  the  beginning,  declines  by  degrees,  and 
ceases  altogether  for  some  time  before  the  pnevnionia  ceases.  It  is  aggravated  by 
cough  ;  by  a  full  inspiration  ;  often  by  sudden  changes  of  posture  ;  by  pressure  made 
upon  the  ribs  or  intercostal  spaces ;  or  by  percussion  of  that  part.     For  the  same 


PNEUMONIA.  567 

reason  the  patients  cannot  lie  on  the  painful  side.  Andral  dec.^res  that  in  all  the 
individuals  in  whom  he  had  noticed  this  pain,  and  who  died,  he  found  the  pleura 
inflamed,  and  covered  more  or  less  with  coagulable  lymph ;  and,  on  the  other  hand, 
that  he  had  constantly  known  the  absence  of  pain  coincide  with  a  sound  condition 
of  the  pleura.  When  there  is  no  sharp  pain,  there  is,  however,  some  morbid  sensa- 
tion, of  trouble,  or  tightness,  or  weight,  or  heat  on  the  affected  side.  He  quotes,  with 
approbation  of  its  justness,  the  ancient  observation  respecting  pneumonia  : — "  Affert 
plus  periculi  quam  doloris."  When  I  come  to  speak  of  pleurisy  as  a  distinct  and 
substantial  affection,  I  shall  revert  to  this  pain. 

It  is,  or  it  was,  a  common  doctrine,  that  one  of  the  general  symptoms  of  pneu- 
monia relates  to  the  posture  which  the  patient  assumes ;  that  the  decubitus,  to  speak 
technically,  is  on  the  side  affected.  The  truth,  however,  is  as  I  have  just  now  stated 
it.  The  breathing,  indeed,  is  more  oppressed  when  the  patient  lies  on  the  sound 
than  when  on  the  diseased  side ;  but,  in  point  of  fact,  patients  labouring  under  this 
disease  almost  all  lie  upon  their  backs :  the  decubitus  is  dorsal.  The  difficulty  of 
breathing  deserves  some  notice.  In  general  it  bears  a  direct  proportion  to  the  extent 
and  severity  of  the  inflammation.  But  there  are  many  exceptions  to  this.  In  some 
persons  the  inflammation  of  even  a  very  small  portion  of  one  lung  will  embarrass  the 
respiration  greatly.  In  others,  who  have  a  much  larger  portion  of  the  pulmonary 
tissue  intensely  inflamed,  the  dyspnea  is  but  slight.  So  that  the  degree  of  difficulty 
of  breathing  is  not  a  certain  measure  of  the  seriousness,  or  rather  of  the  extent  and 
the  degree,  of  the  inflammation.  It  is  probable,  that  if  we  knew  of  what  kind  was 
the  ordinary  breathing  of  the  individuals  thus  differently  affected,  we  should  find  that 
they  whose  respiration  is  generally  indistinct,  or  noiseless,  who  do  not  seem  to  jvant 
all  their  lung  for  the  purpose  of  breathing,  would  best  bear  to  have  a  part  of  it  in- 
fiamod  ;  and  rice  versa.  Caeteris  paribus,  inflammation  of  the  upper  lobe  causes 
greater  dyspnoea  than  inflammation  of  the  lower.  I  may  observe  further  with  respect 
to  dyspnoea  in  general,  that  you  must  not  trust  implicitly  to  what  patients  tell  you 
on  that  head.  They  will  often  deny  that  they  have  any  shortness  of  breath,  when 
one  may  see  them  respiring  with  unnatural  rapidity,  or  observe  that,  in  their  dis- 
course, they  pause  between  every  three  or  four  words  to  take  breath. 

However,  the  dyspnoea  produced  by  pneumonia  varies  greatly  in  its  degree  in 
different  cases.  Sometimes  it  is  so  slight  that  the  patient  is  not  conscious  of  it,  and 
the  physician  scarcely  perceives  it :  sometimes  it  is  so  extreme,  that  the  patient, 
entirely  regardless  of  what  is  going  on  about  him,  seems  wholly  occupied  with 
respiring;  is  unable  to  lie  down;  can  scarcely  speak;  his  face  becomes  lividly  red 
or  pale,  and  is  expressive  of  the  utmost  anxiety ;  his  nostrils  are  expanded,  and  in 
full  action :  the  respiratory  movements  are  very  frequent  and  very  short  or  shallow, 
as  if  the  air  was  not  able  to  penetrate  beyond  the  primary  divisions  of  the  bronchi. 
From  this  state  of  extreme  d3'^spnoea  few  patients  recover :  and  between  this,  and 
the  slightest  hurry  or  embarrassment  of  the  breathing,  there  are  of  course  many 
degrees. 

Delirium  is  a  symptom  which  very  frequently  occurs  in  the  course  of  an  attack 
of  pneumonia ;  and  a  very  ugly  symptom  it  is.  It  denotes  that  the  due  arterializa- 
tion  of  the  blood  is  largely  interfered  with  by  the  pulmonary  affection.  It  measures, 
in  one  sense,  the  quantity  of  mischief  which  is  going  on  within  the  thorax  :  and  it  is  a 
direct  evidence  that  the  pectoral  mischief  is  telling,  through  the  circulation  of  venous 
blood,  upon  ihe  brain. 

The  cough,  in  pneumonia,  has  no  particular  character,  and  affords  but  little  infor- 
mation. It  does  not  usually  take  place  in  paroxysms;  and  its  severity  and  frequency 
are  not  always  proportioned  to  the  intensity  and  extent  of  the  inflammation.  It  is 
usually  dry  in  the  outset;  but  in  a  few  hours  it  is  accompanied  by  the  expectoration 
of  peculiar  sputa,  which  constitute  one  of  the  most  certain  indications  of  the  pre- 
sence of  pneumonia :  and  as  this  is  a  symptom  which  every  one  can  easily  recog- 
nize, I  will  describe  this  characteristic  expectoration,  and  endeavour  to  explain  the 
cause  of  it. 

The  expectoration  of  pneumonia,  when  well  marked,  consists  of  transparent  and 
lawny  or  rust-coloured  sputa,  uniting,  in  the  vessel  containing  (hem,  into  one  jelly 


5G8  PNEUMONIA. 

like  and  trembling  mass  ,  and  of  such  viscidity  that  the  vessel  may  be  turned  upside 
down,  and  strongly  shaken,  without  their  being  detached  from  its  bottom  or  sides. 
It  cannot  be  said  that  when  there  is  no  such  expectoration  as  this,  there  is  no  pneu- 
monia :  but  it  may  be  affirmed  that  where  we  do  find  such  expectoration,  there  almost 
certainly  we  have  pneumonia.  At  the  outset  of  the  disease,  either  nothing  is  spat 
up,  or  simply  some  bronchial  mucus :  but  on  the  second  or  third  day  generally,  the 
matters  expectorated  assume  the  characteristic  appearance :  i.  e.,  they  come  to  be 
composed  of  mucus,  intimately  united  and  combined  with  blood.  It  is  not  that  the 
sputa  are  streaked  with  blood,  as  often  happens  in  bronchitis:  nor  have  we  the  im- 
riiixed  blood  of  hfemoptysis.  But  the  blood  and  the  mucus  are  amalgamated  toge- 
ther ;  and  in  proportion  to  the  quantity  of  the  former,  the  sputa  become  of  a  yellow 
colour,  or  of  the  colour  of  rust,  or  of  a  decided  red :  and  at  the  same  time  they  be- 
come glutinous  and  tenacious :  they  adhere  together,  so  as  to  form  one  transparent 
homogeneous  mass.  So  long  as  this  mass  flows  readily  along  the  sides  of  the  vessel 
when  it  is  tilted,  so  long  have  we  reason  to  hope  (judging  from  that  circumstance 
alone)  that  the  inflammation  of  the  lung  does  not  pass  its  first  degree.  But,  as  I  said 
before,  the  sputa  often  acquire  an  extraordinary  degree  of  viscidity:  so  as  no  longer 
to  separate  themselves  from  the  vessel  when  it  is  inverted :  you  cannot  even  shake 
them  out.  When  this  happens,  we  are  obliged  to  fear  that  the  pneumonia  reaches 
its  second  degree.  In  fact,  when  the  sputa  become  thus  rusty  and  very  viscid,  the 
stricken  chest  almost  always  returns  a  duller  sound,  and  the  vesicular  breathing  is 
abolished,  and  bronchial  respiration  takes  its  place.  The  pneumonia  is  then  at  its 
acme ;  and  the  expectoration  remains  for  some  time  stationary.  At  length,  if  the 
inflammation  recedes,  the  sputa  become  again  less  tenacious,  less  red  or  yellow,  and 
more  like  the  expectoration  of  mere  catarrh.  But  if  the  disease  goes  on  from  bad  to 
worse,  the  rust-coloured  sputa  may  continue  to  the  end.  Commonly  there  is  less 
expectoration  in  that  case,  or  even  none  at  aU.  Not  that  the  mucus  ceases  to  be 
secreted,  but  that  its  ea-cretion  is  no  longer  possible  :  either  on  account  of  its  extreme 
tenacity,  or  on  account  of  the  patient's  debility.  The  sputa  then  accumulate  in  the 
bronchi,  trachea,  and  larynx,  in  succession :  they  fill  up  the  air-passages,  and  suffo- 
cate the  patient.  In  some  instances  the  expectoration,  in  the  advanced  stages  of  the 
disease,  consists  of  a  fluid  having  the  consistence  of  gum-water,  and  of  a  broAvnish- 
red  colour:  like  (as  Andral  says)  liquorice-water,  or  plum-juice.  He  states  that  the 
mere  occurrence  of  this  kind  of  expectoration  has  led  him  to  announce  the  existence 
of  the  third  stage  of  pneumonia ;  and  that  the  subsequent  examination  of  the  dead 
body  has  seldom  failed  to  justify  his  diagnosis.  Sometimes  again,  during  the  third 
stage,  very  perfect  pus  is  excreted. 

That  the  colour  of  the  sputa  peculiar  to  pneumonia  depends  upon  an  intimate 
union  of  blood  with  the  altered  mucus,  is  perfectly  obvious  when  that  colour  is  deep. 
And  even  when  this  transparent  mucus  is  yellow,  you  may  satisfy  yourselves  by  the 
following  simple  experiment  that  the  source  of  the  colour  is  the  same,  and  that  the 
yellowness  does  not  result,  as  some  have  fancied,  from  an  admixture  of  bile  with  the 
matter  expectorated  :  —  If  to  water,  rendered  viscid  by  dissolving  a  certain  quantity 
of  gum  in  it,  you  add  blood,  drop  by  drop,  you  will  obtain,  in  succession,  all  the 
shades  of  colour  that  are  presented  by  the  pneumonic  sputa:  first  a  yellow  tinge; 
then  a  tawny  yellow  Vv^hich  loses  itself  in  a  red,  and  comes  to  represent  the  colour 
of  the  rust  of  iron ;  and  lastly  an  intense  red.  The  sputa  may  indeed,  sometimes, 
but  I  believe  that  does  not  often  happen,  be  coloured  by  bile;  but  bile  is  not  the 
source  of  the  yellowness  which  they  assume  in  cases  of  pneumonia. 

Sputa  composed  of  very  red  mucus,  indicate  pneumonia  less  sunly  than  such  as 
are  tawny.  The  very  red  masses,  in  which  there  is  more  blood  than  mucus,  often 
belong  to  pulmonary  apoplexy. 

Although  these  rust  or  orange-coloured  sputa  are  commonly  present  during  ihe 
more  active  period  of  pneumonia,  and,  as  far  as  m_v  experience  goes,  are  peculiar  to 
that  disease,  you  ought  to  be  aware  that  they  do  not  constantly  accompany  it.  Some- 
times the  matters  expectorated  are  like  those  of  catarrh :  and  sometimes  there  is 
scarcely  any  expectoration  at  all. 

When  the  pneumonia  passes  into  gangrene  —  which  I  repeat  is  an  exceedingly 


PNEUMONIA.  569 

rare  consequence  of  inflammation  in  that  organ, —  the  expectoration  becomes  of  a 
greenish,  or  reddish,  or  dirty  gray  colour ;  and  exhales  a  fetid  smell,  resembling  that 
which  proceeds  from  gangrene  of  the  external  parts. 

T  have  now  described,  seriatim,  the  main  symptoms,  general  and  physical,  which 
mark  the  existence  and  the  progress  of  pneumonia.  And  in  order  to  give  you  a  just 
notion  of  each,  I  have  spoken  of  them  separately.  But  they  exist  together ;  and 
they  must  be  studied  together :  and  some  will  be  found  to  confirm  or  to  correct  the 
indications  that  might  be  drawn  from  the  others.  I  must  briefly  therefore  run  over 
the  phenomena  of  the  disease  we  have  been  considering,  as  it  actually  presents  itself 
in  most  cases. 

The  first  symptom  felt  is  commonly  pain  in  the  side,  which  may  or  may  not  have 
been  preceded  by  rigors.  At  the  same  time  the  breathing  is  constrained  ;  and  the 
patient  coughs  without  expectorating.  At  this  period,  the  ear  may  generally  detect 
a  slight  degree  of  minute  crepitation,  which  is  not  strong  enough  to  mask  entirely 
the  vesicular  rustle;  and  the  stricken  thorax  still  sounds  well :  and  there  is  fever 
withal.  This  assemblage  of  phenomena  constitutes  the  first  period  of  the  disease. 
From  the  second  to  the  third  day,  new  symptoms  appear.  The  expectoration, 
hitherto  absent,  or  merely  catarrhal,  becomes  characteristic ;  being  at  first  moderately 
viscid,  and  having  a  degree  of  colour  proportioned  to  the  variable  quantity  of  blood 
which  it  contains.  The  minute  crepitation  increases,  and  drowns  or  supersedes  the 
natural  respiratory  murmur :  the  clear  sound  produced  by  percussion  begins  to 
diminish  on  that  side  on  which  the  crackling  is  heard  and  the  pain  is  felt ;  and  that 
pain  is  commonly  less  sharp  than  in  the  beginning.  The  dyspnosa  increases,  as  is 
quite  apparent  from  the  short  and  frequent  inspirations  made  by  the  patient.  If  the 
pain  be  acute,  he  cannot  he,  on  that  account,  on  the  side  affected ;  neither  can  he 
place  himself  on  the  sound  side,  because  in  that  position  his  respiration  becomes 
more  laborious ;  he  remains,  therefore,  almost  constantly,  lying  upon  his  back. 

In  this  condition  of  pneumonia,  though  the  disease  may  be  severe,  the  inflamma- 
tion is  as  yet  in  its  primary  stage.  It  often  remains  stationary  for  a  while,  and  then 
recedes,  and  terminates  by  resolution.  The  dyspncea  diminishes,  the  slight  dullness 
of  sound  disappears,  the  crackling  is  gradually  displaced  by  the  natural  murmur  of 
the  pulmonary  expansion,  the  sputa  again  become  those  of  simple  bronchitis,  the 
fever  subsides,  and  ceases  ;  and  all  is  well  again. 

At  other  times,  instead  of  retrograding  towards  resolution,  the  pneumonia  becomes 
more  intense,  or  rather  more  extensive,  without  passing  beyond  its  primary  stage ; 
and  the  patient  may  die  while  it  is  still  in  that  stage.  But  this  is  unusual.  Ordina- 
rily, if  the  inflammatory  engorgement  does  not  cease  by  resolution,  and  the  symptoms 
that  announce  it  are  exasperated,  we  must  expect  that  the  second  stage  will  be 
established.  And  we  may  be  certain  that  it  exists  when  we  observe  the  following 
phenomena  : — the  breathing  becomes  more  and  more  constrained,  short,  accelerated; 
the  speech  ceases  to  be  free ;  the  patient  can  do  no  more  than  pronounce  a  few  in- 
terrupted words  in  a  panting  manner.  The  sputa  acquire  such  a  degree  of  viscidity, 
that  they  can  no  longer  be  detached  from  the  vessel  by  shaking  it ;  the  sound  afforded 
by  percussion,  on  the  side  affected,  is  decidedly  dull :  at  first  we  still  hear  a  little  of 
the  minute  crepitation,  without  the  admixture  of  any  pure  vesicular  breathing;  then 
that  hltle  crepitation  ceases,  and  either  no  sound  at  all  is  perceived  by  the  ear,  or,  in 
the  part  where  the  percussion  is  dull,  bronchial  respiration  is  heard,  and  this  is 
almost  always  accompanied  with  bronchophony.  The  patient  continues  to  lie  on 
his  back. 

In  this  degree  of  the  disease  the  prognosis  is  always  uncertain.  The  patient  often 
sinks  rapidly,  and  dies  from  apnoea.  Yet  even  in  this  degree  resolution  may  still 
take  place.  In  that  case  the  dullness  on  percussion  diminishes;  the  bronchial 
breathing  disappears;  we  hear  afresh  the  smaU  crepitation,  at  first  alone,  then  mixed 
with  the  natural  respiratory  murmur,  which,  in  its  turn,  becomes  alone  audible.  The 
sputa  return  to  their  catarrhal  character.  In  the  meanwhile  the  dyspnoea  and  fever 
jpdiminish,  and  then  cease  entirely. 

It  would  doubtless  be  very  interesting  to  determine,  in  a  given  case,  whether  the 
lung  of  our  patient  was  in  the  second  or  the  third  stage  of  inflammation.    But  there 

2x2 


S70  PiNEUMONIA. 

are  no  certain  means  for  making  -this  distinction.  We  may  guess  that  the  third 
stage  is  established  if  the  face  becomes  exceedingly  pale  and  corpse-like :  we  may 
be  more  confident  of  it  if  the  prune-juice  expectoration  should  occur;  and  our  pre- 
sumption will  be  strengthened  if  the  disease  has  existed  for  a  certain  time.  How- 
ever, this  last  circumstance  will  not  help  us  7nnch  ;  for  sometimes  the  lung  has  been 
found  to  be  in  a  state  of  suppuration  on  the  fifth  day  of  the  disease,  and  sometimes 
it  has  been  found  in  a  state  of  red  hepatization  after  fifteen  or  twenty  days. 

Whether,  when  the  lung  has  reached  this  third  stage,  it  is  still  susceptible  of 
repair,  is  a  question  which  no  one  can  answer.  We  have  not  the  materials  for 
its  solution,  inasmuch  as  we  have  no  sure  sign  of  the  existence  of  this  third  stage 
during  life.  I  should  think  that  recovery  from  diffused  suppuration  of  the  lung  is 
not  possible.  The  rarer  form  of  circumscribed  abscess  certainly  is  not  of  necessity 
fatal. 

The  duration  of  pneumonia  may  be  laid,  upon  an  average,  at  ten  days.  In  a 
table  collected  by  Andral  for  another  purpose,  viz.,  to  determine  whether  there  were 
any  fixed  critical  days  in  respect  to  the  termination  of  the  disease  (a  cjuesiion  which 
I  shall  not  now  discuss),  the  duration,  in  112  cases,  varied  from  four  days  to  six 
weeks.  But  one  only  was  thus  protracted  ;  23  cases  lasted  each  seven  days ;  and 
only  15  of  the  112  instances  continued  longer  than  a  fortnight. 

I  have  very  little  to  add  to  what  I  have  stated  already  of  the  morbid  anatomy  of 
pneumonia.  Of  the  changes  which  the  lung  itself  undergoes  you  are  now  I  hope 
fully  apprized.  The  pleurisy,  which  often  attends  the  disease,  is  seldom  accom- 
panied by  much  effusion;  indeed,  when  the  whole  of  one  lung  is  sohdified  by  in- 
flammation, it  fills  the  cavity  of  the  pleui-a,  and  prevents  much  effusion.  The  heart 
is  found  to  be  in  that  condition  which  I  formerly  described  to  j'ou,  as  being  both  a 
consequence,  and  an  index,  of  death  by  apnoea.  Its  right  cavities  especially  are  dis- 
tended by  black  coagulated  blood ;  and  a  remarkable  degree  of  venous  congestion  is 
frequently  met  with  in  the  liver,  and  spleen,  and  intestines.  The  amount  of  this 
varies  according  as  the  process  of  dissolution — what  the  French  call  the  agony — has 
been  more  or  less  protracted,  and  the  breathing  more  or  less  difficult. 

Neiiher  need  I  enter  upon  any  formal  discussion  of  the  causes  of  pneumonia. 
Sometimes  no  cause  can  be  traced ;  sometimes  the  disease  is  clearly  the  consequence 
of  exposure  to  cold  ;  especially  under  those  circumstnces  which  were  fonnerly  de- 
scribed as  aiding  the  injurious  operation  of  cold  upon  the  human  body.  Why,  in 
one  person,  such  exposure  causes  peritonitis,  in  another  pleurisy,  and  in  a  third  in- 
flammation of  the  substance  of  the  lungs,  we  can  give  no  satisfactory  account. 

It  remains,  then,  only  that  I  should  speak,  first  of  the  prognosis,  and  secondly  of 
the  treatment,  of  pneumonia ;  and  of  the  first  of  these  matters,  of  the  prognosis,  I 
have  already,  incidentally,  told  you  nearly  all  that  is  made  out,  or  worth  knowing. 
It  is  almost  superfluous  to  say  that  the  first  degree  of  the  disease  is  less  dangerous 
than  the  second,  and  the  second  than  the  third.  There  is  no  doubt  that  pulmonary 
inflammation  may  still  undergo  resolution,  although  a  great  part  of  one  lung  should 
be  hepatized  ;  but  there  are  no  facts  which  prove — indeed  there  is  no  possibility  of 
proving — that  the  lung  may  recover  from  the  state  of  purulent  infiltration — the  third 
degree. 

Something  will  depend  upon  the  extent  of  the  inflammation  ;  I  mean  that  pneu 
monia  in  the  first  degree  and  of  great  extent,  is  generalh'  as  serious  as  pneumonia 
in  the  second  degree  but  much  more  circumscribed.  Inflammation  of  the  upper 
lobes  is  also  more  perilous  than  inflammation,  to  the  same  extent  and  degree,  of  the 
lower. 

Of  the  o-e/?cra/ symptoms,  those  which  we  learn  independently  of  auscultation,  tho 
respiration,  as  a  prognostic  sign,  is  the  most  important.  Considerable  dyspnoea, 
whatever  may  otherwise  be  the  condition  of  the  lung,  is  alwa)'s  a  bad  omen.  We 
get  less  help  from  the  state  of  the  pulse.  If,  however,  a  feeble  pulse  goes  along  with 
great  difficulty  of  breathing,  and  if  it  does  not  develop  itself  after  the  first  bleeding, 
we  must  conclude  that  the  inflammation  is  intense,  and  form  therefore  an  unfav^ourable 
prognosis.  The  supervention  of  delirium  is  also  a  discouraging  circumstance.  You 
will  have  inferred  already  the  information  which  may  be  gleaned  from  the  character 


PNEUMONIA.  •  571 

of  the  expectoration,  in  respect  to  the  probable  issue  of  the  disease.  Great  viscidity 
of  the  sputa,  and  a  deep  rusty  colour,  announce  intensity  of  inflammation:  their 
return  to  the  catarrhal  condition  indicates  that  resolution  is  going-  on.  Watery  and 
brownish  sputa,  more  or  less  like  plum-juice,  should  induce  us  to  suspect  suppura- 
tion of  the  lung,  and  are  therefore  of  bad  augury. 

The  great  instruments  to  be  employed  in  the  trccdment  of  inflammation  of  the 
lungs,  are  the  same  which  have  so  often  been  recommended  by  me,  in  other  inflam- 
matory affections,  before :  blood-letting,  tartarized  antimonj'-,  mercury.  Of  these, 
blood-letting  is  the  chief.  Both  reason  and  experience  attest  the  especial  power  of 
bleeding  upon  acutfe  pneumonia.  In  the  first  place  it  tends  to  restrain  or  extinguish 
the  inflammation  as  inflammation.  But,  in  the  next  place,  it  has  the  effect  of  re- 
lieving the  particular  y»Hc/ion  of  the  lungs.  The  more  blood  is  sent  to  them  in 
excess,  the  more  dyspnoea  must  there  be,  the  more  venous  blood  passing  into  the 
arteries,  as  well  as  the  more  risk  of  the  effusion  of  lymph  and  the  obliteration  of  the 
cellular  texture  of  the  organ.  When  we  bleed,  therefore,  in  pneumonia,  we  kill 
two  birds  (as  a  phrase  is)  with  one  stone.  We  do  that  for  the  lung,  which  we  do 
for  an  inflamed  eye  when  we  darken  the  room,  or  for  an  inflamed  joint  when  we 
keep  it  absolutely  at  rest ;  i.  c,  we  do  all  that  we  can  to  spare  the  exercise  of  the 
organ,  and  to  prevent  aggravation  of  the  inflammation  from  that  cause.  And  the 
result  of  the  free  abstraction  of  blood  in  this  disease,  fully  vindicates  the  value  of  a 
practice  which  has  been  pursued  for  ages.  The  late  Dr.  Gregory,  of  Edinburgh, 
was  in  the  habit  of  saying,  in  his  lectures,  that  provided  he  was  called  early  to  a  case 
of  pneumonia,  he  would  be  contented  to  dispense  with  all  other  aids  than  those  of  a 
lancet,  and  water-gruel.  I  am  far  from  desiring  you  to  believe  that  blood-letting  is 
the  only  expedient  required  ;  but  certainly  the  amount  of  the  best  experience,  ancient 
and  modern,  is  strongly  in  favour  of  its  free,  and  I  might  almost  say,  prodigal,  employ- 
ment. Very  lately,  one  most  distinguished  French  writer,  M.  Louis,  has  endeavoured 
to  show  that  venesection  has  not  much  control  over  the  progress  or  event  of  pneumonia; 
and  I  advert  to  his  opinion  on  this  subject  merely  to  caution  you  against  being  misled 
by  it ;  as  you  might  otherwise  be,  considering  his  well-merited  reputation  as  an  exact 
and  faithful  observer. 

1  can  only  lay  down  general  rules  and  indications  with  respect  to  the  manner  and 
amount  of  blood-letting  in  this  disease,  or  in  any  other  disease.  The  abstraction  of 
blood  will  be  effectual,  cxlerii  paribus,  in  proportion  as  it  is  early  ;  during  the  first 
stage  —  the  stage  of  engorgement  —  and  before  the  spongy  texture  of  the  lung  has 
been  obhterated.  The  patient  should  be  bled  in  an  upright  position,  by  a  large  orifice 
and  in  a  full  stream ;  and  the  bleeding  should  be  continued  until  some  sensible  im- 
pression is  made  upon  the  system:  until  the  pjilse  becomes  softer  ;  or,  if  it  were  con- 
tracted, until  it  becomes  fuller  ;  until  the  sensation  of  constriction  is  abated,  and  the 
dyspnoea  relieved  ;  or  until  syncope  appears  to  be  at  hand. 

Bleeding,  in  this  early  stage,  often  gives  very  speedy  relief,  both  to  the  pain  and 
to  the  dyspnoea.  Sometimes  the  pain  does  not  cease  at  once,  but  goes  off  a  few 
hours  afterwards ;  but  I  believe  that  if  the  breathing  be  not  at  all  relieved  at  first,  the 
case  generally  (though  not  always)  ends  ill.  However,  you  are  not  to  expect  that 
one  blood-letting  will  suffice,  even  when  it  is  performed  early  in  the  disease.  Such 
a  favourable  case  may  happen,  but  not  often.  The  patient  should  always  be  seen 
within  four  or  five  hours  from  the  period  of  the  first  venesection,  that  a  timely  repe- 
tition of  it  may  take  place,  if  the  relief  has  not  been  complete,  or  has  not  been  per- 
manent. Many  fatal  cases  have  probably  been  fatal  from  want  of  this  attention;  from 
too  long  an  interval  having  been  suffered  to  elapse  between  the  bleedings.  A  vein 
may  be  opened,  if  necessary,  two  or  three  times  in  the  twenty-four  hours ;  and 
the  ultimate  loss  of  strength,  and  even  loss  of  blood,  will  be  less  under  such  treatment 
than  if  the  blood-lettings  were  repeated  at  longer  intervals ;  and  the  necessity  of  the 
repetition  must  be  judged  of  from  the  circumstances  of  the  case.  As  an  auxiliary  to 
the  lancet,  I  am  much  in  the  habit  of  taking  blood  from  the  surface  of  the  chest  itself, 
by  means  of  cupping-glasses,  or  of  a  large  number  of  leeches.  I  believe  that  much 
good  is  done  by  this  local  emptying  of  the  blood-vessels.  It  is  particularly  indicated 
if  there  be  pain  ;  and  the  part  to  which  the  leeches  or  cupping-glasses  are  applied 


572  PxNEUMONIA. 

should  be  determined  by  the  situation  of  the  inflamed  portion  of  lung,  when  that 
is  ascertained  bj'  the  ear.  I  scarcely  need  say  that  the  Avhole  of  the  antiphlogistic 
regimen  must  be  rigidly  enforced ;  that  the  patient  must  keep  his  bed  ;  and  that  all 
superfluous  exertion  of  his  lungs  in  speaking  must  be  forbidden. 

When  the  inflammation  has  advanced  into  the  second  stage,  we  cannot  expect  that 
the  removal  of  blood  will  have  so  decided  an  influence  upon  the  inflamed  and  solia 
parts;  but  even  then,  if  duly  moderated,  it  will  have  these  good  consequences:  it 
will  diminish  the  force  of  the  heart  and  arteries,  and  so  tend  to  prevent  the  exten- 
sion of  the  inflammatory  process ;  it  will  lessen  the  whole  quantity  of  blood  circu- 
lating through  those  portions  of  the  lung  which  are  still  pervious,  and  thus  reheve 
dyspncea ;  and  it  will  put  the  system  at  large  into  the  condition  most  favourable  for 
the  reabsorption  of  the  lymph  by  which  the  air-tubes  and  vesicles  of  the  afl^ected 
parts  have  been  blocked  up. 

But  a  time  arrives  when  bleeding  is  no  longer  of  use,  or  when  it  is  positively 
hurtful ;  when  it  ceases  to  have  any  good  influence  on  the  local  disease,  and  has  aa 
injurious  influence  on  the  whole  system  :  reducing  the  patient's  strength,  and  inca- 
pacitating him  for  bringing  up,  and  ridding  his  lungs  of,  the  tenacious  mucus 
exhaled  by  the  bronchial  membrane.  This  is  what  takes  place  in  those  cases  in 
which  the  expectoration  is  said  to  be  stopped  by  a  bleeding.  I  have  mentioned  Dr. 
Gregory's  reliance  on  blood-letting  for  the  cure  of  pneumonia ;  and  I  ought  to  tell 
vou  at  the  same  time  Avhat  I  have  been  informed  respecting  the  result  of  his  prac- 
tice. He  "  used  to  bleed  to  the  verge  of  convulsion.  His  colleague,  Dr.  Rutherford, 
seldom  went  beyond  three  bleedings,  and  generally  accomphshed  his  object  by  two, 
judiciously  timed  and  measured.  His  patients  recovered  quickly;  Dr.  Gregory's 
very  slowly." 

We  want  some  remedy,  therefore,  to  assist  the  lancet,  or  to  employ  a'one  when 
the  lancet  can  do  no  more ;  and  we  have  two  such,  in  tartarized  antimony,  and  in 
mercury.  The  tartar  emetic  plan  I  believe  to  be  the  best  adapted  to  the  first  degree 
of  the  inflammation — that  of  engorgement ;  and  the  mercurial  plan  to  the  second — 
to  that  of  hepatization. 

I  need  not  tell  you  that  the  tartarized  antimony  is  not  given  in  this  disorder  with 
the  object  of  producing  vomiting..  It  is  a  very  curious  thing  that  although,  when 
administered  in  a  considerable  dose,  its  first  effect  is  usually  sickness,  followed,  per- 
haps, b}^  purging,  a  repetition  of  the  same  dose  is,  in  the  majority  of  cases,  at  length 
borne  without  any  further  vomiting.  The  stomach  comes  to  tolerate  the  medicine 
as  our  continental  brethren  say ;  and  then  its  beneficial  influence  upon  the  disease 
is  no  less  marked  than  when  nausea  and  retching  take  place.  Some  patients  do  not 
vomit  at  all;  others,  the  majority  in  fact,  vomit  two  or  three  times,  and  then  tolerance 
is  estabhshed.  If  the  sickness  and  purging  go  on,  they  may  be  checked  by  adding 
a  few  drops  of  laudanum  to  each  dose.  Dr.  Thomas  Davies,  who  had  tried  this 
remedy  largely,  and,  as  he  tells  us,  with  great  success,  gives  the  following  as  his 
own  plan  of  administering  it,  and  perhaps  it  is  as  good  as  any.  After  free  bleeding, 
he  begins  with  one-third  of  a  grain  of  tartar  emetic  in  half  a  wineglassful  of  water, 
with  a  few  drops  of  laudanum  or  syrup  of  poppies.  Two  doses  of  this  strength 
he  gives  at  the  interval  of  one  hour  from  each  other.  He  then,  if  the  patient  does 
not  vomit,  omits  the  opium,  but  continues  it  if  he  does,  doubling,  however,  the  quantity 
of  the  tartar  emetic,  giving  two-thirds  of  a  grain  for  two  successive  hours ;  and  in 
this  way  he  goes  on,  adding  a  third  of  a  grain  every  two  hours,  until  he  reaches  two 
grains  every  hour.  This  last  quantity  he  has  not  exceeded,  and  he  says  that  he  has 
continued  it  for  many  days  without  producing  any  injurious  consequences. 

Under  this  plan  of  treatment  the  symptoms  will  often  undergo  a  marked  change 
tor  the  better,  in  three  or  four  hours.  Sometimes,  however,  the  relief  is  not  con- 
spicuous for  twenty-four  or  even  for  thirty-six  hours.  He  states,  and  this  is  accordant 
tvith  my  own  experience  of  the  remedy,  that  the  tartar  emetic  always  acts  best  when 
it  produces  no  effect  except  upon  the  inflammation  itself;  i.  e.,  when  it  does  not 
cause  vomiting,  or  purging,  or  a  general  depression  of  the  powers  of  the  system. 
This  is  an  important  practical  remark,  because  many  persons  have  supposed  that  it 
B'ibdues  the  disease  only  when  it  previously  gives  rise  to  these  symptoms.     I  con- 


PNEUMONIA.  573 

sider  this  testimony  of  Dr.  Da  vies  to  the  power  of  the  tartarized  antimony  in  con- 
trolling inflammation  of  the  lungs  the  more  valuable,  because  he  informs  us,  that 
before  he  had  occasion  to  see  its  admirable  effects  in  the  first  stage  of  pneumonia,  he 
had  been  in  the  habit  of  trusting  to  the  free  use  of  mercury,  after  due  depletion. 

When  dyspnoea  has  been  put  an  end  to  by  antimony  thus  exhibited,  the  medicine 
may  be  intermitted  ;  and  if  the  inflammation  shows  any  disposition  to  rekindle,  it 
must  be  again  extinguished  by  a  repetition  of  the  tartar  emetic. 

When,  however,  the  inflammation  has  reached  the  second  stage,  that  of  solidifica- 
tion, mercury  is  more  worthy  of  confidence,  in  my  opinion,  than  tartarized  antimony. 
And  I  have  little  or  nothing  to  add  to  what  I  formerly  said  in  respect  to  the  mode  in 
which  it  ought  to  be  administered.  The  object  of  giving  it  is  to  make  the  gums 
tender;  and  it  is  expedient  to  do  this  as  speedily  as  may  be.  Small  doses  of  calomel 
repeated  at  short  intervals — a  grain  every  hour,  or  two  grains  every  two  hours,  or 
three  grains  every  three  hours — combined  with  so  much  of  laudanum  or  ot  opium 
as  may  be  requisite  to  prevent  it  from  running  off  by  the  bowels — offer  the  most 
certain  way  of  accomplishing  our  object.  If  the  bowels  are  irritable  under  the  calo- 
mel, blue-pill,  or  the  hydrargyrum  cum  creta,  may  be  substituted  for  it  with  advan- 
tage :  and  if  the  internal  use  of  mercury  is  any  how  contra-indicated,  or  if  it  appears 
slow  in  occasioning  its  specific  effect,,  the  linimentum  hydrargyri  may  be  rubbed  in, 
or  the  strong  mercurial  ointment. 

Many  persons,  I  am  persuaded,  are  saved  by  treatment  of  this  kind,  pushed  to 
slight  ptyalism  :  the  effusion  of  lymph,  tending  to  spoil  the  texture  of  the  lung,  is 
arrested ;  and  the  lymph  already  effused  begins  to  be  again  absorbed :  and  the  ease 
and  comfort  of  the  patient,  as  well  as  the  alteration  for  the  better  of  the  physical 
signs,  attest  the  healing  qualities  of  the  remedy. 

After  the  inflamed  lun'g  has  become  solid  and  impermeable,  the  treatment  must 
be  regulated  rather  by  the  state  of  the  system  at  large,  than  by  the  actual  or  pre- 
sumed condition  of  the  lung :  we  must  look  more  for  guidance  to  the  general  symp- 
toms than  to  the  physical  signs.  If  the  pulse  continues  steady  and  firm,  wait  pa- 
tiently the  effect  of  the  mercury.  But  when  sunken  features,  a  pallid  face,  coldness 
of  the  surface  or  extremities,  a  tendency  to  delirium,  and  (above  all)  a  feeble  or 
irregular  pulse,  proclaim  that  the  vital  powers  are  giving  way,  it  will  be  requisite, 
as  in  other  cases  where  death  is  threatened  by  Asthenia,  to  administer  cordial  and 
stimulant  medicines ;  the  carbonate  of  "ammonia  in  a  decoction  of  seneka ;  wine  : 
and  to  feed  the  patient  well  on  milk,  or  beef-tea. 

Among  what  may  be  called  the  routine  remedies  of  pneumonia,  we  must  rank 
counter-irritation  by  means  of  blisters.  When  one  is  called,  in  consultation,  to  see  a 
patient  labouring  under  inflammation  of  the  lungs,  Ave  may  safely  speculate  upon  the 
conclusion,  that  bleeding  and  blistering,  and  purging  by  calomel,  have  all  been  duly 
performed.  And  I  beheve  that  blisters  are  often  apphed  to  the  chest  much  too  early 
in  such  cases.  In  the  outset,  while  there  is  yet  considerable  fever  present,  they  add 
to  the  irritation,  and  distress  the  patient ;  and  probably  tend  to  aggravate  the  existing 
inflammation.  They  are  also  attended  with  this  inconvenience,  that  they  interfere 
with  the  exploration  of  the  lungs  by  the  ear:  and  this  is  not  a  slight  or  fanciful  dis- 
advantage ;  for  the  information  we  receive,  by  the  sense  of  hearing,  of  the  state  of 
the  lung — whether  the  inflammation  be  making  progress,  or  receding,  or  stationary 
— is  of  great  use  in  directing  the  remedial  management  of  the  case.  But  of  course 
ihis  is  a  consideration  not  to  be  put  in  competition  with  the  benefit  which  may  be 
expected  sometimes  from  a  blister.  When  the  fever  is  no  longer  high,  and  the  skin 
no  longer  burning,  but  the  expectoration  is  still  difficult,  the  dyspnoea  considerable, 
and  a  sensation  of  pain,  or  tightness,  or  oppression,  is  experienced  in  the  chest,  then 
a  large  blister  is  often  productive  of  very  sensible  benefit ;  but  it  should  be  a  large 
one.  The  patient  should  have  a  waistcoat  almost,  or  at  any  rate  a  breast-plate,  of 
blistering-plaster.  1  have  never  seen  such  good  effects  from  placing  blisters  upon 
distant  parts  in  this  disease,  upon  the  thighs  or  arms  for  instance,  as  would  lead  me 
to  plague  the  patient  with  them  in  those  situations. 

Purgatives  are  of  less  certain  value  in  pneumonia  than  in  many  other  mflamma- 
tory  diseases ;  and  less,  especially,  than  in  cerebral  inflammation.    Still,  it  will  ahvay* 


574  PNEUMONIA. 

be  right  to  give  an  active  aperient  at  the  outset,  and  afterwards  to  take  care  that  the 
bowels  be  unloaded  at  least  once  every  day.  A  continued  drain  by  purgation  would 
not  consist  at  all  with  the  mercurial  plan,  which  promises  to  be  most  useful  when  the 
inflammation  has  already  reached  the  stage  of  hepatization. 

^J'his,  then,  is  the  outline  of  the  treatment  which  is  most  likely  to  save  the  life 
of  those  who  are  afiected  with  acute  idiopathic  pneumonia.  Different  cases  will 
require  different  modifications  of  it ;  for  which,  I  repeat,  no  particular  rules  can  bo 
laid  down. 

All  that  I  have  hitherto  been  saying  relates  to  acute  pneumonia,  occurring  in  a 
previously  healthy  person.  But  pneumonia  having  that  character,  and  so  occurring, 
is  a  much  less  common  disorder  than  most  persons  appear  to  suppose,  or  than  I  for- 
merly thought  it  to  be.  I  have  been  surprised  to  find  how  few  cases  of  pure  idiopa- 
thic inflammation  of  the  lungs  present  themselves  among  my  hospital  patients.  Five 
or  six  in  the  year  are  as  many  as  I  see  there.  Intercurrent  pneumonia,  however — 
pneumonia  engrafted  upon  some  other^re-existing  disease — is  abundantly  frequent ; 
and  requires,  in  general,  a  much  less  vigorous  and  more  wary  plan  of  treatment. 
Inflammation  of  the  puhnonary  substance  is  apt  to  supervene  insidiously  upon  various 
disorders  which  are  of  every-day  occurrence:  upon  bronchitis,  upon  phthisis,  upon 
disease  of  the  heart,  and  upon  fevers,  especially  the  exanthematous  fevers.  In  these 
cases,  while  the  physical  signs  are  necessarily  the  same  as  in  the  unmixed  acute  dis- 
ease, the  general  symptoms  are  often  but  slightly  pronounced.  During  the  progress 
of  continued  fever  of  a  low  type,  inflammation  may  steal  upon  the  lung,  and  run 
quickly  through  all  its  stages,  and  spoil  the  organ  irrecoverably,  without  giving  any 
notice  of  its  presence ;  unless,  indeed,  you  suspect,  and  search  for  it  with  your  ear 
The  pneumonia  is  said,  in  such  cases,  to  be  latent.  It  seldom  needs,  the  associated 
disorder  would  seldom  bear,  any  active  depletion.  Much  benefit  often  follows  the 
abstraction  of  small  quantities  of  blood  ;  but  they  should  be  taken  from  the  surface 
of  the  chest  by  the  cupping-glass,  and  not  by  the  lancet  from  the  arm  ;  and  it  is  often 
good  practice  thus  to  aim  at  reducing  the  local  mischief  with  one  hand,  while  with 
the  other  we  support  the  patient's  strength  by  means  of  ammonia,  wine,  and  nour- 
ishing broths.  Bhsters  are  also  of  service  ;  more  so  than  in  the  sthenic  forms  of  pure 
pneumonia;  and  they  may  be  apphed  at  an  earlier  period.  In  conjunction  with 
ihese  remedies,  I  should  advise  the  cautious  employment  of  mercury. 

When  the  convalescence  from  acute  pneumonia  is  decided  and  real,  it  is  shorter 
-than  might  have  been  supposed.  From  the  period  when  the  pulmonary  inflamma- 
tion is  fairly  over,  the  strength  returns  with  unexpected  facility,  even  when  large 
bleedings  have  been  practised  and  repeated.  But  we  have  to  guard,  more  perhaps 
in  this  disease  than  in  most  others,  against  false  or  merely  apparent  convalescences. 
A  patient  can  never  be  pronounced  perfectly  secure  so  long  as  any  trace  of  crepita- 
tion remains  in  the  aff*ected  lung ;  and  this  may  often  continue  long :  nay,  it  not 
unfrequently  ceases  only  upon  the  supervention  of  another  more  surely  fatal,  though 
less  rapid  disorder,  viz. :  tubercular  consumption ;  of  which,  however,  I  must  treat 
as  a  distinct  disease. 

[PxEUMOXiA  IS  Childrex.  —  Pneumonia  is  a  very  frequent  disease  of  childhood  ;  and 
as  It  is  then  marked  by  some  very  important  mouifications  in  its  general  characters  and 
results,  it  demands  a  separate  consideration. 

The  inflammation  may  be  confined  to  the  minute  lobules  of  the  lung,  or  it  may  attack  the 
pulmonary  lobes.  The  first  constituting  lobular,  and  the  second  lobar  pneumonia.  In  both 
forms  of  the  disease  the  inflammation  may  be  confined  to  a  small  portion  of  one  lung,  oi 
extend  to  nearly  the  whole  of  one  or  both. 

In  very  young  children  the  symptoms  of  pneumonia,  particularly  at  the  commencement 
of  tlie  attack,  are  very  obscure,  and  even  when  more  distinctly  marked,  they  differ  but  lit- 
tle from  those  of  bronchitis. 

In  infants  the  attack  is  very  generally  preceded  by  symptoms  of  a  mild  bronchitis,  to 
wnich  there  usually  succeeds  a  chill,  differing  in  its  severity  and  duration  in  different  cases ; 
this  is  followed  uy  increased  heat  and  dryness  of  the  surface,  increased  frequency  of  pul?e, 
accelerated  respiration,  dyspnoea,  and  a  short  dry  cough.  These  symptoms  quickly  augment 
in  intensity — the  lips  become  of  a  bright  red,  the  tongue  of  a  florid  hue,  and  somewhat  dry, 
»nd  coated  along  its  centre  with  a  thick  white  fur.  Often  there  is  from  the  commencement 
of  the  attack  vomiting,  and,  in  young  children,  diarrhoea.     In  many  cases  there  is  considera- 


PNEUMONIA.  575 

ble  agitation  and  anxiety,  in  others  decided  drowsiness,  and  more  rarely  con-v-.;.sions ;  these 
fcre  scraetimes  violent  and  repeated,  and  often  followed  by  an  entire  loss  of  consciousness. 
Convulsions,  according  to  the  observations  of  Rilliet  and  Barthez,  are  confined  to  cases  occur- 
ring in  young  infants,  where  the  inflammation  is  seated  at  the  summit  of  the  lungs. 

In  infants  at  the  breast,  in  the  early  period  of  the  attack,  the  breathing  is  no  longer  affected 
solely  through  the  nose,  but  the  little  patient  lies  with  the  mouth  partly  open,  and  drawing 
in  the  air  through  it.  The  tongue  becomes  in  consequence  preternaturally  dry,  and  the  cliild 
sucks  by  starts — seizing  the  nipple  with  eagerness,  sucking  for  a  few  moments  with  greedi- 
ness, and  then  suddenly  dropping  the  nipple,  and  in  most  instances  commencing  to  cry  or 
moan. 

The  inspiration  in  children  affected  with  pneumonia  is  marked  by  a  peculiar  abruptness, 
occurring  suddenly  before  expiration  is  completed,  and  with  a  more  or  less  dilatation  of  the 
nostrils. 

The  frequency  of  the  respiration  is  not  always  in  proportion  to  the  violence  of  the  attack, 
and  does  not  always  increase  with  the  progress  of  the  disease.  When  pneumonia  occurs  in 
the  course  of  chronic  enteritis,  there  is  often  either  a  very  slight  or  no  acceleration  of  respira- 
tion ;  it  rnaj',  also,  be  masked  by  an  accompanying  atlection  of  the  abdominal  organs  or  of 
the  brain.  In  cases  of  broncho-pneumonia,  the  dyspncea  is  often  so  intense  as  to  threaten 
Euflbcation.  The  dyspncea  is  always  proportionate  to  the  violence  and  extent  of  the  pulmo- 
nary inflammation,  and  augments  with  the  progress  of  the  disease.  It  is  often  attended  with 
great  anxiety,  and  a  sense  of  impending  suflbcation  which  renders  a  recumbent  posture 
insupportable. 

The  cough  is  at  first  frequent,  short,  dry,  and  painful,  but  soon  becomes  moist;  when  ex- 
pectoration occurs,  which  is  seldom  the  case  in  young  children,  it  is,  at  first,  slight,  and  con- 
sists of  a  whitish,  viscid  mucus,  which  becomes  subsequently  reddish.  It  is  rarely,  however, 
rust  coloured.  As  the  cough  becomes  more  moist,  it  gradually  declines  in  violence  until 
towards  the  eighth  or  ninth  day,  when  it  rapidly  diminishes,  and  finally  disappears.  When, 
however,  the  pneumonia  becomes  more  difl'used,  or  occiirs  in  the  course  of  some  acute  aflec- 
tion,  and  in  children  not  much  debilitated,  the  cough  is  very  frequent  and  intense,  and  is 
rarely  attended  with  a  free  expectoration.  The  attacks  of  pneumonia  that  so  frequently 
occur  in  the  course  of  chronic  enteritis,  are  seldom  attended  with  much  cough — occasionally, 
indeed,  it  is  entirely  absent.  There  is  seldom  any  very  decided  pain  of  the  chest  —  when 
present,  it  is  generally  acute,  though  occasionally  dull,  and  is  usually  experienced  at  the  ante 
rior  margin  of  the  axilla — it  is  a/jgmented  by  the  cough,  and  often  disappears  long  before  the 
Other  symptoms. 

The  disease  in  these  cases  is  so  often  destitute  of  leading  symptoms,  that  its  existence 
might  be  overlooked,  were  it  not  for  the  physical  signs  revealed  by  auscultation — the  skin  is 
pale  and  cool,  the  pulse  small,  and  the  face  and  extremities  cedematous. 

In  young  children,  or  those  under  six  years  of  age,  pneumonia  is  frequently  preceded  by 
extensive  bronchial  inflammation.  The  inflammation  of  the  lungs,  which  is  probably  pro- 
duced by  the  extension  of  the  inflammation  from  the  extreme  branches  of  the  bronchi  to  the 
preliminary  tissue,  often  comes  on  so  gradually,  that  it  is  impossible  to  fix  in  most  cases  the 
exact  date  of  its  occurrence.  Occasionally,  at  the  period  the  pneumonia  supervenes,  there 
is  a  well-marked  accession  of  fever  and  dyspncEa,  and  an  aggravation  of  all  the  symptoms. 
The  febrile  symptoms  are  less  than  in  the  other  forms  of  the  disease,  but  the  dyspnea  and 
distress  are  usually  greater,  and  the  face  presents  from  the  first  a  more  livid  hue.  The 
cough  is  less  hard,  but  often  occurs  in  paroxysms  which  greatly  distress  the  patient;  th« 
respiration  is  more  hurried  and  irregular ;  the  irregularity  coming  on  at  an  earlier  period. 
Head  symptoms  are  more  frequent,  the  patient's  rest  is  disturb?d,  and  he  often  mutters  in  his 
sleep,  and  has  far  more  restlessness  and  jactitation  when  awake.  Convulsions  and  coma 
more  frequently  precede  death,  which  occurs  at  an  earlier  period  than  in  the  other  forms 
of  pneumonia. 

Pneumonia  in  children  is  generally  attended  with  loss  of  appetite  and  increased  thirst, 
and  a  torpid  state  of  the  bowels ;  when  the  disease,  however,  is  complicated  with  enteritis, 
profuse  diarrhoea  may  be  present  throughout  the  attack.  In  these  cases  furunculi  or  ecchy- 
moses  occasionally  cover  the  skin,  while  the  blistered  surfaces  are  liable  to  become  ulcerated. 

In  favourable  cases  of  primitive  bronchitis,  the  acceleration  of  pulse  and  respiration  attain 
their  greatest  intensity  generally  by  the  end  of  the  fourth,  fifdi,  or  seventh  day,  o:,  at 
the  farthest,  by  the  ninth  day:  when  the  heat  of  the  skin  and  the  frequency  of  the  pulse 
diminish,  respiration  becomes  slower,  and  the  inspiratory  movement  is  unattended  with  dila- 
tation of  tlie  nostrils.  The  cough  becomes  more  free  and  moist,  the  fever  quickly  disap- 
pears, the  face  becomes  paler,  and  the  expression  of  the  countenance  more  natural.  The 
respiration  finally  assumes  its  normal  rhythm,  the  cough  rapidly  diminishes,  and  in  a  few 
days  convalescence  is  fully  established. 

In  the  more  severe  and  unfavourable  cases,  there  is  intense  dyspnoea  from  the  very  com- 
mencement of  the  attack — intense  anxiety,  a  pallid  hue  of  the  face,  with  a  violet  tinge  of  tli« 
lips  and  summits  of  the  cheeks,  an  extremely  small,  rapid  pulse,  and  a   frequent,  short. 


576  PNEUMONIA. 

dry,  painful  cough.  The  general  symptoms  continue  to  augment  in  violence,  and  death  may 
occur  on  the  third  or  fourth  day.  In  other  cases,  the  symptoms,  from  the  beginning  of  the 
attar k,  are  less  intense,  and  do  not  increase  in  severity  after  the  fifth  or  sixth  day,  but  remain, 
as  it  were,  perfectly  stationary.  Soon,  however,  in  addition  to  the  cough  and  dyspnoea,  there 
occur  pallor  of  the  face,  great  emaciation,  and  constant  diarrhoea ;  and,  at  the  termination  of 
from  three  to  four  weeks,  the  patient,  being  reduced  to  a  state  of  the  utmost  debility,  expires. 
In  other  cases,  again,  after  all  the  prominent  symptoms  have  declined,  and  a  speedy  conva- 
lescence is  anticipated,  from  some  accidental  cause,  the  inflammatory  action  is  re-excited  in 
the  lungs,  the  dyspnoea,  cough,  acceleration  of  the  pulse,  and  fever,  return  with  increased 
violence,  and  deatli  speedily  ensues.  The  fatal  termination  may  also  be  hastened  by  the 
occurrence  of  pleurisy,  measles,  gangrene  of  the  mouth,  &c. 

Acute  pneumonia,  occurring  in  the  course  of  some  other  acute  disease,  is  generally  of  rapid 
progress,  and  terminates  either  in  health  or  fatally,  within  a  few  days. 

The  physical  signs  of  pneumonia,  occurring  in  children,  are  of  primary  importance.  By 
them  alone,  in  many  cases,  can  a  correct  diagnosis  be  established — while  it  is  only  by  them, 
also,  that  the  extent  and  progress  of  the  local  disease  can  be  determined. 

In  simple  primitive  pneumonia  of  children,  if  of  the  lobar  form,  there  are  present,  from 
the  very  commencement  of  the  attack,  crepitant  ronchi;  and  often  bronchial  respiration  on 
one  side  the  thorax  towards  its  base.  The  crepitus  is  generally  larger  than  in  adults.  If 
for  a  short  time  it  cannot  be  heard,  it  may  be  generally  reproduced  by  causing  the  child  to 
cough,  when  it  is  again  to  be  distinguished,  in  the  strong  inspiration  which  .-;.oceeds  the 
cough,  the  sound  resembling  the  cracking  of  a  whip. 

In  the  lobular  form  of  pneumonia,  the  subcrepitant  ronchi  are  more  generally  diffused, 
while  the  bronchial  respiration  is  seldom  heard.  The  extent  of  the  latter  increases  with  the 
progress  of  the  inflammation,  while  the  ronchi  decrease.  When  the  acceleration  of  the 
respiration  and  pulse  has  attained  its  maximum,  the  bionchial  breathing  is  very  audible,  and 
is  accompanied  with  bronchophony,  or  with  a  resonance  of  the  voice  and  extensive  dulness 
of  the  chest.  As  the  general  symptoms  decline,  and  the  cough  becomes  more  moist,  the 
subcrepitant  ronchi  are  very  abundant,  antl  the  resonance  of  the  voice  extends  over  a  greater 
space  ;  the  bronchial  breathing  continues,  but  the  dulness  of  the  chest  diminishes.  Even  after 
convalescence  is  established,  a  slight  prolongation,  as  well  as  a  different  resonance  of  the 
voice,  is  still  perceptible.  The  respiration  continues  feeble  for  several  days,  and  only  slowly 
recovers  its  proper  vesicular  tones. 

In  more  violent  cases,  humid  ronchi  are  heard  throughout  the  chest,  intermixed  with  others 
of  a  drier  character,  or  with  bronchial  expiration  and  a  diflused  resonance  of  the  voice. 
Bronchial  breathing  is  ahvays  a  very  grave  sign.  In  eleven  out  of  twenty  cases  in  which 
it  was  detected  by  Dr.  West  of  London,  the  disease  had  a  fatal  termination. 

The  mucous  ronchus  is  heard  in  most  cases  of  broncho-pneumonia  in  children,  and  in 
cases  of  lobar  pneumonia,  in  the  neighbourhood  of  the  subcrepitant  ronchus, and  occasionally 
wheru  distinct  bronchial  respiration  exists.  It  often  persists  for  a  long  time  after  every  other 
sign  of  disease  has  disappeared. 

In  the  lobular  pneumonia  of  young  children,  the  physical  signs  are  at  first  limited  to  the 
mucous  and  subcrepitant  ronchi,  dependent  upon  the  increased  secretion  of  mucus  in  the 
bronchi.  The  subcrepitant  ronchi  are  frequently  continued  throughout  the  attack,  being  often 
the  only  stethoscopic  signs  present.  They  are  rarely  replaced  by  the  fine  crepitant  ronchi,  as 
in  the  pneumonia  of  adults.  Bronchial  respiration  becomes  developed  when  induration  has 
extended  to  a  considerable  portion  of  the  texture  of  the  lungs.  It  is  chiefly  heard  at  the 
upper  and  middle  portions  of  their  posterior  parts — it  is  rarely  heard  in  the  lower  lobe,  from 
the  comparative  smallness  of  the  bronchi,  and  their  early  obliteration  by  the  progress  of  tlie 
inflammation.  The  respiratory  sounds  are  very  peculiar — the  inspiratory  murmur,  in  place 
of  being  full  and  expansive,  as  in  a  healthy  chikl,  is  short,  obscure,  and  almost  without  the 
vesicular  murmur,  and  may  or  may  not  be  accompanied  with  the  mucous  or  subcrepitant 
ronchus;  the  expiration  is  rarely  distinct,  unless  the  bronchial  respiration  is  fully  developed, 
when  it  is  usually  louder  than  the  inspiration.  The  sounds  indicative  of  inflammation  of 
tlie  texture  of  the  lung  are  often  entirely  obscured  by  the  mucous  ronchi  of  bronchitis. 

The  anatomical  lesions  in  the  pneumonia  of  children  differ  very  materially,  according  as 
the  inflammation  is  lobular  or  lobar,  and  according  to  the  period  of  the  disease  when  death 
takes  place. 

In  lobular  pneumonia  the  lung  is  usually  soft  and  flaccid,  of  a  mottled  appearance  exter- 
nally; patches  of  a  deep  red  or  violet  colour,  generally  distinctly  circumscribed,  of  a  circular  or 
ovai  form,  hard  to  the  touch,  and  slightly  projecting,  being  interspersed  in  the  midst  of  the 
natural  grayish  red  tint.  They  are  commonly  situated  at  the  inferior  edge  of  the  lung,  bii4 
may  occupy  other  portions  of  its  surface.  The  part  occupied  by  these  patches  does  not  col- 
lapse upon  the  chest  being  opened. 

lu  some  cases  this  marbled  appearance  of  the  lung  is  absent;  but  spots  of  induration,  more 
01  less  deeply  seated,  may  be  detected  by  the  fingers,  giving  to  the  lung  an  uneven  or  knotted 
i"eel. 


PNEUMONIA.  577 

The  same  marbled  appearance  is  presented  by  a  section  of  the  lung.  The  dark  patches 
aie  more  or  less  accurately  circumscrilicd  in  the  first  stage  of  the  disease;  they  are  firmer 
than  the  surrounding  tissue,  swim  when  thrown  into  water,  crepitate  beneath  the  finger,  and. 
however  carefully  separated  from  the  sound  portion  of  the  lung,  yield  upon  pressure  a  red- 
dish fluid  intimately  mixed  with  air.  In  the  second  stage  the  dark  patches  form  nodules  of 
a  firmer  and  more  compact  consistence.  Tlieir  cut  surface  is  smooth,  and  when  carefully 
detached  from  the  surrounding  parts,  they  crepitate  none  or  but  slightly,  and  sink  rapidly 
when  thrown  into  water.  When  the  central  portion  alone  of  the  nodule  is  subjected  to 
pressure,- a  red  sanious  fluid  escapes  without  any  admixture  of  air.  It  is  seldom  that  single 
lobules  are  found  affected,  the  induration  usually  comprising  four  or  five,  forming  a  mass  of 
the  size  of  an  almond.  If  the  patient  lives  for  some  time,  the  intervening  substance  usually 
becomes  affected,  and  the  lobular  is  converted  into  lobar  pneumonia,  and  the  inflammation 
runs  its  course,  as  in  the  ordinary  cases  of  this  latter  form  of  the  disease. 

In  the  third  stage  of  the  disease,  the  section  of  the  lung  presents  a  grayish  colour,  inclining 
more  or  less  to  yellow  in  diflerent  cases.  The  pulmonary  tissue  is  friable,  and  when  pressed 
gives  discharge  to  a  purulent  fluid,  its  texture  being  infiltrated  with  pus.  Upon  minute 
examination,  some  of  the  lobides  will  be  found  more  projecting  than  others,  their  vesicles 
not  being  compressed,  as  in  the  less  projecting  parts. 

According  to  Barthez  and  Rilliet,  there  are  two  forms  of  lobular  pneumonia.  In  the  first, 
which  they  denominate  tlie  mammelonated,  is  marked  by  nodules  of  hepatization,  comprising 
one  or  more  lobules,  differing  but  little  in  colour  and  appearance  from  the  surrounding  tissue. 
Their  limits  are  well  defined,  even  when  the  neighbouring  tissue  is  engorged.  They  are 
frequently  surrounded  by  a  layer,  of  about  half  a  line  in  thickness,  white,  firm,  and  of  a 
fibrous  appearance.  The  hepatized  portions  slightly  project  above  the  surface  of  the  incised 
lung,  from  the  collaiise  of  the  surrounding  air-cells.  They  vary  in  size  from  that  of  a  hemp- 
seed  to  that  of  a  pigeon's  egg.  They  are  of  a  spheroidal  form,  and  have  usually  a  regular 
surface.  But  a  single  nodule  may  exist  in  one  lung,'or  there  may  be  from  twenty  to  thirty 
or  more.  They  are  almost  invariably  surrounded  by  a  circle  of  pulmonary  tissue  in  a  state 
of  engorgement.  The  diseased  portions  generally  attain  the  third  stage  of  pneumonic  hepa- 
tization, which  terminates  in  the  formation  of  an  abscess. 

In  the  same  lung  there  may  exist  nodules  of  hepatization  in  the  first  and  second  stages, 
and  also  rounded  masses  of  a  straw  colour,  very  humid  when  cut  into.  At  a  more  advanced 
stage,  the  pus,  which  is  at  first  deposited  in  the  interstices  of  the  pulmonary  tissue,  becomes 
collected  in  the  centre  of  the  nodules.  This  minute  collection  of  pus  is  surrounded  by  two 
concentric  zones,  the  internal  one  yellow  —  hepatization  of  the  third  degree;  —  the  external 
one  red  —  hepatization  of  the  second  degree.  At  a  later  period,  the  size  of  the  abscess  is 
increased  at  the  expense  of  the  inner  zone,  the  outer  zone  at  the  same  time  passing  into  sup- 
puration. At  a  still  later  period,  an  incision  through  the  diseased  portion  of  the  lung  reveals 
cavities  varying  in  size  from  a  few  lines  to  four  or  five.  These  cavities  are  in  general  round, 
more  rarely  oval,  and  contain  usually  a  thick  tenacious  yellow  or  greenish  pus,  perfectly  free 
from  any  admixture  of  air.  Sometimes  small  coagula  of  blood  are  mixed  with  the  pus 
These  cavities  are  at  first  formed  by  a  layer  of  hepatization,  lined  with  a  layer  of  concrete 
pus,  or  with  a  false  membrane,  yellow,  soft,  and  easily  detached.  Subsequently,  this  mem- 
brane becomes  changed  into  a  thin,  smooth,  polished  tissue,  analogous  to  a  serous  membrane. 
The  abscesses  sometimes  communicate  freely  with  each  other,  and  at  the  point  where  the 
bronchi  penetrate  their  cavity,  its  mucous  menrbrane  presents  a  true  solution  of  continuity. 
When  the  inflammation  invades  separately  several  neighbouring  lobules,  the  cavity  of  the 
abscess  is  multilocular,  each  cell  being  isolated  by  a  lamina  of  the  hepatized  tissue,  upon 
the  rupture  of  which  the  different  abscesses  communicate  with  each  other.  These  abscesses 
have  usually  a  tendency  to  approach  the  surface  of  the  lung.  An  adhesion  often  takes  place 
between  the  opposing  surfaces  of  the  pleura,  or  the  pleura  of  the  lungs  becomes  gradually 
thinned  and  finally  perforated,  giving  rise  to  a  true  pneumo-thorax.  It  has  hai)pened,  that 
an  adhesion  has  formed  between  the  lung  and  diaphragm,  and  the  abscess  of  tne  lung  has 
thus  communicated  with  the  peritoneal  cavity.  These  abscesses  are  often  completely  iso 
lated,  and,  with  the  exception  of  the  thin  layer  of  hepatization  in  their  immediate  vicinity, 
are  surrounded  with  a  perfectly  healthy  pulmonary  tissue.  Occasionally,  liowevor,  they  per- 
vade the  great  portion  of  the  whole  of  one  of  the  lobes.  Their  size  is  ordinarily  in  inverse 
proportion  to  their  numbers.  In  the  greater  number  of  cases,  they  are  confined  to  one  lung, 
and  are  more  frequent  in  the  left  than  the  right.  They  are  met  with  most  frequently  in  chil 
dren  imder  six  years  of  age. 

Partial,  which  is  the  second  form  of  lobular  pneumonia,  is  much  less  circumscribed  than 
the  preceding.  Indistinct  limits  exist  between  the  healthy  and  diseased  portions,  and  the 
disease  occupies  a  larger  portion  of  the  lungs.  The  diseased  portions  may  throughout  havo 
reached  the  second  stage,  or  at  the  centre  alone,  the  circumference  being  still  in  the  first 
stage,  nn<'  this  being  in  contact  with  several  other  portions  of  the  lung,  in  a  similarly  dis- 
eased condition:  nearly  the  whole  of  an  entire  lobe  may  present  an  admixture  of  the  c'laiac, 

37  2y 


578  PNEUMONIA. 

teristics  of  pneumonia  in  the  first  and  second  stages,  and  when  the  disease  has  reached  the 
.hird  degree,  it  is  strictly  lobar. 

In  the  major  part  of  the  cases,  lobular  pneumonia  is  double  —  the  disease,  however,  being 
frequently  much  more  extensive  on  one  side  than  the  other.  A  union  of  the  three  forms  of 
pneumonia  —  mammelonated,  partial,  and  general  —  is  often  met  with  in  the  same  patient. 
The  lirst  is  equally  frequent  in  every  portion  of  both  lungs,  while  general  pneumonia  is  far 
more  frequent  in  the  inferior  lobes.  Partial  pneumonia  is  often  disseminated  throughout  the 
three  lobes — it  is.more  frequent,  however,  in  the  inferior.  Mammelonated  pneumonia  is  of 
much  more  :are  occurrence  beyond  the  sixth  year  than  partial  pneumonia,  while  general 
pneumonia  is  still  more  rare  than  the  former  between  the  sixth  and  fifteenth  years.  (Se« 
Barthez  and  Rilliet — Maladies  des  Evfants,  t.  i.,  p.  61.) 

borne  doubts  have  been  suggested  as  to  all  the  changes  in  the  texture  of  the  lungs,  de- 
scribed as  characteristic  of  lobular  pneumonia,  being  actually  the  result  of  inflammation. 
For  the  investigation  of  this  subject,  the  reader  is  referred  to  the  Editor's  Treatise  on  the  Dis 
eases  of  Children,  2d  edit.,  p.  282. 

The  anatomical  characters  of  lobular  pneumonia  in  children  are  the  same  with  those  met 
with  in  the  pneitmonia  of  adults. 

.Inflammation  of  the  bronchi,  particularly  of  tlie  smaller  bronchial  ramifications,  pleurisy, 
and  emjihysema  of  the  lungs,  are  common  complications  of  pneumonia  in  children. 

The  lobular  form  of  pneumonia  is  the  most  frequent  during  childhood — it  is  also  the  most 
serious  at  that  age. 

Lobar  pneumonia  occupying  only  one  lung,  when  it  occurs  in  children  between  six  and 
fifteen  years  of  age,  whose  health  has  not  been  impaired  by  previous  disease,  unless  compli- 
cated by  some  secondary  affection  is  not  a  very  fatal  disease,  if  judiciously  treated  from  its 
commencement.  Its  serious  character  is  however  greatly  enhanced  by  its  being  complicated 
with  other  diseases.  The  most  common  of  these  are  measles,  hooping-cough,  chronic  ente- 
ritis, and  small-jiox. 

Pneumonia  in  children  is  produced  by  the  same  general  causes,  as  give  rise  to  it  in  adults. 
It  is  common  to  both  sexes,  but  more  frequent  iu  boys.  It  is  particularly  liable  to  occur  in 
the  same  child  after  a  shorter  or  longer  interval. 

In  the  treatment  of  the  pneumonia  of  children,  bleeding  will  very  generally  be  demanded 
in  the  commencement  of  the  attack.  In  young  children  leeches  or  cups  should  be  applied 
to  the  anterior  parietes  of  the  chest,  beneath  the  clavicles,  or  between  the  shoulders.  Their 
number  should  be  proportioned  to  the  violence  of  the  symptoms,  and  to  the  age  and  strength 
of  the  patient.  In  older  children,  however,  bleeding  from  the  arm  should  be  preferred.  The 
amount  of  blood  drawn  must  be  proportioned  to  the  extent  of  the  disease.  The  propriety 
of  repeating  the  bleeding  will  depend  upon  circumstances.  When  the  first  bleeding  has 
been  well  timed  and  carried  to  a  sufficient  extent,  a  second  will  seldom  be  required ;  when- 
ever, however,  the  leading  symptoms,  particularly  the  dyspnoea,  continue  with  little  abate- 
ment, we  should  never  hesitate  to  repeat  the  bleeding,  either  from  the  arm,  or  by  leeches  or 
cups,  according  to  the  violence  of  the  remaining  symptoms,  the  age  of  the  patient,  and  the 
amount  of  strength  remaining.  It  is,  however,  in  the  early  period  of  the  attack  alone,  that 
any  very  decided  advantage  is  to  be  expected  from  blood-letting;  in  the  more  advanced 
stages  of  the  disease,  it  will  seldom  be  beneficial  or  admissible  ;  though  cases  may  occasion- 
ally occur,  when  the  cautious  application  of  leeches  or  cups  to  the  chest  or  between  the  shoul- 
ders will  be  attended  with  marked  relief,  even  after  the  disease  has  existed  for  several 
days. 

In  the  commencement  of  the  attack,  if  the  bowels  are  active  or  torpid  it  will  be  proper  to 
administer  a  full  dose  of  calomel,  to  be  followed  in  a  few  hours,  by  a  dose  of  castor  oil,  or 
in  robust  children,  over  three  years  of  age,  a  mixture  of  equal  parts  of  magnesia  and  epsom 
salts.  Subsequently  the  bowels  should  be  kept  regularly  open  by  enemata,  or  occasional 
doses  of  some  mild  purgative ;  a  grain  of  calomel,  with  half  a  grain  each,  of  ipecacuanha 
and  extract  of  hyosciamus,  administered  twice  or  thrice  a  day,  will  usually  effect  this  object. 
Costiveness  is  not,  however,  very  common  in  the  pneumonia  of  infants;  an  opposite  state  of 
ihc  bowels  is  a  more  frequent  and  troublesome  symptom. 

Subsequent  to  blood-letting,  in  robust  children  over  three  years  of  age,  tartarized  antimony, 
jijven  in  small  doses  during  the  day,  will  be  found  highly  beneficial.  But  in  younger  chil- 
dren antimony  in  any  form  is  a  dangerous  remedy,  more  particularly  when  there  is  any 
tendency  to  disease  of  the  alimentary  canal.  Small  doses  of  ipecacuanha  and  calomel  will 
be  found  very  generally  to  act  beneficia'.Iy  in  allaying  the  cough,  dyspnffia,  and  general 
restlessness,  and  may  be  given  to  the  youngest  patient  without  any  inconvenience  resulting; 
adding  to  each  dose  a  minute  portion  of  powdered  digitalis  will  in  most  cases  be  found  ad- 
vantageous. Occasionally  the  calomel  will  purge;  should  this  be  the  case  it  will  be  neces- 
sary to  add  to  it  a  grain  or  two  of  Dover's  powder.  After  the  violence  of  the  disease  has 
been  considerably  abated,  we  have  found  advantage  from  the  administration,  every  three 
hours,  of  small  doses  of  calomel,  ipecacuanha  and  hyosciamus.  Under  the  same  circum- 
stances the  compound  honey  of  squill  may  be  given.    To  children  over  three  years  of  age  it 


PLEURISY.  579 

Is  well  adapted  to  allay  the  cough  and  dyspncea:  to  the  dose  given  in  the  evening  a  few  cirops 
of  paregoric  may  be  added. 

Blisters  to  the  chest  are  certainly  very  important  remedies  in  the  pneumonia  of  children. 
In  violent  cases  occurring  in  patients  over  five  years  of  age,  particularly  when  attended  with 
much  febrile  excitement,  they  should  not  be  applied  imtil  the  violence  of  the  symptoms  have 
been  abated  by  direct  depletion ;  they  should  be  kept  on  no  longer  than  is  necessary  to  pro- 
duce, a  decided  redness  of  the  skin;  they  should  be  then  removed  and  the  reddened  surface 
covered  with  a  soft  emollient  poultice.  In  infants,  as  well  as  in  slight  cases,  and  in  those 
occurring  in  children  of  a  delicate  frame  or  who  are  much  debilitated,  in  place  of  a  blister  a 
thick  slice  of  bread,  dipped  in  vinegar  and  lightly  sprinkled  with  powdered  mustard,  should 
be  applied  to  the  chest,  and  removed  as  soon  as  it  has  reddened  the  skin. 

Warm  sinapired  pediluvia,  or  a  sinapired  hip-bath,  will  often  produce  a  favourable  revul- 
sion from  the  -'ungs,  and  may  be  frequently  repeated. 

In  stubbon;  cares  Dr.  West  speaks  highly  of  mercurial  inunction;  under  its  employment, 
he  has  seen  vecoveiy  to  take  place  even  where  the  circumstances  had  seemed  to  warrant 
a  more  unfavourable  prognosis.  The  full  value  of  mercurial  inunction  is  seen  in  cases  which 
have  been  neglected  until  c!ie  time  for  depletion  has  gone  by,  the  patient  having  becoifie 
exhausted,  and  the  employmeni,  oi  calomel  is  forbid  by  the  presence  of  diarrhcea.  Dr.  West 
employs  it  in  the  proportion  of  oris  drachm,  rubbed  into  the  thighs  and  axilla  every  four 
hours,  in  children  of  four  years  of  age.  He  has  never  seen  salivation  to  be  induced  by  it, 
but  he  has  observed  the  disease  gradually  to  diminish  in  severity  during  its  employment, 
and  the  solid  lung,  to  become  once  more  permeable  to  air. 

When  in  the  advanced  stage  of  the  disease  there  is  great  exhaustion,  with  symptoms  of 
impending  suffocation,  the  use  of  carbonate  of  ammonia  has  been  strongly  recommended — 
but  under  such  circumstances,  there  can  be  but  little  hope  of  the  patient's  recovery. 

In  chronic  cases,  our  chief  dependence  is  upon  revulsives,  applied  either  upon  the  chest, 
or  upon  the  surface  generally,  and  perhaps  upon  a  judicious  mercurial  course,  particularly 
by  inunction. 

In  all  cases  of  pneumonia,  the  exhibition  of  some  mucilaginous  drink,  in  small  portions, 
and  at  short  intervals,  will  be  found  to  abate,  very  sensibly,  tlie  cough,  and  relieve  the  dry- 
ness of  the  fauces,  which,  in  the  early  stage  of  the  disease,  is  often  a  harassing  symptom. 
A  solution  of  gum  acacia,  or  the  mucilage  of  the  elm  bark,  or  pith  of  sassafras,  sweetened, 
will  be  the  best  we  can  employ. 

The  diet  of  the  patient,  in  the  earlier  period  of  the  more  acute  cases,  should  be  confined, 
almost  exclusively,  to  these  mucilaginous  fluids — after  the  violence  of  the  disease  has  been 
subdued,  plain  water  gruel,  arrow-root,  or  tapioca,  may  be  allowed.  When  the  disease  oc- 
curs in  young  infants,  they  should  be  taken  from  the  breast — the  mother's  milk  being  given 
to  them  in  moderate  quantities  by  means  of  a  spoon,  as  well  to  prevent  their  stomach  from 
being  overloaded,  as  to  guard  against  the  mischievous  effects  of  the  violent  exertion  of  the 
respiratory  organs  in  sucking. 

The  patient  should  be  kept  in  a  clean,  well  ventilated,  and  moderately  warm  apartment. 
It  is  all-important  to  guard  him  from  cold  and  dampness,  and  from  sudden  transitions  of 
temperature.  He  should  be  placed  upon  his  bed  or  couch  in  a  half-recumbent  position,  in 
order  to  render  the  respiration  more  easy,  and  to  prevent  the  injurious  consequences  resulting 
from  the  stasis  of  fluids  in  the  posterior  portion  of  the  lungs. 

AVhen  the  disease  has  arrived  at  an  advanced  stage,  or  involves  a  considerable  extent  of 
the  lungs,  the  patient  should  be  moved  with  the  greatest  care  and  gentleness,  lest  convulsions 
be  induced. 

After  convalescence  is  fully  established,  gentle  exercise  in  the  open  air,  in  mild,  dry  wea- 
tlier,  may  be  taken ;  but,  for  a  long  period,  the  utmost  care  should  be  observed  to  guard  against 
exposure  to  cold  and  dampness ;  and  while  a  gradual  improvement  is  made  in  the  diet — if 
the  child  be  weaned — all  rich,  stimulative,  and  indigestible  food  must  be  avoided,  as  well  as 
the  slightest  excess  in  the  use  of  those  articles  that  are  allowed.  See  Condie  on  Diseases  of 
Children,  2d  ed.,  page  274,  et  seq. — C] 

In  the  next  lecture  I  shall  speak  of  pleurisy. 


LECTURE  LII. 

Pleurisy.  Its  anatomical  chtiraders ;  false  membranes;  liquid  effusion ;  effects 
of  these  tipon  the  shape  and  contents  of  the  chest,  and  upon  its  healthy  sounds. 
Symptoms  of  Pleurisy. 

I  PROCEED  this  afternoon  to  the  subject  of  pleurisy,  having  in  the  last  lecture  con- 
cluded 'what  I  had  to  say  on  that  of  pneumonia ;  that  is.  I  pass  from  inflammation 


580  PLEURISY. 

of  the  substance  of  the  lung,  to  inflammation  of  its  investing  membrane.  The  two 
frequently  exist  together ;  but,  when  that  is  the  case,  the  one  predominates  greatly- 
over  the  other.  Pleurisy,  however,  without  pneumonia,  is  much  more  common  than 
pneumonia  without  pleurisy.  When  both  are  present,  and  the  pneumonia  predomi- 
nates, the  term  pi  euro-pneumonia  is  applied  to  the  compound  disease.  The  whole 
interest  of  such  a  case  merges  in  the  pneumonic  inflammation.  Again,  when  both 
are  present,  and  the  pleurisy  predominates,  the  compound  affection  is  sometimes 
called  pncumo-pleuritis. 

The  pleura,  as  you  know,  is  one  of  the  serous  membranes.  Its  inflammation  is 
attended,  therefore,  with  those  events  which  I  formerly  took  some  pains  to  describe 
as  belonging  especially  to  that  particular  tissue.  The  inflammation  is  of  the  adhe- 
sive kind  :  it  is  accompanied  by  pain,  by  the  pouring  out  of  serum,  of  coagulabla 
lymph,  of  pus,  or  of  blood,  I  think  it  will  be  best,  in  this  instance,  also,  to  lay 
before  you  some  account  of  the  morbid  anatomy  of  the  disease,  before  I  consider  it's 
symptoms. 

The  alterations  that  take  place  in  the  inflamed  membrane  itself  are  not  very 
striking  or  important.  Experiments  upon  living  animals,  made  by  introducing  some 
foreign  substance,  or  injecting  some  slightly  irritating  liquid,  into  the  cavity  of  the 
pleura,  have  proved  that,  as  in  other  cases,  inflammation  is  attended  with  redness  of 
the  part  affected.  But  it  is  scarcely  ever  that  we  observe  this  effect  alo7ie  of  inflam- 
mation, in  the  pleura  of  a  dead  person ;  unless,  indeed,  he  has  died  of  some  other 
Complaint  while  he  happened  to  have  incipient  pleurisy.  The  pleura  has  been  said 
to  be  thickened  by  inflammation ;  but  that  I  apprehend  to  be, a  mistake.  It  often 
appears  to  be  thickened,  in  consequence  of  the  superposition  of  a  false  membrane — 
a  layer,  or  several  layers,  of  plastic  lymph.  But  actual  thickening  of  the  pleura 
itself  seldom  or  never  happens.  Neither  does  the  pleura  easily  soften,  or  readily 
ulcerate,  under  inflammation.  It  peels  off",  in  some  cases,  from  the  lung,  or  from  the 
ribs,  with  more  facility  than  in  the  sound  state. 

The  most  remarkable  effects  of  pleurisy  result  from  the  effusion  of  coagulable 
lymph,  or  of  serous  fluid,  or  of  both,  into  a  shut  sac,  having  peculiar  anatomical 
relations.  One  part  of  the  membrane  lines  the  firm  walls  of  the  chest ;  the  other 
part  envelops  the  soft  and  compressible  lung.  The  opposed  surfaces  of  this  closed 
and  empty  bag  being  opposed  also,  but  freely  movable  one  upon  the  other,  very  dif 
ferent,  and  even  contrary,  effects  may  be  produced  by  its  inflammation.  The  pul 
monary  pleura  may  be  glued  to  the  costal  pleura,  so  as  to  prevent  all  lateral  move 
ment  between  them,  and  to  obliterate  the  pleural  cavity ;  or  the  two  surfaces  of  the 
membrane  which  are  naturally  in  contact,  may  be  forced  unnaturally  apart  by  a 
pouring  forth  of  serum  between  them ;  or  the  opposite  surfaces  of  the  pleurae  may 
be  united  by  coagulable  lymph  in  some  places,  and  separated  by  effused  fluid  in 
others.  And  great  difl^erences  will  arise  in  the  symptoms,  and  in  the  gravity  and 
tendency  of  the  complaint,  according  as  one  onanother  of  these  different  conditions 
of  the  contents  of  the  thorax  is  established. 

Let  us  first  consider  the  effect  of  the  throwing  out  of  coagulable  lymph  only ;  or, 
of  what  comes  to  the  same  thing,  the  effusion  of  coagulable  lymph  with  a  small 
quantity  of  serum,  which  last  is  soon  reabsorbed. 

One  consequence  of  this  is  the  formation  of  false  membranes.  These,  indeed, 
are  formed  whether  there  be  much  or  little  serum  poured  out.  We  continually  meet 
with  them,  sometimes  when  we  least  expect  to  do  so,  in  the  dead  body.  They  vary 
greatly,  in  different  cases,  in  respect  to  their  thickness,  situation,  extent,  organization 
and  effects. 

When  the  lymph  is  first  deposited  upon  the  free  surface  of  the  inflamed  pleura, 
it  is  soft,  and  of  a  grayish-white  colour,  like  paste  somewhat.  It  soon,  however, 
acquires  an  increase  of  consistence,  and  shows  marks  of  vitality ;  becomes,  in  short, 
organized.  Red  points  begin  to  appear  in  it,  few  in  number  and  widely  separated, 
at  first ;  but  they  presently  multiply,  and  lengthen  into  reddish  streaks,  which  run 
aiong  the  surface  of  the  efllised  matter.  Soon  these  red  streaks  may  be  perceived 
to  be  slen-ler  vascular  canals ;  and  at  length  they  inosculate  with  the  vessels  of  the 
pleura,  and  the  lymph,  converted  into  a  false  membrane,  becomes  a  constituent  par* 
nf  tne  livinp-  frame. 


PLEURISY.  581 

It  is  curious,  and  useful  too,  to  know  how  rapidly  this  work  of  organization  may 
go  on. 

Andral  made  experiments  upon  the  pleuroe  of  rabbits,  by  injecting  acetic  acid  into 
them.  He  sometimes  found,  at  the  end  of  nineteen  hours,  soft  and  thin  false  mem- 
brane, traversed  by  numerous  anastomosing  red  lines.  In  other  rabbits,  placed 
under  circumstances  which  appeared  to  be  exactly  similar,  no  such  result  had  taken 
place  at  the  end  of  a  much  longer  period ;  but  the  pleura  contained  only  a  serous  or 
puriform  liquid,  mixed  with  unorganized  flakes  of  lymph.  Now  similar  differences 
have  been  remarked  in  the  human  subject,  under  disease.  False  membranes, 
already  vascular,  have  been  found  in  the  bodies  of  persons  who  died  of  pleurisy 
after  a  very  few  days'  illness :  while  in  other  patients,  who  had  lived  for  many 
months  after  the  invasion  of  the  disease,  there  has  been  no  trace  of  such  vascular 
membranes.  It  is  clear,  therefore,  that  the  organization  of  the  lymph  does  not  de- 
pend solely  upon  the  length  of  time  that  has  elapsed  from  the  period  at  which  it  was 
poured  forth.  It  has  much  more  to  do  with  the  previous  state  and  habit  of  the 
patient.  Cseteris  paribus,  plastic  lymph  and  early  adhesion  are  more  to  be  expected 
in  young,  strong  and  healthy  persons ;  curdy  unorganized  lymph,  granular  deposits, 
with  copious  and  abiding  serous  effusion  tending  to  become  puriform,  in  such  as  are 
old,  feeble,  cachectic,  and  scrofulous. 

The  extent  of  these  false  membranes  varies  according  to  the  extent  of  the  inflam- 
mation which  has  produced  them.  When  that  has  been  general,  they  cover  the 
whole  lung,  and  line  the  whole  costal  surface,  and  spread  themselves  over  the 
diaphragm  and  mediastinum  of  the  same  side.  Supposing  that  there  is  no  serous 
liquid  effused,  or  that  it  is  absorbed,  the  lung  then  becomes  everj'where  adherent 
to  the  sides  of  the  cavity  which  contains  it.  The  medium  of  adhesion,  which  is  soft 
and  tender  while  it  is  recent,  grows  firm,  and  assumes  the  characters  of  areolar  tissue, 
when  the  union  is  of  old  standing. 

The  thickness  of  the  false  membranes  is  also  extremely  variable.     Sometimes  it  1 
not  more  than  that  of  the  pleura  itself,  and  the  lymph  might  then,  in  the  absence  ot 
adhesion,  be  almost  overlooked.     But  in  the  majority  of  cases  their  thickness  is  much 
greater  than  this.     Frequently  several  distinct  layers  or  strata  are  seen,  superposed 
one  upon  another,  to  a  considerable  depth. 

Are  there  any  auscultatory  signs  of  this  process  of  adhesion  when  it  occurs?  Yes. 
There  is  a  morbid  sound  not  hitherto  mentioned  by  me,  whereby  it  is  sometimes  dis- 
closed :  the  sound,  namely,  oi friction  ;  the  sound  produced  by  the  rubbing  together 
of  the  dry,  or  inflamed  and  roughened  surfaces.  You  doubtless  are  aware  that  every 
time  a  tolerably  deep  inspiration  takes  place,  the  relation  between  the  ribs  and  the 
lung  undergoes  a  change.  While  the  ribs  are  elevated,  the  lung  descends  a  little  : 
and  consequently  any  given  point  of  the  surface  of  the  lung  is  no  longer  in  contact 
with  the  same  point  as  before  of  the  thoracic  parietes.  You  may  convince  yourselves 
of  this  fact  by  carefully  making  a  small  incision  through  an  intercostal  space,  in  a 
living  animal.  Now  the  pulmonary  pleura,  when  that  membrane  is  inflamed,  does 
not  slip  and  glide  over  the  costal  in  its  usual  smooth  and  noiseless  manner ;  but  it 
makes  a  creaking  or  rubbing  sound,  which  the  ear,  applied  to  the  corresponding  sur 
face  of  the  chest,  readily  catches.  I  have  many  times  heard  this;  yet  it  is  not 
at  all  a  common  sound  :  indeed  I  had  heard  it,  in  one  instance,  some  time  before  I 
knew  what  the  noise  meant.  The  sound  has,  mostlj^  an  interrupted  character, 
occurring  in  a  series  of  three  or  four  jerks.  The  patient  is  often  made  aware  of  the 
harsh  movement,  by  some  internal  sensation ;  and  a  bystander,  who  places  his  hand 
flat  upon  the  corresponding  surface  of  the  thorax,  may  sometimes  feel  this  grating  of 
the  membrane  upon  itself.  You  may  wonder,  as  adhesions  are  so  common,  that  this 
sound,  and  these  sensations  are  not  oftener  heard,  and  felt.  In  truth,  they  are  tran 
sitory  phenomena,  and  cease,  of  necessit}',  as  soon  as  adhesion  prevents  any  further 
motion  of  the  opposed  pleurfe  upon  each  other.  If  we  do  not  happen  to  listen  during 
that  period,  usually  a  short  one,  in  which  the  pleurcc,  roughened  by  inilaiamntiou 
and  effused  lymph,  but  not  separated  by  liquid,  still  chafe  against  each  other,  we 
lOse  the  opportunity  of  hearing  the  sound  at  all.  This  rubbing  sound,  this  noise  of 
fiiciion,  we  shall  find  to  be  of  greater  importance  in  relation  to  certain  diseases  of 

2y2 


582  PLEURISY. 

the  heart,  than  m  cases  of  acute  pleurisy.  In  pleurisy  the  liquid  matters  poured 
into  the  membranous  sac  have  far  more  interesting  consequences  :  and  to  these  I  now 
beg  your  attention. 

In  some  instances  we  find,  after  death,  a  clear  serous,  or  watery  fluid,  without 
colour,  or  of  a  pale  lemon  colour,  and  perfectly  limpid  and  transparent.  This  may 
occur  independently  of  inflammation  of  the  pleura ;  from  some  mechanical  obstacle 
to  the  circulation.  It  then  constitutes  a  species  of  dropsy;  a  true  hydrothorax : 
and  this,  though  less  common  than  ascites,  is  by  no  means  an  uncomxnon  conse- 
quence of  disease  of  the  heart.  When  the  efflision  does  not  proceed  from  a  cause 
of  that  kind,  it  is  always,  probably,  the  result  of  inflammation  of  the  pleura  itself, 
although  we  may  find  only  a  slight  degree  of  redness  upon  its  surface,  or  a  few 
patches  of  coagulable  Ij'mph.  More  frequently,  besides  this  clear  hquid,  with  flakes 
of  albuminous  matter  floating  in  it,  there  is  also  a  coating  of  lymph  on  the  inflamed 
membrane.  Very  often  the  thinner  fluid  is  turbid,  or  whitish,  like  whey  ;  sometimes 
it  is  distinctly  puriform ;  sometimes  it  is  tinged  more  or  less  deeply  with  blood ; 
sometimes  it  consists  of  nothing  else  but  blood,  which  has  separated  into  the  serum 
and  crassamentum.  There  being  no  wound,  nor  visible  rupture,  of  large  or  of  small 
vessels,  we  conclude,  in  such  cases,  that  the  blood  has  exuded,  or  been  exhaled,  from 
the  membrane. 

The  different  kinds  of  fluid  effused  into  the  pleurce  are  alwa)'s,  or  almost  always, 
without  smell ; — provided  that  it  has  remained  a  closed  bag :  I  mean  when  no  com- 
munication has  been  established  between  the  cavity  of  the  pleura  and  the  external 
air,  either  through  an  opening  in  the  walls  of  the  chest,  or  through  a  pulmonary 
fistula  leading  to  the  trachea,  or  through  some  breach  of  the  oesophagus.  I  have 
met  with  but  one  exception,  and  that  a  doubtful  one,  to  this  rule.  A  patient  died  in 
the  hospital,  who,  some  years  before,  had  nearly  killed  himself  by  swallowing,  in 
mistake  for  beer,  a  solution  of  caustic  potass.  The  result  of  this  had  been  ulceration, 
and  subsequently  stricture,  of  the  gullet.  His  left  pleura  was  perfectly  full  of  most 
stinking  pus  ;  and  we  were  unable  to  detect  any  channel  of  communication  with  the 
outward  air,  although  the  circumstances  of  the  case  rendered  it  not  improbable  that 
such  a  channel  might  have  existed. 

Sometimes  air,  or  gas,  is  found  in  the  cavity  of  the  inflamed  pleuia;  either  alone, 
or  (what  is  much  more  common)  together  with  a  liquid.  We  ascertain  this  fact,  in 
the  dead  bod3%  by  the  hissing  sound  that  takes  place  as  soon  as  a  penetrating  inci- 
sion is  made  between  the  ribs ;  or  by  opening  the  thorax  under  water,  and  noticing 
the  escape  of  air  in  the  form  of  bubbles.  It  is  probable  that  these  gases  are  some- 
limes  secreted  or  exhaled  from  the  diseased  membrane ;  sometimes  they  are  the  pro- 
duct of  decomposition  within  the  cavity;  but,  for  the  most  part,  they  are  met  with 
only  when  the  sac  of  the  pleura  communicates  somehow  with  the  external  air. 

Such  being  the  fluid  matters  that  frequently  occupy  the  cavity  of  the  pleura  when 
that  membrane  has  undergone  inflammation,  let  us  next  examine  the  necessary  effects 
of  their  being  collected  in  that  part.  These  efl^ects  \\'\\\  obviously  vary  considerably 
according  to  the  quantity  of  the  fluid  that  accumulates. 

Now  the  quantity  of  fluid  may  vary  from  less  than  an  ounce  to  several  pints.  At 
first  it  is  lodged  in  the  cavity  of  the  pleura  solely  at  the  expense  of  the  yielding  lung, 
which  is  compressed  to  make  room  for  it.  But  if  the  quantitj'-  continues  to  augment, 
other  parts  at  length  displaced  by  the  increasing  pressure,  the  boundaries  of  the  chest 
on  that  side  are  stretched,  and  even  the  abdominal  viscera  are  thrust  out  of  their 
natural  position.  The  lung  is  pushed  back  towards  the  mediastinum  and  vertebral 
column,  and  flattened,  and  brought  to  lie  in  the  smallest  possible  compass ;  the 
diaphragm  is  forced  downwards,  which  sometimes  gives  rise  to  a  considerable  promi- 
nence of  one  or  the  other  hypochondrium,  the  spleen  and  stomach  being  displaced 
on  the  left  side,  or  the  liver  on  the  right.  The  ribs  are  separated  too;  the  intercostal 
spaces  become  wider,  and  are  pushed  out  to  the  level  of  the  bones,  and  the  whole  of 
the  afiected  side  is  smooth  and  obviously  larger  than  the  other.  The  mediastinum 
also  undergoes  some  chansre  of  position,  being  driven  more  or  less  towards  the  side 
opposite  to  that  on  which  the  effusion  exists.  If  the  liquid  happens  to  fill  and  distend 
the  left  side  of  the  thorax,  the  heart  may  be  moved  out  of  its  natural  place,  and  be 


PLEURISY.  583 

heard,  and  felt,  and  seen  to  beat  on  the  right  of  the  sternum.  Andral  mentions 
having  met  with  only  one  instance  of  that  kind.  I  suppose  that  I  cannot  have  wit- 
nessed less  than  a  dozen  such.  So  again  the  heart  may  be  carried  beyond  its  proper 
place,  to  the  left,  by  a  large  effusion  into  the  right  pleural  cavity. 

I  say  when  the  liquid  is  accumulated  in  very  considerable  quantity,  the  luno-  is 
pressed  into  the  form  of  a  thin  cake,  which  occupies  a  very  small  space  alono^side 
the  vertebral  column  :  and  if  it  happens  to  be  covered  over  and  concealed,  as  it  often 
'is,  by  a  strong  layer  of  adventitious  membrane,  we  might  fancy,  at  first  examination, 
that  it  had  completely  disappeared.  It  was  in  cases  of  this  kind— especially  whea 
the  effused  fluid  consisted  of  pus — that  the  lung  was  erroneously  represented  by  the 
older  observers  as  having  been  destroyed  by  suppuration.  However,  you  will  always 
find  the  lung  there  if  you  take  the  pains  to  look  for  it,  and  to  divide  the  false  mem- 
branes that  bind  it  down :  and,  in  many  instances,  it  is  sound  also.  Its  surface  may, 
indeed,  be  wrinkled,  but  the  lung  itself  is  capable  of  being  restored  to  nearly  its 
former  volume  by  insufflation,  as-  it  is  called;  by  blowing  air  into  it  through  the 
principal  bronchus  of  that  side.  In  this  compressed  state  the  lung  does  not  crepitate- 
under  the  finger :  it  is  dense,  and  sinks  in  water ;  in  fact  it  is  wholly  void  of  air, 
and  has  been  brought,  by  the  pressure  of  the  fluid  around  and  upon  it,  into  nearly 
the  condition  of  the  lung  of  the  fcelus  that  has  never  breathed.  But  its  firmness,  its 
resistance  to  being  torn,  and  its  capability  of  being  again  inflated,  prevent  our  con- 
founding it  with  hepatized  lung.  Sometimes  its  cellular  texture  is  obliterated  ;  the 
opposite  surfaces  of  the  vesicles  and  smaller  air-tubes  adhere  together;  the  luno-  will 
aot  admit  air ;  it  looks  like  a  piece  of  muscle,  and  is  then  said  to  be  carni/ied. 

Such  is  the  general  account  of  the  anatomical  characters  of  pleurisy,  as  they  are 
lisclosed  to  us  by  an  examination  of  the  body  after  death.  We  may  now  inquire 
what  effect  these  changes  are  capable  of  producing  on  the  sounds  which  are  heard 
when  the  heahhy  chest  is  percussed,  or  listened  at.  We  shall  then  be  the  better 
prepared  to  appreciate  the  several  symptoms,  general  and  physical,  which  are  known 
actually  to  occur  in  pleurisy.  Now  it  is  clear  that  when  the  lung  is  pushed  away 
from  the  walls  of  the  thorax  by  fluid  between  the  pleurae,  it  will  be  compressed  also  ; 
its  capacity  must  be  reduced  ;  less  air  will  be  able  to  enter  it.  There  will  conse- 
quently be  a  proportional  diminution  in  the  intensity  of  the  respiratory  murmur , 
and  this  murmur  will,  moreover,  be  less  audible  in  consequence  of  the  distance,  from 
the  ear,  of  the  structure  in  which  it  takes  place.  The  lung  is  attached  by  its  roots 
(so  anatomists  speak)  to  the  spinal  column.  A  moderate  amount  of  effusion  will, 
therefore,  cause  it  to  recede  upwards  and  inwards ;  and  a  certain  quantity  of  the 
liquid  will  ascend  between  the  lung  and  the  ribs,  compressing  the  spongy  pulmonary 
tissue  around  the  larger  and  more  resisting  bronchial  tubes.  We  might  expect,  in 
this  condition  of  things,  that  the  passing  breath  and  the  voice,  would  be  audible  in 
those  tubes,  through  the  partially  condensed  lung,  and  through  the  circumfused  layer 
of  liquid:  and  it  is  so.  We  do  hear  bronchial  respiration,  and  bronchial  voice  and 
cough ;  with  some  modification,  indeed,  to  be  noticed  presently.  In  this  respect 
therefore,  you  will  observe  that  pneumonia,  which  solidifies  the  spongy  texture  of 
lung  around  the  bronchial  tubes  by  filhng  it  with  blood,  has  the  same  effect,  so  fai 
as  acoustic  principles  are  concerned,  as  pleurisy,  which  solidifies  a  portion  of  the 
lung  by  expressing  air  from  it,  and  pours  round  the  bronchial  tubes  a  fluid  which 
readily  transmits  sound.  Hence  bronchial  respiration  and  bronchophony  are  not 
always  indicative  of  the  same  condition  of  parts  within  the  chest,  but  derive  their 
true  value  and  meaning  from  the  context,  if  I  may  so  say ;  from  the  circumstances 
under  which  they  occur,  and  with  which  they  are  associated. 

When  the  eflusion  is  so  copious  as  to  squeeze  aU  the  air  out  of  the  spongy  part  ot 
the  lung,  to  pack  the  organ  up  along  the  vertebral  column,  to  distend  the  thorax,  and 
to  compress  strongly  the  bronchial  tubes  themselves,  no  respiratory  murmur  ccri 
then  be  heard,  nor  any  tubular  breathing;  for  the  dilated  chest  can  neither  expanJ 
nor  collapse,  and,  therefore,  no  air  can  pass  along  even  the  larger  air-tubes ;  neithei 
can  these  compressed  tubes  vibrate  with  the  patient's  voice  ,  wherelorc  Lrfonchophony 
also  ceases,  or  is  but  faintly  audible. 

Again,  if  percussion  be  made  over  a  portion  of  the  chest,  where  there  is  inr.onv 


584  PLEURISY 

pressible  serous  fluid  beneath,  in  the  stead  of  healthy  and  spongy  luncr,  a  dull  flal 
sound  will  be  rendered.  But  a  dull  sound  is  rendered  also  when  percussion  is  made 
over  a  solidified  lung.  Hence  the  mere  dullness  of  the  part  struck  does  not  inform 
us  whether  Ave  have  pneumonia  or  pleurisy  tn  deal  with,  or  some  other  disease  that 
has  the  effect  of  making  the  lung  solid,  without  plugging  up  the  larger  bronchi. 

But  an  expedient  presents  itself,  by  which  we  may,  in  some  cases,  render  this 
experiment  of  percussion  conclusive.  The  dull  sound  occasioned  by  hepatization  or 
other  solidification  of  the  lung  occupies  the  same  spot  in  every  position  of  the  patient. 
Not  so,  necessarily,  the  dull  sound  produced  by  the  presence  of  liquid  in  the  cavity 
of  the  pleura.  The  liquid  will  gravitate  to  the  lowest  part  of  that  cavity,  and  will 
carry  with  it  the  dull  sound.  We  place  the  patient,  therefore,  in  different  altitudes  ; 
and  if  we  find  that  the  chest,  when  struck,  is  always  resonant  in  the  higher,  and 
always  dull  in  the  lower  portions  of  the  thorax,  whatever  the  posture  may  be,  then 
we  may  be  sure  that  the  cavity  of  the  pleura  contains  liquid.  In  such  a  case,  when 
the  patient  sits  up,  the  dull  sound  will  be  elicited  from  the  lower  part  of  the  chest, 
on  one  side,  from  the  spine  round  to  the  sternum.  When  he  hes  on  his  back,  the 
anterior  of  the  thorax  sounds  hollow ;  the  posterior  dull :  and  when  he  reverses  that 
position,  and  lies  with  his  face  downwards,  these  sounds  change  places  also ;  the 
hollow  sound  is  still  uppermost,  in  the  posterior  part  of  the  cavity ;  the  dull  sound 
still  undermost,  in  its  anterior  portion. 

There  are  just  two  states  which  may  interfere  with  the  true  interpretation  of  the 
sounds  produced  by  percussion  in  the  manner  now  described ;  and  these  are,  first, 
partial  adhesions  of  the  pleurae,  which  may  confine  and  isolate  the  effused  liquid, 
and  prevent  its  sinking  from  one  part  of  the  chest  to  another  under  the  influence  of 
gravity :  and,  secondly,  so  large  an  amount  of  effusion  as  to  fill  entirely  the  cavity, 
and  fix  the  compressed  and  empty  lung  in  one  position ;  for  it  is  necessary,  in  order 
to  obtain  the  shifting  sounds  in  different  attitudes  of  the  bod}^  that  there  should  be 
light  spongy  lung  to  ascend,  as  well  as  heavier  fluid  to  sink  down,  according  to 
the  posture  of  the  patient.  In  this  last  case,  that  of  excessive  effusion,  the  whole 
surface  of  the  affected  side  will  yield  a  dull  sound.  It  is  seldom  so  in  pneumonia; 
it  is  seldom  that  the  entire  lung  on  one  side  is  so  blocked  up,  in  consequence  of  in- 
flammation, as  to  give  rise  to  universal  dullness  on  percussion.  But  the  diagnosis 
of  these  two  conditions  is  an  important  one,  and  apt  to  puzzle  a  student.  I  hope  to 
elucidate  it  as  we  go  on. 

We  may  now  consider,  with  a  better  chance  of  understanding  some  of  them,  the 
s-ymploms  which  are  generally  met  with  in  a  case  of  pleurisy  under  its  ordinary 
form  and  progress.  The  general  signs,  then,  of  that  complaint  are  rigors,  pain  in 
the  chest,  dyspnoea,  cough,  difliculty  or  impossibility  of  assuming  certain  postures, 
and  fever.  Very  much  the  same,  therefore,  (as  Cullen  truly  stated)  with  those  of 
pneumonia,  and,  it  may  be  added,  with  those  of  pericarditis  :  but  auscultation  dif- 
ferentiates these  diseases.  The  physical  signs  I  will  examine  presently.  The  general 
symptoms  will  bear,  each  of  them,  a  short  comment. 

The  pain  which  the  patient  feels — or  the  stitch  in  the  side,  as  it  is  expressively 
called — is  one  of  the  most  striking  and  characteristic  signs  of  the  disease.  Point  de 
cote,  the  French  name  it.  It  occupies  a  point  or  spot ;  and  patients  feel  as  if  some 
sharp  stabbing  instrumen*  were  driven  in  at  that  spot  every  time  that  the  act  of  inspi- 
ration goes  beyond  a  certain  limit.  The  Latin  medical  writers,  attending  chiefly  to 
this  prominent  syuiptom,  call  pleurisy  *'  morbus  lateris." 

This  pleuritic  stitch  is  subject  to  considerable  variety  in  regard  to  its  situation,  its 
severity,  and  its  dura  ion.  Most  commonly  it  is  felt  on  a  level  with  or  just  beneath 
one  or  other  of  the  breasts,  in  the  part  corresponding  to  the  lateral  attachments  of 
the  diaphragm :  and  this,  even  when  the  inflammation  which  occasions  it  is  of  much 
greater  extent.  'Why  is  this?  What  is  the  cause  of  the  pain  ?  Wherefore  should 
it  bo  restricted  to  one  small  spot,  when  the  inflammation  perhaps  pervades  the  whole 
of  the  pleura?  Pathologists  have  made  attempts  to  explain  these  matters;  but  per- 
haps tht'ir  explanations  are  not  very  much  to  be  trusted  to.  They  say  that  there  is 
a  larger  degree  of  motion  at  the  lower  part  of  the  thorax,  of  the  pulmonary  over  the 
costal  pleura ;  and  that  the  pain  resulting  from  that  friction,  when  the  membranes 


PLEURISY.  585 

are  inflamed,  is  therefore  felt  where  the  friction  is  the  greatest.  However  the  pain 
is  not  always  confined  to  that  spot.  It  is  occasionally  I'elt  in  other  places,  as  in  the 
shoulder  ;  in  the  hollow  of  the  axilla  ;  beneath  the  clavicle  ;  along  the  sternum  :  and 
sometimes  it  is  complained  of  as  extending  over  the  whole  of  one  side  of  the  thorax. 
Andral  states  that  he  has  observed  the  pain  to  prevail  especially  along  the  cartilao-in- 
ous  border  of  the  false  ribs,  when  the  inflammation  has  attacked  that  portion  of  the 
pleura  which  covers  the  upper  surface  of  the  diaphragm.  He  says,  too,  that  in  such 
cases,  the  pain  often  affects  the  hypochondrium,  and  even  extends  as  far  as  the  flank, 
so  that  it  might  be  mistaken  for  a  symptom  of  abdominal  inflammation.  This  ob- 
servation is  Avorth  remembering.  Sliarp  pain,  occupying  the  right  hypochondrium, 
belongs  oftener  to  the  pleura  than  to  the  peritoneum.  I  have  known  several  instances 
m  which  such  pain  was  erroneously  supposed  to  be  a  sign  of  hepatitis,  when  in  truth 
It  resulted  from  inflammation  of  the  pleura.  Cruveilhier  observes,  also,  that  he  has 
known  the  pain  afiect  the  loins,  and  simulate  lumbago. 

Whatever  may  be  the  situation  of  the  pleuritic  pain,  it  is  generally  increased  by 
percussion,  by  intercostal  pressure,  by  lying  on  the  aflected  side,  by  a  deep  inspira- 
tion, by  cough,  and  by  diflerent  movements  of  the  body. 

In  many  patients  the  pain  is  exceedingly  sharp,  whether  it  be  continued,  or  whe- 
ther it  occur  only  at  intervals  :  the  more  circumscribed  it  is,  generally  the  more  acute 
it  is.  The  patients  are  then  in  a  state  of  great  anxiety:  they  make  very  short  and 
imperfect  inspirations,  through  fear  of  aggravating  the  pain  ;  they  dread  the  least 
effort  of  coughing,  or  of  sneezing,  and  suppress  the  desire  to  cough  which  the  dis- 
ease may  occasion.  There  are  other  patients  in  whom  the  pain  is  moderate,  is  felt 
only  when  a  deep  inspiration  is  made,  and  is  scarcely  augmented  by  pressure  or  per- 
cussion. And  there  are  even  some  cases  of  pleurisy  which  are  unattended  with  pain 
from  first  to  last. 

The  pain  commonly  exists  from  the  very  outset  of  the  pleurisy.  It  is  sometimes 
vague  and  fugitive  at  first,  and  becomes  fixed  and  permanent  after  a  day  or  two.  In 
that  case  it  may  be  mistaken  for  a  simple  rheumatic  pain ;  for  pleurodyne ;  or  for 
what  is  thought  to  be  merely  a  nervous  pain.  When  the  pain  is  increased  by  shght 
pressure  made  upon  the  ribs  as  weU  as  between  them ;  when  it  extends  over  a  laree 
space  ;  Avhen  it  is  unattended  with  fever ;  when  it  is  inconstant  or  fugitive — we  may 
suspect  that  it  is  situated  in  the  fibrous  and  muscular  tissue  ;  but  these  circumstances 
do  not  afford  any  certainty  that  such  is  the  case.  In  fact,  I  have  long  been  of  opi- 
nion that  some  at  least  of  the  cases  which  pass  under  the  name  of  pleurodyne,  are 
really  instances  of  what  has  been  called  dry  pleurisy.  You  are  aware  perhaps  that 
adhesions  are  very  constantly  found  to  exist  between  the  lungs  and  the  ribs  in  per- 
sons dead  of  pulmonary  consumption.  Such  persons  are  liable  to  pains  in  the  chest, 
beneath  the  clavicles,  in  the  axilla,  between  the  shoulders,  at  the  upper  part  of  the 
dorsal  region  :  in  short,  in  those  situations  where  the  adhesions  are  found  after  death 
most  frequently  and  in  the  greatest  number.  The  pains  indicated,  it  may  be  pre- 
sumed, the  periods  at  which  the  shghter  forms  of  circumscribed  pleurisy,  attended 
with  no  other  effusion  than  that  of  coagulable  lymph,  took  place.  And  it  is  probable 
that  many  cases  of  pleurodyne  are  really  instances  of  the  same  kind  of  pleuritic 
inflammation.  How  often  do  we  find,  even  when  there  are  no  tubercles  in  the  luno-s, 
firm  adhesions  between  the  pulmonary  and  costal  pleura3,  in  the  bodies  of  persons 
who  were  never  known  to  have  had  any  pectoral  disease  !  The  pain  alone  marks 
the  inflammation  in  those  cases ;  adhesion  presently  ensues  ;  there  is  no  fever  per- 
haps, or  none  that  attracts  much  notice  ;  the  pain  soon  subsides,  and  is  soon  foro-otten  ; 
but  the  adhesion,  the  consequence  of  inflammation,  remains :  and  this  is  a  morbid 
condition  which  is  neither  revealed  to  the  sense  of  hearing,  nor  in  any  other  way.  J 
am  much  disposed  therefore  to  agree  with  Cruveilhier  in  thinking  that  ''pleurodyne 
is  nothing  else  (in  many  cases  at  least)  than  adhesive  pleurisy.'' 

I  need  scarcely  repeat  the  fact  which  has  so  many  times  before  been  mentioned 
in  these  lectures,  viz.,  that  the  inflammation  of  membranous  parts,  and  especially 
of  serous  membranes,  is  attended  with  much  more  pain  than  inflammation  of  paren- 
chymatous parts.  We  cannot  have  a  better  example  of  it  than  is  afforded  in  most 
Cases  of  pneumonia.     Most  cases  of  pneumonia  are  accompanied  in  the  begiiuiing 


586  PLEURISY. 

with  a  stitch  in  the  side ;  some  cases  are  not.  In  those  cases  in  which  the  stitch 
happens,  tiie  pleura  also  is  inflamed  to  a  certain  degree,  and  the  pain  depends 
upon  the  coexistence  of  the  pleurisy :  they  are  cases  of  pleuro-pneumonia.  In 
pure  pneumonia,  on  the  contrary,  the  pleurisy  being  wanting,  the  sharp  pain  is 
wanting  also. 

The  respiration  in  pleuris},  at  its  outset  especially,  and  while  there  is  still  pain, 
is  considerably  embarrassed ;  the  movements  of  inspiration  in  particular  are  short, 
hurried,  and  often  interrupted  or  jerking.  And  this  depends  evidendy  upon  the  pain, 
which  forbids  the  free  contraction  of  the  muscles  that  dilate  the  thorax ;  and  you  may 
often  observe  that  the  dilatation  is  sensibly  less  on  the  affected  side  than  on  the  other. 
Cruveilhier  indeed  denies  this ;  or  rather  he  states  that  he  has  never  observed  it: 
but  it  certainly  is  not  an  uncommon  phenomenon,  I  have  noticed  it,  and  drawn  the 
attention  of  others  to  it,  again  and  again. 

When  effusion  has  taken  place — that,  one  can  easily  understand,  will  be  likely 
to  aggravate  the  dyspnoea;  and  it  will  aggravate  it  in  a  greater  degree,  or  in  a  less, 
according  to  circumstances.  Thus,  if  the  other  lung  happens  to  be  a  diseased  lung, 
then  the  compression  of  that  which  is  on  the  side  of  the  pleurisy  will  have  a  more 
injurious  effect  upon  the  breathing.  The  dyspnoea  arising  from  the  effusion  and  con- 
sequent pressure  upon  the  lung  will  also  be  in  proportion,  first  to  the  amount  of  the 
efTusion  ;  and,  secondly,  to  the  rapidi/y  Avith  which  it  has  taken  place.  When 
the  effusion  has  been  slow — or  when  it  has  long  existed,  and  the  case  has  become 
chronic — the  circulation  through  the  lung  has  had  time  to  accommodate  itself  to  the 
altered  condition  of  the  parts,  the  disturbed  equilibrium  bt?tween  the  quantit)'-  of  air 
and  the  quantity  of  blood  in  the  lung  is  restored,  and  the  dyspncca  is  consequently 
shght. 

But  there  are  very  singular  exceptions  met  with  to  all  this.  Andral  states  (and  1 
have  seen  more  than  one  instance  confirmatory  to  his  statement')  that  there  are  per- 
sons with  pleuritic  effusion  enough  not  merel\^  to  fill  but  to  dilate  that  side  of  the 
chest  on  which  it  exists,  (and  you  will  observe  that  we  cannot  doubt  about  the  pre- 
sence of  the  effusion  in  such  a  case,)  who  appear  nevertheless  to  be  quite  free  from 
dyspncea;  and  that,  not  while  they  are  at  rest  merely,  for  the}'-  talk,  get  up,  walk 
about,  even  take  long  journeys,  without  their  respiration  becoming  so  short  as  to 
make  them  complain  of  it.  Now  this  is  conceivable  enough  in  old  and  chronic  cases  ; 
but  Andral  further  affirms  that  this  absence  of  dyspnea  is  not  restricted  to  those 
cases  in  which  the  collection  of  fluid  has  taken  place  slowly  ;  but  sometimes  happens, 
even  in  patients  in  whom  pleurisy  has  Ld  to  abundant  effiision  in  a  few  days.  He 
gives  a  case  of  this  kind,  in  which  the  patient  was  not  prevented  by  an  enormous 
pleuritic  effusion  from  carrying  on,  without  fatigue,  in  the  streets  of  Paris,  his  busi- 
ness as  a  carter.  I  remember  having  a  butcher  in  the  Middlesex  Hospital  in  ex- 
actly the  same  predicament ;  and  nothing  could  persuade  him  that  he  was  otherwise 
than  well,  and  fit  to  go  out ;  and  out  accordingly  he  went.  Remember,  therefore, 
that  there  are  great  varieties  in  this  respect.  In  some  patients  the  dyspnoea  never 
ceases  to  be  urgent  from  first  to  last ;  and  these  are  apt  to  prove  fatal  cases.  In  others 
the  respiration  is  very  much  impeded  at  first ;  then  the  difficulty  of  breathing  di- 
minishes;  and  at  length  it  ceases  long  before,  the  fluid  is  reabsorbed.  In  others 
again,  by  some  unaccountable  idiosyncrasy,  the  respiration  remains  at  all  times  very 
facile,  both  at  the  outset  and  during  the  progress  of  the  disease. 

Cough  is  another  of  the  ordinary  symptoms  of  pleurisy.  It  does  not  occur  in 
paroxysms.  It  is  small,  half-suppressed,  ineffectual.  In  some  few  cases  this  symp- 
tom also  is  entirely  absent,  even  though  the  inflammation  is  intense,  and  the  efllusion 
into  the  pleura  considerable.  When  cough  does  exist,  it  is  dry  ;  or  it  is  accompanied 
by  the  expectoration  of  slight  catarrh.  If  much  frothy  mucus  should  be  expectorated, 
the  pleurisy  is  complicated  with  bronchitis:  if  rust-coloured  sputa  be  brought  up,  it 
is  complicated  with  pneumonia:  and  in  each  case  other  signs,  proper  respectively  to  , 
those  iwo  diseases,  will  be  present. 

A  good  deal  has  been  said  and  written  respecting  the  position  which  a  patient 
assumes  who  is  labouring  under  pleurisy.  The  manner  of  the  decubitus  has  even 
beeii  regarded  as  one  of  the  pathognomonic  signs  of  the  disease.     Yet,  strange  to 


PLEURISY.  587 

say,  observers  are  much  at  variance  with  each  other  in  respect  to  this  so-called 
pathognomonic  symptom.  Some  affirm  that  the  patient  hes  on  the  side  affected  ; 
others  that  he  can  He  only  on  the  sound  side ;  others  ajjain  that  he  lies  neither  on 
the  one  side  nor  on  the  other;  or  even  that  he  lies  indifferently  in  any  posture.  But 
this  dispute  is  an  exact  counterpart  of  that  celebrated  quarrel  which  took  place  about 
the  colour  of  the  chameleon:  "they  all  are  right,  and  all  are  wrong."  I  believe 
that,  if  you  narrowly  inquire  into  the  facts,  they  will  be  found  to  be  somewhat  as 
follows : — In  the  outset  of  the  disease,  while  there  is  yet  pain,  the  patient  cannot  he 
on  the  affected  side  on  account  of  the  pain,  which  that  position  exasperates ;  he  lies 
therefore  on  the  sound  side,  or  on  his  back  ;  sometimes  he  is  obliged  to  sit  up.  At 
a  more  advanced  period  of  the  disease,  when  the  pain  has  ceased,  and  considerable 
effusion  has  taken  place,  he  cannot  lie  on  the  sound  side,  because  of  dyspnoea :  the 
dilatation  of  the  chest  on  that  side  would  be  impeded  by  such  a  posture ;  and  what 
is  more,  the  effusion,  lying  uppermost,  would  press  upon  the  mediastinum,  and  so 
further  tend  to  restrain  the  expansion  of  the  sound  lung.  But  he  is  no  longer  pre- 
vented by  pain  from  tying  on  the  diseased  side,  and  consequently  he  does,  in  some 
instances,  take  that  position:  but  more  commonly  still  he  lies  in  what  Andral  calls  a 
diagonal  posture  ;  i.  e.,  the  patient  is  not  on  his  back,  nor  on  his  side,  but  between 
the  two ;  on  his  back,  we  may  say,  but  inclining  towards  the  affected  side.  Again, 
however  the  fact  maybe  explained,  it  is  certain  that  there  are  some  few  persons  who 
lie  indifferently  on  the  back  or  on  either  side  without  augmentation  of  the  dyspnoea 
in  any  of  these  positions,  though  one  side  is  choke-full  of  liquid. 

Now  of  the  symptoms  that  we  have  hitherto  been  considering,  the  pain,  the 
dyspncEa,  the  cough,  the  accommodation  of  position,  there  is  not  one  which,  taken 
alone,  can  be  said  to  be  strictly  or  absolutely  pathognomonic;  or  which  indicates  in 
a  positive  and  certain  manner  the  existence  of  pleurisy,  or  of  pleuritic  efflision.  Yet 
when  all,  or  several  of  them,  occur  together,  they  afford  a  degree  of  probability  on 
these  points  almost  equivalent  to  certainty.  There  are  yet  some  other,  and  more 
conclusive  signs,  which  either  in  themselves,  or  taken  in  conjunction  with  those 
already  mentioned,  render  the  diagnosis  of  pleurisy  easy  and  sure.  These  signs  are 
furnished  by  the  size  of  the  thorax  on  the  affected  side ;  by  its  form  and  motions ; 
and  above  all,  as  you  will  have  anticipated,  by  percussion  and  auscultation. 

I  have  already  stated  that  in  some  cases,  that  side  of  the  chest  which  contains  the 
effused  fluid  becomes  evidently  larger  than  the  opposite  side.  The  ribs  and  their 
cartilages  present  that  position  which  they  assume  during  a  deep  inspiration :  the 
intercostal  spaces  are  pushed  outwards  and  brought  up  to  the  level  of  the  ribs ;  and 
occasionally  fluctuation  may  be  perceived  in  those  spaces,  through  the  muscles. 
When  these  appearances  are  observable,  no  doubt  (or  scarcely  a  doubt)  can  remain 
concerning  the  nature  of  the  disease.  This  dilatation  of  the  thorax  on  the  diseased 
side  is  more  common  in  old  chronic  cases  than  in  the  earlier  periods  of  acute  pleu- 
risy ;  yet  it  may  take  place  in  a  very  short  time.  Andral  declares  that  he  has  known 
it  sometimes  reach  a  great  degree  by  the  fourth  or  fifth  day  of  the  acute  disease. 
You  may  satisfy  yourselves  that  the  side  is  dilated,  by  measuring  it  with  a  string. 
Carry  a  string  round  the  chest,  upon  a  level  with  the  extremity  of  the  xyphoid 
cartilage,  then  fold  it  upon  itself,  and  you  will  find  that  the  half  of  it  will  more  than 
encompass  the  sound  moiety  of  the  chest,  and  will  not  reach  round  the  disease.  The 
diseased  side  may  measure  an  inch,  or  an  inch  and  a  half,  or  even  sometimes  two 
inches,  more  than  the  other.  But  this  measurement  by  a  string  is  seldom  necessary. 
The  eye  takes  a  very  accurate  estimate  of  the  comparative  volume  of  the  two  sides  ; 
and  the  obliteration  of  the  intercostal  spaces  can  only  be  ascertained  by  seeing  or 
feehng  them.  It  is  necessary  to  remember  that,  in  most  persons,  the  right  side  is 
naturally  somewhat  the  larger  of  the  two. 

I  say  when  this  dilatation  is  noticed,  scarcehj  a  doubt  can  exist  of  the  true  nature 
of  the  case.  Some  time  ago  I  should  have  said  no  doubt :  but  having  myself  mis- 
taken such  a  case,  and  seen  others  mistake  it,  I  introduce  this  slight  qualification, 
although  it  is  a  thousand  to  one  against  another  such  instance  occurring  to  puzzle  or 
mislead  the  observer.  My  colleague  Dr.  Hawkins  had  a  patient  in  the  hospital,  in 
whom  this  dilatation  of  one  side  of  the  chest  was  exceedingly  well  marked.     It  was 


588  PLEURISY 

the  left  side  that  was  enlarged ;  the  heart  was  evidently  pushed  over  to  the  right  of 
the  sternum.  This  is  another  circumstance  strongly  corroborating  our  conclusion  in 
such  cases.  The  intercostal  spaces  were  effaced,  and  the  whole  of  that  side  was 
perfi  ctly  dull  on  percussion.  The  poor  fellow  had  a  very  unhealthy  aspect ; — and 
he  had,  some  time  before,  suffered  ampatation  of  a  leg,  for  what  was  understood  to 
have  been  scrofulous  disease  of  the  knee-joint.  It  was  not  unnatural,  therefore,  that 
every  one  who  saw  him  should  have  come  to  the  conclusion  that  this  was  a  case  of 
empyema ;  of  fluid,  and  most  likely  of  pus,  collected  in  the  pleura,  and  very  proba- 
bly the  result  of  the  extension  of  scrofulous  disease  from  the  lungs.  Under  these 
circumstances,  and  inasmuch  as  his  dyspnoea  was  not  urgent,  it  was  not  thought 
right  to  take  any  steps  for  evacuating  the  presumed  fluid.  The  case  was  pointed, 
out  to  ihe  pupils  as  a  capital  example  of  empyema.  At  length  the  patient  died  ;  and 
when  his  body  was  examined  we  discovered — what  think  you  ?  not  pus,  nor  serum, 
but  a  larire  red  solid  mass,  in  the  centre  of  which,  when  it  was  divided,  was  still  a 
red,  but  softer,  pultaceous,  half-fluid  substance.  At  first  it  was  thought  to  be  can- 
cerous degeneration  of  the  lung;  but  it  was  soon  noticed  that  the  solider  part  was 
arranged  in  concentric  layers,  like  those  which  are  often  seen  in  aneurismal  tumours  ; 
and  further  research  showed  that  the  effusion  had  indeed  once  been  liquid,  for  it 
consisted  entirely  of  blood,  which  had  coagulated  in  the  manner  I  have  just  described. 
And  the  source  of  the  blood  was  detected.  A  portion  of  two  of  the  ribs  had  been 
destroyed  by  ulceration,  and  one  of  the  intercostal  arteries  had  thus  been  laid  open. 
The  lung  was  found  uninjured,  but  totally  empty  of  air,  and  pressed  flat  up  against 
the  mediastinum. 

No  precaution  could  guard  against  such  a  source  of  fallacy ;  and  you  are  not 
likely  ever  to  meet  with  just  such  another  case:  yet  I  have  thought  it  sufficiently 
interesting  to  relate,  in  illustration  of  the  subject  immediately  before  us. 

It  is  unfortunate,  as  far  as  the  diagnosis  is  concerned  (but  not  in  any  other  sense), 
that  dilatation  of  the  thorax  is  far  from  being  a  constant  symptom,  even  in  cases  in 
■which  the  effusion  is  verj^  considerable. 

There  is  still  a  condition  of  the  thorax  to  be  described,  which  is  the  very  opposite 
to  this.  When  the  effused  fluid  begins  to  be  reabsorbed — and  when  some  cause  or 
other,  generally  the  formation  of  adventitious  membranes,  prevents  the  lung  from 
re-expanding,  and  approaching  the  ribs  in  proportion  as  the  fluid  is  removed — then 
of  course  the  ribs  jjiust  sink  in,  and  approach  the  lung,  to  prevent  that  void  which 
would  otherwise  exist  between  the  ribs  and  the  lung.  Consequently  that  side  of  the 
chest  on  which  the  fluid  has  existed  becomes  narrower  than  the  sound  side.  And 
the  actual  diflerence  between  the  two  will  be  augmented  by  the  circumstance  that, 
in  such  cases,  an  amphfication  of  the  sound  lung,  and  of  the  cavity  in  which  it  is 
lodged,  a  true  compensatory  hypertrophj',  commonly  takes  place. 

This  partial  or  general  retraction  of  one  side  of  the  chest  is  not  so  much  a  sign  of 
disease  actually  in  progress,  as  of  disease  gone  by ;  and  it  may  exist  without  evident 
disturbance  of  the  health  of  any  kind. 

Persons  who  are  thus  affected  have  the  appearance  of  being  inclined  towards  the 
diseased  side,  even  when  they  endeavour  to  hold  themselves  upright:  and  the  de- 
formity, for  such  it  is,  becomes  manifest  to  the  eye  when  the  chest  is  uncovered. 
You  see  that  the  side  is  narrowed  and  shrunken.  All  its  dimensions  are  contracted. 
It  measures  less,  in  circumference,  by  an  inch  or  more,  than  the  other  side.  The 
shoulder  is  depressed ;  the  hypochondrium  is  tucked  up ;  and  the  libs  are  drawn 
close  together.  A  patient  of  mine,  whose  chest  had  been  punctured  (a  remedial 
procedure  to  be  spoken  of  presently),  and  who  drew  off  daily,  with  a  syphon,  pus 
which  did  not  otherwise  find  vent,  had  such  difficulty  at  last  in  introducing  the  tube 
between  his  ribs,  that  excision  of  a  piece  of  the  bone  was  contemplated  by  the  emi- 
nent surgeon  who  had  performed  the  operation.  The  effect  of  the  atmospheric 
pressure  is  sometimes  so  great  as  to  crook  the  vertebral  column,  and  produce  lateral 
curvature  of  the  spine.  This  I  have  myself  witnessed.  And  as  one  of  the  unseen 
walls  of  the  cavity,  viz.,  a  part  of  the  diaphragm,  is  carried  permanently  up  under 
tne  ribs,  so  another  of  the  unseen  walls,  the  mediastinum,  is  liable  to  be  influenced 
by  the  tendency  to  contraction.    The  heart  w4iich,  when  the  left  pleura  is  distended, 


PLEURISY.  589 

IS  apt  to  be  thrust  over,  beyond  the  sternum  on  the  right,  may  thus,  when  the  nght 
pleura  is  contracted,  be  dragged  into  the  same  position.  In  the  former  case,  the 
dull  sound  given  out  by  the  diseased  side  when  struck,  will  transgress  the  mesial 
line,  and  encroach  a  hltle  upon  the  healthy  side  :  in  the  latter,  the  resonance  yielded 
by  the  healthy  will  transgress  the  mesial  line,  and  encroach  a  little  upon  the  diseased 
side. 

The  difference  of  the  two  sides  is  so  striking,  that,  at  first  sight,  an  observer  sup- 
poses it  to  be  even  greater  than  it  is  actually  found  to  be  by  admeasurement.  Yet 
Laennec  tells  us  that  he  had  met  with  this  deformity  in  persons  who  were  not  them- 
selves aware  of  its  existence.  But  all  such  persons  had  suffered  some  long  disease, 
which  appeared  to  be  shuated  chiefly  in  the  thorax. 

The  conditions  I  have  just  been  describing  are  physical  conditions  ;  and  the  signs 
they  furnish  are  physical  signs.  I  have  still  to  speak  of  the  remaining  physical 
signs,  which  are  also  auscultatory  signs.  What  I  have  already  said  upon  this  sub- 
ject in  the  present  lecture  will,  I  trust,  enable  you  almost  to  foresee  the  kind  of 
information  which  these  signs  afford  in  actual  practice. 

As  soon  as  even  a  slight  amount  of  effusion  commences  in  the  pleura,  it  is  an- 
nounced by  a  diminution  of  the  hollow  sound  which  percussion  elicits  in  the  healthy 
state.  In  proportion  as  the  effusion  becomes  more  considerable,  the  chest,  when 
struck,  gives  a  sound  more  and  more  dull.  At  first,  this  flat  sound  is  rendered  oppo- 
site the  lowermost,  depending  part  only  of  the  cavity ;  and  this,  as  I  showed  you 
before,  forms  one  ground  of  distinction  between  the  dullness  on  percussion  in  pleu- 
risy, and  in  pneumonia.  However,  at  length,  the  effusion  augmenting,  the  dead  flat 
sound  may  proceed  from  the  whole  of  the  affected  side ;  and  this  forms  another 
ground  of  distinction  ;  for  it  is  very  seldom  that  the  whole  lung  becomes  so  solid  in 
pneumonia  as  to  yield  a  uniform  dead  sound  over  the  whole  of  one  side  of  the  chest. 
Either  the  dull  sound  is  universal  on  one  side,  or  it  is  not.  If  universal,  it  is  not 
likely  to  be  the  result  of  solidification  by  pneumonia;  or,  I  may  add,  by  tubercles  : 
if  not  universal,  the  dull  sound  will  (except  in  some  rare  cases),  shift  its  place  as  the 
patient  alters  his  posture. 

I  may  mention  another  ground  of  diagnosis,  which  may  be  of  great  assistance 
when  the  case  is  seen  from  the  beginning.  The  dullness  comes  on  much  more 
quickly  in  pleurisy  than  in  pneumonia.  It  has  been  noticed  within  twelve  hours 
from  the  invasion  of  the  disease.  In  living  animals,  a  considerable  quantity  of  serous 
effusion  has  often  been  very  rapidly  produced  by  injecting  some  slightly  irritant 
matter  into  the  cavity  of  the  pleura.  In  pneumonia,  the  dullness  is  commonly  later 
in  its  appearance.  The  induration  of  the  lung  is  gradual;  and  so  is  the  pneumonic 
dullness  on  percussion :  the  effusion  of  serous  fluid  is  early  and  rapid  ;  and  so  also 
is  the  coming  on  of  the  pleuritic  dullness.  Moreover,  as  I  have  just  shown  you, 
pleurisy  may  displace  the  mediastinum,  and  cause  the  whole  sternum  to  give  a  dull 
sound.     A  hepatized  lung  will  render  one-half  on]y  of  it  dull. 

The  intensity,  or  completeness  too  of  the  dull  sound  is  generally  greater  in  pleurisy 
than  in  pneumonia.  In  two  days,  or  even  in  twenty-four  hours  the  whole  cavity  of 
the  pleura  on  one  side  may  be  filled  quite  full ;  and  the  whole  of  the  corresponding 
surface  of  the  chest,  from  its  base  to  its  summit,  will  yield  a  sound  (to  use  one  of 
Avenbrugger's  strong  expressions)  tanquam  percussi  femoris.  It  is  very  uncommon 
for  such  total  and  universal  matite,  as  the  French  call  it,  to  result  from  inflammation 
of  the  lung. 

Again,  in  the  outset  of  the  disease,  while  there  is  yet  little  or  no  effusion,  but 
when  the  pain  is  acute,  the  vesicular  breathing  is  heard  more  faintly  and  feebly  on 
the  painful  side  than  on  the  other.  On  that  side  also  the  walls  of  the  chest  are  less 
forcibly  expanded.  But  percussion,  when  the  pain  will  permit  of  its  being  practised, 
gives  the  same  sound  on  each  side.  It  is  clear  that  the  sharpness  of  the  pain  causes 
the  patient  instinctively  to  expand  the  chest  on  that  side  as  little  as  possible,  and 
consequently  the  quantity  of  air  that  penetrates  the  lung  in  a  given  time  is  diminished, 
and  the  respiratory  murmur  is  feeble. 

As  soon  as  efliision  commences,  the  vesicular  rustle  is  heard  still  less  plainly  on 
the  affected  side ;  and  in  proportion  as  the  fluid  increases,  that  rustle  or  murmur  be- 

2z 


590  PLEURISY. 

comes  more  faint ;  and  at  the  same  time  it  becomes  more  distinct  and  noisy  than 
natural — puerile,  in  fact — on  the  sound  side.  And  while  the  respiratory  murmur  is 
disappearing  on  the  diseased  side,  and  the  spongy  lung  is  becoming  empty  of  air 
from  the  pressure  of  the  augmenting  fluid,  and  the  larger  bronchi  are  surrounded  by 
con)pressed  lung  and  by  incompressible  liquid,  the  bronchial  sounds  begin  to  be 
heard,  which  I  formerly  described — the  bronchial  voice,  the  bronchial  respiration. 
But  the  sounds  are  not  exactly  the  same  as  those  which  are  heard  in  pneumonia. 
They  are  modified  by  the  nature  of  the  substances  through  which  they  pass.  The 
voice,  for  example,  is  still  bronchial,  still  the  voice  of  a  person  talking  into  a  tube : 
but  it  has  a  superadded  character ;  it  is  trembling,  quivering,  thrilling,  cracked,  dis- 
cordant. I  strive  in  vain  to  convey  to  you  by  these  epithets  a  notion  of  this  remark- 
able modification  of  the  voice.  Laennec's  happy  similitudes  may  enable  you  to 
form  a  more  exact  conception  of  it.  It  is  hke  (he  says)  the  bleating  of  a  goat;  or, 
happier  still,  it  resembles  the  voice  of  Punch.  But  when  once  you  have  heard  the 
sound,  you  will  never  forget  it  again.  I  presume  that  this  modification  of  broncho- 
phony (for  such  it  is,  and  such  I  would  have  you  consider  it),  is  caused  by  the  rapid 
undulations  communicated  to  the  effused  liquid  by  the  vibrations  of  the  bronchi  and 
condensed  pulmonary  tissue.  This  sound  is  usually  most  distinctly  heard  near  the 
inferior  angle  of  the  scapula,  the  patient  being  in  a  sitting  position.  It  disappeai-s, 
or  merges  into  pure  and  distant  bronchophony,  when  the  liquid  exceeds  a  certain 
amount,  so  as  to  compress  the  bronchial  tubes  themselves,  and  to  dcimji  their 
vibration. 

I  would  have  you  recollect,  therefore,  that  jegophony,  which  is  the  technical  ap- 
pellation of  the  sound  I  have  just  been  describing  (goat-voice), — aegophony  is  nothing 
more  than  a  species  or  variety  of  bronchophony;  and  the  two  run  each  into  the  other 
by  such  fine  gradations,  that  it  is  sometimes  difficult  to  say  which  it  is  we  are  listen 
ing  to.  When  the  quivering  is  strongly  marked,  we  may  be  certain  that  it  denotes 
effusion  into  the  pleura ;  when  bronchophony  only  is  heard,  we  cannot  be  sure,  froir 
that  sound  alone,  whether  there  be  indurated  lung  between  the  ear  and  the  bronchi 
or  a  liquid,  and  a  portion  of  compressed  and  condensed  lung:  but  other  phenomena 
complete  the  diagnosis. 

Do  not  forget  that  when  any  modification  of  the  voice  is  heard,  or  thought  to  be 
heard,  on  the  suspected  side,  the  sound  of  the  voice  in  the  corresponding  part  of  the 
other  side  of  the  chest  must  be  ascertained  also.  It  is  only  by  a  comparison  of  the 
two  sides  that  we  can  come  to  any  safe  conclusion ;  and  that  comparison  becomes 
often  a  striking  and  most  instructive  contrast. 


LECTURE  LIIl. 


Pleurisy  continued.  Recapitulation  of  Symptoms  ;  of  Diagnostic  Signs.  Causes 
of  Pleurisy.  Pneumothorax;  its  Conditions  and  Signs.  Treatment  of  Pleu- 
risy.    JSmpyema.     Paracentesis  Thoracis. 

In  the  last  lecture  I  enumerated  the  symptoms,  general  and  physical,  which  are 
met  with,  more  of  them  or  fewer,  in  cases  of  acute  pleurisy.  I  then  considered  them 
singly :  it  may  be  well  to  take  a  rapid  recapitulatory  view  of  them  as  they  exist 
together  or  in  succession,  and  compose  the  actual  disease. 

The  outset,  then,  of  pleurisy  is  marked  by  sharp  stabbing  pain,  most  commonly 
situated  beneath  one  of  the  breasts,  and  preceded  or  accompanied  by  rigors.  These 
two  signs,  the  stitch  and  the  shivering,  are  sufficient  of  themselves  to  awaken  a 
strong  suspicion  that  pleuritis  has  set  in.  At  the  same  time  there  are  usually  a  dry 
cough;  a  dread  of  breathing;  a  check  or  catch  in  the  inspiration,  which  is  curbed, 
so  to  speak,  by  the  pain ;  fever ;  often  a  comparatively  feeble  respiratory  murmur 
on  that  side  on  which  the  pain  is  felt ;  and  the  patient  cannot  lie  on  that  side.     If  no 


PLEURISY.  591 

liquid  effusion  takes  place,  these  symptoms  ordinarily  disappear  at  the  end  of  a  few 
days,  and  the  patient  recovers.  The  case  has  been  a  case  of  dry  pleurisy ;  and  the 
chances  are  much  in  favour  of  the  lung  having  become  permanently  adherent  to  the 
ribs. 

I  should  have  said,  with  respect  to  the  fever,  that  at  the  outset  of  the  pleurisy  it 
is  often  high.  And  it  was  matter  of  observation  long  before  the  method  of  ausculta- 
tion was  thought  of,  as  well  as  since,  that  in  the  acute  period  of  the  disease  the  pulse 
is  remarkable  for  its  hardness,  and  forms  a  contrast  with  the  soft  pulse  of  pneumonia, 
and  with  the  small  and  contracted  pulse  of  inflammation  of  the  serous  membranes 
of  the  abdomen.  Indeed,  the  older  physicians  laid  great  stress  upon  the  quality  of 
the  pulse,  in  their  endeavours  to  distinguish  pleurisy  from  pneumonia. 

But  to  resume  the  description  of  the  symptoms  of  pleuritis.  Where  effusion 
takes  place  (and  it  does  so  very  early,  so  as  to  form  a  part  of  the  complaint,  just  in 
the  same  sense  in  which  expectoration  forms  a  part  of  catarrh),  the  sound  elicited  by 
percussion  becomes  dull  on  the  side  on  which  the  effusion  exists.  While  the  effu- 
sion is  moderate,  the  dullness  shifts  its  place  according  to  the  posture  of  the  patient, 
and  is  heaid  only  when  the  lowermost  part  of  the  chest  is  struck.  But  the  fluid 
may  soon  increase  so  much  as  completely  to  fill  the  pleura ;  and  then  the  whole  of 
that  side  is  dull.  Meanwhile  the  murmur  of  respiration  becomes  feeble  and  faint, 
and  at  length,  as  the  effusion  augments,  ceases  altogether;  while  on  the  sound  side 
it  grows  noisy  and  puerile.  Tubular  breathing,  and  that  modification  of  the  bron- 
chial voice  which  medical  men  have  agreed  to  call  aegophony,  become  audible  during 
the  early  periods  of  the  effusion,  ^gophony  is  heard,  however,  only  so  long  as  the 
quantity  of  liquid  poured  out  observes  a  specific  limit.  There  must  be  a  certain 
amount  of  effusion — and  there  must  not  be  more  than  a  certain  amount.  I  have 
sometimes  thought  that  the  peculiar  sound  depended  on  the  undulations  produced  in 
the  surface  of  the  liquid  by  the  bronchial  vibrations.  It  certainly  is  somehow  con- 
nected with  the  presence  of  a  stratum  of  liquid  between  the  lung  and  the  ear.  When 
the  lung  is  strongly  compressed,  and  especially  when  the  cavity  is  stretched  and  dis- 
tended by  the  enclosed  fluid,  the  side  is  necessarily  motionless ;  no  tubular  or  other 
breathing  can  any  longer  be  heard,  or  even  occur  :  nor  is  the  voice  conducted,  except 
perhaps  very  faintly,  to  the  listening  ear  of  the  physician. 

When  the  effiasion  is  great,  that  side  of  the  thorax  on  which  it  has  taken  place 
becomes,  often,  more  or  less  dilated ;  and  I  should  add,  that  the  integuments  on  the 
same  side  are  frequently  cedematous.  The  patient  now  cannot  lie  on  the  sound 
side ;  and  the  most  common  posture  is  that  which  is  intermediate  between  the 
supine  position  and  the  lateral ;  he  lies  towards,  but  not,  in  general,  on,  the  affected 
side. 

I  observed,  in  the  last  lecture,  that  this  inabihty,  after  the  effusion  has  reached  a 
certain  point,  to  lie  on  the  sound  side,  might  be  accounted  for  in  two  ways.  Partly 
it  rnay  be  owing  to  the  impediment  which  lying  on  the  sound  side  offers  to  that  side's 
expansion.  The  muscles  which  dilate  the  healthy  side  have  then  to  lift,  as  it  were, 
the  weight  of  the  body,  and  are,  some  of  them,  pressed  upon  and  encumbered  in 
their  action  by  that  posture.  But  the  inability  in  question  is  chiefly  attributable  to 
another  circumstance,  viz.,  the  pressure  exercised  by  the  efftised  fluid  downwards, 
through  the  mediastinum,  upon  the  only  lung  that  is  left  to  perform  the  function  of 
breathing.  Now,  disputes  or  differences  of  opinion  have  arisen  as  to  which  of  these 
two  circumstances  is  the  most  efficient  cause  in  this  matter  ;  and  therefore  it  may  not 
be  amiss  to  provide  you  with  the  facts  which  prove  that  the  last-mentioned  cause  is, 
in  reality,  the  most  operative — I  mean  the  weight  of  the  superincumbent  liquid,  in 
the  supposed  position,  upon  the  mediastinum  and  upon  the  healthy  lung  below  it. 
This  is  shown  by  the  fact  that  patients,  to  whom  the  decubitus  on  the  sound  side 
had  previously  been  impossible,  on  account  of  dyspncea,  have  been  able  to  rest  in 
that  position  hnmediutdy  cfler  the  artificial  evacuation  of  the  fluid.  Now,  in  such 
a  case,  the  obstruction  to  the  dilatation  of  the  heahhy  side,  produced  by  placing  it 
under  the  weight  of  the  body,  would  remain  the  same  as  before,  or  nearly  so.  A 
hospital  patient  of  mine,  named  Coggs,  could  not  breathe  if  he  attempted  to  lie  on 
hi"  right  side.     His  left  pleura  was  distended  by  liquid  effusion.     I  thought  fit  to 


/ 


592  PLEURISY. 

have  paracentesis  performed  ;  and  the  poor  man  was  greatly  delighted  to  find  him 
self  at  once  enabled  by  it  to  assume  the  posture  which  his  weariness  had  long  made 
him  wish  for,  but  which  he  had  not  been  capable  of  enduring.  We  found  by  per- 
cussion that  the  diseased  side  was  now  filled  with  air  ;  the  compressed  lung  had  not 
risen  at  all;  so  that  the  necessity  for  the  free  expansion  of  the  sound  side  was  just 
as  great  as  before  the  operation.  You  may  find  a  precisely  similar  consequence  of 
the  same  operation  related  in  the  fifth  volume  of  the  Dublin  Transactions. 

The  cede  ma  that  is  sometimes  observed  on  the  diseased  side  is  more  or  less  con- 
nected, probably,  with  the  habitual  position  of  the  patient. 

There  is  yet  another  sign  of  pleuritic  effusion,  M-hich,  as  it  is  very  simple,  and 
readily  perceived  by  even  the  least  instructed  observer,  is  too  valuable  to  be  neglect- 
ed. In  most  persons,  one's  open  hand,  laid  flat  upon  the  surface  of  the  chest,  feels 
the  vibration  or  thrill  which  the  voice  occasions  when  the  person  speaks.  Now,  in 
a  case  of  pleurisy  with  effusion,  you  will  generally  find  a  remarkable  contrast  be- 
tween the  two  sides  in  this  respect ;  {.  e.,  the  thrill  is  strong  and  evident  on  the  sound 
side,  and  not  perceptible  at  all  on  the  other.  Whereas,  when  the  whole  side  is  dull 
in  consequence  of  solidity  of  the  lung,  the  thrill  is  much  augmented  on  that  side. 
But  this  thrill  is  not  always  present  in  the  healthy  state,  and  then  we  can  infer 
nothing  from  its  absence  on  the  diseased  side. 

After  a  while,  when  the  fever  has  ceased,  the  liquid  begins  to  be  reabsorbed  :  but 
as,  in  many  cases,  the  lung  is  more  or  less  bound  down  by  adhesions,  or  overlaid  by 
a  membranous  stratum  of  lymph,  it  cannot  expand  in  proportion  as  the  liquid  is  re 
moved :  and  the  necessary  consequence  is,  that  shrinking  of  the  affected  side  in  all 
its  dimensions,  which  I  fully  described  yesterday. 

Let  me  now  briefly  re-state  the  points  of  distinction  between  pleuritic  effusion  and 
pneumonic  consolidation,  when  the  one  or  the  other  of  these  two  morbid  conditions 
is  proved  to  exist  by  dullness  on  percussion,  extending  over  the  whole  of  one  side 
of  the  chest.  The  question  is  one  which  frequently  arises  ;  and  it  is  one  of  much 
interest  and  importance. 

First,  then,  we  distinguish  these  different  conditions,  having  some  physical  signs 
in  common,  by  their  history.  In  pleurisy,  sharp  pain,  and  a  dry  cough,  or  perhaps 
no  cough,  precede  the  dullness :  and  we  have  not  the  crepitation,  nor  the  rust- 
coloured  sputa,  which  are  antecedent  to  the  dullness  of  pneumonia. 

We  cannot,  however,  always  learn  the  previous  history  of  a  given  case. 

Secondly,  a  lung  rendered  solid  by  inflammation  does  not  distend  the  cavity. 
Copious  pleuritic  effusion  most  frequently  does.  In  the  first  case,  therefore,  we 
have  not  that  separation  of  the  ribs,  that  obliteration  of  the  intercostal  depressions, 
that  protrusion  of  the  corresponding  hypochondrium,  that  mensurable  enlargement 
of  the  side,  that  extension  of  the  dull  sound  beyond  the  middle  of  the  sternum,  or 
that  displacement  of  the  heart,  which  are,  some  or  all  of  them,  apt  to  result  from  a 
collection  of  liquid  in  the  pleura. 

Thirdly,  the  solid  lung  transmits  the  voice  from  the  pervious  bronchi  to  the  sur- 
face of  the  thorax ;  and  if  any  motion  of  the  affected  side  remains,  it  transmits  also 
the  sound  made  by  the  passage  of  the  air  through  them.  These  phenomena  are 
wanting  when  the  pleura  is  so  stretched  by  its  hquid  contents  as  to  make  the  side 
everywhere  dull  to  percussion. 

Fourthly,  the  vibration  of  the  thoracic  parietes,  caused  by  the  patient's  voice,  is 
augmented  by  consolidation  of  the  lung ;  prevented  when  it  is  strongly  compressed 
by  imprisoned  liquid.  The  increase  of  this  thrill  can  be  felt  therefore  in  the  one 
case  ;  its  diminution  in  the  other. 

The  simple  test  fails  to  be  applicable  when,  from  the  feebleness,  or  the  high  pitch, 
of  the  person's  voice,  no  thrill  is  perceptible  on  either  side  in  the  healthy  state. 

Fifthly,  a  patient  having  one  lung  solid,  is  generally  indifferent  as  to  posture.  A 
patient  having  one  pleura  quite  full  of  liquid,  lies  (usually)  on  or  towards  that  side ; 
and  is  distressed  and  suffers  dyspnoea  if  he  attempts  to  lie  on  the  other. 

It 's  of  more  importance  that  we  should  inquire  into  the  exciting  causes  of  pleu 
risy  than  ii.to  those  which  give  rise  to  pneumonia.     They  are  more  numerous  and 


PLEURISY.  593 

complicated,  and  have  a  more  direct  bearing  upon  the  prognosis  and  treatment  in  the 
one  case  than  in  the  other.  I  do  not  desire  to  refine  too  much ;  and  therefore  I  shall 
restrict  myself  to  those  causes  which  are  obvious,  and  which  you  are  likely  to  meet 
with  in  practice. 

1  merely  say  of  exposure  to  cold,  as  an  exciting  cause  of  pleurisy,  that  it  is  a  very 
common — the  most  common — cause.  You  know  already  all  that  I  can  tell  you  of 
the  circumstances  that  are  likely  to  render  that  cause  effectual  in  producing  internal 
inflammations,  and,  among  the  rest,  pleuritic  inflammation. 

But  pleurisy  is  often  occasioned  by  mechanical  violence;  or  by  the  accidental 
extension  of  disease  from  other  parts ;  and  the  course,  and  the  event  of  the  disease, 
are  liable  to  be  considerably  modified  by  the  nature  of  its  cause  in  such  cases. 

Pleurisy  may  be  excited  by  the  splintered  ends  of  a  broken  rib ;  and  if  the  pul- 
monary pleura  be  wounded  in  that  manner,  air  may  get  into  the  pleural  cavity,  as 
well  as  into  the  areolar  tissue  beneath  the  skin  ;  constituting  the  true  and  genuine 
emphysema  of  our  forefathers.  Pleurisy  may  be  determined  also  by  a  penetrating 
wound  of  the  thorax ;  or  by  a  perforating  ulcer  of  the  pulmonary  pleura,  the  exten- 
sion of  a  tubercular  excavation.  In  the  one  case  air  vi^ill  enter  from  without,  if  the 
aperture  be  sufficiently  large  ;  in  the  other,  air  will  pass  from  the  lung  into  the  cavity 
of  the  pleura.  In  all  of  these  cases  of  air  finding  its  way  into  this  serous  sac  while 
in  a  state  of  inflammation,  the  event  of  that  inflammation  is  much  more  likely  to  be 
the  effusion  of  pi(S,  than  w'hen  no  communication  exists  between  the  inflamed  mem- 
brane and  the  atmosphe-re.  This  I  have  mentioned,  and  offered  some  explanation 
of,  before.  But  another  very  curious  consequence  results  from  the  admission  of  the 
air,  and  its  coexistence  with  puriform  or  other  liquids  in  the  sac  of  the  pleura.  New 
auscultatory  signs  arise,  very  easily  appreciated,  very  instructive,  and  therefore  very 
necessary  for  you  to  be  acquainted  with. 

You  must  know  that  when  the  pleura  contains  air  alone,  the  patient  is  said  to 
have  pneumothorax  ;  and  when  (what  is  infinitely  more  common)  the  air  is  there  in 
company  with  liquid,  he  is  said  to  have  pneumothorax  with  effusion.  This  is  the 
name  given  to  that  condition  of  the  chest  by  Laennec ;  and  it  serves  its  purpose 
sufficiently  well.  I  shall  take  leave  to  employ  the  simple  term  pneumothorax,  in 
speaking  of  either  condition ;  whether  there  be  liquid  also  in  the  pleural  cavity  or 
not.  Pneumothorax,  then,  often  proceeds  from  one  or  other  of  those  causes  of  pleu- 
risy just  mentioned.  It  is  sometimes  produced  by  the  operation  of  paracentesis  tho- 
racis ;  by  the  opening  made  into  the  thorax  by  the  trocar  of  the  surgeon,  in  order  to 
let  out  its  fluid  contents;  in  plain  English,  by  tapping  the  chest.  The  modifications 
of  sound  that  resuh  are  particularly  curious.  Of  course  the  air  occupies  the  higher 
portion  of  the  cavity  and  the  liquid  the  lower,  in  whatever  position  the  patient  may 
be  placed.  And  this  being  the  case,  percussion  will  give  a  remarkably  hollow 
sound  when  made  upon  the  uppermost  part,  and  a  totally  dull  and  flat  sound  when 
made  upon  the  lowermost  part:  and  the  change  from  the  hollow  to  the  dull  sound 
will  often  take  place  quite  abruptly,  so  that  you  may  trace  out  the  exact  level  at 
which  the  surface  of  the  effused  liquid  stands.  And  if  you  reverse  the  posture  of 
the  patient,  the  resonant  and  the  dull  sounds  will  interchange  their  respective  places  : 
the  uppermost  part  always  yielding  the  clear,  and  the  undermost  the  flat  sound. 
This  is  just  what  you  would  expect.  The  result  of  the  experiment  is  the  same 
whether  you  make  it  upon  the  human  thorax,  or  upon  a  beer-barrel.  The  resonant 
part,  you  are  to  observe,  will'be  much  more  resonant  than  it  would  be  in  health — 
more  resonant  (you  have  always  the  other  lung  to  test  it  by)  than  the  corresponding 
portion  of  the  opposite  side  of  the  chest — tympanitic,  drum-like :  for  the  air  is  not 
involved  in  spongy  lung,  but  contained  in  a  free  space  ;  and  the  sound  is  not  damped, 
as  in  a  heahhy  chest  it  is  damped  somewhat,  by  the  presence  of  the  lung.  More- 
over no  respiratory  murmur  can  be  heard  where  this  tympanitic  resonance  occurs: 
nor  can  any  thrill  be  felt.  Now  I  say  all  this  is  no  more  than  you  must  have  fore- 
seen. But  the  sounds  detected  in  this  new  condition  of  things  by  the  ear  applied  to 
the  chest,  as  the  patient  breathes,  or  speaks,  or  coughs,  you  would  not,  I  think,  have 
anticipated.  You  hear  then  a  sound  which  I  must  endeavour  to  descrbe  in  words, 
but  which  you  will  scarcely  form  a  right  conception  of  till  you  have  heard  it.  and 
38  2z2 


594  PLEURISY. 

then  all  further  verbal  description  will  be  needless.  I  can  describe  it  by  simihtudes 
only.  The  patient's  breathing  is  like  the  noise  produced  by  blowing  obliquely  into 
an  empty  flask ;  and  so  the  French  have  given  the  sound  the  somewhat  magnificent 
title  of  '•  amphoric  resonance."  I  have  heard,  fifty  times  over,  exactly  the  sound  in 
question  when  I  have  been  out  shooting  in  a  rough  day,  and  the  wind  has  blown 
sidewa3's  into  the  gun-barrel.  It  is  a  ringing  metallic  sound.  When  this  is  present 
during  the  breathing,  the  voice  also  has,  even  more  strongly  in  general,  this  metallic 
character ;  and  so  has  the  cough ;  and  each  of  them  is  apt  to  be  succeeded  by  a 
tinkling  echo.  The  voice  and  cough  resemble  those  of  a  person  who  speaks  or 
coughs  into  a  deep  well :  or  with  his  head  bent  over  an  empty  copper  boiler.  The 
same  ringing  quality  is  often  heard  when  one  speaks  in  a  large  vaulted  room ;  or 
beneath  the  arch  of  a  stone  bridge.  You  may  perhaps  now  have  some  idea  of  what 
these  metallic  sounds  are.  They  are  very  singular :  and  they  are  perfectly  decisive 
(as  far  as  my  experience  has  gone)  of  the  presence  of  air  in  a  considerable  cavity, 
within  the  thorax ;  which  cavity  mostly  contains  liquid  also :  and  of  the  presence 
of  air  and  liquid  in  the  cavity  of  the  pleura  in  particular.  I  do  not  know  that  the 
liquid  is  essential :  I  do  not  believe  it  is ;  but  commonly  there  is  some  liquid,  and  a 
good  deal  of  air.  Almost  always  too — but  that  is  not  indispensable — the  cavity 
communicates  with  the  external  air,  either  through  the  walls  of  the  chest,  or  through 
the  bronchi.  Neither  is  it  necessary  that  the  cavity  should  be  in  the  pleura,  for  it 
may  be  in  the  lung:  and  when  we  come  to  speak  of  phthisis  I  shall  point  out  the 
circumstances  which  will  enable  you  to  determine  whether  the  sounds  proceed  from 
a  tubercular  cavity,  or  from  the  sac  of  the  pleura.  What  you  will  please  to  remem- 
ber is,  that  in  actual  practice,  in  ninety-nine  cases  out  of  a  hundred,  these  sounds 
will  be  found  to  denote  the  presence  of  both  air  and  liquid  in  the  cavity  of  the  pleura ; 
and  the  probable  existence  of  some  passage  of  communication  between  that  cavity 
and  the  external  air:  in  a  single  w'ord,  they  will  reveal  the  existence  of  pneumo- 
thorax. The  voice  reverberates  in  the  little  cavern  just  as  it  does  in  a  large  empty 
room  with  a  stone  roof;  and  this  is  the  best  explanation  I  can  give  you  of  the  phe- 
Tiomenon.  Sometimes,  as  you  are  listening,  especially  if  the  patient  has  recently 
changed  his  posture,  you  will  hear  a  sound  just  like  that  occasioned  by  dropping  a 
p  n's  head  into  a  glass  vase,  or  into  a  metal  basin;  and  to  this  sound  the  name  of 
metallic  tirihling  has  been  given.  It  really  often  closely  resembles  the  distant 
tinkling  of  a  sheep-bell.  This  is  supposed  to  result  from  the  dropping  of  the  liquid 
from  the  upper  part  of  the  cavity ;  or  sometimes  from  the  bursting  of  a  bubble  on 
the  surface  of  the  liquid  during  respiration.  You  may  succeed  now  and  then  in 
hearing  a  species  of  the  same  metallic  tinkling  by  applying  the  stethoscope  over  the 
stomach,  when  percussion  has  already  taught  j-ou  that  it  is  distended  with  gas,  and 
by  getting  the  patient  to  swallow  some  drink  in  successive  teaspoonfuls. 

Another  auscultatory  sound,  arising  out  of  the  same  condition,  viz.,  the  presence 
of  both  air  and  liquid  in  the  cavity  of  the  pleura,  and  known  even  as  early  as  the 
time  of  Hippocrates,  is  rendered  audible  by  siiccussion  of  the  patient's  body.  You 
lay  your  ear  upon  his  side,  and  get  him  to  give  his  body  a  sudden  jerk  or  jog ;  or 
you  get  some  one  else  to  take  him  by  the  shoulders  and  shake  him  ;  and  you  hear 
the  liquid  splashing  within :  just  as  you  hear  it  when  you  shake  a  cask  that  is 
neither  full  nor  empty  of  water.  This  is  an  unequivocal  indication  of  pneumo- 
thorax; and  demonstrates  beyond  a  doubt  that  there  are  both  air  and  liquid  in  the 
pleural  sac ;  for  no  sound  would  arise  if  there  was  liquid  only.  A  moderate  quan- 
tity of  liquid  will  make  a  greater  squash  than  a  large  quantity.  Unequivocal  I  say 
it  is,  because  one  coulJ  scarcely  be  misled  by  the  splashing  which  may  sometimes 
arise  from  wind  and  water  mingling  in  the  stomach.  I  wish  that  a  patient,  who 
was  under  my  observation  for  some  months  last  year  in  the  Middlesex  Hospital,  and 
could  produce  this  splashing  noise  at  will,  were  there  now;  for  he  was  not  a  little 
proud  of  his  fatal  gift,  and  I  should  have  brought  him  down  here  to-day,  and  given 
you  an  opportunity  of  hearing  this  sound  for  yourselves,  worth  a  dozen  descriptions 
of  it. 

It  is  surprising  how  long  this  state  of  things  within  the  thorax  may  last,  without 
Any  great  declension  of  the  patient's  general  heahh  and  strength,  even  when  the 


PLEURISY.  595 

disease  is  (as  it  mostly  is)  incurable.  Two  men,  patients  of  mine,  both  of  whom  had 
well-marked  pneumothorax  in  connection  with  tubercular  phthisis,  remained  in  the 
hospital  for  several  months ;  till,  in  fact,  I  could  conscientiously  keep  them  there  no 
longer :  and  each  of  them  went  away  in  very  tolerable  plight.  1  was  unable  to 
trace  them  afterwards,  for  they  returned  to  their  homes,  the  one  in  Ireland,  and  the 
other  in  the  north  of  Scotland. 

You  see,  then,  that  the  conditions  of  pleurisy,  and  the  symptoms  of  those  condi- 
tions, ma)'  be  modified  by  its  causes.  All  those  causes  that  imply  the  introduction 
of  air  into  the  cavity  of  the  pleura,  imply  also  a  more  serious  state  of  disease  than 
results  from  most  other  causes.  The  perforation  of  the  pleura,  by  the  extension  oi 
a  vomica,  I  have  mentioned  as  one  of  those  causes.  But  tubercles  in  the  lungs  are 
frequently,  very  frequently,  the  cause  of  pleurisy,  when  no  such  perforation  has 
taken  place.  A  tuhercle,  or  a  group  of  tubercles,  approaches  the  surface  of  the 
lung,  but  does  not  break  through.  Generally  the  pleurisy  so  produced  is  slight  and 
partial,  and  ends  in  the  formation  of  adhesions  :  it  is  dry  pleurisy.  And  this  very 
common  occurrence  of  adhesions  between  the  costal  and  pulmonary  pleurae,  in  the 
course  of  tubercular  disease  of  the  luugs,  is,  in  truth,  one  reason  why  perforation  of 
the  pleura,  and  pneumothorax  from  that  cause,  is  comparatively  so  rare.  The  part 
where  the  perforation  is  hkely  to  take  place  has  generally,  though  not  always,  been 
secured  and  clouted,  as  it  were,  by  previous  adhesion.  So  that  even  here  we  find 
that  inflammation  has  a  conservative  tendency,  and  helps  to  postpone  the  fatal  ending 
of  the  specific  disease. 

Pleurisy  may  terminate  in  resolution  and  complete  recovery;  or  in  adhesion, 
which  is  its  next  best  termination,  and  which  obtains  for  the  patient,  at  the  expense 
of  some  trifling  embarrassment  of  his  breathing,  complete  security  for  the  future 
against  the  dangers  of  pleuritic  efTusion.  Again,  acute  pleurisy  may  end  in  chronic 
disease  of  the  pleural  cavity:  i.  e.,  in  a  shrinking  inwards  of  the  walls  of  the  chest, 
attended  with  total  uselessness,  or  a  very  imperfect  and  limited  use,  of  the  corres- 
ponding lung.  Lastly,  pleurisy  may  terminate  in  death.  It  may  cause  efTusion  so 
copious,  that  the  patient  will  die  of  actual  suffocation,  unless  the  fluid  be  removed  by 
art.  On  the  other  hand,  he  may  die  worn  out  and  exhausted  by  the  disease,  espe- 
cially if  it  be  attended  with  suppuration.  In  that  case  he  will  suffer  hectic  fever, 
and  all  its  wasting  and  mournful  accompaniments;  and  death  ultimately  by  asthenia. 
It  is  seldom  that  simple  idiopathic  pleurisy  proves  fatal. 

As  the  matter  from  a  tubercular  cavity  may  break  in  tipon  the  pleural  sac,  and 
lead  to  the  admission  of  air,  and  the  establishment  of  pneumothorax ;  so  the  puriform 
fluid  which  has  resulted  from  inflammation  of  the  pleura,  and  was  for  some  time 
imprisoned  in  its  sac,  may  also  break  out,  and  the  result  will  still  be  the  admission 
of  air,  and  pneumothorax.  This  is  not  a  very  frequent  result  of  pleurisy,  however. 
When  it  occurs,  an  abscess  forms  externally,  generally  in  front  of  the  chest ;  and 
either  the  abscess  bursts,  or  it  is  opened  by  the  surgeon,  and  then  it  is  found  to  com- 
municate with  the  cavity  of  the  pleura. 

Sometimes  air  is  eflused  into  the  sac  of  the  pleura,  in  consequence  of  the  rupture 
of  dilated  air-cells  on  the  surface  of  the  lung:  sometimes  gas  is  generated  there  from 
the  decomposition  of  effused  liquids  ;  and  in  such  cases  the  gas  has  a  strong  odour, 
like  that  of  sulphuretted  hydrogen :  sometimes,  again,  gas  appears  to  be  secreted 
from  the  membrane  itself.  All  these  events  are,  however,  uticommon.  When  air, 
from  whatever  source,  is  shut  up  in  the  cavity  of  the  pleura,  and  goes  on  accumu- 
lating there,  it  will  compress  the  lung,  just  as  certainly  and  efTeciually  as  if  there 
were  a  liquid  extravasated.  And  such  compression,  if  suddenly  brought  about,  may 
cause  speedy  death  by  apnoea :  and  this  is  more  apt  to  occur  from  a  puncture  of  ihe 
pulmonary  pleura  by  the  extremity  of  a  fractured  rib,  than  from  any  other  cause. 

As  to  the  treatment  of  pleurisy,  you  will  have  anticipated  that  in  the  outset  of  the 
disease  we  must  have  recourse  to  the  lancet.  I  have  stated,  more  than  once,  that 
blood-letting  tells  more,  and  is  better  borne,  in  inflammation  of  serous  membranes, 
than  in  any  other  case.  If  you  see  the  patient  while  the  stitch  in  the  side,  and  the 
restrained  and  cautious  respiration  are  present,  you  will  bleed  him,  in  the  upright 


596  PLEURISY. 

posture,  from  a  large  orifice,  until  the  pain  is  relieved,  and  he  can  draw  a  full  breath 
again  with  ease  and  satisfaction ;  or  until  he  is  about  to  faint.  And  if  the  pain  and 
catch  in  the  breathing  should  return,  and  the  pulse  continue  firm  and  hard,  you  will 
bleed  again  in  the  same  way ;  or  cover  the  painful  side  with  leeches ;  or  abstract 
blood  by  the  cupping-glass  and  scarificator.  It  is  best  to  bleed  fearlessly  at  first ; 
and  in  proportion  as  you  do  so,  the  chance  will  be  diminished  of  a  repetition  of  the 
blood-letting  being  needed.  The  blood,  in  pleuritis,  is  always  deeply  buffed  and 
cupped. 

Tartar  emetic,  which  is  so  useful  when  the  mucous  membrane  of  the  air-passages 
is  inflamed,  is  not  adapted  to  inflammation  of  the  pleura.  On  the  other  hand,  mer- 
cury, from  its  well-known  power  to  check  the  effusion  of  coagulable  lymph,  is  espe- 
cially indicated.  Of  course  it  is  to  be  given  with  a  view  to  its  specific  effect  on  the 
system ;  i.  e.,  in  equal  doses,  repeated  at  frequent  and  equal  intervals,  and  guarded 
by  a  small  quantity  of  opium.  And  in  very  severe  cases,  or  when  the  internal^ 
employment  of  mercury  is  in  any  way  contra-indicated,  recourse  must  be  had  to 
inunction  of  the  linimentum  hydrargyri,  or  of  the  strong  mercurial  ointment. 

By  the  early  and  vigorous  adoption  of  these  measures,  the  inflammation  may 
generally  be  subdued  in  no  long  time.  If,  though  the  fever  diminish,  there  still  be 
pain  in  any  part  of  the  chest,  leeches  may  be  again  applied,  or  the  part  may  be 
covered  with  a  blister.  I  do  not  think  a  blister  does  any  good, — on  the  contrary,  it 
is  likely,  by  the  additional  irritation  it  causes,  to  do  harm — while  the  inflammation  is 
yet  recent  and  active. 

But  though  pain  may  have  ceased,  and  no  fever  remains,  and  the  patient  is  not 
conscious  of  much  dyspnoea,  there  may  be,  and  there  often  will  be  evidence,  not  to 
be  mistaken,  of  effusion  into  the  cavity  of  the  pleura.  Dullness,  I  mean,  on  percus- 
sion, bronchial  respiration,  segophony  ;  and  the  object  of  our  treatment  is  now  to  get 
rid  of  the  fluid.  We  seek  to  do  so  by  keeping  the  patient  on  low  diet.  The  more 
(says  Broussais,  with  some  quaintness),  the  more  the  patient  eats,  the  sooner  he  will 
die.  We  pursue  the  same  object  by  keeping  his  gums  tender  with  mercury  ;  by 
applying  blisters  one  after  another  to  the  affected  side ;  and  by  purgatives,  and 
diuretics.  By  keeping  the  vessels  empty  we  facilitate  as  much  as  in  us  lies,  the 
absorption  of  the  liquid  contents  of  the  pleura.  A  very  good  form  of  diuretic  for 
this  state  of  matters  is  a  combination  of  squills,  digitalis,  and  mercury.  Half  a  grain 
of  digitalis,  one  grain  of  squills,  and  three  or  five  grains  of  blue  pill,  repeated  and 
continued  according  to  the  state  of  the  mouth. 

Under  this  kind  of  treatment  the  effused  fluid  will  often  be  completely  removed  ; 
and  the  chest  restored  to  its  former  state.  I  last  week  dismissed  a  lad  from  the 
hospital  in  whom  all  this  was  accomplished. 

But  in  other  cases,  though  the  fever  and  the  inflammation  are  at  an  end,  and  ab- 
sorption of  the  liquid  takes  place,  the  parts  within  the  thorax  do  7iot  revert  to  their 
original  condition.  This  we  know  by  that  shrinking  of  its  dimensions  on  the  side 
affected,  which  was  described  in  the  last  lecture.  This  shrinking  and  narrowing  arc 
the  necessary  consequence  of  the  absorption  of  the  liquid,  unless  the  compressed 
luno-  dilates  a^ain  in  proportion  as  the  fluid  is  taken  up.  In  most  cases  of  this  kind 
the  lung  cannot  rise ;  being  bound  down  by  thick  and  firm  false  membranes :  and 
then  the  deformity  is  irremediable,  and  lasts  for  life.  If  the  lung  is  completely 
emptied  of  air,  and  enveloped  by  strong  bands  of  lymph,  so  that  it  is  permanently 
unable  to  admit  air  again — in  that  case,  as  the  bony  framework  of  the  thorax  can 
yield  to  a  certain  extent  only,  there  will  always  remain,  I  presume,  some  liquid  in 
the  pleural  cavity.  If,  again,  the  lung  recovers  a  part  of  its  lost  volume,  and  nieets 
the  contracting  parietes  of  the  chest,  adhesion  may  take  place  :  and  the  cavity  of  the 
pleura  be  obhterated  by  thick  layers  of  false  membrane.  And  other  changes  t.re 
apt  to  arise  in  the  lymph  which  is  adherent  to  the  pleura  in  these  cases  of  imperfect 
repair.  Sometimes  tubercles  form  in  it.  Sometimes  ossific  matter  is  deposited,  I 
show  you  a  fine  specimen  of  this  kind  of  ossification  of  the  pleura.  There  is  yet 
another  supposable  case :  the  investing  adventitious  membrane  may  be  thin  and 
weak,  and  yielding;  and  though  the  lung  may  not  expand  to  its  full  dimensions  at 
Srst    it  may  gradually  force  its  way  against  the  binding  power  of  the  coagulable 


PLEURISY.  597 

lymph,  and  then  the  external  configuration  of  the  chest  may  be  restored,  and  the 
symmetry  between  the  two  sides  return.  That  this  sometimes  takes  place  I  cannot 
doubt:  but  I  have  only  once  met  with  a  case  in  which  the  dwindling-  of  the  side 
was  entirely  recovered  from.  In  May,  1834,  I  was  asked  to  see  a  child  four  )'ears 
old,  who  had  had  cough,  and  had  wasted  to  mere  skin  and  bone,  after  scarlet  fever. 
I  found  the  whole  of  the  right  side  of  the  chest  perfectly  dull  on  percussion,  and  no 
respiration  could  be  heard  on  that  side.  He  was  taken  by  his  parents  into  the 
country,  and  I  did  not  see  him  again  for  some  weeks.  He  then  had  ceased  to  cough, 
and,  in  a  great  measure,  had  regained  his  strength ;  but  he  presented,  on  the  side 
which  had  been  dull,  the  most  marked  and  complete  example  I  ever  saw  of  the 
sinking  in  of  the  ribs,  flattening  and  contraction  of  the  chest,  and  depression  of  the 
shoulder,  which  denote  bygone  pleurisy  and  diminished  size  of  the  lung.  About  a 
year  from  the  occurrence  of  the  original  disease  his  father  brought  him  to  my  house, 
that  I  might  see  the  change  which  had  again  taken  place.  The  boy  was  plump  and 
rosy,  and  in  perfect  health ;  the  right  side  of  the  chest  was  as  full  and  round  as  the 
other ;  the  symmetry  of  the  two  sides  was  completely  restored  ;  the  breathing  natural 
and  perfect ;  and  the  sound  on  percussion  hollow.  His  father,  to  whom  the  former 
shrunk  state  of  the  side  had  been  pointed  out,  told  me  that  he  had  watched,  with 
deep  interest,  the  process  of  recovery,  and  that  it  had  been  very  gradual.  Whether 
after  once  having  sunk  in,  the  ribs  ever  quite  return  to  their  natural  position  in  the 
adult  subject,  I  do  not  know.     I  have  never  seen  that  happen. 

There  are  yet  other  cases  in  which  the  effusion  continues  and  increases,  and  the 
side,  instead  of  shrinking,  enlarges ;  the  functions  of  the  lung  on  that  side  are  en- 
tirely abolished ;  nay,  the  use  of  the  remaining  lung  is  greatly  interfered  with,  by 
the  pushing  over  of  the  mediastinum ;  and  the  patient  is  in  imminent  danger  of 
suffocation.  In  such  cases,  whether  the  effusion  has  taken  place  rapidly  or  slowly 
— whether  the  disease  has  been  acute  or  chronic  pleurisy — we  must  reheve  the  op- 
pressed lung  by  letting  the  fluid  out — by  tapping  the  thorax ;  and  the  sooner  that 
is  done,  when  such  a  state  of  things  exists,  the  belter. 

The  operation  is  not  difficult,  nor  formidable ;  but  a  mistafte  in  the  diagnosis  may 
be  very  formidable.  I  have  heard  of  two  instances,  one  in  Scotland,  and  one  in  this 
town,  in  which  the  operation  of  paracentesis  thoracis  was  determined  on,  to  relieve 
the  oppression  caused  by  empyema :  but  the  opening  was  made  on  the  wrong  side  ; 
and  the  patient  in  three  minutes  was,  in  each  case,  a  corpse.  There  was  effusion, 
which  had  already  put  a  stop  to  the  play  of  one  lung ;  and  upon  air  being  admitted 
to  the  surface  of  the  other,  it  collapsed  also,  ond  immediate  suffocation  took  place. 
I  do  not  mention  these  mishaps  to  deter  you  irom  performing  the  operation.  They 
both  took  place  some  years  ago.  Such  a  mistake  would  be  unpardonable  now.  But 
I  mention  them  to  show  the  necessity  of  our  being  sure  of  our  ground  before  we 
proceed  to  open  the  thorax  of  a  living  person.  A  surgeon  told  me  very  recently 
that  with  the  sanction,  and  at  the  suggestion,  of  a  physician,  who  understands  aus- 
cultation exceedingly  well  I  believe,  he  passed  a  trocar  into  the  chest  of  a  patient ; 
but  no  fluid  followed,  to  the  no  small  mortification  of  the  physician.  This  proved  to 
be  a  case  of  malignant  disease  of  the  lung;  and  fluid  was  let  out  afterwards  by 
puncturing  the  thorax  in  another  place,  and  much  relief  afforded  ;  although  of  course 
the  disease  proved  ultimately  fatal.  The  surgeon  informed  me  that  he  had  suspected 
the  true  nature  of  the  case,  from  observing  a  livid  protrusion  in  front ;  which  was  in 
fact,  the  specific  disease  making  its  way  through. 

You  will  take  care,  then,  to  survey  the  chest  narrowly  before  you  plunge  a  trocar 
into  it.  If  you  see  by  your  eye,  and  ascertain  by  measurement,  that  one  side  is 
larger  than  the  other ;  if  the  intercostal  depressions  be  effaced  on  that  side ;  if  the 
whole  surface  affords  a  dull  sound  when  percussed  ;  if  the  side  does  not  move  at  ali. 
or  scarcely  moves  during  respiration  ;  if  no  vibration  can  be  felt  on  that  side  when 
the  patient  speaks ;  if  no  breathing  can  be  heard  in  the  corresponding  lung ;  if  tht 
heart  be  found  beating  in  an  unnatural  place,  down  towards  the  left  hypochondriuni, 
or  in  the  other  direction  on  the  right  of  the  sternum ;  and  if,  at  the  same  time,  the 
other  side  of  the  chest  moves  freely,  sounds  resonantly,  communicates  a  thrill  to  the 


598  PLEURISY. 

hand  while  the  patient  converses,  and  is  full  of  puerile  respiration  ;  then  you  may 
be  sure  that  the  larrrer  side  is  distended  with  fluid. 

But  it  does  not  follow  that  you  should,  therefore,  open  that  side.  The  propriety 
of  doing  so  will  depend  upon  circumstances. 

In  my  judgment,  that  operation  ought  never  to  be  performed  unless  the  hfe  of  the 
patient  is,  or  seems  to  be,  in  jeopardy,  from  the  continued  presence  of  the  liquid 
within  the  thorax. 

Now,  life  is  plainly  in  jeopardy  when  the  vital  functions  of  the  lungs,  or  of  the 
heart,  are  greatly  hindered ;  when  symptoms  present  themselves  of  approaching 
death  by  apnoea,  or  by  syncope.  If  we  discover  no  cause  for  those  symptoms, 
except  the  increasing  pressure  of  liquid  pent  up  in  the  pleura,  we  are  warranted  in 
ascribing  them  to  such  pressure,  and  bound  to  act  upon  that  persuasion.  When- 
ever, with  the  physical  signs  of  abundant  effusion,  we  have  great  labour  and  dis- 
tress of  breathing;  an  anxious  and  livid  aspect;  a  tendency  to  delirium — or  extreme 
faintness,  and  a  vanishing  pulse — there  is  no  time  to  be  lost :  it  is  our  duty  to  pro- 
pose and  to  urge  the  mechanical  removal  of  the  pressure,  which  must  else  be  fatal. 

Again,  when  the  patient,  without  suffering  much  dyspncea  while  he  lies  quiet,  is 
yet  evidently  losing  ground  from  day  to  day,  and  early  death  by  asthenia  appears  to 
be  inevitable,  without  the  operation ;  and  when  all  other  means  for  getting  rid  of  the 
imprisoned  liquid  have  failed  ;  and  when  no  other  condition  of  disease,  or  of  advanced 
age,  exists  to  account  for  the  progressive  sinking ;  then  also,  in  my  opinion,  the 
patient  should  not  be  denied  the  chance  which  the  operation  may  afford. 

Thirdly,  whenever  (no  matter  how  we  ascertain  the  fact)  the  effused  liquid  con- 
sists of  jms,  it  should  be  let  out. 

In  either  of  these  three  predicaments,  and  in  no  other,  should  we  be  justified  (as 
I  think)  in  making  an  opening  into  the  living  thorax. 

But  I  wish  to  be  understood  as  giving  you  simply  the  impression  which  my  own 
experience  has  made  upon  my  own  mind.  I  know  that  some  practitioners  recom- 
mend the  early  employment  of  the  trocar  ;  while  (they  say)  the  false  membranes, 
which  are  apt  to  prevent  the  compressed  lung  from  expanding  again,  are  yet  tender 
and  unorganized.  But  surely  we  should  risk  much,  and  gain  nothing,  by  admitting 
air  into  the  pleura  while  the  inflammation  is  still  in  progress.  Most  cases  of  mere 
pleurisy  with  effusion  do  well.  The  mortality  from  uncomplicated  pleurisy  is  ex- 
ceedingly small.  It  would,  I  fear,  be  vastly  augmented  if  every  patient  having  mani- 
fest effusion  were  to  be  tapped.  The  danger  of  the  operation  is  this ; — that  it  may, 
and  probably  will,  induce  suppuration,  or  cause  the  elfused  liquid  to  become  putrid. 
Generally  the  effusion  consists  of  serous  fluid,  which  is  at  length  spontaneously  re- 
absorbed ;  the  lung  expands  again,  or  the  walls  of  the  chest  shrink  inwards :  and 
the  ultimate  state  of  such  a  patient  is  as  good  as  it  probably  would  have  been  after 
a  successful  tapping. 

To  make  assurance  doubly  sure,  it  is  always  right,  before  proceeding  to  the  ope- 
ration of  paracentesis,  to  adopt  the  expedient  first  suggested  and  used,  I  believe,  by 
Dr.  Thomas  Davies,  of  trying  the  chest  by  means  of  a  grooved  needle  ;  making  a 
tentative  exploration  of  the  nature  of  its  contents  in  that  manner.  The  passage  of 
this  little  instrument  —  like  the  dismissal  of  a  pilot  balloon  —  affords  information 
which  is  useful  in  guiding  the  particulars  of  the  subsequent  process.  It  not  only 
ascertains  that  there  really  is  liquid  within  the  pleura,  but  it  discovers  the  kind  and 
quality,  and  exact  place,  of  the  liquid.  If  it  be  serous,  it  will  flow  readily  along  the 
groove,  and  trickle  down  the  patient's  side.  \i  it  be  puriform  and  thick,  it  will  not 
exude  so  freely,  but  a  drop  or  two  will  probably  be  visible  at  the  external  orifice; 
and  when  the  needle  is  withdrawn,  its  groove  will  be  found  to  contain  pus.  In  the 
former  case,  it  is  possible  that  there  may  be  no  false  membranes  ;  in  the  latter,  they 
are  likely  to  be  thick.     You  would  use  a  larger  trocar  to  evacuate  the  thicker  fluid. 

The  puncture  thus  made  is  quite  harmless,  and  inflicts  very  trifling  pain.  Dr. 
Davies  gives  this  useful  piece  of  advice  in  respect  to  the  trocar,  that  its  point  should 
be  sharp ;  for  otherwise,  after  the  serous  membrane  has  been  penetrated,  if  there 
happen  to  be  thick  tough  layers  of  coagulable  lymph,  not  very  closely  attached  to 


PLEURISY.  599 

the  costal  pleura,  they  may  be  driven  before  the  instrunaent,  and  so  the  liquid  will 
not  be  reached,  but  the  operator  will  be  perplexed  and  baffled. 

Connected  with  the  operation  itself  there  are  some  questions  concerning  which 
medical  opinions  and  medical  practice  are  not  yet  settled.  I  do  not  pretend  to  decide 
these  questions ;  yet  I  cannot  pass  them  by — I  must  point  them  out  to  you ;  and  I 
shall,  at  the  same  time,  state  what  my  own  observation  has  suggest  d  in  regard  to 
\hem. 

1.  Should  all  the  liquid  be  let  out  at  once  ? 

Some  say  yes  :  some  say  no.  If  we  appeal  to  experience  on  this  point,  we  obtaia 
no  satisfactory  answer.  I  have  known  patients  get  rapidly  and  perfectly  well,  after 
as  complete  an  evacuation  of  the  liquid  as  was  possible.  On  the  other  hand,  I  have 
heard  of  speedy  recovery  when,  by  a  sort  of  accident,  very  little  had  been  with- 
drawn ;  enough  to  relieve  the  pressing  distress ;  but  much  less  than  the  operator 
intended. 

We  must  try  the  matter,  therefore,  by  our  reason. 

I  think  it  very  probable  that  when  the  serous  membrane  is  stretched  by  the  pres- 
sure of  its  contents,  its  natural  absorbing  power  may  be  lessened.  But  we  have  no 
reason  to  suppose  that  the  mere  relief  of  this  tension  will  often  suffice  to  renew  the 
process  of  absorption,  and  to  enable  the  flattened  lung  to  re-expand. 

The  theoretic  objection  to  the  thorough  emptying  of  the  thorax  in  such  cases  is  (1 
conceivej,  that  the  introduction  of  air  is  likely  to  be  hurtful,  by  converting  the  adhe- 
sive into  the  suppurative  form  of  inflammation,  and  by  promoting  decomposition  of 
the  extravasated  fluids.  No  doubt  there  is  this  risk  ;  but,  in  general,  it  cannot  be 
avoided.  Unless  the  lung  freely  rises  at  once,  the  liquid  cannot  all,  nor  even  much 
of  it,  come  out,  without  air  getting  in.  Some  attempts  have  indeed  been  made,  of 
late,  to  draw  the  water  into  an  exhausted  bag,  by  the  help  of  a  pipe  and  stop-cocks. 
But  it  is  obvious  that,  in  most  cases,  very  little  can  be  so  abstracted.  The  mere 
admission  of  air  to  the  pleura  does  not  necessarily  create  inflammation  of  the  mem- 
brane. This  we  know  from  what  happens  sometimes  in  emphysema  produced  by 
a  fractured  rib.  In  the  only  instance  of  pure  pneumothorax  which  I  ever  saw,  the 
sac  of  the  pleura  had  become  half-filled  with  air,  through  a  very  minute  opening  in 
the  pulmonary  membrane,  communicating  with  the  air-passages.  There  was  no 
mflammation  of  the  pleura  in  that  case.  Except  that  it  was  preternaturally  dry,  it 
seemed  perfectly  healthy.  Neither  does  the  access  of  air  necessarily  superinduce 
suppuration  in  the  membrane  already  inflamed.  Certainly,  if  pus  follows  the  passage 
of  the  instrument,  as  much  should  be  removed  as  we  can  get.  And,  for  my  own 
part,  I  should  take  away  as  much  as  would  come,  if  the  inclosed  liquid  proved  to 
be  serous.        • 

2dly.  Is  the  orifice  to  be  healed  up,  or  to  be  kept  open  ? 

Here,  also,  practical  men  differ.  I  should  say,  if  pus  comes  out,  by  all  means 
keep  the  aperture  open  ;  and  inasmuch  as  detention  of  the  pus  would  be  injurious, 
and  the  depending  point  is  difficult  to  hit,  and  the  orifice  is  apt  to  clog,  I  would  do 
more  than  leave  it  open :  I  would  draw  the  puriform  fluid  ofT  twice  a  day  by  a 
syphon. 

If  serum  is  let  out,  by  all  means  close  and  heal  the  wound.  Then,  if  all  goes  on 
well,  our  object  is  achieved.  But  should  the  condition  of  the  patient  fail  to  improve  ; 
should  hectic  fever,  after  a  day  or  two,  set  in  or  even  continue  ;  should  much  consti- 
tutional distress  or  disturbance  arise  ; — under  such  circumstances,  I  would  re-open 
the  wound.  There  was  mere  serum,  or  liquor  sanguinis  :  there  now  is,  in  all  pro- 
bability, puriform  matter  pent  up  in  the  pleura,  and  even  stinking  and  poisonous 
gases. 

On  six  occasions  I  have  myself  witnessed  the  evacuation,  by  puncture,  from  the 
human  pleura,  of  a  clear  transparent  liquid.  Some  of  the  patients  were  under  my 
own  charge,  some  under  the  charge  of  others.  Of  these  six  patients,  one  died  the 
day  after  the  operation  ;  I  can  scarcely  say  why.  She  was  an  extremely  timid  and 
susceptible  J'eung  woman  ;  and  I  am  inclined  to  attribute  her  death  to  the  shock  pro- 
duced, by  apprehension  of  the  operation,  upon  her  sensitive  nervous  syste  n.  Two 
others  recovered  forthwith,  and  perfectly.     The  wound  presently  healed  in  the  threr. 


600  PLEURISY. 

remaining  cases  also  ;  but  in  one  of  the  three  it  soon  broke  out  again,  and  a  quantity 
of  h-althy  pus  was  discharged  daily.  After  some  time,  the  expedient  of  keeping 
the  cavity  free  from  accumulated  pus  by  the  use  of  a  syphon  was  resorted  to.  Under 
this  plan  the  discharge  became  gradually  less  and  less,  and  at  the  end  of  many 
months  it  finally  ceased.  The  patient  has  a  contracted  chest,  but  his  general  health 
is  quite  re-established.  He  was  on  the  brink  of  sufTocation  when  the  operation  was 
performed.  I  have  been  told  of  a  man  who,  for  the  last  fifteen  years,  has  had  a 
similar  thoracic  fistula,  and  who  has  nevertheless,  during  nearly  the  whole  of  that 
period,  being  actively  engaged  in  the  various  labours  of  a  farm-servant. 

I  have  still  two  of  the  six  patients  to  account  for.  They  were  both  much  reheved 
by  the  operation  for  a  while ;  but  after  a  few  days  they  again  fell  off;  and  after 
many  more  days  of  gradual  sinking  and  distress,  they  died.  The  cavity  of  the 
pleura  contained,  in  both  cases,  much  puriform  liquid,  and  a  quantity  of  most  offensive 
gas,  consisting  in  great  part,  as  I  judged  from  its  odour,  of  sulphuretted  hydrogen.  I 
have  since  thought  that  both  these  patients  would  have  had  a  much  better  chance  for 
life,  if  this  corrupt  and  corrupting  mass  had  been  duly  removed. 

Again,  I  have  twice  seen  pus  let  out,  by  the  primary  puncture  of  the  chest.  One 
of  these  two  patients  sunk,  exhausted,  some  months  after  the  opening,  which  never 
healed,  was  made.  The  empyema  of  the  other  had  been  occasioned  by  fracture  of 
a  rib.  The  discharge  continued  for  a  short  time,  then  ceased,  the  orifice  closed,  and 
the  lad  got  well. 

This  constitutes  the  amount,  or  nearly  so,  of  my  personal  experience  of  the  ope- 
ration of  paracentesis  thoracis.  You  will  see,  in  the  statement  I  have  been  making, 
the  grounds  of  those  opinions  which  I  have  formed  and  expressed  respecting  it.  A 
full  and  final  solution  of  the  grave  and  difficult  questions  that  it  involves  would  re- 
quire a  much  wider  field  of  observation  than  any  one  individual  is  likely  to  command. 
Dr.  Thomas  Davies  has  published  a  tabular  account  of  the  several  cases  of  operation 
which  he  had  then  superintended.  In  sixteen  cases  of  empyema,  so  treated,  there 
were  twelve  recoveries ;  that  is,  the  operation  was  successful  in  three-fourths  of  the 
whole  number  of  cases :  a  very  encouraging  result.  In  three  of  the  less  fortunate 
cases,  the  lung  could  not  expand  after  the  evacuation  of  the  fluid,  in  consequence  of 
the  thickness  of  the  false  membranes  covering  it. 

The  value  of  Dr.  Davies'  table  would  have  been  greater,  if  it  had  shown  in  each 
case  the  time,  after  the  commencement  of  the  disease,  at  which  the  operation  was 
performed ;  the  symptoms  that  called  for  its  performance  ;  the  nature  of  the  liquid 
evacuated ;  and  whether  the  orifice  made  by  the  trocar  was  closed  or  not. 

The  quantity  of  liquid  which  the  distended  pleura  is  capable  of  holding  is  enor- 
mous. I  have  seen  upwards  of  a  gallon  let  out  at  once.  Dr.  Townsend  mentions 
the  case  of  a  patient  of  Dr.  Croker's,  in  Dublin,  from  whose  left  pleura  Mr.  Cramp- 
ton  drew  off  the  almost  incredible  quantity  of  fourteen  imperial  pints  of  pus.  Of 
course  this  could  not  have  accumulated  there  without  making  injurious  pressure  in 
all  directions :  upon  the  ribs,  upon  the  heart  and  mediastinum,  upon  the  diaphragm, 
and  the  abdominal  viscera  beneath  it.  It  is  interesting  to  know  with  what  rapidity 
the  capacity  of  the  diseased  side  of  the  thorax  will,  in  favourable  cases,  diminish. 
The  same  writer  gives  the  history  of  a  boy,  12  years  old,  in  whom  the  circumference 
of  the  diseased  side  was  sixteen  inches  and  six  lines,  while  that  of  the  sound  side 
was  fourteen  inches  and  one  line.  JNine  days  after  the  operation  the  circumference 
of  the  diseased  side  had  decreased  nearly  three  inches:  it  measured  thirteen  inches 
and  nine  lines  ;  that  is,  rather  less  than  the  circumference  of  the  healthy  side.  The 
side  had  shrunk  somev.-hat  within  its  natural  size.     This  is  common  in  such  cases. 

There  is  yet  a  third  question  of  some  importance.  Whereabouts  should  the 
opening  be  made  ? 

If  any  soft  inelastic  tumour  has  appeared,  marking  a  tendency  in  the  effused  liquid 
to  make  its  own  way  outwards,  that  tumour  should  be  punctured  without  loss  of 
time  ;  for  there  will  be  no  chance  of  the  reabsorption  of  the  pus  ;  and  if  the  swelling 
be  left  to  itsflf,  troublesome,  burrowing  sinuses  will  be  apt  to  form  in  the  thoracic 
and  abdominal  parietes.  As  we  have  no  choice  in  such  a  case  about  the  place 
where  the  aperture  is  to  be  made,  authors  have  termed  the  operation  the  operation 


PLEURISY.  bUl 

of  necessity ;  and  they  distinguish  the  case  in  which  the  surgeon  is  at  liberty  to  m 
troduce  his  trocar  whenever  he  pleases ;  they  say  that  then  the  operation  of  election 
takes  place.     Now  the  question  is,  what  spot  is  the  best  for  this  operation  of  election  ? 

If  there  be  any  part  of  the  surface  which  is  resonant  on  percussion,  or  which 
affords  any  sound  of  respiration,  that  part  must  be  avoided.  It  is  probable  thai  the 
lung,  in  that  place,  is  fastened  by  adhesions  to  the  costal  pleura.  Of  course  you 
would  not  thrust  in  a  trocar  where  you  saw  or  felt  that  the  heart  was  beating. 

The  object  to  be  kept  in  view  is  that  of  making  the  opening  in  the  situation  which 
will  allow  the  most  free  and  perfect  vent  for  the  liquid.  The  intercostal  space 
between  the  sixth  and  seventh  true  ribs,  where  the  digitations  of  the  serratus  major 
meet  those  of  the  obliquus  externus  muscle,  is  the  place  usually  recommended. 
Laennec  prefers  the  space  between  the  fifth  and  sixth  ribs.  He  observes  that,  on 
the  right  side,  an  enlarged  liver  frequently  reaches  as  high  as  the  sixth,  or  even  as 
the  fifth  rib.  When  the  diaphragm  is  pushed  as  high  as  this  (and  I  believe  that 
Dr.  Edwin  Harrison,  who  has  paid  much  attention  to  this  point,  will  tell  you  that 
it  is  often  pushed  up  even  higher)  there  is  an  obvious  risk  of  penetrating  it  with 
the  trocar.  In  fact,  Laennec  committed  that  error  himself.  After  making  an  in- 
cision between  the  fifth  and  sixth  ribs,  he  thrust  the  instrument,  as  he  supposed, 
into  the  thorax;  and  was  a  good  deal  surprised  to  find  that  no  gush  of  liquid  fol- 
lowed its  introduction.  The  patient  died  ;  and  dissection  showed  that  the  trocar  had 
entered  the  cavity  of  the  abdomen  after  transfixing  the  diaphragm,  which,  having 
been  forced  upwards  by  a  large  liver,  had  contracted  firm  adhesions  to  the  seventh 
rib.  I  have  myself  witnessed  a  similar  mischance,  on  the  other  side  of  the  chest. 
The  integuments  of  the  side  were  csdematous ;  and  it  was  thought  that  a  little  serum 
issued  upon  the  passage  of  the  grooved  needle.  The  serum  must  have  come  from 
the  infiltrated  areolar  tissue.  No  liquid  was  evacuated  by  the  trocar.  The  patient 
died  a  day  or  two  afterwards  of  peritonitis.  The  instrument  had  perforated  the 
diaphragm,  and  entered  the  spleen,  which  was  unusually  large. 

I  am  tempted  to  relate  the  particulars  of  one  of  the  prosperous  cases  that  I 
before  briefly  adverted  to.  It  occurred  in  a  lad  of  nineteen ;  a  patient  of  my  col- 
league, Dr.  Wilson.  On  his  admission  into  the  hospital  he  bore  all  the  marks  of 
copious  effusion  into  the  left  pleura  ;  the  side  enlarged  and  motionless,  and  dull  on 
..percussion  ;  the  intercostal  spaces  tense,  and  even  with  the  ribs  ;  the  heart  beating 
to  the  right  of  the  sternum;  respiration  puerile  on  the  right  side,  inaudible  on  the 
left ;  urgent  dyspnosa ;  a  tendency  to  coma,  marked  by  drowsiness  and  blueness 
of  the  cheeks  and  lips.  In  short,  the  boy  was  on  the  very  verge  of  suffocation. 
He  had  been  ill  about  a  month  :  and  had  been  bled,  and  cupped,  and  brought  under 
vhe  specific  influence  of  mercury.  Dr.  Wilson  judiciously  directed  that  the  liquid 
should  be  let  out. 

A  grooved  needle  was  first  passed  between  the  fifth  and  sixth  ribs  ;  and  some 
serum  following  the  puncture,  a  trocar  was  then  introduced  by  Mr.  Tuson,  and 
nine  pints  of  a  clear  fluid  were  drawn  off.  During  the  operation  the  patient  became 
faintish  at  times,  and  then  the  orifice  in  the  canula  was  stopped  for  a  moment  by 
the  finger.  The  immediate  effect  of  the  tapping  was  most  interesting  and  grati- 
fying. Even  while  the  liquid  was  flowing,  the  heart  was  observed  gradually  to 
move  over  from  beneath  the  right  mamma  towards  its  natural  situation ;  and  his 
difficulty  of  breathing  was  signally  relieved.  At  the  beginning  of  the  operation  he 
respired  fifty  times  in  a  minute ;  at  its  conclusion  thirty-eight  times  only.  A  good 
deal  of  air  entered  while  the  liquid  vvas  escaping:  and  for  some  days  after  the 
operation  a  splashing  sound  vvas  audible  on  succussion  of  the  chest :  and  one  part 
of  that  side  was  unnaturally  resonant,  when  struck,  and  another  part  unnaturally 
dull ;  and  whatever  was  the  posture  of  the  patient,  the  hollow  sound  was  uppermost, 
and  the  dull  sound  was  undermost ;  and  when  he  sat  up  and  spoke,  or  coughed,  a 
brazen  resonance  was  heard  by  the  ear  applied  to  the  scapular  region.  This  lad 
got  quite  well,  without  the  recurrence  of  a  single  bad  symptom.  He  afterwards 
presented  himself  at  the  hospital ;  and  I  understand  that  the  left  side  was  found  to  bo 
in  a  very  slight  degree  smaller  than  the  right. 

The  liquid  evacuated  in  this  case  was  clear  and  transparent.     It  separated,  on 

3a 


G02  PLEURISY. 

cooling,  into  three  parts :  one  of  quite  water)-  consistence,  one  more  viscid,  and  a 
third  which  constituted  a  soft,  transparent,  jelly-like  mass  of  fibrin. 

In  this  instance  no  injurious  consequences  resulted  from  the  free  admission  of  air 

It  may  sometimes  be  necessary  to  puncture  the  cavity  for  mere  pneumothorax : 
when,  for  instance,  the  pulmonary  pleura  has  been  pricked  by  a  fractured  rib,  and 
air  passes  from  the  lung  into  the  pleural  sac  faster  than  it  can  be  absorbed ;  fast 
enough  to  compress  the  lung,  and  to  threaten  death  by  apnosa.  The  diagnosis  of  ' 
such  a  state  cannot  be  difficult.  The  existence  of  the  fracture,  the  t3'mpanitic  sound 
yielded  by  the  chest  on  the  injured  side,  the  absence  of  respiratory  murmur  in  the 
tympanitic  part,  and  the  increasing  dyspnoea,  all  point  to  the  same  conclusion.  Now 
a  trocar  of  the  smallest  size — or  even  an  acupuncture  needle — maj-  suffice  to  give 
vent  to  the  imprisoned  air,  which  will  escape  with  an  audible  hissing  noise.  In 
some  cases  it  must  have  existed  in  a  very  large  quantity,  for  the  stream  of  issuing 
air  has  been  strong  enough  to  blow  out  a  candle  several  times  in  succession ;  the 
flame  being  each  time  immediately  re-lighted. 

The  same  necessity  for  puncturing  the  cavity  of  the  pleura  from  without  may 
arise  in  cases  of  pneumothorax  depending  on  specific  disease  in  the  lungs :  but  we 
cannot  regard  the  operation  as  curative  in  such  peases.  Its  value  is  very  different 
from  that  which  experience  has  shown  to  belong  to  it  in  empj^ema  from  acute  or 
chronic  (but  simple)  pleurisy.  Yet  if  it  saves  life  for  the  time,  if  it  prevents  im- 
pending suffocation,  and  relieves  existing  distress,  and  postpones  the  fatal  event,  it  is 
not  ivithout  its  value ;  and  it  has  many  times  been  done,  and  been  followed  by  very 
gratifying  results ;  but  it  has  never,  that  I  knoAV  of,  been  followed  by  entire  recovery. 
Dr.  Davies  had  superintended  the  operation  in  nine  instances  of  pneumothorax  with 
efi'lision :  and  all  the  patients  died  from  tubercular  complications. 

There  are,  indeed,  on  record  examples  of  recovery  after  the  operation,  when 
pneumothorax  had  existed,  and  under  very  unpromising  circumstances.  I  should 
have  stated  before,  that  as  the  pus,  in  empyema,  sometimes  finds  its  way  outwardly, 
penetrating  between  the  ribs,  and  forming  an  external  swelhng,  which,  if  not  opened 
by  the  scalpel,  will  at  length  burst ;  so  it  also,  sometimes,  escapes  bj^  making  a  road 
into  some  part  of  the  air-passages,  and  being  expectorated.  Now  the  operation  of 
paracentesis,  in  such  a  case,  there  being  no  tv.l'erciilar  disease,  has  been  successi'ul. 
Le  Dran  relates  an  instance  in  which  he  operated  for  empyema,  where  "  the  injec- 
tion of  a  small  quantity  of  mel  rosarum  and  barley-water  through  the  wound  excited 
coughing,  and  part  of  it  was  coughed  up  through  the  mouth,  mixed  Avith  pus  ;"  thus 
clearly  proving  the  existence  of  a  fistulous  passage  through  the  lung ;  notwithstand- 
ing which  the  patient  recoA^ered  completely.  The  effusion  Avas  probably  circum- 
scribed. But  you  Avill  find  other  cases  of  a  similar  kind  referred  to  by  Dr.  ToAvnsend, 
in  the  Cyclopxdia  of  Practical  Medicine. 

This  concludes  Avhat  I  have  to  say,  not  only  of  pleurisy,  but  also  of  pneumothorax, 
and  of  empyema,  Avhich  are  often  treated  of  as  separate  and  independent  disorders. 
They  are  more  frequently  connected  Avith  pleurisy  than  Avith  any  other  form  of  dis- 
ease, and  they  are  almost  always  consequences  of  disease  or  of  injury.  But  I  believe 
I  have  omitted  nothing  of  importance  in  respect  to  either  of  them. 

[Typhoid  Pneumonia. — A  state  of  conptestion,  or  of  inflammation,  more  or  less  intense, 
of  the  lungs,  accompanied  by  that  impairment  of  the  sensorial  powers,  and  morbid  condi- 
tion of  the  circulation  and  of  the  organism  generally,  which  characterize  the  more  grave 
forms  of  typhus  fever,  iias  repeatedly  prevailed  in  diflerent  portions  of  the  United  States,  as 
an  epidemic,  often  of  Avide  extent,  and,  in  its  earlier, visitations,  producing  an  amount  of 
mortality  truly  appalling. 

The  first  notice  we  have  of  the  appearance  of  this  form  of  disease,  remarks  Dr.  Dickson, 
(Essay  on  Pathology  and  Therapeutics,  vol.  i.  435),  "was  in  the  year  1S06,  in  Medfield,  a 
town  of  tlie  ^tate  of  ^Massachusetts,  whence  it  spread  gradually  —  extending  itself,  iv-nter 
after  winter,  throughout  New  England,  into  Canada,  and  the  ^Middle  States,  progressing 
fiom  A'illage  to  village,  and  from  one  portion  of  the  country  to  another,  until,  in  1S13,  it  had 
reached  Philadelphia.  In  the  winter  of  1S15  it  first  prevailed  in  South  Carolina,  and  was 
then,  .and  more  A\-idely  in  ]  SIC,  epidemic ;  since  Avhich  time  its  raA'ages  in  this  s'ate  ha'.w 
'been  slight.  It  continues  to  show  itself,  sporadically,  everywhere,  I  believe,  wheie  it  has 
oace  found  footing  In  South  Carolina  we  scarcely  pass  a  winter  without  meeting  with 
iastances  of  it,  espi>cially  among  the  blacks."' 


PLEURISY.  603 

The  disease  Is  of  frequent  occurrence  in  other  portions  of  the  United  States,  and  may  be 
considered,  to  a  certain  extent,  as  endemic  in  several  localities. 

We  are  informed  by  Dr.  Gibbes,  (jlmericati  Journal  of  the  Medical  Sciences,  Oct.,  1842.)  that 
it  prevails  extensively  during  the  winter  months,  on  the  rivers,  svv^ampy  plantations,  in  the 
neighbourhood  of  Columbia,  South  Carolina,  and  destroys  more  negroes  than  all  the  other 
maladies  combined  to  which  they  are  ordinarily  liable. 

According  tu  Dr.  Dickson,  it  has  not  been  observed  farther  south  than  the  State  of  Georgia, 
nor  is  it  of  very  frequent  occurrence  beyond  the  latitude  of  Charleston. 

Typhus  pneumonia,  as  it  prevails  in  the  United  States,  is  very  similar  in  character  to,  and 
is  probably  the  same  affection  as  that  described  by  Sydenham,  Huxham,  and  others  of  the 
older  writers,  as  peripneumonia  notha.  Sauvages  has  very  accurately  portrayed  the  disease 
under  the  denomination  of  peripneumonia  typhcides.  An  account  is  given  by  the  late  Dr. 
John  Bard,  of  New  York,  of  an  epidemic  that  prevailed  on  Long  Island,  in  the  winter  of 
1749,  which  he  terms  a  malignant  pleurisy,  that  in  all  its  essential  features  corresponds  ex- 
actly M'ith  the  disease  under  consideration;  a  similar  ailectior  is  also  noticed  by  Dr.  Hugh 
Williamson,  as  prevailing  in  North  Carolina  in  1792. 

Typhoid  pneumonia  is  described  by  Dr.  Stokes  as  not  uncommon  in  Ireland,  while  Dr. 
Burne,  of  the  Westminster  Hospital,  mentions  that  a  great  number  of  cases  of  what  he  calls 
"the  spotted  fever,"  were  brought  into  that  institution  in  the  year  1838.  He  describes  the 
affection  as  "an  adynamic  or  typhus  fever,  combined  with  a  latent  and  dangerous  pneumonia, 
and  exhibiting  on  the  surface  a  very  regular  and  uniform  spotted  eruption  —  not  petechiaj." 
This  is  evidently  the  same  disease  as  the  typhus  pneumonia  of  this  country,  which,  when'it 
first  attracted  attention,  was  so  frequently  attended  with  an  eruption  upon  the  skin,  that  it 
was  very  generally  designated  by  the  popular  name  of  spotted  fever.  The  eruption,  how- 
ever, soon  ceased  to  attract  attention ;  it  was  seldom  observed  as  a  phenomenon  of  the  dis- 
ease south  of  the  Potomac,  and  even  in  the  northern  and  middle  portions  of  the  United  States, 
the  eruption  ceased  early  to  present  itself 

Dr.  Mackintosh,  of  Edinburgh,  describes  a  forni  of  pneumonic  inflammation,  attended  by 
symptoms  that  are  generally  denominated  t3^phoid,  and  which,  in  consequence,  has  obtained 
the  name  of  pneumonia  typhoides,  as  very  prevalent  among  the  British  troops  stationed  in 
exposed  situations  along  the  coast,  and  in  large  garrisons  where  the  duty  is  severe.  Dr. 
Mackintosh,  however,  objects  to  the  adjunct  typhoides,  as  expressing  erroneous  ideas  of  the 
pathological  condition  of  the  body; — and  the  objection  is  not  without  foundation — for  although 
that  peculiar  form  of  pulmonary  engorgement  quickly  followed  by  inflammation  aiid  hepa- 
tization, to  which  the  term  typhoid  pneumonia  has  been  applied,  does  very  frequently  occur 
in  connection  with  genuine  typhus,  it  is  likewise  a  very  common  complication  in  certain 
seasons  and  localities  of  the  bilious  remittent  fever,  while  it  is  also  met  with  in  cases  of 
gastro-enteritis,  of  ambnlent  and  erratic  erysipelas,  of  diffuse  cellular  inflammation,  and  of 
other  diseases  by  which  the  thoracic  affection  is  more  or  less  modified,  and  often  completely 
masked;  hence  to  denominate  the  pneumonic  disease  as  essentially  and  invariably  typhoid 
in  its  character  is  evidently  a  misnomer,  and  very  liable  to  lead  to  serious  errors  in  practice. 

In  the  United  States  the  disease  is  known  by  various  names,  according  to  the  predomi- 
nance of  particular  symptoms.  In  the  more  violent  cases,  the  patient  being  suddenly  seized 
with  a  very  severe  chill,  accompanied  with  marked  coldness  of  tlie  surface,  it  is,  according 
to  Dr.  Gibbes,  frequently  denominated  the  cold  plague.  The  head  being  almost  invariably 
affected,  before  the  pneumonic  symptoms  are  developed,  it  is  often  called  head  pleurisy.  In 
tlie  autumn  or  spring,  when,  in  particular  districts  of  country,  it  is  frequently  attended  by  the 
symptoms  of  ordinary  bilious  fevers,  it  is  called  bilious  pleurisy.  From  the  symptoms  of  pros- 
tration by  which  the  disease  is  so  generally  attended  throughout  its  whole  course,  and  the 
rapidity  with  which  the  patient  sinks  in  the  more  violent  cases,  the  term  typhoid  pneumonia 
has  become,  however,  the  one  by  which  it  is  most  frequently  designated. 

In  its  mode  of  attack,  and  the  general  symjitoms  by  which  typhoid  pneumonia  is  ordinarily 
attended,  there  is  no  uniformity.  Usually,  however,  the  disease  is  ushered  in  by  a  chill, 
which  is  often  of  great  severity  and  long  continuance  —  the  heat  of  the  whole  surface  being 
to  the  touch  much  below  the  standard  of  health.  The  cold  stage  is  not  unfrequently  so  in- 
tense as  to  destroy  the  patient  before  the  slightest  reaction  occurs.  Where  the  disease  is  vio- 
lent in  its  attack.  Dr.  Gibbes  states,  that  the  patient  may  suddenly  become  cold  and  pulseless, 
lethargic,  and  often  insensible  without  previous  complaint ;  he  has  known  instances  in  which 
the  patient  was  foimd  dead,  or  died  within  three  or  four  hours  after  being  apparently  well 

During  the  cold  stage,  the  respiration  is  short  and  oppressed,  and  a  pain  on  one  or  othei 
side  of  the  chest  is  generally  complained  of;  pain  of  the  head  is  also  present  in  most  cases; 
and  not  unfrequently  the  patients  experience  severe  pains  in  the  back,  limbs,  and  other  parts 
of  the  body — similar  occasionally  to  those  of  rheumatism.  The  muscular  strength  is  greatly 
prostrated,  and  there  is  a  sense  of  general  uneasiness  and  great  rest.'pssness.  .Vfier  a  period. 
longer  or  shorter  in  different  cases,  but  usually  protracted,  reaction  ensues,  and  the  heat  of 
the  surface  is  restored — it  is  seldom,  however,  increased  much  above  the  ordinary  standard 
of  health.     The  heat  is  often  unequally  ditfused  over  the  surface — portions  being  decidedly 


604  PLEURISY. 

hot  while  others  arc  comparatively  cool.  Occasionally,  the  skin  hecornes  hot,  dry  and  harsh, 
while,  at  other  times,  it  is  relaxed,  cool,  and  clammy.  The  pulse,  when  reaction  ensues, 
becomes  somewhat  fuller,  and  more  quick  and  frequent,  but  in  very  few  cases  does  it  acquire 
any  degree  of  tensioii,  excepting,  perhaps,  when  the  disease  attacks  young  subjects  and  those 
who  retain  some  degree  of  vigour.  Most  commonly  the  pulse  is  soft,  or  it  yields  to  the 
slightest  pressure.  During  the  febrile  stage,  the  pain,  oppression  of  the  chest,  and  difficulty 
of  respiration  are  increased,  and,  very  generally,  a  cough  comes  on  within  the  first  twenty- 
four  hours,  by  which  the  pain  in  the  thorax  is  greatly  aggravated.  When  the  cough  is  at- 
tended with  expectoration,  the  pain  in  the  side  is  considerably  relieved,  and  the  oppression 
of  respiration  diminished.  When,  however,  the  cough  continues  dry,  or  the  expectoration  is 
slight,  all  the  more  serious  symptoms  become  aggravated.  The  matter  expectorated  is  a 
thick,  tenacious  mucus,  often  tinged  with  blood,  but  at  other  times  of  an  ash  or  dark-brown 
colour.  The  respiration  besides  being  oppressed  is  usually  hurried,  and  irregular — the  pa- 
tient's spirits  are  greatly  depressed — he  often  utters  deep  and  heavy  sighs,  and  complains 
of  a  sense  of  weight,  or  of  constriction  at  the  prsecordia ;  he  is  often  affected  with  nausea, 
and  occasionally  with  vomiting. 

Dr.  JNIann  (il/erf.  Sketches,  page  308),  notices,  as  a  common  symptom  of  the  disease,  a  re- 
markable pink-coloured  suffusion  over  the  whole  face,  distinct  from  the  usual  febrile  redness 
of  the  cheeks — the  face  becoming,  at  the  same  time,  puffed  or  bloated.  This  appearance  is 
most  conspicuous  in  individuals  of  a  light  complexion  j  it  is  present,  also,  upon  the  body,  but 
to  a  less  extent.  In  nrany  cases  it  is  not  observed  even  on  the  face,  or  in  a  very  slight 
degree,  and  for  a  short  period. 

The  tongue,  in  the  first  period  of  the  disease,  is  often  clean  but  red,  particularly  at  its 
edges ;  in  other  cases,  and  perhaps  most  commonly,  it  is  thickly  coated  with  a  yellowish 
mucus,  which,  in  the  progress  of  tlie  disease,  changes  to  a  dark-brown — the  tongue  becoming, 
at  tlie  same  time,  dry,  hard,  and  rough — often  chapped.  Upon  the  separation  of  the  crust, 
the  tongue  presents,  not  unfrequently,  a  bright-red  colour,  which  colour  occasionally  pervades 
also  the  fauces. 

In  many  cases,  the  patient  exhibits  from  the  very  commencement  of  the  attack,  particularly 
where  there  is  much  pain  of  the  head,  more  or  less  delirium,  and  great  restlessness. 

As  the  disease  advances,  the  teeth  and  the  whole  interior  of  the  mouth  become  coated 
with  a  dark-coloured  sordes ;  the  breathing  becomes  shorter  and  more  oppressed  —  the 
strength  more  prostrated,  the  pulse  smaller  and  weaker — the  patient  sinks  into  a  state  of  low 
muttering  delirium  or  of  coma,  more  or  less  complete,  and  the  fatal  event  takes  place  as  in 
the  ordinary  cases  of  typhus  fever. 

The  duration  of  the  disease  is  very  variable.  Death,  as  we  have  seen,  may  occur  within 
a  very  few  hours  from  the  commencement  of  the  attack.  Dr.  Mackintosh  has  seen  the  dis- 
ease, in  the  strongest  subjects,  run  its  course  to  a  fatal  termination  in  from  forty-eight  to  sixty 
hours  j  while  Dr.  Gibbes  has  known  patients  to  be  destroyed  by  it  in  from  three  to  twenty 
hours.     In  other  cases,  the  disease  may  continue  for  several  days  before  a  fatal  event  occurs. 

In  cases  where,  under  an  ajjpropriate  treatment  early  commenced  with,  the  nervous  power 
is  quickly  aroused,  the  activity  of  the  circulation  is  excited  and  a  free  action  of  the  peripheral 
capillaries  restored,  according  to  Dr.  Gibbes,  the  attack  may  be  cut  short,  without  the  occur- 
rence of  any  symptoms  of  pneumonic  disease. 

When  symptoms  of  pneumonia  become  developed,  these  will  often  yield  to  a  proper  treat- 
ment, within  the  first  thirty-six  or  forty-eight  hours,  though  they  will  occasionally  continue 
for  six  or  seven  days,  or  even  longer.  The  pulse  increasing  in  volume  and  in  firmness,  the 
surface  becoming,  throughout,  warm,  soft,  and  moist,  the  tongue  cleaner  and  less  red.  the 
delirium  diminishing,  the  expectoration  becoming  more  free  and  copious,  the  cough  less  fre- 
quent and  annoying,  the  pain  of  the  thorax  less  intense,  the  respiration  more  full  and  easy, 
and  the  occurrence  of  a  quiet  sleep,  from  which  the  patient  awakes  refreshed  and  with 
greater  cheerfulness,  are  the  certain  indications  of  amendment — recovery,  however,  is  in 
general  very  slow — tlie  period  of  convalescence  being  protracted,  while  relapses  readily 
occur  from  slight  exposure  or  the  least  imprudence  of  any  kind. 

Dr.  Gibbes  states,  that  he  has  frequently  known  patients  who  were  convalescent  and  able 
to  walk  about,  complaining,  in  fact,  of  nothing  but  debility,  to  "yield  suddenly  to  a  cold 
change  of  weather,  and  die  in  a  few  hours,  or  linger  several  days  with  pneumonic  symp- 
toms." Symptoms  that  were  before  mild  and  favourable,  will  often  become  aggravated 
upon  a  change  in  the  atmosphere  to  cold  and  damp.  If  a  patient  has  been  much  enfeebled 
by  a  first  attack,  a  second  is  very  likely  to  prove  fatal. 

In  many  cases  of  pneumonia  typhoides,  instead  of  a  gradual  decline  of  the  symptoms  of 
thoracic  disease  taking  place,  these  cease  suddenly,  and  a  severe  pain  is  immediately  expe- 
r'enced  in  some  other  and  perhaps  remote  part  of  the  body,  as  in  the  region  of  the  liver,  in 
the  bowels,  or  in  the  head,  attended  with  the  other  symptoms  of  inflammation  in  these 
ports.  According  to  Dr.  Gibbes,  when  upon  the  cessation  of  the  thoracic  symptoms,  a  he- 
inoiThage  from  the  bowels  ensues,  it  is  generally  critical — when  inflammation  of  the  brain 
or  peritoneum  takes  place,  the  case  usually  terminates  fatally. 


PLEURISY.  605 

The  foregoing  is  the  description  of  pneumonia  typhoides  as  it  most  frequently  presents 
itself.  In  the  different  epidemical  visitations  of  the  disease,  at  different  seasons,  and  in  dif 
ferent  localities,  or  even  during  the  same  periods  and  in  the  same  places,  it  not  unfrequently, 
however,  assumes  a  very  ditferent  form.  Thus,  in  some  cases,  the  only  symptoms  which 
the  patient  exhibits  are  extreme  prostration  and  wandering  pains  of  the  back,  loins,  shoul- 
ders or  legs.  In  other  cases,  after  a  severe  and  protracted  chill,  the  patient  is  seized  with 
severe  pain  of  the  head  and  back,  and  great  gastric  distress — delirium  soon  sets  in,  which 
quickly  gives  place  to  coma,  and  death  ensues  within  a  few  hours. 

"  Occasionally,"  remarks  Dr.  Gibbes,  "  an  acute  pain  in  the  back  part  of  the  eye,  in  the 
ears,  or  side  of  the  neck,  with  stiffness  of  the  muscles,  is  present.  In  severe  cases  the  ton- 
sils, the  submaxillary  and  sublingual  glands  are  swollen,  with  acute  pain  in  swallowing ; 
these  are  usually  the  worst  cases."  In  a  few  instances  the  symptoms  of  genuine  erysipelas 
present  themselves  on  some  portion  of  the  skin,  and  invade  successively  almost  every  part 
of  it. 

In  these  irregular  forms  of  the  disease,  the  symptoms  of  the  thoracic  affection  are  often 
very  slight,  or  they  may  be  entirely  absent.  There  is  usually,  however,  some  sense  of 
tightness  about  the  chest,  some  difficulty  of  respiration,  and  a  slight  occasional  cough — with 
or  without  expectoration ;  and  it  is  remarked  by  Dr.  Stokes,  that  the  physical  signs  of  pneu- 
monia may  frequently  be  detected  in  cases  unattended  with  dyspnoea,  pain,  cough,  or 
expectoration. 

A  very  common  form  of  the  disease  under  consideration — and  which  at  certain  seasons, 
and  in  particular  districts,  is  even  more  prevalent  than  that  to  which  the  appellation  typhoid 
is  ordinarily  applied — is  the  one  usually  known  as  bilious  pleurisy  or  bilious  pneumonia. 

In  this,  the  attack  commences  with  symptoms  differing  but  little  from  those  which  usually 
usher  in  an  ordinary  case  of  bilious  remittent  fever — there  is,  perhaps,  in  general,  a  more 
severe  and  protracted  chill,  and  a  sense  of  distress  and  oppression  about  the  chest,  which  is 
not  usually  observed  in  the  latter  disease.  Occasionally,  the  attack  is  preceded,  for  a  day  or 
two,  by  a  sense  of  fulness  and  weight  in  the  right  hypochondrium,  and,  in  a  few  cases,  by 
symptoms  of  a  dysenteric  character.  Very  generally  there  is  severe  pain  of  the  back  and 
extremities,  and  often  of  the  head  also.  Almost  invariably,  the  attack  is  accompanied  by 
an  acute  pain  of  the  forehead — well-marked  febrile  symptoms,  with,  usually,  decided  exa- 
cerbations in  the  morning  and  remissions  towards  evening. — During  the  exacerbations  the 
face  is  flushed,  and  as  the  skin,  from  the  commencement  of  the  disease  is  more  or  less  tinged 
with  bile,  the  mixture  of  red  and  yellow  gives  to  the  countenance  a  very  peculiar,  sickly 
aspect.  The  eyes  are  red  and  watery,  the  conjunctiva  having  often  a  deep  yellow  hue.  In 
many  instances,  it  is  only  after  the  fever  has  continued  for  several  days  that  pain  in  the 
chest  is  complained  of:  this  is  sometimes  very  severe  and  acute,  more  commonly,  however, 
it  is  obtuse — of  an  aching  rather  than  of  a  lancinating  character — there  is,  at  the  same  time, 
a  sense  of  weight  and  oppression  of  the  chest,  with  more  or  less  difficulty  of  respiration  and 
cough.  The  cough  is  at  first  dry,  and  its  repeated  paroxysms  cause  an  increase  of  the  pain 
in  the  thorax  and  head.  The  expectorated  matter  is  frothy  and  of  a  yellowish  colour,  often 
streaked  with  blood,  and  of  variable  consistence.  The  tongue  is,  at  first,  coated  on  its  sides 
with  a  whitish  mucus,  while  at  the  centre  it  is  covered  by  a  dark-yellow  or  brownish  crust 
— the  edges  of  the  tongue  are  ordinarily  of  a  decided  red.  As  the  disease  advances,  the 
tongue  becomes  dark-brown,  dry,  and  hard.  The  pulse  is  usually  small,  frequent,  and  quick, 
with  a  slight  degree  of  tension. 

There  is  always  more  or  less  gastric  distress,  and  very  commonly  vomiting,  the  matter 
discharged  from  the  stomach  being  often  bile  or  a  thick  ropy  mucus  mixed  with  bile.  In 
many  cases  the  epigastrium  is  hot,  and  painful  upon  the  slightest  pressure.  The  urine  is 
always  of  a  deep  yellow  colour  from  the  presence  in  it  of  the  colouring  matter  of  the  bile. 

The  stage  of  excitement  in  bilious  pneumonia  is  ordinarily  of  short  duration,  and,  unless 
the  disease  is  arrested  by  an  appropriate  treatment,  great  muscular  prostration  speedily 
supervenes,  and  the  same  train  of  symptoms  ensue  as  in  the  tyj)hoid  form  of  the  disease. 

In  the  affection  we  have  described,  under  whatever  form  it  may  present  itself,  the  periou 
of  convalescence  is  always  slow,  irregular,  and  for  a  long  while  in)perfect.  "Chronic  hepa- 
tization, with  or  without  hectic  fever,  or  a  lurking  congestion,  may  continue  for  weeks ;  and 
although,  under  appropriate  management,  the  disease  may  be  ultimately  removed,  atrophy 
of  the  lungs,  with  or  without  ulcerative  disease,  is  often  established.  In  certain  cases,  months 
may  elapse  before  the  respiratory  murmur  is  heard,  and,  in  many  instances,  it  is  never  re- 
established. On  the  other  hand,  it  has  been  known  to  cease  in  a  single  day,  on  the  super- 
vention of  an  attack  of  gastritis  or  enteritis."  (^Dnnglison' s  Practice  of  Medicine,  vol.  i.  313.) 
The  principal  exciting  cause  of  pneumonia  typhoides  is  unquestionably  protracted  expo- 
sure to  a  damp  and  cold  atmosi)here,  while  the  predisposition  to  its  attacks  is  promoted  by 
all  those  causes  which  tend  to  reduce  the  vital  energies  of  the  system — as  bodily  or  menta' 
fatigue,  intemperance,  improper  or  deficient  diet,  insufficient  clothing,  mental  distress  or 
anxiety,  long  watching,  previous  disease,  &c.  Nothing,  remarks  Dr.  Mann,  predisposes  to  its 
attack  in  So  high  a  degree  as  an  intemperate  use  of  intoxicating  drinks.     The  soldiers,  sayi 

3  a2 


606  PLEURISY. 

Dr.  Mackintosh,  were  often  seized  with  the  disease  who  were  exposed  at  night  as  sentinels — 
"instead  of  walking;  about  they  frequently  stand  shivering  in  their  sentry-boxes,  the  surface 
continues  long  chilled,  and  with  a  view  to  fortify  themselves,  and  to  produce  warmth,  the/ 
are  in  the  habit  of  drinking  ardent  spirits  in  considerable  quantity." 

It  is  a  common  complaint  among  the  poor  and  labouring  classes  in  many  parts  of  thla 
country,  during  the  prevalence  of  long-continued  cold  and  damp  weather,  such  as  frequently 
occurs  during  the  spring  and  autumn,  in  the  more  northern  states,  as  well  as  during  the  open 
winter  of  the  middle  states.  In  the  south,  according  to  Dr.  Gibbes,  it  is  rarely  met  with  on 
highland  plantations,  and  if  at  all,  is  confined  to  such  negroes  as  are  more  or  less  exposed 
to  work  on  low  or  wet  ground.     On  the  swamp  plantations  the  disease  is  endemic. 

As  we  have  already  stated,  the  disease  occasionally  occurs  as  an  epidemic,  but  generally, 
during  seasons  when  the  temperature  of  those  districts  in  which  it  prevails  is  marked  by 
sudden  and  considerable  vicissitudes  from  heat  to  cold,  and  by  extreme  and  long-continued 
moisture. 

Typhus  pneumonia  more  frequently  attacks  males  than  females,  and  aduhs  than  children — • 
this  is  a  statement  in  which  nearly  all  who  have  written  upon  the  disease  concur.  The  pre- 
disposition of  adult  males  to  its  attacks,  is  very  readily  explained  by  the  axuount  of  exposure 
and  fatigue  to  which  they  are  usually  subjected  being  much  greater  than  that  of  females  and 
children — and  probably,  also,  from  the  fact  that  their  habits,  geiaerally  speaking,  are  much 
less  temperate.  The  disease  is  not,  however,  confined  to  any  age,  nor  are  females  and  chil- 
dren entirely  exempt  from  it,  particularly  when  it  prevails  as  an  epidemic.  It  is  usually, 
however,  most  severe  in  individuals  over  fifty  years  of  age,  and  is  very  seldom  seen  in  chil- 
dren under  ten  years.     The  negro  race  is  particularly  liable  to  its  attacks. 

In  the  treatment  of  pneumonia  typhoides  much  must  necessarily  be  left  to  the  judgment 
of  the  practitioner.  In  the  selection  of  his  remedies,  more  perhaps  than  in  any  other  disease, 
must  he  be  guided  by  the  particular  character  of  the  symptoms  present  in  each  case.  It  is 
all  important  that  the  true  nature  of  the  disease  be  carefully  investigated  in  its  earliest 
stages — it  being  then,  in  its  ordinary  form,  readily  controlled  by  an  appropriate  treatment, 
and,  even  when  marked  at  its  onset  by  symptoms  of  very  considerable  severity,  it  may  often 
be  arrested  by  prompt  and  judicious  management. 

In  this  disease,  Dr.  Gibbes  remarks,  and  a  similar  observation  is  made  by  others,"  if  the 
cases  are  immediately  attended  to,  it  is  found  quite  manageable,  as  much  so  as  an  ordinary 
catarrh;  but  when  neglected  for  twelve  or  twenty-four  hours,  and  the  symptoms  are  at  all 
aggravated,  the  patients  are  very  apt  to  die." 

We  shall  often  succeed,  when  the  patient  is  seen  during  the  first  period  of  the  attack,  or 
diuing  the  cold  stage,  as  it  is  not  improperly  termed,  in  rousing  the  nervous  energy — pro- 
ducing a  free  and  equable  circulation,  and  a  due  degree  of  heat  and  moisture  upon  the  sur- 
face, by  resorting  at  once  to  moderate  doses  of  opium,  cainphor,  calomel,  and  ipecacuanha, 
in  conjunction  M'ith  the  milder  class  of  diffusible  stimulants  internally,  and  the  application 
of  heat  and  rubefacients  externally.  By  this  treatment,  early  and  judiciously  pursued,  and 
carefully  watched  so  as  to  prevent  a  state  of  over-excitement  being  produced  by  it,  the  en- 
gorgement of  the  lungs  may  often  be  prevented  or  removed,  and  a  speedy  restoration  of 
health  secured  to  the  patient. 

In  the  more  open  form  of  the  disease,  known  as  bilious  pneumonia,  the  early  administra- 
tion of  an  emetic  will  often  be  found  beneficial.  Richter  states,  that  in  the  bilious  form  of 
the  disease,  emetics  will  often  remove  the  pain  and  aflection  of  the  chest  as  by  a  charm,  and 
Stoll  makes  the  same  observation  {Ratio  Meden.,  i.).  In  the  few  cases  Dr.  Eberle  had  seen 
of  bilious  pneumonia,  he  states  that  the  utility  of  emetics  in  its  treatment  was  strikingly 
evinced.  They,  in  general,  bring  on  an  uniform  diaphoresis,  promote  expectoration,  and 
allay  the  pain  in  the  thorax,  often  almost  immediately.  Dr.  Dickson  also  remarks,  that  he 
has  been  much  pleased  with  the  effects  of  the  early  administration  of  an  emetic,  or  an 
emetico-cathartic.  A  combination  of  ipecacuanha  and  calomel  may  be  given,  or  the  sulphate 
of  magnesia  dissolved  in  a  strong  infusion  of  seneka  or  serpentaria,  with  the  addition  of 
twenty  grains  of  ipecacuanha.  Dr.  Mann,  likewise,  speaks  favourably  of  the  effects  of  an 
emetic  of  ipecacuanha.  In  the  more  decidedly  inflammatory  cases,  the  emetic  was  not  ad- 
ministered by  him  until  after  bleeding  and  cathartics  had  been  employed ;  especially  where 
the  head  or  chest  was  affected  with  severe  pain : — when  after  the  occurrence  of  expectora- 
tion, this  had  become  arrested  from  any  cause,  small  emetics,  he  states,  were  found  benefi- 
cial, and  in  many  cases  had  to  be  frequently  repeated.  The  emetico-cathartic  or  even  the 
emetic  alone,  is,  however,  a  remedy  of  very  doubtful  propriety  in  cases  attended  with  early 
symptoms  of  prostration  and  extreme  muscular  debility. 

The  propriety  of  blood-letting  in  any  of  the  forms  of  typhus  pneumonia,  has  excited  not  a 
little  controversy.  By  some  practitioners,  the  use  of  the  lancet  is  condemned  in  every  case, 
as  a  remedy  fraught  with  danger,  from  its  liability  to  induce  speedily  a  state  of  prostration 
fiom  which  the  patient  is  witli  difl5culty  roused;  while  others  of  equal  celebrity  insist  upon 
ihe  necessity  of  full  and  even  repeated  venesection — considering  it  to  be  an  important,  if  not 
an  mdjspeiisable  remedy  in  the  treatment  of  the  form  of  pneumonia  under  consideration. 


PLEURISY.  •  607 

This  discrepancy  of  opinion  is  satisfactorily  accounted  for  by  the  very  different  characters 
under  which  the  disease  presents  itself  in  different  localities,  and  at  different  periods — often, 
indeed,  during  the  same  epidemic  visitation  ;  south  of  the  Potomac,  we  are  informed  by  Pro- 
fessor Potter,  that  the  disease  is  seldom  so  inflammatory  as  along  the  shores  of  New  Jersey 
Delaware,  and  Maryland;  and  the  farther  south,  the  more  it  is  said  to  assume  a  middle  ty- 
jihoid  complexion.  In  the  winter  epidemic  of  1815-16,  along  the  northern  frontier  of  the 
United  States,  we  are  assured  by  Dr.  IVIann,  that  in  many  districts  "  the  disease  was  highly 
inflammatory  from  its  commencement  to  its  final  resolution,"  and  that,  "  it  was  as  idle  to 
administer  stimulants  for  its  cure,  as  it  would  have  been  to  have  poured  oil  on  fire  to  extin- 
guish the  flame."  "Its  cure,"  ho  adds,  "depended  upon  the  assiduous  administration  of  the 
antiphlogistic  regimen:  evacuants,  expectorants,  and  diaphoretics,  with  the  aid  of  blisters." 
It  is  very  certain  that  in  the  ordinary  cases  of  typhoid  pneumonia,  the  use  of  the  lancet 
will  seldom  be  demanded,  and  in  many,  would  be  altogether  inadmissible.  Cases,  it  is 
true,  will  not  unfrequently  occur,  in  which  the  detraction  of  a  moderate  quantity  of  blood 
from  the  arm,  during  the  early  period  of  the  febrile  stage,  will  be  productive  of  the  best 
effects.  General  blood-letting,  however,  should  always  be  resorted  to  with  the  utmost  cau- 
tion— perhaps  it  would  be  better,  in  every  instance  where  symptoms  of  a  typhoid  character 
early  set  in,  and  the  loss  of  blood  is  considered  advisable,  to  apply  cups  to  the  chest  in  pre- 
ference to  resorting  to  the  lancet.  In  cases  of  bilious  pneumonia,  blood-letting  will  be  much 
more  frequently  demanded  than  in  the  typhoid  form  of  the  disease ;  but  even  in  these  it 
should  be  resorted  to  only  in  the  early  period  of  the  attack,  and  it  is  more  safe  to  take  away 
a  sufficient  amount  at  the  first  bleeding,  than  to  trust  to  small  and  repeated  bleedings.  In 
the  bilious  form  of  the  disease,  when  much  pain  or  tenderness  of  the  epigastrium  is  present, 
leeches  or  cups  to  this  part  are  always  proper,  and  will  often  be  found  to  afford  very  decided 
relief. 

The  bowels  should  be  early  evacuated  by  some  mild  but  effective  laxative — the  best  is 
unquestionably  calomel  in  moderate  doses,  followed  by  castor  oil  or  magnesia — active  or 
"A-atery  purging  should  always  be  cautiously  avoided. 

In  the  cases  marked  by  early  prostration,  and  extreme  muscular  debility,  we  should  resort 
at  once  to  moderately  stimulating  diaphoretics ;  of  these,  according  to  Dr.  Dickson,  camphor, 
nitrous  ether,  the  carbonate  and  acetate  of  ammonia  are  the  best ;  and  they  are  rendered 
more  beneficial  by  combining  them  with  Dover's  powder.  "  The  efiicacy  of  all  these,"  he 
adds,  "  will  be  much  aided  by  the  pediluvium,  and  by  the  application  of  warm  fomentations, 
poultices,  and  heat  in  various  forms  to  the  surface  of  the  patient.  Cataplasms  with  mustard 
must  be  laid  over  the  chest,  if  pain  or  dyspnoea  is  present,  and  applied  also  to  the  wrists  and 
insteps.  Epispastics  are  also  of  use,  by  their  double  power  of  stimulants  and  revulsives 
tlie  back  of  the  neck,  if  the  head  be  affected,  the  sternum  and  the  epigastric  region,  if  the 
lungs  or  heart  or  stomach  suffer,  should  be  selected  for  their  application.  There  has  been 
some  dispute  as  to  the  preference  due  to  the  dry  or  moist  form  of  heat,  as  the  best  to  be  re- 
sorted to  in  this  disease.  It  is,  I  think,  easy  to  decide.  If  the  skin  be  dry,  I  prefer  fomen- 
tations, or  even  the  vapour-bath ;  if  moist,  I  prefer  bottles  of  hot  water,  heated  bricks,  bags 
of  hot  salt,  chaff,  &c.  Sweating  will  in  the  greater  number  of  cases,  come  on  readily,  but 
must  be  regulated.  If  too  profuse,  and  kept  up  for  too  long  a  time,  it  may  prove  injurious 
and  debilitating.  You  restrain  it  by  substituting  dry  for  moist  applications,  and  removing 
some  of  the  bed-clothes,  and  changing  cautiously  the  body  linen  of  the  patient;  dry  garments 
carefully  and  well  aired,  being  put  on  in  the  place  of  those  moistened  by  the  cutaneous 
discharge." 

In  cases  where  a  tendency  to  sinking  is  early  evinced.  Dr.  Gibbes  recommends  sma.l  doses 
of  calomel  as  a  general  excitant  of  the  secretions,  with  camphor,  opium,  carbonate  of  am- 
monia, and  free  vesication. 

In  nearly  every  form  of  the  disease,  whether  typhoid,  bilious,  or  more  openly  intlam- 
matory,  the  effects  of  small  doses  of  calomel,  combined  with  ipecacuanha  and  opium  are 
spoken  of  as  particularly  beneficial.  Large  blisters  over  the  chest  will  also,  in  most  cases, 
be  found  of  the  highest  importance,  from  the  very  commencement  of  die  attack.  In  obstinate 
cases.  Dr.  Mann  directs  them  to  be  renewed  daily  until  the  pain  of  the  chest  is  removed. 

Where  the  patient's  strength  rapidly  fails,  and  he  is  sinking  into  diat  low  typhoid  condi- 
tion which  marks  the  second  period  of  die  disease,  stimulants  must  be  freely  resorted  to :  of 
these  Dr.  Dickson  prefers  "  the  volatile  alkali  in  large  doses,  from  five  to  ten  grains  every 
half  hour  or  hour,  widi  wine  whey  or  brandy  toddy;  spts.  nit.  dulc.,  spts.  of  turpentine,  the 
tincture  of  cantharides."  "I  can  set,"  he  remarks,  "no  limit  to  the  administration  of  this 
class  of  remedies,  but  the  excitement  of  a  notable  degree  of  reaction,  which  being  observed, 
will  guide  you  in  the  future  quantities  to  be  exhibited ;  taking  care,  however,  that  the  patient 
shall  not  suffer  by  dieir  timid  or  ineflicient  amount,  nor  be  allowed  to  retrograde  by  any  sud- 
den subtraction  of  dose." 

"  It  is  well  to  be  reminded,"  observes  the  same  writer,  "  that  in  this  strange  disease  it  ia 
never  permitted  to  despair  of  your  patients,  recoveries  being  in  considerable  number  recorded 


608  PULMONARY  HEMORRHAGE. 

fiom  circumstances  the  most  deplorable,  and,  indeed,  to  all  reasonable  anticipations,  abso 
lutely  hopeless." 

During  the  whole  period  of  convalescence  the  patient  will  require  to  be  watched  with 
care. — -  You  must  abstract  gradually  from  the  amount  of  stimulants  which  have  been  given 
him,  and  substitute  in  their  stead  the  more  permanent  tonics.  Of  these  each  practitioner  has 
his  favourite.  Arsenic  is  preferred  by  many  of  the  New  England  physicians,  and  is,  accord- 
ing to  Dr.  Dickson,  without  doubt,  highly  serviceable."  The  muriate  of  iron  is  also  spoken 
of  as  well  adapted  to  this  period  of  the  disease  —  and  is  certainly  preferable  in  all  respects 
to  the  arsenic.  Dr.  Mann  states,  that  the  only  stimulant  employed  by  him  in  the  convales- 
cent state,  was  a  mixture  of  spts.  nit.  dulc,  and  aqua  ammoniae  ;  a  teaspoonful  of  this  proved 
a  cordial  and  expectorant,  at  the  termination  of  the  disease,  when  repeated  every  two  or 
three  hours;  as  did,  also,  a  mixture  of  equal  parts  of  the  camphorated  tincture  of  opium  and 
antimonial  wine,  where  the  cough  was  troublesome.  Other  practitioners  prefer,  as  a  tonic, 
at  the  close  of  the  disease  and  during  the  period  of  convalescence,  the  cinchona  or  the  sul- 
phate or  muriate  of  quinia.  Dr.  Dickson  gives  the  bark  in  infusion,  combining  it  with  ser- 
pentaria,  adding  to  each  dose  a  small  proportion  of  carbonate  of  potass,  and  camphorated 
tincture  of  opium.  The  patient  should  be  supplied  with  a  light  diet  of  nourishing  and  easily 
digested  food  —  and  should  be  guarded  sedulously  from  the  slightest  amount  of  exposure  to 
cold  or  damp,  and  should  be  guarded  from  sudden  alternations  of  temperature  for  a  con- 
siderable time  after  recovery  • — he  should  to  that  end  vi^ear  flannel  next  his  skin,  and  adapt 
his  clothing  not  only  to  the  season,  but  to  the  temperature  of  each  day  and  each  portion  of 
the  day. — C] 


LECTURE  LIV. 

Pulmonary  Hemorrhage  ;  its  varieties  ;  its  connection  with  pulmonary  consump- 
tion, and  with  disease  of  the  heart.  Pulmonary  apoplexy.  Prognosis  in 
Hxmoptysis.     Symptoms.     Treatment. 

Having  gone  over  the  inflammatory  affections  of  the  organ  of  respiration  ;  having 
brought  before  you  inflammation  of  the  membrane  which  lines  the  air-passages,  or 
bronchitis  ;  inflammation  of  the  membrane  which  invests  the  lungs,  or  pleurisy ; 
and  inflammation  of  the  ichole  substance  of  those  organs,  or  pneumonia  ;  I  proceed 
next  to  the  subject  of  pulmonary  hemorrhage. 

You  may  remember  that,  in  an  early  part  of  the  course,  I  drew  your  attention  to 
some  general  facts  respecting  internal  hemorrhages.  I  showed  you  that  the  blood 
does  sometimes  proceed  from  visibly  ruptured  vessels,  but  that  it  is  much  oftener 
poured  forth  from  unbroken  surfaces,  in  the  way  of  exhalation  ;  and  that  hemorrhage 
of  this  kind  takes  place  from  the  mucous  membranes  far  more  frequently  than  from 
any  other  natural  surface  of  the  body.  I  observed  also  that  such  hemorrhage  is 
almost  always  preceded  by  congestion ;  either  by  active  congestion,  which  is  less 
common,  or  by  passive  and  mechanical,  which  is  extremely  common  :  and  we  speak, 
accordingly,  of  active  and  passive  hemorrhage.  Hemorrhage  is  also  sometimes 
primary,  or  idiopathic,  and  then  constitutes  the  whole  disease  ;  while  at  other  times 
it  is  merely  a  symptom,  direct  or  indirect,  of  some  other  disorder,  in  which  case  we 
call  it  secondary. 

Now  in  the  lunsfs  we  find  examples  of  all  these  varieties  of  internal  bleeding;  but 
pulmonary  hemorrhage  is  secondary  much  more  often  than  it  is  primary. 

In  speaking,  therefore,  of  some  forms  of  pulmonary  haemorrhage,  I  must  touch 
upon  certain  diseases  of  which  the  bleeding  is  a  symptom  :  but  I  shall  not  go  further 
into  the  consideration  of  those  diseases  at  present,  than  may  be  necessary  to  elucidate 
the  hemorrhage.  Bleeding  from  the  lungs  is  a  thing  of  most  fearful  interest ;  and 
It  will  be  useful  to  take  a  general  view  of  that  phenomenon,  whether  it  be  a  substan- 
tial disease  in  itself,  or  merely  a  sign  of  other  pre-existing  diseases. 

Tne  blood,  then,  in  pulmonary,  as  in  all  other  hemorrhages,  may  issue  through  a 
breach  in  the  walls  of  some  considerable  blood-vessel ;  or  it  may  proceed  from  innu- 
merable points  in  the  mucous  membrane  of  the  lungs,  by  the  process  of  exhalation  : 
«nd  the  latter  mode  of  hemorrhage  is  much  the  more  common  of  the  two,  although 


PULMONARY  HEMORRHAGE.  609 

it  is  the  popular  belief  tfiat  the  "breaking  a  blood-vessel  in  the  lungs"  is  of  very- 
frequent  occurrence. 

The  particular  vessels  injured  in  the  first  class  of  cases,  and  the  nature  and  origin 
of  the  breach  made  in  their  sides,  are  matters  of  infinite  variety.  Sometimes  the 
blood  is  extravasated  through  apertures,  the  results  of  a  disorg:mizing  process  which 
has  commenced  in  the  coa-ts  of  the  vessels  themselves  ;  as  when,  for  example,  aneu- 
risms of  the  thoracic  aorta,  or  of  its  primary  divisions,  burst,  and  pour  their  contents 
into  the  air-tubes.  Having  pointed  out  this  accidental  and  hopeless  form  of  pulmo- 
nary hemorrhage,  I  shall  postpone  any  further  account  of  the  disease  that  gives  rise 
to  it,  to  a  future  lecture. 

Sometimes,  again,  a  large  blood-vessel  is  laid  open  by  the  encroachment  and  ex- 
tension of  disease  from  contiguous  structures.  Here  is  represented  (Carswell,  fasc, 
vi.  plate  iii.  fig.  5)  the  perforation  of  a  large  branch  of  the  pulmonary  artery,  and  of 
a  neio-hbouring  bronchial  tube,  by  the  extension  of  tubercular  ulceration.  The  blood 
escaped  so  abundantly  in  this  case,  that  the  patient  was  dead  in  less  than  a  quarter 
of  an  hour.  And  here  I  show  you  a  preserved  specimen  of  a  similar  opening  made 
in  the  pulmonary  vein. 

It  will  be  necessary  that  T  should  anticipate  somewhat ;  and  in  order  to  include  in 
one  view  all  that  relates  to  p'llmonary  hemorrhage,  that  I  should  speak  cursorily  of 
Us  connect'on  with  tubercular  phthisis.  No  one  here  can  be  ignorant  that  in  that 
terrible  disease  portions  of  the  lung  are  liable  to  be  hollowed  out  by  the  softening 
and  expulison  of  tubercular  matter,  into  what  are  called  vomicx.  Now  seeing  that 
hsemoptysis  occurs  very  frequently  in  persons  labouring  under  consumption,  and 
that  the  expectoration  of  blood  is  often  copious,  and  takes  place  when  it  is  evident 
that  there  are  tubercular  excavations  in  the  lung,  it  would  be  vevy  natural  for  you 
lo  suppose  that  the  bleeding  in  such  cases  proceeded  from  large  vessels  which  had 
been  laid  open  during  the  softening  of  the  tubercles,  or  by  the  subseq.isnt  extension 
jf  the  ulcerating  cavities.  But  in  point  of  fact,  this  is  very  rarcbj  iho  case.  I  shall 
explain  to  you  hereafter  how  it  happens  that  this  hemorrhage  from  the  larger  vessels 
is  generally  prevented  ;  still  it  does  sometimes  happen. 

But  in  a  far  greater  number  of  instances  the  blood  in  haemoptysis  is  exhaled  from 
the  mucous  membrane  that  lines  the  air-passages.  For  when  this  surface  is  examined 
in  the  dead  body,  and  immediately  after  the  occurrence  of  pulmonary  hemorrhage, 
it  is  very  often  found  to  be  perfectly  entire,  from  the  commencement  of  the  trachea 
10  the  remotest  divisions  of  the  bronchial  tubes ;  as  far,  at  least,  as  minute  dissection 
can  follow  them.  The  membrane  in  these  cases  is  usually  red,  as  in  simple  bron- 
chitis ;  but  it  is  sometimes  pale,  or  with  scarcely  any  traces  of  vascularity.  The 
former  of  these  appearances  results  from  the  continued  turgescence  of  the  capillary 
vessels ;  the  ktter  is  the  consequence  of  their  having  been  completely  emptied  of 
blood  by  the  last  hemorrhage.  We  shall  meet  with  analogous  conditions  when  we 
come  to  examine  the  hemorrhages  that  proceed  from  other  mucous  surfaces ;  and 
especially  from  that  of  the  alimentary  canal. 

When  blood  is  thus  exhaled  from  the  mucous  membrane  of  the  air-passages,  the 
hemorrhage  may  be  strictly  primary  or  idiopathic;  i.  e.,  it  may  be  independent  of 
any  discoverable  alteration  of  texture,  either  in  the  mucous  surface  itself,  or  in  any 
other  part  which,  by  reason  of  some  intelligible  connection  of  structure  or  relation, 
seems  capable  of  influencing  the  capillary  circulation  of  the  membrane.  But  the 
occurrence  of  pulmonary  hemorrhage  strictly  idiopathic  has  been  more  frequently 
affirmed  than  proved.  Active  hemorrhage  from  the  lungs  is  stated  by  systematic 
writers  to  be  the  hemorrhage  of  adolescence,  as  epistaxis  is  that  of  childhood.  I 
believe,  however,  that  idiopathic  active  hemorrhage  from  these  organs  is  very  rare 
indeed  ;  unless  we  may  consider  as  such,  certain  forms  o^  vicarious  bleeding,  which 
I  shall  presently  advert  to.  Andral  tells  us  that  in  one  instance  only,  in  whicn 
hemorrhage  from  the  surface  of  the  air-passages  had  been  the  immediate  and  appa- 
rently the  sole  cause  of  death,  had  he  ever  found  the  substance  of  the  lungs  free 
from  tubercles,  and  perfectly  healthy.  He  does  not,  however,  state  whether  in  this 
one  instance  the  heart  also  was  in  its  natural  condition :  an  important  omission,  as 
we  shall  hereafter  perceive.  He  relates,  indeed,  as  an  examnle,  of  idiopathic 
39 


()I0  PULMONARY    HE3I0RRHAGE. 

hccmoptysis,  the  case  of  a  young  man  who  suffered  profuse  hemorrhage  from  the 
luntrs  on  four  several  occasions,  between  the  ages  of  twelve  and  eighteen,  without 
any  apparent  detriment  to  his  health,  which  remained  excellent.  It  is  consistent, 
however,  with  much  experience  to  suppose  that  crude  tubercles  might  have  been 
scattered  in  the  lungs  of  this  person,  and  have  sufficed,  on  the  application  of  some 
exciting  cause,  to  determine  the  hemorrharje,  although  as  j'et  their  presence  was  not 
indicated  by  any  other  sign.  Almost  every  systematic  writer  quotes,  as  an  example 
of  idiopatliic  hemorrhage  from  the  lungs,  the  story  of  the  Roman  governor,  men- 
tioned by  Pliny,  who  lived  to  the  age  of  r  'nety,  though  he  was  afflicted  with  habitual 
hajmoptj'sis.  Now  the  frequent  citatiot  of  this  supposed  instance  is  of  itself  a  suffi- 
cient proof  that  spontaneous  pulmonary  jemorrhage  is  far  from  being  common. 

Cscteris  paribus,  the  disposition  to  pulmonary  hemorrhage  is  increased  by  what- 
ever tends  to  diminish  the  capacity  of  the  thorax,  and  to  compress  the  lungs,  or  the 
heart  and  great  blood-vessels.  The  "lechanical  congestion  thus  produced  may  be- 
come a  very  intelligible  cause  of  the  '.xhalation  of  blood  from  the  mucous  membrane. 
And  it  is  partly  on  this  principle  that  Ave  may  account  for  the  frequency  of  hae- 
moptysis in  persons  with  crooked  spines  ;  in  tailors,  who  sit  continually  in  a  stooping 
posture  :  in  young  women  who  lace  their  stays  too  tightly  ;  and  even  in  those  who 
labour  under  dropsy,  or  other  cause  of  distension  of  the  belly.  Haemoptysis  accom- 
panying ascites  has  been  known  to  cease  at  once  upon  the  performance  of  the 
operation  of  tapping,  and  to  recur  upon  the  reaccumulation  of  the  dropsical  fluid  ; 
and  this  is  not  on  one  occasion  only,  but  so  often  and  regularly  as  to  preclude  all 
notion  of  accidental  coincidence.  There  can  be  little  doubt,  however,  that  in  this 
class  of  cases,'  or  at  least  in  a  vast  majoritj'^  of  them,  the  haemoptysis  is  mainly  to  be 
ascribed  to  organic  disease  of  the  heart  or  of  the  lungs  ;  and  that  the  pressure  which 
precedes  and  determines  the  bleeding  is  simply  a  concurrent  cause. 

If  we  cannot  properly  rank  that  pulmonary  hemorrhage  as  idiopathic,  which  is 
constitutional  and  vicarious  of  some  other  natural  or  morbid  discharge, — and  most 
frequently  of  all  of  the  menstrual  discharge  in  females, — it  may  be  considered  as 
forming  a  link  of  connection  ;  as  lying  midway  between  secondary  and  primary 
hemorrhages.  There  are  a  great  number  of  very  curious  and  well-authenticated 
facts  upon  record  concerning  this  singular  form  of  hemorrhage  by  deviation.  .  will 
give  you  one  history  of  the  kind  by  w^ay  of  sample;  it  is  related  by  Pinel,  who  held 
that  there  was  no  supplemental  hemorrhage  more  common  than  the  haemoptysis  that 
is  vicarious  menstruation. 

A  female,  58  years  old,  born  of  healthy  and  robust  parents,  of  strong  constitution, 
of  a  sanguine  and  plethoric  temperament,  and  of  great  sensibility,  lived  in  the  Sal- 
petriere,  and  was  therefore,  under  constant  observation  from  the  age  of  14.  She 
enjoyed  excellent  health  till  she  was  1(>  years  old.  In  her  IGth  year  the  menstrual 
discharge  commenced  without  mishap  or  difficulty  ;  but  this,  \\ex  first  menstruation, 
was  suddenly  suppressed,  in  consequence  of  the  fright  and  agitation  produced  by  the 
eight  of  an  epileptic  patient  in  strong  convulsions.  From  that  time  the  catamenia 
never  reappeared,  nor  did  any  kind  of  discharge  take  place  from  the  genital  organs , 
but  at  the  next  period,  when  regular  menstruation  ought  again  to  have  come  on,  the 
girl  was  attacked  with  violent  hcemoptysis.  The  hemorrhage  was  preceded  by  vague 
pains  in  the  uterus  and  loins,  and  by  other  symptoms  which  frequently  announce  the 
catamenia.  It  lasted  two  days,  during  which  time  the  girl  expectorated  nearly  a 
quart  of  blood.  With  one  interval  of  exception  only,  this  female  continued  to  men- 
struate through  her  lungs  at  each  monthly  period,  from  her  IGth  to  her  5Sth  year, 
t.  c.,  during  42  years  of  her  life.  The  coming  on  of  the  hemorrhage  was  sometimes 
a  little  accelerated  by  strong  mental  excitement ;  sometimes  a  little  retarded  by 
causes  of  a  contrary  nature.  It  was  suspended  during  one  whole  year,  without  any 
serious  impairment  of  the  general  health,  or  the  occurrence  of  any  other  hemor- 
rhage :  during  this  interval,  however,  the  patient  suffere'?  most  severe  headaches. 
Occasionally  the  hremojotysis  was  complicated  with  ha^mateinesis.  The  symptoms 
by  which  the  pulmonary  hemorrhage  in  this  instance  was  generally  preceded  or 
accompanied  were  the  following : — a  sensation  of  weight  and  uneasiness  in  the  loins 
and  in  the  .situation  of  the  uterus,  soon  followed  by  chilliness  of  the  surface,  general 


PULMONARY  HEMORRHAGE.  611 

lassitude,  and  a  feeling  of  oppression  and  heat  in  the  chest,  with  some  dyspnoea. 
The  face  became  red,  and  she  had  intense  headache.  Then  she  began  to  have  a 
distinct  sensation  of  pricking,  and  of  a  sort  of  bubbhng,  in  the  trachea  and  about  the 
commencement  of  the  bronchi ;  then  followed  sharp  cough,  and  the  expectoration 
of  blood,  often  bright-coloured  and  frothy,  sometimes  of  a  darker  hue.  The  dura- 
tion of  the  haemoptysis  was  generally  confined  to  a  single  day,  and  it  never  exceeded 
three  days.  It  recurred  with  tolerable  exactness  at  monthly  periods ;  sometimes  the 
interval  was  longer,  and  then  the  hemorrhage  continued  longer,  but  was  less  abun- 
dant ;  and  upon  the  whole,  about  the  same  quantity  of  blood  was  lost  on  each  occa- 
sion. This  woman  continued  plump,  and  otherwise  healthy,  though  liable  to  some 
thickness  of  the  breath  upon  unusual  exertion. 

Cases  of  this  kind  are  not  at  all  uncommon ;  although  the  vicarious  hemorrhage 
seldom  persists  so  long  and  so  steadily.  They  are  not  usually  attended  with  any 
peril  to  life. 

It  is,  however,  a  melancholy  truth,  that  the  hemorrhage,  which  takes  place  by 
exhalation  from  the  mucous  membrane  of  the  air-passages,  is  dependent,  in  a  very 
large  proportion  of  instances,  upon  incurable  disease.  The  hemorrhage  is  secondar}^; 
and  the  clisease  of  which  it  is  symptomatic  is  usually  a  fatal  disease.  And  the  com- 
plaint of  which  hcsmoptysis  is  by  far  the  most  frequentli/ symptoma.tic,  is  tubercular 
phthisis.  When  the  tubercles  are  found  upon  dissection  to  be  yet  crude  and  entire, 
and  no  breach  can  be  detected  in  the  membrane,  then  no  doubt  can  be  entertained 
about  the  source  and  manner  of  the  bleeding;  and  even  when  cavities  exist,  espe- 
cially if  they  are  found  to  contain  no  blood,  it  is  probable  that,  in  most  cases,  the 
hemorrhage  has  had  a  similar  origin. 

When  haemoptysis  is  thus  actually  symptomatic  of  tubercular  disease  of  the  longs, 
it  is  liable  to  considerable  variety  in  regard  to  the  period  of  its  first  occurrence,  and 
the  symptoms  by  which  it  is  succeeded.  There  are  many  persons  in  whom  the  first 
attack  of  htcmoptysis  precedes,  even  for  years,  the  primary  symptoms  of  unequivo- 
cal phthisis.  There  are  others  in  whom  the  iirst  attack  of  haemoptysis  is  imincul- 
atclij  followed  by  all  the  signs  which  announce  vhe  presence  of  tubercles  in  the  lungs. 
Man}',  again,  do  not  spit  blood  until  the  tubercles  have  acquired  a  considerable 
degree  of  development,  and  the  phthisical  symptoms  have  been  for  some  time  clearly 
marked  ;  and  occasionally,  in  these  cases,  the  first  hemorrhage  proves  fatal.  Lastly, 
it  is  far  from  being  an  uncommon  thing  to  see  pulmonary  consumption  run  its 
whole  course,  and  terminate  in  death,  without  having  been  attended  with  any  spitting 
of  blood. 

Andral  gives  the  following  statement  as  the  result  of  his  own  observation,  in  re- 
gard to  the  relative  frequency  of  these  several  modes  of  connection  between  haemo- 
ptysis and  consumption. 

Of  the  persons  whom  he  had  known  to  die  of  that  disease,  one  in  six  never  spat 
blood  at  all.  Three  in  six  (or  one  half  of  the  whole  number)  did  not  spit  blood 
until  the  existence  of  tubercles  in  the  lungs  was  already  made  certain  by  unequi- 
vocal symptoms.  In  the  remaining  two-sixths  the  haemoptysis  preceded  the 
other  symptoms  of  tubercular  disease,  and  seemed  to  mark  the  period  of  its  com- 
mence-menl. 

By  this  comparative  statement  you  will  see  how  very  frequently  hosmoptysis 
occurs  as  one  of  the  symptoms  connected  with  tubercular  phthisis.  Under  this 
physician's  observation  it  happened  in  live  cases  out  of  six.  In  the  experience, 
however,  of  M.  Louis,  the  proportion,  though  very  large,  is  not  quite  so  great  as 
Andral  found  it.  Among  eighty-seven  instances  of  consumption,  there  were  fifty- 
seven,  or  four  in  every  six,  in  which  hcemoplysis  had  been  present. 

It  has,  however,  been  made  a  question,  whether  the  spitting  of  blood  which  thus 
occurs  in  connection  with  tubercular  phthisis,  is  always  to  be  considered  as  indica- 
tive of  the  existence  already  of  tubercles  in  the  lungs  ;  or  whether  it  may  not  some- 
times precede,  and  give  occasion  to,  their  formation  in  those  organs.  This  question 
has  evidently  been  suggested  by  those  cases  (constituting,  according  to  Andral,  one 
third  of  all  that  happen)  in  which  the  ordinary  signs  of  phthisis  begin  to  manifest 
their»seives  immediately  upon  the  occurrence  of  the  first  haemoptysis,  or  within  a 


612  PULMONARY   HE3I0RRHAGE. 

short  time  afterwards.  Morton,  who  has  noticed  this  kind  of  pulmonary  hemorrhajje, 
includes  among  his  species  of  phthisis,  the  "  phthisis  ab  hcemoptoe ;"  and  Cullen 
held  that  spilling  of  blood  was  oflen  the  cause  of  pulmonary  consumption.  It  is  a 
very  important  question,  and  I  shall  revert  to  it  again  hereafter. 

Next  to  tubercular  disorganization  of  the  lungs,  the  most  frequent  source  of  pul- 
monary hemorrhage  is  to  be  found  in  the  organic  disease  of  the  heart.  It  has  been 
stated  by  Chomel,  Bouiilaud,  and  others,  both  in  this  country  and  abroad,  that  the 
disease  in  these  cases  is  most  commonly  situated  in  the  I'ight  chambers  of  the  heart. 
But  certainly  this  is  a  mistake.  The  error  has  arisen  from  arguing  upon  erroneous 
analogies,  instead  of  attending  to  matters  of  fact.  However,  the  statement  is  just  as 
httle  supported  by  reason  as  it  is  by  the  result  of  general  experience.  The  only 
alteration  in  the  right  cavities  of  the  heart  which  we  could  suppose  likely,  a  priori, 
to  cause  pulmonary  congestion,  and  thereby  haemoptysis,  would  be  increased  strength 
and  thickness  of  their  muscular  parietes :  hypertrophy ;  a  morbid  condition  which 
is  comparativily  rare  on  that  side  of  the  heart,  and  which,  perhaps,  would  not  suffice 
for  the  production  of  haemoptysis,  even  if  it  did  oftener  exist.  The  direct  effect,  on 
the  other  hand,  of  any  obstacle  to  the  free  passage  of  the  blood  in  the  right  cham- 
bers of  the  heart,  would  be  to  gorge  the  liver,  and  the  system  of  the  vena  portse  ; 
and  to  prevent  the  lungs  from  receiving  their  due  proportion  of  blood.  But  any 
material  obstruction  existing  in  the  left  auricle  or  ventricle  will  impede  the  return 
of  blood  from  the  lungs,  lead  to  its  accumulation  in  those  organs,  give  rise  to  me- 
chanical congestion,  and  so  dispose  strongly  to  pulmonary  hemorrhage.  And,  in 
point  of  fact,  we  find  that  haemoptysis  is  very  frequently  the  result  of  disease  in  the 
left  side  of  the  heart ;  and  this  leads  me  to  speak  here  of  one  very  remarkable  morbid 
condition  of  the  lungs,  which  is  often  directly  connected  both  with  pulmonary  he- 
morrhage and  with  cardiac  disease  ;  though  it  is  not  always,  or  necessarily,  associated 
with  either. 

The  morbid  state  to  which  I  allude  is  far  from  being  infrequent ;  yet  it  had  been 
scarcely  noticed  by  or  known  to  pathologists,  until  Laennec  described  it  under  the 
title  of  pulmonary  apoplexy.  It  appears  under  two  forms.  In  the  one  form  we 
find  an  uncertain  number  of  hard  knobs,  or  compact  masses,  situated  here  and  there 
in  the  substance  of  the  lungs,  chiefly  in  their  lower  lobes,  and  towards  their  posterior 
surface.  Their  size  varies  from  that  of  a  marble  to  that  of  a  hen's  egg.  When 
cut  through  they  are  seen  to  be  very  exactly  circumscribed,  the  cut  surface  being 
more  or  less  circular,  of  a  uniform  and  very  dark  colour  throughout,  and  exhibiting 
a  strong  contrast  with  the  surrounding  tissue.  Careful  examination  shows  that  these 
masses  are  composed  of  blood  that  has  coagulated  in  the  pulmonary  vesicles.  Occa- 
sionally the  pulmonary  substance  seems  broken  down,  or  torn,  by  the  extravasated 
blood  ;  and  in  these  cases,  perhaps,  the  resemblance  between  the  injury  done  to  the 
lung,  and  that  which  is  inflicted  on  the  substance  of  the  brain  in  cerebral  hemorrhage, 
is  tolerably  close.  Generally,  however,  there  is  no  such  laceration  of  the  pulmonary 
tissues ;  but  one,  or  more,  of  the  lobules  of  the  lungs  are  gorged  and  crammed  with 
blood,  which  has  been  poured  out  from  the  surface  of  the  mucous  membrane.  These 
lobules,  it  is  weU  known,  have  no  direct  communication  with  each  other ;  but  are 
isolated  (except  where  they  severally  open  into  the  bronchial  tubes  from  which  they 
spring)  by  a  distinct  investment  of  areolar  tissue ;  and  it  is  to  this  peculiarity  in 
their  structure  and  disposition,  that  the  exact  circumscription  of  the  dark-red  indu- 
rated masses  is  to  be  attributed. 

In  the  other  form  of  pulmonary  apoplexy,  there  are  fewer  of  these  solid  spots; 
perhaps  one  only,  large,  diffused,  occupying  sometimes  nearly  the  whole  of  one 
lobe,  its  limits  obscurely  defined,  and  its  colour  gradually  deepening  to  the  centre, 
which  is  obviously  formed  by  little  else  than  a  black  clot  of  blood. 

Now  the  principal  symptom  attendingthe  formation  of  these  masses  is  hasmoptysis; 
and  the  principal,  though  not  the  only  cause  is  disease  of  the  heart.  The  hemor 
rhage  is  often  severe  and  copious  in  the  first,  or  circumscribed  form :  sometimes 
shght  and  scanty,  but  commonly  slow,  oozing,  and  persistent,  in  the  second  or  uncir- 
oumscribed  form.  The  heart  disease  is  in  its  left  chambers,  and  very  often  consists 
<n  contraction  of  the  mitral  orifice.     No  example  of  pulmonary  apoplexy,  or  of 


PULMONARY   HEMORRHAGE.  i  t)l3 

pulmonary  hemorrhage,  even  apparently  dependent  upon  hypertrophy  of  the  right 
side  of  the  heart,  has  ever  fallen  under  my  notice. 

In  truth  the  morbid  condition  of  the  lungs  which  I  am  now  speaking  of,  has  been 
badly  named.  The  application,  by  Laennec,  of  the  term  apoplexy  to  \.\\q  lungs  was 
singularly  unfortunate  :  for  it  suggests  an  analogy  between  two  things,  which,  though 
resembling  each  other  in  the  appearances  which  they  leave  behind  them  in  the  organ 
affected,  are  yet,  essentially,  unlike.  I  have  shown  you,  in  a  previous  part  of  the 
course,  that  cerebral  hemorrhage  depends  almost  always  upon  the  giving  way  of  a 
blood-vessel,  in  consequence  of  the  morbid  brittleness  of  its  coats ;  while  what  is 
called  pulmonary  apoplexy  can  very  seldom  indeed  be  so  caused.  The  notions  which 
I  have  been  led  to  form  upon  this  subject  differ  materially  from  those  which  you 
will  find  expressed  in  the  works  of  almost  every  writer  on  pulmonary  apoplexy. 
The  opinions  I  entertain  were  stated  several  years  ago,  in  some  lectures  which  I 
was  appointed  to  deliver  before  the  College  of  Physicians ;  and  I  have  constantly 
been  in  the  habit  of  mentioning  them  to  the  pupils  of  the  Middlesex  Hospital,  and 
to  my  medical  friends.  It  is  a  matter  of  satisfaction  to  me  to  find  that  they  are 
esteemed  to  be  correct  by  so  sound  a  pathologist  as  Dr.  Carswell,  who  has  alluded 
to  them  in  one  of  his  fascicuh  on  the  Elementary  Forms  of  Disease.  Laennec 
speaks  of  the  pulmonary  apoplexy,  as  if  it  were  the  cause  of  the  haemoptysis.  But 
ihis  is  surely  a  very  incorrect  view  of  the  matter.  The  partial  engorgement,  and 
ihe  haemoptysis,  are  not  mutually  connected  with  each  other  as  cause  and  effect,  but 
they  are  concurrent  effects  of  the  same  cause ;  of  that  cause  which  gives  rise  to  the 
extravasation  or  exhalation  of  the  blood  in  the  first  instance.  A  part  of  the  blood  so 
extravasated  passes  outwards  by  the  trachea  and  mouth ;  while  a  part  is  forced  in 
the  contrary  direction,  into  the  ultimate  divisions  of  the  bronchi,  so  as  to  fill  and 
block  up  the  whole  tissue  of  a  single  lobule,  or  of  a  bunch  of  contiguous  lobules, 
and  thus  arises  the  circumscribed  variety.  Andral  conceives  that  the  sanguine  effu- 
sion takes  place  in  the  ultimate  air-cells ;  and  he  applies  to  this  form  of  disease  the 
term  pneumo-hemorrhage,  to  distinguish  it  from  ordinary  haemoptysis,  which  he  calls 
6ronc/jo-hemorrhage ;  and  this  I  believe  to  be  the  true  pathology  of  the  wicircum- 
scribed  variety.  But  it  seems  to  me  vastly  more  probable,  that  in  the  other  form  of 
the  complaint  the  seat  of  the  effusion  is  in  one  or  more  of  the  larger  branches  of  the 
air-tubes;  and  that  the  blood,  a  part  of  it  at  least,  is  driven  backwards  into  certain, 
of  the  pulmonary  lobules,  by  the  convulsive  efforts  to  respire  w^iich  the  patient 
makes  when  threatened  with  suffocation  by  the  copious  explosion  of  blood,  or  by  a 
paroxysm  of  cough  and  extreme  dyspnoea :  especially  if  the  blood  is  poured  out  from 
the  membrane  while  the  chest  is  in  the  state  of  ea;piration.  It  is  easy  to  understand 
how  certain  portions  of  the  lungs,  without  undergoing  any  actual  change  of  texture, 
may  in  this  manner  be  so  choked  up,  and  crammed  with  blood,  which  afterwards 
coagulates,  as  to  preclude  any  subsequent  admission  of  air. 

This  view  of  the  formation  of  circumscribed  pulmonary  apoplexy  affords  an  easy- 
explanation  of  some  of  the  phenomena  attending  it,  which  it  would  be  difficult  to 
account  for  on  any  other  supposition :  I  mean,  first,  the  occurrence  of  several  of  the 
clots  or  masses  of  blood,  in  different,  and  sometimes  in  distant  parts  of  the  lung  at  the 
same  time;  and  secondly,  the  exact  manner  in  which  they  are  commonly  bounded 
and  hmited  to  certain  lobules.  And  if  (as  is  sometimes,  though  seldom,  the  case), 
even  the  texture  of  the  lung  be  lacerated,  it  is  easier  to  conceive  that  this  may  happen 
in  consequence  of  the  violence  of  regurgitation  during  the  struggle  of  impending  suf- 
focation, and  that  the  mere  impulsion  of  a  thickened  muscle  at  the  centre  of  the  cir- 
culation should  be  capable  of  driving  the  blood  through  the  walls  of  an  artery  with 
sufficient  force  to  tear  and  break  down  the  substance  of  the  lung  around  it. 

In  the  didused  or  uncircumscribed  form  of  pulmonary  apoplexy,  the  congested 
lung  is  not  relieved  by  a  sudden  and  copious  gush  of  hemorrhage,  but  the  impeded 
and  stagnating  blood  oozes  slowly  through  the  vessels  containing  it  into  the  neigh- 
bouring interstitial  and  vesicular  tissues,  clogs  up  a  larger  and  larger  space,  and  is 
partly  expectorated  in  separate  dark-red  sputa,  combined  with  a  certain  quantity  of 
mucus,  A  similar  condition  of  the  lung  sometimes  occurs  in  purpura  hccuiurrnngira 


014  PULMONARY  HEMORRHAGE. 

without  any  mechanical  impediment  to  the  passage  of  the  blood  into  and  through  the 
heart. 

The  belief  that  the  dark-coloured,  circumscribed  spots  seen  in  the  lungs,  and 
spoken  of  as  pulmonary  apoplexy,  are  often,  if  not  always,  produced  in  the  manner 
1  have  just  been  describing,  was  suggested  to  me  by  the  observation  of  a  case,  in 
which  these  appearances  existed,  and  in  which  they  certainly  were  so  occasioned.  I 
tokl  j'ou,  when  speaking  of  cynanche  tonsillaris,  that  I  had  seen  one  person,  and  one 
only,  die  in  consequence  of  that  complaint;  and  that  his  death  was  occasioned  by  the 
laying  open  of  the  lingual  branch  of  the  carotid  artery  in  the  progress  of  ulceration. 
The  phenomena  attending  that  patient's  dissokition  were  of  deep,  though  of  painful 
interest.  I  described  them  to  you  before.  He  had  been  taken  out  of  bed,  and  laid 
upon  a  table  in  the  ward,  in  the  middle  of  the  night,  in  order  that  Mr.  Mayo  might 
more  conveniently  place  a  ligature  upon  the  carotid.  Suddenly  the  bleeding  burst 
forth  afresh:  and  he  expired,  before  our  eyes,  in  the  course  of  two  minutes:  not 
from  syncope  or  exhaustion,  but  evidently  suffocated.  The  blood  entered  and  choked 
up  the  trachea,  and  ho  had  not  strength  enough  left  to  expel  it  by  coughing,  i  (Vlt 
his  heart  and  the  artery  at  his  wrist  pulsate  firmly  for  some  little  time  after  the  last 
attempt  to  dilate  the  chest  had  been  made.  This  you  know  is  what  always  hap;)ens 
Vv-hen  death  takes  place  from  the  sudden  denial  of  air  to  the  lungs.  We  found  the 
upper  surface  o"f  the  glottis  covered  by  a  clot  of  blood.  There  was  blood  also  in  the 
windpipe ;  and  scattered  through  the  substance  of  the  lungs  there  were  numerous 
hard,  and  dark,  but  not  ver)''  large  masses,  precisely  resembling  those  described  by 
Laennec  as  constituting  pulmonary  apoplexy.  This  man  had  shown  no  symptoms 
of  any  pulmonary  complaint ;  nor  was  thevre  any  morbid  appearance  in  his  lungs 
except  those  which  resulted  from  the  presence  of  the  blood  that  had  been  poured  into 
them  through  the  trachea,  and  rammed  home  into  some  of  the  air-cells,  in  his  con- 
vulsive attempts  to  breathe.  All  that  I  have  observed  since  this  case  happened,  has 
tended  to  confirm  my  belief,  that  what  has  been  erected  into  a  distinct  form  of  dis- 
ease, under  the  objectionable  name  o^ puhnonary  apoplexy,  is  simply  an  accident  of 
pulmonary  hemorrhage.  When  haemoptysis  has  occurred,  to  any  amount,  in  con- 
sumption, it  is  by  no  means  uncommon  to  find  pulmonary  apoplexy  after  death  ;  and 
Dr.  Latham  has  mentioned  to  me,  in  conversation,  one  remarkable  instance  of  that 
disease,  strongly  corroborative  of  the  doctrine  I  have  been  endeavouring  to  support. 
A  young  female  patient  of  his,  labouring  under  confirmed  phthisis,  was  attacked,  for 
the  first  time,  with  haemoptysis.  The  bleeding  was  so  profuse  as  to  cause  almost 
immediate  death  by  suffocation.  IJer  lungs  were  found  riddled  with  small  tubercu- 
lous cavities  ;  and  each  of  these  little  cavities  contained  a  little  clot  of  blood.  Surely 
It  is  more  credible  that  the  blood  should  have  reached  each  cavity  by  regurgitation 
from  the  larger  air-tubes,  than  that  each  should  have  been  the  seat  of  an  independent 
hemorrhage  at  the  same  moment.  It  is  by  a  similar  reflux  of  blood  that  the  ap- 
pearances are  produced  which  characterize  the  circumscribed  form  of  pulmonary 
apoplexy. 

Upon  the  whole,  the  occurrence  of  hsemoplysis,  considered  in  reference  to  the 
probable  duration  of  life  in  those  who  are  the  subjects  of  it,  is  of  melancholj^  omen. 

I  have  long  arrived  at  this  conclusion  : — that  if  from  any  given  number  of  persons 
who  have  been  known  to  spit  blood,  we  subtract  those  in  whom  that  symptom  was 
connected  with  irregularity  in  the  uterine  functions,  there  will  remain  but  few  in 
whom  the  haemoptysis  did  not  depend  upon  disease,  incurable  and  progressive  in  its 
nature,  of  the  lungs,  or  of  the  heart ;  and  that  if  w^e  still  further  subtract  those  per- 
sons in  whom  the  hemorrhage  was  symptomatic  of  cardiac  disease,  there  will  be 
very  few  indeed  deft,  in  whose  lungs  the  existence  of  tubercles  may  not  be  confi- 
dently predicated. 

Among  these  few  may  be  reckoned  persons  who  have  suffered  hasmoptysis  de- 
pendent upon  the  detachment  and  expulsion  of  "  bronchial  polypi;"  and  who  exhioit 
no  other  indication  of  cardiac  or  pulmonary  disease. 

You  vvill,  of  course,  understand  that  1  do  not  include  in  this  estimate  of  hgemo- 
ptysis  a?  a  prognostic  symptom,  those  cases  in  which  (as  in  simple  bronchitis)  the 
expectoration  is  merely  s/rer//c«Z  with  blood: — nor  those  in  which  small  quantities 


r 


ULMONARY    HEMORRHAGE.  '  615 

of  blood  are  intimately  combined  and  amalgamated  with  the  bronchial  mucus,  and 
form  the  rust-coloured  sputa  so  indicative  of  the  presence  of  pneumonia  : — nor  those 
in  which  the  hemorrhage  is  a  consequence  of  mechanical  injury  to  the  chest. 

Of  those  individuals  whom  Andral  had  known  to  spit  blood  at  some  period  or  other 
of  their  hves,  there  was  only  one  in  five  whom  he  did  not  also  know  t-o  have  tuber- 
cular pthisis.  On  the  other  hand,  Louis  states  that  for  three  years  he  asked  all  the 
patients  who  came  before  him,  in  the  practice  of  a  large  hospital,  and  who  were  not 
affected  with  pthisis,  whether  they  had  ever  spat  blood;  and  the  answer  was  always 
in  the  negative,  excepting  only  a  few  instances  in  which  the  patients  had  received 
violent  blows  upon  the  thorax;  and  the  cases  of  females  in  whom  the  menstrual  dis- 
charge had  been  suddenly  suppressed. 

The  quantity  of  blood  which  is  brought  up  in  different  cases  of  pulmonary  hemor- 
rhage, is  extremely  variable.  Sometimes  it  is  so  copious  and  overwhelming  that  the 
patient  either  dies  suffocated,  or  he  dies  of  syncope,  outright :  but  this  is  not  very 
common.  Sometimes,  on  the  other  hand,  a  small  quantity  of  blood  finds  its  way  into 
the  mouth,  the  patient  scarcely  knows  how.  And  between  these  two  extremes  there 
is  every  gradation  in  respect  to  quantity. 

"  When  blood  is  thrown  out  by  the  mouth  (says  Cullen),  it  is  not  always  easy  to 
determine  from  what  internal  part  it  proceeds;  whether  from  the  internal  surface  of 
the  mouth  itself,  from  the  fauces,  or  adjoining  cavities  of  the  nose,  from  the  stomach, 
or  from  the  lungs.    It  is,  however,  very  necessary  to  distinguish  the  different  cases." 

Now  the  diagnosis  between  hemorrhage  from  the  lungs  and  hemorrhage  from  the 
stomach,  in  other  words  between  hxmoptysis  and  hscmatemesis,  I  shall  not  enter 
upon,  until  I  have  described  the  latter  disease.  And  the  diagnosis  between  hemor- 
rhage from  the  fauces  or  cavity  of  the  mouth,  and  hemorrhage  from  the  luno-s,  can 
never  be  very  difficult,  if  once  the  doubt  suggests  itself,  and  the  necessary  examina- 
tion of  the  mouth  be  made.  And  1  would  advise  you  not  to  omit  that  inspection.  I 
could  tell  you  of  cases  in  which  the  neglect  of  this  simple  precaution  has  led  to 
needless  activity  of  treatment,  and  to  the  ukimate  discredit  and  disadvantage  of  the 
practitioner.  Blood  may  ooze  into  the  mouth  from  spongy  gums,  or  drip  from  the 
posterior  nasal  orifices,  and  be  at  length  spat  out  in  considerable  quantity.  Etymo- 
logically  speaking,  these  are  cases  of  hsemoptysis ;  but  they  do  not  constitute  the 
particular  disease  or  symptom  to  which  alone  nosologists  have  agreed  to  restrict  that 
term.  The  sources  of  the  bleeding  are  manifest  as  soon  as  they  are  carefully  looked 
for. 

Patients  who  are  subject  to  hjEmoptysis  generally  know  by  experience  when  it  is 
about  to  happen.  It  is  frequently  preceded  by  some  uneasy  feeling  within  the 
thorax — pain,  or  a  sense  of  weight,  or  of  heat  or  of  pricking,  beneath  the  sternum, 
with  anxiety ;  and  they  tell  you  that  they  taste  the  blood  in  their  mouths  before  it 
comes  up,  i.  e.,  they  perceive  a  saltish  taste ;  and  just  before  the  blood  appears,  a 
tickling  sensation  is  experienced  about  the  top  of  the  larynx.  To  relieve  this  sensa- 
tion, the  patient  coughs  or  hawks  a  little,  and  a  certain  quantity  of  frothy  and  florid 
blood  is  expectorated. 

In  a  person  disposed  to  pulmonary  hemorrhage,  the  bleeding  may  be  determined 
by  a  variety  of  causes ;  which  ought  to  be  pointed  out  to  him,  in  order  that  he  may 
avoid  them.  Any  thing  which  hurries  the  circulation  will,  of  course,  have  a  ten- 
dency to  excite  the  hermorrhage.  Straining  of  any  kind  ;  great  efforts  of  the  body; 
active  exercise  ;  much  talking;  and  more  especially  public  speaking,  or  singing,  or 
playing  on  wind  instruments.  A  diminution  in  the  superincumbent  weight  of  the 
atmosphere  is  supposed  to  be,  in  some  cases,  sufficient  to  bring  on.  hcemoptysis  ;  iind 
blood  is  said  to  have  been  forced  even  from  sound  lungs,  in  persons  vi'ho  have 
ascended  very  high  mountains,  where  the  atmosphere  is  rare,  and  where  the  pres 
sure  upon  the  surface  of  the  body  is  sensibly  lessened.  Perhaps  the  labour  of  th<. 
ascent  may  have  shared  in  the  production  of  the  hemorrhage  ;  for  I  am  not  awaro 
that  any  such  efl^ect  has  ever  occurred  to  persons  who  have  much  more  rapidly 
readied  a  very  great  altitude  in  balloons. 

Auscultation  and  percussion  do  not  stand  us  in  much  stead  in  cases  of  hajmoptysib. 


016  PULMONARY  HEMORRHAGE. 

so  far  as  that  symptom  itself  is  concerned.  Indeed,  if  they  were  capable  of  affording 
us  information,  it  would  in  most  cases  be  superfluous  ;  for  we  see  the  blood,  and  we 
can  generally  satisfy  ourselves  that  it  comes  from  the  lungs. 

But  pulmonary  hemorrhage  may  occur  without  hocmoptysis.  In  what  is  called 
pulmonary  apoplexy  there  is  extravasation  of  blood :  and  it  is  not  always  attended 
with  the  expulision  of  a  portion  of  the  extravasated  fluid  through  the  mouth.  Laennec 
and  others  pretend  to  say,  that  when  there  is  blo;d  in  the  bronchi,  they  can  dislin 
guish,  by  the  peculiar  character  of  the  crepitation  to  which  it  gives  rise,  that  it  is 
blood,  and  not  mucus ;  that  the  bubbles,  passing  through  a  thinner  liquid,  are 
larger,  and  break  oftener,  than  those  produced  by  the  passage  of  air  through  viscid 
mucus.  This  distinction  is  too  subtle  for  me.  If,  indeed,  there  has  been  hsemoptj'sis 
and  especially  if  the  hosmoptysis  has  been  sudden  and  copious,  and  if,  after  it,  j'ou 
hear  a  large  crepitation  in  one  or  more  isolated  parts  of  the  lung,  it  will  be  reasonable 
to  conclude  that  the  air-tubes  contain  blood  in  those  parts.  Those  lobules  that  are 
plugged  up  with  blood,  to  the  entire  exclusion  of  air,  will  not,  of  course,  be  the  seat 
of  any  sound  during  respiration ;  but  this  limited  absence  of  sound  will  be  scarcely 
appreciable  unless  the  infracted  portion  lies  near  the  surface  of  the  lung.  Around 
the  spot  thus  rendered  solid  the  sound  of  crepitation  may  be  audible. 

Yet,  although  the  method  of  auscultation  furnishes  but  little  help  towards  the 
detection  of  pulmonarj''  hemorrhage,  it  will  often  afford  us  most  precise  and  valuable 
information  respecting  the  disease  of  which  the  hemorrhage  is  a  consequence,  and 
an  index.  Thus,  it  will  frequently  teach  us,  with  absolute  certainty,  that  the  heart 
is  diseased,  or  that  the  lungs  are  occupied  by  tubercles.  The  precise  sounds,  or  de- 
ficiencies of  sound,  which  supply  the  key  to  this  knowledge,  I  shall  describe  when  I 
come  to  th6se  disorders. 

Whatever  may  be  the  source  and  organic  cause  of  the  hcemoptj'sis,  the  bleeding 
should  be  stopped  as  soon  as  possible :  not,  however,  merely  by  suppressing  it,  but 
by  relieving  the  necessity  on  which  it  depends.  The  longer  it  is  sufl^ered  to  con- 
tinue, the  more  likely  is  it  to  add  to  the  damage  which  already,  in  too  many  cases, 
exists  in  the  lungs.  If  it  leads  to  the  formation  of  blocks  of  pulmonary  apoplexy,  the 
portions  of  lung  so  filled  up  are  rendered  useless  for  a  long  period,  and  probably  for 
ever.  Now  as  in  most  cases  the  hemorrhage  is  a  hemorrhage  by  exhalation,  and 
depends  upon  congestion,  active  or  mechanical,  we  shall  stay  the  hemorrhage  if  we 
remove  the  congestion.  , 

The  congestion  may  be  either  mechanical  or  active  when  it  results  from  the  pre- 
sence of  tubercles  in  the  lungs ;  it  is  almost  always  mechanical  when  it  depends 
upon  disease  of  the  heart.  The  tubercles  may  press  upon  the  blood-vessels,  and 
so  lead  to  mechanical  engorgement ;  or  they  may  provoke  by  their  presence  an 
active  determination  of  blood  to  those  organs,  just  as  we  know  that  they  often 
provoke  inflammation,  Avhich  is  congestion  and  something  more;  and  just  as  any 
foreign  body  lodged  in  the  lung  may  cause  either  the  one  or  the  other  of  these 
conditions. 

Frequently  there  is  a  distinct  febrile  movement  accompanying  the  hemorrhage : 
the  heart  beats  with  increased  force  and  frequency,  the  cheeks  are  flushed,  and  the 
skin  is  hot ;  sometimes  the  pulse  is  quite  hard,  and  full,  and  bounding,  and  people 
speak  of  such  a  pulse  as  a  Itcmorrhagic  pulse.  Now  I  mentioned  in  a  former  part 
of  the  course,  that  hemorrhage  occurring  under  such  circumstances  as  these,  often 
works  its  own  cure  ;  but  it  is  belter,  when  an  organ  so  vital  and  important  as  the  lung 
is  the  seat  of  the  effusion  of  blood,  that  tve  should  cure  the  bleeding  than  that  it 
should  cure  itself — that  we  should  diminish  the  congestion  with  which  it  is  linked, 
through  the  safer  channel  afforded  by  the  veins  of  the  arm.  The  patient  is  to  be 
surrounded  with  cool  fresh  air.  His  head  and  shoulders  should  be  elevated.  He 
should  b'>  restricted  to  the  most  meagre  diet;  and  be  forbidden  to  exert  himself,  or  to 
speak  more  than  is  absolutely  necessary.  His  bowt-ls  should  be  freeljf^  purged,  in 
the  first  instance,  and  then  kept  lax  and  open,  both  with  the  view  of  deriving  (as  it  is 
".alied)  from  the  thorax,  and  of  preventing  costiveness  and  straining.  And,  in  con- 
junction with  these  measures,  he  should  lose  blood  from  the  arm.  The  amount  and 
il-e  repetition  of  the'bleedmg  must  be  determined  by  the  circumstances  of  the  case 


PULMONARY  HEMORRHAGE.     '  617 

{.  e.,  by  the  cessation  or  continuance  of  the  hemorrhage,  and  especially  by  the  con- 
dition of  the  pulse.  It  would  be  idle  to  attempt  to  lay  down  precise  rules  on  this 
matter.  We  do  not  bleed,  however,  so  resolutely  and  perseveringly  in  haemoptysis 
as  we  are  often  obliged  to  do  in  acute  inflammation. 

A  prejudice  has  been  taken  (such,  at  least,  I  think  it)  against  local  blood-kfling 
in  pulmonary  hemorrhage.  Inasmuch  as  leeches  applied  to  the  groins  in  amenorrhosa 
appear  sometimes  to  restore  the  catamenia,  so  they  have  been  thought  hkely,  when 
appUed  over  the  surface  of  the  chest,  to  attract  the  blood  somehow  to  that  part  of 
the  body,  and  even  to  cause  hemorrhage  when  none  before  existed.  Now  I  have  so 
many  times  taken  blood  from  some  part  or  other  of  the  exterior  of  the  thorax  by 
leeches,  or  cupping-glasses,  without  observing  any  such  effect,  of  causing  hemoptysis, 
or  of  increasing  it  while  already  present,  that  I  cannot  help  considering  the  objection 
rather  a  fanciful  one. 

When  the  fever  or  congestion  are  abated ;  or  when  there  has  been  no  constitu- 
tional disturbance,  and  the  hemorrhage  has  shown  a  passive  character  from  the 
beginning,  and  when  a  continuance  of  it,  so  far  from  being  curative  in  its  nature,  is 
hkely  to  be  injurious  ;  then  we  are  to  employ  those  remedies  which  have  been  found 
efficacious  in  restraining  and  suppressing  hemorrhages. 

Now  of  the  substances  which  are  held  to  possess  more  or  less  of  a  specific  virtue, 
when  taken  internally,  in  arresting  the  efflux  of  blood,  the  sugar  of  lead,  the  phimbi 
acetas,  enjoys  in  this  country  the  highest  reputation.  And  it  certainly  is  a  very 
serviceable  remedy.  Dr.  Paris  speaks  of  it  as  one  of  the  most  valuable  resources  of 
physic :  and  says  that  in  respect  to  its  power  over  internal  hemorrhage  there  is 
nothing  simile  aiit  secundum.  He  states  also  that  its  use  is  equally  safe  and 
manageable.  There  is,  in  fact,  no  doubt  of  its  efficacy :  but  most  other  writers  use 
very  cautious  language  in  recommending  its  employment.  Physicians  have  been 
deterred  from  giving  it  by  the  fear  of  its  poisonous  qualities ;  by  the  dread  of  pro- 
ducing the  disease  called  coUca  pictonum.  Cullen  observes,  that  the  preparations 
of  lead  are  certainly  powerful  in  controlling  hemorrhage,  but  that  they  are  otherwise 
of  a  character  so  pernicious  as  to  forbid  their  use  except  in  cases  of  the  utmost  dan- 
ger. Of  late  years  this  drug  has  usually  been  administered  in  small  doses,  and 
guarded  by  opium ;  and  it  is  to  this  combination  that  Dr.  Paris  refers  when  he  de- 
clares it  to  be  a  safe  and  manageable  remedy.  More  recently,  however,  a  statement 
has  be«n  made  by  Dr.  A.  T.  Thomson,  which  must  be  considered  of  much  impor- 
tance if  further  experience  shall  show  it  to  be  well  founded.  He  was  led,  it  seems, 
by  some  accidental  circumstance,  to  suspect  that  lead  acted  as  a  poison  upon  the 
animal  body,  only  in  the  shape  of  its  carbonate.  And  the  result  of  a  series  of  expe- 
riments upon  brutes  satisfied  him  of  the  correctness  of  this  notion.  He  holds,  that 
when  the  acetate  of  lead  produces  the  well-known  symptoms  of  the  painter's  colic, 
it  does  so  in  consequence  of  its  being  somehow  converted,  after  its  reception  into  the 
body,  into  the  carbonate ;  that  the  conversion  may  be  obviated  by  a  very  simple  ex- 
pedient; and  that  the  remedy  may  then  be  given  with  perfect  safety  in  large  and 
efficient  doses.  The  expedient  is  merely  that  of  administering  the  lead  in  draughts 
containing  some  dilute  acetic  acid,  which  prevents  the  decomposition  of  the  acetate 
by  any  carbonic  acid  that  happens  to  be  present  in  the  intestinal  canal.  In  this  way 
he  tells  me  he  has  given  as  much  as  fifteen  grains  daily  for  ton  days  together,  with- 
out any  inconvenience,  and  with  most  excellent  effect  upon  the  hemorrhage.  I  have 
often  exhibited  lead  in  this  manner;  and  I  have  never  known  it  to  give  rise  to  any 
unpleasant  consequences.  At  any  rate  this  method  of  administering  it  deserves 
further  and  careful  inquiry. 

[We  liave  also  administered  acetate  of  lead  very  extensively  in  cases  of  hremoptysis,  and 
in  tolerably  large  doses,  continued,  at  short  intervals,  for  one  or  two  days,  and  have  neve* 
known  any  injurious  or  even  unpleasant  effects  to  be  produced  by  it.  As  a  means  of  con- 
trolling the  hemorrhage  from  the  lungs  we  know  of  no  remedy  so  certain  in  its  effectb.  In 
the  disease  under  consideration,  we  have  very  generally  combined  a  small  portion  of  ipeca- 
cuanha with  the  acetate  of  lead. — C] 

In  slight  cases  of  hfemoptysis,  the  mineral  acids,  with  or  without  alum,  are  oftoi 
insufficient ;  or,  if  there  be  feverishness,  the  saline  draught  with  nitre  and  digitalis. 

3b2 


618  PULMONARY  EMPHYSEMA. 

Of  the  numberless  r/iher  drugs  which  have  been  vaunted  as  specific  in  hemorrhage 
I  have  very  little  personal  experience  ;  at  least  in  pulmonary  hemorrhage.  In  cer- 
tain other  ibrms  or'  internal  bleeding  there  are  some  of  them  that  are  worth  trying. 
But  in  haemoptysis  there  are  none  I  can  venture  to  recommend  out  such  as  I  have 
now  mentioned.'  You  may  sometimes  be  urged  to  give  a  celebrated  quack  medicine 
— JRuspi)u''s  styptic,  which  has  obtained  a  high  repute,  and  sells  at  a  high  price. 
This  nostrum  seems  for  a  long  while  to  have  baffled  analysis.  The  late  Dr.  Wol- 
laston  told  Dr.  Maton  that  it  contained  no  metaUic  substance ;  Dr.  Thomson  has 
.since  announced  that  it  mainly  consists  of  a  solution  of  gallic  acid  in  alcohol  diluted 
with  rose-water.  But  I  believe  that  all  the  remedial  agents  which  contain  gallic 
acid  are  more  effectual  in  another  form  of  internal  hemorrhage,  to  be  considered 
hereafter. 

Of  mercury,  as  a  remedy  for  pulmonary  hemorrhage,  I  have  already  mentioned 
both  my  own  insufficient  experience,  and  the  very  favourable  report  of  some  excel- 
lent judges  who  have  much  employed  it.  • 


LECTURE  LV. 


Pulmonary  Emphysema  ;  vesicular  and  interlobular.  Jinatomical  characters  of 
vesicidar  emphysema  ;  physical  signs ;  general  symptoms  ;  causes;  treatment. 
Interlobular  emphysema :  its  o.natomical  characters,  symptoms,  cause,  and  cure. 
(Edema  of  the  lungs.     Phthisis  Pulmonalis. 

T  HAVE  yet  one  or  two  morbid  conditions  of  the  lungs  to  consider  and  to  describe, 
before  I  go  to  that  which  is  the  most  common  and  most  extensively  fatal  of  all  its 
morbid  cond'tions — tubercular  phthisis. 

There  is  a  slate  of  the  lung,  or  rather  there  are  two  or  three  different  states,  to 
which  Laennec  has  applied  the  name  emphysema.  A  very  injudicious  name  it  was 
for  him  so  to  impose.  We  are  infinitely'-  indebted  to  Laennec  for  the  entirely  new 
light  which  his  able  researches  have  thrown  upon  the  morbid  anatomy  and  tl^  pa- 
thology of  the  lungs  :  but  we  have  to  regret  that  he  should  have  employed,  in  several 
instances,  a  vicious  nomenclature.  Emphysema  is  a  term  that  had  long  been  fa- 
miliar among  medical  men  in  a  certain  sense.  It  was  used  to  express  the  indation 
of  the  areolar  tissue  of  the  body  with  air;  and  surgeons  still  make  much  of  it  as  an 
indication,  in  cases  of  fractured  rib,  that  tlie  bone  has  grazed  the  pleura,  and  allowed 
air  to  pass  into  the  areolar  tissue,  and  to  diffuse  itself  over  the  chest  and  neck,  and 
other  parts ;  so  that  these  parts,  when  pressed,  convey  a  curious  sense  of  crackling 
to  the  finder.  But  emphysema  of  the  lung,  as  that  term  is  employed  by  -Laennec, 
includes  dilatation  of  the  air-cells  of  the  lungs,  and  rupture  of  the  partitions  which 
separate  them  from  each  other;  and  also  the  infiltration  of  air  into  the  interlobular 
areolar  tissue,  or  into  the  subpleural  areolar  tissue.  In  strictness  of  language  these 
last  conditions  alone  should  have  been  called  emphysema  of  the  lung.  Laennec  has 
distinguished  the  two  species  in  this  way.  To  the  dilatation  of  the  air-cells,  with  or 
without  a  breach  of  their  partitions,  he  gives  the  name  of  vesicular  emphysema: 
"the  vesicular  (I  quote  the  words  of  Dr.  Forbes'  translation),  or  pulmonary,  properly 
so  called."  Now  in  truth  this  is  emphysema  improperly  so  called.  To  the  infiltra- 
tion of  the  areolar  tissue  in  or  around  the  lung  with  air,  i.  e.,  to  emphysema  of  the 
ungin  the  old  sense  of  that  word,  he  applies  the  title  of  interlobular  emphysema. 
We  cannot  change  these  denominations  now.  They  have  fastened  themselves  upon 
medical  language.  But  it  is  very  fit  that  you  should  be  aware  of  their  inconsistency 
with  the  ancient  signification  of  the  same  Avord,  and  have  clear  notions  of  what,  in 
Laenncc's  nomenclatun-,  they  are  intended  to  express. 

The  change  called  vesicular  emphysema  was  not  vnknoivn,  as  a  mere  morbid 
:-ondition.  before  the  time  of  Laennec ;  but  it  had  been  noticed  by  vriry  few  writers, 


PULMONARY  EMPHYSEMA.  619 

and  practically,  it  was  lohoUy  unattended  to.  Yet  it  is  extremely  common  ;  much 
more  so  than  you  would  suppose :  and  when  rightly  studied  it  is  of  great  inieres;:. 
too,  in  relation  to  the  general  pathology  of  the  chest.  But  it  is  still  so  new,  aucl 
may  so  readily  escape  observation,  both  in  the  dead  and  in  the  living  body,  if  it  be 
not  looked  for,  thai  I  shall  devote  a  somewhat  more  minute  attention  to  it,  on  those 
accounts. 

Laennec  was  undoubtedly  the  first  to  put  emphysema  pulmonum  upon  the  list 
of  definite  and  cognizable  diseases;  to  point  out  its  frequency;  and  to  collect  its 
symptoms.  But  when  he  affirms  that,  before  his  time,  the  pulmonary  change  which 
constitutes  the  disorder  was  misunderstood  by  nearly  all  those  persons  who  had  no- 
ticed it,  he  scarcely  does  them  justice.  "All  of  them  (says  he)  seem  to  have  thought 
that  the  derangement  in  question  consisted  in  the  infiUration  of  the  cellular  substance 
of  the  lungs  with  air."  He  inconsistently  adds,  "  Ruysch  and  Valsalva  are  the  only 
authors,  as  far  as  I  know,  who  have  observed  in  individual  cases,  the  dilatation  of 
the  cells  ;"  and  with  still  greater  inconsistency  he  proceeds  to  quote,  from  Morgagni, 
the  following  passage,  in  which  this  dilatation  is  very  clearly  described :  "  Sinistri 
pulmonis  lobus  superior,  qua  claviculam  spectabat,  vesicidas  ex  quibus  constat 
minim  in  modum  auctas  habebat ;  ut  nonnullre  avellanse  magnitudinem  sequarent; 
easterns  multo  minores  erant."  You  will  find  the  same  change  noted  by  Dr.  Baillie, 
in  his  Morbid  Anatomy :  and  by  earher  writers  than  he. 

Vesicular  emphysema,  then  (to  adopt  Laennec's  phraseology),  consists  in  dilata- 
tion of  the  air-cells.  The  enlarged  cells  become  misshapen  also  in  many  cases. 
They  vary  in  magnitude  from  that  of  a  millet-seed  to  that  of  a  swan-shot:  nay,  the 
cavities  may  even  reach  the  size  of  a  nutmeg,  or  of  a  hen's  eg^:  but  when  they  are 
as  big  as  this — and  a  fortiori  if  they,  are  still  bigger — the  distension  and  vacuity  are, 
no  doubt,  the  result  of  the  union  of  several  air-cells,  broken  into  one,  by  the  stretch- 
ing or  destruction  of  the  partitions  that  naturally  divide  and  isolate  them.  You  may 
see  the  dilated  vesicles  very  plainly  through  the  pleura,  if  you  carefully  examine  the 
surface  of  the  lung.  They  appear  to  the  naked  eye  as  the  healthy  vesicles  appear 
when  seen  through  a  magnifying-glass.  Sometimes  all  the  vesicles  belonging  to  one 
lobule  are  enlarged,  while  those  of  the  adjoining  lobules  are  of  the  natural  size.  In 
that  case,  the  emphysematous  lobule  is  conspicuous  both  by  its  peculiar  colour,  and 
by  its  protrusion.  The  surface  of  the  lung  is  often  rendered  quite  irregular  and  ^ 
unevei*  by  projections  of  this  kind.  Sometimes  one  large  globular  prominence  is 
seen,  like  a  bubble  on  the  water,  or  like  a  little  bladder  springing  from  a  footstalk; 
but  if  you  examine  it  closely,  you  will  generally  find  that  the  footstalk  is  merely  a 
constriction  at  the  surface,  and  that  there  is  as  large  a  cavity  beyond  it,  in  the  lutig, 
as  there  is  without.  These  bullce  you  cannot  slip  about  by  pressure  from  one  part 
of  the  pleura  to  another. 

The  unevenness  produced  by  vesicular  emphysema  upon  the  outside  of  the  lung 
IS  manifest  enough,  when  looked  for;  but  the  same  condition  of  the  air-cells  exists 
also  within,  and  7/?ere  it  is  wo/  so  readily  perceptible.  The  fluids  which  the  lung 
"ontains  obscure  all  distinction  of  parts  when  the  organ  is  cut.  The  best  way  of 
getting  a  fair  view  of  the  dilated  cells  as  they  appear  in  the  substance  of  the  lung, 
is  to  inflate  the  emphysematous  portion,  by  blowing  air  in  at  the  bronchial  trunk 
which  belongs  to  it,  and  then  tying  that  trunk  to  prevent  the  escape  of  the  air.  The 
inflated  lung  should  be  hung  up  in  a  current  of  wind,  so  that  it  may  quickly  dry, 
and,  during  the  drying  process,  it  should,  from  time  to  time,  be  reinflaled ;  for  else 
the  included  air  gets  out  somehow,  and  the  piece  of  lung  shrinks  and  shrivels  up. 
When  it  is  quite  dry,  if  a  section  of  it  be  made  with  a  thin  sharp  knife,  the  altered 
state  of  the  air-cells,  some  of  which  are  more  and  some  le^s  dilated,  will  be  very 
conspicuous. 

No  part  of  the  lung  is  exempt  from  liability  to  these  morbid  changes  ;  but  gene 
rally  they  are  limited  to  certain  portions  of  the  organ ;  and  they  are  much  more 
common  and  more  pronounced  at  its  loose  anterior  borders,  and  near  its  summit, 
than  anywhere  else.  Both  lungs  appear  to  be  alike  obnoxious  to  the  disease,  which 
seldom  affects  the  one  without  affecting,  in  a  greater  or  less  degree,  the  other  also. 
The  parts  that  are  emphysematous  are  usually  paler  than  the  rest,  and  sometim»-a 


620  PULMOxVARY   EMPHYSEMA. 

they  are  quite  white.  In  extreme  cases,  the  surface  of  the  lung  presents  a  sort  of 
piebald  appearance  ;  large  patches  of  it  looking  as  if  they  had  been  bleached.  Thii 
pale  colour  is  oftenest  seen  towards  the  free  edges  of  the  lung.  Sometimes  those 
edges  are  rounded  and  thick;  sometimes  thinner,  and  folded  back;  while  sometimes 
the  margin  is  blown  out,  as  it  were,  into  an  irregular  fringe ;  some  of  the  inflated 
portions  remaining  connected  with  the  lung  by  slender  pedicles,  and  thus  forming 
appendices  to  it  of  a  light  yellow  colour.  I  presume  that  what  was  thought  and 
called  a  fringe  of  fat,  garnishing  the  edges  of  the  lung,  in  the  body  of  King  George 
IV.,  was  of  this  kind.  At  least  I  have  never  seen  nor  heard  of  any  other  example 
of  fat  deposited  in  those  organs.  If  you  hold  the  emphysematous  border  between 
your  eye  and  the  light,  you  perceive  that  it  is  translucent :  if  you  prick  it  with  a 
pin,  the  pufty  part  surrounding  the  puncture  collapses  ;  which  shows  that  the  dilated 
vesicles  communicate  together. 

An  emphysematous  lung  is  not  only  paler,  but  drier  also,  than  ordinary ;  and  for 
the  same  reason.  It  possesses  fewer  capillary  blood-vessels,  less  blood,  and  conse- 
quently less  moisture.  It  is  dry  and  Hght,  and  floats  high  upon  water,  like  a  bladder 
filled  with  air. 

If  )'0U  take  such  a  lung  out  of  the  body,  having  its  surface  embossed  with  irre- 
gular groups  of  enlarged  air-cells — and  if  you  inflate  that  lung,  by  blowing  into  the 
bronchi — the  emphysematous  portions  will  seem  to  sink  in,  and  flatten,  and  return 
to  the  ordinary  level  as  the  lung  becomes  distended.  In  point  of  fact,  however,  these 
portions  remain  permanently  dilated,  and  the  other  parts  of  the  surface  rise,  as  the 
air  enters  them,  until  the  whole  is  smooth  and  even.  Air  is  shut  up  in  the  emphy- 
sematous portions,  which  do  not  subside,  as  the  adjoining  portions  do,  when  left  to 
the  agency  of  their  proper  elasticity.  Hence  you  will  see  how  it  is  that,  when  the 
vesicular  emphysema  is  extensive,  so  as  to  occupy  nearly  the  whole  of  the  lung,  the 
lung  becomes  apparently  too  big  for  the  case  in  which  it  is  contained.  Not  only 
does  it  not  collapse  when  the  sternum  is  raised,  and  the  pressure  of  the  atmosphere 
is  admitted  to  its  external  surface,  but  it  even  protrudes,  the  moment  that  the  open 
ing  is  made.  When  you  handle  such  a  lung,  it  gives  a  very  difl^erent  sensation  tr 
the  fingers  from  that  produced  by  pressing  a  healthy  lung.  It  feels  like  a  down 
pillow.  It  crepitates  less ;  the  air  is  less  easily  forced  out  of  it,  and  escapes  slowly, 
with  a  slight  hissing  noise. 

Such  being  the  state  of  the  lung,  as  discovered  after  death,  you  will  naturally  be 
inquisitive  to  know  by  what  signs  the  existence  of  a  condition  so  remarkable  is  re- 
vealed during  life.  First,  then,  when  the  emphysematous  distension  is  considerable 
in  amount,  and  extensive,  it  produces  alterations  in  the  shape  and  movements  of  the 
chest.  The  lung,  having  lost  much  of  its  elasticity,  does  not  subside  as  a  healthy 
lung  does.  The  act  of  expiration  is  arrested  and  incomplete.  Consequendy,  the 
thorax  remains  nearly  in  that  position  which  it  assumes  after  inspiring.  It  is  promi- 
nent and  rounder  on  the  diseased  side,  or  on  both  sides,  if  both  lungs  be  affected; 
but  it  is  apt  to  be  irregularly  prominent,  and  unsymmetrical ;  to  bulge  here  and 
there  in  correspondence  with  the  bulging  of  the  lung  within.  The  ribs  are  less 
oblique  than  they  should  be,  and  the  chest  is,  therefore,  more  cylindrical.  The  cla- 
vicles are  ill-defined  in  such  persons.  They  are  so,  as  you  know,  in  fat  persons  ; 
wherefore  this  aid  to  the  diagnosis  is  of  most  value  in  those  who  are  spare.  In  them 
it  is  a  valuable  sign,  for  it  is  simple  and  obvious.  The  distended  lung  presses  up- 
wards, as  well  as  in  other  directions,  and  tends  to  efface  the  depressions  which  natu- 
rally exist  both  above  and  below  the  collar-bone.  This  symptom  is  the  more  to  be 
depended  on  if  it  presents  itself  on  one  side  only.  The  manner  of  breathing  is 
instructive  also.  The  rihp,  never  receding  within  their  proper  limits  after  w.pira- 
tion,  can  move  but  little  during  j^ispiration ;  and  the  breathing  is  in  a  great  measure 
abdominal. 

Now,  all  these  signs  are  physical  signs.  But  what,  in  the  second  place,  are  the 
anscidiutory  physical  signs  ?  Why,  in  the  emphysematous  regions,  which  com- 
itionly  are  also  the  most  bulging,  percussion  yields  an  unnaturally  clear  and  resonant 
»nund,  while  auscultation  discovers  a  very  indistinct  vesicular  murmur.  The  two 
modes  check  and  explain  each  the  information  afforded  by  the  other.     Percussion 


PULMONARY  EMPHYSEMA.  621 

ascertains  that  there  is  air  beneath  the  part  struck :  auscultation  ascertains  that  there 
is  little  or  no  air  in  motion  beneath  that  part.  It  follows,  therefore,  that  there  is 
stagnant  air;  air  shut  up  in  the  enlarged  air-cells,  or  air  interposed  between  the  ear 
and  the  lung  in  the  cavity  of  the  pleura:  air  at  rest,  in  fact.  I  say  the  respiratory 
murmur  is  very  feeble.  This  partly  depends  upon  the  limited  play  of  the  ribs,  partly 
and  chiefly  upon  the  circumstance  that  the  air  is  imprisoned  in  the  dilated  cells. 
When  none  enters  or  leaves  them  during  respiration,  no  vesicular  breathing  can  be 
heard ;  and  then  we  must  call  in  the  aid  of  other  considerations  to  determine  whe- 
ther the  air  be  contained  in  the  cavity  of  the  pleura,  or  in  the  emphysematous  lung. 

Pure  pneumothorax  is  extremely  rare.  Pneumothorax  with  liquid  effusion  is 
easily  recognised  by  its  proper  signs.  If  these  be  absent,  we  conclude  that  the 
stagnant  air  occupies  the  lung,  and  not  the  pleura ;  and  this  conclusion  is  strength- 
ened if  the  unduly  resonant  part  be  prominent  also.  Almost  all  writers  on  this 
subject  follow  Laennec  in  stating  that  dry  crepitation  may  be  heard  in  the  emphy- 
sematous parts.  It  may  be  so;  but,  if  so,  I  cannot  distinguish  it.  I  mean  that  I 
know  no  crepitation  but  that  which  is  moist,  and  which  proceeds  from  the  formation 
and  rupture  of  bubbles,  as  air  passes  through  liquids  in  the  bronchial  tubes.  But 
other  people  believe  that  they  can  hear  a  dry  crackling,  such  as  may  be  produced 
by  inflating  a  portion  of  dry  areolar  tissue  out  of  the  body,  or  a  dry  bladder.  You 
will  try  this  by  your  own  experience.  I  do  not  deny  that  such  a  sound  exists :  I 
only  say  that  if  it  does  exist,  I  cannot  tell  when  I  hear  it,  and  when  I  hear  largo 
moist  crepitation.  But  I  more  than  suspect  that  no  such  sound  is  given  out  by  an 
emphysematous  lung,  and  that  the  sound  heard  is  really  large  crepitation  in  tho 
neio-hbourhood  of  the  dilated  cells ;  for  emphysema  is  very  often  accompanied  b}' 
catarrh ;  and  the  sounds  in  question,  authors  agree,  are  not  permanently  audible. 

So  much  for  the  physical  signs  of  emphysema  pulmonum.  The  general  signs, 
when  the  change  is  extensive,  are  an  habitual  shortness  of  breath,  with  occasional 
paroxysms  of  extreme  dyspnoea;  cough  which,  however,  is  far  from  being  a 
constant  symptom :  palpitation  in  most  instances  as  the  disease  advances,  and  more 
or  less  oedema  of  the  ankles.  Usually  the  appetite  remains  unimpaired,  and  the 
patient  does  not  lose  flesh.  The  disorder  is  unattended  with  fever ;  and  is  essen- 
tially chronic. 

The  paroxysms  of  urgent  dyspnoea  are  frequently  concurrent  with,  and  apparently 
excited  by  attacks  of  smart  bronchial  catarrh  ;  but  they  sometimes  arise  without  any 
obvious  cause.  They  are  apt  to  come  on  suddenly,  in  the  night,  and  the  patient  is 
obliged  immediately  to  sit  up,  and  even  to  open  the  doors  and  windows  of  his  bed- 
room, that  he  may  breathe  more  freely.  In  one  word,  he  undergoes  a  paroxysm  of 
asthma.  These  attacks  become  more  frequent  and  more  severe  as  the  patient  and 
the  disorder  grow  older.  They  are  attended  with  much  wheezing ;  and  in  the  lower 
posterior  part  of  the  lungs  crepitation  is  generally  audible.  At  first  the  palpitation 
of  the  heart,  and  oedema  of  the  feet,  abate  and  cease  as  the  violent  dyspnoea  goes  off: 
but  at  length  these  symptoms  become  permanent. 

We  see  a  reason,  in  the  physical  condition  of  the  thorax,  why  the  breathing  should 
be  more  oppressed,  and  why  the  paroxysms  of  orthopnoea  should  occur  more  fre- 
quently in  the  night.  Whenever  the  respiration  is  principally  abdominal  it  is  apt  to 
be  embarrassed  by  the  recumbent  posture,  which  throws  a  j)art  of  the  weight  of  the 
viscera  of  the  belly  upon  the  diaphragm.  The  horizontal  position  is  always  ill  borne 
by  these  patients ;  and,  for  similar  reasons,  flatulence  or  fulness  of  the  stomach,  how- 
ever caused,  distresses  them. 

Cough,  as  I  observed  before,  is  an  occasional,  but  by  no  means  an  essential  accom- 
paniment of  vesicular  emphysema:  the  expectoration,  where  there  is  any,  is  thin- 
nish,  like  gum-water,  and  full  of  foam. 

Louis,  who  has  analyzed,  with  his  accustomed  care  and  exactness,  a  considerable 
number  of  cases  of  emphysema,  states  that  the  disease  is  seldom  complicated  with 
tubercles  in  the  lungs.  We  may  suspect  that  complication,  if  haemoptysis,  or  ema 
ciation,  occur  ;  which  are  otherwise  rare  symptoms. 

To  what  cause  can  we  ascribe  this  dilatation  of  the  pulmonary  vesicles,  whereby 
the  proper  function  of  the  lung,  in  the  part  affected,  is  impaired,  or  annulled ' 


C22  PULMONARY  EMPHYSEMA. 

Mainly,  I  think,  in  the  outset  at  least,  to  the  imprisonment  of  air  within  them,  undei 
circumstances  of  disease.  You  may  often  trace  back  ihe  shortness  of  breath  to  the 
period  of  inilmcy.  Patients  will  tell  you  that  from  their  earliest  recollection  they 
have  been  easily  put  out  of  breath:  that  they  never  were  able  to  engage  heartily, 
and  to  the  same  degree  with  their  companions,  in  the  active  sports  of  childhood,  "it 
is  easily  to  conceive  that  under  chronic  inflammation,  or  other  disease  of  the  mucous 
membrane,  air  may  enter  the  vesicles  more  readily  than  it  can  escape  from  them 
again.  The  act  of  inspiration  is  voluntaiy  and  strong ;  the  tubes  are  made  patent 
by  it,  and  air  rushes  in  and  finds  its  way  to  their  extremities.  But  the  act  of  expi- 
ration is  passive,  and  comparatively  feeble.  Slight  tumefaction  of  the  membrane, 
or  a  little  plug  of  viscid  mucus,  may  so  close  up  a  small  bronchial  ramification,  that 
the  air  cannot  pass  through  it  in  expiration  :  and  more  and  more  air  may  thus  be 
accumulated  and  incarcerated  in  certain  air-cells,  which  yield  to  its  distending  force, 
and  losing  their  elasticity  become  permanently  large.  And  this  process  will  be  acce- 
lerated if  the  original  disorder  which  gives  rise  to  it  is  attended  with  violent  cough ; 
wiih forcible  efforts,  that  is,  of  expiration.  Etnphj'sema  is  always  (in  my  opinion) 
a  consequence  of  pre-existing  disease  or  disorder  of  the  chest.  There  are  some  who 
believe  it  to  be  occasionally  a  congenital  and  idiopathic  affection.  They  build  this 
notion  upon  the  fact  that  the  complaint  is  traceable,  from  one  generation  to  another, 
in  certain  families;  and  as  it  often  is  present  at  an  early  age  in  children  born  of 
emphysematous  parents,  they  conclude  that  the  emphysema,  in  such  cases,  is  a  vice 
of  the  original  bodily  formation.  I  am  not  convinced  by  this  mode  of  reasoning. 
The  facts  upon  which  it  rests  show  simply  that  the  disorder  runs  much  in  families, 
and  that  the  tendency  to  it  is  sometimes  inherited.  The  lax  or  weak  fabric,  which 
favoured  the  production  of  the  disease  in  the  parent,  is  repealed  in  the  offspring,  and 
imparts  the  same  predisposition.  Children  are  very  liable  to  severe  coughs,  such  as 
are  calculated  to  strain  and  overstretch  the  cells  of  their  delicate  lungs.  What  can 
be  more  likely  to  do  so  than  the  reiterated  and  violent  paroxysms  of  coughing  which 
occur  in  pertussis  ?  After  the  cough  has  ceased,  however,  the  shortness  of  breath 
which  it  leaves  behind  is  easily  overlooked,  until  with  the  increase  of  the  emphysema, 
it  forces  itself  into  notice.  For  when  once  the  morbid  process  has  begun  it  tends, 
slowly  often,  but  surely,  to  its  own  augmentation.  As  the  cells  dilate,  the  capillary 
blood-vessels  distributed  over  their  parietes  are  gradually  compressed  and  emptied  : 
and  many  of  them  are,  at  length,  completely  obliterated.  Hence,  not  only  an  ex- 
sanguine condition  of  the  pulmonary  tissue,  but  atrophy  also  of  the  intervesicular 
partitions,  which  become  first  thin,  then  tattered  and  imperfect.  In  dried  specimens 
of  emphysema  you  see  wexy  plainly  the  remains  of  the  former  walls  of  separation 
between  the  vesicles. 

It  is  this  interference  with  the  nutrition  of  the  lung  which  causes  vesicular  em- 
physema to  be  always  a  progressive  disease.  We  see  why  it  is  that,  speaking  gene- 
rally, the  extent  of  the  morbid  change  is  proportioned  to  the  age  of  the  patient : 
why  paroxysms  of  severe  d3'spncea  at  length  supervene ;  and  become  more  and 
more  frequent  and  trying.  The  function  of  the  lung  becomes  year  by  year  more 
limited  ;  until  it  can  no  longer  bear,  without  a  struggle  of  distress,  that  further  en- 
croachment upon  its  office  and  capability  which  a  slight  catarrh,  rapid  movements  of 
the  body,  a  distended  abdomen,  or  even  the  recumbent  posture,  may  be  sufficient  to 
produce. 

Laennec  attributes  the  dilatation  of  the  air-cells,  in  the  first  instance,  to  what  (with 
a  curious  infelicity  of  diction)  he  terms  dry  catarrh,  which  is  characterized  by  its 
tendency  to  recur,  and  by  the  expectoration  of  small  pieces  of  hard,  pearly  phlegm. 
But  doubtless  the  disorder  may  be  produced,  and  aggravated  when  produced,  by  any 
cause  that  impedes  the  free  exit  of  the  air  from  the  lungs  during  expiration :  by 
blowing  on  wind  instruments  of  music,  by  pressure  made  on  parts  of  the  lung ;  bj 
tumours  therefore  in  the  thorax,  a  large  heart,  aneurism  of  the  thoracic  aorta,  de- 
formity of  the  chest  from  crookedness  of  the  spine,  tight  lacing,  and  even  the  pre- 
sence of  tubercles  ;  although  lungs  that  are  full  of  tubercles  are  not,  in  general,  much 
affected  by  emphj-sema.  This  last  fact  has  led  to  the  absurd  project  of  attempting 
«o  present  phthisis  by  producing  emphysema.     It  is  the  same  disease  which  exists 


PULMONARY  EMPHYSEMA.  623 

in  broken-Avinded  horses ;  and  Sir  John  Floyer,  in  his  Treatise  of  the  Jlsthma,  pub- 
lished in  1()!)8,  sets  forth,  in  the  quaint  language  of  that  olden  time,  both  the  altera- 
tion which  Laennec  thought  he  had  been  the  first  to  describe,  and  the  mode  in  which 
it  takes  place.  His  observation  respecting  the  lungs  of  horses  are  equally  applica- 
ble— and  he  no  doubt  intended  to  apply  them — to  the  hnman  lungs.  After  speaking 
of  "the  broken  wind,  from  the  rupture  or  dilatation  of  the  bladders  of  the  lungs,  by 
which  the  air  is  too  much  retained  in  the  bladders  or  their  interstices,  and  thereby 
produces  a  permanent  flatulent  tumour" — and  stating  that  "  these  horses  «'heeze 
much  after  filling  their  stomach,  by  water  or  food,  because  that  keeps  up  the  dia- 
phragm"— he  goes  on  thus.  "As  it  happens  in  external  flatulent  tumours,  they  at 
first  go  off  and  return,  but  at  last  fix  in  permanent  flatulent  tumours ;  so  it  is  in  the 
flatulent  asthma,  the  frequent  nervous  inflations  induced  at  last  a  constant  windy 
tumour  or  inflation  ;  and  it  ought  to  be  considered  how  far  holding  the  breath  in 
hysteric  fits,  or  the  violent  coughing  in  long  catarrhs,  or  the  great  distension  of  the 
lungs  by  an  inflammation  in  the  peripneumonia,  may  strain  the  bladders  and  their 
muscular  fibres,  and  thereby  produce  the  same  rupture  or  dilatation  or  hernia  as  hap- 
pens in  the  broken-winded.  This  must  be  observed  by  the  help  of  the  microscope; 
and  if  the  air  blown  into  any  lobe  will  not  be  expelled  thence  by  the  natural  lone  or 
muscle  of  the  bladders,  that  the  lobe  may  again  subside  of  itself,  'tis  certain  some 
injury  is  done  to  the  ventiducts ;  the  bladders  are  either  broken,  and  admit  the  air 
into  the  membranous  interstices,  or  else  they  are  over-distended  like  a  hernia  in  the 
peritoneum  ;  and  this  will  produce  an  inflation  of  the  whole  substance  of  the  lungs, 
and  that  a  continual  compression  of  the  air  and  blood-vessels,  which  will  produce 
a  constant  asthma."  Really  this  is  a  capital  piece  of  pathology  for  the  seventeenth 
century. 

It  is,  at  first  sight,  a  matter  of  surprise  that  vesicular  emphysema  of  the  lung,  and 
dilatation  of  the  bronchi,  do  not  more  often  go  together.  Sometimes,  indeed,  the 
smaller  branches  of  the  air-tubes  do  partake  of  the  dilatation  of  the  cells  :  but  this  is 
not  commonly  the  case.  Still  the  mechanism  of  both  diseases  appears  to  be,  in  the 
first  instance,  the  same.  The  detention  of  mucus  in  them  leads  to  dilatation  of  the 
bronchial  tubes:  the  incarceration  of  air  in  them  to  enlargement  of  the  pulmonary 
vesiiles. 

Vesicular  emphysema  may  arise  then,  and  receive  increase  from,  various  disor- 
dered conditions  that  precede  or  accompany  it,  and  of  which  it  is  the  effect.  On 
the  other  hand,  it  is  often  itself  the  cause  of  subsequent  disease,  not  merely  in  the 
lung,  but  in  other  parts ;  and  above  all,  of  disease  in  the  right  chambers  of  the  heart. 
The  smaller  blood-vessels,  as  I  have  shown  you,  are  gradually  effaced  as  the  dilata- 
tion of  the  air-cells  proceeds:  the  emphysematous  lung  is  evidently  in  a  state  of 
comparative  anaemia,  and  incapable  of  admitting  all  the  blood  which  is  due  to  it 
from  the  pulmonary  artery.  In  other  words,  the  right  side  of  the  heart  does  not 
empty  itself  with  its  accustomed  ease.  Hence  increased  muscular  contractions  of 
the  right  ventricle:  and  a  yielding  of  its  walls  to  the  augmenting  pressure  of  the 
contained  blood.  And  this  embarrassment  of  the  circulation  in  the  right  side  of  the 
heart  is  aggravated  at  those  periods  when  the  paroxysms  of  urgent  dyspnoea  occur. 
Now  nothing  is  a  more  sure  cause  of  anasarca  than  a  permanent  dilatation  of  the 
right  cavities  of  the  heart:  and  this  influence  of  the  emphysematous  lung  upon  that 
organ  is  clearly  seen  in  the  palpitations  to  which  such  patients  are  liable,  and  in  tho 
oedema  of  the  feet  and  anlcles  which  often  becomes  manifest  at  the  same  time. 

I  must  beg  you  to  bear  in  mind  that  emphysema  of  the  lung  is  one,  and  a  very 
common,  cause  of  a.sthmn.  The  asthma  so  arising  is  less  perilous  than  that  which 
l)roceeds  from  certain  other  organic  changes,  to  be  described  hereafter.  Vesicular 
emphysema,  indeed,  in  its  simple  uncomplicated  form,  is  seldom  attended  with  much 
danger.  When  it  proves  fatal,  it  is  so  in  consequence  of  the  superaddition  of  some 
other  disease.  Laennec  states  very  truly,  that  of  all  the  varieties  of  asthma,  this  is 
the  one  which  affords  the  patient  the  best  hope  of  a  long  life. 

The  condition  that  I  have  been  describing,  when  once  it  has  fairly  been  establish- 
ed, can  scarcely  admit  of  a  cure.  We  shall  do  our  patients  good,  not  by  any  treatment 
addressed  to  the  existing  emphysema  itself,  but  by  guarding  them  ao-ainst  those  f-jr- 


C24  INTERLOBULAR  EMPHYSEMA. 

cumstances  which  are  likely  to  aggravate  it ;  and  by  miligatinor  or  removing  those 
other  disorders  with  which  the  emphysema  is  apt  to  be  combined.  Whatever  is 
calculated  to  put  the  patient  out  of  breath  is  bad  for  him.  It  is  observed  that  they 
who,  having  emphysema,  are  obnoxious  also  to  catarrhs,  during  which  the  dyspnoea 
is  singularly  increased,  are  much  more  free  from  such  attacks  in  the  warm  weather 
of  summer,  than  in  the  winter.  This  explains  the  beneficial  influence  of  a  judicious 
change  of  climate  upon  such  persons,  and  it  points  to  the  necessity  of  warm  clothing 
m  the  colder  seasons  for  those  who  are  obliged  to  remain  in  this  country.  The  feet 
especially  should  be  kept  dr}''  and  warm ;  and  the  liability  to  catarrh  may  be  some- 
times diminished  by  the  use  of  the  cold  shower-bath,  in  the  way  I  formerly  recom- 
mended. During  the  fits  of  extreme  dyspncea,  you  may  hear  the  expiratory  wheeze 
remarkably  loud  and  protracted  ;  and  if,  withal,  you  hear  any  small  crepitation,  in- 
dicative of  pneumonic  inflammation,  you  will  do  well  to  cup  the  patient  between  his 
shoulders.  This  will  always  give  relief  to  loaded  lungs,  whether  there  be  inflam- 
mation present  or  not.  But  the  great  assuager  of  the  dyspncea  in  this  disorder  is 
opium;  and  especially  opium  combined  with  aether.  Haifa  drachm  of  Hofl^man's 
anodyne,  with  a  third  of  a  grain  of  the  acetate  or  muriate  of  morphia,  in  camphor 
julep,  will  operate  like  a  charm  often,  in  quieting  the  whole  system,  and  removing 
the  difficulty  of  breathing.  This  circumstance  would  lead  us  to  suppose  that  the 
access  depended,  in  part  at  least,  upon  a  spasmodic  state  of  some  of  the  muscles 
concerned  in  respiration.  To  this  question  I  shall  revert  when  I  speak  of  asthma 
as  a  separate  disease.  At  any  rate  you  will  find  that  some  such  formula  as  I  have 
just  mentioned  will  stand  you  in  good  slead  when  you  have  to  deal  with  asthma 
engrafted  on  emphysema.  And  I  may  add,  that  this  is  a  case  of  exception  to  a  rule 
I  formerly  laid  down.  You  need  not  be  deterred  from  giving  a  full  dose  of  opium 
by  the  blueness,  which  is  temporary,  of  the  patient's  lips  and  countenance. 

The  interlobular  and  suh-pleural  emphysema  of  the  lungs  is  a  species  of  trut 
emphysema,  the  air  being  contained  in  the  meshes  of  the  common  areolar  tissue. 
When  it  appeai-s  on  the  surface  of  the  lung,  it  may  be  distinguished  from  the  bladder- 
like prominences  which  sometimes  form  there  by  the  dilatation  of  the  air-cells,  in 
this  waj^ :  the  bullae  which  are  situated  in  the  areolar  tissue  connecting  the  pleura 
with  the  lung,  may  be  made  to  move  hither  and  thither  under  pressure;  whereaa 
those  which  result  from  the  protrusion  of  an  enlarged  cell  or  cells  cannot  be  madfe 
thus  to  change  their  place.  This  sub-pleural  efTusion  of  air  is  sometimes  enormous. 
I  have  seen  it  as  large  as  a  hen's  cg2,'  Bouillaud  mentions  a  case  in  which  the 
bladder  or  pouch  was  equal  to  the  size  of  a  stomach  of  ordinary  dimensions.  It 
proceeds,  I  presume,  from  the  rupture  of  a  superficial  air-vesicle.  Sometimes,  as  I 
mentioned  before,  the  pleura  also  gives  way,  and  air  is  poured  into  the  cavity  of 
the  thorax.  More  commonly  the  membrane  remains  entire,  and  then  these  large 
bubbles  of  air  may  be  seen  upon  the  surface  of  the  lung. 

Of  interlobular  emphysema  I  can  give  you  but  little  account  except  from  the  ob- 
servations of  others.  I  have  never  seen  more  than  one  well-marked  example  of  it. 
The  lobules  of  the  lungs  cohere  together  by  means  of  areolar  tissue,  which  is  dense 
and  close  in  the  natural  state,  but  which  admits  of  considerable  expansion  when  it  is 
inflated  with  air.  If  the  emphysema  be  slight  in  degree,  the  lozenge-shaped  spaces 
visible  on  the  surface  of  the  lung  are  defined  by  little  bubbles  of  air,  that  look  like 
beads  strung  upon  a  thread  But  in  extreme  cases  the  lobules  are  fairly  blown 
asunder  bv  the  air ;  the  partitions  between  them  increase  in  width,  and  are  said  to 
be  sometimes  as  much  as  an  inch  broad.  They  are  broadest  towards  the  surface  of 
the  lung,  and  narrower  towards  its  roots ;  and  exhibit  somewhat  of  the  arrangement 
seen  m  the  section  of  an  orange,  the  septa  radiating  and  diverging  from  a  centre. 
If  the  areolar  tissue  could  be  taken  out,  there  would  be  left  cracks  and  clefts  in  the 
lung.  When  the  interlobular  emphysema  penetrates  to  the  roots  of  the  lung,  the 
air  readily  passes  into  the  areolar  tissue  of  the  mediastinum,  and  thence  to  the  sub- 
cutaneous tissue  of  the  neck  and  chest — and  then  we  have  the  genuine  emphysema 
ui  authors  who  wrote  prior  to  Laennec. 

There  is  this  material  difference  between  vesicular  and  interlobular  emphysema; 


INTERLOBULAR  EMPHYSEMA.  625 

that  the  one  is  slow  and  gradual  in  its  formation,  the  other  sudden.  The  permanent 
dilatation  of  the  air-vesicles  is  the  work  of  time.  They  yield,  and  lose  their  elasti- 
city, and  break  into  one  another,  only  by  degrees.  The  interlobular  effusion  of  air 
may  be  effected  in  a  few  minutes  or  seconds.  It  is  caused  by  violent  straining 
effbris ;  such  as  those  made  by  a  woman  in  childbirth,  or  by  any  one  who  exerts 
himself  to  lift  a  weight  which  is  too  much  for  hiin.  A  deep  inspiration  is  taken ; 
then  the  glottis  is  voluntarily  closed,  and  a  strong  expiratory  effort  is  made.  Some 
rupture  must  take  place  and  form  a  communication  between  the  air-vesicles  and 
the  areolar  tissue ;  but  such  rupture  has  never  been  traced,  nor  is  it  hkely  that  it 
should  be. 

They  say  that  this  form  of  emphysema  is  revealed  also  by  large  dry  crepitation ; 
why  it  should,  is  not  evident.  1  can  only  say  of  that  sound,  as  I  said  before :  it 
may  exist,  and  it  may  be  distinguishable  from  large  moist  crepitation,  but  my  ear  is 
not  delicate  enough  to  distinguish  it :  and  to  speak  the  truth,  I  doubt  exceedingly 
whether  any  such  sound  really  occurs  at  any  time.  But  do  not  let  my  doubts  infect 
you :  try  for  yourselves ;  and  till  you  have  had  opportunities  of  investigating  this 
point,  consider  it  as  adhuc  sub  judice. 

Again,  they  say  that  the  noise  of  friction  denotes  the  existence  of  interlobular  and 
subpleural  emphysema.  On  this  point  I  can  give  you  no  information  of  my  own 
knowledge.  That  you  may  sometimes  hear  the  costal  pleura  rub  against  the  pul- 
monary during  inspiration  and  expiration,  I  know ;  I  have  often  heard  that  sound 
(as  I  mentioned  to  you  before)  when  the  membrane  has  been  roughened  by  pleurisy; 
but  that  a  soft,  smooth,  moist  lung,  though  embossed  by  emphysema,  will  give  rise 
to  a  rubbing  sound,  I  do  7iot  know.  It  may  be  so,  but  it  has  never  occurred  to  me 
to  hear  it. 

We  may  be  more  certain  that  interlobular  emphysema  has  arisen  when,  im- 
mediately after  some  violent  straining  effort,  considerable  dyspncea  and  oppression 
ensue,  and  presently  the  subcutaneous  areolar  tissue  becomes  emphysematous. 
You  will  understand  how  rapidly  the  inflation  of  the  areolar  tissue  may  take 
place  if  you  ever  saw  a  butcher  blow  up  that  of  a  calf  which  he  is  in  the  act  of 
skinning. 

As  interlobular  emphysema  differs  from  vesicular  emphysema  in  its  seat,  and  in 
the  suddenness  of  its  formation,  and  in  some  sort  also  in  its  cause,  so  does  it  differ  in 
its  curability.  Under  favourable  circumstances  it  will  soon  cure  itself — the  air  will 
be  reabsorbed,  and  the  dyspnoea  cease.  I  do  not  know  that  we  can  do  much  by  art 
to  accelerate  that  process.  If  the  dyspnoea  be  extreme,  it  will  be  relieved  by  blood- 
letting ;  and  if  the  air  makes  its  appearance,  and  can  be  felt,  crackling,  beneath  the 
skin,  you  may  let  it  out  by  making  a  few  punctures  with  a  lancet,  and  the  deeper- 
seated  emphysema  will  be  lessened  as  the  air  escapes.  I  believe  that  this  inter- 
lobular emphysema  is  more  common  in  infancy  than  in  any  other  part  of  life  ; 
on  account,  I  suppose,  of  the  greater  dehcacy  and  tenderness  of  all  the  tissues  at 
that  age. 

The  interstitial  areolar  tissue  of  the  lungs,  as  well  as  the  air-cells,  is  liable  to  be 
filled  not  only  with  air,  but  with  serous  fluid  ;  and  this  constitutes  adenia  of  the 
lungs  ;  a  condition  which  is  by  no  means  uncommon,  and  one  of  which  you  ought 
therefore  to  be  aware  ;  but  it  need  not  long  occupy  our  attention  at  present.  When 
a  lung,  or  a  portion  of  a  lung,  is  anasarcous  (and  you  will  often  find  that  the  oedema 
is  limited  to  the  most  depending  part  of  those  organs),  it  is  generally  of  a  pale  gray 
or  yellowish  tint;  is  heavier  than  healthy  lung,  and  less  crepitant;  and  pits  more 
on  pressure — is  doughy.  And  if  the  cedema  is  extensive,  the  lung  does  not  collapse 
when  the  chest  is  laid  open.  When  incisions  are  made  into  the  lung  in  this  state,  a 
thin  wati'ry  fluid  flows  out,  more  or  less  spumous  ;  and  if  the  lung  be  well  squeezed, 
the  vvhole  of  the  liquid  may  be  expressed;  and  then  it  will  be  obvious  that  the  tex- 
ture of  the  organ  is  sound,  but  that  it  had  previously  contained  less  air  than  usual. 
in  consequence  of  the  presence  of  the  watery  fluid. " 

Tliis  condition  of  the  lung  seldom  takes  place  except  as  a  part  of  general  anasarca 
and  we  may  discover  its  existence,  first  by  noticing  that  there  is  dropsy  of  the  areola/ 
40  3c 


G2G  PHTHISIS    PULMONALIS. 

tissue  in  other  parts  ;  secondly,  that  the  patient  has  dyspncea  ;  and  thirdl}',  by  hearing 
crepitation,  produced  by  large  bubbles,  at  the  lowermost  portions  only  of  the  lungs. 
Into  those  portions  the  liquid  gravitates ;  just  as  it  sinks  into  the  ankles  when  the 
patient  sits  up  or  walks  about.  There  is  still  air  in  the  osdeniatous  portion  ;  so  that 
percussion  still  gives  a  hollow  sound  :  as  hollow  at  least  on  the  one  side  as  on  the 
other.  With  the  air  there  is  also  liquid,  which  transudes,  I  suppose,  from  the  areolar 
tissue,  or  is  exhaled  from  the  surface  of  the  membrane  :  and  the  liquid  is  from  time  to 
time  coughed  up  and  expectorated.  Sometimes,  however,  there  is  but  little  expecto- 
ration. What  does  come  up  is  chiefly  aqueous,  witli  occasionally  a  piece  or  two  of 
mucus  floating  upon  it;  and  it  is  somewhat  foamy  also. 

This  CEdema  or  anasarca  of  the  lung  is  symptomatic  of  other  disease ;  generally 
of  disease  of  the  heart  or  great  blood-vessels :  and  it  is  capable  of  no  other  rational 
treatment  than  such  as  is  suited  to  the  original  disorder  :  and  therefore  I  have  nothing 
further  to  say  about  it  now. 

I  proceed,  in  the  next  place,  to  that  most  prevalent  and  lamentable  disease  of  the 
lungs,  which  is  well  known  to  everybody,  under  the  titles  of  pulmonary  consump- 
tion, and  tubercular  phthisis.  And  without  pausing  to  make  any  general  reflec- 
tions, respecting  facts  which  must  be  familiar  to  you  all  —  the  fatal  and  almost 
hopeless  character  of  the  disease,  and  the  havoc  it  produces  among  the  young,  the 
most  gifted,  and  the  most  beautiful,  of  the  human  race  —  I  shall  commence  by 
inquiring  into  the  morbid  anatomy  of  tubercular  phthisis:  which  will  naturally 
introduce  us  to  the  consideration  of  its  symptoms,  causes,  treatment,  and  general 
history. 

Phthisis,  you  know,  means  a  wasting  away,  or  a  consuming ;  but  of  late  years 
the  term  has  been  restricted  to  that  species  of  wasting  disease,  which  consists  in  the 
occupation  of  the  lungs  by  tubercular  matter,  and  the  changes  which  that  matter 
sujjh's  and  works.  But  it  would  be  an  error  to  suppose  that  the  disease  is  restricted 
to  the  lungs  in  these  cases.  The  lung  disease  would  be  sufficient  at  leng<.n  to  destroy 
hfe  ;  but  its  mortal  tendency  is  aided  and  accelerated,  in  most  instances,  by  disease 
of  a  similar  character,  situated  in  other  organs.  "  The  pulmonary  consumption  (as 
Dr.  Latham  justly  observes)  is  no  more  than  a  fragment  of  a  great  constitutional 
malady."  But  that  malady  plays  its  part  most  conspicuously  in  the  lungs.  1  shall 
notice  its  complications  as  I  go  on  ;  but  I  am  desirous  of  cautioning  you  in  the  outset 
against  supposing  that  tubercular  phthisis  is  exclusively  a  pulmonary  disease. 

Before  I  proceed  to  a  more  particular  description  of  the  changes  that,  in  the  pro- 
gress of  consumption,  are  wrought  in  the  lungs,  I  must  briefly  recall  to  your  recol- 
lection certain  points,  relating  to  tubercular  disease  in  general,  which  were  brought 
before  you  in  an  earlier  part  of  the  course.  The  formation  of  tubercles  is  closely 
linked  with  the  existence  of  the  scrofulous  diathesis.  Tubercles  themselves  are  com- 
posed of  unorganized  matter,  deposited  from  the  blood,  of  a  yellowish  colour,  opaque, 
friable,  and  of  about  the  firmness  and  consistence  of  cheese.  This  is  what  all 
pathologists  agree  in  regarding  as  the  true  tubercular  matter.  It  is  most  commonly 
deposited  on  the  free  surface  of  mucous  membranes ;  and  not  unfrequently  amidst 
areolar  tissue.  You  will  remember  that  tubercles  are  not  necessarily,  as  some  have 
supposed,  of  a  round  shape.  Their  form  depends  upon  the  nature  of  the  tissue  in 
which  the  tubercular  matter  is  deposited.  Wherever  it  is  laid  down,  it  is  liable  to 
increase  m  quantity  by  the  continual  accretion  of  fresh  matter  of  the  same  kind. 
Hence,  when  a  speck  of  this  peculiar  matter  is  deposited  in  any  soft  uniform  tissue — 
such  as  tiie  brain,  or  the  areolar  membrane — there  being  no  inequality  of  pressure 
from  any  quarter,  it  preserves  a  spherical  or  globular  form  as  it  grows  larger.  But 
taking  the  lung,  with  which  we  are  at  present  chiefly  concerned,  the  round  form  is 
•sometimes  real,  sometimes  apparent  only.  It  is  real  when  the  tubercular  matter  fills 
up,  or  fines,  and  therefore  takes  the  shape  of,  the  pulmonary  vesicles.  So  it  is  when 
a  number  of  these,  contiguous  to  each  other,  coalesce  by  the  increase  of  deposit  and 
compose  one  large  globular  mass.  And  you  may  often  catch  the  tubercles,  if  I  may 
so  say,  in  the  process  of  forming  these  large  rounded  masses ;  i.  e.,  you  may  see 
liiem  arranged  in  circular  groups  or  clusters,  tbj  interstices  between  them  beconting 


PHTHISIS   PULMONALIS.  627 

gradually  smaller  and  smaller.  But  when,  as  is  often  the  case,  the  tubercular  matter 
is  laid  down  in  the  smaller  ramifications  of  the  bronchi,  it  assumes  a  cylindrical 
shape.  This  you  may  ascertain  by  carefully  following  the  branching  of  the  air- 
tubes  :  but  in  the  manner  in  which  the  lung  is  usually  divided  by  the  scalpel,  you 
see  merely  sections  of  these  cylinders;  and  then  the  round  form  is  apparent  c.nly. 
If  the  tubercular  matter  comes  to  fill  one  of  these  smaller  air-tubes,  and  also  all  the 
vesicles  to  which  that  tube  conducts,  then  the  new  substance,  when  fairly  displayed, 
represents  a  branch,  with  a  cauhflower  termination ;  hke  a  twig  with  a  bunch  of 
leaves  at  its  extremity.  You  may  see  these  appearances  dehneated,  from  nature,  in 
Dr.  Carswell's  admirable  lithographic  drawings. 

If  this  account  of  the  formation  of  tubercles,  as  explained  by  Dr.  Carswell,  be  the 
true  one  ; — of  which  [  entertain  little  doubt ; — it  will  follow,  as  a  matter  of  necessity, 
that  no  alteration  ccm  take  place  in  the  tubercular  matter,  after  it  has  once  assumed 
the  solid  form,  except  through  the  agency  of  the  parts  around  and  in  contact  with  it. 
No  change  can  originate  in  the  organic  tubercle  itself. 

Besides  this  true  and  undisputed  species  of  tubercle,  you  will  often  find  the  lungs 
more  or  lt>ss  thickly  studded  with  a  number  of  small  granules,  of  firmer  consistence, 
almost  as  hard  as  cartilage,  semi-transparent,  and  of  a  bluish  gray  colour.  Respect- 
ing the  nature  of  these  granules — which  are  sometimes  called  miliary  tubercles, 
sometimes  the  granulations  of  Bayle,  who  first  described  them — many  difl'erent 
opinions  are  entertained.  Laennec  considered  them  to  represent  the  incipient  stage 
of  the  opaque  yellow  substance ;  and  he  calls  them  accordingly  nascent  tubercles. 
Andral  believes  that  they  are  simply  some  of  the  pulmonary  vesicles  rendered  solid 
and  hard  by  chronic  inflammation.  Dr.  Carswell  explains  their  formation  in  this 
way.  The  membrane  lining  the  air-passages  secretes  from  the  blood,  not  only  the 
matter  of  tubercle,  but  its  own  proper  fluid  ;  whence  it  sometimes  happens  that  a 
dull  j'ellowish  point  of  tubercular  matter  becomes  enclosed  and  set,  as  it  were,  in  a 
small  pallet  of  gray,  tough,  semi-transparent  mucus.  Whatever  may  be  the  true 
theory  respecting  these  little  bodies,  it  is  certain  that  they  acknowledge  some  intimate 
connection  with  the  true  cheesy  tubercle.  They  both  occur  in  the  same  persons,  in 
the  same  lungs,  in  the  same  parts  of  the  lung.  One  very  seldom  occurs  without  the 
other.  They  both  belong  essentially  to  the  disease  we  are  considering — pulmonary 
pthisis.  Louis,  a  minute  and  faithful  observer,  states  that  the  granules  present,  at  a 
certain  period  of  their  development,  a  central  opacity.  Upon  the  whole,  it  seems 
probable,  that  Lacnnec's  doctrine,  in  regard  to  the  relation  subsisting  between  the 
gray  semi-transparent  granule  and  the  yellow  opaque  tubercle,  was  well  founded. 

He  was  wrong,  however,  in  some  other  points,  especially  in  his  statement  that  the 
softening  of  tubercles  begins  in  their  centres.  Dr.  Carswell  has  shown  how  the  ap- 
pearance of  a  central  softening  arises,  first,  in  the  smaller  tubercles;  secondly,  in  the 
larger  agglomerated  tubercular  masses.  The  morbid  secretion  is  deposited,  princi- 
pally, upon  the  mucous  surface — upon  the  inner  lining  of  the  air-cells,  and  of  the 
bronchial  tubes  communicating  with  them.  Now  it  may  so  accumulate  as  to  Jili 
those  cavities ;  and  then,  sections  of  them  will  represent  the  crude  tubercles  of 
Laennec.  But  it  may  only  line  the  cavities :  it  may  leave  a  central  vacuity,  con 
taining  mucus  or  other  secreted  fluids ;  and  if  the  lung  be  cut  across  under  these 
circumstances,  the  divided  air-cells  will  look  like  rings  of  tubercular  matter  grouped 
together ;  and  so  also  will  the  divided  bronchial  tubes.  We  then  have  the  appear- 
ance of  tubercles,  with  central  depressions,  or  soft  central  points  ;  and  Laennec  was 
deceived  by  those  appearances. 

But  the  larger  masses  begin  also,  he  says,  to  soften  at  the  centre.  True :  we  do 
find  the  process  of  softening  going  on  at  several  points  within  them  at  the  same  time. 
The  masses,  you  must  bear  in  mind,  are  formed  by  the  growing  together  of  many 
smaller  tubercles;  and  the  areolar  tissue,  with  the  other  tissues  which  originally 
separated  these  tubercles,  still  exists,  though  it  ceases  to  be  visible.  At  length,  under 
the  augmenting  pressure,  or  some  other  influence,  it  suppurates;  and  in  this  way  the 
tubercular  mass  is  broken  down.  Now  this  is  the  very  process  by  which  the  tubercles 
are  at  length,  often,  expelled  from  the  body.  They  increase  till  the  surrounding  parLs 
take  on  inflammation,  either  from  the  increasing  pressure,  or  from  some  accidental 


628  PHTHISIS    PULMONALIS. 

cause.  The  inflammation  thus  excite:>(l,  occurring  in  scrofulous  persons,  has  the 
scrofulous  character.  The  thin  pus  which  it  throws  out  pervades  and  loosens  the 
tubercular  deposit;  a  process  of  ulceration  goes  on  in  the  surrounding  textures  ;  and, 
at  last,  the  softened  scrofulous  matter  is  graduailj?-  coughed  up  and  expectorated. 

This  explanation  of  the  mode  in  which  the  tubercles  are  formed,  and  increase,  and 
soften,  and  are  removed,  has  been  given  to  the  Avorld  within  the  last  few  years,  by 
Dr.  Carswell ;  and  it  is  much  the  most  simple  and  probable  of  any  that  I  have  seen. 
It  is  moreover,  perfectly  consistent  with  the  best  ascertained  facts  concerning  the 
progress  of  tubercular  disease.  You  will  find  numberless  theories  broached  by  dif 
ferent  authors  on  this  subject,  if  you  like  to  look  for  them ;  but  I  do  not  think  you 
will  find  any  so  satisfactory  as  Dr.  Carswell's.  And  having  recalled  these  things  to 
your  memor)"  (for  it  is  some  time  now  since  I  mentioned  them  before)  we  may  go 
on  to  the  further  consideration  of  the  morbid  anatomy  and  pathology  of  tubercular 
phthisis. 

It  is  a  remarkable  and  very  important  fact,  that  tubercles,  when  they  affect  th& 
lungs,  are  not  deposited  at  random,  or  indifferently  in  all  parts  of  those  organs.  It  is 
in  the  upper  lobes,  and  in  the  upper  and  back  parts  of  those  lobes,  that,  in  nineteen 
cases  Out  of  twenty,  and  in  more  than  that  proportion,  we  meet  with  tubercles  when 
they  are  few.  It  is  in  the  same  part  that  they  are  largest,  and  most  numerous,  when 
they  are  scattered  throughout  the  whole  lung.  It  is  here,  also,  that  they  first  ripen, 
and  grow  soft,  and  become  ready  for  expulsion  through  the  bronchi  and  trachea : 
consequently,  it  is  here,  that  we  have  the  most  frequent,  the  most  numerous,  and  the 
largest  excavations  in  the  lung — what  are  technically  called  vomiar.  And  the 
iiumber  and  magnitude  of  the  tubercles  and  of  the  vomicas  gradually  diminish  from 
■  he  summit  of  the  lungs  downwards. 

Now  these  are  not  merely  curious  facts:  they  have  a  most  important  bearing 
upon  the  diagnosis,  in  cases  that  might  otherwise  be  doubtful.  It  is  a  rule  which 
has  but  few  exceptions — ^just  enough  to  establish  its  claim  to  be  a  rule — that  the 
favourite  habitat  of  pulmonary  tubercles  is  the  upper  part  of  the  superior  lobes  of  the 
lungs ;  and  I  may  remind  you  that  the  converse  of  this  is  true  (though  with  more 
numerous  exceptions)  of  common  inflammation  of  the  lungs.  Pneumonia  affects  by 
preference  the  lower  lobes;  it  does  sometimes  commence  in  the  up])er,  but  that  is 
comparatively  rare.  When  it  occupies  the  superior  lobes  it  generally  has  arrived 
there  by  travelling  upwards  from  the  inferior.  You  Avill  at  once  perceive  the  prac- 
tical advantage  of  knowing  these  points  of  contrast. 

It  is  a  curious  fact  also — less  practically  useful,  perhaps,  than  the  former,  but  still 
a  valuable  fact — that  the  left  lung  is  much  more  obnoxious  to  tubercular  disease  than 
the  right.  Modern  observers  have  collected  numerical  statements  showing  that  this 
really  is  so.  Why  it  should  be  so,  I  know  not.  Thus  Louis,  whose  volume  is  tho 
result  of  immense  labour  in  observing,  and  is  full  of  the  most  instructive  matter,  had 
met  with  seven  cases  in  which  tubercles  were  confined  to  a  single  lung:  in  tivo  of 
the  seven  cases  it  was  the  right  lung  that  was  thus  exclusively  affected,  in  Jive  it  was 
the  left.  Of  08  instances  in  which  the  upper  lobe  was  totally  disorganized  by  the 
disease  on  one  side,  28  were  of  the  left,  and  only  10  of  the  right.  Eight  times  he 
had  known  the  pleura  perforated  by  the  extension  of  tubercular  disease  ;  and  seven 
times  out  of  the  eight  the  perforation  happened  on  the  left  side  of  the  chest.  So  also 
Reynard  met  with  27  cases  of  pneumothorax  on  the  left  side,  to  13  on  the  right.  No 
less  curious  is  it  that  here  also  the  facts  ascertained  with  respect  to  pneumonia  are 
just  the  contrary  of  those  which  belong  to  phthisis.  I  mentioned,  in  a  former  lecture, 
Andral's  conclusion,  derived  from  the  observation  and  collation  of  210  examples,  that 
pneumonia  is  more  than  twice  as  common  on  the  right  side  as  on  the  left.  M.  Lom- 
bard, of  Geneva,  found  the  ratio  somewhat  less  than  this,  but  still  great.  Of  8(58  in- 
stances of  pneumonia,  413  occurred  on  the  right  side  alone,  2(i0  on  the  left  alone, 
and  }9o  on  both  sides  at  once.  That  is,  there  were  three  on  the  right  side  alone,  for 
every  two  on  the  left  alone. 

The  tubercular  matter,  then,  being  deposited  on  the  mucous  surface  of  the  vesi- 
cles, and  of  the  small  bronchial  tubes  that  conduct  to  them — groups  of  these  diseased 
nir-cells,  lvi/ig  contiguous  to  each  other,  become,  more  or  fewer  of  them,  amalga- 


PHTHISIS.  629 

mated,  or  fused,  as  it  were,  into  one  large  mass :  and  generally  there  are  tuberclea 
of  various  sizes,  from  that  of  a  pin's  head,  to  that  of  a  pigeon's  egg,  in  the  same 
lung.  And  there  is  yet  another  disposition  which  the  tubercular  matter  is  apt  to 
take  :  it  sometimes  is  diffused  uniformly  over  a  considerable  space,  occupying  all  the 
areolar  and  interstitial  portions  of  the  part  affected,  and  having  no  distinct  circum- 
scribing boundary.  The  part  looks  as  if  fluid  tubercular  matter  had  been  poured 
into  it,  and  there  had  hardened.  This  is  what  the  French  call  tubercular  infiltration 
of  the  lung. 

The  tubercular  matter,  once  deposited,  may  remain  for  a  longer  or  shorter  time  in 
what  is  called  the  crude  state ;  surrounded  by  perfectly  healthy  lung,  undergoinp- 
no  increase  in  quantity,  and  no  alteration  of  consistence.  But  in  a  vast  majority  of 
cases,  scrofulous  inflammation  is  sooner  or  later  set  up  around  the  tubercles — or  in 
the  areolar  tisssue  imprisoned  within  the  agglomerated  masses — and  then  the  whole 
breaks  down  in  the  way  I  mentioned  before ;  and  the  detritus  is  conveyed  through 
one  or  more  tubes  into  the  primary  divisions  of  the  bronchi,  and  thence  to  the 
mouth,  to  be  expectorated.  Of  course  there  is  an  excavation,  cavity,  cavern,  or 
vomica,  left.  All  these  names  are  given  to  the  void  space  which  the  tubercular 
matter  previously  occupied.  Now  there  are  some  curious  particulars  to  be  men- 
tioned respecting  these  cavities ;  but  I  must  postpone  them  till  our  next  meeting. 


LECTURE  LVI. 

Phthisis,  continued.  Vomicae;  adhesions  of  the  pleurae  ;  ulceration  of  the  larynx 
and  trachea — of  the  intestines  ;  fatty  liver  ;  auscultatory  signs  of  a  vomica : 
gurgling,  cavernous  respiration,  pectoriloquy :  general  symptoms  of  phthisis  : 
cough,  expectoration,  dyspnoea,  pain,  hectic  fever,  diarrhoea,  wasting,  oedema, 
aphthae. 

We  were  engaged,  when  we  separated  yesterday,  in  investigating  the  morbid 
anatomy  of  consumption.  Bear  in  mind  how  and  where  the  tubercular  matter, 
which  is  the  essence  of  that  disease,  is  deposited  in  the  lungs :  that  it  occupies,  by 
preference,  their  upper  lobes,  and  the  upper  part  of  those  lobes ;  invading  gradually 
the  lower  lobes,  from  above  downwards,  as  the  disease  advances.  Both  lungs  are, 
commonly,  affected  at  the  same  time,  though  in  unequal  degrees.  Among  one 
hundred  and  twenty-three  instances  of  phthisis,  Louis  found  that  the  tubercles  were 
limited  five  times  to  the  left  lung,  and  twice  to  the  right.  The  tubercular  matter, 
once  deposited,  may  remain  quiet  and  unchanged  for  some  time;  but  in  general  it 
increases  in  quantity,  until  at  length  inflammation  of  a  low  and  scrofulous  character 
arises  in  the  pulmonary  substance  in  immediate  contact  with  the  tubercles — or  in  the 
areolar  tissue  involved  in  the  larger  agglomerated  masses — in  consequence  of  which 
inflammation  a  sort  of  suppuration  takes  place  ;  the  tubercular  matter  becomes  soft, 
and  breaks  down,  and  is  ultimately  expelled  through  the  bronchi,  trachea,  and 
mouth.  The  vacuities  left  in  the  lung  after  this  process  of  expulsion  are  called  cavi- 
ties, excavations,  caverns,  vomicce.  And  I  go  on  to  consider  certain  points  of  prac- 
tical interest  connected  with  these  vomicas. 

In  the  first  place,  as  j'-ou  may  see  by  the  specimens  upon  the  table,  they  vary 
greaiiy  in  size.  They  may  be  m*  bigger  than,  or  not  so  big  as  a  pea  :  or  they  ...ci) 
be  large  enough  to  contain  a  pint  or  more  of  fluid.  Sometimes  the  whole  of  the 
upper  lobe  is  converted  into  a  bag  of  this  kind.  These  large  cavities  are  never  mel 
with  in  the  lower  lobes.  They  are  formed  by  the  union  of  several  that  are  smaller; 
so  that  they  are  often  of  very  irregular  shajje,  and  divided,  as  it  were,  into  chain 
bers,  by  imperfect  partitions,  or  by  bands  Avhich  cross  them  in  various  direction* 
Opening  into  the  cavity  there  is  always  one,  and  there  are  generally  several,  per 

3c2 


G30  PHTHISIS. 

vious  bronchial  tubes,  which  seem  as  if  they  had  been  cut  off  just  wliere  they  enter 
the  cavity.  But  you  never,  or  very  seldom,  indeed,  find  a  hlood-vessfl  thus  opening 
into  the  cavity.  And  the  reason  of  these  differences  is  plain  enough.  ]t  is  not,  as 
some  modern  authors  have  fancied,  that  the  arterial  or  venous  tissue  possesses  a  low 
degree  of  vitality,  and  therefore  resists  or  avoids  the  destruction  in  which  the  sur- 
rounding tissues  are  involved.  That  principle  may  be  applicable  to  other  cases,  but 
it  is  not  applicable  to  this.  The  opinion  I  am  now  referring  to  proceeds  on  the  sup- 
j)Osilion  that  the  bands  which  sometimes  cross  the  cavities  are  really  blood-vessels 
that  have  escaped  the  disorganizing  process.  Such  seems  to  have  been  the  nouon 
entertained  by  Bayle ;  and  it  has  been  more  recently  and  more  expressly  advanced 
by  Cruveilhier.  But  the  truth  is,  that  these  bands  rarel_v  contain  blood-vessels:  and 
when  they  do  contain  them,  the  blood-vessels  are  mostly  impervious.  In  one  \iun- 
dred  and  twenty-three  cases,  Louis  found  pervious  blood-vessels  in  the  bandb  no 
oftener  than  five  times. 

The  true  reason  why  bronchial  tubes  open  into  these  cavities,  and  blood-vecsels 
do  not,  is  to  be  found  in  the  natural  differences  between  the  two  sets  of  vesseL.  in 
respect  to  their  structure,  and  in  respect  to  the  fluids  that  pass  through  them.  The 
blood-tubes  yield  readily  to  external  pressure.  Many  of  them  are  pushed  aside  and 
flattened  by  the  progressive  increase  of  the  tubercular  matter  around  them ;  s&me, 
probably,  are  obstructed  by  its  gradual  accumulation  within.  In  either  case  the 
stagnant  blood  coagulates,  and  the  vessel  is  obliterated  to  some  distance  from  the 
place  of  the  original  obstacle  ;  just  as  you  know  a  clot  forms,  and  seals  up  an  artery, 
which  has  been  tied  during  life,  for  some  Httle  way  anterior  to  the  ligature.  But 
the  bronchial  tubes  are  neither  so  easily  compressed,  nor  do  they  carry  any  coagu- 
lablc  fluid.  In  the  agglomeration  of  the  tubercular  masses,  by  the  softening  of  which 
the  cavities  are  formed,.the  air-tubes  included  within  the  mass  are  filled  up  by  it; 
and  when  the  whole  breaks  down  in  scrofulous  suppuration,  they  are  expectorated 
with  the  rest  of  the  detritus.  Meanwhile,  their  open  mouths,  on  the  hither  side 
of  the  point  where  the  tubercular  matter  stopped,  remain,  and  afford  a  channel 
through  which  the  same  matter,  after  it  has  become  soft,  finds  its  way  towards  the 
trachea.  Occasionally,  indeed — but  that,  I  repeat,  is  a  rare  occurrence — a  con- 
siderable blood-vessel  does  get  laid  open  during  the  formation  of  a  vomica,  and  then 
copious  and  fatal  hemorrhage  ensues.  Occasionally,' also,  an  oozing  or  exhalation 
of  small  quantities  of  blood  takes  place  from  the  inner  surface  of  the  cavity,  tinging 
the  matter  expectorated. 

AVhen  the  vomica  is  first  formed,  by  the  expulsion  of  the  tubercular  matter,  its 
inner  surface  is  soft  and  ragged ;  and  if  other  softening  tubercles  are  in  the  imme- 
diate neighbourhood,  the  cavity  goes  on  enlarging;  that  is,  two  or  more  vo micas 
coalesce.  If,  however,  there  happen  to  be  no  more  tubercles  thereabouts,  the  cavity 
may  remain  stationary.  Its  inner  surface  then  becomes  smoother ;  and  something 
like  a  membrane  forms  upon  it:  and  sometimes  a  puriform  fluid  is  poured  out  by 
this  surface,  and  sometimes  not.  G' r^ralljMhe  pulmonar)'  tissue  around  such  a 
cavity  is  condensed  and  solidified ;  par  /  perhaps  by  crude  tubercular  matter  which 
it  contains,  partly  in  consequence  of  the  inflammatory  process  of  which  it  has  been 
the  seat  during  the  softening  of  the  tubercles.  It  is  important  to  bear  in  mind  this 
fact  of  the  condensed,  solid  state  of  the  lung  immediately  surrounding  a  vomica;  for 
it  explains  certain  peculiarities  met  with  in  the  symptoms. 

There  is  another  point  of  much  interest  connected  with  these  vomicae.  When 
they  occur  singly,  without  other  tubercles  or  cavities  (which,  though  a  very  rare 
thing,  does  sometimes) ;  and  when  occurring  thus  singly  they  have  been  completely 
*?mptied  of  the  tubercular  matter;  they  may  gradually  contract,  and  ultimately  be- 
come obliterated.  This  approach  of  their  sides  Ic^ds  to  a  puckering  of  the  pleura 
on  the  surface  of  the  lung;  and,  on  the  other  hand,  a  puckering  of  the  surface  indi- 
cates that  beneath  it  there  is  probably  a  collapsed  vomica.  Its  inner  surface  becomes 
converted  in  that  case  into  a  substance  resembling  cartilage  ;  and  the  appearance  it 
presents  is  called  a  cicatrix  ;  and  really  it  deserves  that  name.  The  process  which 
lias  gone  on  is  a  process  of  natural  recovery  ;  and  the  recover}^  would  be  complete, 
kC  nc  fresh  deposit  of  tubercular  matter  took  place.     Too  often,  however,  the  tuber- 


PHTHISIS.  631 

cles  multiply,  until  at  length  their  number,  or  size,  or  effects,  become  inconr  palible 
with  the  further  continuance  of  Jife. 

This,  then,  is  one  way  in  which  tubercular  disease,  limited  to  one  small  portion 
of  the  lung,  may  be  eliminated,  and  the  part  which  it  occupied  undergo  a  kind  of 
repair.  But  the  disease,  lohen  so  limited,  maij  cease  in  another  way.  The  more 
watery  parts  of  the  morbid  secretion  may  be  absorbed,  and  the  earthy  salts  it  con- 
tains may  concrete,  and  the  whole  be  converted  into  a  shrivelled,  hard,  chalky  mass, 
which  somcumes  is  coughed  up ;  sometimes,  in  favourable  cases,  remains  for  years 
in  the  lung,  an  inert  and  almost  harmless  body. 

Let  me  smte,  while  I  think  of  it,  that  the  expectoration  of  these  chalk-like  concre- 
tions, denoting,  as  it  usually  does,  the  existence  of  pulmonary  consumption,  marks 
at  the  same  time  the  chronic  character  of  the  case.  I  am  acquainted  with  a  gentle- 
man who,  though  delicate,  enjoys  a  very  fair  share  of  health,  and  who  has  for  years 
been  coughing  up,  at  intervals,  little  branching  fragments,  like  bits  of  white  coral, 
consisting  principally  of  carbonate  and  phosphate  of  lime,  and  evidently  moulded  in 
the  smaller  bronchial  tubes. 

When  the  tubercles  are  numerous — or  rather  when  they  lie  near  to  the  surface 
of  the  lung,  as,  of  course,  they  are  likely  to  do  when  thej--  are  numerous — they  very 
generally  give  rise  to  dry  or  adhesive  pleurisy.  So  that,  in  a  person  dead  of  con- 
sumption, it  is  a  very  rare  thing  to  find  the  lungs  free  from  adhesions  to  the  ribs.  I 
mentioned  before  that  this  attachment  of  the  lung  to  the  walls  of  the  chest  affords  a 
protection  against  a  much  more  formidable  condition;  namely,  perforation  of  the  pul- 
monary pleura,  and  the  escape  of  tubercular  matter  and  air  into  the  serous  cavity; 
producing  that  worst  kind  of  pleurisy  which  constitutes  pneumothorax.  That  the 
pleurisy  and  adhesion  are  consequences  of  the  presence  and  irritation  of  the  tuber- 
cles, appears  from  this : — that,  for  the  most  part,  the  extent  and  the  situation  of  the 
adhesions  correspond  with  the  extent  and  situation  of  the  tubercular  disease.  Thus, 
a  single  spot  of  adhesion  has  been  seen  to  unite  the  costal  and  pulmonary  pleurae 
exactly  opposite  a  solitary  tubercle  which  lay  near  the  surface  of  the  lung.  As  the 
summit  and  back  part  of  the  upper  lobes  are  most  thickly  set  with  tubercles,  so 
here  also  is  the  adhesion  the  most  constant,  and  the  most  firm.  You  will  often  find 
the  upper  part  of  the  lung  invested  with  a  thick  cap  of  false  membrane ;  and  the 
connection  between  the  pleural  so  tough,  that  the  lung  breaks  down  in  the  attempt  to 
separate  them. 

To  show  you  that  these  statements — which  have  long  been  familiar  to  those  much 
conversant  with  disease  and  with  morbid  anatomy — to  convince  you  that  they  are 
strictly  borne  out  by  numerical  or  tabular  facts,  I  may  again  have  recourse  to  Louis. 
He  tells  us  that  in  112  cases  which  he  himself  examined  of  persons  dead  of  con- 
sumption, and  having  therefore  tubercles  in  their  lungs,  there  was  but  one  in  which 
both  lungs  were  free  from  adhesions.  In  eight  cases  the  right  lung  was  exempt 
from  them,  and  in  seven  cases  the  left.  Again,  in  twenty-five  other  instances,  there 
were  either  no  cavities,  or  very  little  ones ;  and  the  adhesions  were  accordingly  of 
small  extent,  and  easily  broken  down.  In  the  remainder  there  were  large  vomicae, 
and  the  adhesions  were  extensive,  dense,  and  firm. 

Such  is  a  sketch  of  the  changes  which  take  place  in  the  lungs,  in  consequence 
of  the  deposition  of  tubercular  matter  in  them,  and  of  the  changes  which  that  matter 
undergoes.  But  the  air-passages  that  lead  to  the  lungs  are  very  liable  to  become 
implicated  as  the  disease  proceeds.  The  mucous  membrane  of  the  larynx  and  tra- 
chea ulcerate ;  and  when  the  morbid  condition  of  the  larynx  gives  rise  to  prominent 
symptoms,  and  especially  (as  it  is  apt  to  do)  to  hoarseness  and  loss  of  voice,  the  dis- 
ease is  sometimes  called  laryngeal  phlhisis.  But  there  is  no  such  disease,  that  f 
know  of,  existing  by  itself.  I  mean,  that  scrnfalous  ulceration  of  the  larynx  anu 
trachea  occurs  only  when  the  lungs  are  affected  -with  tubercles.  It  is  curious  thai 
when  ulcers  are  met  with  in  the  trachea,  they  are  often  found  on  one  side  of  it  onlv : 
on  the  side,  viz.,  which  corresponds  with  the  diseased  lung,  or  with  that  lung  which 
is  most  diseased.  In  like  manner,  when  some  of  the  bronchi  are  found  red  inter- 
nally, and  even  ulcerated,  these  appearances  are  confined  to  those  bronchi  which 
CO  nmunicate  with  cavities  ;  and  do  not  occur  in  the  bronchial  canals  leading  to 


C32  PHTHISIS. 

crude  tubercles.  It  is  towards  the  back  part  also  of  the  trachea  that  the  ulcers,  espe 
cially  when  large,  are  most  commonly  observed ;  the  floor  of  that  channel  when  the 
patient  lies  supine.  And  when  the  epiglottis  is  involved  in  the  mischief,  the  ulcers 
are  situated,  almost  always,  on  its  larjmgeal  surface  alone.  We  have  strong  reasons, 
therefore,  for  believing  that  their  formation  is  influenced  by  the  contact  of  the  matter 
which  is  expectorated,  in  its  frequent  passage  over  the  mucous  membrane.  More- 
over, the  little  mucous  glands  wherewith  the  membrane  is  provided,  are  most  num*'- 
rous  at  the  posterior  part  of  the  trachea  and  bronchi ;  and  these  glands  are  especially 
prone  to  ulcerate. 

In  respect  to  these  points,  also,  Louis  has  made  comparative  observations.  Among 
180  persons  who  died  of  some  chronic  disorder,  not  phthisical,  he  once  onlj'-  met 
with  ulceration  of  the  larynx ;  whereas,  of  those  who  perished  with  consumption, 
nearly  one  in  even/ five  had  ulceration  of  the  epiglottis  and  larynx,  and  nearly  one 
in  three  had  ulceration  of  the  windpipe.  Hence  it  would  appear  that,  if  we  except 
the  eflxxts  of  the  syphilitic  poison  upon  the  larynx,  ulceration  of  that  part  is  almost 
peculiar  to  phthisis  pulmonalis. 

I  have  told  you  that  consumption  is  not  merely  a  lung  disease.  Its  local  ravages 
are  most  obvious,  indeed,  in  the  thorax ;  but  it  leaves  in  the  abdomen,  also,  traces  of 
its  destructive  agency,  not  less  definite  and  scarcely  less  constant.  You  know  that 
the  surface  of  the  intestinal  canal  is  strewed  throughout  with  separate  mucous  folli- 
cles, and  that  the  lower  portion  of  the  ileum  is  furnished  with  other  follicles,  collected 
together  in  oval  or  circular  groups.  When  I  come  to  speak  of  continued  fever,  I 
shall  have  much  to  say  about  the  changes  which  these  little  glandular  bodies  undergo, 
in  one  form  at  least  of  that  disease.  These  same  glands  are  the  frequent  seat  ol 
tubercular  deposit  in  phthisis.  Here  and  there  you  may  see  a  solitary  yellow  tumour, 
not  larger  than  a  hemp-seed,  projecting  from  the  surface  of  the  bowel.  In  other 
places  the  ripened  little  tumour  has  burst,  the  tubercular  matter  is  gone,  and  a  ragged 
roundish  ulcer  remains.  More  frequently  the  aggregated  glands  are  afl^cted  ;  and 
the  ulceration,  in  them,  varies  much  in  form  and  extent.  It  often  involves  the  whole 
patch,  and  then  the  shape  of  the  ulcer  is  more  or  less  elliptical.  Louis  met  with 
ulceration  of  these  glandulse  agminatte  in  five-sixths  of  all  the  fatal  cases  of  phthisis 
that  he  examined.  Ulcers  of  greater  magnitude  were  very  nearly  as  common  in  the 
large  intestines.  And  it  is  worthy  of  notice  that,  the  disorganizing  process  being  in 
these  cases  slow,  nature  has  time  (if  I  may  use  such  metaphorical  language)  to  pro- 
vide against  the  threatened  perforation  of  the  gut.  The  tissue  that  forms  the  base 
of  the  ulcer,  whether  it  be  the  muscular  or  the  peritoneal  coat,  is  thickened  and 
vamped  ;  or  the  bowel  becomes  adherent  to  some  contiguous  surface.  Once  only  in 
my  life  have  I  known  scrofulous  ulceration,  in  phthisis,  penetrate  the  serous  tunic, 
and  allow  the  contents  of  the  intestine  to  escape  into  the  sac  of  the  peritoneum. 

It  is  fitting  you  should  know — although  the  facts  possess,  as  yet,  no  practical  value 
— that  the  stomach  is  often  much  enlarged  and  thinned  in  those  who  die  of  consump- 
tion ;  and  that  the  liver  is  ver3''apt  to  undergo  a  remarkable  change,  almost  peculiar, 
i  believe,  to  that  disease.  It,  too,  enlarges,  and  becomes  full  of  adipose  matter, 
greasing  the  hands  and  scalpel  of  the  anatomist,  and  yielding,  when  heated,  an  oily 
substance,  which  makes  a  grease-spot  on  paper  placed  in  contact  with  it.  The 
whole  gland  partakes  in  the  alteration,  is  of  soft  consistence,  loses  its  natural  red  tint, 
and  assumes  a  pale  fawn  colour.  No  profession  contributes  so  much  as  ours  to  the 
introduction  of  new,  barbarous,  and  dissonant  words  into  the  English  language.  We 
have  accordingly  invented  an  epithet  for  this  kind  of  liver.  We  call  it  (not  they«/, 
bui)  ihefatti/  liver.  In  three  years, Louis  met  with  this  fatty  liver  forty-nine  times; 
and  forty-seven  of  the  patients  died  phthisical.  It  occurred  in  one-third  of  the  whole 
number  of  the  victims  to  consumption  ;  whereas,  among  two  hundred  and  twenty- 
three  cases,  not  phthisical,  there  were  two  examples  only  of  this  hepatic  change. 
Its  presence  is  revealed  during  life  by  no  symptoms,  except  that  the  enlargement 
belonging  to  it  may  sometimes  be  ascertained  by  percussion  and  pressure  with  the 
u  nge  rs. 

Let  us  now  mquire  Avhat  modifications  of  the  healthy  sounds  arise  from  the 
"tiiered  conditions  of  the  lungs  in  phthisis.     Most  of  them  are  such  as  you  would 


PHTHISIS.  G33 

naturally  expect.  Whether  a  portion  of  lung  be  rendered  solid  by  comn.on  inflam- 
mation, or  by  the  presence  of  tubercles  in  it,  the  result,  so  far  as  the  ascultatory  signs 
are  concerned,  will  be  the  same.  In  such  a  piece  of  lung,  supposing  the  solidifica- 
tion complete,  no  vesicular  breathing  can  be  heard  ;  but  bronchial  breathino-  and 
bronchophony  will  be  audible,  in  each  case,  if  the  solidified  portion  encloses  a  con- 
siderable bronchus,  and  comes  near  the  surface  of  the  chest.  And  percussion  will 
give  a  dull  sound,  whether  the  lung  lying  beneath  the  part  struck  be  hepatized,  or 
blocked  up  by  tubercular  matter.  On  these  points,  therefore,  after  what  was  said  in 
a  preceding  lecture,  I  need  not  dwell.  But  the  excavations,  the  empty  or  half-empty 
vomicae — these  are  something  new.  We  have  hitherto  met  with  no  condition  ex- 
actly similar  to  that  of  a  large  cavity.  And  accordingly  I  have  to  make  you 
acquainted  with  two  or  three  new  sounds :  or  sounds  which  are  modifications  of 
those  formerly  described,  and  in  most  instances  sufficiently  distinct  from  them  to 
have  acquired  peculiar  names.  You  will  remember  that  what  we  have  called  laro-e 
crepitation  depends  upon  the  passage  of  air  through  liquids ;  the  liquids  being  con- 
tained in  tubes  ;  those  tubes  the  bronchi  and  their  ramifications.  But  when  pus  or 
vitiated  mucus,  or  liquid  of  any  kind,  is  collected  in  a  vomica,  which  communicates 
freely  with  the  trachea  through  pervious  bronchi,  the  bubbles  produced  by  the 
entrance  and  exit  of  air  will  be  still  more  numerous  and  large  ;  and  a  sound  is  then 
produced  which  the  word  gurgling  expresses  well.  Laennec  calls  it  gargouille- 
ment.  This  sound  is  heard,  too,  in  a  circumscribed  space  ;  and  not  diffused,  as  laro^e 
crepitation  usually  is.  Whenever,  therefore,  we  hear  gurgling  during  respiration, 
or  during  the  act  of  coughing,  there,  we  conclude,  exists  a  cavity.  But  the  cavity 
is  not  necessarily  a  vomica.  In  ninety-nine  cases  out  of  a  hundred,  it  will  be  so  ; 
but  in  the  hundredth  case  perhaps  it  will  not.  Bear  in  mind  what  was  formerly 
stated  of  dilatation  of  the  bronchi :  how  sometimes  they  terminate  in  a  considerable 
globular  expansion  ;  sometimes  belly  out  and  contract  again  several  times  alternately: 
and  you  will  see  that  cavities  containing  liquid,  or  liable  to  contain  hquid,  belono-ino- 
equally  to  the  one  condition  and  to  the  other,  and  the  sound  in  question  dependino- 
solely  on  the  intermixture  and  agitation  of  air  with  liquid  in  a  cavity,  we  cannot  be 
sure  from  mere  gurgling  respiration,  or  gurgling  cough,  that  we  have  a  tubercular 
excavation  beneath  our  ear;  or  that  the  case  is  one  of  consumption.  Gurgling  may 
also  proceed  from  that  very  rare  morbid  condition,  abscess,  the  result  of  common 
inflammation  of  the  lung.  These  constitute  the  only  sources  of  fallacy  in  the  matter. 
The  fallacy  seldom  interposes ;  but  it  does  sometimes  interpose ;  and  therefore  it 
must  qualify  om  conclusion  from  this  symptomof  gurgling,  in  respect  to  cases  other- 
wise doubtful. 

Again,  the  vomica  may  be  empty  of  liquid ;  and  then  we  hear,  as  the  patient  re- 
spires, not  vesicular  breathing  of  course,  nor  yet  exactly  bronchial  breathing ;  it  is 
something  more  than  that  when  the  cavity  is  large,  something  different  in  character 
from  it  when  the  cavity  is  small:  but  whatever  the  character  of  the  sound,  as  ws 
believe  it  to  take  place  in  a  vomica  or  cavern,  we  call  it  cavernous  respiration.  It  is 
a  hollow  sound,  especially  when  the  cavity  is  of  considerable  size ;  an  exaggeration 
of  mere  bronchial  respiration.  But  the  cavity  may  be  small.  The  moment  a  por- 
tion of  tubercular  matter  is  separated  and  discharged  through  a  neighbouring  bron- 
chial tube,  the  cavity  has  commenced  ;  and  the  sound  produced  through  these  little 
cavities  during  the  breathing  may  be  of  various  kinds.  It  may  be,  and  it  often  is,  a 
click,  hke  the  opening  and  shutting  of  a  valve  ;  or  a  chirp  ;  or  a  creaking;  or  like 
many  other  well-known  sounds:  but,  as  all  these  sounds,  under  certain  circum- 
stances, denote  the  formation  of  a  vomica,  it  is  best  for  simphciiy's  sake,  to  call  them 
all  by  the  same  name — cavernous  respiration. 

Dr.  Latham  explains  in  a  few  words  the  causes  of  these  differences.  "Th(!  vari- 
eties of  cavernous  breathing  are  doubtless  owing  to  different  sizes,  and  forms,  and 
situations  of  cavities,  and  to  different  conditions  of  the  surrounding  lun^.  A  cavity 
may  be  very  large  or  very  small.  Several  bronchi  may  open  into  it,  or  only  one.  It 
may  be  a  simple  cavity,  or  it  may  have  many  chambers.  Its  sides  may  be  con- 
densed and  equal,  or  rough  and  ragged.  The  lung  around  it  may  be  solid  and  m 
durated,  or  pervious  and  vesicular."   It  may  be  near  the  ribs,  or  far  from  them 


634  PHTHISIS. 

adherent  to,  or  separate  from  the  pleura.  It  is  quite  obvious  that  these  different  cir- 
cumstances are  calculated  to  modify  the  sound,  which  will,  nevertheless,  be  always 
such  as  indicates  a  cavity." 

A  tubercular  cavity  may  be  so  large,  and  of  such  a  kind,  as  to  yield  the  metallic 
sounds  which  are  apt  to  be  heard  in  pneumothorax.  I  show  you  a  cavity  in  which 
those  sounds  were  actually  heard,  most  distinctly,  by  many  persons,  during  the 
patient's  life  while  he  was  under  my  care  in  the  Middlesex  Hospital.  I  was  certain 
beforehand  that  these  sounds  proceeded,  not  from  the  cavity  of  the  pleura,  but  from  a 
tubercular  excavation.  Once  subsequently,  in  a  patient  who  was  dying  of  phthisis 
and  diabetes,  I  have  heard  the  same  sounds ;  also,  I  am  sure,  in  a  tubercular  cavity. 
The  patient  insisted  on  leaving  the  hospital,  and  I  lost  sight  of  him  before  he  died. 

I  promised,  when  speaking  of  these  metallic  sounds  as  arising  (as  they  much 
more  commonly  do)  from  pneumothorax — a  collection  of  air,  or  of  air  and  fluid,  in 
the  sac  of  the  pleura — I  promised  to  point  out  the  circumstances  whereby  you  may 
tell  which  of  the  two  conditions  in  question  the  sounds  denote.  Both  of  the  conditions 
imply,  in  general,  the  existence  of  tubercular  phthisis ;  and  therefore  the  observation 
of  the  ordinary  symptoms  of  phthisis  will  not  help  us  much. 

Now,  in  the  cases  seen  by  me,  there  were  two  circumstances  that  stamped  them 
as  beino-  cases  in  which  the  sound  proceeded  from  a  cavity  in  the  lung,  and  not 
exterior  to  it.  One  was  the  situaiion  in  which  the  sound  was  invariably  heard. 
The  other  was,  the  absence  of  excessive  resonance  when  that  part  was  percussed. 
You  know  that  when  air  is  contained  within  the  pleura  itself,  the  sound  yielded  on 
percussing  the  chest  in  the  corresponding  spot  is  quite  tympanitic,  like  that  of  a 
drum.  But  it  is  a  well-ascertained  fact,  (though  contrary  perhaps  to  what  you  would 
suppose,)  that  the  sound  is  duller  over  tubercular  cavities,  in  nine  cases  out  of  ten, 
than  over  sound  lung.  The  explanation  of  this  fact  is  simple  enough.  It  is  that  the 
layer  of  lung  which  still  remains  in  such  cases,  thick  or  thin,  is  dense  and  solid,  and 
damps  the  sound  which  the  vomica  might  otherwise  make  resonant.  But  then  again 
the  situation  of  the  metallic  sounds  was  a  guide.  They  occupied  the  upper  part  of 
the  chest;  the  very  part  where  vomicae  are  wont  to  be  the  most  common,  and  the 
iaro-est :  and  moreover  a  part  where  pneumothorax  seldom  or  never  exists.  The 
summit  of  the  lung  is  generally  covered  in  phthisis  with  a  cap  of  false  membrane, 
which  binds  it  to  the  ribs :  and  this,  as  I  observed  before,  is  the  main  reason  why 
perforation  of  the  pleura  pulmonalis  is  so  rare  in  that  disease  ;  and  it  is  also  the  reason 
why,  when  it  does  take  place,  it  seldom  takes  place  at  or  near  the  apex  of  the  lung. 
In  truth  it  is  found  by  experience  that  (though  the  rupture  of  the  pleura  maij  hap- 
pen in  any  part)  the  place  where  it  usually  occurs  is  in  the  lower  and  back  part  of 
the  upper  lobe  of  the  lung,  opposite  the  angle  of  the  third  or  fourth  rib  ;  that  is,  just 
beneath  the  edge  of  the  false  membrane  by  which  the  summit  of  the  lung  is  gene- 
rally adherent.  But  the  sound,  in  the  cases  I  refer  to,  was  invariably  heard  at  the 
very  top  of  the  chest.  It  did  not  shift,  as  that  of  pneumothorax  may  often  be  made  to 
shift,  when  the  patient  changed  his  posture.  Attention  to  these  points  will  always 
lead  you  to  an  exact  diagnosis.  You  may  say,  perhaps,  "  The  complaint  being  in 
each  case  a  mortal  one,  what  is  the  use  of  so  much  refinement?"  Why,  there  is 
this  utility  in  it.  We  may  sometimes,  as  I  stated  before,  give  great  relief  to  the 
patient,  and  save  his  life  for  a  time,  by  tapping  the  chest  of  pneumothorax.  The  air 
mav^et  in  with  each  inspiration,  and  threaten  immediate  suffocation  ;  and  the  thorax 
being^puncmrcd  it  will  issue  in  a  blast.  But  no  one  would  think  of  tapping  a  tuber- 
cular cavity. 

To  giveout  the  amphoric  resonance  and  the  metallic  sounds,  the  vomica  must,  I 
presume,  be  a  large  one.  That  which  is  before  you,  the  only  one  I  ever  saiv  in 
which  those  sounds  had-been  heard,  is  very  large.  Its  inner  surface  is  smooth  :  it 
adheres  to  the  ribs  externally  by  at  least  two-thirds  of  its  circumference :  and  the 
medium  of  aflhesion  is  very  thin.  Quite  low  down,  a  single  bronchial  tnbe,  of  about 
the  third  division,  may  be  seen  to  enter  it. 

So  much,  then,  lor  the  modification  by  a  tubercular  cavity,  of  the  sounds  heard 
dunng  respiration.  But  the  voice  will  also  be  modified,  if  the  cavity  be  of  consi- 
derabfe  size,  and  near  the  surface,  and  have  dense  walls,  and  be  empty.     Then  we 


PHTHISIS.  635 

hear,  in  that  part,  when  the  patient  speaks,  the  sound  which  is  called  pectoriloquy: 
as  if  the  voice  proceeded  from  the  chest.  The  words  are  distinctly  articulated  into 
the  ear  oi  the  listener.  But  1  need  not  trouble  myself  or  you  by  attempting  to  de- 
scribe pectoriloquy.  You  may  any  day  hear  the  exact  sound  that  word  is  intended 
to  denote,  by  placing  a  stethoscope  over  the  trachea  of  one  of  your  friends,  aj)plying 
your  ear  to  the  other  end  of  it,  and  getting  him  to  speak :  just  as  you  may  obtain  an 
exact  notion  of  bronchial  respiration  by  listening  then  to  his  breathing. 

For  some  time  after  the  first  appearance  of  Laennec's  great  and  original  work  on 
the  diseases  of  the  chest,  pectoriloquy  was  deemed  to  be  the  pathognomonic  and 
infallible  sign  of  a  vomica.  "Oh,"  the  young  auscultator  would  say,  "I  detect  pec- 
toriloquy beneath  the  clavicle.  There  can  be  no  further  doubt  about  the  nature  of 
the  disease.  My  patient  has  not  only  tubercles,  but  a  cavity,  in  his  lung."  So  I 
long  thought ;  and  so  some,  I  fancy,  think  still.  Yet  the  evidence  afforded  by  mere 
pectoriloquy  of  the  presence  of  a  vomica,  or  even  of  the  presence  of  tubercles,  is  far 
from  being  certain  or  trustworthy.  Experience  ha'd  taught  me  this  before  I  knew 
that  many  others,  studying  under  the  same  schoolmaster,  had  learned  the  same  truth. 
Among  my  hospital  patients  some  years  ago  was  a  man  who  laboured  under  phthisis. 
Percussion  gave  a  dull  sound  under  his  right  collar-bone,  and  in  the  same  spot  loud 
and  distinct  pectoriloquy  Avas  audible.  I  well  recollect  inviting  the  particular  atten- 
tion of  the  pupils  to  this  case,  as  affording  an  exquisite  specimen  of  pectoriloquy ; 
and  I  predicted  very  confidently  that  after  the  patient's  death,  v/hich  was  obviously 
at  hand,  a  large  excavation  would  be  found  in  the  summit  of  his  right  lung.  My 
prediction  did  me  no  credit.  The  left  lung  indeed  was  hollowed  by  cavities,  but 
there  was  nothing  like  a  cavity  in  the  right.  The  upper  part  of  the  lung  was  tho- 
roughly and  uniformly  solid  ;  filled  with  hard,  gray,  tubercular  matter.  The  large 
bronchial  tubes  were  pervious,  and  the  voice  descending  into  them  had  been  con- 
ducted by  the  solid  lung  with  perfect  and  almost  painful  distinctness  to  the  listener's 
ear.  This  was  a  useful  lesson  to  me :  and  I  mention  it  that  it  may  be  a  lesson  to 
you.  Remember  that  solidification  of  the  summit  of  the  lung  will  modify  the  sound 
of  the  patient's  voice,  very  much  in  the  same  manner  as  a  large  vomica  there  situ- 
ated. It  is  stated,  indeed,  and  perhaps  truly,  that  a  practised  ear  can  discriminate 
between  the  loud,  diffused,  though  articulate,  resonance  of  the  voice  produced  by 
solid  lung,  and  the  circumscribed,  whiffing,  pectoriloquy  of  a  cavity.  But  the  dis- 
tinction is  too  nice  for  the  average  of  practitioners.  Piow  since  the  pulmonary  tissue 
may  be  rendered  dense  and  solid  by  other  causes  than  tubercles,  pectoriloquy  does 
not  a]wa3's  indicate  the  existence  of  consumption.  The  fallacious  condition  does  not 
often  occur;  for  common  inflammation  is  seldom  hmited  to  the  upper  part  of  the 
lung ;  and  the  whole  of  that  part  is  seldom  completely  hardened  by  crude  tubercles. 
But"  whenever  it  does  occur,  it  is  apt  to  mislead  or  puzzle.  I  was  consulted  last  year 
about  a  gentleman  in  whom  this  phenomenon  of  pectoriloquy  was  strono-ly  marked. 
Two  excellent  auscultators  had  been  led,  by  this  symptom,  to  the  belief  that  a  cavity 
existed  in  the  lung.  Remembering  the  case  I  have  just  mentioned,  and  learning  that 
the  patient  had  been  ill  for  a  few  days  only,  and  had  not  previously  suffered  cough, 
nor  any  apparent  pectoral  complaint,  I  was  of  opinion  that  the  summit  of  his  right 
lung  had  become  hepatized  by  acute  pneumonia.  And  it  was  so.  The  patient  died; 
and  the  diagnosis  I  had  formed  was  verified  upon  the  inspection  of  the  lung.  Dr. 
Latham  relates  one  or  two  examples  to  the  same  purpose.  Dr.  Stokes  goes  so  far 
as  to  consider  pectoriloquy  the  least  important  and  most  fallacious  of  all  the  physical 
signs  of  phthisis.  Taken  alone  (he  says)  it  is  absolutely  without  value.  Dr.  Forbes 
has  come  to  similar  conclusions.  Certainly  cavernous  respiration  is  a  much  more 
alarming  sound. 

Wherever  actual  pectoriloquy  from  a  cavity  is  heard,  there  also  will  be  heard 
cavernous  res])iration.  But  the  converse  of  this  is  not  necessarily  true.  There  may 
be,  and  there  often  is,  cavernous  respiration  and  a  cavity,  yet  no  peclcri^loquy.  Tho 
cavity  is  not  large  enough,  or  not  near  enough  to  the  surface  of  the  chest,  or  not  of 
such  a  kind  as  to  reverberate  the  voice. 

C^flen  when  pectoriloquy  is  absent,  and  cavernous  respiration  is  doubtful,  and  gurg- 
ung  even  cannot  be  heard  (because  the  communication  with  the  bronchi  is  not  free). 


636  PHTHISIS. 

a  slight  splashing  sound  will  occur  when  the  patient  coughs :  nay,  you  niay  some- 
times hear  it,  if  he  holds  his  breath,  with  every  beat  of  his  heart,  which  causes  a 
little  succussion  in  the  cavity :  but  its  contents  must  then  be  ihin. 

Now  when  the  sounds  I  have  been  engaged  in  describing  are  well  marked,  they 
denote  the  existence  of  a  vomica.  The  only  source  of  fallacy  is  that  which  I  formerly 
mentioned:  the  same  sounds  may  arise  from  a  cavity  in  the  lung,  whatever  be  its 
nature ;  and  therefore  they  may  arise  when  the  bronchi  are  expanded  into  cavities. 
But  I  repeat  that  this  is  a  deceptive  condition  which  you  cannot  calculate  upon  meet- 
ing with  often. "" 

When  the  sounds  are  not  w^ell  marked,  take  time  before  you  pronounce  a  decided 
opinion  respecting  them.  Strong  bronchophony  comes  very  near  to  weak  pectorilo- 
quy :  bronchial  respiration  may  closeJy  resemble  some  varieties  of  cavernous  breath- 
ing :  large  crepitation,  confined  to  a  small  spot,  may  simulate  gurgling.  It  is  better, 
when  the  sounds  are  thus  equivocal,  and  when  they  may  denote  conditions  so  very 
different  in  their  nature  and  tendency,  to  suspend  one's  judgment,  and  to  give  a 
guarded  opinion.     A  httle  time  in  such  cases  will  clear  away  the  doubt. 

I  am  afraid  of  being  tedious  about  these  sounds ;  but  really  they  are  of  immense 
importance.  Upon  their  exact  appreciation,  and  correct  interpretation,  will  depend 
the  opinion  you  will  be  culled  upon  to  express :  and  that  opinion  will,  in  many  cases, 
be  a  sentence  of  fife  or  death  in  respect  to  the  dearest  friends  of  those  who  hear  it. 
A  correct  diagnosis  is  also  very  important,  in  early  periods  of  the  disease  especially, 
for  another  reason.  It  is  in  those  early  periods  alone  that  we  can  hope  to  arrest  the 
progress  of  the  complaint  by  art,  or  by  change  of  climate. 

I  must  now  consider  the  general  symptoms  of  this  most  afflicting  disease:  and 
while  doing  so,  I  shall  point  out  how  the  physical  signs  confirm  or  confute  their  lan- 
guage, in  cases  which  might  otherwise  be  doubtful. 

The  general  symptoms  of  phthisis  are  cough,  dyspnoea,  expectoration,  haemo- 
ptysis, wasting,  hectic  fever,  hoarseness,  or  loss  of  voice,  diarrhosa ;  and  there  are 
some  other  symptoms  which  mark  often  some  of  its  stages,  and  to  which  I  shall 
incidentally  advert.  I  shall  speak  of  them  all  as  briefly  as  is  consistent  with 
clearniess. 

Cough  is  one  of  the  earliest  symptoms  of  consumption  ;  and  it  is  that  which  com- 
monly "first  attracts  the  attention,  and  awakens  the  fears  of  the  patient,  or  the  patient's 
friends.  Generally  at  first  it  is  slight,  occasional,  and  dry  :  it  occurs  upon  the 
patient's  getting  out  of  bed  in  the  morning ;  or  if  he  makes  any  unusual  exertion  in 
the  course  of  the  day.  It  feels  to  him  as  if  it  was  caused  by  irritation  about  the 
throat.  Sometimes  it  \\\\\  cease  for  a  while,  as  in  the  w^arm  w^eatlier  of  summer, 
and  recur  in  winter  when  the  external  temperature  is  lower.  By  degrees  it  begins 
to  be  troublesome  in  the  night :  and  to  be  attended  with  more  or  less  mucous  ex- 
pectoration. 

Now  when  such  a  cough  steals  upon  a  person  gradually,  and  when  no  reason  can 
be  assigned  for  its  occurrence,  that  circumstance  alone  is  enough  to  excite  suspicion 
as  to  its  true  nature  and  cause.  But  chronic  cough  may  exist  without  any  tubercular 
disease  of  the  lungs  ;  as  you  well  know.  It  may  depend  upon  a  disordered  state  of 
the  stomach;  the  pneumogastric  nerve  may  be  irritated  there.  It  may  be  the 
cough  of  chronic  catarrh;  it  may  result  from  disease  of  the  heart ;  it  may  be  the 
nervous,  barking,  importunate  cough  which  I  formerly  mentioned  as  of  frequent  oc- 
currence in  hysterical  girls.  And  bearing  these  circumstances  in  your  mind,  you 
will  inquire  and  you  will  generafly  make  out  without  much  ditliculty,  whether  there 
be  any  unnatural  or  deranged  stale  of  the  digestive  organs ;  or  chronic  catarrh ;  or 
cardiac  disease ;  or  hysteria.     These  are  points  on  which  I  need  not  further  insist. 

I  may  obuerve,  here,  that  as  chronic  cough  may  exist  when  there  is  no  consump- 
tion ;  so  consumption  may  sometimes  exist,  and  even  prove  fatal,  and  large  portions 
at  the  lungs  may  be  disorganized,  without  there  having  been  any  cough  ;  or  at  least 
without  the  occurrence  of  cough  enough  to  draw  the  notice  of  the  patient  or  his 
friends  to  it.  This  is  not  common,  howe^^er :  cough  is  usually  present  more  or  less, 
during  al.'  the  stages  of  phthisis,  and  it  is  often  that  symptom  which  most  distresses 
•md  iiarasses  both  the  patient  and  his  family. 


PHTHISIS.  637 

Great  a  tention  used  to  be  paid  to  the  expectoration  in  cases  of  suspected  phthisis. 
It  was  thought  that  if  a  patient  spat  pus,  he  was  in  a  state  of  confirmed  consump- 
tion :  and  whole  volumes  have  been  written,  and  prizes  awarded  to  their  authors, 
respecting  the  means  of  distinguishing  pus  from  mucus.  But  we  now  know  that, 
so  far  as  the  diagnosis  of  phthisis  is  concerned,  this  is  a  very  idle  inquiry.  The 
inflamed  bronchial  membrane  may  secrete  pus ;  so  that  the  presence  or  absence  of 
pus  in  the  sputa  is  no  test  at  all  of  the  presence  or  absence  of  tubercles  in  the  lungs. 
If  you  are,  nevertheless,  curious  to  know  how  pus  may  be  recognized,  one  easy 
criterion  is  that  proposed  by  the  late  Dr.  Young.  You  are  aware  that  pus,  like  the 
blood,  contains  globules ;  and  these  globules,  when  examined  through  transmitted 
light,  will  exhibit  prismatic  colours  ;  appear  surrounded  by  rings  of  colours,  some- 
what resembling  those  of  the  rainbow,  but  differently  arranged,  and  often  beautifully 
brilhant.  Mucus  having  no  such  globules,  affords  no  such  coloured  rings.  The 
way  to  make  the  examination  is,  to  put  a  minute  quantity  of  the  fluid  between  two 
small  pieces  of  plate  glass ;  to  hold  the  glass  close  to  the  eye  ;  and  to  look  through 
it  at  a  distant  candle,  having  a  dark  object  behind  it.  A  yet  readier,  and  I  believe  a 
better  test  is  furnished  by  the  liquor  potassx,  which  converts  pus  into  a  viscid  stringy 
mass,  while  it  liquefies  mucus. 

Whether  the  expectoration  be  puriform  or  not,  has  ceased,  however,  to  be  a  ques- 
tion of  much  importance  as  regards  the  diagnosis  of  phthisis.  A  portion  of  the 
matter  expectorated  comes  from  the  surface  of  the  bronchi,  and  consists  of  altered 
mucus :  and  therefore  the  sputa  brought  up  in  phthisis,  and  the  sputa  brought  up  in 
bronchitis  are,  in  a  great  degree,  the  same.  These  are  partly  composed  of  a  stringy 
transparent  fluid,  in  which  opaque  masses  of  a  yellow  or  greenish  colour  are  seen  to 
float ;  and  intermixed  also  with  which  there  may  be  a  good  deal  of  froth.  The 
froth  is  a  measure  of  the  difficulty  with  which  the  mucus  is  brought  up :  and  it  is 
usually  less  abundant  and  conspicuous  in  phthisis  than  in  bronchitis.  The  heavy 
sage-leaf  sputa  that  we  sometimes  see,  belong  to  both  diseases. 

You  may  occasionally  find  portions  of  tubercular  matter  in  the  expectoration;  a 
circumstance  quite  decisive,  when  we  are  sure  of  it,  of  the  nature  of  the  case :  dull 
yellow  streaks,  or  little  curd-like  fragments  involved  in  the  mucus.  But  smaU  opaque 
specks  of  that  character  are  sometimes  formed  in  the  follicles  of  the  tonsils ;  and 
this  makes  the  appearance  more  equivocal.  The  sputa  most  characteristic  of  tuber- 
cular disease  consist  of  globular  flocculent  masses,  which  look  like  little  portions  of 
wool  more  than  any  thing  else.  Nummular  sputa  the  French  call  these,  because 
when  spat  into  a  vessel  not  containing  water,  they  assume  a  flat  circular  form,  hke  a 
piece  of  money,  and  remain  separate  and  distinct  from  each  other.  When  they  are 
spat  into  a  glass  of  water,  you  perceive  that  some  of  them  subside  to  the  bottom — 
some  float  on  the  top,  suspended,  apparently,  by  healthier  mucus  in  which  they  are 
entangled,  or  by  bubbles  of  air  —  and  some  remain  stationary  at  different  depths. 
When  stirred  and  agitated  in  the  water,  they  render  it  shghtly  milky.  This  kind 
of  expectoration  commonly  marks  a  confirmed  and  advanced  state  of  the  disease; 
but  it  will  continue  for  weeks  sometimes.  It  is  not  perfectly  pathognomonic,  but 
nearly  so.  On  one  occasion  I  found  expectoration  of  this  nature  from  a  man  whom 
I  did  not  very  diligently  examine  by  my  ear ;  and  I  set  the  case  down  as  one  of 
phthisis  chiefly  on  the  observation  of  that  symptom.  The  patient  evidently  had  not 
long  to  live.  Our  apothecary  at  the  hospital,  Mr.  Corfe,  had  more  time  to  explore 
trhe  condition  of  the  chest:  and  he  came  to  the  conclusion,  that  the  disease  was  not 
tubercular  phthisis,  but  extensive  chronic  bronchitis  :  and  sure  enough  he  was  right. 
When  we  came  to  examine  the  lungs  after  the  patient's  death,  not  a  tubercle  could 
be  foimd.  I  am  satisfied  that  there  is  no  kind  of  expectoration  which  indicates 
phthisis  with  perfect  certainty ;  but  that  which  I  have  just  been  describing  very 
seldom  occurs  except  there  is  phthisis.  Louis  appears  to  have  noticed  these  round 
separated,  woolly  masses  twice  only  unconnected  with  tubercles  ;  and  once  the  same 
thing  has  occurred  to  Chomel :  so  that,  when  the  other  symptoms  are  obscure  and 
doubtful,  this  will  materially  augment  the  gravity  of  the  prognosis.  Fiies  appear  to 
be  more  attracted  by  the  sputa  of  phthisis  than  by  any  other. 

Haemoptysis  is  a  kind  of  expectoration;   the  expectoration  of  Hood.     I  hava 

3i> 


638  PHTHISIS. 

already  spoken  of  this  symptom  as  connected  with  phthisis,  and  have  stated  my 
belief  on  that  subject;  viz.,  that  if  a  person  spits  blood  who  has  received  no  injury 
of  the  chest,  in  whom  the  uterine  functions  are  healthy  and  right,  and  who  has  no 
disease  of  the  heart,  the  odds  that  there  are  tubercles  in  the  lungs  of  that  person  are 
fearfully  high.  Excluding  cases  of  amenorrhcea,  and  of  mechanical  injury  to  the 
thorax,  Louis  did  not  meet  with  a  single  example  of  haemoptysis  among  twelve  hun- 
dred patients,  except  in  such  as  were  phthisical. 

I  touched,  at  the  same  time,  upon  the  question,  whether  haemoptysis,  which  some- 
times precedes  for  a  while  the  manifestation  of  any  other  symptoms  of  consumption, 
is  ever  really  the  cause  of  it,  as  the  old  authors  maintained.  You  will  understand 
iny  persuasion  to  be  that,  occurring  in  connection  with  tubercles,  pulmonary  hemor- 
rhage is  always  the  consequence,  and  never  the  cause,  of  their  presence  in  the  lung. 
Andral  relates  a  curious  case,  from  which  the  contrary  opinion  might  be  argued. 
"A  man,  ill  of  chronic  peritonitis,  had  been  for  nearly  two  months  in  La  Charite, 
and  had  never  presented  any  morbid  symptom  which  had  relation  to  the  organs  of 
respiration.  He  had  no  cough,  and  he  breathed  easily.  One  evening,  for  the  first 
time,  he  sufl~ered  some  dyspnoea ;  and  in  the  course  of  that  night  he  spat  up  a  large 
quantity  of  florid  and  frothy  blood.  For  the  five  following  days  the  hasmoptysis 
continued  abundant,  then  it  diminished  by  degrees,  and  at  length  stopped.  But  the 
patient  continued  to  cough,  and  to  breathe  with  difficulty,  and  at  length  he  died.  In 
the  right  lung  there  were  found  several  masses  of  a  brownish-red  colour,  exactly 
circumscribed,  and  constituting,  in  short,  that  condition  w^iich  Laennec  has  called 
*  pulmonary  apoplexy.'  One  of  these  masses  contained  a  considerable  number  of 
granulations  of  a  yellowish-white  colour,  and  having  all  the  characters  of  minute 
tubercles  in  an  early  state.  Two  other  of  the  red  masses  contained  each  a  very 
small  number  of  these  white  granules ;  and  in  the  remaining  masses  no  tubercles  at 
all  could  be  discovered,  nor  was  there  any  trace  of  them  in  other  parts  of  the  lungs  ; 
but  they  were  numerous  in  the  false  membranes  of  the  peritoneum. 

Andral  argues,  that  in  this  case  the  partial  collections  of  blood  that  were  found  in 
the  lung  could  not  have  been  occasioned  by  the  presence  of  tubercles,  because  in 
the  majority  of  these  masses  no  traces  of  tubercular  matter  could  be  perceived.  On 
the  other  hand,  their  existence  appears  connected  with  that  of  the  apoplectic  masses, 
because,  except  in  the  midst  of  some  of  these,  no  pulmonary  tubercles  could  be  seen. 
But  such  a  case  as  this  hardly  bears  out  the  conclusion  that  pulmonary  hemorrhage 
is  ever  the  cause  of  tubercles.  There  were  tubercles  in  the  abdomen  before  ;  there- 
fore, the  disposition  to  tubercular  disease  pre-existed  in  this  individual ;  and  then 
tubercular  matter  was  deposited  in  the  places  where  blood  was  extravasated ;  just  as 
we  know  it  is  deposited  in  the  blood  itself,  in  the  spleen  sometimes  ;  or,  what  1  think 
more  probable  still,  the  cluster  of  granulations  provoked  the  hemorrhage  from  the 
spot  they  occupied,  and  other  lobules  of  the  same  lung  became  blocked  up  by  the 
reflux  of  blood  in  the  manner  formerly  explained. 

Prior  to  the  age  of  fifteen,  haemoptysis,  even  in  phthisical  children,  is  extremely 
uncommon. 

Dijspnira  is  not  a  very  important  symptom  in  phthisis.  It  is  seldom  extreme  till 
towards  the  termination  of  the  disease,  and  not  always  then.  Patients  who  fear,  and 
yet  are  unwilling  to  believe,  that  they  are  consumptive,  will  fetch  a  deep  breath,  and 
Did  you  remark  how  thoroughly  they  can  distend  their  lungs  ;  and  they  expect  you 
to  say  that  there  can  be  no  disease  in  those  organs.  I  have  been  told  that  the  late 
Dr.  Baillie  died  of  pulmonary  phthisis  ;  and  that  even  he  was  accustomed  to  delude 
himself  by  this  test.  However,  though  phthisical  persons  do  not  in  general  suiTer 
much  from  dyspnoea,  their  breathing,  though  they  may  not  bo  aware  of  it,  or  choose 
10  acknowledge  it,  is  generally,  in  some  degree  or  other,  short,  or  hurried.  You 
may  wonder  that  a  disorder  in  which  so  large  a  portion  of  the  breathing  apparatus  is 
often  effectually  spoiled,  should  be  attended  by  so  little  distress  in  respiration ;  so 
liitie  dyspnoea :  but  your  surprise  will  be  diminished  if  you  consider  the  insufficient 
manner  in  which  consumptive  patients  are  nourished,  in  consequence  of  abdominal 
•-  isease ;  and  the  extent  to  which  their  blood  is  wasted  by  diarrhoea,  and  by  perspi- 
ration     Thc^  mass  of  blood  is  thus  kept  down  to  that  measure  which,  passing  through 


■^  PHTHISIS.  639 

the  still  pervious  portions  of  the  lungs,  is  capable  of  being  arterialized  without  any 
great  deviation  from  the  ordinary  mode  and  frequency  of  breathing. 

Neither  is  pain  of  the  chest  a  very  important  symptom  in  consumption.  In  some 
cases  severe  pains  are  complained  of,  resembling  those  of  rheumatism,  in  the  sides, 
or  beneath  the  clavicles.  In  others,  no  pain  at  all  is  experienced.  When  sharp 
pain  occurs,  it  may  be  supposed  that  the  pleura  is  inflamed  and  beginning  to  adhere 
in  the  painful  part. 

There  is,  however,  one  contingency  of  which  the  two  symptoms  last  mentioned  are 
sometimes  very  significant.  When,  during  the  progress  of  phthisis,  violent  pain  of 
the  side,  and  extreme  dyspnoea  and  anxiety,  set  in  suddenly,  they  denote,  with  much 
certainty,  perforation  of  the  pleura,  and  its  serious  consequences. 

The  hectic  fever  which  accompanies  phthisis  is  of  much  greater  moment.  It  often 
creeps  upon  the  patient  insidiously.  He  feels  chilly,  perhaps,  towards  evening; 
and  in  the  night  his  hands  and  feet  are  dry  and  burning;  and  in  the  morning  he 
perspires.  The  most  marked  symptoms  of  the  hectic  are  to  be  found  in  the  perspi- 
ration, and  in  the  state  of  the  pulse.  The  perspiration  is  usually  out  of  all  proportion 
to  the  previous  chilliness  and  dry  heat.  It  seems  to  have  a  close  connection  with 
the  sleep  of  the  patient :  it  seldom  comes  on  while  he  continues  to  be  awake ;  but 
after  sleeping  he  wakes,  and  find  that  he  is  sweating.  The  perspiration  is  generally 
most  copious  on  the  upper  part  of  the  body,  the  chest  and  head.  Sometimes  it  is 
moderate ;  sometimes  the  patient  is  drenched  and  drowned  in  it.  There  is  a  good 
deal  of  uncertainty  about  this  symptom,  and  of  obscurity  as  to  its  cause.  Generally 
speaking,  it  belongs  to  the  more  advanced  stages  of  phthisis  ;  but  occasionally  it 
accompanies  its  early  period.  It  will  cease  without  any  apparent  cause ;  and 
return  again  with  the  same  capriciousness,  A  poor  friend  of  mine,  who  died 
with  phthisis,  and  was  particularly  harassed  by  the  nocturnal  perspirations,  took  it 
into  his  head  that  joos/t/re  had  something  to  do  with  them  ;  and  slept  for  several  nights 
in  succession  sitting  in  an  easy  chair:  and  during  those  nights  he  certainly  did  not 
sweat,  though  he  had  been  doing  so  profusely  before.  Louis  found  that  one  patient 
in  ten  escaped  this  symptom. 

This  is  a  symptom  which  is  often  very  distressing  to  the  patient,  making  him  even 
dread  to  go  to  sleep ;  it  tends  also  to  the  rapid  exhaustion  of  his  strength ;  and 
betokens,  it  is  believed,  when  copious  or  persistent,  a  short  duration  of  the  disease. 

Frequency  of  pulse  is  a  symptom  so  generally  present  in  tubercular  phthisis,  that 
too  much  importance  has  been  ascribed  to  it  as  a  diagnostic  sign.  I  mean,  it  has 
been  too  much  the  opinion  that  the  lungs  are  safe,  when  the  pulse  does  not  rise  above 
its  natural  standard.  Sometimes  it  remains  steady  nearly  up  to  the  period  of  disso- 
lution.    Such  cases  are,  I  beheve,  generally  slow  in  their  progress. 

Very  recently  I  lost  a  friend  whose  lungs  were  full  of  cavities  and  crude  tubercK's. 
He  had  been  a  valetudinarian  for  years ;  but  the  pulmonary  disorder  had  been  mani- 
fested by  decided  symptoms  during  a  few  months  only.  At  no  period  did  his  pulse 
exceed  sixty-eight  beats  in  the  minute.  Commonly,  however,  the  pulse  is  habitually 
above  ninety  ;  and  often  it  is  much  more.  When  there  is  nothing  to  account  for  this 
increased  frequency  of  pulse,  it  is  a  suspicious  symptom. 

Diarrhcpais  a  common, and  an  ugly  symptom  in  phthisis.  When  it  occurs  early, 
as  it  sometimes  does ;  when  a  patient,  having  habitually  costive  bowels,  becomes 
habitually  relaxed  ;  and  you  suspect  only,  from  other  causes,  that  he  may  have  inci- 
pient phthisis  ;  this  change  often  sets  its  seal  upon  the  nature  of  his  disorder.  Usually, 
however,  diarrhosa  does  not  become  urgent  until  the  disease  is  far  advanced,  and  has 
aheady  declared  itself  by  other  and  unequivocal  symptoms.  When  it  so  occurs,  it 
is  apt  to  harass  the  patient  exceedingly ;  and  rapidly  to  waste  his  strength  and  flesh. 
He  appears  to  melt  away  under  the  influence  of  the  purging ;  which  is  therefore  said 
to  be  colliquative.  It  used  to  be  held  that  the  diarrhcea  and  the  perspiration  bore  iw. 
inverse  ratio  to  each  other:  that  when  one  of  them  abated,  the  other  always  increased. 
But  the  more  exact  observations  of  Louis  and  others  have  proved  that  this  is  not  so  : 
that  neither  in  phthisis,  nor  in  other  diseases,  have  these  symptoms  any  such  regular 
reciprocal  relation.  One  reason,  perhaps,  fw  this  error,  may  be  found  in  the  cii 
cumstance,  that  acids,  which  have  the  effect  often  of  checking  the  perspiration,  tend 


640  PHTHISIS. 

also,  as  is  well  known,  to  produce  diarrhoea.  Louis  found  that  this  symptom  began 
early  in  the  disease,  and  continued  through  its  whole  course,  in  one  out  of  every 
eight  patients  ;  and  in  one  case  only  in  every  twenty-two  was  it  wholly  wanting.  It 
depends  most  commonly,  if  not  always,  upofi  scrofulous  ulceration  in  the  small  intes- 
tines and  in  the  colon.  In  Louis'  experience,  there  w-ere,  invariably,  large  ulcers, 
whenever  the  diarrhoea  had  been  chronic  and  abiding,  and  the  stools  had  been 
numerous.  In  the  small  intestines  the  ulceration  evidently  commences  in  the 
mucous  follicles  ;  the  glandulse  solitarias,  or  the  glandulse  agminatase  ;  and  sometimes, 
though  not  often,  the  ulcer  perforates  the  bowel.  It  is  probable  that  in  the  large  in- 
tesune  ulceration  begins  in  the  same  waj',  by  the  deposit  of  tubercular  matter  (which 
is  subsequently  removed)  in  the  sohtary  glands  :  but  when  once  begun  the  ulceratino- 
process  extends  itself  indefinitely  to  the  surrounding  mucous  membrane. 

I  should  have  stated  before  that,  with  this  disease  of  the  intestinal  canal,. there  is 
often  found  enlargement  of  the  corresponding  glands  of  the  mesentery,  which  are 
frequently  filled  also  with  tubercular  matter. 

Several  of  the  symptoms  that  I  have  been  mentioning — the  state  of  the  digestive 
organs,  which  interferes  with  the  due  assimilation  of  the  food  ;  the  drain  implied  in 
the  profuse  sweats,  and  in  the  habitual  diarrhea ; — conduce  to  cause  another  con- 
stant accompaniment  of  phthisis  ;  and  that  is  emaciation. — You  know  that  the  wasting 
in  this  complaint,  when  it  is  not  cut  short  by  some  accidental  complication  before  it  has 
reached  what  may  be  called  its  natural  termination,  is  extreme.  It  often  is  one  of 
the  earliest,  as  it  is  one  of  the  most  alarming,  of  the  symptoms  which  the  patient 
presents  ;  and  it  frequently  becomes  excessive  before  any  perspiration  or  purging 
have  taken  place  to  account  for  it.  If,  without  any  apparent  cause,  a  person  grows 
thin  and  his  pulse  is  quick,  and  his  breath  at  all  siiort — these  are  intimations  which 
seldom  prove  unfaithful,  that  tubercular  disease  is  at  work  in  the  lungs,  and  in  the 
abdomen. 

(Edema  of  the  ankles,  and  even  some  pufHp.:ss  of  the  hands  and  face,  are  circum- 
stances which  seldom  fail  to  appear  in  pulmonary  consumption  :  but  they  are  among 
the  latest  of  the  symptoms.  (Edema  does  not  tell  us  what  the  disease  is  in  such 
cases.  We  have  been  satisfied  as  to  that  some  time  before.  But  (unless  there  is 
some  marked  disease  of  the  heart)  it  tells  us  that  the  disease  is  about  to  terminate. 
It  is  worth  attention  as  a  prognostic  symptom  merely. 

And  the  same  may  be  said  of  aphtha).  This  is  one  of  the  last  of  the  symptoms . 
but  it  does  not  always  occur  at  all.  I  have  lately  described  this  morbid  condition 
of  the  mucous  membrane  of  the  mouth  and  tongue,  and  have  nothing  more  to  say 
of  it  at  present.  It  has  the  same  relation  to  phthisis  as  to  other  chronic  disorders  : 
it  marks,  for  the  most  part,  the  approach  of  their  fatal  termination. 

It  is  always  interesting  to  couple  changes  of  structure  with  their  appropriate  signs. 
I  will  therefore  take  this  opportunity  of  telling  you  what  Louis  has  observed  of  this 
relation,  in  respect  to  the  larynx  and  windpipe. 

Ulceration  of  the  epiglottis  w'as  often  latent ;  gave  no  appreciable  signal  of  its 
existence.  The  symptoms  that  belong  to  it  are,  a  raw,  or  pricking,  or  burning  sen- 
sation at  the  upper  part  of  the  thyreoid  cartilage,  with  occasional  dysphagia,  and  the 
rejection  of  liquids  through  the  nose,  while  the  tonsils  and  pharynx  present  no  visible 
alteration. 

Ulceration  of  the  interior  of  the  larynx  is  marked,  when  slight,  by  trivial  pain  in 
that  part,  and  some  variation  from  the  natural  voice ;  when  deep,  by  severer  pain, 
and  abiding  aphonia. 

Ulceration  of  the  trachea  is  seldom  revealed  by  any  symptom.  And  this  is  worth 
remembering :  for  patients  are  continually  persuaded  by  medical  men  who  know  no 
better,  that  their  symptoms  are  all  tracheal. 

There  are  still  a  {e\\  other  circumstances  which,  when  they  occur,  accumulate 
conviction  as  to  the  nature  of  the  disorder.  The  catamenia  are  suspended  in  women  : 
and  the  hair  falls  ofl^.  There  are  certain  physical  peculiarities  too,  which  are  strongly 
indicative  of  a  tendency  to  consumption  ;  or  perhaps  I  should  say  of  the  scrofulous 
diathesis.  Largeness  of  the  pupil,  with  a  sluggish  iris — in  other  w-ords,  a  nof.  very 
sensible  retina — constitutes  one  of  these.     A  clubbed  state  of  the  ends  of  th«  fu'.gers 


PHTHISIS.  641 

with  convex  and  adunque  nails,  forms  another.  Yet  this  last  is  not  peculiar  to  tuber- 
cular consumption.  I  have  heard  of  one  case  in  which  it  was  strongly  marked  :  the 
patient  died  after  a  long  illness  —  chronic  puriform  discharge  from  the  pleura  after 
>aracentesis  thoracis  :  but  there  were  no  tubercles. 


LECTURE  LVII. 

Phthisis,  conlinued.  Diagnosis.  Forms  and  varieties  of  Phthisis.  Ordinary 
duration.  Age  at  which  it  is  most  frequently  fatal.  Influence  of  sex  ;  and 
of  occupation.     Question  of  Contagion.     Treatment. 

In  a  former  lecture,  the  twelfth  of  this  course,  I  entered  somewhat  fully  into  the 
pathology  of  scrofulous  and  tubercular  diseases  in  general.  I  pointed  out  the  fact, 
that  though  such  diseases  afftct  vast  numbers  of  persons,  and  are  most  extensively 
fatal,  yet  that  they  affect  almost  exclusively  certain  classes  of  persons.  That  while 
some  are  so  prone  to  tubercular  disease,  as  to  fall  into  it  upon  the  operation  of  the 
slightest  external  causes,  or  even  spontaneously — nay,  in  spite  of  every  care  to  the 
contrary  —  others,  again,  who  are  constantly  exposed  to  influences  likely  to  call 
scrofulous  disease  into  action,  either  do  not  suffer  therefrom;  or  if  they  do  become 
scrofulous,  it  is  only  when  the  external  circumstances  most  favourable  to  the  pro- 
duction of  such  disease  have  been  intense  in  degree  and  protracted  in  their  appli- 
cation. 

At  the  same  time  I  showed  you  how  commonly  the  disposition  to  scrofula  de- 
scends in  families :  and  I  told  you  what  observation  has  collected  in  respect  to  the 
causes  which  may  excite  scrofulous  disease  in  persons  hereditarily  disposed  to  it.  I 
shall  not,  therefore,  go  over  that  ground  again.  What  I  then  said  of  scrofulous  dis- 
ease in  general  is  true  of  tubercular  consumption  in  particular.  I  will  merely 
remind  you  that  these  exciting  causes  are  essentially  causes  of  debility.  Whatever 
tends  to  depress  the  vital  powers,  and  permanently  to  weaken  the  body,  tends  also, 
in  a  predisposed  frame,  to  engender  or  to  call  forth  this  fearful  and  most  destructive 
malady. 

With  respect  to  the  detection  of  tubercular  disease  in  the  lungs,  it  is  sometimes 
very  easy,  sometimes  extremely  difficult.  It  is  easy  when  the  tubercles  are  numerous, 
large,  or  far  advanced  :  difficult,  sometimes,  when  they  are  crude,  scanty  in  number, 
and  thinly  scattered,  and  individually  small.  In  the  latter  case  they  may  not  cause 
any  appreciable  deviation  from  the  natural  resonance  of  the  chest  on  percussion,  or 
from  the  natural  smooth  equable  rustle  of  the  breathing.  It  would  be  tedious  to 
travel  over  again  all  the  auscultatory  and  other  symptoms,  with  the  view  of  pointing 
out  their  bearing  upon  the  diagnosis.  I  touched  upon  that  point  incidentally,  when 
discussing  the  individual  symptoms,  in  the  last  lecture.  Many  of  the  symptoms  tell 
their  story  so  plainly  that  any  attempt  to  expound  or  interpret  them  would  be  quite 
superfluous.  One  or  two  cardinal  points,  however,  which  have  rather  been  hinted 
at  before  than  expressed,  I  may  just  advert  to. 

The  fact  that  tubercles  occupy  the  upper  part  of  the  lung  by  preference,  is  of 
great  moment  in  relation  to  the  diagnosis.  When  the  symptoms  are  equivocal ; 
when,  as  far  as  they  are  concerned,  the  case  may  either  be  one  of  chronic  bronchitis, 
or  of  tubercular  consumption  ;  a  careful  examination  of  the  superior  regions  of  the 
chest  will  often  decide  the  anxious  question.  The  sound  resulting  from  the  first 
gentle  tap  upon  or  beneath  the  clavicle,  often  rings  in  the  physician's  ear  the  knoll 
of  his  unfortunate  patient.  Even  unusual  distinctness  of  the  sound  of  e.rpiration,  if 
heard  at  the  summit  of  the  lung,  and  <2  fortiori  if  at  the  summit  of  one  lung  only, 
warrants  the  terrible  suspicion  that  tubercles  are  breeding  in  that  luntr.  It  may, 
indeed,  be  laid  down  as  a  rule,  which  is  diversified  with  but  few  exceptions,  that  if 
you  find  dulness  on  percussion  ;  or  coarse  or  insufficient  breathing;  or  undue  resa 
41  3d2 


642  PHTHISIS. 

nance  of  the  voice  ;  or  a  click  or  morbid  noise  of  some  sort  when  the  patient  respires, 
or  speaks,  or  coughs  ;  if  you  find  this  day  after  day  and  always,  between  the  clavicle 
and  the  mamma  in  front,  or  between  the  clavicle  and  upper  edge  of  the  scapula, 
over  the  top  of  the  shoulder,  and  nowhere  else ;  and  more  especially  if  these  devia- 
tions from  the  healthy  sounds  be  limited  to  one  side,  or  greater  on  one  side  than  on 
'.he  other,  or  different  in  quality  on  the  two  sides ;  you  may  set  the  case  down  as  a 
case  of  tubercular  phthisis.  On  the  other  hand,  if  in  the  same  parts  you  still  distin- 
guish all  the  natural  sounds  of  the  respiration,  and  can  still  obtain  a  clear  sound  on 
percussion,  you  are  not  to  condemn  the  case,  nor  to  despair  of  recovery,  whatever 
its  other  circumstances  may  be.  The  worst  symptom  certainly,  when  auscultatory 
signs  are  wanting,  is  haemoptysis. 

Incipient  consumption  is  most  liable  to  be  confounded  with  chronic  bronchitis. 
Yet  the  leading  features  of  the  two  are  well  contrasted.  The  morbid  sounds  belong- 
ing to  chronic  bronchitis  are  chiefly  audible  in  the  lower  lobes  of  the  lungs :  those 
of  phthisis  in  the  upper.  Some  degree  of  expectoration  attends  the  cough  of  bron- 
chitis from  the  first :  the  cough  of  phthisis  is  often,  for  a  long  while,  dry.  Simple 
bronchitis  is  not  accompanied  by  haemoptysis.  The  pain  that  occurs  in  bronchitis 
is  felt  beneath  the  sternum :  in  phthisis  pain  most  commonly  afiects  the  sides,  and 
the  space  between  the  shoulders.  It  is  enough,  I  trust,  to  have  drawn  your  atten- 
tion to  these  points,  without  dwelling  upon  them  longer. 

Dr.  Latham,  in  the  little  work  which  I  have  several  times  referred  to,  has  laid 
down  certain  distinctions  most  deserving  of  your  notice,  in  respect  to  the  various 
forms  of  phthisis.  This  portion  of  his  book  is  quite  original.  The  facts,  indeed, 
nave  long  been  known ;  but  they  have  never  before,  that  t  am  aware  of,  been  made 
so  instructive,  by  being  clearl}'^  disposed,  and  exhibited  in  their  proper  bearings. 

He  first  divides  phthisis  generally  into  two  forms,  which  he  calls  mixed  phthisis 
and  unmixed  phthisis.  And  he  illustrates  what  he  means  by  those  terms  very 
simply  and  skilfully.  He  takes  the  case  of  an  absorbent  gland  in  the  neck,  affected 
with  scrofulous  disease.  The  changes  which  are  liable  to  take  place  in  it  are 
wrought  before  our  eyes.  We  have  the  privilege  of  watching  them.  Now,  such  a 
gland  will  sometimes  enlarge,  in  consequence  of  the  deposition  of  tubercular  matter 
in  its  substance :  it  will  grow  large  and  hard  without  there  being  any  pain,  or  heat, 
or  redness,  observable ;  and  it  may  remain  in  that  state  for  weeks,  or  months,  or 
years. 

But,  in  the  majority  of  instances,  the  absorbent  gland,  after  remaining  for  a  certain 
time  in  this  condition,  will  undergo,  and  cause,  other  changes.  Pain,  heat,  and  red- 
ness, will  ensue;  the  hard  gland  will  soften;  the  integuments  will  grow  thin,  and 
at  length  give  way  ;  the  softened  tubercular  matter,  mingled  with  pus,  will  escape  ; 
and  then  the  pain  and  heat  and  redness — the  inflammation,  in  short — will  disappear  ; 
and  the  abscess  will  heal,  leaving  behind  it  nothing  more  than  a  slight  scar.  This 
process  may  happen  to  one  such  gland,  or  to  more  than  one,  simultaneously  ;  or  to 
several  in  succession. 

In  this  case  there  has  been  no  more  inflammation  than  was  just  enough  to  accom- 
plish its  purpose  of  removing  from  the  body  the  tubercular  matter.  The  inflamma- 
tion has  not  transgressed  what  Dr.  Latham  has  called  its  specific  limit. 

But  again  it  may  go  beyond  that  limit ;  it  may  be  both  more  severe  and  more 
extensive  "than  is  necessary  for  the  removal  of  the  tubercular  matter  in  the  diseased 
gland.  It  may  pervade  the  whole  neck,  giving  rise  to  diflused  redness,  and  swell- 
nig,  and  pain ;  and  the  whole  of  the  subcutaneous  areolar  tissue  between  the  angle 
of  the  jaw  and  the  clavicle  may  be  loaded  with  effused  serum  and  pus. 

All  this  you  may  see  almost  any  day  in  the  wards  or  waiting-rooms  of  a  hospital. 
And  Dr.  Latham  has  happily  chosen  this  affection  of  the  cervical  glands  to  elucidate 
what  happens  when  the  tubercular  matter  is  deposited  in  the  lungs,  where  one  can- 
not see  the  changes  it  is  suffering  or  producing. 

Tubercles  in  the  lungs  may  remain  for  an  indefinite  period  of  time,  in  their  crude 
state  ;  never  softening  at  all,  or  softening  only  at  a  very  late  period.  Or  they  may 
give  rise  to  just  so  much  of  inflammation,  and  no  more,  in  the  pulmonary  tissue  sur- 
rounding them,  as  is  sufficient  to  bring  about  their  own  softening  and  subsequent 


PHTHISIS.  643 

expulsion.  Or,  lastly,  the  tubercles  may  excite  much  more  mflammation  of  the  lung 
around  them  than  is  requisite  for  their  elimination  :  inflammation  of  every  degree, 
and  of  any  extent. 

Now,  to  the  first  two  cases,  when  they  occur,  he  gives  the  name  of  unmixed 
phthisis  :  the  third  he  calls,  on  the  other  hand,  mixed  phthisis.  We  learn  from  aus- 
cultation whether  the  case  be  one  of  mixed  or  unmixed  consumption  ;  i.  e.,  we  hear, 
in  the  unmixed  forms,  the  sounds  or  modifications  of  sound  which  result  from  the 
presence  of  tubercles  or  of  vomicEe  ;  and  we  hear  these  morbid  sounds  only  :  in  every 
part  of  the  lung  where  they  are  not  audible,  we  hear  the  vehicular  murmur  of 
health.  But  in  the  mixed  form  we  also  hear  these  sounds.  True,  and  we  hear  other 
morbid  sounds  beside.  The  tubercular  disease  is  mixed  with  common  inflamma- 
tion ;  and  we  hear  the  sounds  that  denote  common  inflammation  of  the  mucous 
membrane,  or  of  the  substance  of  the  lung — sibilus,  or  large  or  small  crepitation — 
we  hear  these  sounds  mixing  themselves  with  the  sounds  which  belong  to  the  tuber- 
cular affection. 

This  distinction  is  of  considerable  importance,  for  it  concerns  the  treatment  of  the 
malady.  The  tubercular  disease,  when  established,  is  beyond  our  power.  The  inflam- 
mation which  is  incidental  to  it,  we  may  hope  to  alleviate  or  to  remove.  It  is  in  the 
stage  of  vomicae  that  the  disease  commonly  assumes  the  mixed  character;  and  some- 
times the  bronchial  or  vesicular  effusion  upon  which  the  added  sounds  depend,  may 
be  got  rid  of  by  the  seasonable  application  of  a  few  leeches,  or  of  cupping-glasses, 
or  of  a  blister,  or  by  a  moderate  bleeding  from  the  arm,  and  the  disease  be  brought 
back  again,  for  a  time  at  least,  within  its  specific  limits,  and  the  patient  be  relieved 
from  much  distress  and  imminent  danger.  It  is  upon  this  principle  that  Dr.  Latham 
explains  the  fact  that  most  consumptive  patients  improve  considerably,  soon  after 
their  admission  into  the  wards  of  a  hospital.  The  poor  are  necessarily  much  ex- 
posed to  those  causes  which  tend  to  complicate  the  tubercular  disease.  The  tuber- 
cular disease  may  as  )^et  be  slight  and  limited ;  but  the  superadded  mischief,  the 
bronchial  and  vesicular  effusion,  may  be  immense  ;  and  this  being  submitted,  often 
for  the  first  time,  to  treatment,  upon  their  admission  to  a  hospital,  is  for  a  while 
removed. 

Now,  if  we  had  not  the  advantage  of  the  method  of  auscultation,  we  could  not 
ascertain  these  differences,  nor  detect  them  when  they  existed.  You  will  perceive, 
I  am  sure,  their  practical  importance. 

Of  course,  the  more  ready  the  surrounding  lung  is  to  take  on  inflammation — in 
other  words,  the  stronger  the  disposition  in  the  complaint  to  assume  the  mixed  cha- 
racter— the  more  rapidly  fatal  is  it  likely  to  be. 

But  of  the  unmixed  form  of  phthisis  Dr.  Latham  has  made  two  interesting  varie- 
ties ;  and  the  truth  of  the  distinctions  he  has  drawn  will  be  more  manifest  to  you,  the 
more  you  see  of  this  terrible  disease.  In  one  of  these  varieties  the  lungs  are  appa- 
rently tenanted  by  a  multitude  of  tubercles,  which  remain  crude  and  unaltered  for  a 
considerable  length  of  time.  In  the  other,  successive  crops  of  tubercles  appear  to 
form;  or  at  any  rate  the  tubercles  ripen  and  are  expelled  in  successive  crops;  and 
there  may  be  long  intervals  between  each  crop  and  the  next. 

Dr.  Latham  thus  describes  the  former  of  these  two  varieties : — "An  individual 
loses  the  complexion  of  health,  and  becomes  thin ;  he  coughs  a  little ;  but  perhaps 
he  has  no  notable  fever,  and  no  constant  acceleration  of  pulse."  Upon  auscultation 
of  his  chest,  it  is  found  that  there  is  dullness  beneath  one  or  both  clavicles,  or  about 
one  or  both  scapulae,  and  an  indistinct  respiratory  murmur  in  those  parts;  but  the 
vesicular  breathing  is  free  and  perfect  in  every  other  part  of  the  lung.  Here  we 
have  tubercles,  crude,  and  in  the  upper  lobe  alone  ;  and  this  state  of  things  may 
endure  for  years,  without  variation  ;  the  patient  remaining  always  a  great  valetudi- 
narian. "  To  such  a  patient  (says  Dr.  Latham)  it  is  a  continual  puzzle  why  he  does 
not  get  well.  He  consults  an  infinite  number  of  medical  men  ;  and  it  is  remarkable 
that  he  gets  no  comfort  or  satisfaction  from  those  who  understand  his  disease  the 
best,  and  the  greatest  comfort  and  satisfaction  from  those  who  understand  nothing 
about  it.  Those  who  know  what  it  is,  out  of  kindness  do  not  tell  him  the  truth ; 
and  they  cannot  asseverate  a  falsehood  stoutly  enough  to  carry  any  weight  with  it ; 


644  •  PHTHISIS. 

whereas  they  who  know  nothing  about  it  affirm  boldly  and  unhesitatingly  that  it  is 
all  stomach  ;  really  beheving  that  the  whole  and  sole  disorder  is  in  the  stomach,  and 
that  it  is  wiihin  the  reach  of  an  easy  cure." 

But  at  length — perhaps  after  a  very  long  period — vomicas  are  formed  ;  and  then 
the  patient  sinks  rapidly,  and  his  lungs  after  death  are  found  riddled  by  cavities  and 
stuffed  with  tubercles ;  but  every  part  of  them  not  occupied  by  tubercles  or  vomicae 
is  crepitant  and  healthy.  In  these  cases,  disease  lingers  long  in  the  crude  stage ; 
new  tubercles  are  added,  probably,  year  after  year ;  but  none  of  them  soften.  They 
do  not  excite  inflammation  in  the  lung  around  them.  You  recognise  the  presence 
of  the  tubercular  matter  by  the  ear ;  but  there  are  no  vomicas.  At  last  vomicae  are 
tbrmed,  many  at  the  same  time,  or  in  rapid  succession,  and  the  patient  presently 
succumbs. 

The  other  variety  of  unmixed  phthisis  may  be  just  as  protracted  as  this  ;  but  its 
character  and  progress  differ  materially.  In  the  former  case  the  patient's  condition 
was  one  of  invariable  ill  health ;  in  the  one  I  am  about  to  mention  he  has  fits  of  ill 
health,  and  fits  of  comparative  good  health.  He  spits  for  a  time  considerable  quanti- 
ties of  puriform  matter,  and  then  ceases  from  expectorating  altogether.  He  has  hectic 
fever,  and  then  throws  it  off',  and  then  suffers  it  again :  wastes,  and  recovers  his 
flesh,  and  again  loses  it.  .  You  will  find  such  cases  common  enough ;  and  in  these 
cases  the  morbid  sounds  will  be  correspondent  to  the  symptoms.  During  the  fits 
of  illness  you  will  hear  gurgling  respiration  or  gurghng  cough  at  the  apex  of  one  or 
noth  lungs :  and  during  the  fits  of  good  health  you  will  hear  cavernous  respiration, 
or  pectoriloquy,  in  the  same  parts  ;  but  ever}'where  else  you  will  hear  a  clear  sound 
of  vesicular  breathing.  Here  the  tubercular  matter  excites  just  enough  inflamma- 
tion around  it  to  achieve  its  own  expulsion,  and  no  more.  The  lung  is  destroyed 
bit  by  bit.  Fresh  portions  of  tubercular  matter  are  deposited  ;  these  ripen  and  soften, 
and  are  expectorated,  and  a  vomica  is  the  result :  and  then  there  is  a  period  of  quiet. 
And  there  being  still  a  large  portion  of  each  lung  to  breathe  with,  the  patient  regains 
more  health  and  strength  in  the  intervals  of  his  attacks,  than  the  former  patient  pos- 
sessed habitually. 

But  in  this  form  of  unmixed  pulmonary  consumption,  a  period  at  length  arrives 
when  the  patient  does  not  revert  to  the  former  state  of  apparent  health.  The 
quantity  of  lung  that  has  now  been  destroyed  forbids  it.  You  may  hear  the  sounds 
proper  to  tubercular  disease  over  a  large  space,  between  the  clavicle  and  the 
mamma,  or  anywhere  about  the  scapula,  on  one  or  both  sides ;  yet  still  that  part  of 
the  lung  which  is  free  from  tubercles  and  vomicae  is  pervious  and  healthy :  but  the 
hectic  continues,  the  emaciation  increases,  and  the  strength  declines ;  and  the  fatal 
consummation  arrives. 

Of  these  two  varieties  of  genuine  and  unmixed  consumption,  the  first  is  the  most 
hopeless.  The  tubercles  are  numerous  ;  they  probably  go  on  increasing  in  number 
though  they  do  not  soften ;  there  is  not,  and  there  cannot  be,  any  even  temporary 
return  to  health,  either  real  or  apparent. 

Whereas  where  the  tubercles  come  singly,  or  in  successive  crops,  and  rapidly 
soften,  and  are  expectorated ;  and  where  some  long  time  interposes  between  the 
crops ;  the  health  and  strength  return,  and  there  is  just  a  chance  that  no  more 
tubercles  may  form.  It  is  in  this  variety  of  unmixed  phthisis  that  a  natural  cure, 
by  the  contraction  and  cicatrization  of  a  vomica,  may  by  possibility  take  place. 
VVe  cannot  expect,  and  we  must  not  permit  ourselves  to  encourage  hope,  that  the 
disease  ivill  cease  in  that  manner :  but  if  it  ceases  in  any  form  of  the  malady,  it  is 
in  this. 

[In  regard  to  the  curability  of  pulmonary  consumption,  Dr.  Wood,  in  his  Treatise  on  the 
Practice  of  Medicine,  vol.  ii.,  p.  109,  remarks,  as  follows : — 

"  I  am  not  one  of  those  who  believe  that  phthisis  is  in  all  cases  necessarily  fatal.  On  the 
contrary,  I  believe  that,  in  one  stage  or  another,  it  is  occasionally  cured,  or  at  least  ends  in 
perlect  recovery.  It  is  no  very  unfrequent  event  to  see  threatening  symptoms  of  phthisis 
ffive  way  under  suitable  treatment.  It  cannot  be  proved,  with  absolute  certainty,  that  these 
symptoms  were  tuberculous ;  because  the  evidence  of  dissection  is  wanting,  and  the  phy- 
eical  signs  are  not  sufficiently  positive,  in  mild  cases  of  early  phthisis,  to  authorize  a  certain 
conclusion.     But  they  are  undistingtiishable  from  symptoms,  which,  in  oth'  i   cases,  are  the 


PHTHISIS.  645 

forerunners  of  confirmed  phthisis;  and  we  have  abundant  evidence  from  dissection,  that 
tubercles  are  capable  of  undergoing  favourable  modifications.  The  probability  is,  that  the 
tuberculous  matter  is  absorbed,  and  sometimes,  as  shown  by  dissection,  replaced  by  calcare- 
ous matter :  and,  if  the  diathesis  be  so  far  subdued  as  to  prevent  the  deposition  of  other  tu- 
bercles, before  these  have  completely  run  their  course,  the  disease  may  be  said  to  be  cured 
The  circumstance  that  such  remains  of  tubercles  are  not  unfrequently  found  in  the  lungs  of 
old  persons,  who  have  died  of  other  diseases,  would  seem  to  show,  that  these  cures  are 
sometimes  permanent. 

"  But  this  is  not  all.  It  occasionally  happens,  that  consumptive  symp^toms  disappear  en- 
tirely even  in  the  second  stage  of  the  disease,  after  the  formation  of  a  cavity.  This  event,  it 
is  true,  is  comparatively  rare ;  but  some  such  cases  have  probably  fallen  within  the  notice  of 
almost  every  practitioner  of  extensive  experience.  Even  should  the  disease  ultimately  return, 
still,  the  case  may  be  said  to  have  been  cured ;  as  the  occurrence  of  a  second  attack  of  pneu- 
monia is  certainly  no  proof  that  the  first  was  not  cured.  But  there  have  been  cases  in  which 
no  return  of  the  symptoms  has  taken  place  during  the  residue  of  life,  even  though  consider- 
ably protracted.  Two  instances  of  this  kind  have  occurred  in  medical  men  of  this  city. 
One  of  the  patients  was  affected,  when  a  young  man,  with  all  the  symptoms  of  phthisis, 
including  frequent  attacks  of  hjemoptysis,  severe  cough,  hectic  fever,  &c.,  from  which  ho 
completely  recovered,  and  continued  exempt  up  to  the  time  of  his  death,  which  occurred 
many  years  afterwards  of  typhoid  fever.  (See  N.Am.  Med.  and  Surg.  Journ.,  viii.  277.)  The 
other  was  my  preceptor  and  friend,  the  late  Dr.  Joseph  Parrish,  who  in  early  life  laboured 
for  a  time  under  the  symptoms  of  phthisis,  and  after  his  death,  at  an  advanced  age,  was 
found  to  have  several  cicatrices  of  the  upper  part  of  one  lung,  which  were  obviously  the 
remains  of  tuberculous  cavities.  (See  jlm.  Jour,  of  Med.  Sci.,  xxvi.  25G.)  The  probabilities 
upon  tlie  whole  are,  that  each  tubercle  has  a  tendency  towards  health,  and,  if  alone,  would 
in  time  end  in  perfect  recovery;  so  that  the  great  fatality  in  phthisis  consists  in  the  continued 
predisposition  which  causes  the  constant  or  frequently  repeated  deposition  of  other  tuber- 
cles, before  those  first  deposited  have  had  time  to  run  a  favourable  course.  We  may,  there- 
fore, always  entertain  some  hope,  if  applied  to  in  the  early  stage,  in  cases  of  no  great  se- 
verity, of  seeing  a  cure  efiected ;  and,  even  in  the  second  stage,  when  the  diathesis  is  not 
very  strong,  or  the  local  disease  extensive,  there  is  no  reason  for  absolute  despair.  Even  in 
cases  which  appear  to  offer  no  chance  of  ultimate  recovery,  we  may  hope  to  be  able  very 
much  to  prolong  the  duration  of  the  complaint,  and  sometimes  even  to  add  years  to  a  valua- 
ble life.  There  is  an  individual  now  pursuing  an  active  business  in  Philadelphia,  though 
with  a  cavity  in  his  lung,  who  eight  years  since  was  under  my  care  with  severe  cough,  co- 
pious purulent  expectoration,  night-sweats,  hectic  paroxysms,  and  great  emaciation  and  debi- 
lity. When  the  second  stage  is  clearly  established,  with  severe  constitutional  symptoms,  and 
the  physical  signs  of  extensive  disease  in  the  lungs,  there  is  scarcely  any  ground  for  hope. 
If  to  the  ordinary  s)a-nptoms,  in  such  instances,  are  suj^eradded  continued  vomiting  and 
diarrh(Ea,  the  case  may  be  considered  as  quite  desperate ;  and  speedy  death  may  be  ex- 
pected."— C] 

This  grouping  of  the  different  characters  under  which  puhnonavy  consumption 
may  appear,  has  been  performed  by  Dr.  Latham  with  perfect  fidehty.  There  is 
nothing  overstrained  or  fanciful  about  his  sketch;  it  is  after  nature  ;  and  it  is  by  tlie 
hand  of  a  master.  And  there  is  something  very  refreshing  in  original  views  of  this 
kind.  Vastly  more  instructive  too  they  are,  than  those  presented  by  a  dull  compi- 
lation. I  therefore  again  recommend  you  to  study  his  little  volume.  I  am  sure 
that  /  have  derived  much  useful  and  usable  knowledge  from  it ;  and  so  also 
may  you. 

There  is  another  form  still  of  tubercular  consumption  which  Dr.  Latham  has  not 
omitted  to  notice  ;  but  his  observations  on  this  form  are  not  so  new.  It  is  a  strikino-, 
but  not  very  common  form ;  and  it  is  sure  to  arrest  the  attention  of  the  practitioner 
when  it  does  occur.  I  have  met  with  three  or  four  examples  of  it.  The  phenomena 
are  of  this  kind.  The  patient  has  difficulty  of  breathing,  cough,  htemoplysis  per- 
haps, night-sweats,  and  much  hectic  fever :  the  symptoms,  in  short,  which  constitute 
the  acute  phthisis  of  some  authors.  But  if  you  listen  to  the  chest,  you  do  not  heat 
the  sounds  that  are  peculiar  to  phthisis  :  you  do  not  find  dullness  confined  to  the 
upper  lobes,  or  pectoriloquy,  or  gurgling  respiration :  but  you  rather  find  the  super- 
added sounds  which  accompany  mixed  phthisis ;  small  crepitation  all  over  thu 
lungs,  succeeded  by  an  absence  or  deficiency  of  the  proper  breathing  everywhere 
Meanwhile  there  will  be  none  of  the  expectoration  which  is  characteristic  of  phthisis 
In  short,  you  would  not  suppose  that  the  disease  was  phthisis  at  all.  Yet  it  must 
be  called  such,  for  after  death  you  find  the  lungs  thickly  bestrewed  everywhere  witb 


646  PHTHISIS. 

what  I  spoke  of  before  as  the  granulations  of  Bayle  ;  nascent  tubercles,  myriads  of 
them,  gray  and  minute  :  what  many  persons  call  miliary  tubercles.  The  tubercular 
matter,  from  some  cause  which  we  know  nothing  of,  is  thickly  and  uniformly  sown 
over  the  whole  of  the  air-passages,  or  throughout  the  entire  extent  of  the  lungs,  and 
its  sudden  presence  there  in  such  abundance  excit-es  inflammation,  which  masks  and 
conceals  the  specific  disease ;  and  the  true  nature  of  the  case  is  not  suspected  unti. 
after  the  patient's  death.  All  the  instances  that  I  have  seen — three  or  four  only  in 
number — were  supposed  by  me  to  be  cases  of  extensive  inflammation  of  the  lungs; 
and  so  indeed  they  were,  but  they  were  something  more.  The  tubercles,  doubtless, 
were  the  cause  of  the  inflammation ;  and  not  the  inflammation  the  cause  of  the 
tubercles. 

From  what  I  have  been  stating  you  will  perceive  how  difficult  it  is  to  say  what  is 
the  ordinary  duration  of  phthisis ;  concerning  which  a  question  was  put  to  me  at 
the  close  of  the  last  lecture.  The  disease  may  be  present  for  some  time  v,-ithout 
declaring  itself  b)^  any  marked  or  unequivocal  symptoms ;  and  therefore  without 
attracting  attention.  But  taking  the  cases  as  thej'  occur,  and  estimating  the  duration 
of  the  malady  from  the  time  when  it  first  manifests  itself  in  a  decided  form,  we  find 
there  is  quite  enough  of  variation  to  warrant  the  distinction  that  has  been  made  by 
authors  between  chronic  and  acute  phthisis ;  or,  to  use  the  more  popular  and  more 
expressive  phraseology,  between  slow  and  galloping  consumption.  The  following 
tabular  statement  jf  the  results  observed  by  Bayle  and  Louis,  will  give  you  a  some- 
Vv'hat  more  precise  notion  of  the  general  progress  and  duration  of  the  disease.  The 
whole  number  of  cases  noted  was  314.  Of  these  24  died  within  three  months  ;  69 
between  three  and  six  months ;  69  also  between  six  and  nine  months ;  32  between 
nine  and  twelve  months  ;  43  between  twelve  and  eighteen  months ;  30  within  from 
eighteen  months  to  two  years  ;  12  between  two  and  three  years  ;  11  between  three 
and  four  years ;  5  between  four  and  five  years ;  1  between  five  and  six  years ;  3 
between  six  and  seven  years ;  1  between  seven  and  eight  years ;  3  between  eight 
and  ten  years;  and  11  between  ten  and  forty  years. 

You  will  remark  that,  as  far  as  this  account  goes,  more  than  one-half  of  the  whole 
number  died  within  nine  months  from  the  time  when  the  disease  first  became  mani- 
fest. This  agrees  with  the  experience  of  the  late  Dr.  Gregory,  of  Edinburgh.  He 
used  to  state  that  the  ordinary  duration  of  phthisis  was  about  six  months  ;  that  some- 
times it  lasted  onl}'  two  or  thvee  months ;  and  that  he  had  seen  one  case  which 
proved  fatal  on  the  seventeenth  day  after  the  sj'mptoms  were  first  observed.  On  the 
other  hand,  he  had  known  one  man  who  was  at  least  72  years  old  when  he  died,  in 
whom  symptoms  of  phthisis  first  appeared  at  the  age  of  18,  and  who  was  never 
free  from  them  during  all  the  intervening  period  ;  being  often  hectic,  and  frequently- 
spitting  blood.  The  average  or  mean  duration  of  consumption  has  been  computed 
to  be  about  two  years.  This  is  a  different  thing,  you  will  please  to  observe,  from  its 
ordinary  duration. 

There  are  many  other  points  in  the  statistical  history  of  phthisis  well  worthy  of 
attention  and  inquiry ;  but  I  have  not  time  to  go  into  them  in  any  other  than  a  sum- 
mary manner.  This  part  of  the  subject  is  very  well  worked  up  in  Sir  James  Clark's 
lucid  and  sensible  book  upon  Consumption :  but  you  will  have  perceived,  from  the 
references  I  have  so  frequently  had  occasion  to  make  to  M.  Louis,  that  his  work  is. 
the  great  storehouse  or  treasury  of  tabular  information,  in  respect  to  the  facts  of  tuber 
cular  phthisis. 

It  is  an  interesting  question  to  determine  at  what  period  of  human  life  consump- 
tion numbers  the  most  victims.  There  are  two  short  tables,  one  drawn  up  by  Louis, 
containing  observations  relative  to  123  cases,  and  the  other  by  Bayle,  respecting  100 
— which  throw  some  light  on  the  question.  The  two  tables  agree,  in  the  main, 
very  closely.  Thus,  from  the  age  of  15  to  that  of  20,  Louis  met  with  11  deaths 
from  phthisis,  Bayle  with  10;  from  20  to  30,  Louis  met  with  39,  and  Bayle  23; 
from  30  to  40,  Louis  83,  Bayle  23  ;  from  40  to  50,  Louis  23,  Bayle  21  ;  from  50 
to  60,  Louis  12,  Bayle  15 ;  from  60  to  70,  Louis  5,  Bayle  8.  You  see  from  this 
account  how  erroneous  the  common  notion  is,  that  consumption  does  not  occur  at  an 
advanced  period  of  life :  that  a  person  who  has  reached  his  thirtieth  or  fortieth  year 


PHTHISIS.  647 

IS  thenceforth  safe  from  that  disease.  From  these  two  tables,  and  others  collected 
by  Sir  James  Clark,  it  appears  that,  taking  decennial  periods,  the  greatest  number 
of  deaths  from  phthisis  happens  between  the  ages  of  20  and  30:  the  next  greatest 
number  from  30  to  40 :  the  next  from  40  to  50 :  and  that,  after  these,  it  is  a 
doubtful  matter  whether  more  perish  of  consumption  between  50  and  60,  or  between 
15  and  20,  which  last  is  only  one-half  a  decennial  period.  These  calculations  refer, 
as  you  will  remark,  to  human  life  after  the  age  of  puberty.  Before  that  age,  tuber- 
cular disease  is  fearfully  common,  especially  in  infancy  and  childhood.  Among  920 
children  (532  girls  and  388  boys)  who  died  from  the  age  of  2  to  that  of  15  years, 
no  less  than  538  (nearly  three-fifths  of  the  whole)  were  affected,  Dr.  Papavoine  tells 
us,  with  tubercles. 

As  far  as  numerical  observation  has  hitherto  been  extended,  it  would  appear  that 
more  women  than  men  die  of  consumption.  Statistical  researches  are  of  still  greater 
interest,  perhaps,  when  they  elucidate  the  influence  of  different  trades  and  occupa- 
tions in  calling  phthisis  into  existence.  Sir  James  Clark  has  brought  together  much 
curious  information  on  this  point.  There  are  certain  occupations  which  appear  to 
provoke  pulmonary  consumption  by  the  direct  application  of  local  irritants  to  the 
lungs  themselves :  and  there  are  others  which  tend  indirectly  to  bring  on  phthisis, 
by  lowering  the  tone  of  the  general  health  :  by  producing  debility  and  cachexia. 
But  these  two  causes  often  go  together:  and  it  is  difficult  to  estimate  with  accuracy 
their  separate  effect.  The  workmen  whose  employments  have  a  directly  irritating 
operation  upon  the  respiratory  organs,  are  stone-masons,  miners,  coal-heavers,  flax- 
dressers,  brass  and  steel  polishers,  metal-grinders,  needle-pointers ;  and  many  others 
who  of  necessity  inhale  during  their  labour  an  atmosphere  loaded  with  irritating 
particles  of  matter.  But,  then,  most  of  these  men  work  also  in  towns,  and  remain 
for  many  hours  day  after  day  in  a  constrained  position,  in  crowded  or  in  close  apart- 
ments. Moreover,  some  of  these  occupations,  being  sedentary,  and  requiring  no 
great  muscular  povv'er,  are  unfortunately  selected,  for  that  reason,  by  persons  who 
are  naturally  of  feeble  or  delicate  constitution.  On  the  other  hand,  butchers,  fisher- 
men,  and  their  families,  and  farm-servants,  are  said  to  be  comparatively  free  from 
phthisis.  Beddoes  ascribed  this  exemption  to  the  use  of  animal  food  by  these  classes; 
but  much  of  their  better  health  is  due,  no  doubt,  to  their  habits  of  active  exercise  in 
the  open  air ;  and  to  the  circumstance  that  such  employments  demand  a  certain 
amount  of  bodily  strength  and  energy,  and  therefore  are  not  likely  to  be  adopted  by 
weak  and  scrofulous  individuals.  It  is  obvious  that  the  whole  inquiry  is  beset  Avith 
sources  of  fallacy.  We  know,  however,  on  the  evidence  of  undoubted  facts,  that 
certain  occupations  do  tend  to  induce  pectoral  complaints,  and  to  shorten  life.  Dr. 
Knight,  of  Sheffield,  informs  us  that  fork-grinders,  Avho  are  what  are  called  dry 
grinders,  die  there  of  the  grinder'' s  asthma,  or  grinder'' s  rot,  before  they  are  thirty- 
two  years  old.  Razor-grinders,  who  grind  wet  and  dry,  live  a  little  longer :  the 
moisture  diminishes,  of  course,  the  number  of  floating  particles  of  metal.  Table- 
knife  grinders  work  on  wet  stones,  and  survive  till  they  are  between  forty  and  fifty. 
I  must  refer  you  to  Sir  James  Clark's  book  for  similar  facts  in  respect  to  the  inhala- 
tion of  silex,  of  the  dust  of  mines,  and  so  forth.  Without  pretending  to  assign  to 
each  alleged  injurious  influence  its  precise  contribution  of  mischievous  effect,  we 
must  be  content,  at  present,  with  the  practical  inference,  that  such  employments 
should,  if  possible,  be  avoided  by  all  those  who  show  any  tendency  to  scrofulous 
disease. 

Is  phthisis  contagions?  No  :  I  verily  believe  it  is  not.  A  diathesis  is  not  com- 
municable from  person  to  person.  Neither  can  the  disease  be  easily  (if  at  all)  gene- 
rated in  a  sound  constitution.  Nor  is  it  ever  imparted,  in  my  opinion,  even  by  one 
scrofulous  individual  to  another.  Yet  in  Italy  a  consumptive  patient  could  not  be 
more  dreaded  and  shunned  if  he  had  the  plague.  And  in  this  country  the  suspicion 
Will  now  and  then  arise  that  the  disease  may  be  infectious.  A  girl  dying  of  phthisi'! 
is  nursed  by  her  sister,  who  afterwards  droops  and  dies  of  the  same  complaint, 
Here  the  presence  of  peculiar  diathesis  is  strongly  presumable.  But  the  parties  may 
be  different  in  blood.  A  wife  watches  the  death-bed  of  her  consumptive  husband, 
and  presently  sinks  herself  under  consumption ;  and  there  may  be  no  traceable  or 


648  PHTHISIS. 

ncKnowledged  example  of  scrofula  in  her  pedigree.  Yet  even  here  the  latent  dia- 
thesis may  fairly  be  presumed  to  have  existed.  Very  few  families  are  perfectly 
pure  from  the  strumous  intermixture.  The  predisposition  may  be  slight;  it  may  be 
dormant  for  a  generation ;  or,  like  other  inherited  peculiarities,  it  may  light  caprici- 
ously on  some  individuals  only  of  the  kindred.  In  both  the  supposed  cases  there 
have  been  other  influences  at  work,  more  authentic  than  the  alleged  contagious  pro- 
perty, in  calling  forth  the  fatal  malady.  Watching,  the  want  of  rest,  confinement  in 
the  unwholesome  air  of  a  sick  chamber,  and,  above  all,  protracted  mental  anxiety, 
than  which  no  single  cause  perhaps  has  more  power  to  foster  and  forward  the  inbred 
tendency  to  phthisis.  The  disorder,  I  am  satisfied,  does  not  spread  by  contagion. 
Nevertheless,  if  consulted  on  the  subject,  I  should,  for  obvious  reasons,  dissuade  the 
occupation  of  the  same  bed,  or  even  of  the  same  sleeping  apartment,  by  two  persons, 
one  of  whom  was  known  to  labour  under  pulmonary  consumption. 

The  treatment  to  be  adopted,  and  the  plan  of  regimen  to  be  observed,  in  respect 
to  tubercular  phthisis,  resolve  themselves  into  the  methods  of  prevention  when  the 
disease  is  likely  to  occur  ;  of  arresting  its  progress  when  that  disease  is  incipient 
or  limited  in  extent;  and  of  alleviating  the  most  distressing  symptoms,  when  no 
hope  remains  of  stopping  its  course,  or  averting  its  fatal  close. 

With  regard  to  the  prevention  of  the  disease,  in  those,  who,  by  inheritance,  or  by 
circumstances,  are  predisposed  to  it,  a  great  deal  might  be  said ;  but  the  subject 
belongs  rather  to  the  head  of  medical  police,  or  hygiene,  than  to  the  practice  of 
physic.  We  deem  that  a  person  has  that  predisposition,  which  is  ahnost  a  neces- 
sary condition  of  the  development  of  tubercular  disease,  when  we  observe  those 
marks  of  the  scrofulous  diathesis  which  I  pointed  out  in  an  earlier  part  of  the  course  : 
or  when  we  know  that  the  parents  possess  that  peculiarity  of  constitution ;  or  when 
brothers  have  displayed  it.  It  would  be  well  indeed  for  society  if  the  multiplication 
and  diffusion  of  the  strumous  diathesis  could  be  checked  by  a  prudent  avoidance  of 
ill-assorted  marriages.  But  we  cannot  say — no  legislature  could  say — to  a  scrofu- 
lous man  or  woman,  you  shall  not  marry,  and  propagate  scrofula.  It  is  reasonable, 
however,  to  conclude,  and  the  conclusion  is  amply  borne  out  by  the  observation  of 
facts,  that  where  both  parents  are  strumous,  the  child  will,  in  all  probabiUty,  be 
doubly  so ;  or  that,  at  any  rate,  its  chance  of  escaping  the  scrofulous  disposition  will 
be  small.  It  is  very  desirable,  therefore,  that  correct  notions  on  these  subjects  should 
be  generally  prevalent :  and  that  persons  who  are  conscious  that  scrofula  in  any  of 
its  shapes  exists  in  their  family,  and,  a  fortiori,  they  who  know  that  it  exists  in  their 
own  corporeal  frame,  should  avoid  allying  themselves  with  such  as  are  in  the  same 
predicament :  and  this  prudence  might  be  enforced  if  they  could  be  made  to  foresee 
the  suffering  and  misery  its  neglect  is  calculated  to  inflict  upon  their  ofl^spring.  In- 
termarriages of  persons  of  the  same  family,  when  that  family  is  subject  to  tubercular 
disease,  are  earnestly  to  be  deprecated.  But  on  these  points  our  advice  is  seldom 
asked. 

We  are  liable,  however,  to  be  consulted  respecting  the  mode  of  ivarding  q^ scro- 
fulous disease  in  those  who  have  derived  an  hereditary  tendency  to  it  from  their 
ancestors.  Now  the  first,  and  most  efl"ectual  prophylactic  in  such  cases,  is  residence 
in  a  warm  climate :  and  next  to  that  is  the  avoidance  of  all  causes  likely  to  foster 
the  morbid  tendency.  I  need  not  repeat  what  I  formerly  told  you  on  this  subject. 
Pure  air;  nourishing,  but  unstimulating  food;  moderate  exercise;  early  hours; 
cleanliness;  warm  clothing;  and  abstinence  from  excessive  study,  from  severe  bodily 
toil,  and  from  vicious  and  exhausting  indulgences  of  all  kinds:  these  are  the  topics 
upon  which  we  much  insist,  when  our  advice  is  sought  for  respecting  the  means  of 
preventing  consumption  in  children  or  others,  who  are  in  danger  of  contracting  it. 

But  when  the  disease  is  present — when  tubercles  actually  exist,  and  are  ascer- 
tained to  exist  in  the  lungs — may  the  progress  of  the  disorder  be  ever  suspended  by 
a  change  of  climate  ?  Indeed  I  believe  it  may :  but  only  in  certain  cases,  and  in 
zertam  stages  of  the  disease.  When  phthisis  occurs  in  either  of  its  slow  and  un- 
mixed forms,  the  question  of  a  change  of  sky  will  be  worth  entertaining.  In  that 
form  in  which  tubercles  remain  long  in  the  crude  state,  I  believe  life  may  be  pre- 
served or  lengthened  by  leaving  this  country,  and  residing  under  a  higher  and  more 


PHTHISIS.  649 

equable  temperature,  provided  that  no  softening  of  the  tubercular  matter  has  yet 
taken  place.  And  in  the  other  form — when  a  vomica  or  vomicae  have  occurred,  and 
the  strength  is  apparently  restored,  and  the  remainder  of  the  lungs  gives  out  the 
sounds  of  health — in  that  case  also  I  would  recommend  a  voyage  to  a  milder  climate 
to  those  persons  who  could  afibrd  to  migrate,  and  to  whom  it  was  a  matter  of  im- 
portance that  they  should  prolong  their  earthly  existence.  I  believe  there  is  no  place 
to  which  such  persons  could  go  with  more  hope  of  benefit  than  to  Madeira.  There 
are,  however,  places  on  our  own  coast  that  offer  no  ineffectual  substitute  for  warmer 
lands  beyond  the  sea,  to  those  who  cannot  so  conveniently  expatriate  themselves. 
Hastings,  for  instance ;  the  Isle  of  Wight ;  and  more  especially  Torquay  on  the 
coast  of  Devonshire  ;  and  Penzance,  or  its  neighbourhood,  in  Cornwall.  In  those 
sheltered  spots  the  patient  may  sometimes  pass  the  colder  weather  of  our  winter  and 
spring  months  in  comparative  security.  If,  however,  the  lungs  are  already  in  a  state 
of  rapid  disorganization,  no  benefit,  but  on  the  contrary  much  inconvenience  and 
useless  expense  will  result  from  change  of  place,  unless  that  place  in  which  the 
patient  is  residing  be  notoriously  unhealthy.  When  I  am  asked  about  removal, 
either  to  another  country,  or  to  some  distant  part  of  our  own,  and  the  state  of  the 
patient  is  such  as  I  have  just  alluded  to,  I  always  advise  that  he  should  not  forego 
the  comforts  of  his  home  —  and  leave  his  family  and  friends  —  to  seek  advantao-e 
which  he  will  not  find,  among  strangers,  and  amid  the  discomforts  of  a  lodging  per- 
haps, or  an  incommodious  dwelling.  I  think  it  cruel  and  wrong  to  send  people 
away  merely  to  die :  and  that  many  are  so  sent  to  this  place  and  that,  in  the  almost 
certain  prospect  of  their  never  returning,  no  one,  I  think,  can  doubt. 

You  will  find  a  great  discrepancy  of  opinion  among  authors,  and  among  practi 
tioners  with  whom  you  may  converse,  in  respect  to  the  regimen,  which  consump- 
tive persons  should  follow.  One  man  gives  all  his  phthisical  patients  beefsteaks  and 
porter ;  another  restricts  all  his  to  vegetables  and  asses'  milk :  and  each  will  boast, 
and  bring  forward  most  triumphant  examples,  of  the  success  of  his  system.  Now  it 
is  quite  obvious  that  for  a  sick  person  who  receives  benefit  from  the  one  of  these 
plans  of  diet,  the  contrary  plan  could  scarcely  be  otherwise  than  injurious  ;  and 
reason  at  once  suggests  that  there  must  be  some  distinction  between  the  cases  that 
get  better  under  the  one  system,  and  those  that  improve  under  the  other.  Doubtless, 
we  must  have  regard  to  the  constitution  and  habits  of  the  patient ;  and  sometimes 
trial  alone  will  show  which  plan  is  the  most  beneficial;  but  I  beheve  the  best  clue 
to  lead  us  out  of  the  difficulty  will  be  found  in  Dr.  Latham's  division  of  phthisis  into 
mixed  and  unmixed.  The  object  is,  to  sustain  the  patient's  strength  without  excitino- 
inflammation  in  his  lungs.  If,  with  the  specific  disease,  there  be  conjoined  an  in- 
flammatory condition  of  the  pulmonary  substance  around  the  tubercles,  or  of  the 
bronchial  membrane ;  in  such  cases  an  antiphlogistic  diet  is  the  proper  one.  On 
the  other  hand,  when  the  disease  manifests  no  tendency  to  trangress  its  specific  limits, 
then  the  diet  should  be  generous  and  full:  and  it  may  be  so  without  being  over- 
stimulant.  Debihty,  however  induced,  adds  to  the  disposition  to  the  deposit  of  tuber- 
cular matter ;  and  therefore  the  debility  arising  from  insufficient  nutrition  is  to  be 
avoided  as  carefully  as  is  compatible  with  the  other  indication,  which  is,  to  obviate 
inflammation  of  the  lung.  With  these  hints,  you  will  be  able,  I  trust,  to  strike  the 
balance  between  the  risk  of  augmenting  the  local  mischief  directly,  on  the  one  Jiand, 
and  that  of  depressing  the  general  strength,  and  so  increasing  the  local  mischief  indi- 
rectly, on  the  other.  Milk  is  a  sort  of  animal  diet,  and  it  is  both  nutritious  and  un- 
stimulating;  therefore  milk  may,  in  many  cases,  form  the  staple  of  the  food,  if  the 
patient  hkes  it,  and  it  agrees  with  him :  but  there  is  much  variety  in  this  respect  in 
difierent  persons.  I  repeat,  that  you  will  too  often  find  prejudices  entertained,  on 
the  one  side  or  the  other,  in  regard  to  the  diet  proper  for  consumptive  persons  :  but 
the  commonest  error  of  the  two  is,  I  believe,  that  of  reducing  the  patient's  strength 
by  a  needless  restriction  of  his  nutriment,  lest  inflammation  should  ensue. 

Louis,  should  you  refer  to  him,  would  be  likely  to  lead  you  into  the  opposite  mis- 
take ;  for  he  affirms,  that  neither  bronchitis,  nor  pneumonia,  nor  pleurisy,  have  any 
effect  in  exciting  tubercular  phthisis.  But  this  opinion  is  quite  opposed  to  the  general 
sense  of.  most  men  of  experience.     Many  a  case  of  consumption  can  be  traced  back 

3e 


650  PHTHISIS. 

to  a  severe  catarrh,  and  no  further.  Many,  which  rar.  a  short  course,  were  dat»,'d, 
\\-ilhin  my  own  knowledge,  from  the  last  visitation  of  influenza.  If  M.  Louis  had 
meant  that  thoracic  inflammation  will  not  produce  tubercles  in  the  lungs  of  a  person 
who  has  not  the  scrofulous  diathesis,  and  that  tubercles  may  and  do  arise  without 
any  previous  inflammation,  I  should  quite  agree  with  him.  But  he  dryws  his  con- 
clusions from  cases  of  phthisis.  I  have  no  doubt  whatever  that  the  dormant  predis- 
position is  often  awakened  into  actual  disease,  and  that  latent  tubercles  are  often  : 
accelerated  in  their  progress,  by  inflammation  of  the  pulmonary  tissues.  Whether 
this  happens  directlj^  from  the  local  inflammation,  or  indirectly  from  its  effects  in 
lowering  the  vital  powers,  is  a  question  which  no  one  can  solve,  and  of  which  the 
solution  is  not  of  much  consequence.  What  we  are  sure  of  is,  that  every  one  who 
bears  a  real  or  suspected  taint  of  scrofula  in  his  frame,  should  scrupulously  guard 
against  every  known  and  avoidable  cause  of  catarrh,  pneumonia,  or  pleurisy.  I  hold 
M.  Louis's  doctrine  on  this  head  to  be  unsound  and  unsafe  :  and  I  mention  it  only  to 
admonish  you  against  it. 

In  offering  you  a  few  final  observations  on  the  remedies  of  phthisis,  I  shall  take 
leave  to  abstain  from  Aveighing  the  pretensions  of  a  number  of  specifics,  that  have 
from  time  to  time  been  highly  recommended  ;  but  which  never  have  come  into 
general  use,  as  they  would  have  done,  no  doubt,  if  they  had  been  entitled  to  such  a 
denomination. 

In  the  first  place  we  must  satisfy  ourselves  as  to  the  kind  of  case  we  have  to  deal 
with;  whether  it  be  mixed  or  unmixed.  We  must  watch  our  patient:  and  keep 
him  on  low  diet,  and  take  blood  either  in  small  quantities  from  the  arm,  or  by  leeches 
or  cupping  from  the  chest,  whenever  inflammatory  symptoms  arise;  whether  they 
are  discovered  by  observation  of  the  general  or  of  the  physical  signs.  The  bleedings 
must  of  course  be  small — and  palliative  only  of  the  symptoms. 

Emetics,  frequently  repeated,  have  been  recommended  in  the  early  stage  of 
phthisis  :  partly  on  account  of  their  reputed  efficacy  ;  partly  on  theoretical  grounds  ; 
it  being  supposed  that  the  tubercular  matter  may  be  thus  removed  from  the  mucous 
surfaces  as  fast  as  it  is  deposited.  Of  the  value  of  this  emetic  plan,  I  am  unable  tc 
speak  from  any  experience  of  my  own. 

Counter-irritation  is  often  of  undoubted  service :  mustard-poultices  to  the  chest 
when  it  is  painful;  or  a  blister  or  succession  of  blisters,  or  pustulation  by  tartar- 
emetic  ointment,  to  encounter  local  symptoms.  The  effect  of  counter-irritation  upon 
the  progress  of  the  tubercular  disorder  is  apparent  sometimes  by  accident.  Dr. 
Abercrombie  has  related  an  example  in  which  cerebral  disease  operated  in  this  way ; 
the  previous  symptoms  of  phthisis  disappearing.  In  some  cases  mania  seems  to 
have  a  similar  consequence,  obscuring  the  manifestations,  and  probably  retarding  the 
course,  of  consumption.  It  has  been  often  remarked — you  will  find  this  stated  by  Sir 
B.  Brodie — that  after  amputation  of  a  scrofulous  leg,  phthisical  symptoms,  very  little 
noticed  before,  have  rapidly  increased.  And  there  is  another  fact,  in  relation  to 
phthisis,  analogous  to  these,  which  it  is  fit  you  should  know  and  attend  to,  viz. 
that  the  progress  of  consumption  is  often  suspended  by  pregnancy : — and  when  a 
mother  is  suckling  her  child,  if  the  suckling  be  not  too  long  continued,  so  as  to  ex- 
haust the  mother.  I  suppose  there  is  no  doubt  that  women  disposed  to  phthisis  have 
been  kept  alive  by  successive  pregnancies  and  sucklings.  It  is  a  very  rare  thing 
for  a  pregnant  woman  to  die  of  phthisis.  I  have  known  only  one  instance  of  iL 
One  of  my  patients  in  the  hospital,  a  French  woman,  died  of  that  disease ;  and  we 
found  suppurating  tubercles  in  her  lungs  :  and  a  fostus  of  about  five  months  in  her 
womb. 

Riding  on  horseback  has  been  strongly  advised  in  the  earlier  periods  of  the  dis- 
ease. Its  main  advantage  seems  to  arise  from  its  allowing  the  enjoyment  of  fresh 
air,  and  of  exercise,  without  putting  the  patient  out  of  breath  ;  and  these  advantages 
are  great.  It  is  affirmed  that  many  phthisical  patients  remain  free  from  cough,  and 
those  affected  with  hfemoptysis  cease  to  spit  blood,  so  long  as  they  continue  to  take 
exercise  on  horseback.  Gestation  in  a  carriage,  or  in  a  boat,  has  the  same  good 
efl^jcts,  but  in  a  less  degree.     We  are  not  able,  however,  to  look  upon  equitation  as 


PHTHISIS  65] 

so  certain  a  cure  in  consumption  as  Sydenham  did,  who  says  that  riding  on  horse 
back  is  as  much  a  specific  in  phthisis,  as  the  Peruvian  bark  is  for  an  ague. 

Iodine  and  its  compounds,  and  especially  the  iodide  of  potassium,  ha\'e  been 
much  praised  of  late  years  for  their  reputed  efficacy  in  phthisis.  Given  in  small 
doses,  I  believe  that  they  often  have  a  beneficial  influence  upon  the  general  health. 
I  wish  I  could  tell  you  that  I  had  ever  known  them  operate  a  cure  of  the  manifested 
disease. 

Often — too  often — all  that  we  can  attempt  to  do  is  to  relieve  the  most  urgent  or 
distressing  symptoms,  and  to  make  easier  the  patient's  decline.  One  symptom 
which  is  both  distressing  and  weakening  is  the  nocturnal  perspiration.  The  com- 
mon remedy  for  this  is  the  dilute  sulphuric  acid  ;  and  a  very  good  remedy  it  is,  but 
it  is  not  equally  adapted  to  all  cases.  If  the  bowels  are  costive — or  if  the  bowels 
have  not,  as  they  often  have,  a  tendency  to  be  relaxed — then  the  sulphuric  acid  may 
be  freely  given  ;  and  it  will  often  have  very  good  results.  It  may  be  exhibited  three 
or  four  times  a  day,  in  doses  of  from  twelve  to  twenty  minims.  But  when  this  fails, 
or  when  the  bowels  are  irritable  and  will  not  bear  it,  we  must  have  recourse  to  other 
means.  One  of  these  is  sponging  the  surface  of  the  body  at  bed-time,  or  before  the 
patient  settles  himself  for  the  night,  with  tepid  vinegar  and  water;  using  twice  as 
much  Avater  as  vinegar.  And  if  the  bowels  are  at  the  same  time  purged,  I  fiind  the 
compound  kino  powder  of  the  Pharmacopoeia  an  admirable  medicine.  It  certainly 
has  much  power  over  the  perspiration ;  and  it  has  these  further  advantages,  that 
(containing  opium)  it  tends  to  control  the  diarrhcea,  and  to  calm  the  cough. 

Steel  is  another  substance  which  exercises  a  marked  influence  sometimes  over  th' 
hectic  fever.  It  was  its  efficacy  in  this  way  that  gave  celebrity  to  the  famous  ant: 
hectic  mixture  of  Dr.  Griffith,  the  Mistura  Ferri  Composita  of  the  Pharmacopogis. 
Certain  it  is,  that  when  steel  is  borne  in  the  advanced  stage  of  consumption,  it  often 
docs  a  world  of  temporary  good ; — but  in  many  cases  it  is  not  borne  vvell.  It  in 
creases  the  cough,  occasions  headache,  and  distresses  instead  of  reheving  the  patient. 
Nor  is  it  always  easy  to  say  beforehand,  whether  it  is  likely  to  suit  the  case  or  not. 
I  apprehend  it  will  at  length  be  found  most  applicable  to  the  unmixed  forms — the 
uninflammatory  forms,  that  is — of  phthisis.  I  have  frequently,  however,  succeeded 
in  checking  the  wasting  sweats  by  the  tindura  ferri  miirialis,  given  in  doses  of 
twenty  minims  thrice  a  day,  after  other  expedients  had  failed  me. 

When  the  cough  is  very  troublesome,  and  especially  when  it  breaks  the  patient's 
rest  at  night,  we  must  endeavour  to  quiet  it ;  and  there  is  no  drug,  I  fear,  that  wc 
can  depend  upon  for  that  purpose,  but  opium.  The  old  paregoric  has  been,  and  is, 
a  favourite  form  for  giving  opium  to  appease  cough  ;  and  old-fashioned  apothecaries 
will  tell  you  that  the  alteration  which  was  made  by  leaving  the  aniseed  out  of  this 
compound  tincture  of  camphor,  in  the  last  Pharmacoposia  but  one,  impaired  its  effi- 
cacy. Whether  it  was  so  or  not,  I  cannot  tell ;  but  Dr.  Prout  is  of  opinion  that 
aniseed  has  considerable  power  in  allaying  the  irritation  on  which  the  cough  depends. 
He  infuses  three  drachms,  or  half  an  ounce,  of  the  bruised  seeds  in  half  a  pint  of 
distilled  water  at  a  temperature  not  exceeding  120°,  and  lets  it  stand  till  it  is  cold. 
On  his  strong  recommendation  I  have  tried  this,  as  a  vehicle  for  paregoric,  when  the 
same  dose  in  other  vehicles  had  failed  ;  and  I  must  say  that  it  has  frequently  been 
followed  by  a  marked  abatement  of  the  frequency  and  violence  of  the  cough.  The 
aniseed  is  restored  in  the  paregoric  of  the  last  Pharmacopeia,  that  of  1836.  Hy- 
drocyanic acid  has  sometimes  a  very  soothing  effect  upon  this  harassing  symptom. 
However,  at  last,  opium  will  be  found  our  sheet-anchor,  not  merely  for  the  cough, 
but  for  the  diarrhoea  which  is  so  seldom  absent  in  the  later  periods  of  phthisis.  The 
diarrhoea  depends,  as  I  have  told  you,  upon  an  ulcerated  state  of  the  bowels.  In 
those  cases  in  which  it  could  scarcely  be  kept  in  check  at  all,  t  have  always  found 
very  extensive  ulceration  in  the  large  intestines ;  but  the  diseased  condition  is  often 
seated  higher  up,  in  the  ileum  or  jejunum.  Catechu  is  of  great  service  in  these 
cases,  combined  with  laudanum  and  with  the  officinal  chalk  mixture ; — or  a  few 
grains  of  the  confectio  opii  may  be  given  in  peppermint  water,  after  every  loose 
evacuation ;  or,  in  obstinate  cases,  a  pill  composed  of  a  quarter  of  a  grain  of  the 
sulphate  of  copper,  and  the  same  quantity  of  opium,  will  often  answer  well,  thougli 


652  MELANOSIS 

it  sometimes  gripes.  I  mention  these  several  expedients,  for  you  will  often  require 
them  all.  The  injection  of  a  small  quantity  of  starch,  as  much  as  the  rectum  will 
receive  and  retain,  with  ten  or  twenty  drops  of  laudanum,  generally  affords  the 
patient  most  sensible  comfort,  and  suspends  the  further  action  of  the  bowels  for  a 
considerable  time. 

These,  I  think,  are  the  principal  means  by  which  we  may  endeavour  to  smooth 
the  pillow  of  the  patient  dying  of  consumption.  Sometimes  very  httle  pain  or  dis- 
tress is  felt  at  all,  from  first  to  last ;  the  intellect  remains  free,  and  the  patients  are 
proverbially  sanguine  about  the  issue  of  their  disorder.  In  other  cases,  do  what  we 
will,  the  patient  suffers  greatly.  One  harassing  incidental  combination  of  symptoms 
is  nausea  and  vomiting.  I  should  have  stated  before,  that  when,  in  phthisis,  these 
symptoms  last  long,  and  are  accompanied  by  pain  and  tenderness  of  the  epigastrium, 
they  denote,  almost  always,  a  thinned  and  softened  condition  of  the  mucous  mem- 
brane of  the  stomach.  They  may  be  alleviated  by  a  few  leeches — by  a  blister — by 
the  effervescing  draught ;  or  the  prussic  acid  may  be  used  ;  that  is  a  medicine  which 
certainly  tranquillizes  an  irritable  stomach,  and  it  now  and  then  seems  to  allay  an 
urgent  cough.  Sometimes,  again,  the  bones  of  the  miserable  patient  are  laid  bare, 
in  consequence  of  pressure  upon  parts  in  which  the  circulation  is  already  very  feeble. 
We  cover  these  with  soap-plaster ;  take  off  the  pressure  by  arranging  cushions  ;  or, 
what  is  much  the  best  of  all,  we  put  the  patient  upon  the  water-bed,  invented  by  Dr 
Arnott. 


LECTURE  LVIII. 

Melanosis  of  the  Lung  ;  true,  and  spurious.     Accidental  intrusion  of  solid  sub' 
stances  into  the  air-passages. 

I  YESTERDAY  adverted  to  certain  callings  which  are  unhealthy  for  various  reasons, 
and  among  the  rest  for  this  :  that  the  work-people  engaged  in  them  breathe  habitu- 
ally an  atmosphere  loaded  with  particles  of  matter  which  clog  or  irritate  the  pulmo- 
nary tissues.  There  is  one  morbid  condition,  so  produced,  which  hitherto,  or  till 
lately,  has  scarcely  been  mentioned  by  writers  on  disease,  but  which  deserves  a  mo- 
ment's attention ;  for  although  it  is  very  uncommon  in  many  parts  of  this  country, 
it  is  by  no  means  rare  in  some  others.  The  texture  of  the  lungs  is  spoiled  by  mat- 
ters carried  in  with  the  air,  in  the  acts  of  breathing.  This  morbid  state  has  been 
called  spurious  melanosis.  The  lungs  are  found  after  death  to  be  throughout  of  a 
black  colour,  more  or  less  uniform.  Sometimes  the  pulmonary  substance  is  dry  and 
friable,  as  well  as  black  ;  sometimes  moist,  (Edematous,  infiltrated  with  an  inky  fluid  ; 
not  unfrequently  broken  down  into  irregular  cavities  of  various  sizes ;  and  thesi! 
cavities  are  often  full  of  the  same  black  liquor. 

You  are  not  to  confound  these  appearances,  when  you  happen  to  meet  with  them 
-—(and  as  you  will  probably  scatter  yourselves,  some  here  and  some  there,  over  vari- 
ous parts  of  the  kingdom,  some  of  you  are  very  fikely  to  meet  with  them)  you  must 
avoid,  I  say,  mistaking  these  black  appearances  and  products,  for  true  melanosis. 
The  disease  so  denominated  is  a  singular  one.  It  was  first  fully  described  and  named 
by.  Laennec  in  1806.  It  consists  in  a  morbid  product,  presenting  a  black  or  deep 
brown  colour  of  various  degrees  of  intensity,  moist  generally,  unorganized,  and  dif- 
fering in  the  form  it  assumes,  and  in  its  consistence,  according  lo  circumstances.  I 
shall  take  this  opportunity,  for  I  am  not  likely  to  have  a  better,  to  tell  you  the  little 
that  has  been  ascertained  in  regard  to  this  kind  of  disease ;  and  having  done  so,  I 
shall  revert  to  a  short  account  of  spurious  melanosis. 

These  black  deposits  take  place  most  frequently  of  all  in  the  areolar  tissue,  and  in 
the  adipous  tissue  :  and  they  occur  in  greater  abundance,  and  in  larger  masses,  ac 
cording  as  these  reticular  tissues  are  more  plentiful,  and  more  lax.  They  are  met 
^kh  also  m  the  compound  organs  of  the  body ;  especially  in  the  hver.     Less  fre 


MELANOSIS.  653 

quently  in  the  lungs.  Sometimes  in  the  eye.  Occasionally  m  the  brain.  The  serous 
membranes  are  obnoxious  to  the  same  kind  of  disease ;  the  mucous  very  little  so. 
The  black  or  dark-coloured  matter  may  also  exist,  in  a  liquid  condition,  in  the  natural 
cavities  of  the  body.  And  lastly,  the  melanotic  material  is  sometimes  mixed  up  with 
scirrhous  and  brain-like  malignant  tumours. 

With  respect  to  the  shapes  in  which  it  appears — it  is  sometimes  dotted,  the  sur- 
faces affected  by  it  looking  as  if  they  had  been  thickly  sprinkled  over  with  coal-dust 
or  soot.  But  more  commonly  melanosis  assumes  the  form  of  solid  tumours,  of  vari- 
able magnitude.  These  tumours  are  largest,  where  reticular  tissue  is  most  loose  and 
abundant.  They  may  be  no  bigger  than  a  pin's  head,  or  they  may  be  as  large  as  a 
man's  head.  Masses  of  this  kind  have  been  found  in  the  horse,  weighing  as  much 
as  six-and-thirty  pounds.  In  the  human  subject  they  may  attain  the  size  of  an 
orange.  These  large  tumours  (like  large  pulmonary  tubercles)  are  usually  formed 
by  the  union  and  agglomeration  of  several  smaller  ones,  and  hence  they  have  gener- 
ally a  lobulated  surface  :  while  the  shape  of  the  separate  smaller  tumours  is  naostly 
spherical.  Sometimes  the  areolar  tissue  lying  around  the  melanotic  masses  is  con- 
densed into  a  kind  of  cyst :  more  generally  the  black  matter  is  in  naked  contact  with 
the  tissue,  whatever  that  may  be,  in  which  it  is  lodged. 

From  the  serous  surfaces,  especially  from  the  pleura  and  peritoneum,  knobs  of  a 
dark  colour  are  seen  in  some  instances  to  project;  in  others,  the  round  tumours,  as 
big  as  peas,  or  cherries,  hang  from  these  surfaces  by  a  sort  of  peduncle.  The  omen- 
tum is  a  common  habitat  of  melanotic  tumours. 

Occasionally,  I  say,  the  black  matter  is  found  spread  in  a  continuous  layer  upon 
the  serous  membranes  ;  or  is  collected  in  a  liquid  state  in  their  cavities.  But  this, 
compared  with  the  occurrence  of  solid  tumours,  is  rare. 

When  this  remarkable  disease  is  met  with  in  one  tissue  or  organ  of  the  body,  it 
is  met  with  in  others.  It  is  never  confined  to  one  part,  but  pervades  several :  re- 
sembling in  this  respect  both  the  scrofulous  matter  which  constitutes  tubercle,  and 
the  matter  of  cancer.  Miiller  indeed  considers  melanosis  to  be  a  species  or  variety 
of  carcinoma. 

Scattered  notices  of  these  singular  and  striking  changes  in  the  animal  frame  occur 
in  the  works  of  Morgagni  and  of  Haller ;  but  since  the  period  when  Laennec  first 
drew  the  special  attention  of  the  profession  to  the  subject,  the  black  matter  has  been 
carefully  analyzed  by  several  expert  chemists.  Without  going  into  any  tiresome 
detail,  which  you  could  scarcely  remember,  as  to  its  exact  composition,  it  is  interest- 
ing to  know  that  it  is  very  like  that  of  the  blood  :  and  no  doubt  the  material  is  some- 
how deposited  from  the  blood.  Very  little,  however,  has  been  ascertained  about  its 
primary  origin  and  cause.  Some  have  supposed  that  the  melanotic  matter  is  ana- 
logous to  the  natural  pigments  which  are  found  in  the  animal  economy ;  all  of  which 
are  known  to  be  rich  in  carbon.  It  is  a  curious  fact  that  the  disease  has  been  more 
often  observed  in  white  or  gray  horses  than  in  others.  (I  should  tell  you  that  the 
complaini  is  not  at  all  uncommon  in  various  quadrupeds :  examples  of  it  have  been 
noted  in  ihe  horse,  ox,  dog,  cat,  rabbit,  rat,  and  mouse.)  It  has  been  conjectured  that, 
in  white  animals,  the  colouring  matter  of  the  surface,  and  of  the  hair,  has  been  di- 
verted, by  some  morbid  process,  from  its  proper  locahty.  But  the  very  same  disor- 
der occurs  also,  though  not  so  often,  in  dark,  or  bay,  horses  and  cows :  and  certain 
pathologists  imagine  that  in  these  cases  there  has  been  an  undue  accumulation,  in  the 
blood,  of  the  carbon  which  is  destined  to  colour  different  parts.  In  the  one  case,  you 
see,  they  hold  that  the  pigment  is  misplaced  ;  in  the  other  that  it  is  excessive.  What 
value  these  speculations  as  to  the  nature  and  origin  of  the  disease  may  posse^ss,  time 
alone  can  determine. 

When  the  tumours  are  divided,  and  moist,  or  when  they  are  rendered  moist  by 
admixture  with  water,  they  freely  impart  the  colouring  matter  ;  staining  white  paper, 
and  blackening  one's  fingers,  just  as  Indian  ink  might  do.  The  disease  most  fre- 
quently happens,  when  it  happens  at  all,  in  the  decUne  of  hfe. 

The  changes  to  which  the  melanotic  tumours  are  liable,  are  very  much  like  the 
changes  which  tubercular  matter  is  apt  to  undergo.  In  certain  situations  where  the 
secr^tjd  black  material  is  subject  to  pressure,  and  is  poured  out  in  a  soft  consistence 

3e2 


654  SPURIOUS    MELANOSIS. 

ihe  watery  parts  are  sometimes  absorbed,  and  the  rhass  becomes  hard  and  firm. 
On  the  other  hand,  the  pressure  occasioned  by  the  tumour  sometimes  provokes 
inflammation  in  the  tissues  surrounding  it ;  and  then  it  is  hable  to  be  broken  down, 
pxactl\-  in  the  same  way  as  that  in  which  tubercles  soften  prior  to  their  expulsion 
from  the  lungs. 

The  injurious  effects  of  these  collections  of  black  matter  arise  from  the  pressure 
they  occasion ;  and  they  may  evidently  thus  cause  pain,  irritation,  ulceration ;  and 
according  to  their  situation,  number,  and  extent,  they  may  materially  interfere  with 
important  functions.     And  in  this  manner  they  do,  in  fact,  at  length  destroy  life. 

There  are  no  symptoms  that  I  know  of,  distinctive  of  this  disease,  except  the  ap- 
pearance of  the  black  masses  upon  the  surface  of  the  body.  Nor  can  I  pretend  to 
point  out  to  you  any  cure  for  it,  when  it  is  ascertained  to  exist. 

Yet  it  is  right  that  you  should  be  aware  of  what  pathologists  have  learned  re- 
specting this  curious  morbid  state  ;  although  that  be  little,  and  not  very  satisfactory. 
And  I  have  introduced  this  brief  consideration  of  melanosis  here,  somewhat  irregu- 
larly, perhaps,  to  enable  you  to  distinguish  from  it  that  pulmonary  disease  to  which  I 
referred  in  the  outset  of  the  lecture,  and  to  which  I  shall  now  return.  This,  I  say, 
has  been  called  spurious  melanosis :  and  it  has  doubtless  been  mistaken  for  the  spe- 
cific disease  of  which  I  have  just  given  you  a  sketch ;  for  real  melanosis. 

It  is,  however,  a  very  difTerent  affection. 

Laennec  had  conjectured  that  certain  kinds  of  black  discoloration  of  the  lungs 
.vere  of  extraneous  origin ;  were  owing  to  the  introduction  of  black  matters  from 
without  in  che  process  of  respiration  ;  and  Mr.  Pearson,  in  this  country,  had  thrown 
out  the  same  idea.  But  this  was  first  ascertained  to  be  actually  the  case  in  Edin- 
burgh. Dr.  J.  C.  Gregory  had  a  patient  who  died  in  the  infirmary  of  that  city,  and 
whose  lungs  exhibited  the  following  appearances : — They  both  presented  one  uni- 
form black  carbonaceous  colour,  which  pervaded  every  part  of  their  substance.  The 
right  lung  was  broken  down,  in  its  upper  and  middle  lobes,  into  irregular  cavities ; 
and  the  walls  of  these  canities  were  black ;  and  they  contained  a  considerable  quan 
tity  of  a  black  liquid  like  ink.  Portions  of  the  pulmonary  substance  were  dense, 
hepatized,  and  friable.  The  rest  of  this  lung  was  (Edematous;  and  when  the  serum 
which  then  rendered  it  thus  cedematous  was  pressed  out,  it  also,  the  serum  I  mean, 
was  quite  black.  The  left  lung  was  infiltered,  in  the  same  manner,  with  black  serum. 
No  tubercles  could  be  detected.  The  bronchial  glands  were  not  enlarged,  but  they 
were  stained  of  the  same  sable  hue  as  the  substance  of  the  lungs.  No  other  organ 
of  the  body  presented  any  trace  of  this  black  discoloration. 

Dr.  Chrisiison,  who  is  known  to  be  a  very  exact  and  able  chemist,  undertook  an 
analysis  of  the  black  matter  contained  in  the  serum  expressed  from  these  lungs.  I 
shall  not  follow  out  the  details  of  his  researches  (you  may  read  them  at  length  in  the 
l(K)th  number  of  the  Edinburgh  Medical  and  Surgical  Journal),  but  content  myself 
with  stating  their  result.  And  I  may  state  it  in  Dr.  Christison's  own  words.  "In 
the  product  of  this  experiment  (he  says)  it  is  scarcely  possible  not  to  recognize  the 
ordinary  products  of  the  distillation  of  coal.  A  gas  of  the  same  quality  was  procured, 
and  likewise  a  naphthous  fluid  holding  in  solution  a  crystalline  principle,  analogous 
to,  if  not  identified  with,  naphthaline." 

Now  the  man,  whose  lungs  presented  the  appearances  I  have  described,  had,  for  the 
last  ten  or  twelve  j^ears  of  his  fife,  been  employed  in  the  coal-mines  at  Dalkeith.  He 
had  been  exposed,  therefore,  to  the  habitual  inhalation  of  coal-dust  into  his  lungs  in 
breathing :  and  taking  this  circumstance  in  conjunction  with  the  result  of  the  analysis 
of  the  black  matter  contained  in  the  lungs,  and  nowhere  else  throughout  the  body, 
we  cannot  doubt  that  the  carbonaceous  substance  so  abundant  in  these  organs  was 
introduced  from  without.  In  truth  we  have  now  a  large  amount  of  evidence  in 
proof  that  it  must  have  been  so.  In  the  twenty-first  volume  of  the  Medico-Chirur- 
gical  Transactions,  Dr.  William  Thomson  has  recorded  the  results  of  extensive 
inquiry  into  the  subject.  Thus  he  gives  ten  examples  of  black  sputa  going  along 
with  pulmonary  symptoms  during  life,  and  of  black  infiltration  of  the  lungs  disco- 
vered after  death  ;  and  of  the  ten  persons  who  were  the  subjects  of  these  observations, 
nme  had  been  engaged  in  working  coal-mines,  and  the  tenth  was  a  moulder  at  the 


SPURIOUS   MELANOSIS.  655 

Carron  iron-works.  He  gives  also  six  cases  of  black  infiltration  of  the  lungs,  all 
occurring  in  persons  exposed  to  the  inhalation  of  carbonaceous  matters  (one  of  them 
was  an  engineer,  and  the  others  were  all  colliers) ;  but  in  these  six  cases  there  had 
been  no  black  expectoration  noticed  during  life. 

That  such  carbonaceous  particles,  floating  in  the  atmosphere,  may  be,  and  must 
be,  and  actuall}^  are,  drawn  into  the  lungs  during  inspiration,  no  one  who  has  been 
long  in  this  smoky  town  can  doubt.  Many  persons  remark  that  they  expectorate 
during  winter,  and  while  in  London,  a  little  mass  or  two  of  dark  gray,  dirty  mucus, 
every  morning;  but  when  in  the  country,  in  the  summer,  the  mucus  so  spat  up  is 
transparent  and  clean.  So  I  have  noticed,  and  pointed  out  to  some  of  you,  that  the 
crachoirs  of  the  patients  in  the  hospital  often  bear  witness  that  there  has  been  during 
the  previous  twelve  hours,  one  of  our  dense  and  dirty  fogs,  which  come  with  an 
easterly  wind  and  bring  wnth  them  a  vast  quantity  of  blacks,  and  soot,  and  smoke. 
Immediately  after  the  prevalence  of  one  of  these  filthy  blankets  of  vapour,  we  find 
the  contents  of  each  of  the  httle  vessels  given  to  the  patients  whose  expectoration  is 
kept  for  inspection,  to  be  deeply  tinged  with  black.  And  I  had,  in  the  year  1832,  a 
patient  whose  sputa  were  remarkably  loaded  with  dark  matter.  He  came  into  the 
hospital  complaining  of  cough,  and  shortness  of  breath,  and  a  sensation  at  the  lower 
part  of  the  right  side  of  the  chest,  as  if  it  were  pierced  by  needles  ;  and  he  was  spit- 
ting a  considerable  quantity  of  thick  mucus,  which  was  almost  black.  Tliis  colour 
never  entirely  left  the  expectoration  while  he  remained  in  the  hospital ;  but  it  very 
greatly  diminished  in  proportion  as  his  ailments  were  relieved.  Now  this  man  was 
a  stoker  at  one  of  the  gas-works.  And  he  attributed  his  illness,  which  had  come  on 
gradually,  to  the  great  alternations  of  heat  and  cold  to  which  his  occupation  exposed 
him :  and  the  blackness  of  the  sputa  he  ascribed  to  the  continual  inhalation  of  coal- 
dust.     And  no  doubt  he  was  right. 

It  may  seem  strange,  if  the  inhalation  of  atmospheric  air  loaded  with  minute  par- 
ticles of  coal  or  other  carbonaceous  matter  be  sufficient  to  produce  this  remarkable 
condition  of  the  lungs,  and  the  characteristic  black  spit,  that  the  change,  and  its 
nature  and  cause,  should  not  have  been  earlier  made  out ;  considering  the  vast 
number  of  men  who  are  employed  in  our  mines  and  collieries.  It  appears,  however, 
that  a  great  repugnance  has  existed,  and  probably  still  exists,  among  the  labourers 
in  the  coal-mines,  to  allowing  their  dead  to  be  opened  and  examined.  And  it  ap- 
pears also  that  the  peculiar  state  of  the  lungs  which  I  have  been  speaking  of  is  pro- 
duced in  a  comparatively  small  number  of  those  who  are  so  employed.  The  precise 
cause,  why  some  are  thus  affected,  and  some  are  not,  is  yet  to  be  discovered.  Dr. 
Thomson  has  circulated  among  medical  men  residing  in  the  coal-districts,  a  fist  of 
queries  (which  he  gives  in  his  paper),  respecting  various  points  of  interest  in  relation 
to  this  pulmonary  condition  :  and  we  may  expect  to  obtain,  by  degrees,  more  exact 
information  about  it.  I  recommend  it  as  an  interesting  subject  of  inquiry  to  such 
among  you  as  may  have  opportunities  of  prosecuting  it.  It  has  been  conjectured 
that  the  specific  change  takes  place,  in  a  marked  degree,  only  in  lungs  that  were 
previously  unsound.  It  is  a  question  whether  the  cavities  met  with  in  the  pulmonary 
substance,  in  the  fatal  cases,  were  the  result  of  spurious  melanosis ;  or  of  the  explo- 
sion of  tubercular  matter  which  had  co-existed  with  the  melanotic  state.  It  is  a 
curious  circumstance  that  the  black  spit,  as  it  is  called  in  those  districts,  sometimes 
does  not  make  its  appearance  until  some  time  after  the  labour  in  the  coal-mines  was 
given  up.  Certainly  this  is  a  complaint  that  offers  several  interesting  points  of  re- 
search, and  requires  further  investigation. 

You  will  remark  that  the  spurious  melanosis  is  distinguished  from  the  true,  by  ita 
occurrence  in  those  persons  only  who  are  somehow  exposed  for  a  certain  length  of 
time  to  breathe  an  atmosphere  which  is  largely  encumbered  with  carbonaceous  par- 
ticles ;  whereas  true  melanosis  may  occur  in  any  locality.  The  spurious  discolora- 
tion never  affects  any  other  oro-ans  than  the  lungs  and  bronchial  glands ;  the  true 
black  deposit  of  melanosis  is  never  confined  to  a  single  organ  or  tissue.  Moreover,  the 
one  disorder  is  absolutely  beyond  remedy  ;  the  other,  as  soon  as  its  presence  is  ren- 
dered probable,  by  the  black  expectoration,  and  the  pulmonary  distress,  may  be 
tnitigited,  checked,  perhaps  gradually  cured,  by  removing  the  patient  from  the  ope 


656  INTRUSION    OF    SOLIDS 

ration  of  the  exciting  cause,  and  pursuing  such  other  measures  as  the  symptoms  may 
seem  to  require.  The  distinction  is  not  a  matter  therefore  of  mere  curiosity  :  it  bears 
upon  the  treatment  to  be  followed,  which  is  our  proper  business.  It  is  connected 
also  with  medical  police  or  hygiene,  which  w^e  should  all  of  us  cultivate  as  exten- 
sively as  we  may  :  as  a  science  intimately  related  to  our  strictly  professional  pursuits, 
and  to  the  welfare  of  the  community. 

Other  forms  of  disease,  unquestionably  cancerous,  occasionally  infest  the  lungs. 
Their  chief  symptoms,  when  the  malady  does  not  reach  the  surface  of  the  body 
result  from  the  pressure  which  the  carcinomatous  masses  exercise  on  the  parts  in  their 
neighbourhood.  I  shall  postpone  a  more  particular  consideration  of  these  efTects  of 
intra-thoracic  pressure,  until  I  come  to  aneurismal  tumours,  which  have  a  similar 
mechanical  influence. 

There  is  yet  another  affection  of  the  breath-machine,  to  which  I  must  briefly  direct 
your  attention  :  a  casualty  that  is  apt  to  befal  the  air-tubes.  I  said  nothing  of  this, 
indeed,  last  year;  but  having  since  witnessed  an  example  of  the  accident  to  which  I 
allude — the  entrance,  namely,  of  some  solid  substance  into  the  windpipe — 1  have 
thus  been  reminded  of  my  former  omission,  and  taught  at  the  same  time  the  neces- 
sity that  every  medical  man  should  have  well  considered  such  cases.  I  was  taken 
to  Kentish  Town,  in  the  autumn  (1837),  by  a  professional  friend,  to  see  a  child,  into 
whose  trachea  a  small  nail,  what  is  commonly  called  a  tack,  was  thought  to  have 
passed.  When  I  saw  the  boy,  he  seemed  to  have  nothing  the  matter  with  him  :  but 
he  had  been  subject,  ever  since  the  accident,  to  paroxysms  of  most  violent  choking 
cough;  alarming  the  parents  and  his  attendants  for  his  hfe,  There  was  good  reason 
for  concluding  that  the  nail,  which  was  missing,  and  which  he  said  he  had  swal- 
lowed, had  really  got  into  the  windpipe,  and  was  still  there,  or  in  the  lungs ;  and  the 
question  w^as  much  discussed,  what  ought  to  be  done  in  such  a  case?  The  result 
was,  that  nothing  was  done :  but  that,  after  the  lapse  of  several  weeks,  the  nail  was  at 
length  coughed  up. 

Now  there  are  some  interesting  points  arising  out  of  this  sort  of  mischance.  The 
instance  I  have  just  referred  to  will  probably  be  published  ;  and  therefore  I  dwell 
upon  it  the  less.  Dr.  Stokes  has  devoted  a  short  chapter  to  the  consideration  of 
foreign  bodies  in  the  air-passages :  and  examples  of  that  accident  are  more  common 
than  you  might  suppose. 

It  is,  at  first  sight,  a  surprising  circumstance,  that  a  solid  body  of  any  considerable 
magnitude  (a  molar  tooth  for  instance),  should  be  able  to  pass  at  all  through  the  nar- 
row chink  of  the  glottis.  But,  supposing  the  chink  to  be  plugged  by  the  sudden 
entrance  of  a  passing  substance,  just  at  the  commencement  of  a  forcible  endeavour 
to  inspire,  when,  of  course,  the  opening  is  at  the  widest,  that  substance  must  neces- 
sarily sustain,  as  the  chest  expands,  a  strong  degree  of  pressure  from  the  external 
atmosphere  :  strong  enough,  often,  to  force  it  through.  If  you  cork  a  bottle  that  con- 
tains air  only,  and  sink  it  sufficiently  deep  in  the  sea,  the  pressure  of  the  water  will 
push  the  cork  into  the  bottle.  The  condition  of  the  lungs,  in  the  case  supposed,  and 
the  condition  of  the  bottle,  are  analogous.  A  vacuum  beyond  the  plug  is  attempted 
by  the  act  of  inspiring,  and  obviated  by  the  displacement  of  the  plug,  inwards. 
There  are  no  such  powerful  forces  called  into  action  to  drive  the  intruding  substance 
out  again. 

The  matters  which  have  been  actually  thus  caught  in  the  rima  glottidis,  and 
forced  through,  are,  as  you  might  almost  expect,  oddly  various  in  kind.  Morsels  of 
food  :  the  stones  of  fruit ;  of  these  there  are  many  instances  :  teeth  ;  three  such  are 
referred  to  by  Dr.  Stokes  :  portions  of  bone  :  pebbles  :  a  piece  of  money  :  a  nut :  a 
nut-shell :  a  button :  a  musket  ball :  a  large  shot :  a  fragment  of  nutmeg :  iron 
nails :  kidney  beans :  ears  of  grass  or  corn ;  of  these,  four  examples  at  least  have 
been  noticed :  one  is  mentioned  by  Dr.  Stokes,  two  are  recorded  in  the  Gazette 
Medicate,  and  I  show  you  a  monument  of  the  fourth,  in  this  interesting  preparation, 
for  the  history  of  which  I  am  indebted  to  Mr.  Mayo,  The  young  son  of  an  English 
nobleman  was  riding  in  a  carriage,  in  or  near  Paris,  and  had  an  ear  of  rye  in  his 


INTO   THE   AIR-PASSAGES.  GST 

mouth.  The  carriage  made  a  sudden  jolt,  and  the  ear  of  rye  disappeared.  Little 
was  thought  about  this  at  the  time  :  but  soon  afterwards  symptoms  of  pulmonary 
irritation  set  in,  attended  with  hectic  fever,  and  with  the  most  foetid  expectoration. 
The  boy  gradually  sunk.  The  ear  of  rye  lay,  as  you  may  perceive,  in  an  abscess 
which  was  common  to  the  right  lung  and  to  the  hver,  through  the  diaphragm. 

If  any  of  you  have  tried  the  boyish  trick  of  slipping  boiieath  your  wristband  an 
ear  of  bearded  corn,  you  will  have  no  difhculty  in  understanding  how  and  why, 
with  every  movement  of  the  parts  in  contact  with  it,  the  ear  will  travel  onwards ; 
and  how  improbable  it  is  that  such  a  substance  should  ever  be  expelled  from  the 
lungs  by  coughing.  Yet,  in  one  of  the  cases,  recorded  in  the  Gazette  Mklicale,  by 
a  physician  whose  sister  was  the  subject  of  the  accident,  an  ear  of  barley  was  so 
rejected,  seven  years  after  its  entrance.  During  that  long  period  she  had  suffered 
repeated  attacks  of  copious  hfemoptysis.     Her  recovery  was  perfect. 

The  very  enumeration  which  I  have  just  made  may  convince  you  that  the  acci- 
dent is  not  a  very  unfrequent  one ;  and  it  is  more  than  probable  that  fatal  cases  hap- 
pen, the  nature  of  which  escapes  detection. 

The  results  of  the  accident  are  various  also. 

In  the  first  place,  it  sometimes  causes  speedy  death  by  apnoea. 

2dly.  It  may  be  followed  by  inflammation  of  the  lung,  and  perhaps  abscess ;  and 
so  destroy  life. 

3dly.  Death  may  ensue,  after  symptoms  resembling  those  of  chronic  phthisis. 

4thly.  The  "  foreign  body,"  as  we  oddly  enough  call  it,  may  be  expelled  through 
the  glottis,  after  a  variable  period  of  time.  Sometimes,  yet  not  always,  its  expulsion 
is  the  condition  and  the  harbinger  of  the  patient's  recovery ;  but  he  is  never  safe 
while  it  remains. 

Death  may  take  place  in  a  few  seconds  when  the  substance  sticks  in  the  glottis. 
Death  has  occurred  within  three  days,  when  the  substance  had  passed  the  glottis : 
and  in  eleven  days  when  it  had  reached  the  lung.  The  intruding  piece  of  matter 
has  escaped,  through  the  natural  passages,  after  remaining  imprisoned  for  seventeen 
years.  In  that  case,  the  patient  died,  hectical  and  emaciated,  a  year  and  a  half 
afterwards. 

It  may  be  worth  our  while  to  consider  these  particulars  somewhat  more  closely ; 
and  to  inquire  what,  in  different  cases,  becomes  of  the  foreign  body  which  thus,  to 
use  a  common  phrase,  "  goes  the  wrong  way ;"  and  what  the  symptoms  are  to 
which  it  gives  rise. 

First,  then,  I  say,  it  may  get  wedged  in  the  slit  of  the  glottis,  and  produce  imme- 
diate suffocation.  I  mentioned,  before,  the  frequency  of  this  kind  of  death  by  mis- 
adventure. If  you  are  summoned  to  any  one  whom  you  find  comatose,  or  apparently 
just  dead,  and  you  learn  that  he  had  been  suddenly  attacked  with  choking  during  a 
rneal,  lose  no  time  in  examining  his  pharynx  and  gullet.  You  may  chance  to  save 
a  life  so.  The  accident  often  happens  to  persons  who  ar.e  drunk.  No  doubt  it  hap- 
pens oftener  than  we  are  aware  of.  The  attack  is  very  likely  to  be  mistaken  for  an 
apoplectic  seizure. 

In  these  cases  of  sudden  choking,  the  morsel  of  food  is  not  always  caught  in  the 
rima  glottidis.  If  it  be  large  enough  to  stick  fast  in  the  pharynx,  it  may  provoke, 
through  a  reflex  action,  an  abiding  spasm  of  the  httle  laryngeal  muscles,  and  so  pro- 
duce death  by  apnoea.  The  remedy  for  such  an  emergency,  as  Dr.  Marshall  Hall 
truly  observes,  must  be  immediate :  and  this  is  what  he  tells  us  should  be  done. 

"  Pressure  being  made  on  the  abdomen,  to  prevent  the  descent  of  the  diaphragm, 
a  forcible  blow  should  be  made  by  the  flat  hand  on  the  thorax.  The  effect  of  this  is 
to  induce  an  effort  similar  to  that  of  expiration;  the  larynx  being  closed,  OBsophageal 
vomiting  lakes  place,  and  the  morsel  is  dislodged." 

"  If  this  plan  fail,  not  an  instant  being  lost,  the  pressure  should  be  kept  up  on  the 
abdomen,  the  finger  should  be  introduced  into  the  throat,  and  the  same  smart  and 
forcible  blow  made  on  the  thorax  as  before.  By  the  irritation  of  the  fauces  the 
cardia  is  opened,  and  by  the  blow  on  the  thorax  (firm  pressure  being  made  on  the 
abdomen)  an  effort  similar  to  that  of  expiration,  with  a  closed  larynx,  is  made,  and  a 
direct  vomiting  ensues,  and  the  morsel  of  food  is  carried  away." 
42 


ak 


658  INTRUSION    OF    SOLIDS 

2dly.  The  substance,  if  small,  may,  after  it  has  passed  the  chink,  remain  in  the 
[ar3-nx :  entangled  in  its  ventricles,  or  between  the  chordae  vocales.  In  that  case 
it  usually  occasions  very  severe  laryngeal  symptoms — spasmodic  gasping  coucrh, 
choking  sensations,  croupy  respiration,  and  pain  in  the  'arynx — symptoms  which 
harass  the  patients  without  intermission,  until  death  ensues,  or  until  the  substance  is 
driv-en  upwards  into  the  pharynx,  or  passes  downwards  into  the  windpipe.  There 
7s,  however,  one  instance  on  record,  in  which  a  piece  of  gold  was  lodged  for  years 
in  the  ventricles  of  the  larynx,  without  these  distressing  consequences. 

3dly.  Having  passed  the  upper  part  of  the  larynx,  it  may  stop,  and  become  fixed 
beneath  the  cricoid  cartilage,  or  in  the  trachea.  In  these  situations,  unless  it  quite 
blocks  up  the  passage,  its  presence  may  be  productive  of  but  little  distress.  A 
wheezing  or  croupy  sound  during  one  or  both  of  the  movements  of  respiration,  and 
some  degree  of  pain  and  tenderness  of  the  part  where  the  substance  was  lodged, 
have  constituted  all  the  evidence  of  its  position  in  the  air-passages,  in  more  than  one 
instance.  A  very  singular  and  whimsical  case  of  this  kind,  related  by  Professor 
Macnamara,  is  referred  to  by  Dr.  Stokes.  A  boy  had  made  a  whistle,  by  perforating 
a  plum-stone,  and  extracting  the  kernel.  This,  during  a  strong  inspiration,  passed 
from  between  his  lips,  through  the  glottis,  and  became  fixed  transversely  in  the 
larynx.  So  little  inconvenience  did  it  create,  that  the  boy,  finding  that  he  still 
whistled  as  he  breathed,  went  about  for  some  hours,  pleased  to  display  this  new  ac- 
complishment. For  three  days  he  continued  to  occupy  himself  in  his  childish 
amusements,  suffering  now  and  then  a  seizure  of  suffocating  cough.  He  was  then 
taken  to  the  Meath  Hospital.  He  had  no  pain  in  deglutition ;  but  he  said  when  the 
cough  was  severe,  it  caused  pain  in  his  throat.  He  had  also  uneasiness  in  the  epi- 
gastrium, a  bloated  countenance,  and  a  frequent  pulse.  The  chest  sounded  well  on 
percussion,  and  the  vesicular  murmur  was  natural.  The  fits  of  coughing  were  fol- 
lowed by  white  frothy  expectoration.  Laryngolomj^  was  performed;  but  during  the 
struggle  and  the  convulsive  cough  which  took  place  when  the  opening  was  made, 
the  stone  (so  the  patient  declared)  was  coughed  up,  and  swallowed.  The  symp- 
toms, were  relieved;  and  the  whistling  ceased.  But  it  was  found  that,  as  the  wound 
healed,  the  distress  and  the  whistling  sound  returned  ;  which  showed  that  the  stone 
lay  above  the  opening;  and  that  the  disappearance  of  the  symptoms  had  been  owing, 
not  to  its  dislodgment,  but  to  the  admission  of  air  below  the  point  where  it  was  fixed. 
Soon  after  this,  however,  it  changed  its  place,  passed  down  into  the  right  bronchus, 
and  then  up  again  towards  the  larynx.  By  a  second  operation  it  was  extracted ; 
and  the  lad  recovered  without  any  bad  symptom. 

4thly.  The  substance  may  get  beyond  the  trachea,  into  one  of  the  bronchi,  and  stay 
there.  And  it  is  a  very  curious  fact,  and  one  which  has  evident  importance  in  respect 
to  diagnosis,  that  it  is  almost  always  the  n^/t/  bronchus  which  the  substance  enters. 
Dr.  Stokes  has  explained  why  it  is  so.  The  septum  that  divides  the  extremity  of 
the  trachea  into  two  branches,  is  not  placed  in  the  middle  of  the  channel,  but  de- 
cidedly towards  the  left ;  so  that  any  solid  body  falling  down  through  the  windpipe, 
is  naturally  directt-d  into  the  right  bronchus.  Perhaps  this  tendency  is  aided  by  the 
more  vertical  direction,  and  by  the  somewhat  greater  capacity  of  that  tube,  com- 
pared with  its  fellow.  Now  you  will  readily  apprehend  what  sort  of  symptoms  would 
be  likely  to  result  from  the  impaction  of  a  solid  body  in  either  of  the  primary  bronchi. 
It  would  be  very  apt  to  excite  inflammation  of  the  corresponding  lung,  which  inflam- 
mation would  reveal  itself  by  its  proper  signs;  but  it  would  produce  pecuhar  aus- 
cultatory phenomena,  prior  to  and  independent  of  such  inflammation.  It  would 
prevent,  partially  or  ahogether,  the  entrance  of  air  into  the  lung  of  that  side.  Hence, 
when  we  have  other  reasons  for  thinking  that  a  solid  body  has  passed  the  glottis, 
if  we  find  the  vesicular  murmur  suspended  or  enfeebled  in  one  lung,  while  percus- 
sion gives  out  its  usual  clear  sound,  we  may  conclude  that  the  intruder  is  lodged  in 
the  bronchus  belonging  to  that  lung. 

Dr.  Stokes  believes,  and  his  opinion  is  fortified  by  his  own  experience  on  the  sub- 
ject, that  smooth  bodies  (beans  or  shots,  for  example),  are  more  calculated  than  such 
as  are  rugged  and  uneven  to  cause  urgent  distress  when  impacted  in  one  of  the 
nronchi ;  inasmuch  as  they  more  completely  plug  and  obstruct  the  tube,  thereby 


INTO    THE   AIR-PASSAGES.  659 

Jepriving  the  patient  at  once  of  the  use  of  half  his  lungs.  An  irregular  substance, 
which  can  neither  seal  the  passage  up,  nor  be  closely  grasped  by  its  spasmodic  con- 
traction, will  probably  occasion  less  dyspnoea,  and  at  the  same  time  will  be  less  likely 
to  be  dislodged  by  the  effort  of  expiration.  Under  these  circumstances  we  look  for 
more  chronic  symptoms. 

Sthlj^  and  lastly.  The  intruding  substance  may  not  be  fixed  anywhere,  but  may 
shift  its  place  from  time  to  time  ;  and  this,  in  fact,  is  what  most  frequently  happens ; 
and  when  it  does  happen,  it  gives  rise  to  a  very  striking  and  distinctive  series  of 
symptoms.  Paroxysms  of  suffocating  cough  and  extreme  distress,  when  the  sub- 
stance is  driven  up  into  or  near  the  larynx;  with  intervals  of  comparative  quiet,  and 
sometimes  indeed  of  apparent  health,  when  it  subsides  into  the  trachea  or  bronchi. 
But  during  these  intervals,  the  signs  that  sometimes  mark  its  situation  in  those  tubes 
may  perhaps  be  discoverable. 

There  are,  then,  a  set  of  general  symptoms,  which  lead  us  to  behave,  or  to  suspect, 
that  some  solid  body  has  entered  the  air-passages :  and  there  are  other  sets  of  par- 
ticular symptoms,  which  inform  us,  with  more  or  less  certainty,  whereabouts  it  is 
fixed,  or  that  it  is  not  fixed  at  all.  A  person,  previously  in  good  health,  is  seized 
with  violent  cough  and  choking  dyspnoea,  suddenly,  during  a  meal,  or  while  he  had 
in  his  mouth  some  loose  substance,  which  he  fancies  he  has  swallowed.  This  is  a 
sufficient  clue  to  the  probable  nature  of  the  case  :  and  we  next  inquire  for  a  sense  of 
soreness  in  the  windpipe,  and  wheezing  respiration;  for  signs  of  bronchitis  or  of 
pneumonia,  especially  in  the  right  lung ;  for  signs  of  obstruction  of  the  bronchus  on 
one  side,  and  especially  on  the  right  side,  or  of  alternations  of  suffocating  cough, 
with  intervals  of  outward  calm.  In  the  last  case,  we  may  expect  to  find  the  bronchus 
unstopped  during  the  periods  of  laryngeal  irritation  ;  and  vice  versa. 

When  we  know  that  a  sohd  body  has  been  entrapped  in  the  air-tubes,  our  business 
is  plain  ;  there  is  no  room,  in  my  opinion,  for  hesitation ;  we  must  let  the  substance 
out  through  an  artificial  wicket.  There  is  danger,  so  long  as  it  remains  in  these 
vital  passages,  of  speedy  suffocation  ;  of  fatal  damage  to  the  larynx,  or  to  the  lungs  ; 
of  cerebral  mischief  during  the  violent  paroxysms  of  coughing.  Convulsions  and 
apoplexy  have,  under  such  circumstances,  actually  occurred.  Against  these  perils 
there  is  no  security,  except  in  the  early  performance  of  tracheotomy.  If  the  in- 
cluded substance  be  loose  and  smooth  it  will  presently  be  shot  forth  at  the  new 
orifice;  if  it  be  fixed,  or  angular,  it  may  generally  be  extricated  by  a  skilful  and 
delicate  hand. 


Even  while  this  sheet  has  been  passing  under  the  press,  (May,  1843,)  another 
instance  has  occurred  of  the  same  accident,  and  excited  a  degree  of  anxious  interest 
in  the  public  mind,  scarcely  less  than  is  accorded  to  a  royal  illness.  It  befel  a  gen 
tleman  whose  name  was  previously  famous.  Mr.  Brunei,  in  amusing  the  children 
of  a  friend  with  some  tricks  of  legerdemain,  put  a  half-sovereign  into  his  mouth ; 
and  the  coin  shpped,  as  from  its  size  and  shape  it  might  easily  do,  through  the  chink 
of  the  glottis.  It  seems  to  have  occasioned  no  very  urgent  distress.  The  patient 
was  made  aware,  by  some  internal  sensation,  that  it  lay  towards  the  tight  side.  After 
more  than  three  weeks  had  passed,  the  trachea  was  opened  ;  but  the  piece  of  money 
did  not  come  forth.  Probably  its  weight  prevented  its  being  driven  up  and  down  in 
the  windpipe ;  and  its  form,  when  it  lay  edgeways,  did  not  oppose  much  impedi- 
ment to  the  breath.  The  same  weight,  however,  brought  it  back  to  the  larynx  when- 
ever Mr.  Brunei  placed  himself  with  his  head  downwards.  In  some  of  these 
experiments,  coming  crossways  I  suppose,  it  produced  most  violent  cough,  and  feel- 
ings of  impending  suffocation :  but  in  a  final  and  happier  trial,  at  the  end  of  six 
weeks,  it  dropped  out  again,  through  the  natural  passage — ^just  as  a  coin  may  some- 
times, by  good  luck,  be  shaken  out  of  a  box  through  a  sht  in  its  lid 


660  DISEASES   OF   THE   HEART. 


LECTURE  LIX. 

Diseases  of  the  Heart :  usually  partial.  Changes  in  its  Muscular  Texture.  Me 
chanism  of  those  changes.  Natural  Dimensions  of  the  Heart.  Natural 
Sounds.  Modifications  of  these  by  Disease.  Review  of  the  Physical  and 
General  Signs  that  accompany  Cardiac  Disease. 

You  will  perhaps  accuse  me,  gentlemen,  of  a  disposition  to  magnify  the  import- 
ance of  every  new  class  of  diseases  at  which  we  arrive,  in  our  survey  of  the  morbid 
conditions  of  the  various  parts  of  the  body  in  succession.  There  are  few  complaints, 
in  truth,  which  are  not  important ;  either  from  the  discomfort  to  which  they  give 
rise,  or  from  their  tendency  to  abbreviate  the  span  of  human  existence.  Yet  of  tha 
s'.rictly  vital  organs  the  derangements  are  necessarily  the  most  perilous ;  and  there- 
fore, to  us,  the  most  interesting.  Two  props  of  the  tripod  of  life  we  have  passed  in 
review,  and  seen  how  they  may  be  weakened,  an-d  how  they  may  fail  altogether. 
The  office  of  the  heart  is  not  less  essential  to  life  and  health,  than  that  of  the  brain, 
or  of  the  lungs.  The  well-being  of  every  portion  of  the  frame  depends  upon  its 
being  duly  supplied  with  arterial  blood,  and  duly  relieved  of  that  which  has  become 
venous :  and  this  supply  and  relief  require  that  the  central  organ  of  the  circulation 
should  be  sound  in  its  structure,  and  perfect  in  its  working.  But  it  is  frequently 
otherwise.  I  can  remember,  indeed,  the  time  w'hen  disease  of  the  heart  was  thought 
to  be  a  very  rare  thing ;  but  it  is  now  well  known  to  be  one  of  the  commonest  of 
disorders,  and  it  connects  itself  with  a  variety  of  other  affections,  with  which  it  was 
formerly  supposed  to  have  no  relation. 

Like  other  organs  that  are  complex  of  structure  and  formed  of  different  tissues,  the 
heart  is  subject  to  partial  disease.  Its  lining  membrane  alone  may,  in  the  first  in- 
stance, become  the  seat  of  inflammation,  with  its  various  effects ;  or  its  investing 
membrane  only  may  undergo  morbid  alterations ;  or  the  muscular  substance  that 
constitutes  the  organ  itself  may  be  gradually  changed  in  its  qualities,  in  its  bulk,  or 
in  its  proportions. 

But  the  morbid  conditions  of  the  investing  and  lining  membranes  do  not  always, 
or  immediately,  compromise  the  fife  of  the  patient.  They  are  fatal  at  length,  in 
ninety-nine  cases  out  of  a  hundred,  through  the  alterations  to  which  they  lead  in  the 
muscle  wherewith  they  are  connected.  It  may  be  practically  useful  therefore  to 
consider,  first,  these  ultimate  morbid  states  which  are  incompatible  with  the  con- 
tinuance of  life ;  and  then  to  trace  them  back  to  the  next  fink  in  the  chain  of  their 
causes,  which  will  be  found,  in  a  very  great  number  of  instances,  to  consist  in  some 
antecedent  morbid  state  of  the  exterior  or  of  the  interior  membrane. 

The  heart,  you  know,  is  a  living  forcing-pump ;  a  hollow  muscular  engine,  with 
its  chambers  and  their  outlets,  its  contractile  walls  and  their  strength  and  thickness, 
so  admirably  adjusted,  that  the  healthy  balance  of  the  circulation  is  continually  main- 
tained, under  many  varying  outward  influences  and  inward  emotions  which  tend  to 
destroy  it.  In  treating  of  disease  of  the  heart  we  have  to  consider,  therefore,  the 
modes  in  which  its  mechanism  may  be  spoiled  or  deranged  :  and  the  effects  of  such 
derangements. 

Not  only  the  component  tissues,  but  different  portions  also  of  the  organ,  may  be 
separately  diseased.  It  seldom  happens,  indeed,  that  the  whole  heart  is  affected ; 
although  that  is  probably  the  vulgar  belief.  The  left  side  is  much  more  obnoxious 
to  morbid  changes  than  the  right :  and  when  both  sides  are  implicated,  the  altera- 
tion is  almost  always  more  decided  and  conspicuous  in  the  left  than  in  the  right 
chambers. 

In  the  rapid  sketch  which  I  attempted  of  general  pathology,  in  the  outset  of  the 
course,  I  pointed  out  the  various  kinds  of  alteration  to  which  the  tissues  and  organs 
of  the  body,  and  therefore  the  heart  among  the  rest,  are  subject.  One  or  more  of 
the  chambers  of  the  heart,  you  will  remember,  may  become  larger  or  smaller  than 
IS  natural ;  or  have  their  walls  increased  or  diminished  in  thickness,  and  consequently 


DISEASES    OF    THE    HEART.  661 

>«3  power  ;  or  one  or  more  of  its  outlets  and  orifices  of  communication  may  be  widened 
Pf  contracted  :  and  the  purposes  and  function  of  the  organ  will  be  more  or  less  im- 
paired by  these  changes. 

In  order,  then,  to  have  a  clear  conception  of  cardiac  disease,  it  is  necessary  to 
analyze  it,  and  to  investigate  the  derangements  of  the  several  parts  of  the  heart. 
And  I  begin  with  hypeiirophy ;  augmentation  of  bulk  in  its  muscular  substance. 
And  I  must  first  of  all  define  one  or  two  phrases  which  are  current  among  patholo- 
gists in  respect  to  this  condition. 

The  muscular  tissue  of  one,  or  more,  of  the  chambers  of  the  heart  may  become 
thicker  and  stronger  than  natural,  while  the  capacity  of  that  chamber,  or  of  those 
chambers,  remains  unaltered.     The  hypertrophy  in  that  case  is  said  to  be  simple. 

But,  while  the  muscular  parietes  are  thickened,  the  corresponding  chamber  may 
become  unnaturally  large.  This  constitutes  the  active  aneurism  of  the  heart  of 
Corvisart,  the  eccentric  hypertrophy  of  more  modern  writers. 

On  the  other  hand,  it  has  been  supposed  that  the  capacity  of  a  cavity  of  the  heart 
may  diminish  in  size  as  its  walls  increase  in  thickness :  that  the  hypertrophy  may 
take  place  at  the  expense  (as  it  were)  of  the  chamber.  This  has  been  called  con- 
centric hypertrophy. 

Now  of  these  three  reputed  forms  of  hypertrophy,  considered  in  their  relation  to 
disease,  two  only,  the  simple  and  the  eccentric,  have  any  real  existence.  The  third, 
or  concentric  form,  never  occurs,  I  believe,  except  as  a  congenital  malformation. 
And  of  the  two  genuine  species  of  hypertrophy,  the  eccentric,  which  is  plainly  a 
compound  affection,  consisting  of  hypertrophy  with  dilatation,  is  much  the  most 
common.  The  reason  of  this  is  to  be  found  in  the  physical  cause  of  the  morbid 
condition,  in  most  instances.  The  physical  cause,  in  nineteen  cases  out  of  twenty, 
is  some  obstacle,  mechanical  or  virtual,  to  the  perfect  accomplishment  of  the  func- 
tion of  the  chamber ;  some  obstruction  opposed  to  the  free  and  thorough  exit  of  the 
blood  from  it ;  or  something  which  hinders  the  easy  play  of  the  organ :  hence,  in 
the  first  place,  a  gradual  yielding,  or  tendency  to  yield,  in  the  sides  of  the  affected 
chamber,  from  the  continual  and  unwonted  pressure  of  the  accumulated  blood  against 
them,  and  in  the  second  place,  a  striving  action  of  the  muscle  to  overcome  the 
hindrance,  or  to  counterbalance  the  obstacle ;  and  consequently,  according  to  the 
law  formerly  announced,  an  augmentation  in  the  bulk  of  the  muscle  whereof  the 
function  is  thus  increased.  If  the  hypertrophy,  which  is  the  result  of  a  truly  con- 
servative process,  keeps  pace  exactly  with  the  amount  of  the  obstacle  and  exactly 
balances  it,  no  dilatation  happens,  or  next  to  none.  But  this  is  comparatively  seldom 
the  case.  According  to  the  principles  of  mechanics,  a  httle  distension  of  the  sphe- 
roidal cavity  must  require  an  increase  of  force  to  propel  from  it  a  given  quantity 
of  blood,  in  the  same  time,  through  a  given  discharging  orifice.  So  that  incipient 
dilatation  becomes  (in  addition  to  the  supposed  obstacle)  an  efficient  cause  of  hyper- 
trophy :  and  the  two,  the  dilatation  and  the  hypertrophy,  commonly  make  progress 
together.  Ij 

Cruveilhier  appears  to  have  been  the  first  to  reject  concentric  hypertrophy  from 
the  catalogue  of  cardiac  diseases.  The  smallness  of  its  cavity,  with  a  proportional 
increased  thickness  of  its  walls,  was  regarded  by  him  as  a  transient  condition  of  the 
ventricle,  depending  upon  the  mode  of  death.  He  found  these  phenomena  very 
strongly  marked  in  the  hearts  of  all  those  whose  bodies  he  had  examined  after  de- 
capitation by  the  guillotine ;  "  Les  parois  ventriculaires  se  touchaient  dans  tous 
leurs  points."  It  is  therefore  his  opinion  that  the  hearts  which  had  been  thought 
by  others,  to  present  examples  of  concentric  hypertrophy,  were  in  reality  "  hearts 
more  or  less  hypertrophied,  which  death  had  surprised  in  all  their  energy  of  con 
iractility." 

This  question  has  since  been  considered  by  Dr.  Budd,  in  a  communication  to  tht 
Medical  and  Chirurgical  Society,  which  you  may  read  in  the  twenty-first  volume  of 
its  Transactions.  He  has  lately  favoured  me  with  a  statement  of  his  matured  viewa 
upon  the  subject. 

The  semblance  of  concentric  hypertrophy  is  most  common  in  the  left  ventricle ; 
and  depends  upon  the  ventricle  being  nearly  empty  at  the  time  of  death,  and  upon 

3f 


662  DISEASES    OF    THE    HEART. 

the  corpse  being  examined  while  the  heart  is  contracted  by  the  rigor  mortis.  The 
fallacious  appearance  is  accordingly  noticed  in  cases  where,  from  the  manner  of 
death,  the  left  ventricle,  or  the  entire  heart,  contains  but  little  blood,  and  where,  from 
the  muscular  powernol  having  been  previously  exhausted,  the  rigor  mortis  is  of  long 
duration. 

"  In  all  these  concentrically  hypertrophied  hearts  (writes  Dr.  Budd)  the  ventricle 
may  be  readily  dilated  by  means  of  the  fingers,  and  always  dilates  of  itself  when  the 
rigor  mortis  goes  off." 

"  In  the  published  cases  of  concentric  hypertrophy,  in  which  there  was  no  disease 
of  the  valves  (I  have  given  eight  such  cases  in  my  paper,  and  could  now  add  a  long 
list  to  them)  there  were  no  signs,  or  only  very  slight  signs,  of  disease  of  the  heart, 
during  the  lifetime  of  the  patient.  This  circumstance  is  sufficient  proof  that  the 
cavities  of  the  heart  in  these  cases  could  not  have  been  during  life  permanently  in 
the  contracted  state  in  which  they  were  found  after  death.  A  left  ventricle  that 
could  scarcely  contain  an  almond  (a  common  form  of  expression  in  the  description 
of  these  cases)  would  surely  have  caused  a  great  impediment  to  the  circulation." 

Moreover,  concentric  hypertrophy  could  answer  no  mechanical  purpose ;  nor 
could  its  formation  be  accounted  for  on  mechanical  principles.  But  "  concentric 
hypertrophy  of  a  ventricle,  in  a  high  degree,  with  obstruction  at  its  discharging 
orifice,  and  an  extraordinary  channel  for  the  passage  of  the  blood,  occasionally 
exists  as  a  congenital  malformation  ;  and,  in  most  cases,  the  right  is  the  ventricle  so 
affected." 

To  resume.  Recollect  that  there  may  be  two  distinct  kinds  of  physical  cause  of 
excessive  action  of  the  heart,  and  therefore  of  hypertrophy.  In  the  one  kind,  there 
is  some  mechanical  obstruction  to  the  exit  of  the  blood  from  one  or  more  of  the  cavi- 
ties;  a  constricted  state  of  the  orifices  is  the  most  common  condition.  In  the  other 
kind,  without  any  such  mechanical  bar  or  dam  to  the  fluid,  there  is  something  to 
hinder  the  free  and  sufficient  play  of  the  organ ;  an  adhering  pericardium,  it  may 
be,  or  mal-position  of  the  heart.  If  the  heart  be  pushed,  for  instance,  out  of  its  pro- 
per place  and  posture  by  effusion  into  the  pleura,  or  by  distortion  of  the  chest,  it  will 
not  work  with  the  same  ease  as  when  all  is  perfect  and  symmetrical;  and  the  unu- 
sual labour  imposed  upon  it  fully  to  execute  its  office,  will  lead  to  hypertrophy. 
The  causes  of  hypertrophy  may  therefore  be  situated  within  the  heart  itself,  or  with- 
out and  beyond  it ;  but  in  all  those  cases  in  which  the  effect  of  the  hindrance  or 
obstacle  is  to  detain  the  blood  in  one  or  more  chambers,  the  hypertrophy  will  be 
likely  to  be  accompanied  by  dilatation:  and,  generally  speaking,  the  h)''pertrophy 
and  dilatation  result  from  disease  in  some  part  which  lies  beyond  the  affected  cham- 
ber, in  the  order  of  the  circulation.  Thus,  either  a  narrowing  or  a  dilatation  of  the 
aorta  at  its  commencement,  will  tend  to  cause  hypertrophy  and  dilatation  of  the  left 
ventricle. 

That  contraction  of  the  aorta,  or  of  the  aortic  orifice,  may  have  this  consequence, 
you  will  have  no  difficulty  in  perceiving.  The  blood  cannot  so  readily  pass  through 
the  narrowed  channel;  hence  it  will  tend  to  accumulate  in  undue  quantity  in  the 
ventricle,  therefore  to  stretch  and  dilate  it;  and  the  increased  muscular  efforts  neces- 
sary to  drive  the  delayed  blood  onwards,  tend  also  to  thicken  the  muscle  itself.  But 
it  may  not  be  so  obvious  that  dilatation  of  the  mouth  of  the  aorta — a  wider  channel 
of  egress — would  also  virtually  prove  an  obstacle  to  the  emptying  of  the  ventricle.  Yet 
it  certainly  would,  in  two  ways.  In  the  first  place,  dilatation  of  the  entrance  of  the 
aorta  implies  a  diminution  in  the  elasticity  of  that  vessel;  and  the  blood,  after  it  has 
left  the  heart,  is  urged  onwards  by  the  heaUhy  elasticity.  But,  again,  dilatation  of 
the  mouth  of  the  aorta  commonly  implies  an  imperfect  closure  of  that  vessel  by  the 
sigmoid  valves ;  so  that,  during  the  diastole,  a  part  of  the  blood  is  apt  to  regurgitate 
from  the  aorta,  and  to  keep  the  ventricle  morbidly  full.  You  see,  therefore,  that  a 
deviation  from  the  healthy  state  of  the  aorta,  and  of  the  valvular  apparatus  which 
lies  ac  its  mouth,  may  obstruct  the  course  of  the  blood,  and  lead  to  hypertrophy  and 
dilatation,  whether  the  deviation  be  in  the  one  way  or  in  the  other ;  whether,  I  mean, 
uie  naturai  size  of  the  vessel  be  increased  or  diminished.  Again,  disease  of  the 
mitral  valve,  obstructing  the  flow  of  the  blood  at  that  point,  will  lead  to  an  accumu- 


HYPERTROPHY.  663 

lation  in  the  left  auricle,  in  the  pulmonary  veins,  and  in  the  lungs  them- 
selves. The  auricular  action  is  always  less  regular  and  energetic  than  the  ven- 
tricular, so  that  we  less  frequently  meet  with  hypertrophy  of  the  auricles ;  but  very 
often  with  dilatation.  And  if  we  go  to  the  other  side  of  the  heart,  we  find  hyper- 
trophy with  dilatation,  and  more  especially  dilatation  of  the  right  ventricle,  when, 
from  some  reason  or  other,  the  blood  passes  with  difficulty  towards  or  through  the 
lungs:  either  from  disease  of  the  pulmonary  artery,  or  from  disease  in  the  substance 
of  the  lungs — emphysema,  for  instance :  and  if  the  difficulty  be  great,  the  accumu- 
lation and  distension  will  atfect  successively  the  right  auricle,  and  the  vensB  cavas ; 
and  then  we  have,  in  most  cases,  general  dropsy.  So  that,  I  repeat,  disease  in  the 
heart  tends  to  propagate  itself  in  a  direction  contrary  to  that  of  the  circulation.  Fur- 
thermore, if  the  muscular  tissue  of  the  heart  be  pale,  flabby,  soft,  and  weak — as  it 
frequently  is  in  feeble,  ill-nourished,  cachectic  persons-^it  will  the  more  readily  yield 
to  the  centrifugal  pressure  of  the  blood  it  embraces.  In  this  way  we  may  have  dila- 
tation without  any  hypertrophy.  I  am  anxious  that  you  should  in  the  outset  com- 
prehend the  mechanism  by  which  the  natural  dimensions  and  relative  proportions 
of  different  parts  of  the  heart  may  be  altered  in  disease. 

One  reason  why  disease  of  the  heart  used  formerly  to  be  overlooked,  was  that 
these  natural  dimensions  and  relative  proportions  were  not  ascertained  or  much 
attended  to.  It  is  not  easy  to  form  any  very  precise  estimate  of  the  size  of  a  healthy 
heart.  It  is  commonly  held  that  if  the  heart  be  about  the  same  size  with  the  closed 
fist  of  the  subject,  its  general  dimensions  maybe  considered  as  being  natural.  Bouil- 
laud,  who  has  taken  much  pains  with  this  matter,  weighing  and  measuring  a  great 
number  of  different  hearts,  states  that  the  mean  weight  of  that  organ,  with  the  ori- 
gins of  its  large  vessels,  and  empty  of  blood,  in  adults  from  twenty-five  to  sixty  years 
old,  is  from  eight  to  nine  ounces  ;  that  in  subjects  from  sixteen  to  twenty-five  years 
old,  it  may  be  one  or  two  ounces  less ;  and  that,  in  very  large  and  robust  persons,  it 
may  rise  to  ten  or  eleven  ounces.  Also,  what  we  should  expect,  that  the  weight  is 
less  in  women  than  in  men. 

So  much  for  the  general  bulk  of  the  heart.  And  we  must  have  some  standard 
whereby  to  estimate  its  relative  proportions.  Every  one  knows  that  the  walls  of  the 
left  ventricle  are  thicker  than  those  of  the  right.  Bouillaud  found  that  the  mean 
thickness  of  the  walls  of  the  left  ventricle  at  its  base  was  seven  lines,  while  that  of 
the  right  ventricle  was  two  and  a  half  fines.  And  taking  the  thickness  generally 
he  says  that  the  thickness  of  the  parietes  of  the  right  ventricle  has  not  a  greater  ratio 
to  that  of  the  parietes  of  the  left,  than  two  to  five,  or  even  than  one  to  three. 

So  again  of  the  auricles ;  he  lays  it  down  that  the  mean  thickness  of  the  walls  of 
the  left  auricle  is,  to  the  mean  thickness  of  those  of  the  right,  as  three  to  two. 

He  holds,  also,  that  the  mean  capacity  of  the  right  ventricle  exceeds,  by  a  little, 
that  of  the  left ;  and  that  the  right  auricle  is  larger  than  the  left.  You  must  always 
make  allowance,  in  actual  cases,  for  the  possible  distension  of  these  cavities  with 
blood,  beyond  the  size  to  which  they  would  have  contracted  if  they  had  contained  no 
blood. 

I  may  add,  that  the  same  author  declares  the  rule  I  just  now  mentioned,  which  had 
been  proposed  before  his  researches  were  instituted — the  rule,  viz.,  which  makes  the 
bulk  of  the  heaUhy  heart  equal  to  the  fist  of  the  subject — to  be  tolerably  correct. 
By  keeping  in  mind  these  general  facts,  you  will  be  better  able  to  appreciate  the 
appearances  presented  by  the  heart  when  it  is  taken  from  the  body  to  be  examined ; 
but  you  will  recollect  that  they  relate  to  averages  only. 

Now,  having  pointed  out  the  modes  in  which  the  natural  proportions  of  the  heart 
and  of  its  several  parts  may  be  morbidly  altered;  and  given  you  a  rough  standard 
which  may  enable  you  to  estimate  these  proportions  in  the  state  of  health,  and  the 
deviations  from  them  in  the  state  of  disease ;  I  will  go  on  to  consider  the  symptom,* 
by  which  the  altered  conditions  are  accustomed  to  declare  themselves.  And  it  ij 
with  respect  to  the  heart,  as  with  respect  to  the  lungs ;  there  are  general  symptoms 
or  signs,  and  there  are  physical  symptoms  or  signs  :  and  the  information  derived  from 
these  sources  respectively  is  of  variable  utility.  Neither  of  them  can  be  safely  ne- 
o-lected ;  and  it  is  often  found  that  the  indications  derived  from  one  of  these  sets  of 


664  DISEASES    OF    THE    HEART. 

symptoms  are  confirmed  or  corrected  by  those  collected  from  the  other.  I  believe  it 
will  be  best  to  pursue  the  same  course  in  both  cases,  and  to  speak,  in  the  first  place, 
of  the  signs  that  are  brought  within  our  notice  by  the  sense  of  hearing. 

But,  in  order  that  we  may  comprehend  the  morbid  sounds  of  the  heart,  we  must 
first  make  ourselves  acquainted  with  those  that  belong  to  its  healthy  condition. 

The  heart  ma)''  be  heard  by  the  ear  laid  flat  against  the  prascordial  region,  or 
through  a  stethoscope,  to  beat  over  a  certain  space.  That  space,  in  ordinary  cir- 
cumstances, corresponds  to  the  inferior  half  of  the  sternum,  and  to  the  cartilages 
of  the  ribs,  from  the  fourth  to  the  seventh,  on  the  left  side.  The  apex  of  the  organ 
may  often  be  seen  to  pulsate  between  the  cartilages  of  the  fifth  and  sixth  left  ribs ; 
about  two  inches  below  the  nipple,  and  or..^  inch  from  it  towards  the  sternum. 

This  is  the  space  over  which,  in  the  sound  state  of  the  heart  and  lungs,  the  pulsa- 
tions of  the  former  are  plainly  audible.  But  there  are  several  diseased  conditions 
both  of  the  heart  itself,  and  of  the  parts  around  it,  which  interfere  with  this  rule. 

In  the  first  place,  if  the  heart  be  larger  than  natural,  it  will  be  heard  to  beat  over 
a  proportionally  larger  space.  In  this  way  it  may  come  to  be  heard  all  over  the 
chest  in  front ;  and  behind  on  the  left  side  of  the  spine  ;  and  even,  in  extreme  cases, 
on  the  right  side  of  the  spine. 

Again,  the  extent  of  space  over  which  the  heart  may  be  heard  to  beat  will  be  in- 
creased in  proportion  to  the  thinness  of  its  walls ;  and  diminished,  csetcris  paribus, 
according  to  the  thickness  of  its  walls.  So  that  when  the  heart  is  nearly  its  proper 
size,  if  its  walls  be  thin,  it  will  be  heard  beyond  its  natural  limits ;  and  if  its  walls 
be  morbidly  thick,  i.  e.,  if  it  be  affected  with  considerable  hypertrophy,  it  will  not 
be  heard  beyond,  nor  even  to  the  extent  of  its  natural  limits.  I  will  endeavour,  pre- 
sently, to  explain  the  reason  of  these  differences. 

Again,  and  this  it  is  of  great  importance  to  remember,  the  heart  may  be  heard  far 
beyond  its  natural  limits,  even  when  it  is  perfectly  healthy,  in  consequence  of  the 
lung  between  the  ear  and  the  heart  having  become  solid,  and  therefore  a  better  con- 
ductor of  sound :  and  the  solidification  may  have  resulted  from  hepatization,  or  from 
the  presence  of  a  number  of  crude  tubercles.  The  sound  of  the  heart's  action  will 
also  be  conveyed  to  a  distance  by  the  liquid  effusion  in  pleurisy.  If  we  are  not 
aware  of  these  circumstances,  we  are  continually  liable  to  fall  into  mistakes. 

The  heart  is  likewise  heard  more  distinctly,  and  over  a  space  which  is  compara- 
tively larger,  in  children  than  in  adult  persons ;  and  I  need  scarcely  say  that  it  may 
be  heard  over  a  wider  extent  of  the  chest  whenever  its  action  is  augmented  by  exer- 
cise, by  emotion  of  mind,  or  by  febrile  excitement. 

The  impidse  of  the  heart  is  another  point  which  you  must  attend  to.  In  healthy 
persons  who  are  thin,  you  may  generally  feel  the  stroke  which  the  heart  gives  to 
the  ribs,  by  placing  your  hand  on  the  prcecordial  region.  In  persons  who  are  fat, 
you  often  cannot  feel  the  heart  at  all  in  this  manner.  For  obvious  reasons,  it  is  felt 
more  distinctly,  over  a  larger  space,  and  higher  up,  while  the  person  is  stooping  for- 
wards, or  makes  a  forced  expiration  ;  less  distinctly,  over  a  smaller  space,  and  lower 
down,  when  he  makes  a  deep  inspiration,  or  is  lying  on  his  back.  In  proportion  as 
the  heart  is  enlarged  by  disease,  it  can  be  felt  more  extensively :  and  when  there  is 
hypertrophy,  the  force  with  which  it  strikes  the  parietes  of  the  chest  is  sometimes 
extraordinary,  and  very  instructive.  You  will  see  the  ear  and  head  of  the  listener 
distinctly  lifted  at  every  pulsation ;  sometimes  the  whole  of  the  patient's  body,  nay 
his  very  bed,  is  shaken  by  the  strong  shock  of  the  heart  during  its  systole.  There 
is  no  sign  of  hypertrophy  so  sure  as  that  afforded  by  the  heart's  impulse.  You  feel, 
not  a  smart,  quick,  and  sudden  knock,  but  a  steady,  heaving,  irrepressible  swell, 
which  is  perfectly  characteristic.  You  may  always  infer  increased  thickness  of  the 
walls  of  the  organ,  when  you  meet  with  this  regular  heaving  motion  ;  and  the  extent 
to  which  the  whole  heart  is  enlarged  in  such  cases  may  be  conjectured  by  the  extent 
of  space  over  which  the  heaving  impulse  is  perceptible. 

The  sounds  which  we  hear  are  two.  One  of  them  coincides,  in  point  of  time, 
with  the  impulse;  and  barely  precedes  the  beat  of  the  radial  artery.  It  happens, 
therefore,  when  ih^  ventricles  contract;  during  the  systole.  It  is  called,  accord 
ugly,  the  systolic  sound,  or  the  Jirst  sound  of  the  heart.     The  other  of  the  two 


NATURAL   SOUNDS.  665 

sounds  coincides  with  the  diastole,  and  is  spoken  of  as  the  second  or  the  diastolic 
sound.  It  takes  place  at  the  instant  when  the  heart  reverts  to  that  place  aftd  condi- 
tion in  which  it  had  been  prior  to  the  systolic  movement.  These  two  sounds  occur 
m  quick  and  regular  succession,  and  then  follows  an  interval  of  silence,  after  which 
the  two  sounds  are  repeated  ;  and  so  on. 

The  two  sounds  are  not,  however,  exactly  alike.  They  differ  somewhat,  both  in 
quality  and  in  duration.  The  first  is  a  dull,  prolonged  noise  ;  the  second  a  shorter 
and  smarter  sound,  having  more  of  a  clacking  or  flapping  character.  Attempts  have 
been  made  to  assign  the  respective  duration  of  each  sound,  and  of  the  period  of  re- 
pose, I  confess  that  I  have  never  succeeded  in  measuring  them  satisfactorily  in  my 
mind.  Probably  Dr.  C.  J.  B.  Williams'  estimate  is  as  near  the  mark  as  any.  He 
divides  the  whole  period,  from  the  beginning  of  one  pulsation  to  the  beginning  of  the 
next,  into  five  equal  parts :  and  allots  two  of  these  to  the  first  sound,  one  to  the 
second,  and  the  remaining  two  to  the  interval  of  silence.  This  order  of  succession 
/s  called  the  rhythm  of  the  heart :  and  it  may  be  perverted. 

Respecting  the  physical  causes  of  these  natural  sounds,  there  have  been  much 
/ecent  discussion  and  research.  Our  time,  however,  will  permit  me  to  do  little  more 
than  tell  you  what  I  believe  to  be  the  facts  of  the  matter.  And  I  take,  first,  the 
disastolic  sound,  as  being  the  simpler  of  the  two.  It  used  to  be  ascribed  to  the 
coKtraction  of  the  auricles :  but  that  was  quite  a  mistake.  The  contraction  of  the 
auricles,  such  as  it  is,  happens  immediately  before  each  systole  of  the  ventricles ; 
whereas  the  sound  in  question  occurs  immediately  after  it,  and  is  succeeded  by  the 
period  of  silence.  This  we  know  from  the  visible  movements  of  the  organ  when 
sxposed  in  a  hving  animal.  In  truth,  the  auricular  contractions  are  very  feeble, 
and  not  attended  with  any  appreciable  noise.  I  have  no  doubt  that  the  second  sound 
is  produced  mainly,  if  not  altogether,  by  the  sudden  shutting  of  the  floodgates  placed 
at  the  mouths  of  the  two  great  outlets  of  the  heart.  The  recoiling  blood  forces  back 
Jie  semilunar  valves  of  the  aorta  and  of  the  pulmonary  artery,  as  one  unfurls  an 
ambrella:  and  with  an  audible  check  as  they  tighten.  There  is  no  other  tenable 
mode  of  accounting  for  the  sound.  Experimenters  have  contrived,  by  hooks  and 
vvires,  to  prevent  these  valves  from  unfolding;  and  then  the  flapping  sound  has  been 
converted  into  a  hiss.  Disease  of  the  same  valves  demonstrates  the  same  things; 
as  we  shall  presently  see.  Nevertheless,  it  is  both  possible  and  probable  that  the 
relapse  of  the  whole  organ  to  its  former  place  may  contribute  an  ingredient  towards 
uiis  second  sound. 

The  first,  or  systolic  sound,  is  more  complex.  Partly  it  is  owing,  as  I  believe,  to 
a  similar  cause  with  that  which  occasions  the  diastohc  sound,  viz.,  the  abrupt  closure 
of  the  orifices  of  communication  between  the  auricles  and  ventricles,  by  the  reflux 
of  the  blood  against  the  ventricular  surfaces  of  the  tricuspid  and  mitral  valves ; 
panly,  sometimes,  to  the  blow  of  the  heart's  apex  against  the  ribs ;  chiefly,  however, 
it  consists  of  the  sound  that  results  from  the  muscular  contraction  of  the  ventricles. 
The  systolic  sound  commences  with  the  tightening  of  the  walls  of  the  ventricles, 
including  the  valves ;  and  it  is  prolonged  by  the  muscular  noise.  You  are  aware, 
I  dare  say,  that  the  vigorous  contraction  of  a  large  muscle  is  accompanied  by  audi- 
ble sound.  If,  during  the  stillness  of  night,  when  lying  in  bed,  with  your  cheek 
and  eai  upon  the  pillow,  you  set  your  teeth  firmly,  you  will  hear  a  continuous  dull 
rumbhng,  like  the  noise  of  carriage-wheels  in  the  street,  and  evidently  caused  by 
tlie  action  of  the  masseter  and  the  temporal  muscles.  Dr.  Williams  slates  that, 
with  the  help  of  a  flexible  stethoscope,  one  may  hear  the  voluntary  jerking  con- 
traction of  his  own  abdominal  muscles  ;  the  sound  being  as  loud  as  that  of  the  heart's 
systole,  and  very  Hke  it  in  character.  That  the  systolic  sound  is  essentially  due  to 
muscular  contraction  is  proved  by  the  fact,  that  when  a  heart  is  taken  from  the 
living  thorax  and  placed  upon  a  table,  its  contractions  (which  persist  for  awhile)  arc 
still  attended  with  a  noise  similar  to  the  natural  first  sound,  though  weaker.  Here 
there  is  neither  collision  of  the  blood,  nor  valvular  reaction,  nor  impulse  against  the 
ribs,  to  render  the  experiment  ambiguous. 

If  you  acknowledge  and  comprehend  this  source  of  sound,  you  will  understand 
without  difficulty  why  the  heart,  cscteris  paribus,  is  heard  more  clearly  and  exteti- 

3f2 


666  DISEASES    OF    THE   HEART. 

sively  when  its  walls  are  thin,  less  widely  and  loudly  when  they  are  ihick.  "The 
transition  (says  Dr.  Williams)  of  a  thick  muscle  from  slack  to  tight  can  never  be  so 
complete  and  sudden  as  that  of  a  thin  one.  Where  there  are  many  fibres  they 
choke  and  muffle  each  other's  vibrations ;  hence  the  sound  is  dull  and  prolonged, 
rather  than  loud  and  clear.  If  we  observe  the  different  sounds  produced  on  tight- 
ening thin  silk  and  thick  baize  or  cloth,  we  find  that  the  thinness  of  the  silk  gives  a 
unity  and  briefness  to  the  impulse  which  it  receives,  and  the  sound  is  short  and  loud ; 
whilst  in  the  baize  the  impulse  is  divided  and  prolonged  in  the  complexity  of  the 
fibres,  and  the  sound  is  dull  and  less  brief:  so,  under  similar  circumstances,  a  thin 
ventricle  w'ill  give  a  louder,  sharper  sound  than  a  thick  one." 

The  natural  sounds  which  I  have  been  describing  are  liable  to  be  changed,  or 
modified,  by  disease.  Some  of  the  modifications,  indeed,  I  have  adverted  to  as  I 
went  along.  But  others,  of  a  more  striking  and  extraordinary  character,  are  yet  to 
be  explained.  Either  sound,  or  both,  may  be  accompanied  by  a  noise,  which,  in  its 
commonest  type,  very  closely  reseml)les  that  produced  by  the  blowing  of  a  pair  of 
bellows.  Four  persons  out  of  five,  I  should  think,  if  they  were  asked  what  this 
sound  resembled,  when  they  heard  it  accompanying  each  sj'-stolic  movement  of  the 
heart,  would  say  that  it  was  exactly  like  the  repeated  blowing  of  bellows  in  an 
adjoining  room.  It  is  called,  accordingly,  by  the  French,  the  "bruit  de  soufflet ;" 
and,  in  homely  English,  a  bellows  sound.  This  is  the  generic  sound.  It  may  be 
divided  into  species ;  but  it  is  scarcely  worth  while  so  to  divide  it.  We  are  only 
likely  to  confuse  our  notions  by  over-refinement.  So  I  will  only  add,  that,  when 
this  bellows  sound  is  very  harsh  or  rough,  persons  will  tell  you  that  it  is  more  like 
the  noise  of  a  rasp,  or  a  file,  or  a  saw :  but  all  the  while  it  is  some  kind  of  bellows 
sound.     These  sounds  are  often  denominated  murmurs  also. 

Now  what  is  the  cause  of  this  singular  deviation  from  the  natural  noises  made  by 
the  successive  contractions  and  relaxations  of  this  hollow  muscle,  the  heart  ?  The 
whole  matter  may,  I  believe,  be  briefly  thus  expressed.  The  blowing  sound  may  be 
occasioned  by  any  change  which  alters  the  due  proportion  between  the  chambers  of 
the  heart,  and  their  orifices  of  communication  with  each  other,  and  with  the  blood- 
vessels that  respectively  enter  or  leave  them  ;  it  may  also  be  occasioned  by  a  preter- 
natural velocity  in  the  passage  of  the  blood  through  a  healthy  and  well  adjusted 
heart.  Dr.  Elliotson,  I  think  it  is,  who  has  offered  this  apposite  iUustration  of  the 
phenomenon.  If  the  arches  of  a  bridge  have  a  certain  relation  to  the  quantity  of 
water  in  the  river,  and  to  the  force  of  the  current,  the  water  passes  through  them 
quietly,  and  without  any  noise.  Diminish  the  size  of  the  arches,  and  the  water 
begins  to  go  through  them  with  an  audible  rushing  or  roaring  sound.  The  very 
same  thing  wifl  happen  if  the  arches  remain  unchanged  in  size,  but  the  quantity  of 
water  in  the  river,  and  therefore  its  velocity  and  force,  be  augmented  by  heavy  rains. 
So  it  is  in  the  heart.  If  one  of  its  orifices — say  the  aortic  orifice — be  narrowed,  by 
disease  of  the  valves,  or  in  any  other  way,  the  blood  wiU  not,  as  before,  glide  through 
it  smoothly  and  without  noise,  but  will  yield  that  sound  which  we  call  a  bellows 
sound.  So  also,  if  the  orifice  retain  its  natural  dimensions,  but  the  capacity  of  the 
cavity  from  which  the  blood  is  driven  be  augmented.  Nay.  the  same  blowing  sound 
may  be  produced  though  the  cavities  and  orifices  are  all  healthy,  and  duly  propor- 
tioned to  each  other,  if  the  velocity  of  the  circulating  blood  be  increased  beyond  a 
certain  measure.  If  you  bear  this  explanation  in  mind,  it  will  be  found  applicable,  I 
think,  to  almost  every  case  in  which  there  is  a  blowing  sound  accompanying  the 
systole  of  the  organ.  If,  at  the  same  time,  the  valves  over  which  the  blood  must  pass 
be  rigid,  or  rough,  or  even  loose  and  vibrating,  those  circumstances  may  modify  the 
blowing  sound  and  render  it  louder,  or  lioarser  than  it  would  otherwise  be,  and  justify 
the  appellations  of  bruit  de  scie,  and  bruit  de  rape,  with  which  you  will  find  the 
French  books,  and  many  of  our  English  also,  fuU. 

But  this  explanation  applies  to  a  systolic  blowing  sound  only.  What  are  we  to 
say  when  there  is  a  similar  sound  attending  the  diastolic  movement  of  the  heart  ? 
Why  a  diastolic  bellows  sound  will  mostly,  if  not  always,  be  found  to  accompany 
and  denote  some  organic  disease  affecting  the  valves  of  the  heart.  Thus,  if  the 
mitral  valve  be  converted,  as  it  often  is,  from  a  loose  flapping  valve  into  a  bony  and 


NATURAL    SOUNDS.  637 

rigid  unvarying  chink,  the  blood  which  passes  through  it  from  the  auriclt,  to  the 
ventricle,  during  the  diastole,  may  (though  it  seldom  does)  cause  a  rushing  or  blow- 
ing sound.  On  the  other  hand,  the  reflux  of  blood  through  the  unshut  mitral  orifice, 
during  the  ventricular  contraction,  may  also  be  attended  with  an  audible  noise ;  and 
thus  we  have  another  and  not  unfrequent  source  of  a  systolic  murmur.  Again,  if 
the  aortic  valves  are  imperfect,  as  they  often  are,  and  do  not  effectually  close  that 
vessel,  blood  will  regurgitate  through  them  during  the  diastole,  and  produce  a  bellows 
sound.  That  this  is  the  true  explanation  of  the  diastolic  murmurs,  1  am  convinced, 
both  by  the  observation  of  disease,  and  by  the  results  of  experiments  on  animals. 
In  some  of  Dr.  Hope's  experiments,  which  he  was  good  enough  to  allow  me  to  wit- 
ness, the  short  clack  of  the  diastole  was  at  first  distinctly  audible  ;  then  hooks  were 
introduced,  so  as  to  prevent  the  perfect  closure  of  the  sigmoid  valves  during  the 
diastole,  and  then  the  short  smart  clack  was  converted  into  a  prolonged  bellows 
murmur;  and  upon  letting  them  go  again,  the  short  smart  clack  recurred.  The 
presence  of  a  diastohc  bellows  sound  has  repeatedly  enabled  me  to  foretell  some  dis- 
ease of  the  sigmoid  valves,  interfering  with  their  proper  function — that  of  forbidding 
the  re-entry  of  the  blood  into  the  ventricle  from  the  aorta ;  and  what  I  have  thus  pre- 
dicted during  life,  has  been  verified  by  observation  after  death. 

Such  are  the  principal  sounds,  natural  and  morbid,  which  are  audible  to  the 
naked  ear,  applied  to  the  precordial  region,  or  which  may  be  heard  through  the 
stethoscope.  But  we  derive  assistance,  in  respect  to  cardiac  disease,  from  percus- 
sion also.  It  enables  us  to  measure,  in  some  cases,  the  bulk  of  the  heart ;  in  others, 
to  ascertain  that  the  pericardium  is  distended  by  fluid.  In  the  perfectly  healthy 
state  of  the  viscera  of  the  thorax,  the  heart  is  somewhat  overlapped  by  the  thin  edge 
of  the  lungs ;  and  the  sound  elicited  by  percussion  over  a  part  of  the  prsecordial 
region  is  intermediate  between  the  hollow  sound  rendered  by  lung,  and  the  flat  sound 
yielded  by  the  solid  heart.  In  the  centre  of  the  prsecordial  region,  where  the  heart 
is  not  covered  by  lung,  the  sound  is  decidedly  dull.  When,  however,  the  heart  is 
enlarged  by  disease,  a  larger  part  of  its  surface  is  exposed,  and  a  larger  portion  of 
the  prsecordial  region  yields  a  dull  sound  on  percussion.  And  when  the  pericardium 
is  full  of  liquid,  which  distends  and  expands  it,  you  will  sometimes  find  that  not  less 
than  a  third  part  of  the  anterior  and  lateral  portion  of  the  left  side  is  quite  dull :  and 
it  is  interesting  often  to  measure,  by  percussion,  the  diminution  or  extension  of  the 
limits  of  the  dulness,  as  the  amount  of  fluid  decreases  or  aucfments. 

What  I  stated  before,  concerning  the  effect  of  diflierent  positions  of  the  body  upon 
the  space  over  which  the  healthy  beating  of  the  heart  may  be  heard,  felt,  and  some- 
times seen,  applies,  ?>tz//a/«s  mutandis,  io  the  natural  dullness  which  it  causes  when 
the  prsecordial  region  is  percussed.  This  dullness  comprehends  a  space  of  between 
one  and  two  square  inches,  reckoning  from  the  spot  where  the  impulse  is  felt,  toward 
the  left  edge  of  the  sternum.  The  dullness  should  diminish  or  disappear,  in  the 
supine  position,  and  when  a  full  breath  is  drawn ;  and  increase  in  degree  and  extent 
upon  a  forced  expiration,  and  when  the  posture  is  prone. 

There  is  another  physical  sign  which  is  much  dwelt  upon  by  Laennec,  and  which 
is  sometimes  very  striking.  In  certain  conditions  of  disease,  the  hand  placed  over 
the  situation  of  the  heart  perceives  a  peculiar  thrill  or  vibration  accompanying  its 
movements.  The  sensation  conveyed  to  the  hand  is  really  very  much  like  whai 
Laennec  compares  it  to,  viz.,  that  tremor  which  you  feel,  when  coaxing  the  back  of 
a  cat  while  it  is  purring  with  pleasure.  Accordingly  he  calls  this  sensation,  "  fre- 
missement  cataire,"  the  purring  thrill.  You  feel  this  vibration  often  when  there  it, 
present  also  a  loud  and  strong  bellows  sound ;  and  Dr.  Davis  is  of  opinion,  that  the 
bruit  de  soufflet,  and  the  fremissement  cataire,  constitute,  in  fact,  but  one  phenomenon, 
which  is  rendered  evident  to  the  touch  by  the  vibrations  communicated  to  the  hand; 
and  to  the  ear  by  the  vibrations  communicated  to  it  through  the  solid  walls  of  the 
chest.  I  know,  however,  that  the  fremissement  cataire  does  accompany  other  sounds, 
as  well  as  the  bellows  sounds :  sounds  of  which  I  have  not  yet  had  any  occasion  to 
speak,  but  which  I  shall  make  you  acquainted  with  when  we  come  to  the  subject  of 
pericarditis.     And  I  pass  from  this  general  account  of  the  sounds  belonging  to  th'^j 


668  PALPITATION. 

action  of  the  heart,  in  health  and  in  disease,  to  consider  tlie  other  symptoms  by  which 
ue  judge  that  such  disease  is  present. 

Among  the  general  symptoms,  then,  of  cardiac  disease,  some  are  direct — as  pain  ; 
palpitation  or  excessive  action  of  the  heart  perceptible  by  the  patient ;  irregular  or 
inlernn'ttent  action,  which  the  patient  may  or  may  not  be  conscious  of:  and  some 
are  indirect,  declaring  themselves  through  the  medium  of  other  parts  and  organs — 
such  are  dyspnoea;  cough;  dropsical  accumulations;  hemorrhages;  various  affec- 
tions of  the  nervous  system,  especially  an  increased  and  morbid  sensibility,  what 
IS  usually  called  nervousness :  and  some  others,  which  I  will  cursorily  notice  as  we 
proceed. 

I  shall  take  this  opportunity  of  considering,  once  for  all,  some  of  these  symptoms  ; 
whether  they  reall}^  proceed  from  organic  disease  of  the  heart  or  not :  for  the  deter- 
mination of  the  question,  whether  they  do  or  do  not  indicate  such  disease,  is  often  of 
great  moment,  and  is  not  always  easy. 

We  are  not,  in  general,  sensible  of  the  beating  of  our  hearts  :  but  when  the  pulsa- 
tions become  inordinately  forcible,  they  make  themselves  felt,  and  the  sensation  is, 
m  many  cases,  a  most  troublesome  and  distressing  one.  Palpitation  implies  increased 
force,  or  increased  frequency — or  an  increase  both  in  force  and  in  frequency — of  the 
contractions  of  the  heart.  Every  one  has  experienced  palpitation  in  his  own  person 
who  has  run  himself  out  of  breath.  The  pulsations  are  sometimes  tumultuous  also, 
and  irregular,  as  well  as  unduly  frequent  and  forcible;  but  this  is  by  no  means  al- 
ways or  necessarily  the  case.  There  may  be  great  palpitation  with  perfect  regularity 
of  the  heart's  action.  The  increased  beating  not  only  can  be  fek  internally  by  the 
patient,  but  it  may  often  be  heard  both  by  himself  and  by  others.  However,  we  do 
meet  with  persons  whose  hearts  throb  with  excessive  violence,  without  their  being  at 
all  aware  of  it.  Such  cases  are  always,  I  believe,  cases  of  disease ;  whereas  the 
palpitations  that  annoy  and  harass  the  patient  are  very  often  connected  with  functional 
disorder  only. 

In  egular  action  of  the  heart  consists  in  some  derangement  or  discord  of  its  rhythmi- 
cal movements,  and  is  discovered  by  the  condition  of  the  arterial  pulse — by  unna- 
tural fluctuations  in  the  strength,  or  in  the  number,  of  its  beatings,  or  in  both.  Some- 
times a  few  rapid  and  feeble  pulsations  occur  at  uncertain  intervals,  and  are  followed 
by  others  that  are  fuller  and  slower.  Sometimes  one  or  more  beats  are  left  out,  and 
the  next  beat,  as  if  to  make  up  for  this  pause,  is  unusually  strong.  The  pulse  is 
then  said  to  intermit.  The  intermissions  may  be  unperceived  by  the  patient  him- 
self; but  in  general  they  are  attended  wi.th  a  singularly  disagreeable  fluttering,  or 
trembhng  sensation  in  the  breast.  The  pulse  may  intermit  though  the  heart  does 
not :  the  ventricle  may  now  and  then  contract  so  faintly  as  not  to  propel  a  wave  of 
blood  so  far  along  the  artery.  Intermission  implies  irregularity  ;  but  the  action  may 
be  irregular  and  disorderly  without  intermitting. 

Now,  any  of  these  deviations  from  the  natural  rhythm  and  action  of  the  heart  alarm 
people  ver}"  much,  and  impress  them  with  a  belief  that  they  have  some  fixed  disease 
of  that  organ  ;  and  you  will  cojitinually  be  appealed  to  for  your  opinion  on  this  point. 
I  suppose  there  are  few  medical  students  who  have  not,  at  some  time  or  other,  ad- 
mitted into  their  minds  the  apprehension  that  they  had  disease  of  the  heart ;  an 
apprehension  engendered  by  its  occasional  palpitation  or  irregularity.  For  though 
there  may  be  palpitation  wuhout  irregularity,  yet  it  is  practically  convenient  to  con- 
sider the  two  together. 

These  deviations  certainly  belong  both  to  organic  disease  and  to  mere  functional 
disorder  of  the  heart;  but  I  repeat,  that  in  a  great  number,  nay,  in  a  great  majority, 
of  the  cases  in  which  they  so  distress  and  alarm  the  patient  as  to  lead  him  or  her  to 
complain  of  them,  tliey  are  unconnected  with  any  change  of  structure ;  and  this  it 
is  of  much  importance  that  you  should  be  aware  of. 

Palpitation  of  the  heart,  and  intermission  or  irregularity  of  the  pulse,  are  often 
dependent  upon  some  disordered  condition  of  the  stomach,  and  will  cease  at  once 
when  that  disorder  is  rectified.  Tt  is  curious  that  this  may  happen  although  the  gas- 
tric afTection  does  not  manifest  itself  by  any  other  symptom :  and  it  is  curious,  too, 
liow  slight  a  cause  may  suffice  to  produce  the  irregular  action.     A  friend  of  mine, 


VENOUS    MURMURS.  669 

a  barrister,  used  to  be  very  anxious  about  himself,  because  a  fluttering  sensation  fre- 
quently occurred  at  his  heart ;  an  intermission  of  one  or  two  beats,  and  then  a  vio- 
lent throb  when  the  organ  again  resumed  its  play.  This  is  a  sensation  very  familiar 
to  myself,  and  probably  most  persons  have  occasionally  experienced  it.  However, 
It  happened  so  often  to  the  gentleman  I  speak  of,  that  it  made  him  very  unhappy. 
He  persuaded  himself  that  he  had  disease  of  the  heart,  and  that  he  should  some  day 
suddenly  drop  down  dead.  But  there  was  no  other  symptom  of  cardiac  disease 
direct  or  indirect,  general  or  physical.  He  was  accordingly  told  that  the  intermis- 
sion depended  upon  some  fault  in  his  digestive  organs ;  and  he  was  advised  to  leave 
off  different  articles  of  food  and  drink  in  succession,  in  order  to  discover  whether 
any  one  thing  in  particular  offended  the  stomach,  and  gave  rise  to  the  symptom.  He 
began  by  abstaining  from  tea,  which  he  had  been  in  the  habit  of  drinking  in  consi- 
derable quantity ;  and  thereupon  the  fluttering  of  the  heart  ceased.  After  a  while 
he  took  to  tea  again,  and  then  the  fluttering  returned.  He  repeated  the  experiment 
many  times,  and  always  with  the  same  result,  till  at  length  his  mind  was  satisfied  ; 
and  by  renouncing  tea  altogether  he  got  rid  of  his  palpitation  and  of  his  apprehen- 
sions. I  mention  this  instance,  because  it  came  within  my  own  cognizance ;  but 
it  is  only  a  sample  of  many  such,  and  tea  is  frequently  found  to  be  the  disturbing 
substance. 

I  must  caution  you,  however,  against  the  mistake,  which  is  often  made,  of  infer- 
ring that  the  heart  is  free  from  orgaiixfi  change  because  its  irregular  movements  are 
accompanied  by  dyspeptic  symptoms.  Structural  disease  of  that  organ  is  very  apt 
to  derange  the  digestive  functions.  You  will  commonly  find  that  patients  who 
labour  under  such  disease  are  exceeoingly  liable  to  flatulence  of  the  stomach  ;  and 
free  eructation  of  the  gas  which  plagued  them  mitigates  wonderfully  the  cardiac  dis- 
tress. It  does  so,  no  doubt,  by  relieving  the  diaphragm  from  that  upward  pressure 
which  embarrassed  the  motions  of  the  heart. 

We  judge  that  palpitations  and  irregularities  are  merely  symptomatic  conse- 
quences of  gastric  disorder,  when  they  occur  occasionally  only ;  when  the  rhj'^thm 
of  the  heart  is  perfect  during  the  intervals ;  and  when  we  fail  to  discover  any  other 
pl^sical  or  general  signs  that  its  texture  has  undergone  alteration. 

Besides  these  overstrong  or  irregular  movements,  Avhich  are  symptomatic  of  dis- 
order of  the  stomach,  and  are  remedied  by  correcting  that  disorder,  there  are  pal- 
pitations of  a  purely  nervous  kind.  *I  mean,  that  they  depend  upon  a  peculiar  and 
highly  sensitive  condition  of  the  nervous  system  ;  which  condition  is  itself  dependent, 
in  general,  upon  a  particular  state  of  the  vascular  system.  Persons  of  a  "movable" 
constitution,  whether  male  or  female,  are  subject  to  these  palpitations  :  but  especially 
young  women  ;  and,  of  these,  such  as  are  pale,  exsanguine,  hysterical,  in  whom  the 
menstrual  functions  are  deficient,  or  excessive,  or  somehow  unnatural.  Ansemia,  if 
not  a  constant,  is  certainly  a  frequent  and  most  remarkable  feature  of  this  nervous 
state.  The  blood  is  aqueous ;  poor  in  fibrin,  and  in  red  particles.  The  age,  and 
frequently  the  sex,  of  the  patient  form  leading  points  in  the  diagnosis.  Nervous 
palpitations  are  apt  to  come  on  when  the  patient  is  quite  at  rest :  palpitations  that 
result  from  organic  disease  are,  on  the  contrary,  always  mitigated  by  repose.  The 
occurrence  of  palpitations  in  the  night,  however,  is  but  an  equivocal  circumstance, 
for  nervous  persons  who  dream,  awake  often  with  palpitation  ;  and  the  recumbent 
posture  generally  excites  or  aggravates  the  palpitations  that  are  organic.  Neither, 
m  forming  our  diagnosis,  can  we  trust  entirely  to  the  presence  or  absence  of  physi- 
cal signs.  The  heaving  impulse  of  hypertrophy  is  indeed  wanting;  but,  as  I  told 
you  formerly,  the  short  abrupt  knock  of  chlorotic  palpitation  is  often  attended  with 
a  bellows  sound.  The  weak  and  flabby  muscle  dilates  (I  fancy),  and  the  natural 
proportion  between  the  chamber  and  its  outlet  is  for  a  time  destroyed.  The  sound 
may  partly  depend  upon  the  thinness  of  the  blood  in  such  patients  ;  and  this  reminds 
me  of  another  diagnostic  clue  which  you  should  be  acquainted  with.  In  nervous, 
susceptible  persons,  especially  if  they  exhibit  the  pallor  of  anaemia,  very  curious 
noises  are  often  audible,  by  means  of  the  stethoscope,  in  the  neck.  Continuous  rush- 
ing or  roaring  sounds,  very  like  those  which  are  to  be  heard  in  shells,  and  whicn 
poets  feign,  and  the  vulgar  beheve,  to  be  the  noise  of  the  distant  sea 


670  DISEASES    OF   THE    HEART. 

Shake  one,  and  it  awakens  ;  then  apply 
Its  polished  lips  to  your  attentive  ear, 
And  it  remembers  its  august  abodes, 
And  murmurs  as  the  ocean  murmured  there. 

Sometimes  the  sound  is  more  like  the  hum  of  a  gnat,  or  the  sighing  of  the  wjnd 
through  a  crevice.  Dr.  Hope  very  truly  states  that  it  may  be  imitated  by  a  pro- 
longed whispering  pronunciation  of  the  syllable  ivho.  Bouillaud,  from  its  resem- 
blance to  the  whizzing  of  a  well-known  toy,  calls  it  the  "  bruit  de  diable."  He  sup- 
posed this  singular  sound  to  reside  in  the  arteries  of  the  neck ;  but  it  is  quite  distinct 
from  the  true  arterial  bellows  murmur;  and  it  has  been  clearly  shown  (tirst  by  Dr. 
Ogier  Ward,  of  Birmingham,)  that  it  is  produced  by  the  descent  of  the  attenuated 
blood  through  the  great  cervical  veins.  The  sound,  though  continuous,  has  often  a 
marked  and  regular  increase,  or  swell,  which  keeps  time  with  the  heart's  systole, 
and  is  believed  to  depend  upon  the  pulsating  pressure  of  the  contiguous  artery.  It 
is  best  heard  on  the  right  side  of  the  neck,  just  above  the  clavicle,  and  just  behind 
the  posterior  edge  of  the  sterno-mastoid  muscle.  You  must  take  care  not  to  pro 
duce  these  sounds,  as  you  easily  may,  by  pressure  with  the  stethoscope.  So,  also, 
you  may  suspend  them  at  your  pleasure,  by  pressing,  above  the  stethoscope,  upon 
the  track  of  the  veins,  so  as  to  stop  the  current  of  blood  through  them,  without 
arresting  the  pulsation  of  the  arteries.  This  proves  that  the  murmurs  are  venous. 
I  have  no  leisure  to  go  more  into  particulars  concerning  these  sounds  ;  but  when  you 
meet  with  them,  concurring  with  cardiac  palpitations,  in  a  young,  nervous,  anasmic 
subject,  the  palpitations,  ninety-nine  times  in  a  hundred,  will  turn  out  to  be  simply 
functional — independent  of  any  organic  disease.  No  doubt  there  may  be  co-existing 
change  of  structure  ;  but  that  is  a  rare  exception,  and,  when  it  does  occur,  the  signs 
proper  to  structural  disease  will  be  present,  and  will  betray  it. 

Now,  these  palpitations,  and  these  musical  or  rushing  sounds  in  the  jugular  veins, 
are  to  be  cured  by  remedying  the  state  of  the  blood.  And  the  remedies  are  prepa- 
rations of  steel,  aloetic  purgatives,  animal  food,  the  cold  shower-bath,  and  exercise 
short  of  producing  great  fatigue,  in  pure  air. 

I  have  further  to  remark,  with  respect  to  intermissions  of  the  heart's  action,  aftd 
therefore  of  the  pulse  at  the  wrist,  that  they  are  frequently  connected,  both  in  health 
and  in  disease,  with  feebleness,  and  also  with  unusual  slowness,  of  pulsation.  So 
that  a  slow  pulse,  which  is  likewise  feeble,  is  often  converted  into  an  intermitting 
pulse  by  depletion ;  by  blood-letting,  for  example,  or  by  an  active  purgative ;  and 
the  intermittence  may  be  removed  again  by  a  stimulant.  I  mention  this  now,  be- 
cause there  is  another  and  very  different  state  of  disease,  in  which  the  pulse  is  apt 
to  intermit.  1  mean  when  there  is  plethora  capitis,  and  cerebral  mischief  is  present 
or  impending.  But  then  the  pulse  will  be  full  and  strong,  and  labouring.  In  these 
cases,  a  stimulant  treatment  would  of  course  be  injurious  ;  while  blood-letting,  which 
would  cause  the  other  form  of  intermission,  is  the  remedy  of  this. 

Some  assistance  in  determining  between  organic  disease  and  mere  functional  dis- 
order of  the  heart,  may  perhaps  be  derived  from  observing  the  position  of  the  patient. 
It  is  stated  that  when  there  is  mere  nervous  palpitation,  the  patient  lies  as  well,  and 
perhaps  better,  on  the  left  side  than  otherwise  ;  whereas,  when  the  heart  is  actually 
diseased,  the  decubitus  on  the  right  side  is  more  comfortable  than  that  on  the  left. 
If  there  be  any  tenderness  of  the  heart,  or  of  its  enveloping  membrane,  the  posture 
on  the  right  side  is  supposed  to  be  the  easiest,  because  the  heart  is  further  removed 
from  the  ribs,  and  impinges  upon  them  during  the  systole  with  less  force.  How- 
ever, no  great  stress  can  be  laid  upon  this  symptom. 

Of  the  remaining  general  symptoms  of  heart-disease  there  is  not  much  to  be  said. 
Dy!>pncea  and  cough  are  indirect  symptoms  declared  through  the  lungs,  between 
which  and  the  heart  there  is  a  close  and  obvious  reciprocal  influence.  But  dyspnoea 
und  cough  are  direct  symptoms  of  pulmonary  disease  ;  and  even  of  pulmonary  disease 
they  scarcely  help  the  precise  diagnosis.  That  disease  of  the  heart  may  materially 
alter  the  quantity  of  blood  that  is  sent  to,  or  transmitted  from  the  lungs,  is  too  plain 
V>  require  any  formal  proof;  and  where  the  quantity  of  blood  in  the  lungs  is  affected, 


I 


DISEASES    OF   THE    HEART.  671 

the  quantity  of  air  necessary  to  ventilate  that  blood  must  vary :  in  other  words,  dysp- 
noea must  ensue.     Hcemoptysis  is  also  an  equivocal  symptom. 

One  very  common  effect  of  cardiac  disease  is  an  impeded  and  sluggish  trans 
mission  of  venous  blood  from  the  abdominal  viscera.  Hence  congestions  of  various 
parts,  and  especially  of  the  liver,  which  enlarges  and  grows  tender;  and  the  biliary 
secretion  and  functions  are  deranged.  These  symptoms  are  a  fruitful  source  of 
mistake,  leading  the  unwary  practitioner  into  the  belief  that  the  whole  of  his  patient's 
malady  is  hepatic ;  whom  he  comforts  accordingly  with  the  assurance  that  "  it  is  all 
liver." 

The  circulation  through  the  brain  is  also  apt  to  be  much  disturbed  in  heart  dis- 
eases ;  and  to  this  circumstance  we  must  attribute  the  headaches  and  giddiness  that 
often  accompany  them ;  the  dread  and  causeless  apprehension  which  such  patients 
frequently  exhibit ;  the  cowardice  and  irritability  which  disease  of  the  heart  engen- 
ders in  men  who  previously  were  intrepid,  and  of  strong  and  firm  nerves ;  also  that 
propensity  to  dreaming,  and  especially  to  distressful  and  frightening  dreams,  so  com- 
monly observable  in  them ;  and  the  sudden  starting  from  sleep  in  horror  and  alarm. 
The  relations  that  exist  between  apoplexy  and  organic  disease  of  the  heart,  were 
full}'-  discussed  in  a  former  lecture. 

One  of  the  most  common  indirect  symptoms  of  cardiac  disease  is  dropsy;  yet, 
sometimes,  the  disease  of  the  heart  may  continue  long,  and  even  prove  fatal,  without 
giving  rise  to  any  dropsy.  It  will  produce  that  symptom,  or  not,  according  as  it 
leads  to  venous  congestion  or  not.  Hence,  dropsy  is  more  particularly  connected 
with  dilatation  and  attenuation  of  the  right  cavities  of  the  heart.  But  these  are 
points  to  which  I  must  revert. 

Having  thus  run  over,  gentlemen,  the  morbid  changes  to  which  the  heart,  as  a 
muscular  organ,  is  liable ;  the  alterations  of  thickness  in  its  walls,  and  of  capacity 
in  its  chambers,  and  the  derangements  of  the  natural  relations  between  the  several 
cliambers  and  their  orifices ;  having  considered,  also,  in  a  brief  and  cursory  man- 
ner, the  sounds  which  the  heart  gives  out  in  its  different  movements  during  health, 
and  the  modifications  to  which  these  sounds  are  subject  in  disease ;  and  having, 
moreover,  passed  in  revietv  the  general  symptoms  which  frequently  display  them- 
selves in  connection  with  cardiac  disease,  we  shall  be  the  better  prepared,  I  hope, 
to  investigate,  when  we  next  meet,  some  of  the  specific  diseases  of  that  important 
organ. 


LECTURE  LX. 

Diseases  affecting  the  muscular  texture  of  the  heart ;  and  their  treatment.  Changes 
to  which  the  valves  of  the  heart  are  subject.  Effects,  and  diagnosis  of  thos« 
changes.     .Angina  pectoris. 

I  KNOW  not  how  I  can  so  well  put  you  in  possession  of  what  I  know,  or  think  cou 
cerning  particular  structural  diseases  of  the  heart,  as  by  taking  them  in  succession, 
and  offering  a  sort  of  running  commentary  upon  them.  The  mechanism  of  those 
structural  changes,  and  the  altered  sounds,  and  the  other  physical  signs,  arising  out 
of  them,  I  endeavoured  to  explain  in  the  last  lecture.  Bear  in  mind  that  in  this 
place  I  can  do  no  more  than  draw  broad  outhnes. 

Simple  hypertrophy  of  the  left  ventricle.  This  sometimes  occurs  when  we  can 
discover  no  mechanical  obstacle  to  the  passage  of  the  blood  out  of  the  ventricle, 
which  might  account  for  it :  none,  I  mean,  by  the  closest  scrutiny  made  even  after 
death.  Is  it  then  possible  that  this  change  may  be  brought  about  by  physical  causes 
which  are  not  perniarient,  and  have  no  place  within  the  body :  such  as  undue  action 
of  the  organ  for  a  length  of  time,  in  consequence  of  habitual  bodily  exertion  ?  A 
runner,  for  example,  vve  may  conceive  to  keep  his  heart  beating  with  a  degree  of 
force  and  frequency  beyond  what  is  natural,  for  the  greater  part  of  the  day;  and  thai 


672  DISEASES    OF    THE    HEART. 

for  many  days,  or  weeks  together.  Again,  can  simple  hypertrophy  grow  out  of  that 
excessive  action  of  the  heart  which  may  be  kept  up,  day  after  day,  fbr  a  long  period 
by  protracted  mental  emotion?  It  is  difficult  to  answer  these  questions.  But  I  pre- 
sume that  causes  of  this  kind — that  any  cause,  in  short,  which  im.plied  long-continued 
uicrease  in  the  function  of  the  organ, — would  suffice  to  generate  hypertrophy.  What 
's  certain,  however,  is  that  such  causes  seldom  do  act  with  sufficient  intensity  and 
constancy  to  produce  these  effects:  and  simple  hypertrophy  of  the  left  ventricle, 
with  no  ph3'sical  obstruction  to  the  flow  of  blood  through  the  heart,  and  no  impedi- 
ment to  the  free  play  of  the  organ,  is  rare. 

We  ascertain  its  existence  when  it  does  exist,  first,  b)"-  the  account  which  the 
patient  gives  of  himself.  He  has  a  sensation  of  beating  of  his  heart,  which  he 
ought  not  to  have ;  he  feels  it,  and  hears  it  beating  as  he  lies  awake  in  bed ;  or  even 
at  other  times  when  he  is  at  rest.  The  pulsations  are  regular.  Hypertrophy  has 
no  tendency  in  itself  to  cause  the  pulse  to  intermit  or  to  become  irregular.  There  is 
no  marked  dyspnoea :  the  circulation  of  the  blood  through  the  lungs  is  not  much  af- 
fected by  this  akeration  of  the  left  ventricle  ;  they  are  in  fact  protected  by  the  mitral 
valve  :  there  is  seldom  any  dropsy :  but  the  arterial  circulation  being  forced,  there  is 
a  tendency  to  active  congestion  in  the  capillary  vessels.  As  there  is  no  mechanical 
obstacle  to  bridle  the  excessive  power  of  the  muscle,  the  pulse  is  full  and  strong;  the 
face  is  florid  ;  the  patient  is  liable  to  headache,  to  bleeding  from  the  nose,  to  active 
hemorrhage,  and  to  local  inflammation.  If  you  listen  to  the  heart  in  such  a  case,  you 
find  that  the  systolic  sound  is  less  loud  and  clear  than  natural.  It  is  not  heard  beyond 
the  prtecordial  region,  nor  even  perhaps  over  its  whole  extent :  but  there  is  no  bel- 
lows sound.  And  if  you  place  your  hand  upon  the  left  breast,  you  feel  that  steady, 
swelling,  incontrollable  impulsion,  which  I  spoke  of  in  the  last  lecture  as  the  surest 
sign  that  I  am  acquainted  with,  of  hypertrophy.  Sometimes  the  prsecordial  region 
is  manifestly  bulging  and  prominent. 

If  I  were  to  preach  for  an  hour  concerning  the  treatment  of  such  cases,  I  could  say 
no  more  than  this :  that  they  require  perfect  quiet  of  mind  and  body  ;  undeviating 
abstinence ;  in  short,  the  strict  observance  of  the  antiphlogistic  regimen  as  formerly 
described ;  and  some  of  the  antiphlogistic  remedies :  particularly  moderate  topical 
bleedings,  often  repeated ;  v\'ith  a  close  attention  to  the  functions  of  the  digestive 
organs.     These  are  the  cases  in  which,  if  any,  we  may  expect  to  cure  hypertrophy. 

If  simple  hypertrophy  of  the  left  ventricle  be  rare,  hypertrophy  of  the  same 
chamber  from  a  mechanical  obstacle,  or  from  some  hindrance  to  the  easy  working 
of  the  hydraulic  machine,  is  exceedingly  common.  What  difl^erence,  then,  let  ua 
inquire,  is  made  in  the  symptoms,  in  the  treatment,  and  in  the  prospect  of  recovery, 
by  the  presence  of  a  physical  impediment,  out  of  which  the  hypertrophy  has  grown  ? 

The  mechanical  impediment  will  frequently  signify  its  existence,  by  causing  some 
unnatural  sound :  a  systolic  bellows  sound  most  commonly,  which  is  audible  over 
the  sternum,  along  the  course  of  the  aorta.  And  the  mechanical  impediment  will 
tend  to  cause  faltering  of  the  pulse;  but  generally  the  hypertrophy  corrects  that 
tendency.  So,  on  the  other  hand,  the  mechanical  obstacle  corrects  the  tendency  of 
the  hypertrophy  to  cause  active  capillary  congestion :  and  when  the  obstacle  is  con- 
siderable, it  will  prevent  the  pulse  from  being  so  full  and  strong  as  in  the  former 
case.  If  to  the  physical  signs  of  hypertrophy  of  the  left  ventricle  there  be  added  a 
bellows  sound,  and  a  disproportionate  smallness  and  feebleness  of  the  pulse  at  the 
wrist,  we  may  safely  conclude  that  there  is  some  impediment  to  the  escape  of  the 
blood  from  the  left  ventricle  into  the  aorta ;  and  that  this  impediment  has  given 
occasion  to  the  hypertrophy. 

Now,  in  this  case,  the  hypertrophy  is  really  an  endeavour  towards  health.  The 
mcreased  power  of  the  ventricle  compensates  for  the  bar  which  is  opposed  to  the 
current  of  the  blood.  The  blood  would  not  be  able  to  goon  without  the  hypertrophy. 
There  would  ensue  a  tendency  to  stagnation  in  the  circulation,  a  faltering  pulse,  im- 
perfect arterialization  of  the  blood,  blue  cheeks  and  lips,  dyspncea,  dropsy ;  but  the 
augmentation  of  bulk  and  force  in  the  impelling  muscle  obviates  this ;  obviates  it  at 
least  for  a  while  :  puts  off"  the  evil  day  to  a  distance.  Since  this  is  the  case,  and 
since  rt'e  have  no  means  of  removing  the  mechanical  impediment,  we  should  be  mad 


DISEASES    OF    THE    HEART.  673 

to  desire  the  cure  of  the  hypertrophy,  which  is  to  a  certain  degree  a  remedy  for  the 
impediment;  nor  indeed  could  we  cure  it  if  we  would.  But  we  have  to  endeavour 
to  keep  it  within  due  bounds.  If  the  beating  be  troublesome  to  the  patient,  we  may 
alleviate  that  symptom,  and  check  what  there  may  be  unnecessarily  active  in  the 
contractions  of  the  morbid  chamber,  by  abstracting  blood  from  the  pra:!Cordia  by 
leeches  ;  and  by  sohciting  the  action  of  the  kidneys,  by  means  of  cooling  diuretics, 
among  which  small  doses  of  digitalis  may  find  an  appropriate  place.  The  labouring 
action  of  the  heart  is  sometimes  calmed  by  the  application  of  a  belladonna  plaster. 
In  this  variety,  also,  of  the  disease,  it  is  of  primary  importance  that  no  undue  efforts 
of  the  body  be  made,  and  that  the  patient  be  protected,  as  much  as  possible,  against 
all  causes  of  mental  emotion  ;  that  scrupulous  temperance  be  enforced  ;  and  that  all 
the  functions  of  the  body  be  carefully  watched  and  regulated. 

These  are  not  cases  in  which  we  can  look  for  recovery:  but  they  are  cases  which 
bad  management  and  imprudent  habits  may  hurry  on  to  a  fatal  termination;  and 
which  judicious  treatment  and  a  well-regulated  course  of  living  may  render  tolerable, 
and  carry  forwards  for  a  considerable  period. 

Under  the  same  condition  of  mechanical  impediment,  we  oftener  have  eccentric 
hypertrophy  of  the  left  ventricle  ;  hypertrophy,  i.  e.,  with  dilatation.  Of  course  the 
bulk  of  the  whole  organ  is  augmented  by  both  of  those  conditions ;  and  sometimes  it 
becomes  enormous,  as  big  as  that  of  a  bullock.  The  symptoms  will  differ  somewhat, 
according  as  the  hypertrophy,  or  the  dilatation  preponderates,  and  tiierefore  it  will 
be  as  well  to  state  here  what  are  the  symptoms  of  simply  dilated  ventricles.  They 
are  a  diminished  imptdse  of  the  heart's  action;  and  therewith  a  clearer  sound  than 
IS  natural.  The  first  sound  approximates  to  that  of  the  heart's  diastole  ;  to  the 
clacking  second  sound,  and  it  is  heard  extensively.  There  is  more  or  less  tendency 
to  fluttering  palpitations  and  irregularities  of  the  pulse,  which  is  usually  weak  and 
small ;  to  faintness  and  debility,  and  to  coldness  of  the  extremities:  and  when  the 
right  ventricle  is  dilated,  there  are  some  other  symptoms  which  I  shall  notice 
presently. 

Now,  I  say,  there  will  be  a  mixture  or  modification  of  the  symptoms,  when  the 
left  ventricle  is  both  dilated  and  hypertrophic.  The  dilatation  will  aid  the  mechanical 
impediment  in  giving  a  tendency  to  irregularity  and  intermission  of  the  pulse ;  and 
the  hypertrophy  will  tend  to  rectify  that  disposition.  And  we  must  trim  our  man- 
agement of  such  cases  accordingly.  If  the  pulse  flutters,  we  cautiously  administer 
tonics,  or  stimulants :  if  it  is  steady,  and  the  signs  that  belong  to  simple  hypertro- 
phy predominate,  and  are  excessive  and  troublesome,  we  must  starve  the  patient, 
take  blood  from  his  side,  purge  him,  and  give  him  diuretics;  but  at  all  times  keep 
him  as  tranquil  as  we  can. 

Simple  hypertrophy  of  the  right  ventricle  is  not  a  common  disease.  When  it 
occurs,  it  results  from  some  actual  or  virtual  impediment  to  the  passage  of  the  blood 
from  the  ventricle  into  the  lungs.  The  most  extreme  instance  of  it  that  I  ever  saw, 
was  in  the  heart  of  a  medical  friend's  son,  who  died  at  the  age  of  seventeen  ;  having 
been  for  many  years  affected  with  the  morbus  cseruleus  as  it  has  been  called,  i.  e., 
an  habitual  blue  state  of  the  cheeks,  lips,  and  tongue,  finger-nails,  and  the  skin 
generally ;  attended  with  shortness  of  breath,  and  augmented  by  every  kind  of  ex- 
ertion. It  is  seldom  that  persons  thus  affected  live  so  long  as  this  poor  boy  did. 
The  heart,  as  is  usual  under  such  circumstances,  was  malformed.  The  septum 
between  the  ventricles  was  imperfect  at  its  upper  part ;  and  the  aorta  belonged  as 
much  to  the  one  ventricle  as  to  the  other.  The  pulmonary  artery  would  not  admit 
a  goose-quill ;  the  walls  of  the  right  ventricle  were  as  thick  as  those  of  the  left. 

Authors  tell  us  that  hypertrophy  of  the  right  ventricle  of  the  heart  is  a  cause  of 
pulmonary  apoplexy.  I  explained  to  you  in  a  former  lecture  why  I  cannot  believe 
in  this  doctrine.  In  the  first  place  I  say  that  the  increased  thickness  and  strength 
of  the  walls  of  that  chamber  supply  a  measure  of  the  difficulty,  and  not  of  they'ree- 
dom  and  force,  with  which  the  blood  is  conveyed  to  the  lungs.  In  the  second  place 
pulmonary  apoplexy  does  not  result  from  rupture  of  vessels  by  the  vis  a  tergo,  nor 
in  general  from  rupture  of  vessels  at  all ;  and  therefore  is  a  quite  different  lesion 
from  cerebral  appoplexy.  It  is  simply  an  accident  of  pulmonary  hemorrhage.  Ana 
43  3o 


C74  DISEASES    OF    THE    HEART. 

lastly,  I  never  met  with  pulmonary  apoplexy  coincident  with  mere  hypertrophy  of 
the  right  ventricle.  The  right  ventricle  lies  on  this  side  the  lungs,  in  the  order 
of  the  circulation  ;  and  accordingly,  following  the  rule  I  mentioned  in  the  last  lec- 
ture, its  morbid  states  are  for  the  most  part  effects,  and  not  causes  of  pulmonary 
disease. 

The  commonest  affection  of  the  right  ventricle  is  dilatation  without  any  increase 
of  thickness,  but  with  attenuation  even,  of  its  muscular  parieles.  This  is  in  general 
the  consequence  oi  long  standing  pulmonary  disease  ;  which  has  prevented  the  easy 
passage  of  the  blood  out  of  the  right  ventricle.  It  is  often,  or  ultimately  attended 
with  dilatation  of  the  right  auricle,  and  of  the  jugular  veins,  which  stand  out  in 
relief  from  the  sides  of  the  neck,  and  exhibit  an  undulating  sort  of  pulsation,  pro- 
duced by  the  regurgitation  of  a  part  of  the  blood,  whenever  the  ventricle  contracts. 
I  have  taken  from  the  neck  of  a  person  dead  of  such  disease,  veins  into  which  I 
could  pass  my  forelinger.  With  all  this  there  is  a  fluttering  action  of  the  heart,  an 
irregular  pulse,  great  distress  and  shortness  of  breathing,  a  dusky  skin,  and  blueness 
of  the  countenance,  which  is  bloated  and  anxious:  and  a  tendency  to  delirium  and 
drowsiness ;  while,  sooner  or  later,  the  whole  areolar  tissue  of  the  body  becomes 
charged  with  accumulated  serum.  Some  degree  of  this  may  now  and  then  be 
noticed  towards  the  fatal  close  of  phthisis.  Much  oftener  it  accompanies  the  latter 
periods  of  extensive  pulmonary  emphysema.  The  same  condition  of  the  right  cham- 
bers, producing  the  same  afflictive  consequences,  is  the  very  frequent  sequel  of 
organic  changes  that  originated  in  the  left  side  of  the  heart. 

Disease,  such  as  I  am  now  describing,  in  its  advanced  stages  especially,  is  diiScult 
to  treat.  If  you  stimulate,  you  run  the  risk  of  increasing  the  patient's  distress ;  if 
you  deplete,  you  incur  the  hazard  of  producing  fatal  syncope,  of  bringing  the  heart 
to  a  pause  from  which  it  is  never  able  to  recover.  Here,  again,  you  must  try  lo  keep 
the  kidneys  active ;  you  must  enjoin  that,  as  far  as  may  be  possible,  all  causes  of 
agitation  or  hurry,  everj'thing  which  has  previously  been  found  prejudicial  to  the 
patient,  may  be  sedulously  warded  off.  I  have  found  more  benefit  in  these  cases 
from  steel  cautiously  employed,  than  from  any  other  drug.  Without  forcing  the 
heart's  action,  it  appears  to  have  the  effect  of  increasing  the  tone  of  its  muscle ; 
which  it  thus  enables, ybr  a  lime,  to  compete  more  successfully  with  the  load  it  has 
to  carry,  and  the  impediment  which  it  cannot  overcome.  We  can  do  no  more  in 
such  cases  than  palliate. 

Sometimes  the  parietes  of  one  or  of  the  other  ventricle  becomes  so  thin — either  in 
consequence  of  dilatation  with  tenuity,  or  through  ulceration  of  the  muscular  tissue- 
as  to  bulge  out  into  a  pouch,  or  even  to  crack ;  in  which  case  the  patient  almost 
always  dies  suddenly,  the  motion  of  the  organ  being  stopped  and  strangled  by  the 
effusion  of  blood  into  the  pericardium ;  so  that  to  die  of  a  broken  heart,  is  not  a  mere 
metaphor.  A  clergj'man  from  the  country,  whom  I  previously  knew,  called  at  my 
house  in  the  autunm,  and  waited  some  time  in  my  absence  ;  but  went  away  at  last 
without  seeing  me :  and  after  consulting  Dr.  James  Johnson,  set  out  for  his  home, 
ten  miles  on  the  other  side  of  Colchester.  He  had  been  unwell  for  some  time  ;  had 
suffered  occasional  attacks  of  dyspnoea;  and  was  unusually  nervous  and  irritable. 
He  must  have  been  conscious  of  some  severe  distress,  for  he  was  extremely  anxious 
to  get  home,  and  bribed  the  post-boys  to  drive  fast.  As  soon  as  he  reached  his  own 
house,  he  took  some  supper,  and  went  to  bed,  apparently  comfortable.  Half  an  hour 
afterwards  one  of  his  servants  went  to  him,  and  found,  him  asleep.  At  the  expiration 
of  another  half-hour,  he  was  again  visited,  and  was  then  a  corpse.  Among  other 
changes,  the  pericardium  was  full  of  blood,  which  had  escaped  from  the  heart  through 
a  rent  in  the  left  ventricle,  large  enough  to  admit  one's  finger.  That  part  of  the 
ventricle  which  surrounded  the  laceration,  was  unnaturally  thin,  to  the  extent  of  a 
crown-piece.  There  are  several  specimens  of  rupture  of  the  left  ventricle  in  the 
Museum  at  St.  Bartholomew's  Hospital.  George  II.  died  of  rupture  of  the  heart. 
It  is  curious  enough  that  a  Duchess  of  Brunswick,  of  the  same  family  with  George 
II.,  died  of  the  same  disease.  In  her  case  an  ulcer  penetrated  the  parietes  of  the 
'ight  ventricle,  which  in  other  respects  was  healtny.  In  most  instances,  the  rupture 
has  taken  place  in  the  left  ventricle.   The  same  chamber  is  also  liable  to  aneurisma . 


DISEASES   OF   THE   HEART. 

that  is,  to  partial  distension  of  its  walls  into  lateral  cells  or  pouches.     This  form  of 
disease  has  not  been  met  with  in  the  right  ventricle. 

Hypertrophy — or  dilatation — or  dilatation  and  hypertrophy — may  affect,  in  their 
various  degrees  and  combinations,  one  chamber  only  of  the  heart ;  or  several  at  the 
same  time  ;  or  all  of  them  together.  It  would  be  vain  to  attempt  to  represent,  in 
verbal  description,  these  complicated  changes.  Enough,  I  trust,  has  been  said,  to 
enable  you  to  unravel  them  when  they  come  before  you ;  and  to  ascertain,  with 
sut'ficient  exactness,  the  general  indications  which  they  severally  furnish,  and  the 
plan  of  treatment  which  they  require. 

You  will  often  find  the  muscular  substance  of  the  heart  pale,  soft,  and  flabby; 
easily  broken  down,  or  penetrated  by  pressure.  This  may  occur  with  general  de- 
bihty  and  looseness  of  tissue ;  it  sometimes  accompanies  a  plentiful  deposit  of  fat 
about  the  organ  :  and  it  is  supposed  to  be  sometimes  also  a  consequence  of  inflam- 
mation affecting  the  muscle.  Walls  thus  soft  are  likely  to  yield  under  pressure ; 
but  I  know  of  no  particular  symptom  by  which  we  can  detect  such  a  state  of 
softening. 

The  morbid  conditions  of  which  I  have  been  speaking,  involving  the  muscular 
substance  of  the  heart,  spring  very  frequently  indeed  from  pre-existing  morbid  con- 
ditions of  the  membrane  lining  the  heart,  or  of  the  membrane  investing  the  heart. 
It  is  necessary  therefore,  in  the  next  place,  to  inquire  into  the  nature  and  history  of 
these  morbid  changes :  and  I  will  first  request  your  attention  to  the  diseases  of  the 
Jning  membrane.  The  investing  membrane  is  familiar  to  you  as  the  pericardium. 
Of  late  years,  since  the  diseased  states  of  the  internal  membrane  have  been  more 
studied  and  understood  than  they  formerly  were,  it  has  been  called  the  endocardium: 
a  convenient  enough  name,  which  may  occasionally  spare  us  circumlocution.  Now, 
certain  parts  of  the  endocardium  are  much  more  obnoxious  to  disease  than  others : 
those  parts  which  enter  into  the  fabric  of  the  valves  and  orifices  of  the  organ.  The 
membrane  is  here  in  close  contact  with  a  dense  fibrous  tissue;  and  participates  in 
the  changes  to  which  that  tissue  is  subject.  And  it  is  an  important  fact,  that  the 
valves  and  orifices  of  the  left  side  of  the  heart  are  much  more  frequently  affected 
with  disease  than  those  of  the  right  side.  I  have  adverted  to  this  fact  before.  What 
is  the  prevaiHng  cause  of  it  I  cannot  tell ;  but  it  seems  to  be  a  portion  of  a  more 
general  fact ;  namely,  that  the  arteries  are  more  liable  to  chronic  morbid  changes 
than  the  veins.  Some  explain  the  difference  by  alleging  that  the  left  side  of  the 
heart  has  the  heavier  task  to  accomplish.  But  nature  seldom  executes  her  purposes 
so  clumsily,  as  not  to  adjust  the  strength  of  her  machinery  to  the  labour  it  is  destined 
to  perform.  Others  remark  that  fibrous  tissue  is  more  abundant,  and  therefore  the 
changes  proper  to  that  tissue  are  more  numerous  and  extensive  on  the  left  side.  And 
this  may  be  the  true  explanation.  Others,  again,  have  conjectured  that  the  arterial 
blood  is  more  irritating  than  the  venous.  But  there  is  no  evidence  of  this  :  and  it  is 
better  to  content  ourselves  with  noticing  the  fact,  without  attempting  to  account  for 
it  by  mere  gratuitous  hypothesis. 

You  are  not,  however,  to  suppose  that  the  right  side  is  exempt  from  valvular  dis- 
ease. When  there  is  much  change  on  the  left,  we  often  find  a  less  degree  of  the 
Fame  kind  of  change  upon  the  right.  The  valves  of  the  pulmonary  artery  are,  per- 
haps, the  least  frequently  of  all  the  valves  found  otherwise  than  healthy. 

Many  of  the  alterations  that  take  place  in  the  internal  lining  of  the  heart  result, 
apparently,  from  inflammation,  which  causes  a  deposit  of  lymph  upon  or  beneath 
the  serous  membrane.  The  valves  are  apt  to  lose  their  thinness,  and  transparency, 
and  pliancy.  They  become  thick,  stiff,  puckered,  curled  up,  or  glued  to  each  other, 
or  to  the  opposite  walls  of  the  channel.  On  the  other  hand,  quite  independently 
of  inflammation,  they  may  become  morbidly  thin,  riddled  with  holes,  and  even 
rent  asunder.  What  are  called  vegetations  or  excrescences  may  also  project  from 
them,  very  much  resembling  warts.  Or  they  may  be  converted  wholly  or  partly 
into  bone. 

Alterations  of  some  kind  or  another  are  very  frequent  in  the  semilunar  valves  of 
the  aorta.  When  they  are  of  such  a  nature  as  to  diminish  the  orifice  during  the 
systole,  they  commonly  occasion  a  systolic  bellows  sound.     When  the  diseased 


676  DISEASES    OF   THE   HEART. 

valves  offer  no  obstruction  to  the  exit  of  blood  from  the  ventricle,  but  do  not  close 
again  immediately  afterwxirds,  so  as  effectually  to  prevent  the  reflux  of  that  fluid 
from  the  aorta,  they  commonly  give  rise  to  a  diastolic  bellows  sound.  When  both 
these  defects  of  function  occur,  there  is  often  a  double  bellows  sound  ;  a  sawing 
alternate  noise  ;  one  murmur  during  the  systole,  another,  distinguishable  in  tone  and 
quality,  as  well  as  in  time,  during  the  diastole.  These  sounds  are  conveyed  along 
the  tube  in  which  they  are  formed,  and  are  therefore  most  audible  in  the  track  of 
the  aorta,  as  it  leaves  the  heart.  If  the  sound  be  diastolic,  it  will  take  the  place  of 
the  smart  clack  of  the  second  sound  of  the  heart,  or  perhaps  succeed  it.  Sometimes 
the  new  sound  is  very  loud  and  curious.  I  had  a  patient  in  the  hospital  last  year, 
in  whom  this  diastolic  sound  was,  in  character  and  intensity,  like  the  cooing  of  a 
pigeon.  The  patient  could  plainly  hear  it ;  nay,  it  could  be  heard  by  a  person 
standing  near  him,  but  not  touching  his  body,  even  with  a  stethoscope.  In  that  in- 
stance we  found  one  of  the  aortic  valves  irregularly  thickened,  with  its  free  edge 
loose  and  flapping,  and  unable  to  fulfil  its  function  of  closing  the  aperture.  During 
the  diastole  it  was  retroverted,  and  vibrated  in  the  regurgitating  stream  of  blood ; 
and  thus,  no  doubt,  the  musical  note,  heard  alternately  with  the  first  sound,  was 
produced.  In  March,  1837,  I  heard  in  a  man  (Henry  Milton)  who  was  under  Dr. 
Latham's  care  in  St.  Bartholomew's  Hospital,  and  who  had  had  acute  rheumatism, 
a  very  shrill  diastolic  sound,  like  the  repeated  whining  of  an  imprisoned  puppy-dog 
wishing  to  be  released.  This  remarkable  sound  was  audible  by  means  of  the  stetho- 
scope, even  in  the  radial  artery.  The  patient  died  at  last  in  St.  George's  Hospital, 
and  his  case  is  mentioned  in  Dr.  Hope's  book  on  the  heart.  One  of  the  aortic  valves 
was  torn  downwards  to  some  distance  from  its  edge,  and  formed  a  flap,  which  was 
perforated  by  a  round  hole. 

I  need  not  again  point  out  to  you  the  manner  in  which  such  disease  of  these  semi- 
lunar valves  tends  to  produce  hypertrophy  and  dilatation  of  the  left  ventricle. 

The  niitrul  valve  is  often  thickened  ;  and  it  is  particularly  subject,  more  so  even 
than  the  aortic  valves,  to  ossification.  And  the  effects  of  the  ossification  are  to  pre- 
vent its  closing  the  auricular  orifice  durmg  the  systole  ;  and  to  prevent  its  lying-  flat 
against  the  walls  of  the  ventricle,  and  allowing  a  free  passage  of  the  blood  out  of  the 
left  auricle,  during  the  diastole.  The  orifice  is  often  converted  into  an  unvarying 
oval  slit,  with  puckered  edges,  and  resembling  a  button-hole  ;  or  the  valve  projects, 
like  a  thimble  of  bone,  into  the  left  ventricle.  And  it  is  remarkable  how  small  the 
chink,  which  is  thus  permanent,  may  be,  and  yet  life  go  on.  The  heart  having  been 
taken  out  of  the  body,  and  the  auricle  filled  with  water,  I  have  seen  the  water  pass 
into  the  ventricle,  by  its  gravity,  stillathn  ;  drop  by  drop. 

Let  me  just  remind  you,  that  the  direct  and  necessary  consequence  of  constriction 
of  the  mitral  orifice,  is  an  accumulation  of  blood  behind  it ;  i.  e.,  in  the  left  auricle, 
in  the  pulmonary  veins,  in  the  lungs.  Hence  so  much  mechanical  congestion,  that 
the  blood  bursts  at  length  through  the  bronchial  membrane ;  hemorrhage,  slow  or 
copious,  ensues  from  the  air-passages ;  and  pidmonary  apoplexy  is  formed. 

In  extreme  cases,  where  the  mischief  is  chiefly  confined  to  that  valve,  the  blood 
necessarily  reaches  the  ventricle  in  a  penurious  manner ;  that  chamber  contracts  un- 
steadily and  irregularly ;  and  its  cavity  sometimes  diminishes.  This  I  think  I  have 
seen.  But  far  more  commonly  there  is  disease  of  the  aortic  valves  also;  and  the 
condition  of  the  left  ventricle  is  that  of  hypertrophy  with  dilatation. 

When  there  is  a  permanent  chink  in  place  of  the  limber  valve,  there  may  be  a 
double  bruit.  The  first  heard  during  the  systole,  and  produced  by  the  regurgitation 
of  blood  from  the  ventricle  into  the  auricle,  through  the  rigid  slit.  This  is  common. 
The  second  accompanying  the  diastole,  and  resulting  from  the  mechanical  impedi- 
uient  to  the  free  passage  of  the  blood  from  the  auricle  into  the  ventricle.  This  is 
uncommon.  The  constriction  must  be  great  for  the  diastolic  murmur  to  occur  a* 
all :  and  when  it  does  occur,  it  is  faint ;  from  the  comparative  feebleness  (I  presume) 
of  the  auricular  contractions. 

The  fonn  and  the  consistence  of  the  altered  valves  being  the  same,  no  difference 
whatever  in  the  sounds,  or  in  the  general  symptoms,  will  arise  from  the  particulai 
nature  of  the  changes.     It  will,  1  mean,  make  no  difference  whether  the  obstacle  to 


I 


DISEASES    OF    THE    HEART.  677 

rhe  flowing  blood,  or  the  imperfect  closure  of  the  orifice,  depends  upon  mere  thicken- 
ing of  the  valve  by  cartilaginous  deposition,  or  upon  ossification,  or  upon  wart-like 
vegetations.  These  last  may  be  found  upon  any  of  the  valves,  but,  like  other 
morbid  states,  they  are  less  frequent  on  the  right  than  on  the  left  side  of  the  heart  • 
«nd  they  are  most  common  of  all  on  the  aortic  valves.  Ossification — the  deposition 
of  the  phosphate  of  lime — is  almost  confined,  I  believe,  to  the  left  side.  I  never  saw 
the  tricuspid  valve,  or  the  semilunar  valves  of  the  pulmonary  artery,  converted  into 
bone. 

The  warts,  or  w^art-like  excrescences,  which  are  so  often  found  upon  the  valves 
of  the  heart,  are  very  curious  things.  Sometimes  they  are  separate,  like  rows  of 
beads.  Sometimes  several  appear  to  spring  from  a  common  base,  which  spreads 
out  so  as  to  exhibit  a  cauliflower  appearance.  And  occasionally  they  hang  in  long 
strings  from  the  valve  into  the  adjoining  chamber  of  the  heart.  In  a  patient  of  Dr. 
Hawkins',  I  saw  a  cylindrical  excrescence  of  this  kind  which  measured  an  inch  in 
length.  The  valves  presented  sht-like  perforations ;  and  from  the  edge  of  one  of 
these  slits  in  the  mitral  valve,  this  long  vegetation  dangled  into  the  ventricle.  The 
whole  of  the  valves  of  the  aorta  were  covered,  on  their  ventricular  surface,  with 
similar  but  shorter  excrescences. 

They  vary  much,  these  vegetations,  in  consistence.  Sometimes  they  are  soft, 
easily  crushed,  and  capable  of  being  readily  detached  from  the  smooth  surface  of  the 
valve.  Others  are  more  firm,  and  yet  separable  from  the  valve  without  injury  to  it. 
Others,  again,  are  so  adherent,  so  rooted  into  the  valves,  that  they  can  be  removed 
only  by  tearing  or  cutting  them  off.  They  are  found  sometimes  on  the  free  edge 
of  the  valves ;  sometimes  on  their  surface,  or  even  on  the  inner  membrane  of  one 
of  the  chambers,  especially  of  the  left  auricle. 

Much  difference  of  opinion  has  prevailed  respecting  the  nature  and  origin  of  these 
singular  appearances.  It  was  a  common  notion  among  the  French,  at  one  time,  that 
they  were  really,  what  they  so  much  resemble,  venereal  warts.  What  seems  to  be 
certain  is,  that  they  are  somehow  connected  with  inflammation  of  the  internal  lining 
of  the  heart ;  and  of  that  which  covers  the  valves  in  particular.  But,  then,  are  they 
lymph  poured  out  from  the  inflamed  membrane  ?  or  are  they  fibrin  deposited  from 
the  blood  upon  an  inflamed  membrane  1  It  is  probable  that  the  last  is,  sometimes 
at  least,  the  true  explanation  of  their  origin.  You  know,  that  when  the  membrane 
lining  a  vein  becomes  inflamed,  the  blood  in  contact  Avith  it  has  a  strong  tendency  to 
coagulate  upon  it,  and  to  adhere  to  it.  The  fleshy  excrescences  found  on  the  valves 
are  often  attached  to  the  edges  of  slits  in  the  valve :  the  broken  surface  having  pro- 
bably been  the  especial  seat  of  inflammation.  When  then  the  formation  of  vegeta- 
tions is  recent,  they  are  very  soft  and  frangible.  But  the  most  interesting  fact  that  I 
am  acquainted  with,  in  evidence  of  the  mode  in  which  these  little  projections  arise, 
is  one  that  accidentally  came  to  light  in  one  of  Dr.  Hope's  experiments  upon  an  ass, 
at  which  I  was  present.  The  aortic  valves  had  been  held  back  by  a  wire  passed 
into  the  vessel,  with  the  view  of  ascertaining  the  physical  cause  of  the  second  sound. 
The  animal  was  previously  rendered  insensible  by  a  narcotic  poison ;  and  the  circu- 
lation was  kept  up — languidly,  however,  towards  the  last — by  artificial  respiration. 
Upon  the  final  cessation  of  the  heart's  motions,  the  organ  was  removed  from  the 
body  and  exammed :  and  the  valve  that  had  been  mechanically  irritated  by  the 
wire,  was  found  studded  with  these  little  wart-like  appearances,  which  were  so  soft 
as  to  admit  of  being  readily  brushed  off  from  the  subjacent  membrane.  Here  the 
deposit  took  place  after  the  death  of  the  animal,  and  while  some  of  the  functions  of 
organic  hfe  alone  were  kept  up  by  the  artificial  breathing. 

There  are  still  some  curious  circumstances  to  be  mentioned,  connected,  in  some 
instances,  with  the  formation  of  these  warty  vegetations.  I  shall  not,  however,  enter 
upon  them  in  the  present  lecture :  but  when  I  speak,  at  our  next  meeting,  of  rheu 
matic  inflammation  of  the  heart  and  its  membranes. 

Any  or  all  of  the  lesions  that  I  have  been  describing  may  and  must  lead,  at  lengtli, 
according  to  their  places  and  magnitude,  to  some  of  those  changes  in  the  actual  and 
relative  dimensions  of  the  heart  that  were  considered  in  the  last  lecture.  They 
obstruct  the  stream  of  blood  when  moving  in  its  natural  course,  and  when  its  passage 

3g3 


678  DISEASES    OF    THE    HEART. 

ought  to  be  free  ;  or  they  allow  of  its  refluent  course,  when  it  ought  to  be  effectually 
opposed  :  and  the  necessary  results,  in  either  case,  are  dilatation  of  one  or  more 
of  the  chambers  of  the  heart,  with  thickening,  or  with  attenuation,  as  the  case  may 
be,  of  its  walls.  I  have  already  spoken  of  the  symptoms,  physical  and  general,  to 
which  these  secondary  changes  give  rise ;  and  of  the  treatment  which  they  admit 
and  require. 

There  being  valvular  disease,  and  that  valvular  disease  giving  rise  to  a  bellows 
sound,  can  we  distinguish  the  particular  valve  affected  ?  Generally,  we  can.  Our 
skill  in  diagnosis  outruns  here,  as  indeed  it  too  often  does,  our  skill  to  cure.  A  few 
simple  rules  and  considerations  enable  us,  in  most  cases,  to  satisfy  our  natural  curi- 
osity to  penetrate  the  exact  conditions  even  of  changes  that  are  incapable  of  repair. 
These  rules  relate  chiefly  to  the  time  when  the  murmur  is  heard  ;  to  the  direction  in 
which  it  is  most  audible ;  and  to  the  state  of  the  arterial  pulse. 

When  a  bellows  sound  accompanies  the  systole,  it  must  be  caused  by  a  current 
passing  out  of  a  ventricle.  But  serious  disease  of  the  valves,  sufficient  to  occasion 
a  murmur,  on  the  right  side  of  the  heart,  is  very  rare.  In  nineteen  cases  out  of 
twenty,  valvular  murmurs  belong  to  the  left  side;  so  that  practically  the  distinction 
lies,  almost  always,  between  two  orifices,  the  mitral  and  the  aortic,  the  inlet  and  the 
outlet  of  the  left  ventricle.  The  natural  inlet  has  become  an  outlet  also:  or  the 
natural  outlet  is  obstructed.  Now  if  the  sound  be  heard  at  the  base  of  the  heart, 
and  along  the  track  of  the  thoracic  aorta,  up  towards  the  right  clavicle,  and  even  in 
the  carotids ;  and  if  it  be  less  audible  towards  the  apex,  and  if  the  pulse  be  steady 
and  regular,  the  mischief  is  seated  in  the  semilunar  valves  of  the  aorta :  there  is 
some  obstacle  which  produces  a  ripple  in  the  onward  stream  of  the  blood. 

On  the  other  hand,  if  the  pulse  be  irregular,  and  if  the  sound  be  heard  better 
towards  the  apex  of  the  organ,  on  the  left,  it  is  owing  to  regurgitation  through  a  dis- 
eased mitral  valve.     Such  regurgitation  is  often  attended  with  a  purring  thrill. 

When,  what  scarcely  ever  happens,  the  sound  does  result  from  injury  of  the 
semilunar  valves  of  the  pulmonary  artery,  it  is  heard  plainest  in  the  track  of  that 
vessel,  up  towards  the  left  clavicle.  So  also  a  murmur  produced  by  change  in  the 
tricuspid  valve  would  be  loudest  towards  the  apex,  on  the  right.  The  arterial  pulse, 
for  obvious  reasons,  is  but  little  influenced  by  disease  affecting  the  orifices  of  the 
right  heart. 

Again,  if  the  morbid  sound  be  diastolic,  it  accompanies  the  entrance  of  blood  into 
a  ventricle  ;  and  for  similar  reasons  as  before,  the  fault  is  most  probably  in  the  left 
ventricle.  It  may  be  owing  to  the  direct,  but  impeded,  passage  of  the  blood  from 
the  left  auricle  through  a  narrowed  mitral  orifice :  yet  this  very  seldom  occasions 
any  audible  noise.  Or  the  diastolic  murmur  may  proceed  from  regurgitation  through 
the  defective  aortic  valves  :  the  natural  outlet  having  become  an  inlet  also :  and  this 
is  exceedingly  common.  We  attend,  as  before,  to  the  situation  and  the  track  in 
which  the  sound  is  the  loudest.  We  listen  also  for  the  smart  clack  of  the  natural 
second  sound  ;  and  if  it  is  not  to  be  heard,  or  is  verj'  indistinct,  we  have,  in  that  cir- 
cumstance, corroborative  evidence  of  an  imperfect  aortic  flood-gate.  Moreover,  we 
are  again  assisted  by  the  pulse.  The  pulse  of  aortic  regurgitation  is  very  striking 
and  peculiar :  sudden,  like  the  blow  of  a  hammer,  without  any  prolonged  swell  of 
the  artery.  It  always  reminds  me  of  the  well  known  chemical  toy,  formed  by 
including  a  small  quantity  of  liquid  in  a  glass  tube,  exhausted  of  air,  and  hermeti- 
cally sealed.  On  reversing  the  tube,  the  liquid  falls  from  one  end  of  it  to  the  other 
with  a  hard  short  knock,  as  if  it  were  a  mass  of  lead.  The  sensation  given  to  the 
finger  by  the  pulse,  when  there  is  much  regurgitation  through  the  aortic  valves,  is 
very  similar  to  this.  It  is  as  if  successive  balls  of  blood  were  suddenly  shot  along 
under  the  finger.  Dr.  Hope  calls  this  pulse  a  jerking  pulse  ;  the  pulse  of  unfilled 
arteries.  And  this  abrupt  pulse  makes  itself  visible  in  the  arteries :  the  wave  of 
blood  lifts,  and  moves,  and  sometimes  contorts  the  vessel.  When  this  kind  of  pulse 
occurs  with  a  diastolic  bellows  sound  heard  in  the  track  of  the  aorta,  and  the  short 
clack  of  the  second  sound  is  absent  or  diminished,  you  may  be  quite  sure  that  the 
aortic  orifice  is  patulous  during  the  diastole.  The  reflux  of  the  blood,  when  the 
patency  is  great,  is  strong  enough  sometimes  to  produce  a  palpable  shock  or  iog. 


DISEASES    OF   THE    HEART.  .  679 

called  the  diastolic  impulse.  And  this  refilling  of  the  ventricle  from  the  artery  may 
even  provoke  it  to  a  supernumerary  contraction. 

In  a  patient  by  whom  I  was  lately  consulted,  the  hard,  sudden,  hammering  pulse 
led  me  to  conclude  that  the  blood  regurgitated  from  his  aorta ;  and  accordingly, 
upon  applymg  my  ear  to  his  chest,  I  discovered  a  loud  murmur,  coincident  with  the 
diastole,  and  most  distinct  in  the  direction  of  the  right  clavicle.  The  shock  of  this 
man's  artery  was  plainly  to  be  felt,  through  his  clothes,  by  one's  hand  laid  lightly 
upon  the  bend  of  his  arm.  His  wife  told  me  that,  for  five  years  past,  this  jarring 
blow  had  made  it  uncomfortable  for  her  to  take  his  arm  when  they  were  walking 
together.  The  same  kind  of  jerking  impulse  was  strikingly  perceptible  in  the 
femoral  arteries,  and  in  the  carotids. 

Of  regurgitant  sounds  belonging  lo  the  right  side  of  the  heart  I  can  tell  you 
nothing.  I  never  heard  one,  that  I  know  of,  from  the  pulmonic  valves.  Through 
the  tricuspid  orifice  the  blood  is  believed  to  be  often  refluent ;  causing,  as  I  stated 
before,  turgescence  and  pulsation  of  the  jugular  veins.  The  structure  of  the  valve 
permits  this  ebbing  movement  of  the  blood  under  circumstances  which  might  other- 
wise be  perilous.  The  tricuspid  has  accordingly  been  called  the  safety  valve  of  the 
heart.     But  the  reflux  seldom,  if  ever,  announces  itself  by  a  bellows  sound. 

We  cannot  always  thus  rigidly  connect  morbid  changes  with  definite  signs.  Dis- 
orders arise,  of  which  the  symptoms  are  more  cognizable  and  constant  than  the  seat. 
We  assign  a  name  to  the  peculiar  assemblage  of  symptoms,  and  make  it  thenceforth 
a  distinct  object  of  our  study ;  tracing  the  symptoms,  as  well  as  we  can,  up  to  their 
organic  causes  and  conditions.  Now,  the  complaint  called  angina  pectoris  is  one  of 
this  kind.  It  is,  moreover,  a  very  curious  and  interesting  disorder ;  and  I  shall  de  • 
vote  the  remainder  of  the  present  hour  to  its  consideration. 

This  disease  was  first  accurately  described,  in  this  country  at  least,  by  the  cele- 
brated Dr.  Heberden,  the  author  of  the  Commentaries.  It  had  been  adverted  to  by 
many  writers  before,  but  obscurely ;  and  Dr.  Heberden's  observations  were  quite 
original.  The  description  that  he  has  given  of  the  complaint,  in  the  second  volume 
of  the  Transactions  of  the  College  of  Physicians,  is  very  accurate  and  striking.  He 
calls  it  a  disorder  of  the  breast ;  and  observes  that  "the  seat  of  it,  and  the  sense  of 
strangling  and  anxiety  with  which  it  is  attended,  may  make  it  not  improperly  be 
called  angina  pectoris." 

"  Those  who  are  afflicted  with  it  are  seized  whilst  they  are  walking,  and  more 
particularly  when  they  walk  soon  after  eating,  with  a  painful  and  most  disagreeable 
sensation  in  the  breast,  which  seems  as  if  it  would  take  their  fife  away,  if  it  were  to 
increase  or  to  continue.  The  moment  they  stand  still,  all  this  uneasiness  vanishes. 
In  all  other  respects  the  patients  are,  at  the  beginning  of  this  disorder,  perfectly  well ; 
and  in  particular  have  no  shortness  of  breath,  from  which  it  is  totally  different." 
Such  is  the  brief  description  of  the  malady  given  by  Dr.  Heberden.  You  will 
observe  that  the  distress  occurs  in  paroxysms,  and  the  patient  at  first  has  intervals  of 
apparent  health ;  and  even  when  the  disease  is  more  advanced,  he  has  periods  of 
comparative  ease  between  fits  of  suffering.  The  paroxysms  are  especially  liable  to 
come  on  Avhen  the  patient  is  walking,  and,  above  all,  when  he  is  ascending — going 
up  a  hill.  He  is  then  seized,  all  at  once,  with  a  painful  sensation,  which  seems  to 
be,  in  many  cases,  indescribable,  but  which  is  always  referred  to  the  heart,  or  its 
neighbourhood.  Sometimes  the  sensation  is  spoken  of  as  being  a  spasm,  as  giving 
the  patient  a  notion  of  constriction  ;  but  it  also  carries  with  it  the  impression  that  any 
continuance  of  the  exertion,  the  stirring  another  step,  would  be  fatal.  Yet  the  patient 
is  not  out  of  breath.  It  is  not  dyspnosa  that  oppresses  him  ;  for  he  can,  and  gene- 
rally does,  breathe  freely  and  easily.  He  lays  hold  of  any  neighbouring  object  for 
support.  His  face  is  pale  and  haggard  ;  and  you  would  suppose,  from  his  appear- 
ance, that  he  was  actually  at  the  point  of  death.  But  in  the  early  stages  of  the  dis- 
ease, the  pang  soon  subsides,  the  distress  is  over,  and  the  patient  is  entirely  himseK 
again.  However,  after  the  lapse  of  some  time,  generally  of  some  months,  the  anguish 
does  not  so  instantaneously  cease  upon  standing  still,  nor  does  it  always  require  somt* 
bodily  exertion  to  bring  it  on.     It  will  occur  when  the  patient  is  quiet,  even  xn  be.' 


080  DISEASES    OF   THE   HEART. 

He  feels  as  if  the  action  of  the  heart  was  arrested ;  and  he  is  obliged  to  rise  up 
every  night  perhaps,  for  many  weeks  together.  In  exquisite  cases  it  will  be  brought 
on  by  causes  of  any  kind  that  slightly  accelerate  the  circulation  :  coughing,  straining 
at  stool,  mental  emotion. 

The  pain,  which  is  at  first  referred  to  the  region  of  the  heart,  frequently  extends, 
accompanied  by  a  sort  of  numbness,  from  that  part  to  the  left  shoulder,  and  down 
the  left  arm  ;  slopping  short,  in  a  curious  manner,  and  from  some  inexplicable  cause, 
either  just  about  the  insertion  of  the  deltoid  muscle,  or  at  the  elbow,  or  at  the  wrist. 
Sometimes,  however,  it  runs  down  to  the  very  extremities  of  the  fingers  ;  particularly 
of  the  last  two  fingers,  following  mainly  the  course  of  the  ulnar  nerve.  And  occa- 
sionally similar  pains  affect  the  right  side  and  arm.  There  is  (I  say)  no  dyspnoea  in 
the  genuine  form  of  the  disease;  although  you  will  find  it  stated  by  some  modern 
writers  of  good  repute,  that  the  paroxysm  is  accompanied  with  difficulty  of  breath- 
ing. In  the  instances  that  I  have  seen,  and  they  have  been  few,  the  patient  was 
able  slowly  and  fully  to  inspire  and  expire,  even  when  the  fit  was  on  him.  The 
truth  I  believe  to  be,  that  other  affections,  more  akin  to  asthma,  have  been  confound- 
ed with  angina  pectoris ;  and  this  confusion  has  led  to  the  belief  that  it  is  not  altoge- 
ther so  dangerous  a  complaint  as  used  to  be  thought ;  but  in  its  genuine  shape  it  is 
undoubtedly  a  very  fatal  disorder.  Dr.  Forbes,  by  a  diligent  search  among  authors, 
has  collected  some  statistical  facts  respecting  it  which  are  worth  remembering.  Thus, 
out  of  eighty-eight  cases,  eight  only,  or  one  in  eleven,  occurred  in  females.  The 
ages,  in  eighty-four  of  these  eighty-eight  cases,  are  recorded ;  and  of  the  eighty- 
four,  seventy-two  were  above  fifty  years  ;  and  twelve,  or  one-seventh  of  the  whole, 
under  fifty  years.  It  is  a  disease,  therefore,  for  the  most  part,  of  advanced  life  ;  and 
this  alone  would  afford  a  strong  presumption  of  its  dependence  upon  some  organic 
change.  Again,  the  event  of  the  disease  was  recorded  in  respect  to  sixty-four  of  the 
patients.  Of  these,  forty -nine  died,  almost  all  of  them  suddenly  ;  while  fifteen  reco- 
vered, or  were  relieved.  And  among  the  forty-nine  fatal  cases,  there  were  only  two 
of  women. 

That  the  seat  of  the  disorder  is  the  heart,  and  that  it  consists  in  some  structural 
change,  can  scarcely  be  doubted.  Yet  some  pathologists  are  disposed  to  consider  it 
a  merely  neuralgic  afft.'ction,  "  commencing  for  the  most  part  in  the  pneumogastric 
nerve,  and  spreading  in  different  directions,  as  other  nerves  become  involved."  But 
this  doctrine  is  scarcely  consistent,  in  my  judgment,  with  the  facts — first,  that  the 
paroxysm  is  excited  by  such  causes  as  are  "  especially  calculated  to  disturb  the  natu- 
ral action  of  the  heart,  bodily  exertion,  and  mental  emotion  ;"  and,  secondly,  that  the 
disease  is  so  very  frequently  and  so  suddenly /«/«/.  This  is  not  at  all  the  character 
<f^  mere  neuralgic  diseases  in  general.  And  when  we  add  to  these  facts  the  further 
fact,  viz.,  that,  in  a  vast  majority  of  instances,  organic  disease  of  the  heart,  or  of  the 
great  blood-vessels,  has  been  discovered  after  death,  I  think  we  shall  be  obliged  to 
admit  that  the  symptoms  are  often  (for  I  will  not  say  always)  dependent  upon  cardiac 
disease.  One  theory  explains  the  "  breast-pang,"  by  supposing  that  the  blood,  when- 
ever its  movement  is  accelerated  by  exercise  or  otherwise,  arrives  in  the  heart  faster 
than  it  can  be  transmitted  onwards,  and,  accumulating  in  its  cavities,  painfully  dis-  1 
tends  them.  It  is  not  improbable  that  the  paroxysm  may  be  sometimes  so  produced.  ' 
The  great  Dr.  Jenner  took  a  most  ingenious  view  of  the  matter,  which  was  made 
public  and  further  enforced  by  Dr.  Parry.  He  had  found,  in  examining  the  bodies 
of  some  who  had  died  of  well-marked  angina  pectoris,  that  the  coronary  arteries  of 
the  heart  were  ossified  ;  converted  into  bony  canals,  and  constricted  in  their  calibre. 
He  thence  concluded  that  the  paroxysms  result  from  the  circumstance,  that  when 
some  increase  of  the  muscular  contraction  of  the  heart  happens  to  be  called  for,  the 
increased  supply  of  blood,  rendered  necessary  by  the  additional  exertion,  is  not  capa- 
ble of  being  furnished  by  the  diseased  nutrient  arteries  of  the  organ  ;  that  the  heart 
comes  to  a  stand,  because  its  muscular  tissue  is  not  duly  injected  with  arterial  blood  ; 
and  the  phenomena  of  the  paroxysm  agree  remarkably  well  with  that  theory.  He 
calls  the  disease,  accordingly,  "  .syncope  anginosa."  And  this  simple  and  beautiful 
theory  was  for  some  time  admitted  as  the  true  one.  However,  later  investigations 
have  abun'lantly  shown  that  angina  pectoris  may  occur  in  a  decided  form,  without 


DISEASES   OF   THE   HEART.  681 

there  being  any  ossification  or  other  disease  of  the  arteries ;  and,  on  the  other  hand, 
that  the  coronary  arteries  may  be  ossified,  and  yet  no  angina  pectoris  be  the  result. 

I  may  here  again  avail  myself  of  the  researches  of  Dr.  Forbes,  and  give  you  a 
numerical  account  of  the  organic  changes  in  the  heart  that  have  been  found  asso- 
ciated with  this  disease.  The  total  number  of  instances  collected  by  him,  in  which 
the  body  was  examined  after  death,  was  forty-five.  Of  this  number,  there  was  dis 
ease  found  in  the  hver  only,  in  two  instances :  organic  disease  of  the  heart,  or  great 
vessels,  in  forty-three.  Dr.  Forbes,  indeed,  makes  the  last  number  thirty-nine, 
instead  of  forty-three,  excluding  four  cases  in  which  nothing  morbid  was  found  in 
or  about  the  heart,  except  an  excessive  coating  of  fat.  This  Dr.  Fothergill  consid- 
erea  the  essence  of  the  disease ;  and  certainly  a  heart  cannot  hi  said  to  be  in  a 
healthy  condition  which  is  thus  loaded  with  adipous  matter.  The  fat  is  generally 
deposited  at  the  expense  of  the  muscular  substance,  which  is  apt  in  such  cases  to  be 
thin,  pale,  and  soft ;  atrophied,  in  short.  Taking,  however,  the  table  as  it  is  given 
by  Dr.  Forbes,  the  thirty-nine  cases  in  which  there  was  no  disease  except  in  the 
heart  and  great  vessels,  were  thus  distributed  : — In  ten  of  the  cases  there  was  organic 
disease  in  the  heart  alone :  in  three,  organic  disease  of  the  aorta  alone.  In  one 
instance  only  was  the  disease  confined  to  the  coronary  arteries ;  but  there  was  ossifi- 
cation, or  cartilaginous  thickening  of  the  coronary  arteries,  combined  with  other 
disease,  in  sixteen  instances.  Again,  there  was  ossification,  or  other  disease  of  the 
valves  of  the  heart,  in  sixteen  cases  also.  There  was  disease  of  the  aorta  (ossifica- 
tion, or  dilatation,  or  both),  in  twenty-four  cases ;  and  in  twelve  cases  there  was  pre- 
ternatural softness  of  the  heart. 

My  friend,  Dr.  Latham,  lately  gave  me  this  sketch  of  a  case  of  angina  pectoris, 
which  had  fallen  under  his  own  observation.     It  is  remarkable  for  the  shortness  of 
its  course.     A  gentleman,  about  fifty  years  old,  was  recovering  from  the  influenza, 
of  which  nothing  remained  but  a  slight  cough,  that  troubled  him  at  night.     It  was 
to  relieve  this  that  Dr.  Latham  was  consulted.     The  gentleman  looked  perfectly 
well.     After  Dr.  Latham  had  prescribed  for  this  little  ailment,  the  patient  begged  to 
see  him  the  next  day,  to  talk  over  with  him  (he  said)  a  very  strange  affection  he  had. 
Accordingly,  he  then  described  a  paroxysm  of  angina  pectoris  in  terms  that  could  not 
be  mistaken  ;  dwelHng  especially  upon  the  prsecordial  pain,  the  sensation  down  the 
left  arm,  the  sense  of  approaching  dissolution,  and  then  the  perfect  recovery.     This 
gentleman  had,  during  the  previous  summer,  performed  a  walking  tour  through 
Switzerland,  and  returned  home  in  excellent  health.     The  first  notice  of  his  angina 
was  not  more  than  a  month  ago,  when  he  was  walking  up  Hampstead  Hill.     It  was 
then  that  he  had  his  first  paroxysm.     In  the  short  period  which  had  elapsed,  the 
attacks  had  rapidly  increased  in  severity  and  frequency ;  occurring  now  every  two 
jr  three  days,  or  every  day,  or  several  times  a  day,  with  or  without  an  exciting 
cause.     Dr.  Latham  made  a  careful  examination  of  the  chest,  and  found  the  respi- 
ration perfect,  the  heart  free  from  all  unnatural  murmurs,  and  its  beats  rhythmical. 
The  only  t-hing  that  particularly  attracted  his  notice  was  the  exceeding  feebleness  of 
its  impulse.     In  the  afternoon  of  the  next  day.  Dr.  Latham  visited  him  again,  when 
he  described  a  paroxysm  he  had  suffered  in  the  course  of  the  morning,  of  much 
greater  severity  than  any  that  he  had  hitherto  experienced.     Dr.  Latham  saw  enough 
to  convince  him  that  his  patient's  existence  was  very  precarious :  and  as  he  had  pre- 
viously been  a  stranger  to  him,  he  inquired  about  his  friends,  and  took  down  the 
address  of  a  brother,  intending  to  call  and  apprise  him  of  what'he  feared.    On  reach- 
ing his  own  home,  two  hours  afterwards,  a  messenger  met  him,  announcing  that  his 
patient  had  fallen  into  another  paroxysm,  soon  after  he  left  the  house,  and  was  dead 
The  body  was  carefully  examined  by  a  thorough  anatomist,  Mr.  Stanley.     There 
was  no  disease  of  the  aorta,  or  of  the  heart  generally ;  but  the  coronary  arterici 
resembled  tubes  of  coral,  being  completely  ossified  as  far  as  they  could  be  traced. 

The  patient  may  even  expire  in  the  first  or  second  paroxysm.  This  happened, 
I  believe,  in  the  case  of  the  late  lamented  Master  of  Rugby  school. 

You  will  perceive,  from  what  has  been  said,  that  the  prognosis  of  this  singular 
and  formidable  affection  is  extremely  unfavourable.  The  cases  are  very  rare  in 
which  no  disease  of  the  heart  has  been  detected ;  and  the  organic  changes  thai 


682  PERICARDITIS. 

have  been  found  are  remediless,  and,  for  the  most  part,  progressive ;  and,  in  point 
of  fact,  the  greater  number  of  those  who  have  laboured  under  the  disease  have  died 
suddenl3^ 

It  follows,  also,  as  another  corollary  from  the  facts  now  brought  before  you,  that 
there  are  very  few  cases  in  which  we  can  dare  to  contemplate  a  cure.  Our  mea- 
sures must  be  preventive  when  the  paroxysms  are  absent;  and  our  object  will  be  to 
shorten  the  fit  when  it  is  present  and  protracted. 

Now,  the  preventive  measures  are  simple  and  obvious.  The  patient  must  be  cau- 
tioned to  avoid  the  exciting  causes  of  the  paroxysm ;  walking  up  hill,  or  against  the 
wind,  which  has  also  been  known  to  produce  it.  Whatever  is  likely  to  hurry  the 
circulation,  and  therefore,  among  the  rest,  all  mental  emotion  and  anxiety,  should  be 
guarded  against  as  much  as  possible.  John  Hunter  died  of  angina  pectoris :  and 
the  fatal  seizure  was  brought  on  by  a  fit  of  anger.  Care  should  be  taken  also  to 
obtain  and  preserve  a  healthy  state  of  the  digestive  organs.  It  is  observable  of  this, 
as  1  mentioned  before  it  is  observable  of  other  cardiac  diseases,  that  they  are  often 
attended  and  aggravated  by  flatulence  of  the  stomach  and  bowels.  Persons  labour- 
ing under  a  paroxysm  of  angina  often  experience  great  and  sudden  relief  upon  get- 
ting rid  of  a  quantity  of  gas,  by  which  the  stomach  had  been  distended.  The  flatu- 
lence acts,  no  doubt,  by  pressing  the  diaphragm  upwards,  and  so  diminishing  the 
dimensions  of  the  thorax,  and  impeding  the  play  of  the  heart.  It  is  upon  the  same 
principle  that  we  must  explain  the  fact,  that  the  paroxysms  are  particularly  apt  to 
come  on  if  the  patient  walks  soon  after  a  meal:  also  that  they  occur  in  the  night, 
when  he  is  in  a  horizontal  position,  and  are  relieved  by  his  getting  out  of  bed  ;  that 
is,  by  his  assuming  the  vertical  posture,  and  taking  off  the  pressure  of  the  abdominal 
viscera  from  the  diaphragm. 

In  the  paroxysm  itself,  bleeding  has  been  fairly  tried  ;  but,  as  I  think  might  have 
been  foreseen,  it  has  seldom  been  attended  with  any  benefit,  and  sometimes  it  appears 
to  have  done  harm.  The  affection  has  a  nearer  relation  to  sy'icope,  and  often  to 
syncope  by  asthenia,  than  to  any  thing  else.  That  is  the  way  in  which  the  patients 
die;  and  consequently,  cordials,  stimulants,  and  antispasmodics,  are  found  to  be  of 
service.  Dr.  Elliotson  thinks  prussic  acid  is  the  best  thing  you  can  administer 
Dr.  Davies  has  more  faith  in  belladonna  plasters  than  in  most  other  things.  Dr. 
Copland  advises  stimulant  liniments  externally;  and  warm  carminative  or  aperient 
medicines,  as  the  circumstances  may  require,  internally.  The  general  condition  of 
the  sufferer  will  suggest,  I  believe,  the  proper  treatment.  Not  that  it  will  suggest 
any  particular  drug,  but  it  will  teach  you  the  main  principle  on  which  you  are  to 
proceed.  If  auscultation  reveal  any  of  those  morbid  states  of  the  heart  which  were 
noticed  in  the  beginning  of  the  lecture,  the  means  which  I  pointed  out  as  suitable 
for  remedying  them  may  be  put  in  force. 


LECTURE   LXI. 

Pencardifis ;  its  frequent  connection  with  Acute  Articular  Rheumatism.  Rhcit- 
malic  Carditis.  Anatomical  characters  of  acute  Inflammation  of  the  Pericar- 
dium ;  of  the  Eiidocardium.  General  symf '07ns  Auscultatory  signs.  Rela- 
tions of  Carditis  with  Rheumatic  Fever. 

I  YESTERDAY  Considered,  cursorily  indeed,  but  as  fully  as  the  limits  of  these  lectures 
will  permit,  the  effects  of  hypertrophy,  and  of  dilatation  with  and  without  hypertro- 
phy, of  the  several  chambers  of  the  heart :  and  of  the  means  we  possess  of  obviating 
t»r  alleviating  those  effects.  I  passed  in  review  also  the  chronic  changes  to  which 
the  endorcardir/m,  especially  in  those  parts  where  it  covers  the  valves,  and  the  ten- 
dinous rings  that  give  support  to  the  valves,  is  liable  ;  and  most  of  the  circumstances 
which  give  origin  to  such  changes  :  and  I  spoke  of  that  singular  and  perilous  aflTcction 


PERICARDITIS.  683 

to  which  the  name  of  angina  pectoris  has  been  applied.  I  proceed  this  aflernoon  to 
the  diseased  conditions  of  the  pericardium.  This  membrane  is  often  the  seat  of 
acute  inflammation ;  and  the  consequence  of  such  inflammation  is  sometimes,  though 
rarely,  the  speedy  extinction  of  life.  But  in  nineteen  cases  out  of  twenty,  the  dis- 
order proves  fatal  at  a  remote  period  ;  destroying  the  subject  of  it  more  slowly,  ind<^ed, 
but  almost  as  surely.  Pericarditis  is  therefore,  and  has  always  been  regarded  as,  a 
very  interesting  disease  ;  a«d  the  more  so,  that  it  is  in  many  instances  a  very  insidious 
disease  also. 

Acute  pericarditis  is  Hable  to  arise,  like  all  other  internal  inflammations,  after  ex- 
posure to  cold ;  or  when  no  exciting  cause  is  to  be  discovered.  But  for  one  such 
case  of  what  may  be  called  spontaneous  acute  inflammation  of  that  membrane,  you 
will  meet  with  a  dozen,  or  more,  in  which  it  occurs  in  connection  with  a  disease  that 
we  have  not  yet  had  before  us — acute  rheumatism;  a  febrile  disorder,  characterized 
by  inflammation  of  a  specific  character,  affecting  the  structures  that  lie  around  the 
joints,  or  enter  into  their  composition — the  Jibrous  tissues.  I  shall  therefore  consider 
acute  pericarditis  with  reference  to  its  occurrence  in  rheumatic  fever  ;  for  in  so  doing, 
I  shall  embrace  all  the  practical  points  which  belong  to  it  under  any  form.  But  I 
must  tell  you  that  when  /pericarditis  happens,  in  the  course  of  an  attack  of  rheuma- 
tism, so  also,  to  the  best  of  my  belief,  in  almost  every  instance,  does  enc/ocarditis. 
For  this  reason  I  shall  include,  in  the  account  I  am  desirous  to  give  you  of  rheumatic 
carditis,  both  these  inflammations :  inflammation  of  the  investing  membrane,  and  in- 
flammation of  the  lining  membrane  of  the  heart.  I  mentioned  in  the  last  lecture,  that, 
in  respect  to  the  latter,  to  endocarditis,  there  were  some  peculiarities  noticeable  which 
I  should  reserve  for  the  present  occasion. 

The  pericardium  is  one  of  the  serous  membranes ;  so  also  may  the  endocardium 
be  considered.  But  the  pericardium  is  also  a  shut  sac;  and  the  primary  effects  of 
inflammation  upon  it  are  the  same,  mutatis  mutandis,  as  upon  the  shut  sac  so  near 
it,  the  pleura.  The  second  series  of  effects  is,  however,  much  more  formidable. 
Adhesion  of  the  pleura  does  not  necessarily  abbreviate  the  natural  term  of  the 
patient's  life ;  adhesion  of  the  pericardium  almost  always  does  :  and  effusion  into  the 
cavity  that  contains  the  lung  is  far  less  serious  than  effusion  into  the  bag  that  sur- 
rounds the  heart.  In  the  one  set  of  organs  the  mischief  may  be  great,  but  it  is  final; 
in  the  other,  it  leads,  with  unfailing  certainty,  sooner  or  later,  to  worse  changes,  which 
at  length  prove  incompatible  with  the  further  continuance  of  life. 

You  will  understand,  then,  without  the  necessity  of  my  going  again  into  much 
detail,  that  the  pericardium,  under  acute  inflammation,  may  undergo  the  same 
changes,  which,  on  a  former  occasion,  we  saw  that  the  pleura  might  undergo. 
Coagulable  lymph  may  be  poured  forth  from  the  entire  membrane,  and  abolish  the 
cavity  by  glueing  the  whole  of  the  pericardium  to  the  heart :  or  serous  fluid  may  be 
effused,  distending  the  bag  of  the  pericardium,  and  keeping  its  smooth  surfaces  more 
or  less  asunder  :  or  both  serum  and  lymph  may  be  effused  together  ;  or  fibrin,  in  some 
shape  or  another,  may  be  deposited,  for  aught  I  know,  from  the  homogeneous  fluid 
which  is  thrown  out  by  the  inflamed  membrane  in  the  first  instance  ;  and  the  result  of 
this  mixed  effusion  may  here,  also,  as  in  the  case  of  the  pleura,  be  the  partial  adhe- 
sion of  the  membrane  to  the  heart. 

But  in  the  majority  of  instances  the  inflammation  spreads  over  the  whole  mem- 
brane, as  it  is  apt  to  do  in  serous  membranes  generally ;  and  one  of  these  two  things 
happens  :  either  there  is  a  large  quantity  of  liquid  effusion,  which  is  not  reabsorbed  ; 
and  then  generally  the  patient  dies  in  a  few  days :  or  there  is  not  much  linuid  eflfu- 
sion,  or  the  liquid  part  is  absorbed,  and  the  pericardium  becomes  permanently  agglu- 
tinated to  the  heart,  and  apparent  recovery  takes  place. 

In  the  cases  that  have  proved  fatal  at  an  early  period,  when  the  inflamed  mem- 
brane has  been  unadherent,  it  has  been  found  to  contain  serous  fluid  ;  sometimes  clear, 
oftener  turbid,  frequently  tinged  with  blood :  and  it  has  been  seen  to  be  covt.red 
with  a  coating  of  the  fibrinous  or  albuminous  part  of  the  blood  ;  what  we  caU  plastic 
or  coagulable  lymph.  The  deposited  lymph  assumes  a  variety  of  forms  in  differen: 
cases  ;  but  in  every  case  that  I  have  seen,  the  prevaihng  character  of  the  unattached 
surface  has  been  that  o[  roughness  ;  and  this  is  a  circumstance  of  some  importance. 


684  RHEUMATIC    CARDITIS. 

as  we  shall  presently  sec.  The  lymph  is  not  arranged  in  smooth  layers  ;  but  it  is 
rugged,  villous,  or  cellular.  According  to  the  fancy  of  different  observers,  it  has 
been  thought  to  resemble  lacework,  or  a  sponge,  or  a  honeycomb,  or  some  kinds  of 
coral,  or  the  interior  of  a  calf's  stomach.  Sometimes  it  brisdes  with  a  multitude  of 
small,  short,  pointed  papillae :  less  frequently,  it  is  softer  and  shaggy ;  always  it  is 
rough  and  uneven.  Dr.  Hope,  following  Laennec,  states  that  the  surface  looks  some- 
times like  that  which  would  be  produced  by  suddenly  separating  two  flat  pieces  of 
wood,  between  wdiich  a  thin  layer  of  butter  has  been  compressed.  To  my  own  eye, 
the  appearance  presented  by  the  membrane,  in  its  recent  condition,  has  been  more 
like  the  rough  side  of  the  pieces  of  tripe  which  you  see  in  butchers'  shops  than  any 
thing  else. 

When,  on  the  other  hand,  the  patient  dies,  as  he  sometimes  will  do,  soon  after  the 
whole  of  the  membrane  has  become  adherent,  you  will  find  the  medium  of  adhesion 
to  consist  of  lymph,  in  which  a  number  of  bloody  points  or  streaks  are  visible  :  but 
still  the  connecting  substance  is  soft,  and  the  agglutinated  membranes  can  readily  be 
torn  apart. 

Such  is  the  state  of  things  on  the  outside  of  the  heart  in  such  cases.  But  what 
do  we  find  within  ?  Why,  here  also,  in  all  cases  probably,  certainly  in  by  far  the 
majority  of  cases,  we  discover  evident  traces  of  active  inflammation  ;  and  we  dis- 
cover them  chiefly  on  the  valvular  apparatus.  There  does  not  appear  to  be  such  a 
tendency  in  endocarditis  to  diffuse  itself  over  the  whole  membrane.  Occasion-ilIy 
that  naturally  transparent  portion  of  it  which  covers  the  muscular  fibres  is  rendered 
whitish  and  opaque ;  and  occasionally  some  of  the  deposits  that  are  common  on  the 
valves,  encroach  also  somewhat  beyond  them,  and  even  stud,  here  and  there,  the  in- 
terior of  one  or  more  of  the  chambers  of  the  heart,  and  especially  of  the  left  auricle. 
But  the  valves  or  the  fibrous  rings  from  which  they  spring,  are  the  parts  first  and 
chiefly  implicated,  especially  the  aortic  valves,  and  the  mitral  valve :  not  uncom- 
monly the  tricuspid  valve  also  ;  and  sometimes  even  the  semilunar  valves  of  the  pul- 
monary artery.  Inflammation  thus  affecting  both  the  external  and  internal  mem- 
branes of  the  heart,  in  acute  rheumatism,  I  would  call  rheumatic  carditis. 

The  inflame^-^alves  undergo  two  kinds  of  change,  distinct  from  each  other.  They 
become  thickerV&Jtf^natural ;  they  lose  their  transparency  and  pliancy,  and  are 
puckered.  These  changes  depend  upon  the  deposit  of  lymph  beneath  the  mem- 
brane ;  between  the  membrane  and  the  fibrous  substance  it  covers.  Sometimes  they 
are  folded  down,  and  glued,  as  it  were,  to  the  opposite  surface.  This  must  be  by 
coagulable  lymph  deposited  on  the  outer  side  of  the  membrane.  But  more  frequently 
than  all,  they  present  more  or  fewer  of  those  wart-hke  excrescences,  or  fleshy  granu- 
lations, which  I  spoke  of  in  the  last  lecture,  and  which  are  of  course  above  the  mem- 
brane. Sometimes  these  vegetations  are  scattered  irregularly  over  the  convex  surface 
of  the  valve,  or  in  its  immediate  neighbourhood  ;  but  much  oftener  they  have  a  more 
definite  and  curious  distribution  ;  an  arrangement  which  I  have  never  seen  noticed 
by  any  author,  but  which  it  has  been  my  lot  so  many  times  to  observe,  that  it  has 
led  me  to  remark  an  anatomical  peculiarity  with  which  it  is  connected ;  and  this 
piece  of  minuter  anatomy  I  have  looked  for  in  vain  in  books,  and  have  in  vain  sought 
information  about  it  from  all  my  anatomical  acquaintances.  They  none  of  them 
have  seemed  to  be  aware  of  it,  though  they  acknowledged  that  the  fact  was  so  when 
1  pointed  it  out  to  them.  Recently,  indeed,  I  have  been  told  that  the  peculiarity  of 
structure  to  which  I  allude  is  somewhere  adverted  to  by  Morgagni. 

It  becomes  necessary,  therefore,  that  I  should  describe  this  discovery  of  mine  (if  it 
deserves  so  grand  a  name)  to  you,  as  I  have,  for  several  years  past,  been  in  the  habit 
of  showing  it  to  the  pupils  of  the  hospital  in  the  dead-house.  It  derives  its  chief 
interest  from  the  light  it  throws  upon  the  morbid  appearances  to  be  spoken  of  pre- 
sently. You  will  find,  then,  if  you  examine  closely  the  semilunar  valves  of  the 
aorta,  or  of  the  pulmonary  artery,  that  in  each  valve  there  may  be  distinguished  two 
parts ;  one  thicker,  the  other  thinner.  The  thicker  part  lies  next  the  base  of  the 
valve,  the  thinner  next  its  edge.  And  the  valve  does  not  become  thin  by  degrees, 
but  the  difference  is  marked  by  a  manifest  line  of  separation  between  the  thicker  and 
thinner  portions ;  and  this  is  not  a  straight,  nor  even  one  sweeping  curved  line,  but 


PERICARDITIS.  685 

it  is  a  double  curve.  It  consists  of  two  semicircular  lines,  running  each  from  the 
centre  of  the  edge  of  the  valve,  from  the  sesamoid  body  there  situated,  to  either  extre- 
mity of  the  edge,  where  the  edge  joins  the  side  of  the  aorta.  So  that  there  are  two 
segments,  of  a  crescentic  shape,  thinner  and  less  opaque  than  the  remaining  part  of 
the  valve,  and  lying  near  its  free  margin.  This  peculiarity  of  structure  is  uniformly 
present.  It  is  less  distinctly  visible  in  the  valves  of  the  pulmonary  artery  than  in 
those  of  the  aorta ;  and  it  is  much  less  apparent  in  some  individuals  than  in  others  : 
but  it  is  always  to  be  seen  when  it  is  looked  for. 

The  anatomical  account  of  this  arrangement  is  not  far  to  seek.  The  cardiac 
valves  consist  of  a  loose  duplicaiure  of  the  delicate  endocardium,  between  the  folds 
of  which  is  received  a  thin  prolongation  of  fibrous  tissue,  from  the  tendinous  rings 
surrounding  or  constituting  the  several  orifices  that  are  furnished  with  a  valvular 
apparatus.  In  the  semilunar  valves  tliis  fibrous  substance  does  not  interpose  itself 
between  the  entire  space  of  the  folded  membrane.  It  reaches  the  free  edge  of  each 
valve  at  three  points  only ;  namely,  at  the  centre,  where  it  forms  the  corpus  aurantii, 
and  at  the  two  extremities.  Between  these  points  it  stops  short,  and  has  a  definite 
limit  and  outline ;  a  scolloped  edge :  and  so  leaves  two  crescentic  portions  of  the 
valve  formed  merely  by  the  doubled  endocardium.  The  crescentic  margins  are  thin 
and  transparent :  the  remaining  shield-shaped  portion  of  the  valve  is  more  or  less 
ihick,  firm,  and  opaque. 

And  the  physiological  reason  of  this  arrangement  is  also  apparent  enough  ;  though 
I  failed  to  perceive  ii  until  it  was  pointed  out  to  me  by  JMr.  Thurnam.  Each  valve, 
when  opened  out,  is  convex  towards  the  ventricle.  The  three  valves  do  not  merely 
meet  by  their  edges.  Their  common  purpose  would  be  but  insecurely  provided  for 
if  such  were  the  case.  They  meet  and  bend  up,  and  come  broadly  into  contact 
with  each  other.  Each  valve  during  the  diastole  has  its  right  and  left  crescentic  por- 
tion applied  respectively  to  the  corresponding  portion  of  its  right  and  left  fellow  valves. 
The  thin  segments  are  pressed  mutually  together,  and  lie  dos-d-dos,  as  dancers  say; 
while  their  edges  look  in  the  direction  of  the  vessel.  All  this  you  may  convince 
yourselves  of  by  injecting  the  aorta  of  an  ox  with  wax,  and  picking  out  the  wax 
when  it  is  cold. 

Now  the  curious  fact  which  first  led  me  to  remark  this  natural  structure  is,  that 
the  minuter  vegetations,  which  form  upon  the  aortic  valves,  in  acute  rheumatic  car- 
ditis, most  commonly  arrange  themselves  in  a  row,  like  a  string  of  beads,  along  the 
line  of  union  between  the  scolloped  edge  of  the  thicker  scutiform  portion  of  the  valve, 
and  the  inner  convex  margin  of  the  two  thinner  crescentic  portions.  Sometimes 
they  follow  that  double  festoon  very -exactly  and  completely:  sometimes  the  conti- 
nuity of  the  line  is  broken,  and  the  excrescences  straggle  from  it  a  httle ;  but  still 
the  general  tendency  to  adhere  to  it  is  evident.  No  one  that  I  know  of  has  publicly 
noticed  this  fact ;  yet  that  it  is  a  fact,  a  good  many  persons,  who  have  been  for  some 
time  about  the  Middlesex  Hospital,  are  perfectly  aware.  The  truth  is,  that  death 
seldom  happens  early  in  these  cases ;  and  perhaps  the  valves  have  not  always  been 
carefully  examined  when  opportunity  did  offer.  My  friend.  Dr.  Latham,  had  been 
watching,  for  such  a  case  in  vain  for  some  years.  Recently,  however,  two  of  his 
hospital  patients  died  in  the  first  attack  of  rheumatic  carditis ;  and  he  tells  me  that, 
looking  with  great  interest  for  the  morbid  appearances  within  the  heart,  he  found 
them  such  as  1  have  been  stating.  I  have  chanced  to  see  six  or  eight  such  early 
fatal  cases. 

The  arrangement  just  described  is  the  most  common  one,  so  far  as  the  aortic  valves 
are  concerned :  but  sometimes  even  there,  and  generally  upon  the  mitral  and  the 
tricuspid  valves,  the  little  wart-like  excrescences  have  a  different  position ;  jaggino- 
the  free  edge  of  the  valve  with  numerous  fine  serrae,  like  the  teeth  of  a  small  saw; 
or  being  disposed,  just  within  its  border,  in  one  continuous  line. 

After  what  has  been  said,  you  will  readdy  delect  the  physical  cause  of  this  curi 
ous  distribution  of  the  wart-like  excrescences.  The  membrane  suffers  acute  inflam- 
mation. Soft  lymph  exudes  from,  or  is  deposited  upon  it :  and  as  fast  as  it  is  formed 
it  is  pressed  aside,  by  the  repeated  concourse  of  the  opposed  surfaces,  from  the  cre- 
scentic portions  of  each  valve ;  and  heaped  up  along  the  boundary  lines  of  contain 

3h 


686  RHEUMATIC    PERICARDITIS. 

just  as  a  thin  laj^er  of  butter  on  a  board  would  be  displaced,  and  heaped  uj)  m  a 
little  curvilinear  ridge,  by  the  pressure  of  one's  thumb.  The  double  festoon,  and  the 
httle  marginal  teeth,  are  obviously  both  formed  in  this  way. 

If  my  verbal  description  has  been  insufficient  to  make  all  this  clear  to  your  appre- 
hension, the  drawings  before  you  speak,  I  hope,  in  plainer  language. 

These,  then,  are  the  appearances  commonly  seen  within  and  without  the  heart, 
when  the  patient  does  not  long  survive  the  first  attack  of  rheumatic  carditis.  When 
death  takes  place  at  a  later  period,  you  find  more  than  this.  You  find  the  conse- 
quences which  flow  from  these  primary  lesions,  operating  as  mechanical  causes  of 
further  change :  hypertrophy  and  dilatation  in  their  various  degrees  and  combina- 
tions. 

You  will  please  to  bear  the  primary  changes  in  mind  :  for  they  satisfactorily 
account  for  the  physical  signs  of  pericarditis  and  of  endocarditis  which  are  displayed 
in  these  cases,  and  which  I  shall  describe  and  explain  after  I  have  shortly  inquired 
into  the  general  symptoms. 

The  symptoms,  then,  of  pericarditis,  as  set  down  by  authors,  and  such  as  I  have 
myself  frequently  noticed,  are  the  following.  There  is  often,  very  early  in  the 
disease,  a  singularity  of  manner,  and  peculiar  expression  of  countenance,  difficult  to 
describe,  yet  strikingly  manifest  to  the  observer ;  a  strangeness  of  deportment  mixed 
somehow  with  an  aspect  of  distress.  To  this  are  frequently  added,  palpitation  ;  a 
sense  of  oppression  at  the  epigastrium;  a  catch  in  the  breathing;  a  dry  cough; 
inability  or  unwillingness  on  the  part  of  the  patient  to  lie  on  his  left  side  ;  pain  in 
the  situation  of  the  heart,  increased  by  a  full  inspiration,  by  pressure  upon  or  be- 
tween the  corresponding  ribs,  and  more  particularly  increased  by  pressure  upwards 
against  the  diaphragm  by  means  of  the  fingers  thrust  beneath  the  cartilages  of  the 
false  ribs ;  stifthess  and  pain  in  and  about  the  left  shoulder,  and  extending  thence 
down  the  left  arm,  and  stopping  short  perhaps  at  the  elbow  or  wrist.  This  last  cir 
cumstance,  howev^er,  the  pain  shooting  down  the  arm,  is  more  common  in  chronic 
affections  of  the  heart.  And  I  have  yet  another  symptom  to  mention,  and  a  very 
important  one  ;  and  that  is  delirium,  sometimes  quiet,  but  often  wild  and  furious  de- 
lirium, not  dependent  upon  any  disease  of  the  encephalon. 

Of  course  there  are  also  the  febrile  symptoms  which  accompany  the  acute  rheu- 
iiiatism ;  or  if  the  pericarditis  occur  independently  of  acute  rheumatism,  there  will 
be  fever  symptomatic  of  the  local  inflammation. 

Now  each  of  these  symptoms  I  have  repeatedly  observed  ;  but  they  seldom  all  con- 
cur in  the  same  case.  If  they  did  there  would  not  be  much  difficulty  in  the  diag- 
nosis :  nor  would  the  cardiac  disease  be  so  often  overlooked  as  it  is.  The  diagnosis 
of  pericarditis  has  been  confessedly  uncertain  and  obscure.  Not  unfrequently, 
nearly  all  the  symptoms  I  have  been  enumerating  are  wanting ;  or  so  indistinctly 
marked  as  to  attract  no  attention.  It  is  therefore  an  important  matter  to  ascertain 
what  help  we  may  derive,  in  these  equivocal  cases,  from  auscultation. 

In  truth,  the  help  we  sometimes  get  is  peculiarly  valuable  and  satisfactory.  There 
are  certain  morbid  sounds  to  be  heard  when  the  heart  is  beginning  to  labour  under 
rheumatic  carditis. 

The  morbid  sounds  which  may  reach  the  ear  appHed  in  such  cases  to  the  surface 
of  the  chest  are  two  :  very  distinct  the  one  from  the  other,  and  very  distinguishable: 
depending  upon  different  causes,  and  denoting  diversities  of  operation  and  of  site  in 
the  morbid  processes  going  on  within.     But  they  are  not  both  heard  in  all  cases. 

One  of  these  sounds  I  have  been  accustomed  to  call  a.  to  and  fro  sound.  It 
conveys  to  the  ear  the  notion  of  the  rubbing  of  two  rough  surfaces,  backwards 
and  forwards  upon  each  other.  It  seems  near  to  the  ear ;  and  therefore  near  to 
the  surface  of  the  patient's  body.  Like  all  the  other  morbid  sounds  heard  within 
the  chest,  it  is  capable  of  much  variety  in  tone  and  degree.  Sometimes  it  very  closely 
resembles  the  noise  made  by  a  saw  in  cutting  through  a  board.  Sometimes  it  is 
moie  like  that  occasioned  by  the  action  of  a  file,  or  of  a  rasp,  or  of  a  nutmeg-grater. 
But  its  essential  character  is  that  of  alternate  rubbing;  it  is  a  to  and  fro  sound.  This 
very  pecuhar  sound  I  had  noticed  and  described,  and  explained,  before  I  was  aware 
ihat  it  had  attracted  the  attention  of  any  other  persons.     Others,  however,  had  re- 


PERICARDITIS.  687 

marked  it,  and  had  correctly  interpreted  its  meaning.  I  claim  no  credit  therefore 
for  the  discovery  of  what  I  think  a  very  important  symptom :  but  I  claim  for  the 
sj'mptom  itself  that  additional  weight  which  accrues  to  it,  from  its  having  been 
originally  perceived  by  different  observers,  independently  of  each  other.  The 
physician  who,  in  this  country,  without  my  being  aware  of  it,  had  noted  and  pub- 
lished some  cases  in  which  this  phenomenon  occurred,  is  Dr.  William  Stokes,  of 
Dublin.  There  is  a  good  deal  said  about  it  by  Bouillaud  also  ;  and  he  too  appears 
to  have  discovered  the  sound,  without  any  previous  knowledge  of  its  having  been 
noticed  by  others,  I  have  heard  the  to  and  fro  sound  now  in  upwards  of  a  score 
ofca^es.  In  a  few  of  these  it  never  ceased  except  with  life.  The  patients  died 
during  the  primary  attack,  and  the  to  and  fro  sound  remained  as  long  as  the  heart 
continued  to  beat.  In  all  the  other  cases,  the  to  and  fro  sound  was  audible  for  a 
few  days  only,  and  then  ceased  entirely  and  for  ever :  the  patients  recovering  more 
or  less  completely. 

The  other  of  the  two  morbid  sounds,  is  the  ordinary  bellows  sound,  with  which 
you  are  already  familiar.  In  the  cases  in  question  it  is  a  single  sound  ;  a  deep-seated 
rush,  or  whiz,  accompanying  the  systole  of  the  heart.  It  usually  continues  long ; 
often  for  life. 

These  two  sounds,  the  superficial  to  and  fro  sound  and  the  deep-seated  bellows 
sound,  may  sometimes  be  heard,  by  a  careful  listener,  to  exist  together.  Sometimes 
the  bellows  sound  begins  to  be  distinguished  when  the  rubbing  sound  ceases;  ap- 
pears to  supervene  upon  it,  or  to  take  its  place;  perhaps  it  then  first  becomes  audible, 
simply  because  it  was  previously  drowned  in  the  louder  superficial  sound.  Some- 
times there  is  no  to  and  fro  sound,  but  only  the  deep  blowing  noise;  or  (what  in 
many  cases  is  extremely  probable,  nay,  what  I  may  venture  to  say  is  certain)  the 
to  and  fro  sound  has  C07ne  and  g07ie  unnoticed — un  listened  to. 

Now  of  these  sounds,  which  I  repeat  are  perfectly  distinct,  and  capable  of  being 
easily  discriminated  the  one  from  the  other,  the  first  mentioned,  viz.,  the  to  and  fro 
sound,  is  always  indicative  of  inflammation  of  the  external  membrane ;  the  other, 
the  bellows  sound,  is  always,  as  I  believe,  in  these  cases,  indicative  of  inflammation 
of  the  internal  membrane  of  the  heart.  You  will  bear  in  remembrance,  that  I  am 
speaking  of  these  sounds  as  they  somewhat  suddenly  occur  for  the  first  time,  and 
especially  as  they  occur  in  rheumatic  carditis  at  its  first  accession. 

Those  of  you  who  have  seen  the  thorax  opened  in  an  animal  whose  heart  still 
continued  to  palpitate,  may  have  observed,  as  I  have  done,  that  the  pericardium  lies 
closely  in  contact  with  the  heart,  but  that  a  considerable  extent  of  shpping  motion 
between  them  goes  on  at  every  successive  act  of  systole  and  diastole.  They  glide 
over  each  other  evenly  and  without  noise ;  but  this  is  only  while  the  surfaces  are 
smooth  and  healthy.  When  they  are  already  made  rough  by  inflammation  and  the 
deposition  of  lymph,  which  lymph  always,  as  I  have  shown  you,  is  rough  in  such 
cases,  then  the  irritation  will  be  no  longer  noiseless  :  it  will  give  rise,  in  the  alternate 
movements  of  the  organ,  to  the  harsh  and  superficial  to  and  fro  sound.  But  why 
does  that  sound,  when  once  it  has  occurred,  at  length  cease ;  and  why,  having  once 
ceased,  does  it  never  by  any  accident,  when  the  inflammation  has  been  universal, 
recur?  Clearly  because  the  pericardium  has  become  adherent  to  the  heart :  after 
which  there  can  be  no  motion  of  the  one  membrane  over  the  other,  and  therefore 
no  sound  indicative  of  such  motion. 

That  this  is  the  true  explanation  of  the  occurrence,  and  of  the  permanent  cessation, 
of  the  to  and  fro  sound,  I  am  now  (March,  1837)  convinced.  It  was  a  matter  of 
inference  with  me  for  some  time.  A  few  of  the  patients  died  during  the  primary 
attack.  By  much  the  majority  recovered.  I  do  not  mean  got  perfectly  well  as  they 
had  been  before ;  but  they  regained  a  great  share  of  their  usual  health,  perhaps 
thought  themselves  ivell,  and  left  the  hospital  where  they  had  been  under  treatment. 
Now  of  those  who  died,  the  pericardia  were  non-adherent.  The  opposite  surfaces 
of  the  membranes  were  rough,  and  like  tripe :  and  the  to  and  fro  sound  never  ceased 
in  these  persons.  Such  cases  are  always  soon  fatal.  But,  in  the  others,  did  adhe- 
sion take  place  ?  I  make  no  doubt  of  it.  Within  the  last  twelve  months  I  have  had 
demonstrative  proof  of  it  in  two  instances.  One  of  these  occurred  in  a  hospital  natient. 


688  PERICARDITIS. 

whose  case  has  been  published  in  the  Medical  Gazette*  He  was  a  painter,  nine 
teen  years  old ;  and  he  became  my  patient  last  May,  with  acute  rheumatism  and 
carditis.  From  the  20th  of  May  to  the  13th  of  June,  a  to  and  fro  sound  was  dis- 
tinctly audible,  as  well  as  a  bellows  sound  which  had  preceded  it.  After  that  date, 
the  bellows  sound  continued,  but  the  rubbing  sound  was  no  longer  to  be  heard.  The 
patient  improved  ;  and  was  about  to  be  discharged  from  the  hospital :  when,  on  the 
29th  of  June,  sixteen  days  after  the  sound  of  friction  had  finally  ceased,  he  suddenly 
dropped  down  dead  in  the  garden  of  the  hospital. 

Here  1  had  concluded  that  the  pericardium  was  adherent ;  though  I  had  not  ex- 
pected to  have  so  soon  the  opportunity  of  verifying  my  opinion.  And  accordingly, 
except  over  a  small  portion  of  the  posterior  part  of  the  right  ventricle,  the  union  was 
complete  at  all  points.  The  agglutination  was  evidently  the  work  of  recent  disease. 
The  medium  of  adhesion  was  of  considerable  thickness  :  and  consisted  of  coagulable 
lymph  and  coagulated  half-organized  blood.  The  pericardium  was  stripped  ofT,  as 
1  have  seen  a  poulterer  skin  a  rabbit,  and  with  about  the  same  ease.  This  was  a 
very  interesting  case  to  me,  for  it  was  the  first  in  which  I  had  had  the  privilege  of 
examining  the  heart  after  having  witnessed  the  pecuhar  succession  of  phenomena 
that  I  have  been  describing. 

But  since  that  time,  I  have  met  with  another  such  a  case  in  private  practice.  The 
particulars  of  it  are  sufficiently  important  to  warrant  my  relating  them.t 

In  the  month  of  October,  1836, 1  was  taken  by  Dr.  Sweatman  to  see  a  patient 
of  his ;  whom  I  found  sitting  up  in  bed,  pale,  with  sharp  features,  breathing 
shortly  and  laboriously.  His  legs  were  anasarcous,  and  his  belly  was  tense  and 
fluctuating. 

I  learned  that  he  had  been  for  years  given  up  to  intemperance  in  drinking,  and  to 
indolent  and  low  habits.  He  told  me  that  the  wind  troubled  him,  shooting  up  through 
the  whole  of  the  left  side  of  his  chest.  On  further  inquiry  I  found  that  he  meant 
that  he  had  much  pain  there.  There  was  loud  wheezing  over  the  upper  lobes  of 
both  lungs :  both  sides  of  the  thorax  were  dull  on  percussion  at  their  lower  part ; 
and  on  the  right  side  no  breathing  whatever  was  audible  below.  These  latter  symp- 
toms were  indicative  of  dropsical  effusion  into  the  pleura  also.  The  jugular  veins 
were  swollen  and  tortuous  on  both  sides  of  the  neck.  On  applying  my  ear  to  the 
precordial  region  I  at  once  heard  a  very  loud  and  distinct  to  and  fro  sound.  This 
was  equally  manifest  when  he  held  his  breath.  Dr.  Sweatman,  who  was  not  so 
much  accustomed  as  I  have  been  to  listen  to  the  sounds  of  the  heart  in  disease,  re- 
cognized instantly  the  peculiar  character  of  this  sound.  I  ventured  to  express  my 
certain  conviction,  that  the  patient  was  labouring  under  recent  and  acute  pericarditis. 
I  added,  that  he  had  also  hydrothorax  ;  and  that,  whatever  chronic  changes  might 
have  taken  place  in  his  heart  previously  to  his  present  illness,  dilatation  of  the  nght 
cavities  constituted  at  least  one  of  them. 

He  had  been  attacked  by  his  present  urgent  symptoms  three  days  before  I  saw 
him,  viz.,  on  the  8th  of  October.  On  that  day,  in  all  probability,  the  inflammation 
of  the  pericardium  commenced. 

This  was  his  history.  In  the  spring  of  the  year,  having,  from  indolence,  kept  the 
house  for  months  before,  he  crossed  from  the  Isle  of  Man  to  Liverpool,  and  was  sick, 
and  suffered  a  good  deal  during  the  passage.  After  landing  he  had  a  mile  or  more 
to  walk.  His  companions  outstripped  him,  but  were  called  back  to  him,  and  found 
him  very  pale,  breathing  with  difficulty,  and  unable  for  a  time  to  proceed.  He 
attributed  all  his  subsequent  complaints  to  that  exertion:  and  he  had  been  ailing, 
though  not  confined  to  his  room,  till  the  Sth  of  October.  I  did  not  venture,  in  his 
condition,  to  open  a  vein:  but  leeches  were  applied  to  the  praecordia,  and  he  took 
diuretics. 

I  did  not  see  him  again  till  the  15th  of  October,  four  days  after  my  first  visit.  The 
rubbing  sound  was  still  there,  though  less  loud,  less  harsh,  and  less  extensive.  The 
leeches  had  given  him  much  relief.  His  pulse  was  very  small.  A  blister  was  now 
applied.     On  the  20th  I  saw  him  for  the  third  and  last  time  ahve.     The  rubbing 

•  Vol.  xviii.  p.  701.  +  Medical  Gazette,  vol.  xzi.  p.  544. 


PERICARDITIS.  689 

sound  was  quite  gone.  This  Dr.  Sweatman  also  satisfied  himself  of.  There  was  a 
dull  systolic  bellows  sound  in  its  place.  The  pulse  was  scarcely  perceptible  ;  but 
he  continued  apparently  improving,  making  avast  quantity  of  urine,  while  the  drop- 
sical swellings  fast  diminished,  till  the  31st;  when,  after  talking  a  short  time  oddly, 
and  in  a  peculiarly  loud  voice,  he  sat  up  to  take  some  medicine,  and,  having  done 
so,  reclined  his  head  against  the  nurse,  and  expired.  Mr.  Shaw  assisted  in  the  sub- 
sequent examination  of  the  body.  I  omit  giving  an  account  of  the  conditioa  of  the 
lungs  and  pleura,  which  was  what  we  had  anticipated,  and  confine  myself  to  the 
state  of  the  heart.  That  organ  was  large.  The  pericardium  was  adherent  univer- 
sally by  means  of  lymph,  mottled  with  blood  ;  and  it  was  easily  separated,  so  that 
the  adhesion  must  have  been  recent,  as  was  proved,  indeed,  by  the  symptoms.  The 
right  cavities  of  the  heart  were  very  large,  and  the  aorta  was  diseased. 

The  existence  of  the  to  and  fro  sound  in  these  cases,  no  one  can  doubt  who  has 
once  listened  for  it  when  present ;  and  the  facts  respecting  it,  which  have  been  estab- 
lished beyond  the  reach  of  controversy,  are  these  :  —  1st.  That  when  it  occurs  cle 
novo,  it  always  surely  denotes  acute  inflammation  of  the  pericardium.  I  say  de 
novo,  because  (as  I  stated  in  the  last  lecture)  a  bellows  sound  may  accompany  each 
movement  of  the  heart,  in  consequence  of  internal  disease  of  some  standing;  and 
this  double,  sawing,  bellows  sound,  might  possibly  be  confounded  with  the  alternating 
noises  produced  by  the  attrition  of  the  opposite  surfaces  of  the  inflamed  pericardium. 
2dly.  The  to  and  fro,  or  rubbing  sound,  is  never  of  long  duration,  but  soon  termi- 
nates in  one  of  two  ways.  Either  the  patient  dies  in  a  short  time,  the  sound  conti- 
nuing to  the  last;  and  then  the  pericardium  is  found  coated  with  rough  lymph,  but 
throughout  the  far  greater  part  of  its  extent,  or  altogether,  i<jjadherent :  or  the  sound 
ceases,  never  to  return,  while  the  condition  of  the  patient  improves;  or  he  even 
seems,  to  himself  and  to  others,  to  recover  his  perfect  health.  In  these  cases,  the 
sound  ceases  from  a  physical  impossibility  of  its  continuance,  viz.,  from  adhesion  of 
the  pericardium  over  the  whole,  or  the  greater  part,  of  the  surface  of  the  heart.  And 
in  this  category  of  apparent  but  unreal  recoveries,  I  cannot  doubt  that  many  of  Bouil- 
laud's  cases  of  '■'■  pericarditis  terminating  in  health"  ought  to  be  included. 

It  follows  as  a  necessary  consequence  from  these  facts,  that  acute  pericarditis,  so 
far  advanced  as  to  occasion  the  pathognomic  rubbing  sound,  does  not  admit  of  a  per- 
fect cure ;  and  that  its  best  event  is  the  adhesion  of  the  membrane,  and  the  oblitera- 
tion of  its  cavity. 

And  even  then,  I  say,  the  change  is  not  final.  Mere  adhesion  of  the  pericardium 
does  so  embarrass  the  movements  of  the  heart  as  to  produce  at  length,  sometimes 
rapidly,  sometimes  slowly,  hypertrophy,  or  other  alterations  which  have  already  been 
considered.  It  is  held,  too,  and  I  believe  justly,  though  I  am  not  so  sure  of  this  as 
of  some  of  the  other  points  I  have  been  dwelling  upon,  that  the  inflammation  which 
begins  in  the  membrane,  sometimes  dips  into  the  muscular  substance  of  the  heart,. 
weakens  its  elasticity  and  cohesion,  and  so  leads  ultimately  to  dilatation  of  its 
cavities. 

I  need  not  occupy  much  of  your  time  in  speaking  of  the  other  morbid  sound  that 
is  audible  in  these  cases,  the  bellows  sound :  which  sometimes  may  be  heard  before 
the  to  and  fro  sound  commences  ;  which  I  have  heard  through  the  to  and  fro  sound  ; 
and  which  often  remains  after  the  superficial  rubbing  sound  has  ceased.  This  de- 
pends, no  doubt,  upon  those  alterations  in  the  valves  of  the  heart  which  take  place 
from  inflammation,  at  the  same  time  with  the  alterations  of  the  pericardium.  And 
when  it  is  met  with  in  such  cases,  it  may  be  set  down  as  very  strong  evidence  of  the 
existence  of  endocarditis. 

I  am  anxious  that  you  should  take  an  interest  in  the  disease  which  I  have  been 
speaking  of  at  so  much  length  this  evening,  and  that  you  should  keep  it  in  mind  in 
your  future  practice  ;  for  I  am  sure  that  it  is  a  fertile,  but  often  unsuspected,  source 
of  chronic  disease  of  the  muscular  substance  of  the  heart,  and  of  its  consequences : 
asthma,  dropsy,  sudden  death.  The  number  of  patients  that  come  into  the  hospitals 
of  London  affected  with  acute  rheumatism,  is  annually  very  large ;  and  I  am  sure 
that  I  do  not  exaggerate  when  I  say  that  nearly  one-half  of  them  have  the  heart  or 
•is  membranes  imphcated.  The  cardiac  affection  may  easily  be  overlooked,  both  by 
44  3h2 


690  RHEUMATIC    CARDITIS. 

the  patient  and  the  phj'sician.  The  recovery  may  appear  to  be  perfect.  But  after 
some  time,  palpitation  begins  to  be  occasionally  felt ;  and,  by  degrees,  other  symp- 
toms, marking  disease  of  the  heart,  declare  themselves :  but  their  origin  is  unsus- 
pected dr  forgotten.  You  will  be  surprised,  if  you  search  back  into  the  past  history 
of  all  the  patients  who  apply  to  you  having  disease  of  the  heart,  especially  among 
the  lower  classes  of  society, — you  will  be  surprised  to  find  how  many  of  them  will 
tell  you  that  at  some  time  or  other  of  their  lives  they  have  been  laid  up  with  rheu- 
matic fever. 

It  is  no  part  of  my  purpose  to  treat  at  present  of  that  specific  disease  of  the  joints 
to  which  we  give  the  name  of  acute  rheumatism :  but  I  may  as  well  complete  what 
I  have  to  say  of  carditis  as  it  occurs  in  connection  with  that  disease;  and  then  1  shall 
not  need  to  repeat  myself  when  I  come  to  rheumatism  itself. 

In  the  first  place,  then,  I  would  say  a  word  more  respecting  the  nervous  dis- 
turbance which  is  apt  to  supervene  in  such  cases,  and  to  mask  the  real  disease,  and 
to  mislead  the  unwary  practitioner.  Patients  labouring  under  rheumatic  carditis 
very  frequently  become  affected  with  delirium,  or  violent  mania,  or  stupor  and  coma, 
or  convulsions,  or  all  of  these  in  succession :  and  you  might  suppose  that  they  were 
labouring  under  inflammation  of  the  brain,  or  of  its  membranes.  Such  cases  are  in 
fact  spoken  of  as  cases  of  metastasis  to  the  brain.  It  may  sometimes  be  so,  nay,  I 
know  that  it  sometimes  is  so ;  but  not  often.  Again  and  again,  when  death  has 
occurred,  and  the  delirium  had  been  extreme,  no  traces  of  disease  have  been  dis- 
coverable within  the  skull,  while  marks  of  violent  and  intense  inflammation  were 
visible  in  the  pericardium.  I  presume  that  the  acute  cardiac  affection  interferes 
somehow  with  that  regulated  supply  of  blood  to  the  head,  which  is  necessary  for  the 
due  performance  of  the  cerebral  functions.  But  whatever  the  explanation,  recollect 
the  fact ;  and  whenever,  in  acute  rheumatism,  you  find  your  patient  flighty  and 
wandering,  or  more  distinctly  delirious,  examine  carefully  the  condition  of  his  heart. 
As  this  is  really  a  point  of  great  importance,  and  as  you  will  not  find  much  in- 
formation respecting  it  in  books,  I  shall  take  leave  to  quote,  here,  some  part  of  a 
clinical  lecture  delivered  by  myself  at  the  Middlesex  Hospital,  in  the  year  1835,  and 
printed  in  the  IGth  volume  of  the  Medical  Gazette.  My  subsequent  experience  has 
been  quite  in  conformity  with  what  I  then  stated. 

"The  functions  of  the  brain  not  unfrequently  become  disordered  in  rheumatic' 
fever:  and  disordered  in  such  a  manner  and  degree  as  would  lead,  and  has  led, 
many  to  believe  in  the  presence  of  active  inflammation  of  that  organ,  or  of  its 
enveloping  tissues.  Yet  this  affection  of  the  brain  is  not,  I  beheve,  inflammation, 
tut  some  secondary  affection  of  the  circulation  therein  ;  resulting  from  disturbance 
dt  the  central  organ  of  the  circulation,  capable  of  producing  a  corresponding  derange- 
ment in  the  cerebral  functions.  I  can  best  explain  what  I  mean  by  reciting  a  few 
examples. 

"  The  first  case  of  this  kind  that  I  ever  saw  or  heard  of,  occurred  in  St.  Bartholo- 
mew's Hospital,  many  years  ago.  I  took  notes  of  it  at  the  time,  and  will  read  you 
the  substance  of  them.  Charlotte  Rankin,  aged  17,  was  admitted  there  on  the  12th 
August,  1824,  under  the  care  of  Dr.  Roberts,  with  acute  rheumatism  of  the  joints. 
Her  illness  had  come  on  suddenly  a  week  before,  after  unusual  exposure  to  cold  and 
wet.  The  pain  and  swelling  had  shifted  much  from  joint  to  joint.  She  had  been 
bled,  on  account  of  pain  in  her  left  side,  two  days  before  admission.  On  the  14th, 
she  complained  of  much  difficulty  of  breathing,  and  of  pain  when  even  slight 
pressure  was  made  upon  the  chest.  These  symptoms  were  entirely  removed  by  a 
blistex.  On  the  16th,  she  was  observed  to  be  odd  in  her  manner — peevish,  querul- 
ous, restless,  without  sleep,  and  desirous  of  getting  out  of  bed.  Her  pulse  was  then 
100.  On  the  20th  the  pulse  had  risen  to  120;  it  was  quite  regular.  She  said  she 
felt  no  pain,  except  the  soreness  occasioned  by  the  blister.  She  slept  very  little.  On 
the  21st,  the  pulse  was  128.  Some  jactitation  of  the  left  arm  was  now  observed, 
which,  she  said,  had  never  happened  before.  No  sleep.  On  the  22d,  about  nine  in 
the  evening,  she  became  furiously  maniacal,  and  it  was  necessary  to  confine  her  by 
a  strau-wais'coat.  She  continued  in  that  state  for  upwards  of  four  hours,  and  then 
died 


HEAD    SYMPTOMS.  691 

"Twelve  hours  afterwards  the  body  was  examined.  The  brain  was  found  quite 
healthy  :  its  vessels  seemed,  indeed,  somewhat  fuller  of  blood  than  is  usual,  but  there 
was  no  effusion,  nor  any  other  vestige  of  inflammation. 

"  The  pericardium  was  glued  to  the  heart  in  several  places,  by  recent  adhesions  ; 
and  it  was  universally  coated,  where  not  adherent,  by  a  layer  of  rouo-h,  reticulated 
lymph,  remarkably  harsh  to  the  touch. 

"  Now  here  the  most  prominent  symptoms  were  such  as  we  are  accustomed  to 
refer,  with  tolerable  confidence,  to  inflammation  of  the  membranes  of  the  brain ; 
whereas,  in  fact  the  inflammation  was  strictly  confined  to  the  heart.  If  no  examina- 
tion of  the  body  had  been  made,  the  case  might  have  been  quoted,  with  much  show 
of  reason,  as  a  well-marked  example  of  metastasis  to  the  brain.  It  was  so  considered 
before  the  brain  was  inspected. 

"  There  had,  indeed,  been  symptoms  which  indicated,  and  that  not  obscurely,  the 
cardiac  disease.  At  that  time,  however,  I  did  not  know  how  frequently  carditis  is 
combined  with  acute  rheumatism.  Auscultation  had  not  yet  come  much  into  fashion 
in  this  country ;  at  any  rate,  I  knew  little  or  nothing  of  its  use ;  and  I  had  supposed 
(and  it  had  been  supposed  by  others  who  witnessed  the  case)  that  the  chest  symp- 
toms resulted  from  rheumatism  of  the  intercostal  muscles. 

"Another  instance,  in  which  the  course  of  the  symptoms  was  somewhat  different, 
yet  equally  calculated  to  mislead,  you  have  lately  seen  in  this  hospital. 

"  William  Wilkins,  a  post-boy,  28  years  old,  was  admitted  on  the  25th  of  last 
November. 

"  He  complained  of  pain  in  most  of  the  large  joints,  shifting  from  one  joint  to 
another.  There  was  no  visible  redness  or  swelling,  but  he  had  much  fever.  The 
pain  was  greatest  at  night.  He  had  profuse  perspirations,  during  which  the  pain 
was  not  mitigated. 

"  He  had  been  ill  eight  weeks ;  and  at  first  his  joints  (according  to  the  statements 
of  his  friends)  were  both  swelled  and  red.  He  appeared  to  be  recovering  at  one 
time,  but  relapsed.  For  three  or  four  days  previously  to  his  admission  he  had 
coughed  a  little,  and  spoken  of  pain  at  the  pit  of  the  stomach.  He  lay  more  com 
fortably  on  the  right  than  on  the  left  side,  but  this  was  habitually  the  case.  He  had 
never  had  acute  rheumatism  before. 

"  He  rambled  a  good  deal  during  the  night  of  the  26th,  and  on  the  27th,  he  began 
to  refuse  to  take  his  medicine,  appeared  confused  and  stupid,  and  answered  questions 
tardily  and  imperfectly.  He  was  bathed  in  perspiration,  which  had  the  strong  acid 
smell  so  common  in  cases  of  acute  rheumatism. 

"  During  the  next  ten  days  he  remained  in  a  singular  state  of  quiet  delirium,  re 
jecting  medicine  and  food,  saying  he  had  had  enough  ;  getting  out  of  bed,  especially 
in  the  night,  and  declaring  that  he  was  going  home.  When  questions  were  put  tc 
him,  his  lips  moved,  and  his  limbs  began  to  stir  and  fidget,  as  though  he  Avere  about 
to  answer;  yet  he  said  nothing.  He  understood  what  was  said  to  him,  and  put  out 
his  tongue  when  desired  so  to  do ;  imperfectly,  however,  and  with  slowness  and 
apparent  difficulty.  His  bowels  were  costive,  and  he  passed  his  stools,  when  pur- 
gatives acted,  in  the  bed.  His  pulse  was  small  and  frequent ;  and  when  his  wrist 
was  taken  hold  of  that  the  artery  might  be  felt,  he  always  resisted,  and  forcibly  con- 
tracted his  arm. 

"Then  for  three  or  four  days  he  appeared  to  improve  ;  his  countenance  became 
more  clear  and  lively  ;  but  he  still  showed  the  same  restlessness,  and  maintained 
the  same  dogged  silence  when  spoken  to,  and  obstinately  refused  to  swallow  medi- 
cine. He  was  somewhat  cunning,  too,  for  he  would  take  pills  into  his  mouth,  and 
then,  when  he  thought  he  was  not  observed,  chew  and  spit  them  out  again. 

"  His  pulse  became  at  last  very  frequent,  and  his  strength  diminished  rapidly. 
He  died  on  the  18th  December,  and  the  body  was  examined  on  the  following  day. 

"  The  cerebral  veins  were  gorged  with  dark  blood,  and  there  was  a  considerable 
quantity  of  serous  fluid  beneath  the  arachnoid  and  in  the  lateral  ventricles. 

"  The  pericardium  was  free  from  disease  ;  but  upon  the  mitral  valve,  near  its  edg« 
the/e  was  a  perfect  row  of  small,  slender,  bead-like  warts. 

'  A  lew  weeks  ago  I  was  consulted  in  a  case  of  a  similar  nature  -^-Jiich  occurred 


692  RHEUMATIC    CARDITIS. 

in  the  practice  of  a  gentleman  who  was  formerly  a  pupil  here,  and  who  was  fully 
aware  both  of  the  frequent  occurrence  of  carditis  in  acute  rheumatism,  and  of  the 
anomalous  symptoms  with  which  it  is  sometimes  attended.  The  patient  was  a  young 
man,  24  years  of  age, 

"  On  the  '?2d  of  December  he  was  seized  with  pain  and  swelling  of  several  of  the 
larger  joints,  and  with  fever.  The  attack  was  ascribed  to  exposure  to  cold  the  day 
before  ;  he  had  previously  enjoyed  perfect  health.  The  inflammation  shifted  rapidly 
from  one  joint  to  another.  He  was  confined  to  bed  for  six  days  :  then,  feeling  better, 
he  got  up,  changed  his  room,  and  presently  underwent  a  relapse.  Mr.  Elwin  tells 
me  that,  after  that  time,  he  was  never  comfortable  about  this  patient ;  his  countenance 
was  pale,  and  his  aspect  unpromising;  his  pulse  frequent;  and  more  than  once  he 
complained  of  slight  pain  in  the  epigastrium,  increased  by  a  full  inspiration.  This 
was  removed  by  a  mustard-poultice.  No  morbid  sound  was  detected  upon  a  careful 
examination  of  the  proecorcfial  region  by  the  ear.  He  remained  low-spirited,  but 
slowly  mending,  till  the  3d  of  January,  when  in  the  evening,  without  any  notice  or 
obvious  cause,  he  began  to  be  restless  and  delirious. 

"  On  visiting  him  the  next  morning,  Mr.  Elwin  found  him  with  an  anxious  coun- 
tenance ;  a  frequent  and  irregular  pulse,  which  occasionally  intermitted ;  his  mind 
wandering ;  the  action  of  his  heart  strong,  and  attended  towards  the  sternum  with  a 
loud  bellows  sound.  The  next  day  his  breathing  was  difficult,  and  'catching;'  the 
pulse  120,  hard  and  wiry.  At  that  time  I  had  the  opportunity  of  seeing  him.  He 
was  lying  in  a  sort  of  stupor,  yet  not  unconscious,  for  he  put  out  his  tongue  at  my 
request,  and  answered  pertinently  one  or  two  questions,  after  they  had  been  frequently 
repeated.  He  had  the  air  of  a  person  obstinately  determined  to  say  as  httle  as  pos- 
sible. He  became  more  distinctly  delirious  towards  evening;  and  the  next  day  his 
pulse  and  breathing  were  both  so  frequent  (148,  and  78,  in  the  minute  respectively), 
that  he  was  thought  to  be  dying.  A  distinct  bellows  sound  was  audible  near  the 
left  mamma.  This  state  continued,  with  slight  fluctuations,  till  the  8th,  when  his 
condition  appeared  somewhat  more  hopeful.  He  was  calm,  had  no  d3^spno5a,  and 
conversed  more  readily, — saying  sometimes  that  he  felt  as  if  he  were  'dead  ;'  some- 
times that  he  was  '  burnt  up.'  He  complained,  for  the  first  time,  of  pain  in  the  right 
temple  ;  his  gums  were  slightly  under  the  influence  of  mercury ;  his  pulse  scarcely 
exceeded  100;  the  bellows-suund  was  very  manifest. 

"On  the  9th  he  again  became,  first  restless,  then  violently  and  wildly  delirious, 
screaming  out,  refusing  to  take  medicine,  or  to  open  his  mouth  when  it  was  offered  ; 
yet  he  evidently  knew  what  was  said  to  him.  During  the  night  general  convulsions 
came  on  in  occasional  spasms,  of  a  tetanic  character:  in  the  intervals  between  them 
he  lay  in  a  state  of  coma.     He  survived  in  this  condition  till  the  12th. 

"  I  was  present  at  the  inspection  of  the  body  ten  hours  after  death.  Some  of  his 
family  insisted  on  being  in  the  room  with  us  ;  but  we  were  able  to  make  an  accurate 
examination  of  the  head,  and  of  the  heart. 

"The  veins  of  the  brain  seemed  somewhat  fuller  of  blood  than  is  common.  The 
arachnoid  was  slightly  elevated  by  a  clear  serous  fluid  collected  in  the  pia  mater. 
There  was  but  a  small  quantity  of  a  similar  fluid  in  the  lateral  ventricles.  The  lungs 
appeared  quite  healthy. 

"There  was  no  fluid  in  the  pericardium.  Its  surface  was  everywhere  exceed 
ingly  vascular,  but  it  presented  no  appearance  of  lymph,  e.xcept  where  it  adhered  to 
the  posterior  side  of  the  heart,  over  a  space  about  two  inches  and  a  half  in  length, 
and  upwards  of  an  inch  in  breadth.  The  lymph  which  formed  the  medium  of  con- 
nection was  firm,  but  evidently  of  recent  formation;  and  a  very  slight  degree  of 
force  sufficed  to  separate  the  adhering  membranes.  The  heart  was  rather  small, 
and  the  left  ventricle  had  a  singular  wrinkled  appearance  externally.  Towards  the 
edge  of  the  mitral  va've  there  was  a  profuse  crop  of  little  Avart-like  vegetations,  of 
th*^  size  of  millet-seeds ;  and  numerous  red  lines  converged  towards  them  from  the 
base  of  the  valve.  The  aortic  valves  all  presented  curious  festoons  of  similar  ex- 
crescences, larger,  however,  and  more  prominent,  than  those  upon  the  mitral  valve. 

"  In  the  beginning  of  the  year  1832,  a  girl  nineteen  years  old,  Frances  Kirk  by 
Dame,  was  a  patient  of  mine  in  the  hospital,  with  acute  rheumatism  of  the  joints, 


HEAD    SYMPTOMS.  693 

^■^d  carditis,  manifested  by  many  of  the  most  usual  symptoms — by  pain  in  the  situa- 
tion of  the  heart,  dj'spncEa,  great  frequency  of  pulse,  and  a  distinct  bellows  sound. 
She  lived  two  months  from  the  commencement  of  the  cardiac  disease.  Durin^^  that 
period  she  was  at  times  wildly  delirious — at  times  stupid,  taciturn,  and  almost  idiotic 
— and  at  times  quiet  and  rational.  The  brain  in  that  case  was  found  perfectly  healthy, 
except  a  slight  serous  effusion  beneath  the  arachnoid.  The  pericardium  was  every- 
where adherent  to  the  heart.  By  some  mismanagement  the  opportunity  of  inspect- 
ing the  inner  membrane  of  the  heart  was  lost. 

"In  each  of  the  three  last-mentioned  cases  there  was  more  or  less  serous  fluid 
found  in  the  meshes  of  the  pia  mater,  and  in  the  lateral  ventricles.  You  may  ask, 
perhaps,  whether  this  effusion  was  not  good  evidence  of  previous  inflammation  there  ? 
whether  it  did  not  show  that  the  metastasis,  which  I  have  spoken  of  as  seldom  hap- 
pening, really  did  happen  in  these  very  cases  ? 

"I  apprehend  not;  and  for  the  following  reasons: — In  one  only  of  these  cases 
was  the  amount  of  the  serous  accumulation  at  all  considerable.    There  was  no  other 
trace  of  inflammatory  action  in  any  of  them  ;  no  redness,  nor  pus,  nor  lymph  ;  none 
of  the  unequivocal  products  of  inflammation.     What  quantity  of  serous  effusion  be- 
neath the  arachnoid,  or  in  the  ventricles  of  the  brain,  is  requisite   to  establish  its 
morbid  origin — within  what  hmits  such  effusion  maybe  considered  natural — whether 
it  may  not  be  ascribed  wholly,  or  in  part,  to  mechanical  transudation  after  death ; 
these  are  questions  which  have  not  yet  been  definitely  settled  among  pathologists. 
For  my  own  part,  whenever  I  see  the  veins  of  the  pia  mater  full  of  blood,  I  expect 
to  find  serum  between  that  membrane  and  the  arachnoid.     How  much  of  it  may 
have  been  poured  out  before  death,  and  how  much  afterwards,  it  would  be  difficult 
to  estimate.     In  each  of  the  cases  before  us  there  was  evidence,  not  to  be  mistaken, 
of  cardiac  inflammation.     Now  that  acute  inflammation,  fixing  itself  upon  some 
portion  of  the  heart,  should  embarrass  its  action,  and  modify  the  condition  of  the 
circulation  through  the  cerebral  blood-vessels,  is  not  only  conceivable,  but  highly 
probable.     Any  retardation  of  the  venous  circulation  in  the  head — any  engorgement 
or  congestion  of  that  system  of  vessels — would  be  hkely,  if  we  may  reason  from  the 
analogy  of  other  parts,  to  produce  effusion.     I  have  seen,  in  the  brain  of  a  criminal 
who  had  been  hanged  while  in  a  state  of  perfect  health,  as  much  serum  collected  in 
the  same  parts  as  we  found  in  the  patients  whose  cases  I  have  been  relating.     It  is 
possible  that,  in  them,  the  disorder  of  the  sensorial  functions  depended  upon  simple 
disturbance  of  the  cerebral  circulation  ;  it  is  possible  that  the  same  disorder  depended 
upon  the  serous  effusion  ;  and  it  is  possible,  and  (I  think)  probable,  that  it  depended 
in  part  upon  both  these  causes.     It  is  very  certain   that  similar  symptoms  have 
occurred  in  similar  cases,  when  there  was  no  appreciable  effusion  ;  and,  apparently, 
from  mere  derangement  of  'he  natural  circulation  of  the  blood  in  its  vessels.     On 
the  other  hand,  we  know  that  an  equal,  or  a  greater  amount  of  effusion,  has  often 
been  observed,  when  no  such  cerebral  symptoms  had  manifested  themselves.     I 
conceive,  therefore,  that  the  symptoms  referable  to  the  brain,  and  the  quantity  of 
serum  found  effused  there  (whether  these  bear  to  each  other  the  relation  of  cause 
and  consequence,  or  not),  are  both  to  be  regarded  as  secondary  effects  of  the  cardiac 
disease ;  that  they  denoted  no  inflammatory  condition  of  the  brain,  or  of  its  mem- 
branes, but  were  the  common  result  of  that  inflammation  of  the  heart,  concerning 
the  existence  of  which  the  inspection  of  the  bodies  left  us  no  room  to  doubt. 

"That  this  view  of  the  matter  is  correct,  is  the  more  probable  because  (as  I  just 
now  stated)  the  same  symptoms  have  been  known  to  accompany  carditis,  although 
no  serous  effusion  was  met  with  in  the  head.  There  was  none  in  the  case  of  the 
girl  Rankin ;  none  in  a  case  related  by  Dr.  Davis ;  none  in  a  remarkable  case  do- 
tailed  by  Dr.  Latham  ;  none  in  a  striking  example  of  a  similar  kind  which  fell  under 
the  observation  of  that  accurate  and  most  accomplished  pathologist,  Andral.  I  shf^li 
take  the  liberty  of  citing  these  two  instances. 

" '  One  of  the  children  of  Christ's  Hospital,'  says  Dr.  Latham,  '  had,  in  the  opmion 
of  all  who  saw  him,  the  severest  inflammation  of  the  brain.  The  attack  was  sudden, 
with  great  heat  and  frequency  of  pulse.  He  had  delirium  and  convulsions,  and 
poinl(  d  to  his  forehead  as  the  seat  of  his  pam.     In  three  days  he  died,  and.  upon 


094  RHEUMATIC    CARDITIS. 

dissection,  not  a  vestige  of  disease  was  found  within  the  cranium  ;  but  the  heart  was 
exclusively  the  seat  of  the  disease,  and  no  other  part  of  the  body  discovered  the 
slightest  morbid  appearance.  The  disease  of  the  heart  was  not  confined  to  its  invest- 
ing membrane.  It  was  the  most  intense  inflammation  pervading  the  pericardium 
and  the  muscular  substance.' 

"Andral's  case,  which  is  referred  to  by  Dr.  Latham,  occurs  in  his  Clinique  Me- 
dicale. 

"A  woman,  twenty-six  years  old,  was  brought  to  La  Charite,  in  a  state  of  delirium, 
and  no  account  could  be  obtained  of  her  previous  condition.  The  delirium  was  re- 
markable for  the  obstinate  taciturnity  which  attended  it.  When  questioned,  the 
patient  turned  a  fixed  gaze  upon  the  person  who  spoke  to  her,  but  made  no  reply. 
Her  face  was  pale  ;  her  pulse  smaL'  and  frequent.  During  the  two  following  days 
the  head  was  frequently  drawn  backwards,  the  trunk  was  shaken  at  intervals  by 
convulsive  movements,  and  she  had  subsuhus  tendinum;  but  she  now  spoke,  and 
appeared  to  comprehend  what  was  said  to  her,  but  talked  incoherently.  The  pulse 
was  very  frequent,  and  intermitting.  On  the  fourth  day  the  delirium  ceased  ;  she 
complained  of  nothing  but  great  debility.  The  muscles  of  the  face  were  almost 
continually  agitated  by  convulsive  twitchings,  and  the  arms  from  time  to  time  pre- 
sented a  sort  of  tetanic  stiffness.  On  the  fifth  day  the  delirium  returned ;  the  patient 
then  fell  into  a  state  of  coma,  and  died  the  next  morning. 

"Neither  the  brain,  nor  the  spinal  marrow,  nor  their  membranes,  presented  any 
appreciable  morbid  appearances.  The  pericardium  was  lined  by  coagulable  lymph, 
and  its  opposite  surfaces  were  connected,  in  some  places,  by  recent  bands  of  adhe- 
sion. It  contained  also  some  ounces  of  a  greenish  flaky  serum.  No  other  trace  of 
disease  was  discoverable. 

"Now  if  you  are  not  made  aware  beforehand  of  this  strange  course  of  the  symp- 
toms arising,  sometimes,  out  of  rheumatic  carditis,  you  will  be  apt  to  overlook  the 
cardiac  affection,  and  to  direct  your  remedial  measures  wide  of  the  mark.  In  a  se- 
cond instance  mentioned  in  Dr.  Latham's  essay,  'the  whole  force  of  the  treatment 
was  directed  to  the  head,  from  a  belief  that  the  brain  was  inflamed.  Upon  dissection 
the  brain  and  its  coverings  were  found  in  a  perfectly  healthy  and  natural  state ;  and 
the  pericardium,  towards  which  during  life  there  was  no  symptom  to  direct  the 
slightest  suspicion  of  disease,  discovered  the  unequivocal  marks  of  recent  and  acute 
inflammation.'  Dr.  Davis,  also,  in  reference  to  a  case  published  by  him  so  early  as 
1808,  has  the  following  remark  : — 'The  restlessness  in  the  case  of  Miss  H.  C.  was  also 
attended  with  delirium,  a  symptom  not  previously  noticed  as  belonging  to  pericarditis 
by  any  writer  whom  I  have  consulted.  It  was  so  prominent  a  feature  of  the  disease 
under  which  this  young  lady  laboured,  as  to  divert  the  attention  of  her  medical  at- 
tendants from  its  actual  seat,' 

"This  occurrence,  in  the  course  of  rheumatic  carditis,  of  cerebral  symptoms  calcu- 
lated to  perplex  and  obscure  the  true  nature  of  the  disease,  is  probably  not  so  rare  as 
has  been  supposed.  In  less  than  three  years  three  instances  of  it  have  fallen  under 
my  own  notice ;  and  I  have  been  informed  by  a  medical  man  residing  in  the  neigh- 
bourhood, that  a  friend  of  his,  who  has  a  very  large  general  practice  among  the 
middle  and  lower  classes,  attended  within  the  last  year  or  two  not  less  than  twenty 
cases  of  acute  rheumatism,  in  which  a  metastasis,  or  an  extension  of  the  inflamma- 
tion, appeared  to  take  place  to  the  brain. 

"  In  all  the  detailed  cases  of  this  kind  that  I  have  met  with,  and  in  those  which  I 
have  myself  watched,  there  were  certain  general  points  of  similarity,  which  you  will 
do  well  to  bear  in  mind.  In  all  of  them  the  pulse  was  extremely  rapid  ;  the  deli- 
rium, though  violent  and  active  at  intervals,  was  characterized  for  the  most  par^  by  a 
singular,  and,  as  it  seemed,  perverse  taciturnity :  even  when  the  patient  was  evi- 
dently able  to  speak,  and  understood  the  questions  that  were  put  to  him,  he  main- 
tained a  sullen  silence.  In  most  of  these  patients,  also,  not  long  before  the  fatal 
event,  a  brief  interval  of  amendment  took  place,  and  encouraged  some  hope  of 
rpcovery.  In  many  of  them  various  convulsive  movements  were  observed  ;  and  in 
two  of  the  cases  the  head  symptoms,  and  probably  the  heart  disease  also,  supervened 
after  a  relapse  of  the  rheuniatism  of  the  joints." 


f 


I 


HEAD   SYMPTOMS.  695 

It  is  a  curious  circumstance  that  rheumatic  carditis  is  sometimes  the  first  step  in 
the  whole  disease ;  the  cardiac  s3^mptoms  will  sometimes,  I  mean,  precede  those  of 
the  joints ;  even  by  two  or  three  days.  For  example.  A  lad  was  brought  to  the 
hospital  with  acute  articular  rheumatism,  and  with  unequivocal  symptoms,  which  1 
need  not  detail,  of  carditis.  He  gave  the  following  distinct  history  of  his  illness : — 
He  had  been  on  a  visit  into  the  country  several  days  before,  and  there,  after  having 
felt  poorly  for  nearly  a  week,  with  a  sensation  of  "  sinking  within  him,"  he  ate 
largely  of  oysters,  and  drank  more  porter  than  he  was  accustomed  to.  On  the  same 
day  he  was  seized  with  pain  in  the  left  side  of  the  chest,  and  violent  beating  of  the 
heart.  The  attack  was  probably  a  severe  one,  for  he  applied  to  a  medical  man, 
who  immediately  bled  him.  In  the  course  of  the  ensuing  night  he  began,  for  the 
first  time  in  his  life,  to  feel  some  stiffness  beneath  and  about  his  knees,  but  he  was 
able  to  walk  about  the  next  day.  On  the  evening  of  the  second  day  the  joints 
became  so  painful  and  swollen,  that  he  could  not  leave  his  bed,  and  then  the  pain  of 
the  side  and  the  palpitation  diminished.  This  boy  has  several  times  since  returned 
to  the  hospital  with  acute  rheumatism,  and  on  each  occasion  presented  manifest  in- 
dications of  some  permanent  affection  of  the  heart, — slight,  probably,  in  amount,  but 
aggravated  upon  every  return  of  inflammation  of  the  joints. 

I  have  met  with  one  or  two  other  instances  in  which  the  cardiac  disease  appeared 
to  have  preceded  the  arthritic;  but  none  so  well  made  out  as  that  I  have  just  related 
Dr.  Duncan,  in  the  Edinburgh  Medical  and  Surgical  Journal  for  1816,  gives  a 
case  of  "  inflammation  of  the  heart"  which  began  with  symptoms  oi pectoral  inflam- 
mation, succeeded  the  next  day  by  rheumatic  affections  of  the  joints. 

One  law  respecting  the  connection  between  the  cardiac  and  the  arthritic  symp- 
toms may  be  stated  with  confidence,  namely,  that  the  younger  the  patient  is  who 
suffers  acute  rheumatism  (and  I  have  seen  it  so  early  as  the  third  or  fourth  year)  the 
more  likely  will  he  be  to  have  rheumatic  carditis.  The  chance  of  the  combination 
appears  to  diminish,  after  puberty,  as  hfe  advances.  I  have  known  only  two  persons 
pass  through  acute  rheumatism  with  an  untouched  heart  prior  to  the  age  of  puberty; 
and  in  these  two  I  am  by  no  means  certain  that  the  articular  disease  was  genuine 
rheumatism.  In  each  of  them,  the  large  joints  became  painful,  and  swelled,  for  a 
day  or  two  only,  towards  the  close  of  scarlet  fever : — a  circumstance  not,  I  believe, 
unusual.     I  was  dreadfully  apprehensive  of  carditis,  but  it  did  not  occur. 

I  have  observed,  also,  that  when  a  patient  has  come  under  my  care  who  has  had 
repeated  attacks  of  acute  rheumatism,  in  him  I  have  generally  found  reason  to  believe 
that  some  organic  affection  of  the  heart  was  present.  Probably  the  disposition  to 
such  repetitions  of  the  disease,  so  remarkable  in  some  individuals,  may  be  kept  up 
by  the  cardiac  complication. 

AVith  respect  to  the  period  of  the  actual  attack,  and  the  circumstances  under 
which  the  extension  of  the  disease  to  the  heart  occurs,  no  fixed  law  has  been  ob- 
served. Sometimes  the  cardiac  affection  declares  itself  as  the  inflammation  of  the 
joints  declines.  Quite  as  often,  however,  they  proceed  together,  and  are  aggravated 
or  mitigated  simultaneously.  On  this  point  my  own  experience  nearly  agrees  with 
that  of  Dr.  Latham,  who  says : — "  It  (the  cardiac  affection)  is  incident  to  all  the  de- 
grees and  all  the  stages,  and  all  the  forms  (?)  of  acute  rheumatism.  It  is  not  more  to 
be  looked  for  when  the  disease  is  severe  than  when  it  is  mild;  more  at  its  beginning 
than  during  its  progress  and  decline  ;  more  when  it  is  shifting  and  inconstant  in  its 
seat,  than  when  it  is  fixed  and  abiding." 

There  are  some  other  symptoms  that  I  must  not  omit  to  mention  as  occurring  in 
some  cases  of  pericarditis.  In  one  of  the  fatal  instances  which  fell  under  my  own 
notice,  there  was  a  very  strong  purring  tremor  felt  by  the  hand  placed  upon  the 
region  of  the  heart.  This  is  not  a  constant,  nor  even  a  frequent,  symptom ;  but  it 
has  a  certain  degree  of  corroborative  value  when  it  does  occur. 

When  the  fluid  products  of  the  inflammation  predominate,  when  there  is  much 
serum  poured  out,  the  symptoms,  as  well  as  the  danger,  will  be  different  from  thosw 
which  are  remarked  when  there  is  not  so  much  serous  liquid.     If  the  pericardium 
be  distended,  percussion  will  furnish  a  dull  sound  over  an  unusually  large  space 
much  beyond  the  natural  hmits  of  the  precordial  region:  and  yDu  may  often  mea- 


696  RHEUMATIC    CARDITIS. 

sure  the  amount  of  the  effusion,  and  its  daily  increase  or  decrease,  very  accurately 
in  this  manner.  But  the  general  symptoms  will  vary  also.  The  pulse  will  be 
feebler,  and  more  disposed  to  falter  and  to  become  irregular,  in  proportion  as  the 
liquid  effusion  is  large ;  and  at  the  same  time  the  patient  will  frequently  be  fixed  in 
one  position,  and  unwilling  or  afraid  to  change  it,  lest  that  small  exertion  should  fur 
ther  excite  the  action  of  his  heart,  and  hurry  his  respiration.  He  will  lie,  perhaps, 
always  upon  one  side ;  or  he  will  remain  immovable  on  his  back,  with  his  head  ele- 
vated;  or  he  will  sit  up  continually,  with  his  body  leaning  forwards;  and  he  will 
not  dare  to  alter  his  posture.  But  when  the  solid  products  of  the  inflammation  pre- 
dominate ;  when  there  is  coagulable  lymph,  and  but  little  serum ;  when  the  peri 
cardium,  instead  of  being  distended,  becomes  attached  to  the  heart;  then  the  pulse 
will  retain  that  force  and  regularity  with  which  the  disease  commenced,  the  dull 
sound  yielded  to  percussion  will  not  transgress  the  precordial  limits,  and  the  patient 
will  not  in  general  experience  any  absolute  necessity  of  accommodating  his  body  to 
one  constrained  position. 

Of  a  merely  adherent  pericardium  there  are  no  diagnostic  signs  to  which,  so  far 
as  I  know,  we  can  trust,  either  ausculatory  or  general.  None,  I  mean,  presented  by 
the  body  at  the  time.  If  we  are  accurately  acquainted  indeed  with  the  history  of 
the  patient's  disease,  and  if  we  know  that,  at  any  time,  a  to  and  fro  sound  existed, 
which  to  and  fro  sound  soon  ceased,  and  has  never  recurred  ;  then  our  conclusion 
that  the  pericardium  is  adherent  will  scarcely  be  open  to  any  source  of  fallacy. 

When  the  opposite  surfaces  of  the  membrane  have  been  once  united,  they  never 
separate  again  ;  the  adhesion  remains  for  life.  But  the  lymph  interposed  between 
them,  if  the  inflammation  be  not  renewed,  becomes  less  and  less  thick  ;  until  at  length, 
in  some  cases,  a  mere  layer  of  firm,  but  thin,  areolar  tissue  is  left,  through  which  the 
heart  is  visible. 

But  when  inflammation  has  stiffened  the  valves  of  the  heart,  or  studded  them  with 
little  wart-like  masses  of  fibrin,  how  far  do  these  morbid  states  admit  of  perfect  re- 
covery ?  It  is  not  so  easy  to  say.  I  am  not  aware  of  any  facts,  which  would  forbid 
altogether  the  hope  that  here,  as  in  iritis,  the  re-absorption  or  removal  of  the  lymph 
may  be  total,  and  the  restoration  of  the  parts  complete.  On  the  contrary,  the  com- 
parative infrequency  of  wart-hke  excrescences  in  the  slowly  fatal  cases  of  rheumatic 
carditis  leads  to  the  opinion  that  such  deposits  may  disappear  as  readily  and  entirely 
from  the  valves  of  the  heart  as  from  the  iris. 

Since  I  lectured  upon  this  subject  last  year,  two  examples  of  rheumatic  carditis 
have  occurred  among  my  hospital  patients,  diff'ering  in  some  remarkable  points  from 
any  that  I  had  ever  seen.  A  brief  description  of  them  will  complete  my  personal 
experience  of  this  terrible  disease. 

The  histories  of  the  two  cases  are  curiously  similar.  The  patients  were  young 
women  ;  their  ages  respectively  twenty-one  and  twenty-two.  They  were  admitted 
during  the  same  week  ;  one  a  day  after  the  other.  Both  were  suflvring  under  a  first 
attack  of  rheumatic  fever;  both  had  also  acute  pleurisy,  with  effiision  into  the  chest; 
and  both  died  ;  one  of  them  three  weeks,  and  the  other  a  month,  after  her  admission. 
In  both  cases  there  were  symptoms  referable  to  the  heart ;  pain,  and  unnatural  sounds; 
but  in  neither  case  was  there  any  friction-sound  ;  nor  were  any  traces  of  pericarditis 
discovered  after  death.  But  the  inflammation  had  fallen,  partially,  upon  the  aortic 
valves  ;  whence  it  had  extended  (so  I  imagine)  to  the  muscular  substance.  I  show 
yoii  the  morbid  appearances  represented  in  these  drawings,  made  by  Mr.  Lonsdale 
fit  the  time :  and,  better  still,  I  show  you  the  parts  themselves,  which  are  preserved 
ill  our  museum. 

The  whole  of  one  of  the  aortic  valves  was,  in  each  case,  a  mass  of  ragged  ulcera- 
tion ;  and  the  adjacent  portions  of  the  two  other  valves  Avere,  in  a  slighter  degree, 
implicated  in  the  mischief.  What  remained  of  the  tattered  valve  was  covered  with 
rough  irregular  shreds  of  lymph,  or  vegetations.  In  one  of  the  cases,  the  ulcerating 
process  had  penetrated  through  the  valve,  and  into  the  muscular  substance  beyond, 
and  had  eaten  a  hole  completely  through  the  septum.  A  portion  of  lymph  protruded 
just  below  the  valve  of  the  pulmonary  artery  through  the  channel  of  communication 
ihu?  formed  between  the  left  and  right  sides  of  the  heart.     In  the  other  case,  ari 


ACUTE    PERICARDITIS.  697 

abscess  as  large  as  a  hazel-nut  was  found  in  the  muscular  substance  of  the  septum, 
immediately  opposite  the  disorganized  valve. 

Till  I  met  with  these  cases,  I  was  not  aware  that  this  destructive  incrus'tation  of 
the  cardiac  valves  with  wart-like  excrescences  was  ever  the  result  of  acute  inflamma- 
tion. Chronic  changes  of  that  kind  are  not  uncommon.  Suppuration  in  the  heart 
is  very  rare.  In  these  two  instances  the  cardiac  affection  was  complicated  with  acute 
pleurisy.  I  should  have  mentioned  before,  that  the  pleura  very  often  participates  in 
the  inflammation  when  pericarditis  occurs.  You  will  not  wonder  at  this  if  you 
consider  the  close  vicinity,  and  the  similarity  in  texture,  of  these  two  serous  mem- 
branes. 

I  must  defer  what  I  have  to  say  respecting  the  treatment  of  acute  pericarditis  and 
endocarditis,  to  the  next  lecture. 


LECTURE  LXII. 

Treatment  of  Acute  Pericarditis,  and  Endocarditis :  blood-letting;  mercury; 
blisters.  Chronic  and  partial  Inflammation  of  the  Pericardium.  Disease  of 
the  Aorta.  Thoracic  Aneurisms;  their  various  situations,  and  symptoms; 
plan  of  treatment. 

I  TRUST  that  I  made  distinctly  apparent,  in  the  last  lecture,  the  great  danger  which 
belongs  to  every  case  of  acute  inflammation  of  the  pericardium.  First,  there  is  the 
danger  of  speedy  death.  If  the  inflammation  goes  to  the  extent  of  effusion,  and  the 
collection  of  serous  fluid  be  large,  and  the  pericardium  be  distended  by  it,  the  action 
of  the  heart  is  so  much  oppressed  by  the  liquid  surrounding  it,  that  it  falters  and 
flutters,  and  at  length  stops,  and  goes  on  no  more.  Secondly,  there  is  the  danger 
that  (the  pericardium  having  become  adherent)  other  structural  changes  will,  soon 
or  slowly,  develop  themselves  ;  and  first  render  hfe  bsrdensome  and  full  of  suffering, 
and  then  consign  the  patient  to  an  earher  grave  than  might  else  have  awaited  him. 

Now  what  can  we  do  to  prevent,  or  to  diminish,  these  evils  ?  I  once  thought  that 
d  we  caught  the  inflammation  at  its  very  commencement,  we  might  calculate  upon 
a  perfect  cure,  by  first  bleeding  the  patient  freely,  and  by,  secondly,  putting  him  as 
speedily  as  possible  under  the  specific  influence  of  mercury.  I  am  sorry  to  be 
obliged  to  say,  that  the  more  I  see  of  this  formidable  malady,  the  more  reason  I  find 
for  fearing  that  it  is  seldom  within  the  possibility  of  thorough  repair.  Bring  the  in- 
flammation to  a  stop,  you  perhaps  may ;  or  nature  will  do  it  for  you  ;  and  you  may 
greatly  assist  the  natural  powers  in  effecting  this.  But  that  alone  can  be  called  a 
cure,  which  either  leaves  the  structure  of  the  part  affected  in  its  original  integrity ; 
or,  at  any  rate,  leaves  no  spring  or  source  of  further  changes  for  the  worse  :  and  such 
complete  recovery  as  this  I  seldom  dare  to  hope  for  in  cases  of  acute  and  general 
pericarditis. 

There  can  be  no  use  in  deceiving  ourselves  in  this  matter;  but  we  may  very  easily 
deceive  ourselves.  In  a  large  proportion  of  cases,  Avhether  they  be  treated  well,  or  ill, 
or  not  treated  at  all,  the  patients  will  seem  to  recover.  But  I  say  that  the  recovery 
is  so  far  unreal,  that  it  involves  the  germ  of  future  destruction.  If  any  of  you  have 
read  Bouillaud's  heavy,  yet  instructive  work  on  diseases  of  the  heart,  you  will  know 
that  he  boasts  of  the  success  of  his  treatment  in  acute  pericarditis.  He  declares  that 
by  the  bold  use  of  the  lancet  he  extinguishes  the  inflammation ;  jugulates  (as  he 
calls  it)  or  slaughters  the  disease  at  its  birth ;  and  restores  the  patient  to  the  full  con- 
dition of  health,  or  to  the  state  in  which  he  was  before  the  disease  came  on.  You 
must  hereafter  judge  of  this  question  for  yourselves  ;  but  it  is  my  duty  to  caution  jou 
ogainst  crediting  these  statements.  Not  that  I  Avould  insinuate  a  doubt  of  M.  Bouil 
-aud's  veracity ;  but  I  believe  that  he  has  been  deceived  by  false  recoveries  ;  and  1 

3i 


696  ACUTE    PERICARDITIS. 

would  not  have  you  beguiled,  by  his  representations,  into  the  indiscriminate  adoption 
of  that  "enlightened  hardiness"  which  he  endeavours  to  inculcate. 

But  if  we  look  closely  at  his  statements,  we  do  not  find,  after  all,  any  such  won- 
derful success.  Of  18  patients,  6  died  ;  a  very  large  proportion,  1,  viz.  in  3.  To  be 
sure,  with  some  ingenuity  he  makes  the  proportion  to  be  1  in  7.  For  three  of  the 
fatal  cases  occurred,  he  says,  before  he  took  to  his  heroic  plan  of  blood-letting;  and 
excluding  these  3,  he  has  15  cases,  and  only  3  deaths  ;  or  1  in  5.  But  one  of  these  . 
three  proved  fatal  from  the  supervention  of  tetanus ;  therefore  setting  that  also  aside, 
there  will  be  14  cases  of  the  disease  and  2  deaths.  Now,  I  have  not,  hitherto,  been 
able  to  look  through  my  case-books  in  reference  to  this  point,  but  I  am  quite  certain 
that  the  mortality  m  the  Middlesex  Hospital  has  been  nothing  like  so  great  as  that — 
the  immediate  mortahty,  of  course,  I  mean — either  among  my  patients,  or  among 
those  of  my  colleagues  ;  and  1  know  that,  until  within  the  last  twelve  months.  Dr. 
Latham  had  not  lost  a  single  case  of  rheumatic  pericarditis  in  the  course  of  the  first 
attack  of  that  disease  for  several  preceding  years. 

But  what  I  most  doubt  about,  is  the  true  recovery  of  Bouillaud's  surviving  patients. 
I  say  such  patients  do  apparently  get  well.  In  some  of  them,  indeed,  a  bellows 
sound  remains,  sufficiently  indicative  of  the  damage  that  the  organ  has  sustained : 
and  I  have  already  told  you  that  any  amount  of  change,  however  small,  which  alters 
the  healthy  proportion  of  the  cavities  and  their  outlets,  or  which  interferes  with  the 
natural  play  of  the  heart,  is  a  seed  from  which  further  changes  will  at  length  be 
found  to  rrrow.  But  patients  will  get  so  far  well  that  you  can  detect  nothing  wrong 
about  them.  Follow  them,  however,  in  their  subsequent  lives  ;  and  you  will  learn  that 
many  of  them  very  soon  begin  to  find  that  they  are  incapable  of  doing  or  enduring 
all  that  they  could  do  or  endure  before  their  illness  :  and  if  this  does  not  soon  happen, 
it  does  at  last.  The  disease  of  the  heart  (if  the  patient  be  not  cut  off  by  some  other 
malady)  becomes  at  length  obvious ;  and  when  he  dies,  the  source  of  the  ultima.te 
change^  is  commonly  to  be  detected.  There  is  an  adherent  pericardium  ;  or  there 
is  disease  of  the  valves;  of  which  no  other  account  can  be  given  than  that  it  had 
contmued  to  exist  since  the  primary  symptoms  of  carditis  ceased ;  and  that  it  had 
caused  all  the  rest — the  hypertrophy,  to  wit,  and  the  dilatation. 

The  remarks  that  I  have  now  been  making  bear  upon  the  question,  to  what  amount 
blood-letting  should  be  carried  in  acute  pericarditis.  If  the  general  symptoms  teach 
you  that  it  exists,  and  yet  no  sound  of  attrition  is  heard,  you  may,  in  that  case,  if  in 
any,  hope  to  arrest  tlie  inflammation,  and  to  achieve  a  complete  cure,  by  early  and 
copious  bleeding.  But  if  the  to  and  fro  sound  has  been  audible,  I  do  not  think  the 
consequences  of  the  inflammation  can  be  so  abolished.  I  believe  that  the  best  event 
which  can  then  happen  is  adhesion.  We  must,  however,  in  many  cases,  take  blood 
by  the  lancet  from  the  arm,  or  by  leeches  from  the  precordial  region  ;  yet  not  in  the 
lavish  manner  recommended  by  Bouillaud.  I  know  that  his  treatment  has  been  fairly 
tried  in  this  country,  and  has  failed.  And  I  think  (but  this  I  only  offer  as  an  opinion) 
that  there  is  a  peculiar  risk  in  frequently  bleeding  to  syncope  in  this  aflt-ction.  There 
is,  almost  always,  endocarditis  (in  rheumatic  cases  at  least)  coincident  with  the  peri- 
carditis ;  and  there  is  a  readiness  or  tendency  towards  a  deposition  of  the  fibrin  of 
the  blood,  in  the  shape  of  minute  vegetations,  upon  the  inflamed  valves :  and  it  is 
probable  that  this  tendency  may  be  favoured  by  a  retarded  movement  of  the  blood 
over  them  ;  and  still  more  so  by  its  temporary  stagnation.  In  the  experiments  on 
the  ass,  referred  to  before,  the  circulation  (kept  up  by  artificial  breathing)  became 
lano-uid  and  sluggish,  and  vegetations  were  deposited  upon  those  valves  which  had 
been  irritated  by  the  wire.  Hence  there  is,  I  think,  a  danger  in  bleeding  to  such  an 
extent  in  these  cases,  as  to  bring  the  heart's  action  to  a  pause  in  deliqidiim.  Bleed, 
therefore,  (if  you  deem  it  requisite  to  bleed  at  all,)  till  some  efl^ect  upon  the  pulse  has 
been  accomplished,  and  then  stop :  and  renew  the  venesection,  or  refrain  from  it 
according  to  circumstances.  But  you  may  freely  cup  the  precordial  region,  or  cover 
it  repeatedly  with  leeches  :  and  to  this  mode  of  abstracting  blood,  from  the  neighbour- 
hood of  the  inflamed  part,  my  own  experience  would  assign  the  preference.  In  fact, 
I  seldom  open  a  vein  in  such  cases. 

At  the  same  time,  you  will  endeavour  to  get  the  gums  tender  with  mercury.   And 


ACUTE    PERICARDITIS.  699 

It  is  most  unfortunate  that,  in  this  disease,  the  system  frequently  resists,  with  great 
obstinacy,  the  influence  of  that  mineral.  Sometimes,  do  what  you  will,  you  fail  to 
altain  your  object.  A  knowledge  of  this  fact  may  render  you  less  scrupulous  than 
you  would  otherwise  be  in  the  use  of  the  remedy.  Not  only  should  calomel  be  given 
in  frequently-repeated  doses,  guarded,  if  need  be,  by  opium  :  but  mercurial  inunc- 
tion should  also  be  had  recourse  to,  in  these  perilous  cases,  from  the  first.  When 
the  gums  do  begin  to  rise,  there  will  always  be,  according  to  my  experience,  a 
manifest  subsidence  of  the  distress,  and  mitigation  of  the  symptoms.  There  will  be 
less  pain,  less  palpitation,  less  dyspnoea.  The  mouth  should  be  kept  sore  for  some 
time  together :  for  supposing  the  membranes  to  adhere,  it  does  not  follow  that  the 
inflammatory  process  should  thereupon  cease. 

When  you  learn,  from  symptoms  and  signs  already  described,  that  the  pericardium 
is  distended  by  liquid  eflTusion,  I  would  advise  you  to  lay  a  large  blister  over  the 
precordia.  The  diminution,  or  complete  disappearance  of  the  liquid,  under  this 
treatment,  is  often  rapid  and  striking. 

Even  when  all  the  symptoms  have  vanished,  previous  disappointments  have  taught 
me  not  to  be  sanguine  as  to  the  permanency  of  the  recovery.  I  beheve  that  months, 
and  years  even,  may  elapse  before  the  secondary  effects  of  the  mischief  left  behind 
by  the  inflammation  begin  to  be  palpable.  But  in  many  instances,  they  show  them- 
selves very  early.  Others  have  noticed  all  this:  especially  Dr.  Latham,  who  truly 
remarks,  that  "in  acute  pericarditis  there  is  no  medium  between  complete  cure  and 
certain  death."  He  deemed,  at  the  time  when  the  lectures  from  which  I  quote  were 
given,  that  the  early  and  vigorous  use  of  mercury  would  be  equal  to  the  complete 
cure.  I  think  I  may  venture  to  say  that  he  has  since  seen  reason  to  doubt  on  that 
point.  I  have  several  times  already  expressed  my  own  belief,  that  where  the  to 
and  fro  sound  has  manifested  itself,  that  is,  where  the  inflammation  has  gone  so  far 
as  the  efflision  of  coagulable  lymph,  if  the  patient  does  not  die  outright,  he  survives 
at  the  expense  of  an  adherent  pericardium  ;  and  he  survives  only  for  a  time.  Hacret 
lateri  lelhalis  anindo.  But  I  am  also  of  opinion,  that  by  the  cautious  employment 
of  the  lancet  and  of  leeches,  and  by  the  early  and  unshrinking  use  of  mercury,  the 
mischief  may  be  greatly  limited,  and  the  consecutive  changes  staved  off  to  a  distant 
period.  The  final  catastrophe  arrives  much  more  slowly  where  there  is  mere  adhe- 
sion of  the  pericardium,  than  where  that  condition  is  complicated  with  permanent 
disease  of  the  valves  within  the  heart.  I  need  scarcely  say  that  other,  minor  expe- 
dients are  to  be  put  in  force ;  strict  abstinence  I  mean,  perfect  quiet,  and  an  occa- 
sional purgative  to  clear  out  the  alimentary  canal. 

When  the  pericardium  has  once  become  adherent,  if  (as  is  very  likely)  the  patient 
again  suffers  acute  rheumatism,  he  may  again  have  heart  symptoms.  Not,  of  course, 
the  to  and  fro  sound  ;  but  pain,  palpitation,  and  dyspnoea.  Now  it  is  of  some  prac- 
tical importance  to  be  aware  that  this  renewal  of  morbid  action  does  not  require  that 
active  treatment  which  the  primary  inflammation  demanded.  The  effect  of  such 
renewal  will  be  to  augment  the  existing  mischief;  but  the  morbid  process  is  much 
less  vigorous,  and  much  more  easily  subdued.  It  will  generally  yield  to  the  repeated 
application  of  leeches,  or  of  blisters,  over  the  situation  of  the  heart,  and  to  the  mode- 
rate exhibition  of  mercury. 

Although  acute  inflammation  in  this,  as  in  other  serous  membranes,  shows  gene- 
rally a  strong  disposition  to  spread  all  over  the  affected  surfiice ;  yet  does  the  peri- 
cardium seem  readily  susceptible  of  slight  and  partial  inflammation.  You  will  very 
frequently  indeed  see,  upon  laying  the  bag  open,  a  white  spot,  as  big  as  the  finger- 
nail, upon  the  surface  of  the  heart.  I  have  examined  these  spots  very  often ;  and  I 
believe  they  almost  always  consist  of  a  thin  flake  of  lymph  lying  sometimes  beneath, 
but  ofiener  upon,  the  membrane.  They  may,  in  fact,  be  peeled  off  sometimes,  and 
the  subjacent  membrane  left  smooth  and  sound.  On  one  occasion,  I  met  with  a  long 
riband  of  lymph  passing  from  the  centre  of  one  of  these  white  spots,  to  connect 
itself  with  the  loose  bag  of  the  pericardium.  I  conclude,  therefore,  that  these  spots 
are  really  the  result  of  a  very  limited  inflammatory  process :  but  under  what  condi- 
tions they  arise,  or  whether  during  their  formation  they  furnish  any  synaptoms,  I  do 
not  know. 


700  ACUTE    PERICARDITIS. 

Such  is  the  view  which  I  had  long  taken,  and  taught,  of  these  white  spots  upon 
the  surface  of  the  heart ;  and  I  am  glad  to  have  it  confirmed  by  the  observation  of 
Mr.  Paget,  who  has  recently  adduced  (in  the  twenty-third  volume  of  the  Medico- 
Chirurgical  Transactions)  conclusive  evidence,  both  of  their  frequency,  and  of 
their  inflammatory  origin. 

So  much  then  for  the  heart  itself,  and  its  membranes.  There  still  remain  to  be 
considered  the  morbid  conditions  of  the  great  vessels  that  spring  from  it,  and  lie  in 
the  thorax,  and  especially  of  the  aorta:  those  morbid  conditions  I  mean,  whicl- 
declare  themselves  by  symptoms,  and  which  become  the  object  of  medical  treat 
ment. 

The  aorta  is  very-  frequently  indeed  found  diseased,  and  its  disease,  as  I  have 
already  explained,  is  a  common  cause  of  organic  changes  in  the  left  ventricle  of  the 
heart.  You  will  find  that  its  inner  membrane,  instead  of  being  smooth,  and  of  a 
uniform  yellowish-white  colour,  is  rendered  very  uneven  by  a  great  number  of  yel- 
low opaque  projections,  of  cartilaginous  consistence,  lying  immediatel)'^  beneath  the 
membrane.  And  in  a  more  advanced  stage  of  the  same  diseased  condition,  you  may 
perceive  that  some  of  these  projecting  little  masses  consist  of  irregular  scales  of  bone, 
having  sharp  edges ;  and  sometimes  these  plates  of  ossific  matter  are  quite  bare ;  the 
inner  membrane  is  gone,  and  the  exposed  bone  is  washed  hy  the  current  of  blood. 
Now  the  necessary  effect  of  these  changes  is  to  diminish  and  destroy  the  natural 
elasticity  of  the  vessel ;  and  as  there  is  a  perpetually  recurring  strain  upon  it,  by  the 
blood  sent  out  from  the  heart,  the  vessel  dilates,  becomes  larger  than  it  should  be. 
This,  if  j^ou  please,  you  may  call  aneurism  ;  but  a  simpler  name  is  dilatation.  In 
other  ca.ses,  the  enlargement  is  not  general,  but  partial.  A  pouch  is  formed  on  one 
side  of  the  artery,  and  this  pouch  may  be  very  small  or  very  large.  It  appears  to 
result  from  the  giving  way,  the  rupture  in  short,  or  the  ulceration,  of  the  inner  and 
middle  coats  of  the  artery,  and  then  the  blood,  passing  through  the  broken  part, 
presses  against  the  cellular  coat  of  the  vessel,  and  distends  it  into  a  sort  of  bag. 
There  have  been  curious  discussions  as  to  what  should  be  called  true  aneurism,  and 
what  should  be  called  false  aneurism ;  discussions  upon  which  I  have  neither  time 
nor  taste  for  entering.  It  is  enough  for  all  practical  purposes  to  state,  that  the  artery 
sometimes  dilates  only,  sometimes  throws  out  a  pouch.  I  know  that  you  have  re- 
ceived, or  will  receive,  from  my  colleague,  Mr.  Arnott,  all  the  information  that  is 
requisite  concerning  the  modes  in  which  aneurism  may  arise.  These  are  matters 
of  the  highest  interest  in  surgery,  for  surgery  can  cure  an  aneurism ;  an  achieve- 
ment which  is  but  seldom  within  the  skill  of  physic. 

I  have  known  two  cases  in  which  the  diseased  artery  all  at  once  cracked  across — 
its  inner  and  middle  coats,  I  mean — and  death  very  rapidly  ensued.  In  one  of  these 
instances,  the  crack  extended  round  a  considerable  part  of  the  circumfen'nce  of  the 
aorta.  It  looked  exactly  like  a  clean  cut  made  by  a  sharp  knife.  The  blood,  in  this 
example,  dissected  its  way  (if  I  may  so  say)  between  the  middle  and  external  coat 
of  the  aorta,  and  got  at  last  into  the  pericardium,  and  coagulated  round  the  heart  in 
a  uniform  layer:  so  that  a  bag  of  coagulated  blood  was  enclosed  in  the  bag  of  the 
pericardium.     Of  course,  nothing  can  be  done  for  such  cases  as  these. 

Most  commonly  the  aneurismal  tumour  goes  on  enlarging;  and  often  it  becomes 
lined,  and  sometimes  it  is  nearly  fdled  up,  by  layers  of  coagulated  blood,  which  form 
in  its  interior.     At  length  the  tumour  bursts,  and  the  patient  perishes. 

Aneurisms  of  the  thoracic  aorta  are  met  with  chiefly  in  the  earlier  portions  of  that 
vessel,  in  its  ascending  part,  and  in  its  arch.  There  seem  to  be  two  reasons  for  this. 
One  is,  that  the  diseased  state  of  the  coats  of  the  artery  (to  which  the  rupture  and 
subsequent  aneurismal  pouch,  or  the  dilatation,  as  the  case  may  be,  are  owing)  is 
more  common,  and  more  advanced  generally  in  that  part  of  the  aorta;  and  another 
reason  is,  that  the  momentum  of  the  blood,  as  it  is  forcibly  propelled  from  the  left 
ventricle,  is  sustained  chiefly  by  the  same  part. 

Mere  disease  or  dilatation  of  the  commencing  aorta,  affords,  as  I  formerly  endea- 
voured to  explain,  a  physical  impediment  to  the  due  emptying  of  the  left  ventricle 
It  is  a  common  cause,  therefore,  of  hypertrophy  and  dilatation  of  that  ventricle ; 
and  ronseauently,  the  signs  of  hypertrophy  and  dilatation  of  the  left  ventricle  of 


THORACIC   ANEURISMS.  701 

he  heart  will  at  length  result  from  disease  and  enlargement  of  the  aorta  near  its 
mouth. 

When  aneurismal  pouches  form,  as  they  often  do,  at  the  very  entrance  of  the 
aorta,  or  in  the  coronary  arteries,  they  often  defy  detection.  I,  at  least,  know  of  no 
sign  of  their  existence  upon  which  a  physician  can  rely,  or  which  can  lead  him 
even  to  suspect  such  a  state  of  matters.  But  all  at  once  the  patient  drops  down 
dead  :  and  upon  searching  for  the  cause  of  this  sudden  extinction  of  life,  you  find 
the  pericardium  distended  with  blood,  and  the  source  of  that  blood  you  find  to  be 
the  ruptured  aneurismal  pouch,  so  near  the  root  of  the  aorta,  as  to  project  within  the 
pericardium.  In  the  preparation  which  I  hold  in  my  hand,  an  unbroken  aneurism 
actually  bulges  into  the  right  ventricle  of  the  heart. 

When  the  aneurismal  tumour  occupies  a  portion  of  the  ascending  aorta  a  little 
more  distant  from  the  heart,  or  is  formed  at  the  arch  itself,  it  sometimes  attains  a 
large  size,  and  the  evidence  of  its  existence  is  derived  from  the  effects  its  enlarge- 
ment produces  on  the  surrounding  textures ;  and  these  effects  are  apt,  for  a  while, 
to  be  obscure  and  equivocal,  until  an  external  pulsating  swelling  makes  its  appear- 
ance, or  a  sudden  gush  of  arterial  blood  through  the  mouth  discloses  the  true  nature 
of  the  malady. 

In  these  cases  we  infer  the  existence  of  aneurism  sometimes  from  peculiar  symp- 
toms. Aneurism  at  the  arch  of  the  aorta  may  come  to  press  upon  the  trachea,  and 
impede  the  breathing;  or  by  its  effect  upon  the  recurrent  nerves,  it  may  cause  a 
very  accurate  mimickry  of  laryngitis.  The  operation  of  tracheotomy,  as  I  told  you 
before,  has  more  than  once  been  performed,  to  relieve  the  supposed  inflamed  condi- 
tion of  the  larynx,  while  the  sole  disease  was  aneurism  at  the  arch  of  the  aorta. 
Such  mistakes  are  always  discreditable;  and  the  lesson  they  furnish  should  not  be 
lost  upon  us.  Whenever  we  find  that  a  wheezing  dyspnoea  has  gradually  arisen, 
which  no  apparent  affection  of  the  air-passages  satisfactorily  accounts  for,  and  the 
patient  has  a  sense  of  pulsation  within  the  thorax,  we  may  suspect  that  an  aneurism 
is  at  the  bottom  of  these  symptoms. 

The  effect  of  aneurismal  enlargements  of  the  artery  in  causing  absorption  of  the 
neighbouring  tissues,  upon  which  the  tumour  presses,  is  very  curious.  You  know 
that  even  the  solid  bone  is  removed,  worn  away  as  it  were,  before  an  advancing 
aneurism.  Hence  it  not  unfrequently  happens  that  the  trachea,  or  some  of  the 
larger  bronchi,  are  at  first  flattened,  and  then  give  way;  the  aneurism  breaks  into 
the  air-passages ;  and  the  patient,  overwhelmed  by  a  torrent  of  blood  into  and  from 
•  his  lungs,  perishes  in  a  few  seconds.  Or  the  tumour  may  contract  adhesions  with 
the  pulmonary  tissue,  and  destroy  it  to  a  certain  extent,  and  so  cause  mortal  haemop- 
tysis.    But  such  cases  are  not  always  fatal  at  once. 

Again,  according  to  its  situation  and  extent,  an  aneurism  of  the  thoracic  aorta  may 
press  upon  the  oesophagus,  and  cause  the  ordinary  symptoms  of  stricture  of  that 
tube.  Hence  cardiac  disease,  and  pulsation  within  the  chest,  accompanied  at  length 
by  the  signs  of  a  constricted  oesophagus,  form  strong  presumptive  indications  of  the 
existence  of  an  aneurism ;  and  in  such  cases,  the  oesophagus  may  at  last  ulcerate 
through,  and  then  copious  and  fatal  hemorrhage  ensues.  Hsematcmesis  it  may  be 
called,  though  the  blood  is  vomited  not  from  the  stomach,  but  from  the  gullet.  A 
patient  in  the  Middlesex  Hospital,  with  symptoms  of  stricture  of  the  oesophagus, 
one  day  brought  up  from  the  throat  a  red  mass,  which,  at  the  moment,  was  sup- 
posed to  be  a  bit  of  meat  that  he  had  been  trying  to  swallow.  It  really  was  part  of 
the  clot  from  an  aneurism  ;  and  it  was  speedily  followed  by  a  stream  of  red  blood, 
and  by  death. 

Again,  aneurism  of  the  thoracic  aorta  does  frequently  obstruct,  by  its  juxtaposition 
and  pressure,  the  vena  cava  superior ;  nay,  it  may  even  obliterate  that  vessel,  of 
which  I  have  seen  two  instances.  To  one  of  these  cases  I  alluded  before,  as  a  most 
curious  example  of  dropsy.  It  illustrated  exceedingly  well  the  effect  of  venous  ob- 
struction in  causing  serous  effusion.  The  man  was  a  patient  of  Dr.  Hawkins.  He 
presented  a  most  extraordinary  spectacle.  His  face,  neck,  and  arms,  were  tumid 
and  anasarcous  to  an  enormous  degree ;  while  there  was  not  the  least  trace  of  swell- 
ing or  oedema  anywhere  below  the  ribs.     He  looked  as  if  his  upper  half  had  been 

3i3 


702  THORACIC    ANEURISMS. 

stuHed  ;  and  except  that  it  was  distressing,  nis  appearance  was  extren:ieJj.'  comical 
H»s  countenance  was  livid  ;  his  eyes  soemea  starting  from  their  sockets  ;  and  even 
the  areolar  tissue  beneath  the  conjunctiva  was  cedematous.  The  integuments  of  his 
neck  and  chest  were  quite  brawny  ;  and  his  arms  were  so  swollen  that  they  projected 
from  his  sides.  The  surface  of  the  thorax  in  front  was  embossed  by  numerous  veins, 
which  were  turgid  with  blood  ;  and  here  and  there  patches  of  ecchymosis  were 
visible.  You  may  form  some  notion  of  the  degree  of  mechanical  congestion  that 
existed,  when  I  tell  you  that,  upon  the  scarificator  being  applied,  after  a  cupping- 
glass  was  taken  off,  upwards  of  twenty  ounces  of  blood  escaped  in  two  minutes. 
The  epigastric  veins  were  visible  and  tortuous,  and  a  free  communication  by  anas- 
tomosis existed  between  these  veins  ascending  from  the  inguinal  region,  and  the 
mammary  veins.  There  was  a  bellows  sound,  which  increased  in  loudness  and 
harshness,  from  the  root  of  the  aorta  to  the  top  of  the  sternum.  The  patient  soon 
died ;  and  a  larf^e  aneurism  of  the  aorta  was  laid  open  by  lifting  up  the  sternum, 
to  which  the  artery  had  adhered,  and  into  which,  indeed,  it  had  eaten  a  little.  Not 
far  above  the  right  auricle,  the  vena  cava  was  totally  impervious;  its  sides  having 
been  gradually  pressed  together,  as  the  tumour  grew.  The  other  case,  of  the  same 
kind,  which  occurred  in  one  of  my  own  patients,  I  shall  have  occasion  to  refer  to 
hereafter. 

But  aneurism  of  the  thoracic  aorta  may  exercise  its  pressure  in  another  quarter, 
and  Avear  away  the  bones  of  the  vertebrse,  and  cause  pain  in  the  back,  and  ultimately 
palsy  of  the  parts  below  that  portion  of  the  spinal  cord ;  so  that  pain  in  the  back, 
with  pulsation,  may  justly  awaken  suspicion  of  aneurism  making  its  way  backwards. 
I  remember  hearing  Dr.  Farre  describe  a  case  of  this  kind,  to  inculcate  the  necessity 
of  paying  attention  to  the  sensations  of  a  patient.  A  man  came  to  him  for  advice, 
having  been  told  by  another  physician  that  there  was  nothing  the  matter  with  him — 
that  he  was  fanciful.  But  when  an  adult  person  makes  constant  complaint  of  certain 
morbid  feelings  in  a  part,  the  probability  is  that  he  has  something  the  matter,  and 
we  must  investigate  the  case  with  what  helps  we  can  get.  In  the  instance  in  ques- 
tion, there  were  two  signs  of  disease,  and  two  only ;  a  white  tongue,  and  pain  in  the 
back.  The  whiteness  of  the  tongue  soon  disappeared  under  the  use  of  some  medi- 
cine addressed  to  the  digestive  organs.  The  pain  in  the  back  remained.  Dr.  Farre 
interrogated  the  patient  minutely  every  time  he  visited  him,  till  at  last  the  man  got 
vexed  and  tired,  and  said,  pettishly,  "I  know  that  if  5^ou  split  me  down  the  middle, 
I  am  sound  on  my  right  side,  and  diseased  on  my  left."  Very  soon  after,  he  was 
found  dead  in  his  bed.  What  he  had  said  was  perfectly  true  :  there  was  an  aneu- 
rism pressing  on  the  left  side  of  the  dorsal  vertebras. 

Another  consequence  of  an  enlarging  thoracic  aneurism,  sometimes  observed,  is 
pressure  upon  the  thoracic  duct,  causing  engorgement  of  the  absorbent  vessels  and 
glands,  and  inanition.  In  short,  whatever  parts  the  aneurism  may  reach,  and  subject 
to  its  pressure,  may  have  their  function  thereby  suspended  or  disturbed,  or  their 
structure  spoiled. 

One  sign,  which  I  have  myself. frequently  verified,  of  aneurism  of  the  arch  of  the 
aorta,  is  a  difference  in  the  force  of  the  pulse  in  the  two  radial  arteries.  The  pulse 
in  the  one  wrist  will  be  extremely  feeble,  or  even  disappear.  This  happens  when 
the  state  and  position  of  the  arteria  innominata,  or  of  the  left  subclavian  artery,  be- 
come altered  in  consequence  of  the  enlargement  of  the  aorta ;  and  sometimes  the 
one  or  the  other  of  these  arteries  is  completely  closed  up.  But  inasmuch  as  a  similar 
difference  of  the  pulses  may  arise  from  other  causes,  we  can  only  look  upon  this 
symptom  as  one  which  may  help  to  solve  an  ambiguous  case.  To  give  you  an 
example  of  a  difference  in  the  beating  of  the  arteries  in  the  two  wrists  from  othe' 
causes,  I  may  mention  a  case  in  which  the  subclavian  artery  was  thrown  forwards, 
and  compressed  by  an  exostosis  on  the  first  rib.  The  case  is  mentioned  in  Mr.  Mayo's 
Pathology.  It  occurred  in  a  patient  of  mine,  the  husband  bf  a  nurse  in  my  family. 
I  had  a  girl  for  some  time  in  the  hospital,  in  one  of  whose  arms  no  artery  could  be 
found  to  pulsate.     Why,  we  none  of  us  could  make  out. 

Very  lately,  d  surgeon  from  the  country  came  to  my  house,  desirous  (he  said)  to 
consult  me  about  a  sense  of  discomfort  in  his  head ;  and  particularly  about  the  state 


THORACIC   ANEURISMS.  703 

of  his  vision.  When  erect,  he  saw  things  obscurely.  At  three  yards'  distance  he 
could  see  my  face,  but  could  not  distinguish  the  "separate  features.  What  he 
thought  very  strange  was  that  he  could  see  perfectly  well  when  in  the  horizontal 
posture. 

On  my  proceeding  to  feel  his  pulse,  he  said,  in  a  careless  manner,  "By-the-by, 
that  is  another  thing  wrong  with  me  ;  I  have  no  pulse."  Nor  could  1  detect  any,  in 
either  arm.  He  then  told  me  that,  four  or  five  years  previously,  a  medical  friend, 
intending  to  feel  his  pulse  in  the  left  wrist,  could  find  none.  He  was  confident  pulsa- 
tion had  existed  a  short  time  before  that.  After  a  while,  the  movement  of  the  radial 
artery  returned,  in  a  very  slight  degree ;  and  then  finally  ceased.  Within  nine  or 
ten  months  of  this  discovery,  the  right  pulse,  after  growing  less  and  less  distinct  by 
degrees,  had  vanished  also.  Though  somewhat  weak,  and  subject  to  faintness,  this 
gentleman  had  not  wasted  ;  nor  had  the  muscles  of  his  arms  lost  either  bulk  or  vigour. 
Their  veins  were  full  enough  of  blood.  His  hands  were  often  cold  ;  and  he  felt  alto 
gether  worse  during  cold  weather. 

Failing  to  detect  any  pulsation  in  the  brachial  and  subclavian  arteries,  I  next  felt 
for  the  carotids :  but  I  could  perceive  no  beating  in  the  track  of  their  course.  I  had 
placed  my  finger,  for  a  few  seconds  onl}^  in  front  of  the  left  sterno-mastoid  muscle — 
when  I  saw  that  his  head  drooped,  his  cheeks  became  white,  and  he  was  on  the 
brink  of  fainting.  But  he  recovered  immediately.  Then  I  made  similar  pressure, 
for  a  moment,  on  the  right  side  of  the  neck,  and  the  same  phenomena  were  instantly 
repeated,  with  the  addition  of  convulsive  jerking  movements  of  the  head  and  arms. 
He  rallied  again  directly  upon  my  removing  my  finger,  and  was  scarcely  aware  of 
what  had  happened.  For  a  second  or  two  he  had  been  unconscious.  His  femoral 
arteries  throbbed  as  usual. 

I  next  examined  his  chest.  There  was  no  external  irregularity  or  want  of  sym 
metry.  Percussion  gave  a  clear  resonant  sound  everywhere  in  front.  The  heart 
was  heard,  beating  with  frequency,  but  without  any  bruit,  over  the  greater  part  of 
the  thorax.  Its  impulse  in  the  precordial  region,  below  the  nipple,  was  feeble  :  but 
a  strong  jarring  impulse  was  communicated  to  the  ear  when  the  stethoscope  was 
applied  to  the  upper  part  of  the  sternum. 

The  patient  complained  of  pains  aflfecting  his  shoulders,  clavicles,  and  the  back  of 
his  neck  ;  and  of  slight  difficulty  of  swallowing. 

From  the  intelligent  physician  who  had  attended  this  gentleman  in  the  country  I 
learned  the  instructive  fact  that,  twenty  months  before,  a  loud  rasping  bruit  had  beer 
ludible,  without  impulse,  at  that  part  of  the  sternum  where  he,  as  well  as  1,  now 
found  no  bruit  at  all,  and  a  very  considerable  impulse. 

I  cannot  doubt  that  in  this  painfully  interesting  case  there  is  aneurismal  disease 
of  the  aorta,  interfering  with  and  lessening,  but  not  absolutely  excluding,  the  stream 
of  blood  through  the  arteries  which  spring  from  its  arch. 

In  the  numerous  specimens  upon  the  table,  you  will  find  ample  evidence  and 
illustration  of  almost  every  one  of  the  effects  which  I  have  described  as  apt  to  result 
from  the  pressure  of  thoracic  aneurisms  of  the  aorta.  But  similar  effects  would  ensue 
from  the  same  degree  of  pressure,  however  caused ;  and  other  morbid  tumours, 
cancerous  tumours  in  particular,  are  not  uncommon  within  the  thorax.  Hence  these 
same  effects,  considered  as  symptoms,  are  in  themselves,  of  equivocal  import.  If 
they  occur  in  conjunction  with  signs  of  disordered  circulation,  or  of  a  diseased  heart, 
we  may  reasonably  conjecture  that  they  are  produced -by  an  aneurism.  But  we  can 
seldom  be  quite  sure  of  this,  until  the  advancing  aneurism  comes  near  the  surface, 
and  causes  an  external  prominence  or  tumour  which  pulsates  visibly,  or  of  which 
the  pulsations  are  perceptible  by  the  touch.  And  even  then  it  may  require  some 
care  and  tact,  to  avoid  mistaking  an  enlarged  gland,  or  a  malignant  growth,  lying 
over  a  sound  artery,  and  receiving  an  impulse  from  it,  or  communicating  to  it  some 
unnatural  sound,  from  the  diseased  vessel  itself. 

The  pulsating  tumour,  if  the  aneurism  has  formed  in  the  ascending  aorta,  makes 
its  appearance,  usually,  on  the  right  side  of  the  sternum.  If  the  aneurism  is  situated 
in  the  forepart  of  the  arch,  it  produces  a  bulging  at  the  sternal  extremities  of  the 
upper  ribs  on  that  side.     When  it  springs  from  the  summit  of  the  arch,  the  tumour 


1 


704  THORACIC    ANEURISMS. 

rises  abovo  the  sternum,  and  the  sternal  ends  of  the  clavicles ;  and  when  the  disease 
occupies  the  descending  portion  of  the  thoracic  aorta,  it  will  sometimes  destroy  the 
ribs  and  the  bodies  of  the  vertebrce,  and  push  forward  the  lower  part  of  the  left  sca- 
pula :  or  it  may  show  itself  in  front,  beneath  the  left  clavicle. 

When  such  a  tumour  presents  itself,  and  is  attended  with  a  steady,  heaving  pulsa- 
tion, synchronous  with  the  systole  of  the  heart,  the  doubt  and  obscurity  which  may 
have  previously  hung  over  the  nature  of  the  patient's  disorder  is  cleared  away.  A 
little  attention  to  all  the  circumstances  of  the  case,  will  generally  suffice  to  deter- 
mine its  true  character. 

There  are,  however,  some  errors  prevalent  respecting  these  pulsating  tumours, 
which  errors  I  shall  glance  at  in  passing.  In  the  first  place,  the  pulsation  of  the 
tumour  is  frequently,  most  frequently,  attended  with  a  rough  bellows  sound ;  and 
some  persons  rely  upon  this  as  distinctive  of  the  nature  of  the  pulsating  tumour. 
They  hold  that  this  harsh  bellows  sound  is  always  discernible  in  an  aneurismal 
tumour ;  and  that  when  such  a  sound  cannot  be  heard,  the  tumour  is  not  an  aneur- 
ism. But  this  is  a  mistake.  There  have  been  in  the  Middlesex  Hospital  within  the 
last  six  months  (1887),  two  instances  of  pulsating  tumours  in  the  fore  part  of  the 
thorax,  unattended  with  any  bellows  sound;  yet  they  were  both  ascertained,  after 
death,  to  be  aneurismal  tumours.  One  of  the  aneurisms  is  before  you.  In  the  case 
of  the  country  surgeon,  a  bellows  sound  was  present  at  a  certain  period  of  the  dis- 
ease, and  absent  at  a  more  advanced  period.  I  may  say  the  same  of  the  purring 
thrill.  It  is  a  common,  but  by  no  means  a  necessary  attendant  upon  thoracic  aneur- 
isms. Again,  much  stress  was  laid  by  Laennec,  upon  the  circumstance  of  the 
aneurismal  pulsation  being  single,  being  unattended  by  any  second  sound.  But  this 
is  not  a  true  rule  if  taken  universally.  In  the  instance  which  furnished  this  very 
preparation,  the  sounds  were  double,  just  like  those  of  the  heart.  The  second 
sound  heard  is,  no  doubt,  the  second  sound  of  the  heart,  conveyed  from  the  place  of 
the  aortic  valves,  where  it  originates,  along  the  course  of  the  vessel,  to  the  aneurism  • 
which  often  indeed  lies  in  contact  with  the  heart,  and  could  scarcely  fail  to  have  the 
diastolic  sound  propagated  through  it.  It  is  a  fact  not  so  easily  explained,  yet  it  cer- 
tainly is  a  fact,  that  a  double  sound  may  be  audible  in  aneurisms  very  distant  from 
the  heart.  Dr.  Davies  states,  that  he  never  heard  a  second  sound  in  abdominal 
aneurisms  ;  yet  I  presume  that,  under  favourable  circumstances,  the  sound  of  the 
closing  of  the  floodgates  at  the  root  of  the  aorta,  may  be  heard  far  along  its  channel. 
I  can  account  in  no  other  way  for  the  second  sound,  heard  by  myself  and  by  many 
others,  in  a  popliteal  aneurism,  I  mentioned  before,  a  patient  whom  I  saw  in  St. 
Bartholomew's  Hospital,  and  in  whom  an  exceedingly  loud  diastolic  sound,  like  the 
sharp  whining  note  of  a  dog,  was  audible  by  the  ear  placed  upon  his  arm,  over  the 
brachial,  and  even  over  the  radial  arteries. 

There  are  some  very  judicious  remarks  made  by  Dr.  Hope  upon  the  sounds  that 
are  apt  to  be  heard  in  these  pulsating  aneurismal  tumours  to  the  right  of  the  ster- 
num ;  showing  how  they  may  be  distinguished  from  the  natural  sounds  of  the  heart 
itself,  conveyed  to  that  spot  through  some  dense  conducting  medium.  He  observes 
(and  all  that  I  have  seen  has  been  consonant  with  this  observation),  that  the  first  of 
the  aneurismal  sounds,  when  there  are  two,  the  sound  that  coincides  with  the  pulse 
is  always  louder  than  the  natural  systolic  sound  of  the  heart,  and  generally  louder 
than  any  of  the  morbid  systolic  sounds ;  and  that  instead  of  increasing  in  intensity, 
as  the  stethoscope  is  moved  gradually  towards  the  precordial  region  (as  it  ought  to 
do,  if  it  were  the  conducted  sound  of  the  heart  itself),  it  diminishes  in  loudness, 
until  it  is  gradually  lost  in  the  actual  systole  of  the  heart.  Whereas  the  second 
sound  heard  over  the  tumour  does  augment  as  we  get  nearer  the  heart,  for  it  is,  in 
truth,  the  diastolic  sound  of  the  heart,  and  therefore  is  more  audible  as  we  approach 
the  point  where  it  is  generated.  The  sounds  of  aneurisms  of  the  aorta  are  usually 
audible  in  the  back  also;  and  if  a  very  loud  bellows  sound  be  heard  there,  where 
the  natural  sounds,  if  heard  at  all,  are  always  much  abated,  that  circumstance  fur- 
nishes a  strong  additional  ground  for  suspecting  the  presence  of  an  aneurism,  or  ol 
some  great  change  in  the  aorta. 

To  give  you  some  notion  of  the  course  which  aneurism  of  the  thoracic  aorta 


**  THORACIC   ANEU^IISMS.  705 

may  run,  I  will  describe  another  instance  of  that  disease  which  occurred  under 
my  own  observation.  The  subject  of  it  suppUed  tiie  preparation  to  which  I  last 
referred. 

He  was  a  stout,  healthy-looking  rnan,  forty  years  old,  a  private  coachman.  He 
became  my  patient  in  the  hospital  on  the  Sth  of  September,  1836.  He  complained 
of  pain  and  tenderness  around  and  above  the  right  mamma.  The  pain  was  increased 
by  a  full  inspiration  ;  and  when  lying  on  the  opposite  side,  he  felt  as  though  he  was 
tied  in  the  painful  part. 

He  had  been  ill  a  month  only.  His  illness  commenced  with  severe  rigors, 
and  fever,  and  sudden  pain  in  the  side,  for  which  he  was  bled  three  times  with 
much  relief.  He  attributed  the  attack  to  having  lain,  upon  his  right  side,  in  a  damp 
bed. 

There  was  scarcely  any  projection  at  the  spot  where  the  pain  and  tenderness  were 
-experienced.  By  careful  examination  several  times  repeated,  I  satisfied  myself  upon 
*he  following  points. 

On  the  right  side  of  the  thorax  no  vesicular  breathing  could  be  heard  ;  and  thp 
whole  was  dull  on  percussion.  On  the  left  side  percussion  gave  a  hollow  sound,  and 
(he  respiratory  murmur  was  clear  and  strong.  In  the  tender  spot,  an  inch  and  half 
above  the  mamma  on  the  right  side,  a  strong  pulsation  could  be  felt,  and  two  sounds 
were  distinctly  audible,  the  first  of  them  keeping  time  with  the  pulse  at  the  wrist. 
But  there  was  no  bellows  sound.  M.  Sanson,  the  celebrated  French  surgeon,  was 
then  in  London,  and  went  round  with  me  one  day,  and  examined  this  patient;  and 
he  expressed  his  opinion  that  it  was  not  a  case  of  aneurism,  because  there  was  no 
ivhiz  or  bellows  sound  to  be  heard.  Of  course  his  examination  was  a  cursory  one, 
and  I  mention  this  circumstance  merely  to  show  you  what  importance  is  attributed 
to  the  presence  or  absence  of  a  bruit  de  soiifflet  in  such  cases.  M.  Sanson  suggested 
that  the  heart  might  be  displaced,  and  pushed  over  to  the  right  side.  However,  it 
was  clear  to  me  that  this  could  not  be  the  case,  because  the  breathing  was  deficient, 
not  on  the  left,  but  on  the  right  side ;  and,  above  all,  because  the  apex  of  the  heart 
could  be  both  seen  and  felt  beating  in  its  proper  situation,  in  the  precordial  region  on 
the  left  side.  Also  on  the  left  side,  percussion  made  on  the  edge  of  the  ribs  gave  a 
tympanitic  sound,  indicating  the  place  of  the  stomach ;  on  the  right  a  dull  sound, 
pointing  out  the  situation  of  the  liver ;  so  that  it  was  not  a  case  of  transposition  of 
the  viscera,  such  as  had  been  found,  not  long  before,  in  one  of  my  patients.  In  the 
course  of  the  disease,  a  shght  bellows  sound  did  become  perceptible  over  the  right 
mamma,  when  the  patient  sat  up ;  but  even  then  the  natural  sounds  of  the  heart, 
without  any  morbid  quality,  could  be  heard  in  the  natural  position  of  that  organ. 
QCgophony  was  audible  at  the  back  part  of  the  right  side  of  the  chest. 

This  patient  had  repeated  attacks  of  pain,  dyspnoea,  restlessness,  and  inability 
to  lie  down ;  and  these  attacks  were  always  most  sensibly  mitigated  by  the  appli- 
cation of  leeches  to  the  diseased  part.  By  the  Ilth  of  October  he  was  so  com- 
fortable that  he  wished  to  go  out ;  and  he  went  to  his  master's  in  Connauo-hi 
Place. 

Two  days  afterwards,  he  sent  to  beg  that  I  would  go  and  see  him  there.  He 
had  brought  up,  on  the  preceding  evening,  during  a  paroxysm  of  coughing,  about 
a  pint  of  bright  red  blood ;  and  he  had  continued  to  cough,  and  to  expectorate  small 
quantities  of  blood.  I  had  him  again  brought  to  the  hospital  on  the  14th  of  Octo- 
ber, where  he  remained,  apparently  much  the  same  as  before  he  went  out.  But  on 
the  19th  he  suddenly  expired.  The  whole  duration  of  his  illness  had  been  nine  or 
ten  weeks. 

We  found  the  heart  natural  in  size  and  in  appearance  ;  the  pericardium  healthy, 
and  containing  no  more  than  the  usual  quantity  of  serum.  All  the  cavities  were 
natural  in  their  dimensions,  and  in  the  thickness  of  their  walls ;  and  all  the  valves 
healthy,  excepting  one  white  spot  on  the  mitral  valve,  which  could  not  have  inter- 
fered with  its  motions. 

The  aorta  at  its  origin  was  also  natural  in  size ;  but  it  began  to  i^ilate  just  befoii) 
it  escaped  from  the  pericardium,  and  the  dilatation  continued  to  the  o-iving  ofifof  this 
left  subclavian,  where  the  vessel  resumed  its  proper  capacity.     The  arteries  arisiiii; 
45 


706  THORACIC    ANEURISMS. 

from  the  aorta  did  not  partake  of  the  dilatation ;  but  the  sac  overlapped  and  adhered 
to  the  external  surface  of  the  innominata,  for  about  a  quarter  of  an  inch  from  its 
origin.  This  explained  a  symptom  I  omitted  to  mention,  viz. :  that  the  right  radial 
artery  beat  much  more  feebly  than  the  left. 

The  pouch  formed  by  the  aneurism  adhered  in  front,  for  the  space  of  two  inches, 
to  the  inner  surface  of  the  third  rib ;  and  close  to  the  edge  of  this  adhesion  there 
was  a  small  irregular  aperture  about  two  lines  in  diameter,  by  which  the  interior  of 
the  pouch  communicated  with  the  right  pleural  cavity.  Nearly  a  pint  of  loosely 
coagulated  blood  was  found  in  that  cavity,  together  with  a  greater  quantity  of  serous 
fluid  than  could  have  belonged  to  the  coagulum.  Just  above  the  adhesion  to  the  rib, 
the  pouch  adhered  to  the  substance  of  the  lung,  over  a  space  about  an  inch  square ; 
and  here  the  parietes  of  the  artery  seemed  wholly  wanting.  This,  doubtless,  had 
been  the  channel  of  the  copious  haemoptysis  a  week  before  his  death :  and  it  is  inte- 
resting to  observe  that  the  opening  of  the  aneurism  into  the  lung  was  not  imme- 
diately fatal.  The  artery  was  much  diseased,  in  the  usual  manner.  The  right  lung 
was  nearly  all  of  it  "carnified"  by  the  compression  it  had  undergone. 

If  this  case  had  not  terminated  as  it  did,  no  doubt  the  aneurism  would  have  made 
its  way  outwards  through  the  ribs,  as  happened  in  the  very  remarkable  specimen 
before  you ;  in  which  you  see  that  the  sternum  and  five  of  the  ribs  have  disappeared 
before  the  pressure  of  an  aneurism  in  the  ascending  portion  of  the  aorta.  Some- 
times, the  tumours  that  form  in  this  manner,  project  and  attain  the  size  of  the  head 
of  a  full  grown  fcEtus  before  they  burst. 

What  can  we  do  in  these  melancholy  cases  ?  Not  much.  Certain  points  of  prac- 
tice are  so  obvious  that  it  is  almost  superfluous  to  meniion  them.  I  mean  the  ob- 
servance of  quiet,  and  the  religious  avoidance  of  every  thing  likely  to  excite  or 
quicken  the  circulation  :  bodily  exertion,  therefore ;  straining  of  all  kinds;  mental 
emotion ;  stimulating  food  and  drink.  These  are  not  only  likely  to  aggravate  the 
existing  mischief,  but  prove  often  the  immediate  cause  of  the  rupture  of  the  aneu- 
••ism,  and  of  sudden  death. 

I  mentioned,  in  describing  the  morbid  anatomy  of  aneurism,  that  when  the  diseased 
vessel  began  sensibly  to  dilate,  and  more  especially  when  it  was  protruded  into  a 
sack  or  pouch,  the  blood  began  to  coagulate  upon  the  diseased  membrane.  And  it 
continues  to  do  so,  from  time  to  time,  in  successive  layers,  so  that  upon  dividing  the 
aneurismal  sac,  you  will  see  concentric  laminae  of  firmly  coagulated  blood.  This  is 
clearly  a  strengthening  of  the  weak  place — a  reparatory  and  compensating  process 
analogous  to  others  which  we  have  already  had  occasion  to  notice.  And  our  object, 
here  as  in  other  cases,  must  be,  not  to  interfere  with  the  natural  attempts  towards 
repair,  but  to  assist  and  promote  them,  if  we  can. 

This  principle  has  long  been  distinctly  recognized  in  the  treatment  of  anuerisms 
that  are  incapable  of  relief  by  surgical  means. 

But  it  is  much  to  be  doubted  whether  the  principle,  so  sound  in  itself,  has  been 
judiciously  followed  out.  You  have  probably  heard,  or  will  hear,  a  good  deal  of 
Valsalva's  and  Albertini's  mode  of  treating  aneurisms.  It  was  simply  that  of  bleed- 
ing the  patient  repeatedly,  and  keeping  him  upon  as  low  a  diet  as  was  barely 
enough  to  prevent  his  perishing  of  inanition.  The  object  of  this  plan  of  treatment 
was  to  facilitate  the  coagulation  of  the  blood  by  diminishing  its  force  and  velocity,  in 
the  hope  that  at  length  such  a  solid  barrier  might  be  built  up  and  organized,  as  might, 
in  some  sort,  furnish  a  new  wall  to  the  artery  in  the  dilapidated  part.  When  this 
object  had  had  the  best  chance  of  being  accomplished ;  when  the  patient  had  been 
so  reduced  as  to  be  scarcely  able  from  weakness  to  raise  his  hand  from  the  bed,  to 
which  he  was  strictly  confined  ;  then  Valsalva  increased  his  quantity  of  nourishment 
by  degrees,  until  the  necessary  strength  was  restored. 

Now  I  quite  agree  with  Dr.  Copeland  in  thinking  that  this  practice  may  be  car 
lied,  and  has  been  carried,  to  a  hurtful  extent.  He  says  that  he  has  seen  cases  "  in 
which  aneurismal  tumours  had  existed  for  some  time  without  any  increase,  so  long 
as  the  patient  avoided  any  marked  vascular  excitement,  and  continued  his  accus- 
tomed diet ,  but  when  repeated  depletions,  and  vegetable  or  low  diet  were  adopted, 
gr-^at  augmentation  of  the  tumour,  and  fatal  results,  soon  followed." 


DISEASES   OF   THE   VEINS.  707 

In  truth,  we  shall  perceive  reason  to  expect  that  this  would  be  the  case,  when  we 
consider,  first,  that  the  starving  system,  and  the  frequent  abstraction  of  blood,  diminish 
the  quantity  of  fibrin  in  that  fluid,  rendering  it  more  watery,  and  less  disposed  to 
coagulate  ;  and,  secondly,  that  what  is  called  reaction — or  a  violent  palpitating  action 
of  the  heart — is  very  apt  to  follow  repeated  losses  of  blood ;  and  this  forcible  action 
of  the  heart  must  tend  rather  to  sweep  away  the  existing  coaguk,  than  to  cause  an 
additional  deposit. 

A  more  reasonable  and  hopeful  plan  of  management,  therefore,  would,  in  my 
opinion,  be  one  which  should  keep  the  action  of  the  heart  gentle  and  moderate,  and 
the  motion  of  the  blood  as  slow  and  languid  as  possible,  without  impoverishing  that 
vital  fluid.  We  should  husband  the  materials  of  repair,  and  promote  the  deposit  of 
them  where  they  are  wanted.  A  nutritious  but  unstimulating  diet ;  perfect  repose 
of  mind  and  body ;  and  a  due  regulation  of  the  natural  functions ;  with  the  abstrac- 
tion of  so  much  blood  only  as  may  be  necessary  to  alleviate  pain,  or  to  subdue  exces- 
sive arterial  action,  or  to  unload  vessels  which  are  manifestly  oppressed  by  their 
contents  ; — these,  I  humbly  conceive,  constitute  the  most  rational  means  of  furthering 
the  endeavours  of  nature  towards  a  cure.  Few  cures,  indeed,  can  be  hoped  for  in 
any  way.  Yet  hfe  may  be  prolonged  in  these  cases,  by  great  care  ;  and  the  exten- 
sion of  existence  even  for  a  month  or  two,  or  a  week,  or  a  day,  may  sometimes  be 
an  acquisition  of  the  greatest  moment. 

I  have  little  to  say  concerning  particular  drugs.  Digitalis  may,  perhaps,  be  some- 
times of  use ;  and  the  acetate  of  lead  is  well  spoken  of  by  those  who  have  tried  it. 
I  have  not  had  sufficient  experience  of  either  of  these  remedies  in  the  treatment  of 
aneurism,  to  enable  me  to  state  any  thing  to  you,  confidently,  in  respect  to  their 
value. 


LECTURE  LXIII. 

Diseases  of  the  Veins.  Phlebitis;  adhesive,  and  suppurative:  consecutive  scat- 
tered Abscesses.  Treatment  of  Inflammation  of  Veins.  Effects  of  the  gradual 
obstruction  of  large  Venous  Trunks. 

Yesterday  I  concluded  what  I  had  to  say,  as  a  physician,  respecting  diseases  of 
the  arteries :  and  this  seems  as  fitting  a  time  as  any  for  taking  a  final  notice  of  some 
of  the  morbid  conditions  of  the  veins — especially  of  their  inflammation.  Already, 
more  than  once,  brief  reference  has  been  made  to  this  important  subject :  important, 
whether  we  consider  the  large  amount  of  mortal  disease  which  it  comprehends,  or 
its  wide  and  intimate  relation  with  general  pathology.  I  should  have  done  better  if 
I  had  given  you,  in  the  earlier  part  of  the  course,  a  more  complete  and  connected 
account  of  phlebitis,  and  its  consequences.  It  is  this  malady  which  gives  to  many 
fatal  injuries,  and  to  many,  nay  to  most,  of  the  fatal  operations  of  surgery,  their 
mortal  character :  it  is  of  surpassing  importance,  therefore,  to  the  surgeon.  The 
same  malady  lies  at  the  bottom  of  the  deadliest  cases  of  puerperal  fever :  it  is  con- 
sequently of  the  deepest  interest  to  the  accoucher.  It  occurs  also,  not  seldom,  in  the 
practice  of  the  physician,  appalling  him  by  its  insidious,  its  rapid,  and  too  frequently 
its  resistless  course.  Moreover,  its  pathology,  which  has  been  successfully  investi- 
gated only  within  these  few  years,  furnishes  a  key  to  that  of  other  morbid  conditions 
of  great  moment. 

The  first  efTect  of  inflammation  of  a  vein  is  to  impede,  or  arrest,  the  passing  bJood, 
which,  coagulating  upon  the  inflamed  surface,  adheres  to  it.  In  some  instances  the 
inflamed  coat  of  the  vessel  is  merely  (as  Mr.  Hunter  said)  furred  over:  in  others  its 
channel  is  completely  dammed  up.  The  obliteration  of  a  small  vein  in  this  manner 
can  seldom  have  any  serious  consequence ;  but  much  suffering,  and  distress,  and 
even  death  itself,  may  result  from  the  sudden  and  continued  obstruction  of  one  of  the 
large  venous  conduits.     For  example,  the  painful  disorder,  called  phlegmasia  dolena 


708  DISEASES    OF   THE   VEINS. 

is  caused  by  a  stoppage  of  the  blood  in  the  femoral  vein.  A  similar  arrest  of  its 
current  in  the  sinuses  of  the  brain,  is  a  mortal  change. 

This  adhesive  form  of  phlebitis  is  a  local  disease.  Whatever  ill  effects  it  may 
produce  are  purely  mechanical ;  and  depend  upon  the  closure  of  the  canal.  If  the 
organ  mechanically  affected  by  it  be  not  a  vital  organ  ; — if  the  system  can  await  the 
development  of  a  collateral  venous  circulation  ; — all,  at  length,  may  end  well.  Some- 
times, indeed,  as  the  inflammation  gradually  subsides,  the  coagulum  is  softened  and 
partly  reabsorbed,  the  blood  drills  for  itself  a  fresh  passage  through  the  centre  of  the 
plug,  and  the  restoration  is  restored  to  its  accustomed  channels. 

This  is,  fortunately,  the  commoner  form  of  phlebitis  :  but  sometimes  the  inflam- 
mation advances  beyond  the  adhesive,  and  into  the  suppurative  stage.  Even  then 
the  disease  may  remain  a  local  one.  The  adhesive  process  may  bound  and  isolate 
the  suppurative  in  both  directions :  and  an  abscess  in  the  part  is  then  the  usual 
result. 

But  if  the  suppurating  surface  of  the  vein  be  not  so  shut  off",  and  pus  mingle  and 
circulate  with  the  blood,  the  disorder  is  no  longer  merely  local.  The  contaminated 
blood  is  conveyed  to  distant  parts,  and  the  whole  system  tainted.  The  malady  has 
become  general,  and  of  the  most  formidable  character. 

It  had  long  been  noticed,  as  a  matter  of  fact,  that  collections  of  pus  were  not 
uncommon  in  various  parts  of  the  body,  when  death  had  followed  mechanical  inju- 
ries, or  great  surgical  operations.  Abscesses  in  the  liver,  in  particular,  were  known 
to  be  associated  w:lh  mortal  fractures  of  the  skull.  Very  fanciful  reasons  were 
assigned  for  this  coincidence.  By  degrees  it  was  ascertained  that  these  scattered 
collections  of  matter — occurring  most  commonly  in  the  lungs  and  hver,  but  not  un- 
frequently  in  or  near  the  joints  also,  in  the  serous  cavities,  among  the  muscles,  in  the 
brain,  in  the  eye,  and  elsewhere — were  connected  with  the  introduction  of  some 
vitiating  secretion,  and  especially  of  pus,  into  the  current  of  the  venous  blood. 

And  this  step  having  been  gained,  fresh  speculations  arose,  concerning  the  manner 
in  which  the  internal  collections  of  pus  were  formed.  In  the  viscera  they  were 
usually  small,  well-defined,  surrounded  by  the  healthy  tissue  of  the  organ,  and 
several  in  number.  Some  maintained,  that  the  pus,  in  substance,  was  carried  to  the 
parts  in  which  it  was  found,  and  there  simply  deposited.  Others  were  of  opinion 
that  the  tainted  blood  created  in  the  system  a  general  tendency  to  inflammation, 
which  Avas  developed  in  many  places  simultaneously.  Neither  of  these  suppositions 
was  quite  true,  neither  of  them  quite  false.  The  pus  discovered  in  the  serous  cavi- 
ties was  accompanied  by  unequivocal  traces  of  inflammation  in  those  parts.  This 
alone  rendered  it  probable  that  the  smaller  purulent  collections  were  not  merely 
dropped  there  by  the  blood  in  its  course,  (a  thing  very  difficult  to  conceive,)  but 
were  the  products  of  actual  inflammation,  excited  somehow  in  those  veiy  spots.  And 
it  is  now  believed  that  these  abscesses  of,  as  well  as  in,  a  part,  proceed  from  suppu- 
rative inflammation,  provoked  by  the  presence  of  particles  of  pus,  brought  thither 
with  the  circulating  blood. 

I  told  you  before,  that  foreign  substances,  entering  the  blood,  and  failing  to  pass 
out  of  it  again  through  the  natural  emunctories  of  the  body,  are  liable  to  be  stopped 
when  they  arrive  at  the  first  network  of  capillary  vessels  that  lie  in  their  course. 
Now  the  blood,  circulating  in  the  veins,  reaches  (much  of  it  at  least)  in  each  of  its 
circuits,  two  such  great  networks,  the  hepatic  and  pulmonary.  Through  the  pul- 
monary network  all  the  blood  must  pass,  through  the  hepatic  some  of  it ;  and  it  is 
there,  in  the  capillary  tissue  of  these  organs,  that  particles  of  pus,  and  other  material 
substances,  foreicrn  to  the  blood,  and  incapable  of  elimination  with  the  customary 
excretions,  are  apt  to  stick,  or  to  be  entangled,  and  to  excite  inflammation.  Some 
of  them,  however,  in  general,  pass  on,  and  arriving  at  the  left  side  of  the  heart,  are 
transmitted,  with  the  arterial  blood,  to  various  parts  of  the  body,  there  to  exercise  a 
himilar  deleterious  influence. 

Such  was,  and  is,  the  theory :  and  it  has  been  tested  and  confirmed  by  direct  ex- 
periment. Inasmuch  as  the  conveyance  of  the  pus  cannot  be  traced  by  the  eye, 
nor  the  manner  of  its  being  collected  into  an  abscess  demonstrated,  except  bv  in- 
ference, Cruveilhier  introduced  quicksilver  into  the  veins  of  animals  :  a  metal  whi^h 


PHLEBITIS.  709 

IS  liquid,  and  divisible  into  very  minute  particles,  and  which  exerts  no  chemical 
agency  upon  the  vital  fluid.  When  the  mercury  was  inserted  into  the  veins  whicn 
concur  to  form  the  vena  portce,  the  whole,  or  the  greater  part  of  it,  was  arrested  in 
the  liver.  In  that  organ,  the  animal  being  killed  a  certain  time  after  the  introduction 
of  the  metal,  small,  roundish,  red  spots  were  always  discoverable,  which  passed 
gradually  into  little  abscesses  surrounded  by  a  halo  of  inflammatory  redness  ;  and  in 
the  centre  of  each  red  spot,  and  of  each  abscess,  lay  a  minute  globule  of  mercury. 
A  few  similar  points  of  suppuration  were  usually  to  be  seen  in  the  lungs  also.  But 
when  the  quicksilver  was  put  into  the  blood  in  its  direct  course  towards  the  vena 
cava,  then  it  was  in  the  lungs  that  these  points  were  either  exclusively  detected,  or 
at  any  rate  most  numerous. 

You  must,  I  think,  perceive  how  strictly  these  experiments  bear  upon  the  rational 
humoralism  acknowledged  at  the  present  day.  If  pus,  and  mercury,  may  thus  be 
distributed  to  particular  organs,  and  thus  excite  circumscribed  inflammation,  so 
doubtless  may  other  extraneous  impurities — introduced  by  the  poison  of  what  is 
called  good  living,  by  the  respiration  of  foul  air,  and  in  various  other  ways — reach 
and  settle  in  different  parts  of  the  body  (the  liver,  the  lungs,  the  kidneys,  the  joints), 
and  there  produce,  if  not  inflammation  and  pus,  yet  such  changes  at  least  as  spoil  the 
texture  of  the  organ,  and  pervert  its  healthy  office.  That  cancer  is  propagated  in 
this  way  we  have  heretofore  seen  reason  to  believe.  In  all  probability  the  deposi- 
tion and  increase  of  tubercles  fall  under  the  same  law.  There  is,  however,  this 
remarkable  difference  between  tubercles  and  phlebitic  abscesses,  that  the  former 
occupy  chiefly  the  upper  portions  of  the  lungs,  while  the  latter  are  generally  most 
numerous  in  their  lower  lobes. 

Suppurative  phlebitis — wath  all  its  horrible  efl"ects — is  liable  to  arise,  not  only 
after  severe  but  also  after  slight  injuries ;  from  the  trivial  as  well  as  the  grand  ex- 
ploits of  surgery ;  nay,  spontaneously,  as  it  were,  without  any  local  hurt,  under  the 
agency  of  natural  causes,  such  as  exposure  to  cold.  And  the  part  in  which  the 
phlebitis  occurs  has  some  influence,  as  you  will  now  understand,  in  determining  the 
principal  seat  of  these  scattered  abscesses.  When  they  succeed  amputation  of  a 
limb,  or  fracture  of  the  skull,  or  the  interference  of  surgery  with  varicose  veins,  or 
(as  they  may)  even  the  simple  operation  of  phlebotomy,  they  are  likely  to  be  most 
numerous  in  the  lungs.  But  they  are  more  conspicuous  to  hasty  observation  in  the 
liver  than  in  the  lungs;  and  that  is  why  hepatic  abscess  was  supposed  to  have  some 
special  connection  with  injuries  of  the  head.  Morgagni,  however,  long  ago  pointed 
out  the  fact,  that  other  parts  also  were  affected  in  those  cases.  Again,  we  may  ex- 
pect to  find  these  disseminated  abscesses  chiefly  in  the  liver,  when  suppurative 
phlebitis  occurs  in  any  of  the  tributary  veins  of  the  vena  porta):  when  it  supervenes, 
therefore,  upon  operations  on  the  bladder  or  on  the  intestines — operations  for  the 
removal  of  stone,  for  the  release  of  hernia,  for  healing  fistula  in  ano,  for  the  cure  of 
piles. 

It  is,  however,  very  common  for  the  poison  to  pervade  the  whole  body,  and  for 
abscesses  to  form  in  various  other  situations,  as  well  as  in  the  lungs  and  liver.  I 
once  saw  a  young  woman  die,  in  the  Middlesex  Hospital,  from  phlebitis,  with  large 
abscesses  in  many  parts,  and  especially  in  the  joints,  after  the  simple  excision,  with 
scissors,  of  some  small  spongy  irritable  gxowths  about  the  orifice  of  her  urethra. 

Two  or  three  instances  of  suppurative  phlebitis,  unconnected  with  any  known 
hurt,  and  originating  apparently  in  exposure  to  cold,  have  fallen  under  my  own  ob- 
servation: but  I  prefer  giving  you  the  following  short  case,  with  the  details  of  which 
I  have  been  favoured  by  Dr.  Maiden,  of  Worcester. 

Miss ,  a  teacher  in  a  Ladies'  School,  was  attacked,  after  exposure  to  wet 

and  cold,  with  acute  pain,  heat,  and  redness,  in  the  front  of  the  left  forearm.  Mr. 
Cole,  an  eminent  surgeon,  of  Bewdley,  by  whom  she  was  at  first  attended,  discovered 
inflammation  following  the  course  of  the  cutaneous  veins.  Upon  its  subsidence  the 
veins  were  left  like  hard  cords.  Soon  afier  the  right  arm  was  affected  in  a  similar 
way:  and  next,  both  the  lower  extremities,  which  became  anasarcous.  All  this  was 
attended  with  paroxysms,  simulating  those  of  tertian  ague ;  exhausting  sweats,  diar- 
rhoea, and  a  frequent  feeble  pulse.     At  the  end  of  a  month,  deeo-ocdted  fluctuation 

3k 


710  DISEASES  OF  THE  VEINS. 

was  detected  in  the  rignt  thigh,  three  inches  below  Poupart's  hgament.  The  abscess 
gradually  approached  the  surface,  and  was  opened,  and  more  than  three  pints  of 
very  fetid  pus  were  discharged.  The  wound  never  closed,  and  she  sank,  exhausted, 
a  month  after  it  was  made. 

There  was  no  pain,  premonitory  or  attendant,  connected  with  this  formation  of 
matter. 

The  abscess  was  traced,  after  death,  upwards,  behind  the  muscles  of  the  pelvis,  as 
far  as  the  sacro-ihac  symphysis,  where  the  bones  were  extensively  carious. 

Many  of  the  superficial  veins,  both  of  the  upper  and  lower  extremities,  were 
found  to  be  completely  obliterated  by  adhesive  inflammation,  or  sealed  up  by  coa- 
gula  of  blood. 

This  spreading  and  morbiferous  inflammation  of  veins  is  sometimes  so  remarkably 
prevalent,  as  to  partake  of  the  character  of  an  epidemic  disorder:  and  this,  its  occa- 
sional prevalence,  appears  to  beowing  to  some  peculiar  condition  of  the  atmosphere 
— or  rather  to  some  ^-^'•edisposition  of  the  human  body,  engendered  by  the  operation 
of  influences  which  are  probably  atmospheric.  During  such  periods  prudent  men 
refrain,  if  they  can,  from  the  performance  of  surgical  operations. 

The  view  which  I  have  now  set  before  you  of  suppurative  phlebitis,  and  of  its 
distant  effects,  involves  some  apparent  difiiculties,  and  some  curious  questions.  A 
short  consideration  of  these  may  serve  to  throw  a  clearer  light  upon  the  main  subject. 
First,  then,  how  is  it — if  indeed  the  disseminated  abscesses  result  from  the  intro- 
duction of  pus  into  the  blood — hoAV  is  it  that  we  do  not  meet  with  them  oftener?  Pus 
is  absorbed,  in  numberless  instances,  without  the  occurrence  of  any  such  formidable 
consequences.  We  see  great  abscesses  disappear  spontaneously,  and  yet  no  other 
smaller  scattered  abscesses  ensue.  Does  not  this  fact  invalidate  the  theory  of  the 
cause  and  formation  of  such  distant  points  of  suppuration  ?  No.  It  seems,  that  for 
their  production,  pus  assuch,  pus  in  substance,  pus  in  the  mass,  must  be  received 
into  the  veins,  and  circulate  with  the  blood.  The  pus  which  is  taken  up  by  ordinary 
absorption,  is  altered,  probably,  by  that  process,  before  it  reaches  the  blood  :  at  any 
rate  it  has  not  the  same  mischievous  and  fatal  effect. 

You  may  here  inquire  in  what  manner  pus  gets  into  the  circulation,  in  conse- 
quence of  an  amputation  ?  Is  it  not  absorbed  from  the  suppurating  stump  ?  I  con- 
ceive not.  Supposing  the  amputating  knife  to  cross  and  sink  into  an  existing  abscess, 
and  to  divide  a  vein — then,  indeed,  pus  might  be  sucked  into  the  vein,  and  the  usual 
consequences  follow.  But  the  veins  that  lead  to,  or  rather  from,  a  stump,  become 
blocked  up,  and  impervious,  from  adhesive  inflammation,  or  from  mere  coagulation 
and  adhesion  of  the  blood  in  them,  before  the  stump  has  had  time  to  suppurate. 
How  then  does  the  pus  ever  find  admission  ?  No  doubt  it  is  a  product,  in  this  case 
also,  of  phlebitis.  The  interior  of  a  vein  inflames,  and  goes  on  to  suppuration  ;  and 
the  pus  which  it  pours  forth  mingles,  as  pus,  with  the  circulating  stream. 

Indeed  these  scattered  abscesses  appear  to  originate  always  in  phlebitis.  Such  is 
the  opinion  of  my  colleague,  Mr.  Arnott,  who  has  contributed  a  valuable  paper  on 
this  subject  to  the  MeJico-Chinirgical  Transactions.  Such  is  also  the  opinion  of 
M.  Cruveilhier.  It  has  been  objected  that,  in  some  fatal  cases  of  this  kind,  no 
phlebitis  could  be  detected:  that  the  principal  veins  have  been  diligently  traced,  yet 
no  vestige  of  suppuration,  nor  even  of  adhesive  inflammation,  has  been  visible.  To 
make  this  objection  valid,  all  the  veins  throughout  the 'body  should  be  scrutinized  ; 
and  that  has  seldom,  I  fancy,  been  done.  I  have  known  several  instances,  in  which 
most  of  the  larger  trunks  were  searched  in  vain,  till  at  length  a  short  tract  of  one  of 
them,  an  inch  or  two  perhaps,  was  found,  bearing  marks  of  having  been  inflamed. 
You  must  not  conclude  therefore  against  the  antecedent  existence  of  phlebitis,  until 
vou  have  examined  everj^  vein  in  the  soft  parts  of  the  body :  no,  nor  even  then. 
You  must  go  deeper  than  the  more  obvious  veins.  There  is  good  reason  for  believ- 
ing ihat  the  hones  and  their  veins  are  often  the  seat  of  the  primary  mischief,  the 
fountain  from  which  the  pus,  which  thus  renders  the  blood  a  poison,  first  proceeds : 
the  veins,  for  example,  of  the  diploe  of  the  skull,  when  scattered  abscesses  ensue 
upon  injuries  of  the  head  ;  the  veins  of  the  bones  of  the  extremities  after  unsuccess- 
ful operations.     Tliere  is  yet  another  explanatory  supposition  applicable  to  some 


PHLEBITIS.  711 

cases.     All  local  traces  of  the  primary  inflammation  may  vanish  before  death,  while 
the  vital  powers  are  being  undermined,  and  about  to  sink  under  its  secondar}^  effects, 

Cruveilhier  repeatedly  performed  the  following'  experiment,  and  always  with  simi- 
lar results.  He  introduced  crude  mercury  within  the  hollow  shaft  of  the  thigh  bone 
of  a  living  dog.  When  the  quantity  was  considerable,  death  occurred  in  a  few  days, 
and  the  metal  was  found  strewed  thickly  through  the  lungs,  each  globule  occupying 
a  capillary  branch  of  the  pulmonary  artery,  and  surrounded  by  a  small  sphere  of 
inflammatory  redness.  When  the  quantity  was  minute,  the  animals  lived  longer, 
and  little  abscesses,  enclosing  each  a  particle  of  mercury,  were  then  discovered  in 
the  same  organs.  The  mercury  he  supposes  to  have  found  a  direct  entrance  into  the 
blood,  in  these  cases,  from  the  cancellous  portion  of  the  bone:  and  through  the  same 
channel  it  seems  to  be  that  pus  often  enters  the  circulation.  You  may  remember 
my  relating  some  fearful  examples  of  scattered  abscesses,  supervening  upon  chronic 
disease  of  the  bones  of  the  ear.  Cruveilhier  states  that  having  been  present  at  the 
examination  of  the  body  of  one  who  had  sunk  after  amputation  of  the  leg,  and  whose 
lungs  were  full  of  little  abscesses,  he  sought,  without  success,  for  some  inflamed  vein : 
but  upon  dividiqo-  the  tibia  and  fibula,  he  found  the  spongy  extremities  of  these  bones 
in  filtered  with  pus.  Here,  beyond  question,  had  been  the  source  of  the  visceral 
mischief. 

The  local  phenomena,  when  a  superficial  vein  of  some  magnitude  is  inflamed,  are 
pain  and  tenderness  in  the  course  of  the  vessel,  which,  in  the  adhesive  variety  of  the 
complaint,  is  soon  converted  into  a  tangible,  hard,  and  sensitive  cord.  Whether  the 
vein  be  near  the  surface  or  deeply  seated,  there  is  usually  more  or  less  oedema  of  the 
areolar  tissue  of  the  part.  Phlebitis  of  this  kind  has  been  sometimes  confounded,  I 
believe,  with  inflammation  of  the  lymphatic  absorbent  vessels.  You  distinguish  the 
latter  by  the  slenderness  of  the  painful  cord ;  by  its  position,  which  is  still  more 
superficial  than  that  of  a  subcutaneous  vein ;  by  the  number  of  little  knots  which 
diversify  its  course  ;  and  by  the  streaks  and  patches  of  bright  inflammator}'"  redness 
which  appear  along  the  same  track.  Dr.  Graves  remarks  {Clinical  Medicine,  p. 
451),  that  inflammation  of  the  lymphatics  "  is  seldom  continuous,  but  is  developed 
at  certain  insulated  points." 

In  the  suppurative  form  of  phlebitis  the  general  symptoms  take  the  lead.  The 
formation  of  pus  in  separate  and  often  distant  parts  is  rapid,  and  frequently  unan- 
nounced by  any  local  pain.  When,  however,  the  joints,  or  parts  near  the  joints,  are 
the  seat  of  suppuration,  much  soreness  is  complained  of,  and  the  malady  is  liable  to 
be  mistaken  for  rheumatism ;  and  when  the  serous  cavities  are  implicated,  the  pain 
is  sometimes  severe.  Suppurative  phlebitis  is  commonly  attended  in  its  progress 
v/ith  repeated  shiverings,  and  with  profuse  sweats,  and  occasionally  with  copious  and 
very  unnatural  discharges  from  the  bowels.  These  last  have  been  noticed  in  ani- 
mals soon  after  the  introduction  of  pus,  or  of  putrid  matters,  into  their  veins.  Nature 
seems  to  attempt  to  eliminate  the  poison  in  this  way:  and  where  the  quantity  of  pus 
so  introduced  has  been  small,  the  attempt  is  now  and  then  successful.  But  in  gene- 
ral there  is  a  continual  supply  of  the  noxious  substance,  and  the  system  is  irrecover 
ablj'  infected.  Typhoid  symptoms  occur  in  most  cases,  but  not  in  all.  Very  con- 
stantly there  is  great  agitation,  and  a  marked  disturbance  of  the  nervous  system. 

I  have  called  this  purulent  infection  of  the  blood  a  formidable  disorder :  in  truth 
it  is  almost  always  a  fatal  disorder.  Yet  that  it  is  not  inevitably  mortal  I  know  by  a 
case  which  has  recently  occurred  in  Mr.  Arnott's  practice  at  the  Hospital,  and  which 
he  permits  me  to  mention.  He  had  occasion  to  amputate  the  forearm  of  a  mar. 
whose  hand  had  been  crushed  by  machinery.  Two  or  three  days  after  the  operation, 
the  patient's  pulse  quickened,  and  he  had  a  severe  rigor.  These  two  circumstances 
led  Mr.  Arnott  to  ipprehend  the  supervention  of  phlebitis;  and  accordingly  one  of 
the  large,  superficial,  visible  veins  of  the  forearm  became  swollen,  hard,  and  tender. 
Leeches  v/ere  applied  along  its  course  ;  and  the  parts  were  kept  covered  wjth  the 
water  dressing.  In  no  long  time  an  abscess  formed  in  the  other  arm ;  next,  a  larp,e 
one  in  the  back,  from  which  twenty  ounces  of  pus  were  evacuated;  then  one  beneath 
the  glutei  muscles  of  the  buttock,  on  both  sides — each  of  these  two  contained  about 
sixteen  ounces.     In  short,  datmg  between  the  beginning  of  October  and  the  middle 


712  DISEASES    OF    THE   VEINS. 

of  December,  no  less  than  seven  collections  of  matter  presented  themselves  in  vanoiw 
places.  The  last  of  them  was  in  a  very  unusual  part,  beneath  the  man's  tongue,  in 
the  ordinary  situation  of  ranula,  for  which,  indeed,  it  was  at  first  mistaken.  In  every 
instance  the  pus  was  let  out  as  soon  as  possible,  and  the  main  feature  in  the  general 
treatment  was  the  administration  of  opiates,  and  of  wine,  with  a  Hberal  allowance 
of  good  beef-tea  in  the  earlier  stages,  and  of  meat  afterwards.  This  m'an  recovered  ; 
and  was  seen  in  the  month  of  May  following,  in  perfect  health.  The  case  is  ex- 
tremely interesting.  It  shows,  I  say,  that  suppurative  phlebitis,  even  when  it  dissemi- 
nates consecutive  inflammation  and  suppuration  throughout  the  body,  is  not  absolutely 
and  hopelessly  fatal.  Whether  abscesses,  from  this  cause,  distributed  in  the  lungs 
or  liver,  are  capable  of  repair,  I  cannot  tell  you.  Under  the  treatment  employed,  the 
inflammation  of  the  vein  m  the  arm  gradually  subsided.  All  outward  evidence  at 
least  of  its  existence,  all  induration  even,  disappeared  ;  and  presumptively  all  inward 
evidence  too.  So  that  had  this  patient  sunk,  late  in  the  course  of  his  disorder,  under 
the  multiplied  secondary  abscesses,  his  venous  system  might  probably  have  been 
searched  in  vain  for  any  remaining  traces  of  phlebitis  :  and  yet  we  know  that  at  one 
time  he  had  phlebitis,  more  severe  and  extensive  than  belongs  to  the  natural  and 
kindly  healing  of  every  stump. 

The  treatment  found  most  suitable  in  phlebitis  has  just  been  briefly  indicated ; 
local  depletion  when  the  inflamed  vein  is  accessible  ;  regulation  of  the  bowels  ;  strong 
animal  broths  and  wine  to  support  the  strength.  Our  object  is  in  the  first  place  to 
subdue  and  resolve  the  inflammation ;  or  at  any  rate  to  prevent  its  passing  beyond 
the  adhesive  stage.  To  this  end,  the  vein,  being  obvious  and  superficial,  we  apply 
leeches,  cold  lotions,  or  fomentations. 

[In  cases  of  phlebitis  from  venesection,  the  late  Dr.  Physick  recommended  the  application 
of  a  blister  over  the  orifice  in  the  arm,  as  soon  as  the  inflammation  commences,  the  oritice 
itself  being  first  defended  by  a  plaster  of  simple  cerate  spread  on  linen.  He  found  this  to 
be  invariably  beneficial  in  causing  the  arrest  of  the  inflammation.  Dr.  Dorsey  also  found  a 
blister  thus  applied  to  produce  always  a  good  eflect ;  and  in  a  case  related  by  Dr.  f^vaus, 
(Transac.  College  of  Physicians  of  Philadelphia,  vol.  ii.,  p.  106,)  the  good  eflect  of  blisters  in  a 
case  of  spontaneous  phlebitis,  was  strikingly  evinced. — C  ] 

During  the  progress  of  the  malady,  especially  when  suppurative  phlebitis  is  pre- 
valent, it  would  be  unsafe  to  cut  into  a  large  vein,  lest  by  that  shght  violence  we 
establish  a  fresh  local  phlebitis.  Indeed,  after  the  suppurative  form  has  once  been 
set  up,  general  blood-letling  does  no  good ;  but,  on  the  contrary,  impairs  the  power 
of  the  system  at  large  to  struggle  against  the  disease. 

The  obliteration  of  a  large  vein,  whether  by  adhesive  phlebitis  or  in  anj'  other 
way,  is  perilous  in  proportion  to  its  magnitude,  and  to  the  rapidity  with  which  its 
complete  occlusion  has  been  effected.  The  gradual  stoppage  of  even  the  largest — 
the  primary  venous  trunks,  the  vense  cavce — admits  of  some  degree  of  compensa- 
tion. In  one  instance  of  this  kind,  which  I  briefly  described  yesterday,  and  which 
I  myself  witnessed,  the  superior  cava  was  flattened,  and  its  channel  completely 
effaced,  by  the  pressure  of  an  aneurismal  tumour :  in  another,  which  I  mentioned 
formerly,  on  Mr.  Kiernan's  authority,  an  immense  varix  of  the  superficial  veins  of 
the  abdomen  supplied  to  the  returning  blood  the  passage  denied  to  it,  in  its  natural 
course,  by  the  partial  obliteration  of  the  inferior  cava.  To  impress  upon  your  recol- 
lection the  ordinary  phenomena  that  result  from  these  grave  derangements  in  the 
hydraulic  machinery  of  the  body,  I  will  state  here,  from  my  hospital  case-book,  the 
outlines  of  two  additional  examples  of  a  similar  character. 

James  Buck,  aged  thirty-three,  was  admitted  on  the  (3th  of  March,  1838.  The 
ajjpearance  of  this  man  was  very  remarkable.  His  countenance  was  swollen  and 
livid  ;  his  eyeballs  projected  ;  his  fips,  the  end  of  his  nose,  and  the  rims  of  his  ears, 
were  of  a  deep  purple  colour.  It  was  manifest  that  the  blood  did  not  freely  descend 
from  the  head.  Further  evidence  of  this  became  apparent  when  the  trunk  of  his 
body  was  uncovered.  The  throat  was  very  full  and  tumid,  like  that  of  a  goitrous 
;)erson,  yet  the  swelling  was  not  owing  to  enlargement  of  the  thyreoid  gland,  nor  to 
<£dema  ;  but  fek  firm  and  fleshy.    The  jugulars  were  distended  ;  and  the  whole  sur- 


PHLEBITIS.  713 

face  of  the  thorax  in  front,  with  that  of  the  shoulders,  and  of  part  of  the  abdomen, 
was  thickly  overspread  with  a  network  of  prominent  veins.  The  external  mammary 
veins  were  seen  to  communicate  freely  with  veins  proceeding  from  the  neck  on  each 
side,  with  the  veins  of  both  the  upper  extremities,  and  with  the  epigastric  veins  from 
beneath.  Here  and  there  were  patches  of  minute  purple  varicose  branches,  crowded 
closely  together. 

He  told  us  that  whenever  he  stooped  down,  to  tie  his  shoe-strings,  for  instance,  he 
became  giddy,  his  head  swelled,  and  his  face  and  ears  grew  black :  that  he  was  very 
nervous,  easily  flurried,  and  dreamed  much,  thinking  he  was  flying  in  the  air,  falling 
down  precipices,  and  the  like.  He  had  not  noticed  any  swelling  of  the  face  or  throat 
until  three  weeks  previously  ;  and  he  had  never,  he  said,  had  a  day's  illness  before. 
He  knew  of  no  cause  for  the  complaint ;  had  been  making  no  extraordinary  bodily 
effort ;  had  never  suffered  rheumatic  fever.  He  professed,  also,  temperate  habits, 
but  he  had  been  a  soldier,  and  afterwards  a  pugilist,  and  his  wife  informed  me  that 
he  had  led  an  irregular  life.  • 

The  evidence  1  say  was  strong,  of  some  obstruction  to  the  return  of  the  blood 
through  the  superior  cava.  Now  such  obstruction  is  most  commonly  produced  by 
intrathoracic  tumours — sometimes  by  carcinomatous ;  much  oftener  by  aneurismal 
tumours.  There  were  no  circumstances  to  make  it  likely  that  the  malignant  growths 
existed ;  but  there  were  circumstances  which  corroborated  my  first  suspicion,  that 
the  symptoms  were  dependent  upon  aneurism  of  the  aorta,  or  of  one  of  its  primary 
branches. 

There  Avas  indeed  no  external  prominence,  no  pulsative  or  other  swelling,  no 
aneurismal  whiz,  to  guide  us  to  this  diagnosis.  Upon  careful  and  repeated  auscul- 
tation of  the  chest,  the  murmur  of  respiration  was  found  to  be  in  some  parts  feeble 
and  unequal.  This  might  consist  with  the  presence  of  any  kind  of  tumour.  The 
heart's  action  was  heard,  and  fek,  strong  and  heaving,  in  the  proper  place,  beneath 
the  left  nipple.  To  the  right  of  the  sternum  also,  and  near  the  middle  of  its  upper 
portion,  one's  ear  was  distinctly  jarred  at  each  systole  of  the  heart,  though  with  less 
force  than  in  the  precordial  region.  But  in  the  space  intermediate  between  these 
two  spots,  no  such  jarring  sensation  was  perceptible,  although  the  heart  could  be 
heard,  beating  with  a  slight  bellows  sound.  Moreover,  the  right  radial  artery  was 
considerably  weaker  and  smaller  than  the  left.  This  showed  that  the  innominata 
was  interested  in  the  disease.  The  symptoms,  taken  together,  left  no  doubt  on  my 
mind  than  there  was  an  aneurismal  pouch  beneath  the  sternum,  where  the  jar  was 
experienced.  I  have  gone  somewhat  into  particulars  to  show  you  how  confidently 
sometimes,  by  close  observation,  you  may  pronounce  upon  the  condition  of  parts 
which  you  can  neither  see  nor  touch. 

All  that  could  reasonably  be  hoped  for  from  medicine,  was  postponement  of  the 
evil  day.  To.  relieve  the  oppressed  blood-vessels  by  taking  away  part  of  their  con- 
tents, by  freely  purging  the  patient,  and  by  setting  his  kidneys  to  work — this  Avas 
what  was  to  be  attempted ;  and  this  was  done.  He  was  repeatedly  cupped,  and 
always  with  most  sensible  relief  to  his  feelings,  the  blood  flowing  copiously.  Pur- 
gatives and  diuretics  also  acted  well ;  and  so  much  was  the  man  benefitted  by  these 
measures,  that  twice  he  left  the  ward,  and  became  an  out-patient. 

About  the  middle  of  June  a  new  symptom  arose — severe  pain  extending  from  the 
right  collar-bone  across  the  shoulder.  He  died  on  the  10th  of  July.  Three  or  four 
days  before  his  death,  he  had  rigors  and  extreme  dyspnoea,  complained  of  pain  over 
the  whole  thorax,  and  declared  that  his  "  heart  seemed  on  fire."  These  symptoms 
were  caused  by  the  supervention  of  pericarditis,  which  proved  speedily  fatal,  A  thin 
layer  of  recent,  reticulated  lymph  was  found  covering  a  considerable  extent  of  the 
surface  of  the  heart. 

The  body  was  examined  by  Mr.  Shaw,  after  injection  of  the  veuis,  and  of  the  tho- 
racic duct. 

There  was  a  large  aneurism  of  the  arteria  innominata  ;  of  which  I  omit  all  parti 
cular  description,  my  present  object  being  to  draw  your  attention  to  the  state  of  the 
veins.  The  two  great  trunks  that,  coming  from  either  side,  unite  to  form  the  vena 
cava  superior,  were  completely  closed  up,  as  well  as  the  corresponding  portion  of  :he 

3k2 


714 


DISEASES    OF   THE   VEINS. 


cava  itself,  which  was  lost  and  confounded  in  the  walls  of  tne  aneurisnrial  sac.  The 
subclavian  veins  were  pervious  up  to  the  point  where  they  joined  the  internal  jugu- 
lars, but  no  further.  The  preparation  of  these  parts,  which  is  before  you,  and  the 
rough  diagrams  v/hich  I  here  exhibit,  will  aid  your  comprehension  of  the  mode 
\vhereby  the  blood  descending  from  the  head,  found  its  way  at  length,  through  many 
circuitous  channels,  to  the  heart  The  larger  deep-seated  compensating  veins  were 
not  greatly  magnified,  but  the  number  of  the  smaller  branches  was  much  augmented. 
The  vcnaazygos,  for  example,  was  very  little  above  its  usual  size ;  yet  it  was  appa- 
rently provided  with  a  greater  number  of  considerable  branches  than  are  commonly 
observed  under  natural  circumsiances. 


A,  Obstructed  veins. 

B,  Seat  of  the  ri?ht  auricle. 

C,  Tlioracic,  pectoral  and  mammary  reins  convey- 

ing the  blood  in  a  contrary  course  to  its  usual 
direction,  and  anastomosing  witli  the  inter- 
costal and  epigastric  veins. 

As  the  veins  into  which  the  trunks  of  the  absorbent  vessels  discharge  their  con- 
tents were  obliterated,  it  became  interesting  to  examine  the  state  of  these  vessels,  and 
of  the  lymphatic  glands.  But  the  condensation  and  confusion  of  all  the  parts 
around  the  tumour  rendered  it  difficult  to  trace  the  thoracic  ducts.  The  glands 
were  remarkably  large,  of  a  purple  colour,  and  gorged  with  bloody  serum.  The 
fulness  of  the  neck,  noticed  during  hfe,  was  occasioned  by  this  turgescence  of  the 
glundulx  concatenatie.  Large  glands  were  seen  studding  the  walls  of  the  aneurism, 
and  adhering  to  the  great  vessels  connected  with  it :  /.  <?.,  in  situations  where,  under 
ordinary  circumstances,  such  glands,  from  their  minuteness,  can  scarcely  be  detected 
at  all. 

With  this  case,  contrast  the  following  : — 

Harriet  Baldwin,  thirty-three  years  old,  was  admitted  December  29, 1840,  anasar- 
cous  as  high  as  the  hips,  and  with  an  enlarged  abdomen.  The  swelling  had  begun, 
she  said,  a  fortnight  before. 

She  complained  of  cough,  and  of  expectoration,  which  was  sometimes  tinged  with 
blood.  She  could  not  lie  down  in  bed  for  dyspncEa,  Her  urine  was  scanty  and 
dark-coloured. 

She  told  us  she  had  dropsy,  quite  as  bad,  five  years  ago,  of  which  she  was  cured 
m  St.  Bartholomew's  Hospital. 

All  this  we  learned  in  the  admission-room.  The  next  day,  when  she  was  in  bed, 
we  learned  a  good  deal  more. 

The  large  abdomen  did  not  owe  much,  if  anv   ot  its  bulk  to  ascites.     It  contained 


OBLITERATION    OF   VEINS. 


715 


a  palpable  tumour,  filling  the  right  hypochondrium,  and  extending  thence  far  beyond 
tJje  umbilicus  to  the  left,  and  into  the  right  groin.  This  tumour,  from  its  situation, 
and  from  the  coutinuous  dullness  elicitea  by  percussion  from  the  right  mamma  down- 
w-ards  over  its  whole  extent,  was  evidently  formed  by  the  liver,  much  enlarged,  and 
out  of  its  place. 

But  besides  the  tumour,  the  abdomen  presented  on  its  surface  a  very  singular  ap- 
pearance. Two  zig-zag  lines  of  large,  varicose  veins  ran  up  its  middle,  n^ar  the 
right  edge  of  the  linea  alba.  These,  which  were  evidently  the  epigastric  veins, 
inosculated  above  with  the  mammary.  Large,  but  straighter  veins,  wandered  over 
the  front  of  the  thorax  on  both  sides. 

The  swollen  legs  of  this  woman  were  quite  purple  from  innumerable  clusters  of 
small  varicose  veins. 

Other  symptoms  also  there  were,  but  I  pass  them  by  as  irrelevant  to  my  present 
subject.  It  was  plain  that  the  current  of  the  blood 
along  the  vena  cava  inferior  was  suffering  impedi- 
ment. That  vessel  was  presumably  compressed, 
perhaps  rendered  totally  impervious,  by  the  superja- 
cent tumour.  The  existence  of  the  tumour ;  the 
great  cedema  of  the  legs,  compared  with  the  shght 
amount  of  liquid  in  the  cavity  of  the  belly ;  tlie  va- 
ricose state  of  the  cutaneous  veins  of  the  legs  ;  and, 
above  all,  the  remarkable  condition  of  the  superficial 
veins  of  the  abdomen : — these  were  the  evidences. 
The  blood  from,  the  lower  extremities  passed  mainly 
by  the  way  of  the  intercostal  and  subclavian  veins, 
to  the  heart.  Death  took  place  on  the  19th  of  Janu- 
ary, 1841.  A  part  of  the  liver  appeared  perfectly 
healthy  ;  another  part  contained  a  prodigious  quan- 
tity of  hydatids.  When  removed  from  the  cyst 
which  had  contained  them,  they  filled  a  large  wash- 
hand  basin.  The  sides  of  the  inferior  cava  were 
pressed  together  by  the  tumour,  and  its  channel  was  thus  completely  closed  up  for 
the  space  of  three  inches. 

In  each  of  these  two  cases,  the  closure  of  the  great  venous  trunk  was  gradually 
effected,  as  the  compressing  tumour  augmented  ;  and  time  was  afforded  for  the  deve- 
lopment of  collateral  supplementary  channels.  In  both  cases,  the  superficial  veins 
of  the  thorax  and  abdomen  contributed  largely  to  supply  the  growing  needs  of  the 
system ;  but  the  stream  of  returning  blood  ran  oppositely  in  the  two  cases :  from 
above  downwards  in  the  first,  from  below  upwards  in  the  second.  The  direction  in 
which  the  blood  in  the  veins  is  moving  can,  of  course,  be  always  readily  ascertained  ; 
and  this  might  furnish  a  test,  were  other  tokens  wanting,  whereby  to  determine  whe- 
ther the  obstruction  lay  in  the  superior  or  in  the  inferior  cava.  And  there  is  another 
circumstance  worthy  of  remark,  and  of  which  the  same  use  might  be  made.  In  the 
first  case,  the  dilated  veins  of  the  thorax  were  tortuous,  those  of  the  abdomen  direct. 
In  the  second,  this  was  reversed ;  the  epigastric  veins  were  singularly  sinuous,  the 
mammary  veins  were  straight.  In  other  words,  those  veins  were,  in  each  instance, 
contorted  and  winding,  in  which  the  actual  course  of  the  blood  was  retrograde.  The 
vessels  were  bent  and  twisted  as  the  current  forced  its  backward  way  against  the 
opposing  but  inefl^ectual  barrier  of  the  valves. 

It  is  impossible,  I  think,  to  find  more  clear  evidence  than  these  interesting  cases 
exhibit,  of  the  power  inherent  in  the  animal  body  of  rectifying,  to  a  certain  extent, 
its  own  accidental  derangements.  You  cannot,  under  such  circumstances,  overlook 
the  existence,  or  mistake  the  tendency  a  vis  medicalrix  naturse. 


716  ASTHMA. 


LECTURE  LXI^. 

Ssfhmu :  its  nature;  comjMcations ;  exciting  cauixM ;  and  treatment.     Diseases 
of  the  (Esophagus :  InJIa m /nation ;  Stricture.;  Spasm;  Dilatation. 

I  MUST  not  leave  the  subject  of  thoracic  disease  without  saying  a  word  or  two 
respecting  asthma;  a  complaint  which  might  have  been  properly  arranged  among 
the  nervous  spasmodic  diseases,  in  a  former  part  of  the  course.  But  1  purposely 
deferred  speaking  of  it,  because,  though  in  many  instances  purely  spasmodic,  and 
independent  of  any  discoverable  faulty  structure,  it  is  still  more  often  connected  with 
organic  diseases  of  the  heart,  or  of  the  lungs;  which  diseases  had  not  then  been 
described. 

I  scarcely  need  caution  you  against  the  vulgar  error  of  calling  all  kinds  of  diffi- 
cult breathing  by  the  name  of  asthma.  You  will  be  constantly  meeting  with  per- 
sons who,  labouring  under  some  permanent  embarrassment  of  the  respiration,  tell 
you  they  are  asthmatic.  They  conceive  that  asthma  is  simply  an  inconvenient,  and 
not  at  all  a  dangerous  affection  :  and  they  please  themselves  with  the  notion — con- 
sumptive patients  and  their  friends  do  this  continually — that  they  are  merely  asthmatic. 
Asthma  is  dyspnoea,  but  dyspncEa  is  not  necessarily  asthma. 

Asthma  may  be  defined  as  being — great  difnculty  of  breathing :  occurring  in 
paroxysms;  accompanied  by  a  loud  wheezing  sound  of  respiration  ;  going  off,  after 
some  hours,  with  more  or  less  mucous  expectoration ;  and  unattended  with  fever. 
And  these  paroxysms  of  dyspnoea  are  believed  to  depend  upon  a  spasmodic  constric 
tion  of  the  bronchial  lubes. 

To  go  rather  more  into  detail :  the  phenomena  which  constitute  and  characterize 
a  fit  of  asthma,  are  somewhat  as  follows  : — The  patient,  if  he  have  previously  suf- 
fered under  the  disease,  has  usually  some  well-understood  warnings  that  an  attack 
is  hanging  over  him.  Loss  of  appetite  ;  frequently  much  flatulence  and  eructation  : 
languor,  irritability,  drowsiness,  oppression,  chilliness ;  and  he  goes  to  bed  ill  and 
uncomfortable.  The  dyspnoea  comes  on  generally  after  midnight,  about  two  or  three 
o'clock  in  the  morning;  often  during  sleep;  and  the  patient  wakes  with  a  sense  of 
tightness  and  constriction  about  the  chest,  and  an  inability,  as  it  seems  to  him,  freely 
to  expand  it.  He  is  obliged  at  once  to  rise  up ;  and  he  sits,  leaning  forwards,  with 
his  knees  drawn  up,  his  elbows  on  his  knees,  and  his  head  supported  by  his  hands, 
labouring  for  his  breath,  and  making  such  a  loud  wheezing  noise  as  to  be  audible  at 
a  considerable  distance.  He  experiences  a  strong  desire  or  necessity  for  fresh  air: 
opens  the  door  of  his  room  and  goes  out  upon  the  stair-case,  or  flies  to  an  open  win- 
dow, even  in  very  cold  weaiher :  and  remains  there,  with  his  head  out,  sometimes 
for  hours.  That  he  can  do  so  wiih  impunity  is  a  strong  presumptive  proof  that  it 
is  the  nervous  system  which  is  principally  affected  in  these  cases.  His  extremities 
at  the  same  time  are  usually  cold,  and  his  countenance  is  distressed  and  haggard  : 
while  the  trunk  of  his  body  may  be  wet  with  perspiration.  Sometimes  the  face  is  a 
.ittle  flushed  and  turgid  :  but  more  commonly,  it  is  somewhat  pale,  and  shrunk.  The 
pulse  is  often  small,  feeble,  and  even  irregular;  and  in  many  instances  there  is 
much  palpitation  of  the  heart.  At  other  times  the  pulse  remains  undisturbed.  If 
uriue  be  passed,  as  it  frequently  is,  at  the  beginning  of  a  fit  of  asthma,  it  is  copious 
and  watery,  pale,  and  without  smell,  like  the  urine  of  hysterical  women.  The 
bowels  are  also  sometimes  relaxed,  with  "something  (as  Dr.  Forbes  observes)  of  the 
impatient  hurry  and  imperfection  of  spasmodic  action."  There  may  be  some 
propensity  to  coughing,  but  the  patient  can  hardly  achieve  a  cough  ;  and  is  so  occu- 
pied with  his  breathing,  that  he  can  speak  in  an  interrupted  manner  only,  with 
difficulty  and  uneasiness.  He  has  not,  however,  in  general,  any  misgivings  about 
the  event  of  the  attack,  but  looks  forward  with  hope  to  the  expected  termination  of 
the  paroxysm. 

"  These  symptoms  often  continue  for  many  hours  together  ;  and  particularly  from 
fliidnight  till  morning  is  far  advanced.     Then,  commonly,  a  remission  takes  place 


ASTHMA.  717 

by  degrees.  The  breathing  becomes  less  laborious,  and  more  full ;  so  that  the  per- 
son can  speak  or  cough  with  more  ease.  And  if,  as  is  usually  the  case,  the  cough 
brings  up  some  mucus,  the  remission  becomes  immediately  more  considerable,  and 
he  falls  into  a  much-wished-for  sleep." 

Paroxysms  of  this  kind  will  often  continue  to  recur  for  many  nights  in  succession : 
remitting  at  length  in  their  severity ;  and  ceasing,  for  a  period,  altogether. 

Daring  the  intervals  between  these  paroxysms,  in  the  day-time,  the  patient  may 
be  perfectly  well ;  but  he  seldom  is  so ;  though  so  great  is  the  difference  between 
his  condition  during  the  remissions,  and  in  the  paroxysms,  that  he  declares,  and  per- 
haps fancies,  that  he  is  quite  well.  You  will  mostly  find,  however,  that  he  is  short- 
winded  ;  that  he  does  not  utter  many  words  of  a  sentence  before  he  pauses  to  take 
breath  ;  that  slight  bodily  exertion  hurries  his  respiration  ;  and  that  he  is  not  easy  in 
a  horizontal  posture,  with  his  head  low. 

Ahhough  the  dyspncsa  is  thus  intermittent,  or  remittent,  you  are  not  to  suppose 
that  the  paroxysms  recur  with  the  regularity  of  those  of  ague.  The  interval  is  of 
uncertain  duration  ;  and  the  circumstances  of  the  paroxysm  differ  in  different  in- 
stances. I  may  remark  also,  that  when  the  paroxysm  ceases  with  little  or  no  expec- 
toration, the  case  is  said  to  be  one  of  dry  asthrna ;  when  expectoration  is  copious,  it 
is  humid,  or  humoral  asthma. 

Now  this,  I  say,  is  looked  upon  as  being  essentially  a  spasmodic  affection.  Upon 
what  grounds  ? 

Why,  in  the  first  place,  the  patients  have  a  sensation  of  constriction  in  the  chest. 
An  old  gentleman  whom  I  saw  lately,  and  who  is  subject  to  fits  of  asthma,  made 
use  of  the  term  cramp  when  he  described  what  he  felt  about  the  thorax ;  and  his 
attacks  were  always  accompanied  or  succeeded  by  actual  cramp  of  the  muscles  of 
the  calves  of  his  legs.  This  is  no  uncommon  circumstance,  this  co-existence  of 
decided  spasm  in  other  parts ;  and  it  throws  some  light  upon  the  nature  of  the  dis- 
order. Again,  the  rapidity  with  which  the  dyspnoea  comes  on,  and  the  suddenness 
with  which  it  often  abates,  resemble  the  caprice  of  spasm.  The  supervention  of 
extreme,  sometimes  enormous  flatulence,  and  the  secretion  of  hysterical  urine,  mark 
also  the  nervous  character  of  the  symptoms.  So  likewise  do  the  juvantia  and  the 
Ixdentia,  as  I  shall  presently  explain  further;  the  affection  being  suddenly  produced 
by  certain  causes  of  irritation,  and  even  by  mental  feelings — suddenly  relieved,  some- 
times, by  medicines  which  are  reckoned  antispasmodic.  If  we  add  to  these  consi- 
derations the  fact  that  patients  dead  of  asthma  have  often,  on  being  examined,  pre- 
sented no  vestige  whatever  of  disease,  either  in  the  lungs  or  in  the  heart,  we  obtain 
very  strong  presumptive  evidence,  that  the  phenomena  attending  a  fit  of  asthma  are 
often  the  result  of  pure  spasm. 

But  if  this  be  so,  what  are  the  muscles  thus  fixed  in  spasmodic  contraction  ? 

You  are  doubtless  aware  that  the  air-tubes  are  encircled  with  a  series  of  little 
fibres,  or  bundles  of  fibres.  I  have  more  than  once  shown  you  these,  exaggerated 
by  hypertrophy,  in  the  larger  bronchi.  They  have  been  traced,  by  Reissessen,  in 
tubes  of  a  very  small  diameter.  Laennec  states  that  he  had  distinguished  them  in 
bronchial  ramifications  less  than  one  line  across.  Now,  supposing  these  circular 
fibres  to  be  muscular,  it  becomes  at  once,  and  (i  priori,  likely  that  they,  no  less  than 
other  muscles,  should  be  liable  to  spasm.  And  the  phenomena  of  asthma  prove,  to 
my  mind,  that  they  are  so.  Analogy  would  say  that  the  fibres,  thus  disposed,  are 
slender  muscles,  similar  to  those  which  surround  the  intestines  and  the  urinary 
bladder :  and  the  microscope,  scrutinizing  their  minute  texture  and  appearance, 
asserts  that  they  are  actually  muscles,  of  the  unstriped  kind ;  like  other  involuntary 
muscles  subserving  the  organic  life.  This  fact — which  I  know  has  been  doubted — 
I  state  upon  the  authority  of  Professor  Todd  and  Mr.  Bowman  ;  both  known  to  you 
all  as  faithful  and  expert  observers.  But  a  test,  less  fallible  than  the  microscope, 
has  practically  settled  the  question.  Dr.  Williams  has  recently  demonstrated,  by  a 
set  of  ingenious  and  satisfactory  experiments,  that  the  lungs  and  air-tubes  are  actually 
contractile  to  a  very  considerable  degree,  under  electrical,  chemical,  and  mechanical 
stimuli.  The  contractions  take  place  steadily  and  deliberately ;  and  are  followed, 
as  soon  as  the  stimulus  is  withdrawn,  by  an  equally  gradual  relaxation.     This  is 


718  ASTHMA. 

very  like  tonic  spasm.  The  contractions  were  rendered  apparent  by  means  of  a 
bent  ojlass  tube,  containing  coloured  liquid,  and  adapted  to  the  windpipe  of  an  animal 
just  deprived  of  life.  The  column  of  liquid  in  the  glass  tube  would  of  course  be 
readily  movable  by  any  contraction  of  the  lungs  and  air-tubes,  causing  pressure  of 
the  included  air  against  it.  In  one  of  the  experiments,  "on  passing  a  galvanic 
current  from  the  margin  of  the  lungs  to  the  insertion  of  the  tube  in  the  trachea,  the 
fluid  rose  quickly,  but  gradually,  nearly  two  inches ;  sunk  speedily  on  breaking  the 
contact ;  again  rose  upon  completing  it ;  but  fell  slowly  when  the  current  was  con- 
tinued for  some  seconds ;"  i.  e.,  when  the  irritability  of  the  tissues  was  temporarily 
exhausted.  Temporaril)^  I  say,  for  on  waiting  two  or  three  minutes  between  each 
application  of  the  galvanism,  the  liquid  was  raised  again  and  again  for  upwards  of 
an  hour;  till,  in  fact,  the  organic  life  was  extinct.  Is  not  all  this  exceedingly  like 
the  behaviour  of  parts  acknowledged  to  be  muscular,  under  similar  influences  ? 

The  phenomena  were  not  occasioned  by  any  general  shrinking  of  all  the  pulmo- 
nary tissues.  For  when  the  lungs  were  cut  across  by  sharp  scissors,  at  right  angles 
to  the  air-tubes,  and  the  open  sections  of  these  tubes  were  galvanized,  they  were 
seen  to  contract  to  one-half  of  their  former  diameter;  and  even  to  become  smaller 
than  that.  The  contraction  was  the  most  distinct  in  the  m.iddle-sized  tubes,  being 
about  the  bigness  of  a  straw :  but  it  was  sensible  enough  in  the  trachea,  which  was 
sometimes  so  far  reduced  in  dimensions,  that  the  ends  of  its  cartilaginous  rings  came 
together. 

A  foreign  experimenter,  M.  Valentin,  carries  us  a  step  nearer  to  the  full  solution 
of  this  interesting  question.  He  found  that  the  rings  of  the  trachea  could  be  made 
visibly  and  distinctly  to  contract,  by  irritating  the  par  vagum. 

Upon  the  whole,  we  may  safely  conclude  that  asthma  is  one  of  the  spasmodic 
disorders  of  the  excito-motory  system  of  nerves.  I  believe,  moreover,  that,  as  in 
most  other  disorders  of  the  same  class,  the  spasm  may  be  of  centric,  or  of  eccentric 
origin.  In  the  eccentric  form,  the  par  vagum  is  doubtless  the  afferent  nerve  ;  and 
the  impression  it  conveys  to  the  medulla  oblongata  is  reflected,  through  associated 
motor  nerves,  upon  the  bronchial  muscles.  The  centric  variety  results  from  a  similar 
impression  originating  in  the  nervous  centres :  which  respond,  mysteriously,  to  cer- 
tain feelings  of  the  mind. 

I  have  never  had  a  favourable  opportunity,  since  I  became  aware  of  the  value  of 
auscultation,  of  listening  to  the  sounds  of  the  breathing  during  a  paroxysm  of  pure 
spasmodic  asthma.  But  they  who  have  enjoyed  such  opportunities  declare  that  no 
respiratory  murmur,  or  very  little  indeed,  can  be  heard.  And  an  attentive  inspec- 
tion of  the  outside  of  the  chest  shows,  that  amidst  all  the  tugging  and  heaving  for 
breath,  the  expansion  of  the  thorax  is  very  hmited.  The  patient  cannot  open  his 
lungs  as  it  were :  and  what  air  does  get  in,  has  a  difficult  and  narrow  passage,  as 
the  wheezing  noise  demonstrates.  Laennec  affirms,  that  if  the  patient,  after  holding 
his  breath  nearly  as  long  as  he  can,  attempts  a  quiet  and  gentle  inspiration,  the 
spasm  may  often  be  overcome  as  if  by  surprise  ;  and,  for  a  kw  seconds,  the  entrance 
of  the  air  into  the  cell  may  be  heard  in  a  clear  and  even  puerile  sound.  If  this  be 
true,  it  is  a  strong  additional  proof  that  the  obstruction  to  the  admission  of  air  was 
really  owing  to  a  tonic  contraction  of  the  little  muscular  fibres  of  the  bronchi  and 
their  ramifications. 

The  hereditary  nature  of  asthma  is  perfectly  consistent  with  the  same  theor}% 
It  is  one  of  the  maladies  which  are  distinctly  transmitted  —  the  disposition  to  them, 
I  mean  —  from  parents  to  children.  And  like  other  spasmodic  disorders,  it  facili- 
tates its  own  return.  When  it  has  once  occurred,  it  seldom  fails  to  happen  again 
and  agam. 

But  though  I  believe,  for  the  reasons  I  have  now  mentioned,  that  asthma,  in  the 
restricted  sense  of  that  term,  is  purely  a  spasmodic  affection,  yet  I  know  also  that  it 
is  very  frequently  indeed  combined  with  organic  alterations  within  the  thorax.  These 
changes  of  structure  are  to  be  regarded  as  so  many  strongly  predisposing  causes. 
They  induce  a  readiness  to  take  on  spasmodic  action  :  and  some  of  them  are  perhaps 
aggravated,  or  even  produced,  by  the  fits  of  asthma,  upon  which  they  afterwards 


ASTHMA.  719 

react  injuriously.  Judging  from  my  own  experience,  I  should  say  that  genuine 
uncomplicated  spasmodic  asthma  was  rare. 

The  organic  diseases  with  which  spasmodic  asthma  is  often  found  connected,  are 
principally  emphysema  of  the  lungs,  and  structural  changes  in  the  heart  and  great 
blood-vessels.  It  is  extremely  probable  that  the  first  step  towards  the  production  of 
the  spasm,  consists  in  some  altered  condition  of  the  circulation  through  the  lungs. 
The  chilliness  of  the  surface,  and  the  sensation  of  want  of  air,  make  it  likely  that 
the  blood  accumulates  in  the  lungs  at  those  times:  that  there  is  congestion  of  the 
membrane,  as  well  as  spasm  of  the  circular  fibres.  And  it  would  seem  that,  in  the 
humoral  asthma,  the  congestion  is  relieved  by  a  copious  secretion  of  mucus ;  and 
that,  with  the  congestion,  the  spasm  also  subsides  and  disappears.  You  will  observe 
that  very  generally  the  paroxysms  come  on  during  the  first  sleep :  at  which  time,  as 
Dr.  Alison  has  suggested,  "the  blood  is  perhaps  in  fullest  quantity,  its  movements 
slow,  and  its  congestion  in  internal  parts  easiest,  because  it  is  least  solicited  to  the 
organs  of  sense  or  locomotion."  But  there  seems  to  be  another  reason  for  this  re- 
markable circumstance.  Respiration  is  mainly  an  automatic  act ;  yet  it  also  obeys 
the  will.  During  sleep  this  moderating  influence  of  the  will  is  suspended.  Those 
changes  of  posture,  and  those  voluntary  alterations  in  the  rate  of  breathing,  which 
are  wanted  to  balance  and  correct  the  commencing  derangement  of  the  pulmonary 
circulation,  and  which  are  prompted  at  once  during  the  waking  state,  do  not  occur: 
until  at  length  the  derangement  reaches  that  pitch  at  which  it  provokes  spasmodic 
contraction,  and  rouses  the  sufferer. 

This  same  congestion,  leading  to  spasm,  sometimes  passes  into  a  slight  form  of 
inflammation ;  and  we  have  symptoms  of  bronchitis.  And  these  symptoms  may 
remain  manifest  even  during  the  intervals  of  the  paroxysms.  It  appears  probable 
also  that  the  vesicular  emphysema  of  the  lungs,  which  so  often  accompanies  asthma, 
is  increased  by  the  paroxysms,  even  if  it  be  not,  in  all  instances,  originally  induced 
by  them.     In  either  case,  there  will  be  some  abiding  dyspnoea  between  the  fits. 

Many  of  these  asthmatic  patients  have  just  healthy  lung  enough  to  breathe  with, 
in  tolerable  ease  and  comfort,  under  ordinary  circumstances  ;  and  dyspnoea  is  brought 
on  whenever  even  a  slight  additional  demand  upon  the  respiration  .anyhow  arises. 
Hence,  as  I  stated  before,  flatulent  distension  of  the  intestines,  undue  repletion  of  the 
stomach  by  an  excessive  meal,  the  recumbent  posture,  all  of  which  cause  pressure 
against  the  vmder  surface  of  the  diaphragm,  may  suffice  to  bring  on  the  fit.  Hence, 
also,  probably,  in  part,  its  frequent  occurrence  in  the  night-time. 

In  like  manner,  any  extraordinary  task  imposed  upon  a  heart  which  is  barely 
equal  to  its  functions  while  the  body  is  in  repose,  may  induce  a  paroxysm  of  asth- 
matic dyspnoea. 

Asthma  is  a  disorder  which  is  incident  to  both  sexes,  but  it  is  much  more  common 
in  men  than  in  women.  It  is  incident  to  all  ages  also  ;  but  it  belongs  more  to  adoles- 
cence,  and  to  the  middle  portion  of  life,  than  to  its  extremes.  It  is  not,  I  think,  a 
common  disease  prior  to  the  age  of  puberty  :  yet  instances  of  it  do  occur  at  an  earlier 
period  than  that.  I  have  lately  seen  a  boy  of  eight  or  nine,  who  has  had  several 
well-marked  attacks  of  pure  asthma.  Nor  does  it  often  begin  to  show  itself  in  old 
age.  Sometimes,  after  plaguing  the  subject  of  it  for  several  years,  it  leaves  him  alto- 
gether. The  chronic  dyspnoea,  with  occasional  irregular  exacerbations,  which  is  so 
frequent  a  disorder  among  old  people,  and  which  always  depends  upon  organic  dis- 
ease, is  not  to  be  confounded  with  true  asthma.  It  is  said  that  asthmatic  persons  are 
exempt  from  phthisis :  and  I  understand  that  one  physician  in  this  town,  who  an- 
nounces that  consumption  is  curable,  maintains  the  doctrine  of  the  incompatibility 
of  phthisis  and  asthma  ;  and  endeavours  to  bring  about  the  latter,  that  he  may  protect 
his  clients  from  the  former.  It  may  be  that  persons  affected  with  genuine  asthma 
seldom  become  the  victims  of  pulmonary  consumption  :  but  I  am  sure  the  rule  is  not 
universal.  One  of  my  earliest  friends  had  from  time  to  time,  while  we  were  school- 
fellows, and  long  afterwards,  the  most  exquisite  fits  of  spasmodic  asthma.  At  length, 
when  he  was  between  thirty  and  forty  years  old,  they  wholly  ceased  :  whereupon 
he  greatly  congratulated  himself.  But  they  only  yielded  before  a  worse  aisease. 
He  began,  in  a  few  months,  to  spit  blood :  and  in  a  few  months  more  he  died  of  well 


720         >  ASTHMA. 

marked  phthisis.  Our  lamented  principal,  the  late  Mr.  Rose,  afforded  another  sad 
example  of  the  same  sequence.  And  1  have  known  two  or  three  families  in  which 
one  individual  was  subject  to  asthma,  while  others  were  scrofulous  and  phthisical. 

The  exciting  causes  of  the  asthmatic  paroxysm  are  manifold  ;  and  some  of  them 
curious.  They  seem  to  be  reducible  to  two  classes.  1.  Particular  states  of  the 
atmosphere,  which  irritate  or  offend  the  mucous  surface  of  the  air-passages  ;  or 
rather,  some  of  the  fibrils  of  the  par  vagum.  2.  Certain  subtle  influences  which 
afTect  in  a  peculiar  manner  the  nervous  system.  All  the  known  exciting  causes  of 
catarrh  are  therefore  likely  to  bring  on  attacks  of  asthma  in  the  predisposed.  But 
there  is  a  singular  caprice  in  asthmatic  patients  in  this  respect.  Some  persons,  sub- 
ject to  the  disorder,  are  unable  to  breathe  in  the  thick  smoky  air  of  London  ;  require 
a  high  and  clear  situation;  and  respire  easiest  in  "the  difficult  air  of  the  keen 
mountain-top."  Others  can  nowhere  breathe  so  comfortably  as  in  low  moist  places: 
in  some  of  the  streets  by  the  water-side  in  the  city,  for  instance.  The  friend  to 
whom  I  lately  alluded  lived  at  Newmarket ;  a  most  exposed  and  bleak  spot.  But 
if  he  left  it,  and  attempted  to  sleep  in  a  strange  place,  he  never  was  certain  that  he 
should  not  be  assailed  in  the  night  by  his  well-known  enemy.  So  that  there  were 
towns  in  which,  after  experiencing  the  effects  of  their  atmosphere,  he  dared  not 
sleep ;  and  there  were  others  in  which  he  knew  he  might  go  to  bed  in  security.  It 
would  have  been  difficult,  I  believe,  to  point  out  any  essential  difference  between 
some  of  those  localities.  His  lungs,  however,  formed  an  infallible  eudiometer. 
Another  college  acquaintance  of  mine,  much  tormented  by  asthma,  is  equally  sensible 
to  these  inscrutable  influences.  Two  inns  in  Cambridge  are  named  respectively  the 
Red  Lion,  and  the  Eagle.  He  can  sleep  in  one  of  them,  and  not  in  the  other.  Nay, 
he  is  thus  variously  affected  within  much  narrower  limits.  He  assures  me  that, 
when  in  Paris,  he  never  escapes  a  fit  of  asthma  if  he  attempts  to  sleep  in  the  back 
part  of  Meurice's  Hotel,  and  never  suffers  if  he  sleeps  in  a  front  room.  Dovei 
Street  suits  him ;  Clarges  Street  does  not.  He  cannot  rest  in  Manchester  Square. 
This  he  attributes  to  its  being  built  upon  piles.  Whether  it  really  has  such  a 
foundation  I  do  not  know.  And  agencies  still  more  slight  and  subtle  are  enough  to 
set  the  springs  of  these  seizures  in  motion.  The  mere  absence  of  light,  for  instance. 
Laennec  speaks  of  a  man  who  invariably  was  roused  from  his  sleep  by  a  paroxysm 
of  asthma,  if  his  lamp  was  extinguished ;  or  if  his  chamber-door  was  shut.  The 
consciousness  that  the  customary  preventive  remedy  was  not  at  hand,  has,  appa- 
rently, brought  on  a  fit. 

There  are  many  persons  who  never  fail  to  become  asthmatic  if  they  inhale  cer- 
tain effluvia.  Particles  of  ipecacuan  floating  in  the  atmosphere,  or  (what  is  perhaps 
the  same  thing)  its  mere  odour,  are  insupportable  to  many.  They  are  thrown  into 
a  paroxysm  of  dyspnoea  if  they  enter  an  apartment  where  that  drug  is  under  prepa- 
ration. I  think  I  mentioned  before  a  certain  laboratory-man  at  St.  Bartholomew's 
Hospital  who  possessed  this  peculiar  and  inopportune  susceptibility  :  he  was  obliged 
to  fly  the  place  whenever  ipecacuan  was  about.  Most  persons,  probably,  who  have 
had  much  experience  in  druggists'  shops,  are  acquainted  with  similar  examples :  so 
that  the  influence  of  ipecacuan  in  exciting  fits  of  difficult  breathing,  resembling 
asthma,  is  undoubted,  and  cotnmon  to  many  constitutions.  We  might  as  well  speak 
of  ipecacuan  asthma,  as  of  hay  asthma,  which  is  a  precisely  analogous  affection. 
Dr.  Marshall  Hall  calls  attention  to  the  familiar  but  interesting  fact,  that  the  same 
drug,  ipecacuan,  acting  upon  the  gastric  branches  of  the  par  vagum,  excites  the 
reflex  spasmodic  act  of  vomiting. 

I  have  said,  that  the  relief  afforded  by  antispasmodic  remedies  affords  presumptive 
evidence  of  the  spasmodic  nature  of  these  attacks.  If  asthma  supervene  upon  mani- 
fest bronchitis,  or  if  there^be  any  signs  of  congestion  about  the  head,  it  may  be  pru- 
dent to  abstract  blood  :  but  this  measure  will  not  in  general  be  requisite,  and  when 
not  requisite  it  should  be  avoided  :  for  whatever  tends  to  debilitate  the  patient,  or  to 
»ower  his  vital  powers,  tends,  at  the  same  time,  to  augment  his  susceptibility  to  the 
f  xciting  causes  of  the  disease.  The  dyspnoea  may  frequently  be  moderated  or  alto- 
gether assuaged  by  some  form  of  narcotic.  Now  opium  is  the  narcotic  to  which 
we  most  trust  for  the  mitigation  of  spasm  in  general :  and  opium  is  of  vast  service 


ASTHMA.  .  721 

m  paroxysms  of  asthma.  But  there  is  also  another  of  the  vegetable  narcotic  sub- 
stances which  has  obtained  an  especial  repute  for  its  effect  in  quieting  the  difficult 
breathing  in  these  cases ;  and  that  is  stramonium.  This  herb,  the  datura  stramo- 
nium, and  another  species  of  the  same  genus,  the  datura  ferox,  had  long  been  em- 
ployed in  India  as  a  remedy  for  asthma.  And  when  it  was  introduced  into  this 
country,  about  the  beginning  of  the  present  century,  it  was  cried  up  as  a  specific : 
and  every  body  who  called  himself  asthmatic  began  to  smoke  stramonium  :  for  that 
is  the  way  in  which  it  has  been  chiefly  employed.  The  leaves  and  stalks  are  cut 
and  pui  into  a  pipe,  and  smoked  like  tobacco.  The  smoke  descends,  of  course,  into 
the  lungs:  and  when  the  saliva  is  swallowed,  the  remedy  is  introduced  into  the 
system  in  that  way  also. 

Stramonium  thus  used,  sometimes  fails  altogether  :  sometimes  calms  the  paroxysm 
like  a  charm.  The  late  Dr.  Babington  told  me  of  a  patient  of  his  who  had  been 
grievously  harassed  for  a  series  of  years,  by  asthma,  but  who  declared  to  him,  after 
he  had  made  a  fair  trial  of  stramonium,  that  he  no  longer  "cared  a  fig"  for  his 
asthma ;  which  he  could  always  stop  in  a  moment.  So  a  Mr.  Sills,  in  a  collection 
of  communications  relative  to  the  datura  stramonium,  published  in  London  in  1811, 
states,  that  he  had  been  a  great  sufTerer  from  asthma:  that  the  fits  usually  continued, 
A'ilh  short  interruptions,  from  thirty-six  hours  to  three  days  and  nights  successively; 
'uring  which  time,  he  had  often,  in  the  seeming  agonies  of  death,  given  himself 
jver,  and  even  wished  for  that  termination  of  his  miseries.  But  having  at  length 
discovered  the  virtues  of  stramonium,  he  uses  this  strong  language: — "In  truth,  the 
asthma  is  destroyed.  I  never  experienced  any  ill  effects  whatever  from  the  use  of 
the  remedy ;  and  I  Avould  rather  be  without  life  than  without  stramonium." 

This,  then,  is  an  expedient  which  it  will  always  be  well  to  suggest,  for  relieving 
the  urgent  distress  of  the  paroxysm  of  asthma.  But  most  patients  subject  to  that 
complaint  try  it  of  their  own  accord.  We  have  still  to  learn  why  it  is  so  efficacious 
in  some  cases,  and  so  entirely  useless,  or  even  hurtful,  in  others.  This  probably 
depends  something  on  the  presence  or  absence  of  organic  disease  in  the  lungs 
or  heart :  but  more  accurate  observations  are  wanted  on  this  point. 

Some  of  the  animals  upon  whose  lungs  Dr.  Williams  performed  his  experiments 
had  been  killed  by  poison.  In  two  instances  stramonium  was  the  poison  employed; 
and  it  is  interesting  to  know  that  scarcely  any  contraction  of  the  air-tubes  could  be 
produced  by  the  galvanic  apparatus.  The  trachea,  at  the  same  time,  was  lax.  It  is 
requisite  to  notice  the  condition  of  the  wind-pipe  in  these  experiments ;  for  the  same 
want  of  contractility  would  be  apparent,  supposing  the  parts  to  be  already  in  a  state 
of  tonic  spasm,  from  the  operation  of  the  poison.  This  seems  to  have  been  the  case 
when  conium  was  used  :  the  tluid  in  the  glass  tube  indicated  scarcely  any  com- 
pression of  the  air  contained  in  the  lungs  ;  but  then  the  wind-pipe  was  so  far  con- 
tracted, that  the  extremities  of  its  rings  met.  There  w^s  but  little  contractility,  and 
a  lax  trachea,  after  death  by  belladotma;  and  after  death  by  the  meconate  of  mor- 
phia. The  contractility  was  slight  when  hfe  had  been  destroyed  by  strychnia;  but 
the  condition  of  the  trachea  is  not  reported. 

Experiments  of  this  kind  appear  to  be  well  worthy  of  careful  repetition. 

I  have  found  a  mixture  of  opium  and  sulphuric  aether  of  great  service  in  tranquil- 
izing  the  breathing  in  asthma.  And  in  one  case,  which  was  under  my  care  for  some 
time,  I  made  comparative  observations  respecting  opium  and  stramonium.  Bo*h 
gave  much  relief;  but  stramonium  the  most,  and  the  most  certainly,  if  it  were 
applied  in  time.  This  patient  was  in  the  habit  of  being  roused  from  sleep  by  the 
supervention  of  the  paroxysm:  and  if  he  had  the  means  of  lighting  his  pipe  in- 
stantly,  he  could  slave  the  (it  off'.  But  when  once  it  had  attained  its  full  intensity, 
he  was  nnalde  to  smoke.  Under  such  circumstances,  he  would  swallow  the  mor- 
phia and  aether;  and  the  effect  of  this  depended  also  in  a  great  measure  upon  the 
period  at  which  it  was  taken.  It  would  stop  a  commencing  paroxysm;  but  had 
liule  influence  over  one  that  was  fully  formed. 

It  has  been  suggested,  as  one  clue  towards  determining  the  particular  kind  of  casi: 
to  which  ;he  stramonium  is  applicable,  that  it  succeeds  if  it  produces  expectoration  ; 
and  not  otherwise.  But  I  doubt  about  this.  The  relief  is  sometimes  too  sudden  to 
4G  3l 


722  DISEASES    OF    THE    CESOPHAGUS. 

admit  of  its  being  so  explained.  Dr.  Forbes  quotes  the  following  passage  of  a  letter 
from  an  old  and  intelligent  asthmatic  to  himself.  "  Smoking  tobacco  or  stramonium 
is  sure  to  give  relief,  if  it  produces  expectoration  ;  and  it  will  generally  do  so  if,  the 
moment  I  awake  {i.e.,  in  the  incipient  paroxysm),  I  begin  to  smoke,  and  continue  to 
do  so  for  three  or  four  hours.  Smoking,  I  am  able  to  say,  after  fifteen  years'  prac- 
tice, and  suffering  as  much  as  mortal  can  suffer  and  not  die,  is  the  best  remedy  for 
asthma,  if  it  can  be  relieved  by  exyectoratioti.  I  have  been  in  the  hands  of  all  the 
doctors  of  the  place  for  fifteen  years  ;  and  still  I  say,  smoke.'''' 

The  lobelia  inflata  has  been  of  late  much  lauded  for  its  beneficial  operation  upon 
dyspncea  of  all  kinds,  and  upon  asthma  in  particular.  I  believe  its  virtues  have  been 
overrated.  It  sometimes,  like  stramonium,  has  an  almost  magical  effect ;  but  fre- 
quently it  fails  to  do  the  smallest  good  ;  and  I  know  that  sober  practitioners  who  have 
employed  it  more  than  I  have,  have  thought  that  it  may  occasion  dangerous  symptoms. 
Of  my  own  knowledge,  I  have  nothing  worth  communicating  to  you  of  this  drug. 

Strong  coffee  is  a  common  domestic  remedy  for  asthma.  The  friend  and  school- 
fellow already  mentioned  used  to  take  it  in  considerable  quantities,  and,  as  he  assured 
me,  with  very  great  benefit.  It  is  a  safe,  and  simple,  and  grateful  remedy,  and  has 
numerous  testimonies  from  medical  practitioners  in  its  favour.  But  it  is  much  less 
sure  than  the  stronger  narcotics. 

Ipecacuanha,  which  is  so  frequently  the  canse,  has  also  been  recommended  for  the 
cure  of  asthma ;  and  a  host  of  drugs  besides,  with  which  I  have  no  intention  to 
weary  you.  Among  the  rest,  the  application  of  galvanism  was  once  in  great  vogue. 
In  the  only  patient  who  ever  tried  it  under  my  own  eye,  —  and  he  insisted  upon 
being  galvanized  when  his  fits  were  quite  absent,  —  the  galvanism  broup-ht  one  on 
immediately. 

If  we  can  shorten  or  mitigate  the  paroxj'sms,  we  do  our  patient  a  most  essential 
service,  and  spare  him  a  great  deal  of  suffering.  And  during  the  intervals  between 
the  fits,  we  must  endeavour  to  prevent  their  recurrence. 

For  this  purpose,  I  can  only  just  hint  at  the  principle  upon  which  we  should  go. 
In  the  simple  form  of  the  complaint,  when  it  is  apparently  uncomplicated  with 
any  organic  disease,  we  must  caution  the  patient  against  whatever  has  a  tendency  to 
disturb  the  general  health.  He  must  be  temperate  in  all  things  ;  he  must  pay  atten- 
tion to  the  regulation  of  his  digestive  organs;  he  must  discover  what  kind  of  situa- 
tion suits  him  best ;  and  avoid  those  which  experience  has  shown  to  disagree  with 
him.  And  if  any  one  remedial  measure  be  likely  to  fortify  him  against  his  malady, 
I  believe  that  measure  will  oftenest  be  found  in  the  shower-bath,  employed  in  the 
way  which  I  formerly  recommended. 

If  the  asthma  occurs  in  connection  with  any  obvious  pulmonary  or  cardiac  disease, 
we  must,  in  addition  to  the  means  I  have  now  been  adverting  to,  apply  ourselves  to 
the  mitigation  of  such  superadded  disease.  And  in  respect  to  this  I  have  nothing 
more  to  offer. 

I  go  next  to  the  morbid  conditions  of  the  oesophagus,  so  far  as  they  concern  the 
physician  ;  and  these  morbid  conditions  are  not  many.  The  cesophagus  lies  partly 
in  the  chest,  and  partly  in  the  belly,  and  therefore  may  very  properly  close  the  sub- 
ject of  thoracic  diseases,  and  introduce  those  of  the  abdomen. 

The  oesophagus  is  less  liable  to  disease  than  any  other  part  perhaps  of  the  ali- 
mentary canal.  It  differs  in  structure  somewhat  (as  you  know)  from  all  other  parts. 
Its  mucous  membrane  is  provided  with  a  thick  epithelium,  which  extends  a  httle 
beyond  the  cardiac  orifice  of  the  stomach.  Beneath  lies  a  dense  web  of  areolar 
tissue,  and  two  layers  of  muscular  fibres ;  the  one  layer  being  disposed  circularly 
around  the  tube — the  other  longitudinally,  in  the  direction  of  its  axis.  In  some  cases 
there  are  pouches  found  in  the  sides  of  the  cesophagus,  formed  apparently  by  a  kind 
of  hernia  of  the  mucous  membrane,  between  the  separated  fibres  of  the  muscular 
coat.  These  are  not  common,  however,  and  scarcely  worth  mentioning,  except  that 
their  existence  has  been  supposed  to  have  a  possible  connection  with  a  curious  phe- 
nomenon, peculiar  to  some  persons;  the  power,  viz.,  of  ruminating ;  the  power  of 
cringing  into  the  mouth  again,  by  a  voluntary  effort,  food  which  has  been  for  some 


DISEASES  OF  THE  CESOPHAGUS.  723 

time  swallowed,  as  cows,  and  the  rest  of  the  ruminantia  do.  There  are  but  few 
individuals  of  the  human  species  who  possess  this  faculty ;  there  are  but  few  who 
have  appendices  to  their  oesophagus.  Whether  the  phenomena  in  question  belongs 
to  these  last  few  has  never  been  determined ;  but  as  the  possible  connection  of  the 
two  circumstances  has  been  suggested,  it  is  well  for  you  to  be  aware  of  it,  that  you 
may  refute  or  verify  the  notion,  in  case  you  ever  have  the  fortune  to  examine  the  dead 
body  of  a  person  who  had  the  power  of  ruminating. 

The  covering  of  cuticle  protects  the  oesophagus  from  the  injurious  influence  of 
matters  passing  over  it,  which  might  otherwise  be  hurtful.  The  morbid  state  for 
which  we  are  most  often  consulted  is  stricture,  actual  or  spasmodic.  I  believe  that 
the  oesophagus  is  very  little  subject  to  inflammation,  except  from  mechanical  violence 
or  chemical  injury.  I  have  seen  a  few  cases,  however,  in  which  I  inferred  a  spon- 
taneous inflammatory  condition  of  the  tube,  from  the  symptoms  complained  of; 
which  were  a  sense  of  heat  and  pricking  exactly  in  the  course  of  the  oesophagus, 
and  felt  between  the  shoulders,  and  precisely  in  the  part  (the  patients  said)  where  a 
potato,  swallowed  too  hot,  gives  pain  while  it  is  descending  into  the  stomach.  With 
these  symptoms  there  was  some  degree  of  dysphagia,  not  explained  by  anything 
visible  in  the  throat  or  pharynx :  and  some  degree  of  fever.  In  all  the  instances  of 
this  kind  that  I  have  met  with,  the  symptoms  have  yielded  in  a  ffew  days  to  absti- 
nence, purgatives,  and  the  application  of  leeches  along  the  track  of  the  oesophagus. 

This  part  of  the  alimentary  canal  often  suffers  severe  injury  from  the  deglutition 
of  certain  poisons,  especially  the  corrosive  poisons ;  the  strong  mineral  acids,  'or  ex- 
ample, or  the  caustic  alkalies.  We  have,  in  the  museum  of  the  college,  some  very 
interesting  specimens  of  the  effects  of  these  destructive  substances.  Sometimes, 
when  the  quantity  of  the  poison  has  been  small,  and  its  transit  rapid,  the  cuticular 
hning  alone  of  the  gullet  is  destroyed.  It  is  shrivelled  up,  broken  into  fragments, 
abraded.  At  other  limes,  the  subjacent  textures  are  affected,  and  ulceration  takes 
place,  which  at  length  heals,  and  leaves  a  permanent,  and  generally  a  progressive 
constriction  of  the  oesophagus ;  and  sometimes  the  whole  of  the  internal  membranes 
slough  away,  and  are  discharged  in  one  continuous  tube,  from  the  mouth ;  and  yet 
the  patient  survives  for  some  time.  My  colleague.  Dr.  Wilson,  had  a  case  of  that 
kind.  The  patient,  a  young  woman,  swallowed  about  a  tablespoonful  of  oil  of  vitriol. 
A  week  afterwards,  she  brought  up,  during  a  paroxysm  of  choking  cough,  a  com- 
plete cast  of  the  gullet,  with  ragged  ends  ;  or,  rather,  the  gullet  itself.  Some  of  the 
muscular  fibres  of  the  oesophagus  were  plainly  visible  on  the  outside  of  this  tubular 
slough,  in  its  recent  state.  She  lived  eleven  months  afterwards,  swallowing  all  that 
time  with  difficulty  and  pain,  and  subsisting  on  slops  and  soft  food.  Yet  at  one  pe- 
riod she  certainly  gained  flesh.  After  her  death,  the  channel,  as  it  remained  after 
the  injury,  was  taken  out  and  examined.  They  are  both  before  you — the  original 
slough,  and  the  ultimate  gullet.  The  latter  was  formed  by  a  surface  which  consisted 
of  an  irregular  cicatrix.  The  tube  was  contracted  considerably  in  the  lower  two- 
thirds  of  its  course. 

When  patients  have  sufl^ered  inflammation  and  ulceration  of  the  oesophagus  from 
these  causes,  and  do  not  perish  at  the  time,  they  are  very  liable  indeed  to  hfy^e  their 
existence  abridged  by  the  occurrence  of  stricture  of  the  gullet,  which  goes  on  slowly 
increasing  until  no  food  can  pass  it,  and  then,  of  course,  the  patient  dies  of  starvation. 
I  show  you  here  an  cesophagus  taken  from  a  man  whose  case  I  had  opportunities  of 
observing  from  the  beginning.  He  was  under  the  care  of  Dr.  Macmichael,  in  th& 
Middlesex  Hospital.  He  was  brought  there  in  November,  1830,  having  swallowed, 
half  an  hour  before,  a  solution  of  the  impure  carbonate  of  potass,  which  had  been 
made  for  the  purpose  of  cleaning  paint,  and  which  he  had  mistaken  for  beer.  Not 
more  than  a  tablespoonful  passed  the  fauces,  and  probably  none  of  the  poison  reached 
the  stomach.  He  suffered  severely,  and  was  in  considerable  peril  for  several  days, 
in  consequence  of  inflammation  of  the  fauces  and  epiglottis ;  but  this  gradually  sub 
sided,  and  he  went  out  apparently  well.  From  what  I  knew  of  the  result  of  such 
cases,  I  ventured,  however,  to  predict  that  this  man  would,  sooner  or  later,  come  back 
with  stricture  of  the  oesophagus.     He  had  always  pointed  out  a  spot  about  half-wav 


724  DISEASES   OF   THE   CESOPHAGUS. 

down  the  sternum,  where  he  said  the  oil  of  tartar  had  caused  him  extreme  pain  at 
the  very  first,  and  below  which  he  had  not  felt  it. 

Accordinglj^  I  was  not  surprised  to  see  the  poor  fellow  at  the  hospital  in  February, 
1834,  attending  as  an  out-patient.  He  came  there,  he  told  me,  because  in  eating 
some  soup  he  had  accidentally  swallowed,  without  chewing  it,  a  piece  of  carrot, 
which  lodged  in  its  way  down,  and  which  it  became  necessary  to  push  onwards  into 
the  stomach  by  means  of  a  probang.  Morsels  of  food  had  stuck  in  the  same  spot 
before ;  and  it  was  the  very  spot  where  he  felt  the  efTects  of  the  caustic  at  the  time 
of  the  accident.  He  looked  tolerably  stout  and  healthy ;  but  said  that,  since  swal- 
lowing the  potass,  he  had  never  been  the  man  he  was  before. 

He  continued  to  make  his  appearance,  from  time  to  time,  at  the  hospital,  with 
similar  symptoms,  till  the  5th  of  last  December  (1836),  when  he  was  brought  there 
insensible,  and  evidently  dying.  We  could  obtain  no  satisfactory  account  of  his 
recent  symptoms.  He  had  the  mark  of  a  blister,  however,  on  his  left  side ;  and 
upon  closely  examining  him,  it  was  plain  that  that  side  was  full  of  fluid.  It  was 
perfectly  motionless  in  respiration;  it  was  palpably  larger  than  the  right  side;  it 
yielded  everywhere  a  dull  sound  on  percussion ;  and  no  vesicular  breathing  w^hat- 
ever  could  be  heard  there  by  the  ear.  The  respiration  on  the  right  side  was  puerile  ; 
and  the  beating  of  his  heart,  with  a  systolic  bellows  sound,  was  audible  on  the  right 
of  the  sternum. 

Although  I  was  certain  that  the  left  pleura  was  full  of  liquid  of  some  kind,  I  did 
not  have  the  thorax  punctured ;  because,  in  the  first  place,  he  was  manifestly  in 
articulo  mortis,  and  I  thought  that  his  death,  which  was  certain,  might  be  attributed 
to  the  operation ;  and  secondly,  because  he  was  not  dying  of  suffocation.  His 
breathing  was  not  laborious  or  much  distressed  ;  but  he  was  dying  of  coma,  and  his 
extremities  were  already  cold,  and  his  pulse  was  fluttering.  I  conjectured  that  an 
ulcer  of  the  oesophagus  had  made  its  way  into  the  pleura,  and  caused  inflammation 
there.     But  my  conjecture  was  wrong. 

I  will  mention  the  main  particulars  of  the  examination  of  the  dead  body,  because 
the  case  was,  in  several  respects,  an  interesting  one. 

There  was  a  considerable  quantity  of  serous  fluid  in  the  meshes  of  the  pia  mater, 
bent-ath  the  arachnoid ;  and  there  was  some  liquid  of  the  same  kind  in  the  lateral 
ventricles.  No  other  diseased  condition  could  be  detected  in  the  brain.  The  effu- 
sion was  sufficient,  supposing  it  to  have  come  on  suddenly,  to  explain  the  coma. 

I  had  the  ribs  sawn  away  on  the  right  side,  leaving  their  cartilages  attached  to  the 
sternum  ;  and  then  we  saw  plainly  that  the  heart  and  mediastinum  were  thrust  over, 
about  four  inches  by  measurement,  beyond  the  mesial  line  on  the  right  side.  The 
body  was  on  its  back.  It  was  easy  to  perceive  how  a  pleura  thus  full  of  fluid  must 
oppress  the  lung  of  the  other  side,  especially  when  assisted  by  the  force  of  gravity. 
The  left  cavity  was  distended  by  a  grayish-coloured  and  most  ofTensive  fluid,  of  the 
consistence  of  gruel;  the  pleura  pulmonalis  was  covered  by  a  layer  of  coagulable 
lymph;  and  the  lung  was  flattened  against  the  vertebral  column.  AVe  could  not 
discover  any  communication  between  the  cavity  of  the  pleura  and  the  oesophagus  or 
air-tubes. 

About  the  middle  part  of  the  oesophagus  there  was  a  distinct  stricture,  occupying 
about  half  an  inch  of  the  tube.  Through  this  portion  it  was  impossible  to  push 
one's  little  finger,  which  elsewhere  found  a  loose  and  ready  passage. 

In  this  case,  the  man  did  not  die  of  the  stricture  ;  but  he  w'ould  have  done  so,  had  ' 
not  another  disease  carried  him  off.  I  do  not  know  why  the  constriction,  after  it  has 
once  taken  place,  should  go  on  continually  increasing ;  yet  it  seems  to  be  so.  In 
his  Surgical  Observations,  Sir  Charles  Bell  mentions  three  cases  like  that  just  de- 
scribed. In  one  of  them,  where  soap-lees  had  been  the  substance  swallowed,  death 
took  place  by  starvation  from  stricture  of  the  gullet,  twenty  years  afterwards ;  and 
Sir  C.  Bell  had  no  doubt  that  the  stricture  originated  in  the  chemical  injury  inflicted 
by  tne  soap-lees.. 

When  the  symptoms  of  stricture  come  on  in  these  cases,  physic  can  do  almost 
nothing      Surgeons  pass  bougies  into  the  gullet,  and  attempt  to  dilate  the  strictured 


DISEASES    OF    THE    CESOPHAGUS.  725 

portion,  or  to  prevent  any  further  narrowing.  But  this  expedient  is  usually  of  tem- 
poraiy  benefit  only,  and  the  patient  dies  at  last  of  inanition.  His  miserable  existence 
may  perhaps  be  protracted  a  httle  by  injecting  nutritive  enemata  into  the  rectum. 
Sometimes  the  oesophagus  ulcerates  through,  and  a  communication  is  formed  between 
it  and  the  neighbouring  parts. 

But  the  (Esophagus,  like  the  urethra,  and  like  the  bronchial  tubes, — like  every 
canal,  indeed,  in  the  living  body,  that  is  surrounded  by  circular  muscular  fibres, — is 
liable  to  temporary  constriction  and  closure,  by  the  spasmodic  action  of  its  own  mus- 
cles ;  and  this  affection  is,  of  course,  a  far  less  formidable  one  than  the  last. 

Patients  who  are  subject  to  spasmodic  stricture  of  the  (Esophagus  experience  occa- 
sionally, in  some  point  or  other  of  that  tube,  a  sensation  as  if  there  were  a  knot ;  or 
sometimes  a  feeling  as  if  some  solid  substance  was  ascending  from  the  stomach 
towards  the  pharynx.  If  they  happen  to  be  then  engaged  in  eating,  the  morsels  of 
food,  after  mastication,  readily  pass  the  pharynx ;  but,  at  a  certain  distance  down  the 
gullet,  they  stop,  and  occasion  pain  which  is  felt  between  the  shoulders,  or  distinctly 
in  the  passage  itself.  Great  anxiety  and  distress  accompany  this  stoppage,  and  the 
food  is  often  rejected  by  a  reversed  action  of  the  (Esophagus. 

The  symptoms,  in  fact,  are  identical  with  those  which  result  from  permanent  stric- 
ture of  the  gullet,  except  that  they  are  not  permanent.  When  the  stricture  is  or- 
ganic and  abiding,  the  symptoms  occur  during  or  after  every  meal.  When  it  is 
simply  spasmodic,  they  come  and  go,  capriciously,  we  often  cannot  conjecture  why 
or  wherefore ;  after  the  fashion  of  other  spasmodic  ailments. 

Spasmodic  stricture  may  be  independent  of  any  disease  of  structure  in  any  part 
of  jhe  body ;  but  it  is  of  some  importance  to  be  aware  that  it  may  also  be  symp- 
tomatic of  very  serious  organic  changes.  Mr.  Mayo  relates  the  case  of  a  young 
man  "  who  had  difficulty  of  swallowing ;  he  could  get  diDwn  liquid  food  only  ;  and 
that  not  without  an  effort.  A  bougie  being  introduced,  some  resistance  was  found  at 
the' upper  opening  of  the  (Esophagus,  but  it  yielded  :  the  resistance  was  spasmodic, 
and  depended  upon  neighbouring  irritation  caused  by  ulceration  in  the  interior  of 
the  larynx.  The  use  of  the  bougie  for  a  few  days,  with  appropriate  remedies  to  the 
larynx,  removed  the  dysphagia." 

The  purely  spasmodic  cases  occur  principally  in  persons  of  a  movable  constitu- 
tion :  in  young  women  whose  uterine  functions  are  deranged,  and  who  are  liable  to 
hysteria.  The  remedies  for  hysteria  will  prove  remedies  for  the  spasm  of  the  oeso- 
phagus also.  And  whatever  is  calculated  to  excite  ordinary  hysterical  symptoms, 
•  whatever  tends  to  render  the  system  weak  and  irritable,  will  lend  to  aggravate  the 
oesophageal  stricture.  I  alluded  to  such  cases  in  a  former  lecture.  I  give  you  ano- 
ther, related  by  Sir  Benjamui  Brodie.  A  lady  consulted  him,  unable  to  swallow  the 
smallest  morsel  of  solid  food  ;  and  swallowing  liquids  not  without  great  difficulty. 
The  symptoms  had  been  coming  on  upwards  of  three  years.  A  full-sized  (Esopha- 
gus bougie  being  introduced,  entered  the  stomach  without  meeting  the  slightest 
impediment.  This  lady's  iace  was  pale  and  bleached  :  her  feet  were  ojdemalous. 
She  had  long  laboured  under  internal  piles,  from  which  repeated  discharges  of  blood 
had  taken  place.  Under  the  use  of  remedies  which  reheved  the  piles  and  the  bleed- 
ing, the  difficulty  of  swallowing  went  away. 

It  is  a  singular,  and  it  might,  if  more  frequent,  be  a  puzzling  circumstance,  that 
very  nearly  the  same  symptoms  which  occur  when  the  esophagus  is  permanently  or 
temporarily  constricted,  happen  also  sometimes  under  a  totally  opposite  condition  of 
that  tube ;  I  mean  its  dilatation  into  a  large,  inelastic,  inert  bag.  One  remarkable 
example  of  this  I  witnessed  in  a  woman  whom  I  attended  in  conjunction  with  Mi. 
Mayo,  some  years  ago,  in  the  Middlesex  Hospital.  The  case  has  been  fully  de 
scribed  by  Mr.  Mayo,  in  the  third  volume  of  the  Medical  Gazette ;  and  more  briefly 
in  his  Oullbics  of  Pathology.  She  was  thirty-three  years  old.  She  was  Drought 
to  the  Hospital  in  a  state  of  extreme  feebleness  and  emaciation.  They  who  brought 
her  said  that  for  the  preceding  month  she  appeared  to  keep  down  nothing.  What 
she  took  as  food  seemed  to  her  to  stop  in  the  gullet;  and,  after  a  few  minutes,  it 
leturned.  A  large  ccsophagus  bougie  passed  readily  into  the  stomach.  She  could 
swallow  liquids  more  easily  than  solid  food.    When  she  look  a  small  quantity,  it  did 

3l3 


726  DISEASES    OF    THE    CESOPHAGUS. 

not  feel  to  her  as  if  it  reached  the  stomach  ;  and  in  three  or  four  minutes  it  was  inva- 
riably rejected.  The  vomiting  was  not  preceded  by  nausea,  although  in  its  progress 
it  had  the  appearance  of  ordinary  retching.  She  craved  for  food  and  drink,  and 
seemed  literally  starving.  The  complaint  had  begun  ten  years  before,  during  her 
pregnancy,  and  had  gradually  got  worse.  The  belly  was  so  shrunk  that  the  umbi- 
licus was  not  more  than  an  inch  distant  from  the  spine.  There  was  no  enlargement 
nor  hardness  about  the  stomach  ;  no  particular  tenderness  on  pressure  of  the  epi 
gastrium  ;  nor  any  uneasiness  there.  She  died,  utterly  extenuated,  sixteen  days  after 
her  admission. 

The  stomach  was  found  small,  and  contracted  at  its  middle  to  the  breadth  of  an 
inch  and  a  half.  The  upper  part  of  the  duodenum  was  but  half  the  ordinary  size 
of  the  ileum.     The  oesophagus  I  show  you,  turned  inside  out. 

It  is  enlarged  to  an  extraordinary  degree  of  dilatation,  as  you  perceive.  It  was 
healthy,  and  of  its  natural  size,  at  and  near  each  extremity.  Intermediately  the  lining 
tunic  was  thickened  and  opaque,  with  numerous  depressions  in  it.  The  musculai 
fibres,  which  appeared  to  have  multiplied  with  the  expansion  of  the  canal,  were  of 
their  natural  colour  and  thickness. 

Here  is  another  preparation  :  a  dilated  oesophagus  with  cancerous  degeneration  of 
the  cardiac  orifice  of  the  stomach.  I  do  not  know  its  history ;  but  the  mechanism 
of  such  dilatation  is  intelligible  enough.  The  food,  unable  to  pass  out  of  the  gullet 
into  the  stomach — or  passing  slowly  and  uncertainly — the  tube  behind  it  is  habitually 
distended,  and  loses  at  length  its  proper  contractility.  I  saw  last  summer,  in  con- 
sultation with  Mr.  Mayo,  an  old  gentleman,  of  seventy,  who,  for  two  years,  had 
experienced  difficuhy  in«getting  food  into  his  stomach.  He  would  eat  a  few  mouth- 
fuls  very  well ;  and  then,  of  a  sudden,  the  next  mouthful,  after  passing  the  pharynx, 
would  stop  just  short  of  the  stomach  ;  and  a  sensation  of  swelling  would  arise  in  the 
lovi^er  and  middle  part  of  the  cesophagus  ;  and  presently  up  the  mouthful  would  come 
again.  Sometimes,  by  waiting  quietly  a  little  while,  the  morsel  would  go  on  ;  some- 
times he  could  wash  it  forwards  by  a  gulp  or  two  of  drink  :  but  if  once  the  food  got 
fairly  into  the  stomach  he  had  no  further  trouble  with  it.  This  gentleman  had  no 
discoverable  disease  of  the  heart  or  lungs.  He  gradually  grew  worse.  At  last  he 
began  to  vomit  grumous  matters,  resembling  coffee-grounds,  and  soon  died.  He  was 
at  some  httle  distance  from  London  at  the  time,  and  the  body  was  not  (I  believe) 
examined.  I  have  no  doubt  that  he  had  malignant  disease  of  the  cardia ;  and  I 
think  it  probable  that  his  oesophagus  was  dilated.  I  had  a  female  patient  about  two 
years  ago  in  the  hospital  with  very  similar  symptoms  ;  and  her  stomach  was  found, 
to  be  full  of  cancerous  disorganization.  The  state  of  her  gullet  is  not  recorded. 
We  are  apt,  in  such  cases,  to  satisfy  ourselves  with  ascertaining  the  gastric  disease, 
without  carefully  examining  that  part  of  the  alimentary  canal  which  lies  above. 

For  maladies  like  these  medicine  has  no  cure.  Opiates  may  give  comfort,  and 
promote  the  euthanasia  :  and  that  is  all. 

[During  the  period  of  infancy,  the  mucous  membrane  of  the  cesophagus  is  not  unfrequently 
the  seat  of  inflammation,  of  a  diphtheritic,  follicular,  or  erythematic  character.  The  disease, 
however,  is  not  very  often  detected  during  the  life-time  of  the  patient,  in  consequence  of  the 
symptoms  by  which  it  is  accompanied  being  those  which  are  common  to  many  of  the  affec- 
tions of  the  earlier  months  of  existence.  In  fact,  almost  the  only  symptom  in  many  cases 
of  oesophagitis  in  the  infant  is  frequent  vomiting ;  — 'immediately  after  the  deglutition  of 
drinks,  or  of  aliments  of  any  kind,  these  are  discharged  by  vomiting,  without  having  under- 
gone any  change.  The  infant  usually  refuses  the  breast  and  fluids  generally,  evidently  from 
the  pain  excited  by  the  act  of  deglutition;  occasionally,  however,  he  will  swallow,  without 
much  difficulty,  half  solid  aliment  when  given  in  small  quantities  at  a  time.  If  the  stomach 
be  affected  with  inflammation  at  the  same  time  with  the  cesophagus,  the  undigested  food  and 
drinks  discharged  by  vomiting  will  be,  occasionally,  mixed  with  the  morbid  secretions  of 
that  organ.  The  disease  is  seldom  attended  by  any  degree  of  febrile  excitement  —  The 
infant  is,  usually,  fretful  and  restless,  and  becomes  rapidly  emaciated.  Whenever  an  infant 
iejects  the  breast,  or  any  species  of  fluid  aliment,  vomits  frequently,  and  discharges  what- 
ever he  swallows  in  the  same  state  nearly  as  when  it  was  taken,  it  is  the  duty  of  the  prac- 
titioner to  institute  a  minute  examination,  in  order  that  he  may  detect  the  inflammation  of  the 
oesophagus  if  it  exists.  It  is  probable  that  pressure  along  the  whole  track  of  the  cesophagui 
wrill  pxcit»  the  cries  of  the  child,  when  we  can  have  no  hesitation  as  to  the  diagnosis.     IC 


DISEASES    OF   THE    ABDOMEN.  727 

this  does  not  happen,  we  may  nevertheless  be  tolerably  certain  as  to  the  existence  of  the 
inflammation,  if  the  infant  be  labouring  at  the  time,  or  has  very  recently  been  labouring, 
under  one  or  other  of  the  forms  of  stomatitis.  If  the  inriammation  is  confined  entirely  to 
tlie  mucous  membrane  of  the  gullet,  and  is  not  aggravated  by  improper  food  or  drinks,  it 
will  often  subside,  after  a  few  days,  spontaneously ;  but  when  it  is  connected,  as  is  very 
generally  the  case,  with  inflammation  of  the  stomach  or  intestines,  it  is  an  atfection  diiBcult 
to  control,  and  usually  fatal.  In  perhaps  the  majority  of  cases,  oesophagitis  in  the  infant  is 
preceded  by  erythematic,  diphtheritic,  or  follicular  stomatitis. 

The  frequency  with  which  inflammation  attacks  the  mucous  membrane  of  the  CESophagus 
in  the  infant,  is  evidently  due  to  the  predisposition  which  exists,  at  this  period,  to  disease  of 
all  the  mucous  surfaces  from  their  constant  state  of  hyperssmia ;  it  is  liable  to  be  excited  by 
too  much  or  improper  food,  or  that  which  is  too  hot  or  stimulating.  In  infants  confined  to 
the  breast,  it  may  be  occasioned  by  the  bad  quality  of  the  mother's  milk,  or  by  some  tempo- 
rary morbid  change  occurring  in  the  latter  —  and  which  may  be  produced  by  a  variety  of 
causes.  CEsophagitis  has  been  known  to  result  from  the  reprehensible  nursery  practice  of 
admmistering  to  infants  infusions  of  spices,  or  even  gin  and  water,  for  the  purpose  of  expel- 
ling wind,  or  to  relieve  the  colicky  pains  with  which  they  are  so  frequently  affected.  —  In 
common  with  all  the  affections  of  the  mucous  membrane  in  early  life,  inflammation  of  the 
ossojihagus  occurs  most  frequently,  and  is  the  most  difficult  to  manage  in  infants  exposed  to 
the  baneful  influence  of  personal  and  domestic  filth,  and  a  confined  and  impure  air.  Accord- 
ing to  Billard,  tlie  aflection  of  the  gullet  is  almost  invariably  preceded  by  stomatitis — parti 
cularly,  we  may  add,  of  a  diphtheritic  or  follicular  character. 

The  pathological  changes  detected  after  death  in  cases  of  (Esophagitis,  are  stated  by  Bil- 
lard to  be  vivid  redness,  with  destruction  of  the  epithelium,  of  some  portion  of  the  mucous 
membrane  of  the  cesophagus,  especially  of  its  upper  portion;  in  some  cases,  a  curdlike  ex- 
udation, more  or  less  extensively  difl'used,  is  present ;  in  others  follicular  ulcerations  ;  a  sepa- 
ration of  portions  of  the  epithelium,  often  in  large  shreds,  is  occasionally  met  with ;  nume- 
rous red  or  dark-coloured  striae  occurring  where  the  epithelium  is  not  destroyed ;  large, 
irregular  eschars  of  a  black  colour,  with  intervals  of  deej),  bright-red  excoriations,  are  occa- 
sionally met  with,  and,  in  some  cases,  gelatinous  softening  of  nearly  the  entire  thickness  of 
the  oesophagus. 

When  'an  infant  is  affected  with  oesophagitis,  there  should  not  be  given  to  it  any  stimulat- 
ing or  hot  drinks  —  it  will  be  proper,  however,  to  supply  it,  at  short  intervals,  with  a  small 
quantity  of  some  perfectly  bland  mucilaginous  fluid,  as  gum  water,  or  an  infusion  of  the  pith 
of  sassafras,  or  of  the  inner  bark  of  the  slippery  elm,  given  cold ;  the  throat  should  be  co- 
vered externally  with  a  soft,  emollient  poultice,  especially  when  the  inflammation  of  the 
oesophagus  has  succeeded  to  stomatitis ;  a  few  grains  of  calomel  may  also  be  administered, 
and  followed  by  injections  of  milk  with  the  addition  of  sugar.  If  it  be  found  necessary,  the 
strength  of  the  infant  may  be  supported  by  injections  of  milk  and  broth,  or  milk  with  rice 
flour,  tapioca  or  arrow  root.  We  have  derived  advantage  in  cases  presenting  the  symptoms 
of  oesophagitis,  from  a  few  leeches  applied  along  the  sides  of  the  neck,  and  internally  a  tea- 
*  spoonful,  every  three  hours,  of  a  solution  of  four  grains  of  the  acetate  of  lead  in  one  ounce 
of  water,  with  the  addition  of  a  few  drops  of  strong  vinegar. — C] 


LECTURE  LXV. 

Diseases  of  the  Abdomen:  sometimes  difficult  to  identify.  Method  of  investigating 
these  diseases  ;  by  the  eye,  the  hand,  the  ear.  Inflammation  of  the  Peritoneum: 
its  symptoms;  and  causes.  Puerperal  Peritonitis.  Peritonitis  from  Perfo- 
ration. 

I  AM  about  to  consider  the  diseases  of  the  abdomen.  The  organs  contained  in 
this  cavity  of  the  body  are  not  vital  organs  in  the  same  sense  in  which  the  brain,  the 
the  heart,  and  the  lungs,  are  vital.  That  is  to  say,  the  functions  of  the  abdominal 
viscera  will  bear  to  be  suspended  for  some  considerable  time,  without  the  extinguish- 
nient  of  life.  But  these  parts  are  subject  to  numerous  diseases,  some  of  which  ait 
apt  to  be  quickly  fatal,  and  others  carry  with  them  a  vast  amount,  and  very  severe 
kinds,  of  suffering. 

The  parietes  of  the  fore  part  of  the  belly  being  soft  and  flexible,  you  might  natu 
rally  suppose  that  the  physical  morbid  conditions  of  the  organs  they  cover  would 
submit  themselves  to  an  easy  diagnosis ;  that  the  sense  of  touch,  exercised  through 


728  DISEASES    OF    THE    ABDOMEN. 

these  yielding  walls,  would  detect  alterations  of  bulk,  of  form,  or  of  place,  in  the 
subjacent  viscera,  with  much  facility  and  exactness.  But  the  truth  is,  that  since  the 
discovery  of  the  method  of  auscultation,  the  diseases  of  the  abdomen  are  much  more 
iiard  to  discriminate  than  the  diseases  of  the  thorax.  The  reason  of  this  is  to  be 
found  in  the  number  and  complexity  of  the  parts  contained  in  the  abdomen ;  the 
loose  manner  in  which  some  of  them  are  packed  ;  and  the  consequent  readiness  w'lih 
which  they  pass  out  of  their  proper  and  natural  situations.  It  is  necessary  that  I 
should  say  a  few  words,  but  I  shall  not  detain  you  long,  respecting  the  mode  of  ex- 
mniniag  the  abdomen,  with  the  purpose  of  investigating  its  diseases. 

In  the  description  of  symptoms,  we  are  often  obliged  to  speak  of  particular  por- 
tions of  the  abdomen:  and  it  will  be  of  future  convenience  to  us  if  we  make  ourselves 
acquainted,  at  starting,  with  such  a  superficial  map,  marking  out  the  topography  of 
the  belly,  as  I  exhibited  to  you  sometime  since,  in  reference  to  the  chest.  Draw  a 
horizontal  line  round  the  body,  touching  the  extremity  of  the  ensiform  cartilage;  and 
this  will  form  the  superior  boundary  of  the  abdomen,  thus  roughly  defined  for  prac- 
tical purposes.  Draw  another  such  line  round  the  body,  horizontally,  touching  the 
lower  edge  of  the  last  false  ribs  :  and  a  third  touching  the  crest  of  each  ilium.  We 
then  have  three  horizontal  zones  formed.  These  must  be  further  divided  by  vertical 
lines :  one  on  each  side  from  the  anterior  spinous  process  of  the  ilium  perpendicu- 
larly upwards.  Each  zone  will  thus  be  subdivided  into  three  regions.  The  middle 
region  of  the  upper  zone  is  the  epigastric  region  ;  on  either  side  are  the  hypovhon- 
dria.  The  middle  region  of  the  middle  zone  is  the  umbilical  region ;  the  iliac 
regions  or  the  Jlanks  lie  to  the  right  and  left  of  it.  The  hypogastric  region  is  the 
middle  region  of  the  lowermost  zone ;  and  the  inguinal  regions  are  contiguous  to  it. 
This  is  all  the  division  which  is  necessary. 

Now  independently  of  the  general  signs  of  diseases  that  have  their  seat  in  the 
abdomen,  we  are  greatly  assisted  in  many  cases  by  the  physical  signs.  I  shall  take 
a  very  brief  survey  of  the  modes  by  which  these  physical  signs  are  collected.  They 
are  derived  from  the  exercise  of  the  three  senses  of  sight,  of  touch,  and  of  hearing. 

The  sense  of  sight  suppUes,  occasionally,  very  valuable  information ;  and  in  all 
serious  and  equivocal  cases  we  must  not  dispense  with  its  use.  We  are  not,  indeed, 
to  make  an  ocular  inspection  of  the  naJced  abdomen  unnecessarily:  and  I  hold  it 
superfluous  to  admonish  you  that  when  we  do  avail  ourselves  of  that  mode  of  in- 
vestigation, especially  in  the  case  of  females,  we  are  bound  to  do  so  with  the  most 
careful  attention  not  to  ofiend  the  patient's  delicacy.  We  may  sometimes  ascertain 
all  that  is  required  concerning  the  movements,  size,  and  shape  of  the  abdomen, 
without  removing  the  under  garments. 

This  rule  applies,  indeed,  to  all  parts  of  the  body  that  are  ordinarily  covered  by 
the  dress. 

I  was  lately  consulted  by  a  lady,  who  told  me  she  had,  on  the  rear  of  her  person, 
a  painful  boil.  She  thought  any  physician  ought  to  be  competent  to  prescribe  for  a 
boil,  without  wanting  to  see  it.  But  she  seemed  very  ill,  and  her  sister  told  me  that 
the  boil  had  lasted  a  fortnight,  and  was  a  very  large  one ;  so  that  I  was  obliged  to 
press  for  an  inspection.  And  I  found — a  boil  sure  enough,  but  of  that  gigantic  and 
formidable  species  which  we  call  carbuncle. 

M.  Rostan  relates  a  case  still  more  in  point.  Going  round  the  Avards  of  his  hos- 
pital, he  came  to  an  old  woman,  who  was  complaining  of  severe  pain  in  the  abdo- 
men, towards  the  left  iliac  region.  Her  face  was  flushed,  her  skin  hot,  her  pulse 
strong  and  frequent,  her  tongue  dry ;  and  she  was  very  thirsty.  The  abdominal 
pain  was  exasperated  by  pressure,  and  by  the  movements  of  the  patient.  Upon 
these  data  Rostan  founded  his  diagnosis.  He  concluded  that  the  case  was  one  of 
acute  abdominal  inflammation  ;  and  he  prescribed  accordingly;  and  with  befitting 
energy.  One  of  the  pupils,  however,  lingered  behind  him  :  and  having  removed 
ihe  woman's  chemise,  in  order  to  examine  the  seat  of  the  pain,  he  discovered  that  all 
ihe  symptoms  proceeded  in  reality  from  a  very  harmless,  though  troublesome,  disor 
;ii'i.  herpes  zoster  ;  what  is  vulgarly  called  the  shingles. 

Vestis  adempta  est 
Qua  posita,  nudo  patuit  cum  corpore  crimen. 


PERITONITIS.  729 

In  the  second  place,  we  gather  very  important  intelh'gence  by  the  sense  of  touch. 
We  learn  the  existence  and  the  size  o^  tumours ;  we  approximate  to  a  knowledge  of 
their  nature,  whether  it  be  solid  or  fluid  ;  we  determine  whether  they  are  movable 
or  fixed,  painful  or  indolent,  hard  or  soft,  smooth  or  uneven,  pulsating  or  not.  We 
ascertain  whether  the  surface  be  hot  or  cold.  In  order  to  make  palpation  most 
effectual,  the  patient  should  be  placed  in  the  most  favourable  posture  for  its  perform- 
ance; i.  e.,  he  should  lie  on  his  back,  with  his  head  a  little  raised,  and  his  knees  up. 
In  this  position,  the  abdominal  muscles  are  relaxed  and  unstrung :  and  the  patient  is 
to  be  cautioned  not  to  do  anything  which  may  make  them  tense.  Sometimes,  in 
spite  of  this  caution,  and  in  spite,  probably,  of  the  patient's  endeavours  to  obey  it, 
the  recti  muscles  remain  so  tightly  contracted  as  to  prevent  any  satisfactory  examina- 
tion of  the  parts  beneath  them.  The  very  occurrence  of  this  instinctive  striving 
against  the  pressure  of  our  hand  may  be  taken  as  a  ground  of  suspicion  that  those 
parts  are  not  in  a  healthy  state.  We  must  take  care,  when  the  muscles  are  thus 
obstinately  rigid,  not  to  mistake  the  swelling  central  portions  of  the  recti,  or  their 
well-defined  edges,  for  tumours,  or  for  indications  of  an  enlarged  stomach  or  liver. 
By  a  peculiar  management  of  the  palpation,  we  often  satisfy  ourselves  at  once  of 
the  presence  of  liquid  in  the  cavity  of  the  peritoneum,  or  in  a  cyst:  we  obtain  that 
sensation  which  we  cdX\  fluctuation. 

The  exploration  by  the  sense  of  touch  is  very  much  aided — often  confirmed,  some- 
times corrected — by  that  which  addresses  itself  to  the  sense  of  hearing.  Sometimes 
we  listen  to  the  natural  sounds  through  a  stethoscope ;  and  we  may  thus  decide  the 
important  question,  whether  a  pulsating  tumour  be  or  be  not  an  aneurism ;  or  the 
question,  sometimes  scarcely  less  important,  whether  a  different  kind  of  tumour  en- 
closes another  hving  being  or  not.  But,  for  the  most  part,  our  information  respect- 
ing the  maladies  of  the  abdomen,  collected  by  the  sense  of  hearing,  is  obtained  by 
listening  to  sounds  which  we  ourselves  produce;  in  one  word,  hy  percussion :  and 
mediate  percussion,  percussion  performed  through  the  finger  as  a  ready  plexi meter, 
is  particidarty  applicable  to  the  disorders  of  the  abdomen.  By  this  expedient  we 
can  tell  whereabouts  the  intestines  lie ;  whether  the  parts  beneath  the  place  per- 
cussed be  hollow  and  filled  with  air,  or  solid ;  or,  though  naturally  hollow,  distended 
with  liquid.  By  making  the  patient  change  his  posture,  we  are  enabled  often, 
through  the  aid  of  percussion,  to  trace  fluid  effusions  hither  and  thither,  when  they 
have  changed  their  relative  situation,  by  reason  of  the  force  of  gravity  ;  and  then  we 
know  that  they  occupy  the  cavity  of  the  peritoneum.  All  these  points  I  pass  over 
cursoril}%  because  I  must  advert  to  them  again  when  speaking  of  particular  diseases. 
And  I  shall  proceed,  on  that  account,  without  further  delay,  to  the  consideration  of 
those  special  diseases. 

Consulting  your  convenience,  and  mj'-  own,  rather  than  any  scientific  order,  I 
shall  take,  in  succession,  the  several  parts  and  organs  contained  in  the  cavity  of  the 
belly,  and  inquire  separately  into  their  diseases ;  inflammatory,  organic,  and  func- 
tional. And  I  begin  with  the  peritoneum;  the  great  serous  sac  which  lines  and 
constitutes  the  cavity  of  the  abdomen,  and  in  which  most  of  its  viscera  are  wholly  or 
partially  folded. 

Like  the  serous  membranes  in  general,  the  peritoneum  is  very  ready  to  take  on 
inflammation,  upon  the  operation  of  certain  exciting  causes.  Acute  inflammation, 
beginning  in  one  spot,  is  almost  sure  to  transfer  itself  to  any  other  spot  that  happens 
to  lie  in  contact  with  the  first ;  and  is  very  apt  to  extend  itself  rapidly  to  the  whole 
membrane.  The  inflammation  tends  to  the  effiision  of  serum,  and  of  coagulable 
lymph  ;  it  is  of  the  adhesive  kind  :  and  its  efiects  are  those  of  distending  the  peri- 
toneal cavity  with  fluid — or  of  gluing  its  opposite  surfaces  together  so  as  to  obliterate 
that  cavity — or  of  forming  partial  attachments.  In  all  these  respects,  the  analogy 
between  inflammation  of  the  peritoneum  and  inflammation  of  the  stious  membranes 
of  the  thorax — the  pleura,  and  the  pericardium — is  perfect:  and  therefore  these  aru 
points  which  I  shall  not  dwell  upon,  except  where  specific  differences  arise,  from 
original  diversities  of  structure  or  function  in  the  parts  affected.  1  may  observe  at 
once,  that  the  morbid  conditions  which  are  apt  to  remain  after  peritonitis,  are  some- 
times, hke  those  which  follow  pericarditis,  inceptive  of  further  disease;  sometimes 


730  DISEASES    OF    THE    ABDOMEN. 

like  those  of  the  pleurte,  final,  and  limited  to  their  hmnediate  influence  upon  the 
health  and  comfort  of  the  individual :  or  even  protective  against  some  worse  evil. 

Acute  inflammation  of  the  peritoneum  is  characterized  by  pain  in  the  abdomen, 
increased  on  pressure,  and  attended  with  fever.  But  as  these  symptoms  are  common 
to  almost  all  the  inflammatory  conditions  of  the  parts  contained  in  the  abdomen,  we 
must  look  for  more  distinctive  circumstances.  CuUen  defines  the  disease  in  this 
manner:  "Pyrexia:  dolor  abdominis,  corpore  erecto  auctus,  absque  propriis  aliarum 
phlegmasiarum  abdominalium  signis."  He  concludes  that  it  is  the  peritoneum 
simply  that  is  inflamed,  when  the  specific  symptoms  that  indicate  inflammation  of 
particular  organs  are  wanting.  It  is  not  inflammation  of  the  liver,  for  there  is  no 
pain  of  the  right  hypochondrium  in  particular,  increased  by  lying  on  either  side,  no 
pain  of  shoulder,  no  jaundice,  no  vomiting,  perhaps  :  neither  is  it  inflammation  of  the 
bowels  or  stomach,  for  there  is  no  disturbed  function  of  the  alimentary  canal  to 
denote  such  inflammation. 

The  pain,  Cullen  says,  is  increased  if  the  patient  sits  up.  He  might  have  added, 
that  it  is  increased  also  by  drawing  a  long  breath,  by  coughing,  sneezing,  or  strain- 
ing, and  by  pressure  made  with  the  hand  upon  the  belly.  All  these  circumstances 
resolve  themselves  into  the  same  obvious  principle  ;  viz.,  that  of  pressure  aggravating 
the  pain  of  an  inflamed  membrane.  The  erect  posture  throws  the  weight  of  the 
viscera  upon  the  peritoneum,  and  tends  to  stretch  parts  of  it.  The  pain  occasioned 
by  pressure  is  often  excessive ;  the  patient  cannot  even  bear  the  weight  of  the  bed- 
clothes. Though  the  pain  is,  at  first,  sometimes  confined  to  particular  spots,  yet  it 
generally  soon  extends  over  the  whole  abdomen  ;  and  this  is  a  circumstance  of  some 
importance  as  respects  the  diagnosis.  But  before  the  inflammation  has  become  uni- 
versal, while  it  is  yet  restricted  to  particular  spots,  the  pain  is  often  much  increased 
by  pressure  made  on  other  parts  of  the  abdomen.  In  truth,  in  a  shut  sac  of  that 
kind  you  cannot  compress  any  one  part  without  exercising  pressure  indirectly  upon 
every  other  part.  The  patient  cannot  sit  up,  nor,  usually,  lie  on  his  side ;  but 
remains  always  upon  his  back :  in  which  position  you  will  perceive  that  the  pres- 
sure made  by  the  viscera  upon  the  peritoneum  is  a  minimum  ;  is  the  least  possible. 
He  draws  up  his  legs  too.  And  he  lies  still ;  for  movements  cause  pressure,  and 
therefore  pain.  The  descent  of  the  diaphragm  in  inspiration  presses  also  upon  the 
membrane ;  and  the  patient  not  only  complains  of  the  pain  thus  produced,  but  in 
order  to  avoid  it  gets  into  a  way  of  breathing  by  means  of  his  ribs  only.  So  that 
upon  inspection  of  the  abdomen,  it  is  perceived  that,  instead  of  rising  and  sinking 
alternately  in  respiration,  it  remains  motionless.  The  phenomena  of  thoracic  respi- 
ration is  a  symptom  of  peritonitis.  The  breathing  is  necessarily  shallow  in  these 
cases,  and  less  air  being  admitted  at  each  movement  of  respiration,  the  number  of 
those  movements  therefore  is  increased :  the  breathing  is  quick  as  well  as  shallow : 
there  are  perhaps  forty,  or  even  sixty  respirations  executed  in  a  minute,  instead  of 
-eighteen  or  twenty.  When  we  find  a  person  lying  only  on  his  back,  with  his  knees 
up,  breathing  in  this  manner,  and  complaining  of  tenderness  of  the  belly  on  pressure, 
and  feverish  withal,  we  may  be  tolerably  sure  (unless  that  person  be  an  hysterical 
girl)  that  the  peritoneum  is  inflamed,  whatever  else  may  be  the  matter. 

The  pain  in  peritonitis  is  generally  sharp,  cutting,  or  pricking  in  its  character 
And  independently  of  any  pressure  made  from  without,  or  caused  by  any  change 
of  posture,  this  pain  is  apt  to  be  much  aggravated  at  intervals.  This,  when  the 
inflammation  is  general,  is  sometimes  owing  to  the  passage  of  flatus  along  the  bowel, 
partially  distending  it,  and  stretching  the  inflamed  membrane  ;  so  that  here  also,  it 
is  r^^aWy  pj-essure  which  augments  the  pain. 

When  you  explore  the  abdomen  by  pressure,  take  care  not  to  make  the  examina- 
tion unnecessarily  a  source  of  pain.  Press  first  gently,  with  the  open  flat  hand  ; 
and  keep  your  eyes  on  the  patient's  face  at  the  same  time.  You  will  perceive  by 
the  expression  of  his  features,  Avhether  you  are  hurting  him  ;  even  before  he  takes  to 
verbal  complaining. 

Acute  peritonitis  generally  sets  in  with  well-marked  symptoms  :  sharp  rigors,  and 
nigh  fever,  with  a  hard  and  strong  pulse,  which  very  soon  becomes  frequent,  and 
often  oecomes  feeble,  and  is  sometimes  small  from  the  very  first.     After  the  disease 


PERITONITIS.  731 

has  continued  for  a  certain  time,  it  is  attended  with  tension  and  swelling  of  the  be^Iy. 
The  tension  and  swelhng  are  tympanitic  in  the  earlier  stages.  You  learn  this  with 
certainty  by  mediate  percussion.  As  the  disease  advances,  the  enlargement  is  some- 
times occasioned,  in  part  at  least,  by  the  effusion  of  serum  :  of  the  presence  of  which 
infallible  indications  may  be  obtained  by  the  joint  employment  of  the  finger  and  the 
ear  ;  by  palpation  and  auscultation  ;  and  by  noticing  the  difference,  as  to  the  results 
of  percussion,  caused  by  alterations  of  posture. 

When  the  disease  is  advancing  towards  a  fatal  termination,  the  abdomen  often  be- 
comes greatly  distended  ;  the  pulse  is  exceedingly  frequent  and  feeble  ;  the  counte- 
nance (which  in  all  the  stages  of  the  disorder  is  expressive  of  anxiety)  becomes 
pincheu  and  ghastly  ;  cold  sweats  ensue  ;  and  the  patient  dies  at  length  by  asthenia : 
death  beginning  at  the  heart.     The  mind  is  often  clear  to  the  very  last. 

Such  is  the  ordinary  course  of  peritonitis.  But  other  symptoms,  which  I  have  not 
mentioned,  do  sometimes  accompany  it ;  arising  out  of  the  peculiar  circumstances  of 
different  cases.  Thus  sickness  and  vomiting  occur  very  frequently ;  and  these 
symptoms  are  supposed  to  denote  that  the  peritoneal  covering  of  the  stomach  is 
especially  implicated :  but  I  question  whether  this  is  always  a  correct  inference. 
When  strangury  happens,  which  is  not  uncommon,  that  part  of  the  membrane 
which  is  reflected  over  a  portion  of  the  bladder  is  probably  involved  in  the  mischief. 
Inflammation  of  that  part  of  the  peritoneum  which  lies  in  the  immediate  vicinity  of 
the  kidneys,  may  cause.  Dr.  Abercrombie  thinks,  suppression  of  urine. 

Peritonitis  is  apt  to  arise  under  the  influence  of  cold,  like  other  internal  inflamma- 
tions :  especially  when  cold  combined  with  moisture  is  applied,  under  certain  condi- 
tions, to  the  surface  of  the  body.  It  is  occasionally  produced  by  mechanical  inju- 
ries inflicted  upon  the  abdomen.  It  often  prevails  epidemically,  and  produces 
great  moriality,  among  parturient  women :  and  there  is  ground  for  believino-  that 
this  form  of  the  disorder  is  propagable,  and  often  propagated,  by  contagion.  Be- 
sides this,  a  very  terrible  kind  of  peritonitis  is  a  frequent  result  of  the  extravasation 
of  the  contents  of  the  alimentary  canal,  or  of  urine,  or  of  bile,  into  the  cavity  of  the 
membrane ;  through  apertures  that  are  sometimes  made  by  external  violence,  but 
more  often  are  the  consequences  of  the  progress  of  previously-existing  disease. 

I  shall  make  a  few  observations  in  respect  to  one  or  two  of  these  points,  and  but 
a  few. 

That  awful  disorder,  puerperal  fever,  is  more  frequently  accompanied  with  hiflam- 
mation  of  the  peritoneum,  than  with  any  other  inflammation.  This  variety  of  peri- 
tonitis necessarily  engages  the  attention  of  the  accoucheur;  and  it  doubtless  is  more 
fully  considered  in  the  lectures  of  the  Professor  of  Midwifery  than  I  propose  to 
consider  it.  Indeed,  if  you  would  understand  puerperal  fever  as  a  whole :  its  shiftincr 
aspects,  its  single  source,  and  its  appropriate  management ;  you  must  study  Dr.  Fer- 
guson's masterly  and  conclusive  essay  on  that  subject. 

Of  forty-four  fatal  cases  of  well-marked  puerperal  fever  which  fell  under  the 
observation  of  Dr.  Robert  Lee,  and  in  which  the  bodies  were  carefully  examined, 
the  peritoneum  and  uterine  appendages  were  found  inflamed  in  thirty-two  :  i.  e.,  in 
eight  cases  out  of  every  eleven.  The  inflammation  commences,  no  doubt,  in  the 
uterine  portion  of  the  membrane,  and  spreads  thence  over  the  larger  part  of  its  sur- 
face. Now  this  peritoneal  inflammation,  occurring  in  women  after  childbirth,  may 
be  accidental  and  sporadic  ;  or  it  may  prevail  in  a  district  epidemically.  And  a  most 
dreadful  and  deadly  affection  it  may  then  become.  In  either  case,  the  peritonitis 
may  commence  a  few  days,  or  even  a  few  hours  after  parturition.  The  pain  gene- 
rally begins  low  in  the  abdomen,  in  the  situation  of  the  uterus ;  which  may  be  felt 
through  the  abdominal  parietes,  and  is  tender  on  pressure :  but  soon  a  universal 
swelling  takes  place,  and  the  womb  can  no  longer  be  distinguished.  Cases  of  this 
kind  arise  sometimes,  apparently  from  cold  ;  and  exhibit  no  peculiar  feature.  It  is 
just  what  we  might  expect  when  a  female,  in  a  state  of  weakness  and  irritability, 
happens  to  be  exposed  to  the  exciting  causes  of  inflammation.  In  such  a  state,  a 
less  degree  of  the  exciting  cause  would  be  sufficient  to  produce  the  inflammation . 
and  probably  a  less  degree  of  inflammation  may  prove  fatal. 

But  when  peritonitis  is  frequent  among  women  after  childbirth  in  a  particular 


732  DISEASES    OF    THE    ABDOMEN. 

neighbourhood,  or  in  a  lying-in  hospital,  it  is  marked  by  greater  depression  of  the 
vital  powers,  and  runs  a  more  irregular  course.  The  nervous  system  suffers,  the 
sensorium  is  apt  to  become  affected,  and  the  complaint  assumes  rather  the  character 
of  continued  fever  than  of  simple  inflammation  of  the  peritoneum.  And  no  wonder ; 
since  this  variety  of  peritonitis  forms  part  of  a  disease  which,  like  continued  fever, 
is  a  general  disease,  and  results  from  contamination  of  the  blood.  This,  Dr.  Fergu- 
son has  clearly  established.  The  contamination  may  originate  in  the  body  of  the 
patient  herself:  the  noxious  material  being  supplied  by  putrid  coagula,  or  portions 
of  placenta,  remaining  in  the  uterus.  Or  some  of  the  products  of  inflammation  may 
enter  the  blood-vessels,  and  constitute  the  poison.  And  this  it  may  be  difficult  or 
impossible  to  prevent.  But,  on  the  other  hand,  the  contamination  may  arise  in  the 
way  of  contagion :  this  horrible  malady  may  be  communicated  from  one  lying-in 
\Vornan  to  another  by  the  intervention  of  a  third  person ;  and  doubtless  it  is  so 
carried  and  propagated,  in  many  instances,  by  midwives  and  accoucheurs.  Now 
this  source  of  the  disorder  may  be  obviated ;  and  therefore  it  is  of  the  utmost  im- 
portance that  it  should  be  clearly  recognized,  in  order  that  it  may  be  carefully  pro- 
vided against. 

You  must  know,  however,  that  great  differences  of  opinion  have  existed,  and,  I 
believe,  still  exist,  in  respect  to  the  contagious  quality  of  certain  forms  of  peurperal 
peritonitis  ;  just  as  great  differences  exist  as  to  the  contagiousness  of  continued  fever, 
of  cholera,  of  the  plague.  There  are  parties  who  regard  the  whole  notion  of  con- 
tagion as  a  mere  bugbear:  and  there  are  others  who  embrace  in  their  allegations  of 
contagion  many  more  diseases  than  can  be  proved  to  be  so  caused.  Tlie  same 
strong  assertions  are  made,  the  same  kind  of  eagerness  is  displayed  (the  same  party- 
spirit,  I  had  almost  said)  as  mark  the  strife  of  ordinary  politics.  It  is  our  serious 
duty,  however,  to  inquire  what  is  the  truth  in  this  matter:  for  the  safety  of  indivi- 
duals, and  the  happiness  of  whole  families,  may  often  hang  upon  our  opinions.  I 
must  trouble  j'ou,  therefore,  with  a  few  facts  that  bear  closely  upon  the  subject. 

We  possess  some  valuable  and  highly  instructive  accounts  of  epidemics  of  the 
kind  I  am  alluding  to.  One  by  Dr.  Gordon,  on  the  epidemic  peritonitis  after  child- 
birth, which  took  place  at  Aberdeen,  in  the  years  1789,  1790.  Another  by  Mr.  Hay, 
on  that  Avhich  happened  at  Leeds  from  1809  to  1812.  And  a  third  by  the  late  Dr. 
Armstrong,  on  that  which  was  observed  in  Sunderland  and  its  neighbourhood  in 
1813.  Dr.  Robert  Lee  has  also  collected  some  very  interesting  facts  in  reference  to 
the  spreading  of  thp  peritonitis  by  contagion.  Dr.  Gordon  had,  he  affirms,  unques- 
tionable proof  that  the  cause  of  the  disease  was  a  specific  contagion,  and  that  it  did 
not  arise  from  any  noxious  constitution  of  the  atmosphere.  The  disease  seized  such 
women  only  as  were  visited  or  delivered  by  a  practitioner,  or  taken  care  of  by  a 
nurse,  who  had  previously  attended  patients  affected  with  the  same  disorder.  And 
Dr.  AriUitrong  observed  that  forty  out  of  the  forty-three  cases  that  happened  at  Sun- 
derland, occurred  in  the  practice  of  one  surgeon  and  his  assistant. 

From  among  other  histories — all  tending  to  the  same  conclusion — brought  together 
by  Dr.  Lee,  I  take  the  following : — 

"On  the  IGth  of  March,  1831,  a  medical  practitioner,  who  resides  in  a  populous 
parish  on  the  outskirts  of  London,  examined  the  body  of  a  woman  who  had  died  a 
few  days  after  delivery,  from  inflammation  of  the  peritoneal  coat  of  the  uterus.  On 
the  morning  of  the  17th  of  March  (/.  e.,  the  next  morning),  he  was  called  to  attend  a 
private  patient  in  labour,  who  was  safely  delivered  on  the  same  day.  On  the  19th, 
she  was  attacked  with  severe  rigors,  great  disturbance  of  the  cerebral  functions,  rapid 
feeble  pulse,  with  acute  pain  of  the  hypogastrium,  and  a  peculiar  sallow  colour  of 
the  whole  surface  of  the  body.  She  died  on  the  4th  daj^  after  the  attack,  on  the  22d 
of  March ;  and  between  that  period  and  the  6th  of  April,  the  same  practitioner 
attended  fwo  other  patients,  both  of  whom  Avere  attacked  by  the  same  disease  in  a 
vnalignant  form,  and  fell  victims  to  it.  On  the  30th  of  March  he  bled  a  young  woman 
who  had  pleurisy :  the  wound  became  inflamed  after  a  few  days ;  erysipelatous 
redness  and  swelling  extended  from  it  up  the  arm;  and  in  four  or  five  days  that 
patient  died  of  phlebitis." 

Mr.  Rooerion,  of  Manchester,  states  the  following  facts,  in  a  paper  in  the  Medical 


PUERPERAL   PERITONITIS.  733 

Gazette. — From  the  3d  of  December,  1830,  to  the  4rh  of  January,  1831,  a  midwife 
attended  thirty  patients  for  a  public  charity.  Sixteen  of  these  were  attacked  witii 
puerperal  fever,  and  they  all  ultimately  died.  In  the  same  month,  380  women  were 
delivered  by  other  midwives  for  that  institution ;  but  none  of  the  380  suffered  in  the 
smallest  degree.  All  the  sixteen  had  inflammation  of  the  peritoneal  surface  of  the 
uterus.  So,  also,  Dr.  Robert  Lee  tells  us  that,  in  the  last  two  weeks  of  September, 
1827,  five  cases  came  under  his  observation.  All  the  patients  had  been  attended  in 
labour  by  the  same  midwife:  and  no  example  of  a  febrile  or  inflammatory  disease 
of  a  serious  nature  occurred  during  that  period  among  the  other  patients  of  the 
same  dispensary,  who  had  been  attended"  by  the  other  midwives  belonging  to  the 
hislitution. 

Statements  of  this  kind — and  they  could  be  largely  multipHed — furnish  irresistible 
evidence,  that  the  peritonitis,  which  prevails  epidemically  among  lying-in  women, 
is  of  a  specific  nature,  and  communicable  from  one  person  to  another.  It  is  observed, 
also,  to  reign  as  an  epidemic  especially  in  lying-in  hospitals,  and  that  it  recurs  at 
irregular  intervals,  sometimes  leaving  them  quite  exempt  from  its  ravages  for  years 
together. 

Indeed,  I  beheve  that  these  cases  of  puerperal  fever  occurring  in  succession  to  the 
same  practitioner,  are  examples  of  something  more  than  ordinary  contagion,  operating 
through  the  medium  of  a  tainted  atmosphere.  I  believe  them  to  be  instances  of 
direct  inoculation.  Recollect,  that  the  hand  of  the  accoucheur  is  brought,  almost  of 
necessity,  into  frequent  contact  with  the  uterine  fluids  of  the  newly-made  mother. 
Recollect, — those  among  you  who  have  examined  the  interior  of  the  dead  body  with 
your  own  hands, — recollect,  with  what  tenacity  the  smell,  which  is  thus  contracted, 
clings  to  the  fingers  in  spite  even  of  repeated  washings ;  and  whilst  this  odour  re- 
mains, there  must  remain  also  the  matter  that  produces  it.  Recollect  how  minute  a 
quantity  of  an  animal  poison  may  be  sufficient  to  corrupt  the  whole  mass  of  blood,  and 
fill  the  body  with  loathsome  and  fatal  disease.  Illustrations  will  occur  to  you  in  the 
inoculated  small-pox,  in  hydrophobia,  in  the  viper-bite,  in  the  scratches  and  punctures 
of  the  dissecting-room.  Recollect  the  raw  and  abraded  state  of  the  parts  concerned 
in  parturition ;  the  interior  of  the  uterus  forming  a  large  wound,  and  presenting,  as 
Dr.  Ferguson  observes,  an  exact  analogy  to  the  surface  of  a  stump  after  amputation  ; 
the  more  external  soft  parts  bruised  and  sore.  Bear  in  mind  the  remarkable  fact, 
that  this  contagion  does  not  affect  other  persons,  but  only  lying-in  women.  Reflect- 
ing upon  these  facts,  you  will  see  too  much  likelihood  in  the  dreadful  suspicion,  that 
the  hand  which  is  relied  upon  for  succour  in  the  painful  and  perilous  hour  of  child- 
birth, and  which  is  intended  to  secure  the  safety  of  both  mother  and  child,  but  espe- 
cially of  the  mother,  may  literally  become  the  innocent  cause  of  her  destruction ; 
innocent  no  longer,  however,  if,  after  warning  and  knowledge  of  the  risk,  suitable 
means  are  not  used  to  avert  a  catastrophe  so  shocking. 

I  need  scarcely  point  to  the  practical  lesson  which  these  facts  inculcate.  When- 
ever puerperal  fever  is  rife,  or  when  a  practitioner  has  attended  any  one  instance  of 
it,  he  should  use  most  diligent  ablution ;  he  should  even  wash  his  hands  with  some 
disinfecting  fluid,  a  weak  solution  of  chlorine  for  instancel  he  should  avoid  going  in 
the  same  dress  to  any  other  of  his  midwifery  patients:  in  short,  he  should  take  all 
those  precautions  which,  when  the  danger  is  understood,  common  sense  will  suggest, 
against  his  clothes  or  his  body  becoming  a  vehicle  of  contagion  and  death  between 
one  patient  and  another.  And  this  is  a  duty  so  solemn  and  binding,  that  I  have 
thought  it  right  to  bring  it  distinctly  before  you. 

In  these  days  of  ready  invention,  a  glove,  I  think,  might  be  devised,  which  should 
be  impervious  to  fluids,  and  yet  so  thin  and  pliant  as  not  to  interfere  materially  with 
the  delicate  sense  of  touch  required  in  these  manipulations.  One  such  glove,  if  such 
shall  ever  be  fabricated  and  adopted,  might  well  be  sacrificed  to  the  safety  of  the 
mother,  in  every  labour.  Should  these  precautions  all  prove  insufficient,  the  practi- 
tioner is  bound,  in  honour  and  conscience,  to  abandon,  for  a  season,  his  vocation. 

[The  connection  between  puerperal  peritonitis  and  erysipelas  has  recently  attracted  a  good 
deal  of  discussion.  In  a  large  number  of  instances,  it  has  been  shown  that  the  two  diseases 
prevail  simultaneously  and  in  the  same  localities  ;  and  facts  have  been  adduced,  which  wo  tiil 

3m 


734  DISEASES    OF    THE    ABDOMEN. 

even  appear  to  prove  that  a  contagion  of  some  kind  may  be  communicated  from  a  patient 
labouring  under  erysipelas  to  the  parturient  female,  and  induce  in  her  an  attack  of  puerperal 
fever.  Until,  however,  a  greater  number  of  facts  have  been  accumulated,  and  the  whole 
.subject  more  closely  investigated,  it  will  be  premature  to  draw  any  positive  conclusions. — C] 

That  variety  of  peritonitis  which  results  from  perforation  of  the  stomach  or  intes- 
tines, and  the  effusion  of  their  contents  into  the  cavity  of  the  belly,  is  full  of  interest. 
The  inflammation  is  violent  in  degree ;  universal  (generally)  in  extent :  and  almost 
always  fatal.  The  attack  is  characterized  by  its  suddenness.  All  at  once  intense 
pain  arises  in  some  region  of  the  abdomen,  which  soon  becomes  tender  in  every  part. 
The  pain  is  incapable  of  removal,  and  generally  even  of  mitigation,  by  medicine, 
and  death  takes  place  in  a  short  time.  These  are  the  general  features  of  such  cases. 
Occasionally,  the  symptoms  follow  some  different  order.  Thus,  I  have  seen  a  case 
in  which  no  pain  was  complained  of,  and  the  source  of  the  inflammation  was  not 
suspected  until  the  dead  body  was  examined.  This  was  a  case  oi  fever  ;  and  it  had 
been  attended  with  much  stupor,  which  was  probably  the  reason  that  no  indication 
of  suffering  was  made  by  the  patient.  Occasionally,  but  that  is  uncommon,  the  pain 
intermits.  For  the  most  part,  however,  it  resists  all  treatment,  and  ceases  only  with 
life,  or  a  short  time  before  life  is  terminated. 

Most  of  the  instances  of  this  kind  of  peritonitis  that  I  have  witnessed  have  resulted 
from  perforation  of  the  ileum,  in  the  progress  of  continued  fever.  You  are  already 
aware,  that  the  glandulfe  agminatae,  which  are  found  only  in  that  bowel,  and  the 
glanduloe  solitarise,  which  are  scattered  over  nearly  the  whole  inner  surface  of  the 
alimentary  tube,  are  very  liable,  in  continued  fever,  to  inflammation,  sloughing  and 
ulceration  :  and  sometimes  the  ulcers  go  through :  the  contents  of  the  gut  are  poured 
into  the  cavity  of  the  serous  membrane,  and  intense  inflammation  is  lighted  up.  I 
purposely  abstain  from  going  into  any  particulars  respecting  these  ulcers.  We  are 
no  further  concerned  with  them  at  present  than  as  they  furnish  the  channel  by  which 
the  cause  of  the  peritoneal  disease  is  introduced.  Once,  and  once  only,  as  I  stated 
before,  have  I  known  perforation  occur  from  th-e  extension  of  scrofulous  ulceration 
of  the  same  glands  in  phthisis.  In  general,  in  that  disease,  the  ulcer  runs  a  much 
slower  course.  As  it  approaches  the  peritoneum,  circumscribed  chronic  inflamma- 
tion is  set  up  in  that  membrane ;  lymph  is  thrown  out ;  and  the  bowel  becomes 
adherent  to  some  other  portion  of  the  canal,  or  to  some  of  the  other  viscera  of  the 
abdomen.  In  this  way  the  perforation  is  prevented  ;  or,  should  it  take  place,  the 
escape  of  the  contents  of  the  bowel  into  the  peritoneal  sac  is  prevented.  Occasion- 
ally, when  two  portions  of  the  tube  thus  adhere  together,  a  communication  is  formed 
between  them,  and  the  contents  of  the  intestine  either  reach  an  advanced  point  of 
their  stated  journey  by  a  short  cut,  or  are  carried  back  again  perhaps  to  a  spot  which 
they  had  already  passed. 

A  very  curious  instance  of  this  latter  event  has  been  described  by  Dr.  Abercrombie. 
A  man,  fifty-six  years  old,  who  had  shown  no  signs  of  serious  illness,  but  had  laboured 
under  impaired  appetite,  languor,  and  occasional  pain  in  the  abdomen,  for  two  or 
three  weeks,  was  suddenly  seized,  while  out  walking,  with  vomiting ;  and  he  ob- 
served that  what  he  brought  up  was  stercoraceous ;  and  this  occurred  again  and 
again,  at  variable  intervals  ;  the  matter  vomited  being  distinctly  fecal,  and  sometimes 
so  solid  that  he  was  obliged  to  swallow  warm  water  to  soften  it,  that  it  might  be  ex 
pelled  from  the  stomach  more  easily.  He  never  vomited  his/oo(^;  and  no  tumour 
or  other  sign  of  organic  disease,  could  be  detected  by  external  examination.  He 
lived  about  three  months,  and  died  at  last  of  exhaustion ;  and  then  it  was  discovered 
that  the  stomach  and  the  transverse  arch  of  the  colon  were  adherent  to  each  other, 
and  that  a  ragged  aperture  of  communication  between  them  existed  at  the  place  of 
adhesion. 

It  is  a  curious  fact,  that  the  vermiform  appendage  of  the  caecum  is  not  unfrequently 
tne  seat  of  a  penetrating  ulcer.  I  have  traced  little  groups  of  glands  in  that  slender 
tube :  and  I  have  known  perforation  to  happen  from  the  specific  ulceration  of  con- 
tinued fever ;  and  from  the  accidental  ulceration  caused  by  a  cherry-stone  lodged 
ihetfl 


PERITONITIS    FROM    PERFORATION.  7i{5 

[Many  cases  are  related  of  peritonitis  from  ulceration  of  the  apendicula  vermiformis 
caused  by  the  impaction  of  some  foreign  substance  within  its  cavity.  A  veiy  interesting 
case  of  the  kind  is  detailed  by  Dr.  Pepper,  in  the  Transactions  of  the  College  of  Physicians  of 
Philadelphia,  vol.  i.,  p.  296,  in  which  a  grape  seed  had  passed  into  the  apendicula,  and  was 
the  cause  of  its  ulceration  and  perforation. — C] 

Sometimes  it  is  the  stomach  that  is  perforated,  either  by  a  common  or  by  a  spe- 
cific ulcer ;  and  the  symptoms  are  exactly  the  same  as  when  the  boivel  gives  way. 
Sudden,  unremitting  pain,  tenderness,  and  tympanitic  distension  of  the  abdomen  ;  and 
early  death. 

Perforating  ulcers  of  the  stomach  are  of  various  kinds.  It  is  not  uncommon  to 
find  one  small  roundish  hole,  with  edges  as  smooth  and  clean  as  if  a  piece  of  the 
stomach  had  been  cut  out  by  a  punch,  and  without  any  surrounding  hardness,  or 
other  mark  of  disease.  Occasionally  the  orifice  is  more  irregular,  and  occupies  the 
centre  of  a  thickened  and  indurated  patch  of  the  mucous  membrane.  Several  in- 
stances of  this  sort  of  perforation  have  occurred  under  my  own  eye ;  two  within  the 
last  fourteen  months  (1839).  Almost  all  the  patients  have  been  young  women, 
plump,  and  in  good  condition  ;  who,  up  to  the  moment  of  the  fatal  seizure,  either 
seemed  to  enjoy  perfect  health,  or,  at  most,  had  complained  of  slight  and  vague  feeHngs 
of  dyspepsia.  Ulcers  of  the  stomach  are,  however,  mostly  chronic ;  and  the  diseased 
viscus  is  commonly  fenced  about  and  protected  by  adhesion  to  the  neighbouring 
parts,  before  its  coats  are  completely  penetrated  by  the  ulcer.  You  are  probably 
aware  that  this  happened  in  the  body  of  Napoleon  Bonaparte.  He  died  of  cancer 
of  the  stomach.  That  organ  was  strongly  adherent  to  the  concave  surface  of  the  left 
lobe  of  the  liver,  which  formed  a  part  of  the  wall  of  the  stomach ;  and  this  adhesion, 
no  doubt,  prolonged  his  life. 

Usually  the  actual  perforation,  in  cases  such  as  we  are  now  considering,  takes 
place  merely  from  the  natural  progress  of  the  ulcer;  but  sometimes  it  would  appear 
that  the  thin  membrane  which  remains  is  broken  by  some  accidental  force  applied  to 
it.  Thus  the  symptoms  have  immediately  followed  the  act  of  vomitinof,  brought  on 
by  an  emetic.  Bouillaud  relates  an  instance  in  which  the  perforation  happened 
while  the  patient  was  straining  at  stool ;  and  it  is  conceivable  enough,  that  rough 
pressure  of  the  abdomen  might  complete  the  rupture,  when  the  ulcer  had  already 
eaten  through  all  the  coats  of  the  bowel  except  its  peritoneal  coat. 

Less  commonly  than  this,  in  my  experience  at  least,  the  peritonitis  is  set  up  by 
the  escape  of  urine  from  the  urinary  bladder,  through  the  extension  of  an  ulcer,  or 
from  a  forcible  rupture  of  that  bag  by  a  blow  or  a  fall,  when  it  was  distended  with 
urine.  Rupture  of  the  gall-bladder,  whether  by  violence  or  from  ulceration,  has  the 
same  results ;  so  also  has,  in  general,  the  rupture  of  the  uterus,  which  sometimes 
takes  place  during  the  efforts  of  parturition.  Abscess  of  the  liver,  bursting  into  the 
peritoneum,  is  another  occasional  source  of  severe  and  fatal  inflammation  of  that 
membrane.  Acute  and  general  peritonitis  sometimes  arises,  also,  in  consequence  of 
penetration  from  without ;  i.  e.,  it  succeeds  the  puncture  made  by  the  trocar  in  the 
operation  of  tapping  the  belly :  and  these  cases,  too,  are  almost  all  of  them  mortal : 
chiefly,  I  presume,  because,  in  nine  instances  out  of  ten,  they  occur  in  an  unhealthy 
and  debilitated  subject. 

I  formerly  offered  you  some  observations  respecting  a  form  of  hysteria  which  very 
closely  mimics  peritonitis,  and  would  most  certainly  deceive  a  medical  man  who  was 
not  on  his  guard  against  it.  We  judge  by  the  age  and  sex  of  the  patient  somewhat; 
by  the  presence  of  hysteria  in  other  forms,  or  of  the  hysteric  diathesis;  by  the  ex- 
cessive tenderness  of  the  abdomen,  or  rather  of  its  surface  ;  by  the  co-existence  of  the 
same  exquisite  sensibility  in  other  parts  ;  and  by  the  incongruity  and  shifting  character 
of  the  symptoms.  The  pulse  and  the  tongue  will  perhaps  be  natural,  while  the 
abdominal  irriuation  is  at  its  height.  Forewarned,  you  will  seldom  find  much  dif- 
ficulty in  establishing  the  diagnosis.  Of  the  signs  by  which  peritonitis  may  be  dis- 
'.inguished  from  enteritis,  I  shall  speak  when  I  come  to  the  latter  disease. 


736  ACUTE    PERITONITIS. 


LECTURE  LXVI. 

Treatment  of  Acute  Peritonitis  ;  Bleeding,  Mercury,  Opium .  Ch  ronic  Peritonitis  -, 
Gramdor  Peritoneum.  Ascites  ;  Ovarian  Dropsy  ;  Diagnosis  of  these  diseases. 
Other  forms  of  Abdominal  Dropsy. 

Acute  peritonitis,  in  its  simple  form,  is  always  a  dangerous,  yet  frequently  a 
manageable  disease.  When  it  is  complicated  with  other  and  earher  organic  mischief, 
and  especially  when  it  has  been  excited  by  the  entrance  of  foreign  matters  into  the 
civity  of  the  belly,  it  is  all  but  hopeless  under  any  treatment. 

In  speaking  of  the  mode  of  cure,  I  have  again  to  repeat,  mutatis  mutandis,  the 
grand  remedies  for  inflammation,  and  particularly  for  the  adhesive  inflammation 
proper  to  serous  membranes  :  blood-letting;  mercury. 

It  is  of  the  greatest  importance  in  this,  as  in  many  other  cases  of  inflammation, 
that  the  blood-letting  should  be  performed  early.  You  must  not  be  deterred  from 
bleeding  by  the  mere  smallness  of  the  pulse :  a  quality  which  I  have  frequently 
shown  you  to  be  characteristic  of  acute  inflammation  within  the  abdomen  ;  and  which, 
in  the  disease  now  in  question,  is  often  present  from  the  very  beginning.  If  the 
pulse  be  wiry  and  hard,  we  disregard,  in  these  cases,  its  smallness.  Not  uncom- 
monly it  is  rendered  more  full,  as  well  as  softer,  by  venesection ;  and  this,  when  it 
happens,  gives  assurance  of  the  propriety  of  that  measure. 

Topical  blood-letting  is  of  much  efficacy — of  greater  efficacy  perhaps  than  in  most 
other  forms  of  abdominal  inflammation.  Cupping  is  out  of  the  question,  from  the 
tender  state  of  the  abdomen.  But  in  adults,  after  a  full  bleeding  from  the  arm,  such 
as  has  produced  some  sensible  impression  upon  the  circulation,  or  brought  the  patient 
to  the  vertre  of  syncope,  the  surface  of  the  belly  should  be  covered  with  leeches. 
From  twenty  to  forty  may  be  applied  at  once  ;  and  sometimes  this  will  make  any 
further  loss  of  blood  unnecessary.  But  in  severe  cases,  you  may  expect  to  find  that 
repetitions  of  at  least  the  local  bleeding  will  be  requisite. 

After  the  leeches  have  fallen  off,  a  light  poultice  may  be  laid  over  the  abdomen  ; 
or  it  may  be  assiduously  fomented  with  flannels  wrung  out  of  hot  water.  These 
means  will  encourage  the  bleeding  from  the  leech  bites ;  and  are  generally  found  to 
afford  great  comfort  to  the  feelings  of  the  patient.  Cold  applications  have  been 
recommended  by  some  practitioners  of  high  authority.  Dr.  Sutton  injected  cold 
enemata.  and  applied  cloths,  made  wet  with  cold  evaporating  lotions,  to  the  abdo- 
men with  good  effect :  and  Dr.  Abercrombie  has  since  reported  favourably  of  the 
same  kind  of  treatment.  However,  I  should  think  this  a  more  precarious  plan 
than  the  opposite :  and  I  have  always  observed  so  much  relief  to  be  given  by 
warm  epithems,  that  I  have  never  had  the  inclination,  or  the  courage,  to  employ 
cold. 

It  is  extremely  desirable,  in  these  cases,  to  obtain  as  speedily  as  possible  the 
specific  influence  of  mercury  upon  the  system ;  by  calomel  and  opium,  or  by 
inunction.  It  cannot  be  necessary  that  I  should  again  go  over  in  detail  the  means 
of  following  out  this  indication  ;  but  it  is  an  indication  which  we  must  diligently 
pursue. 

The  treatment  of  puerperal  peritonitis  is  much  more  uncertain  and  difficult :  for 
■  his  reason,  that  it  springs  out  of  an  antecedent  morbid  condition  more  deeply  seated, 
more  o-enerally  diffused,  and  less  accessible  to  remedies,  than  itself.  Whenever  in- 
flammation arises  here  and  there  in  the  body,  in  consequence  of  a  vitiated  state  of 
the  blood,  we  have  not  only  the  inflammation  itself  to  deal  with,  but  its  physical 
cause  also,  which  may  still  be  in  uncontrolled  operation. 

Dr  Fercjuson  justly  remarks  that  "inflammation  being  made  up  of  vascular  and 
of  nervous  action,  of  "the  afflux  of  blood  to  a  part,  and  of  pain,  it  is  not  irrational  to 
jict  on  both  the  elements  of  the  malady  at  the  same  time,  or  in  periods  shortly  con- 
secutive of  each  other."  "The  abdominal  pain  that  occurs  in  puerperal  fever  is 
accompanied  by  two  very  different  states  of  constitution :  one  in  which  little  or  no 


ACUTE    PERITONITIS.  737 

depletion  is  borne,  another  in  which  reHef  is  obtained  only  by  very  large  evacua- 
tions of  blood."  Between  these  two  there  is  every  conceivable  gradation.  "  In  no 
malady  are  a  cautious  boldness,  and  a  sagacious  adaptation  of  remedy  to  constitu 
tional  power,  more  imperatively  demanded." 

"  If  lurge  bleeding  be  determined  on,  it  must,  to  be  beneficial,  be  resorted  to  within 
the  first  twenty-four  hours  from  the  attack.  In  the  second  stage  of  the  disease  it  often 
produces,  rapidly,  a  fatal  result." 

In  ambiguous  cases  he  gives  ten  grains  of  Dover's  powder,  and  covers  the  whole 
of  the  abdomen  with  a  large  linseed-meal  poultice,  sufficiently  thick  to  retain  warmth 
for  four  hours.  At  the  end  of  that  time,  if  the  symptoms  are  alleviated,  "ten  grains 
more  of  the  Dover's  powder,  and  a  fresh  poultice,  should  be  prescribed.  If  within 
four  hours  from  this  second  medication,  the  practitioner  is  not  satisfied  that  the 
malady  is  yielding,  he  must  at  once  resort  to  depletion." 

Of  all  the  means  we  possess  of  arresting  this  malady,  bleeding,  general  or  topical, 
is,  in  Dr.  Ferguson's  experience,  by  far  the  most  extensively  applicable.  "  But,"  he 
says,  "  while  I  admit  this,  I  am  equally  certain  that  large  bleeding  has  not  been 
borne  in  this  complaint,  generally  speaking,  during  the  last  twelve  years." 

Another  most  important  truth  enunciated  by  our  professor  is,  that  "epidemic 
puerperal  fever  has,  invariably,  the  character  common  to  the  ordinary  fevers  raging 
with  it:  if  the  latter  require  depletion,  the  presumption  is  that  the  former  will  also." 

Undoubtedly  the  very  same  species  of  febrile  disease  is  variously  aflected  by 
a  given  remedy  in  different  places:  and  during  diflferent  periods  in  the  same  place. 
There  is  such  a  thing  as  an  epidemic  state  of  the  human  constitution,  gradually  pro- 
duced by  a  gradual  fluctuation  in  the  influences  whereby  communities  of  men  are 
surrounded  and  impressed.  The  fevers  that  were  cured  in  London  ten  or  fifteen 
years  ago  by  copious  blood-letting,  would  now  be  rendered  by  that  measure,  carried 
to  a  like  extent,  irretrievably  mortal.  There  is  scarcely  a  more  important  object  of 
study  to  the  practical  physician  than  this  different  capacity,  exhibited  by  the  average 
of  constitutions  at  different  limes  and  seasons,  of  bearing  active  depletion.  "Nihil 
mihi  prius  est,"  says  the  wary  Sydenham,  "quam  quando  novoe  febres  grassari  in- 
cipiant,  cunclari  paulisper,  et  ad  magna  prsesertim  remedia  non  nisi  suspenso 
pede,  ac  tardius  procedere  ;  diligenter  interim  illarum  ingenium  atque  morem  obser- 
vare,  quibus  itidem  prsesidiorum  generibus  ^gri  juventur  vel  lasdantur,  ut  quam  pri- 
mum  his  repudiatis,  illis  utamur."  The  exciting  cause  of  the  fever  remains  the 
same  ;  the  system  upon  which  it  operates  undergoes  trom  time  to  time  great  changes  ; 
which  are  brought  to  light  partly  by  the  altered  phenomena  of  the  disease,  partly 
and  chiefly  by  the  effects  of  remedial  measures. 

Unless  you  bear  these  differences  in  mind,  you  will  be  perplexed  and  disheartened 
bj  the  discrepant  accounts  given  by  competent  and  faithful  observers  respecting  the 
success  of  difl"erent  or  even  opposite  plg,ns  of  treatment,  in  the  same  complaint. 

Most  writers,  whose  works  I  am  acquainted  with,  recommend  purgatives  as  highly 
serviceable  in  peritonitis.  I  do  not  think  the  good  which  th<iy  are  calculated  to  do 
as  antiphlogistic  remedies  can  at  all  be  put  in  competition  with  the  harm  that  I  am 
persuaded  they  may  produce,  by  increasing  the  peristaltic  action  of  the  intestines, 
and  so  causing  additional  friction  and  tension  of  the  inflamed  membrane.  I  believe 
that  in  all  cases  of  vvell-marked  and  pure  peritonitis,  when  the  inflammation  is  limited 
to  the  serous  membrane,  it  is  far  better  and  safer  to  restrain  than  to  solicit  the  internal 
movements  of  the  alimentary  tube.  In  a  pamphlet  published  several  years  ago  by 
Mr.  Bates,  of  Sudbury,  some  striking  instances  are  recorded  of  recovery  from  severe 
peritonitis,  under  large  and  frequent  doses  of  opium,  and  a  ri^id  adherence  to  the 
horizontal  posture,  until  all  pain  had  subsided.  The  patients  were  not  allowed  to 
raise  themselves,  on  any  account,  into  a  sitting  position:  and  the  opium  was  admi- 
nistered sometimes  by  the  mouth,  sometimes  by  the  rectum.  These  cases,  related 
in  an  unpretending  manner  by  a  practical  observer,  made  a  strong  impression  on 
my  mind  when  I  read  them.  To  simple  inflammation  of  the  peritoneum,  to  those 
perilous  forms  of  peritonitis  which  occur  in  women  after  delivery,  and  to  those  still 
more  terrible  cases  that  follow  perforation  of  the  serous  membrane,  this  principle  of 
keeping  the  intestines  at  rest  is  alike  applicable.  I  stated  a  httle  while  ago,  that  the 
47  3m2 


733  ACUTE    PERITONITIS. 

last-mentioned  cases  are  all  but  hopeless.  That  all  but  I  inserted  on  the  strength  of 
some  most  interesting  facts  published  by  Dr.  William  Stokes,  in  the  second  number 
of  the  Dublin  Jour/ui'  of  Jiledical  and  Chemical  Science.  He  trnlj''  remarks,  that 
in  most  of  these  accidents  the  powers  of  life  sink  so  rapidly,  that  bleeding,  either 
local  or  general,  cannot  be  attempted.  Neither  can  we  employ  mercury  interna II v, 
for  fear  of  excitintr  the  peristaltic  action  of  the  bowels,  which  action  would  tend  to 
tear  asunder  recent  adhesions,  to  keep  the  communication  between  the  mucous  and 
serous  surfaces  open,  and  to  cause  a  fresh  ingress  of  fecal  or  other  extraneous  mat- 
ters into  the  sac.  Yet  in  a  few  instances  we  find  that  the  patients  live  for  several 
dajj-s,  and  that  a  process  of  organization  commences  in  the  effused  lymph.  It  seems 
that  some  years  before  Dr.  Stokes  wrote  this  paper,  he  had  witnessed  the  admirable 
efTects  of  opium  in  low  forms  of  peritonitis,  as  administered  by  Dr.  Graves ;  who 
thus  saved,  without  abstracting  a  drop  of  blood,  two  individuals  in  Avhom  that  disease 
followed  paracentesis.  I  cannot  refrain  from  quoting  to  you  the  particulars  of  one 
instance,  in  which  the  efficacy  of  the  opiate  treatment  was  conspicuous.  The  well- 
known  symptoms  of  perforation  of  tlie  intestines  had  existed  for  two  days ;  the 
patient  was  apparently  sinking,  "  his  countenance  was  collapsed,  anxious  and 
expressive  of  dreadful  suffering;  the  extremities  were  cold,  and  the  pulse  hardly 
perceptible.  The  exhibition  of  sixty  drops,  in  the  twentj'-four  hours,  of  the  pre- 
paration called  the  black  drop,  was  followed  by  the  most  signal  improvement.  The 
pulse  regained  fullness  and  softness,  the  extremities  became  warm,  and  the  counte- 
nance had  lost  the  Hippocratic  expression.  The  patient  could  bear  pressure  on  the 
abdomen,  which,  the  day  before,  was  exquisitel_v  painful.  The  same  treatment  was 
continued  for  twenty-four  hours  longer;  and  by  the  end  of  that  time  every  symptom 
of  abdominal  inflammation  had  completely  subsided.  The  belly  felt  natural,  there 
was  no  tenderness,  the  pulse  was  good,  and  the  patient  declared  himself  well."  At 
this  period  of  the  case.  Dr.  Stokes  omitted  the  opium,  and  gave  the  mildest  possible 
saline  laxative,  as  there  had  been  no  stool  for  forty-eight  hours.  Four  evacuations 
took  place,  followed  by  the  immediate  return  of  the  symptoms  of  peritonitis,  under 
which  the  patient  rapidly  sank. 

"  The  intestines  were  everywhere  agglutinated  together,  and  adherent  to  the  parie- 
tal peritoneum,  except  in  the  left  iliac  fossa,  where  a  quantity  of  yellow  puriform 
matter  was  collected.  On  detaching  the  caput  coli  from  the  peritoneum  lining  the 
right  iliac  fossa,  a  small  perforation  of  the  gut  was  discovered,  b}'-  the  escape  of  the 
contents  of  the  intestines  in  a  jet,"  &c.  &c. 

This  example  puts  in  a  very  strong  light  the  good  effects  of  opium  ;  the  danger- 
ous efft'cts  of  purgatives  ;  and  the  mode  in  which  recovery  from  these  frightful 
accidents  may  sometimes  be  brought  about. 

Dr.  Stokes  gives  another  instance  in  which  the  patient  did  recover;  after  taking 
105  grains  of  opium,  besides  what  was  administered  in  injections:  and  he  alludes 
to  a  third  case,  in  which  the  employment  of  opium  was  successful,  when  peritonitis 
had  supervened  upon  the  bursting  of  an  hepatic  abscess  into  the  cavity  of  the  abdo- 
men. 

Now  I  would  earnestly  recommend  you  to  consider  the  expediency  of  applying 
the  same  principle  of  treatment,  as  an  auxiliar}%  when  the  peritonitis  does  not  grow 
out  of  previous  organic  disease:  in  all  cases,  in  short,  of  mo'e  peritonitis.  The 
opmm  is  not  to  supersede  the  bleeding,  or  the  mercury ;  it  is  not  incompatible  with 
either  of  those  remedies ;  and  it  may,  I  believe,  be  most  advantageously  adopted  in 
conjunction  with  them  both. 

1  shall  relate  one  example,  which  has  lately  occurred  to  me,  of  the  successful  use 
of  opium  in  simple,  but  severe,  peritonitis.  Several  of  you  saw  this  patient.  His 
cuse  is  published  in  the  appendix  to  Dr.  Ferguson's  volume. 

H.  Middlehurst,  a  tailor,  seventeen  years  old,  was  admitted  into  the  JVIiddlesex 
Hospital  on  the  17th  of  September  :  looking  very  ill.  and  complaining  of  pain  in  the 
epigastriiun,  with  extreme  tenderness  over  the  whole  abdomen,  which  was  full  and 
tense.  He  had  been  ill  several  days;  had  shivered  in  the  outset:  and  had  vomited 
fieqaently,  up  to  the  period  of  his  admission.  His  bowels  were  confined  ;  his 
tongue  was  dry  and  white. 


CHRONIC    PERITONITIS.  •fl^ 

Twelve  leeches  were  placed  upon  his  abdomen,  and  calomel,  in  five-grain  doses, 
was  given  two  or  three  times  at  intervals  of  four  hours.  An  enema  of  warm  water 
was  injected,  and  retained.  In  che  evening  sixteen  more  leeches  were  applied,  and 
a  drachm  of  mercurial  ointment  was  rubbed  into  his  arm. 

r  first  saw  him  on  the  18th.  His  countenance  was  then  pinched  and  anxious, 
and  he  lay  moaning  with  pain ;  his  knees  being  drawn  up  towards  his  belly,  which 
was  tense,  and  exquisitely  sensible  to  pressure.  He  complained  of  nausea  and 
retching,  but  had  not  vomited  since  his  admission.  His  tongue  was  thickly  coated  ; 
his  pulse  small,  sharp,  108  in  number.  No  permanent  relief  had  been  obtained 
from  the  leeches. 

I  directed  immediate  venesection  ;  but  not  more  than  four  ounces  of  blood  could 
be  got  from  the  arm.  Thirty  fresh  leeches  were  therefore  put  upon  the  abdomen, 
and  afterwards  a  warm  poultice  to  receive  the  blood  from  their  bites.  Three  grains 
of  calomel,  and  three  of  blue  pill,  were  ordered  to  be  given  every  four  hours. 

The  last  leeches  mitigated  the  pain  ;  but  it  returned  in  the  evening,  with  in- 
creased severity,  and  he  vomited  the  pills.  He  appeared  to  be  in  great  agony.  In 
this  state  the  apothecary  gave  him  twelve  grains  of  calomel,  and  five  grains  of 
opium,  in  one  dose.  Soon  after  this  he  fell  asleep ;  and  slept  during  the  greater 
part  of  the  night.  Next  morning  his  countenance  had  lost,  in  a  great  degree,  its  ex- 
pression of  anxiety ;  his  belly  was  less  tender,  but  still  tense ;  and  his  tongue 
cleaner.     No  stool. 

Capiat  pilulae  saponis  cum  opio  gr.  v.  8va.  quaq.  bora. 

On  the  20th,  the  bowels  were  freely  open,  the  dejections  dark  and  watery ;  the 
abdomen  was  less  tender.  Pulse  114.  He  continued  to  take  a  grain  of  opium 
thrice  daily  till  the  3d  of  October:  the  bowels  being  every  day  moved;  the  pulse 
and  tongue  gradually  improving;  and  the  abdomen  painless  even  under  firm  pres- 
sure. On  the  3d,  as  the  bowels  had  not  acted  for  the  last  two  days,  I  discontinued 
the  opium.  On  the  5lh,  diarrhoea  set  in,  with  some  renewed  tenderness  of  the 
belly  ;  and  the  pinched  and  anxious  countenance  returned.  He  had  then  an  opiate 
enema ;  and  resumed  the  opiate  pills  as  before.  Under  this  treatment  he  at  length 
got  quite  well ;  and  left  the  hospital  on  the  30th. 

Chronic  peritonitis  is  sometimes  merely  the  sequel  of  that  acute  form  of  inflam- 
mation of  the  peritoneum,  which  I  have  just  been  describing.  Plastic  lymph  is 
effused,  and  becomes  organized ;  serous  fluid  is  poured  out,  and  is  not  absorbed 
again;  the  products  of  the  original  inflammation  remain  ;  a  low  degree  of  inflamma- 
tory action  perhaps  remains  also,  or  is  re-excited  by  slight  causes^  the  mischief 
augments  ;  and  the  patient  is  slowly  conducted  to  the  grave. 

There  is,  however,  another,  not  at  all  uncommon,  and  equally  formidable  source 
of  chronic  peritonitis ;  the  presence,  I  mean,  of  a  multitude  of  little  granules,  lying 
within  or  immediately  beneath  the  membrane,  or  occupying,  in  counUess  numbers, 
those  folds  of  the  peritoneum  which  compose  the  omentum.  These  granules  occur 
principally,  if  not  exclusively,  in  scrofulous  persons.  Louis,  indeed,  who  considers 
them  to  be  tubercles,  afiirms  that  they  are  never  met  with  in  the  peritoneum,  without 
being  met  with  also — and  usually  in  a  more  advanced  state  and  greater  abundance — 
in  the  lungs;  but  this  rule  is  not  universally  true.  I  have  seen  more  than  one 
instance  of  well-marked  granular  disease  of  the  serous  membrane  of  the  abdomen, 
without  a  single  tubercle  in  the  pulmonary  tissues.  Still  the  observation  of  Louis 
holds  good  in  a  vast  majority  of  cases :  and  when  we  have  symptoms  of  chronic 
peritonitis,  which  were  not  preceded  by  those  of  acute  inflammation  of  the  mem- 
brane, and  when  we  perceive  at  the  same  time  indications  of  phthisis,  or  of  any 
other  unequivocal  form  of  scrofula,  we  shall  seldom  be  wrong  in  connecting  the 
chronic  peritonitis  with  the  presence  of  these  miliary  granulations.  Whether^'they 
are  truly  scrofulous  tubercles,  or  whether,  as  some  suppose,  they  are  sui  generis,  or 
again,  simply  minute  spherules  of  coagulable  lymph,  I  do  not  undertake  to  detej 
mine.  I  have  been  in  the  habit  of  regarding  them  as  the  cause,  and  not  as  th(!  con 
sequence,  of  the  inflammation  with  which  they  are  found  associated 


740  ASCITES. 

The  symptoms  of  chronic  inflammation  of  the  peritoneum  are  more  obscnre,  m 
general,  than  those  of  the  acute  disease.  And  when  the  disorder  is  primitive,  not 
the  rehcs  I  mean  of  more  active  inflammation,  it  often  begins,  and  steals  on,  in  a  very 
insidious  manner.  The  patient  complains  of  abdominal  pains:  sometimes  slight, 
amounting  to  scarcely  more  than  uneasiness,  but  abiding;  sometimes  occasional 
only.  Usually  there  is  a  sensation  of  fullness  and  tension  in  the  heWj,  although  its 
bulk  may  not  be  sensibly  altered.  Sometimes  there  is  a  sense  of  pricking  felt.  Dr. 
Pcmberton  remarks,  that  you  may  detect  a  sort  of  deep-seated  tension ;  that  the  skin 
and  muscles  lie  loosely  on  the  peritoneum,  which  gives  to  the  hand  a  sensation  as  of 
a  tight  bandage  underneath,  over  which  the  integuments  appear  to  slide.  The 
uneasiness,  or  the  pain,  is  augmented  by  pressure ;  or  perhaps  is  felt  only  when 
pressure  is  made.  Sometimes  the  functions  of  the  intestinal  canal  are  disturbed  : 
there  are  loss  of  appetite ;  nausea  and  vomiting ;  an  irregular  state  of  the  bowels, 
and  unnatural  evacuations  from  them.  Sometimes,  on  the  contrary,  the  digestive 
organs  perform  their  office  in  a  tolerably  healthy  manner.  These  differences  depend 
apparently  upon  the  circumstance  of  the  inflammation  visiting,  or  sparing,  the  peri- 
toneal covering  of  the  stomach  and  bowels;  and  of  the  parts  concerned  in  the  secre- 
tion of  bile.  Sooner  or  later,  in  most  cases,  the  abdomen  enlarges,  and  fluctuation  is 
felt.  All  along  there  is  some  fever,  more  or  less  distinctly  marked ;  with  progressive 
emaciation  and  debility.  The  face  is  pale  and  sallow,  and  wears  an  expression  of 
languor. 

Very  much  the  same  set  of  symptoms  are  apt  to  result  from  scrofulous  disease  and 
enlargement  of  the  mesenteric  glands :  and  consecutive  slow  inflammation  of  the 
peritoneal  membrane. 

Accordingly,  after  de?ih,  we  often  find  those  glands  swelled,  and  red,  and  hard  ; 
sometimes  forming  very  large  tumours :  or  we  discover  the  whole  surface  of  the 
membrane  thickly  bestreAved  with  innumerable  small,  round,  grayish  or  white 
granules :  sometimes  it  is  covered,  here  and  there,  or  everywhere,  with  false  mem- 
branes :  the  intestines  are  frequently  agglutinated  into  one  mass ;  or  they  are  ad- 
herent to  each  other,  or  to  the  other  parts  of  the  peritoneum,  in  places  only.  The 
omentum  is  generally  thick,  red,  and  fleshy,  as  if  its  component  parts  had  been  mat- 
ted together ;  and  there  is  more  or  less  fluid,  commonly  turbid  and  flaky,  in  so  much 
of  the  cavity  as  happens  to  be  left. 

These  are  very  unpromising  forms  of  disease ;  and  it  is  seldom  that  we  can  do 
more  than  mitigate  the  most  distressing  of  the  symptoms,  or  retard,  perhaps,  the 
march  of  the  disorder.  Leeches  to  the  abdomen,  in  moderate  numbers,  and  fre- 
quently repeated,  and  followed  by  soft  warm  poultices.  Blisters,  when  the  pain  is 
not  severe,  and  the  tenderness  less.  Attention  to  the  state  of  the  bowels,  which 
should  be  regulated  by  mild  laxatives,  rather  than  by  drastic  purges.  A  nourishing, 
but  unstimulant  diet.  These  are  the  measures  to  which  we  must  look  for  benefit. 
It  has  been  thought  that  frictions  upon  the  belly,  with  ointments  containing  iodine, 
have  done  good ;  so  that  it  will  be  well  to  make  trial  of  such.  But,  do  what  we 
may,  in  nine  cases  out  of  ten,  our  best-directed  efforts  will  be  disappointed. 

When  there  is  much  fluid  collected  in  the  abdominal  cavity  in  these  cases,  they 
take  their  character  from  this  predominant  symptom,  and  are  called  cases  of  ascites. 
But  this  is  only  one  form  of  ascites — that  form  which  results  from  chronic  inflam- 
mation of  the  peritoneal  membrane.  I  shall  pass,  however,  by  an  easy  transition,  to 
the  other  forms  of  dropsy  of  the  belly. 

There  is  another  form  of  ascites,  not  very  common,  which  approaches  in  its  cha- 
racter to  inflammation,  and  which  is  therefore  called  active  ascites.  I  mean  that*  we 
sometimes  see  persons,  who  were  previously  in  good  health,  become  rapidly  ascitic, 
after  exposure  to  cold  and  wet,  and  rapidly  recover  again  under  the  remedies  that 
Sue  used  to  subdue  inflammation.  Perhaps  it  may  be  said  that  these  are  cases  of 
inflammation  ;  and  it  may  be  so.  But  they  want  many  of  the  ordinaiy  symptoms 
of  peritonitis  ;  and  if  inflammation  be  present,  it  has  no  worse  effect  than  the  effusion 
of  serum,  which,  under  depletion  or  mercury,  is  speedily  taken  up  again.  I  should 
rather  conceive,  however,  that  these  cases  are  to  be  included  in  that  category  of  drop- 


ASCITES.  741 

sical  effusions  which  I  spoke  of  formerly,  as  resulting  from  the  detention  or  absorp 
tion,  in  the  first  place,  of  an  undue  quantity  of  watery  fluid  into  the  blood,  and  its 
subsequent  discharge,  by  a  kind  of  secretion,  either  into  shut  cavities,  or  through 
some  one  of  the  natural  vents  of  the  body.  The  balance  of  the  circulation  between 
the  skin  and  the  internal  surfaces  appears  to  be  destroyed,  on  these  occasions,  by  the 
operation  of  external  cold  upon  the  tegumentary  membranes. 

But  by  far  the  greater  number  of  cases  of  ascites  are  cases  of  passive  dropsy  which 
arise  slowly  from  a  mechanical  obstacle  to  the  free  return  of  the  venous  blood 
towards  the  heart. 

Ascites  occurs,  as  you  know,  in  general  dropsy,  with  anasarca  of  the  universal 
areolar  tissue  ;  and  this  general  effusion  of  fluid  depends,  in  almost  every  case,  either 
upon  a  peculiar  renal  disorder,  or  upon  organic  disease  of  the  viscera  of  the  thorax ; 
of  the  lungs,  or  of  the  heart,  or  of  both  ;  and,  above  all,  upon  such  disorder  as  is 
attended  with  dilatation  of  the  right  chambers  of  the  heart. 

But  I  exclude  this  form  of  ascites,  wherein  the  dropsy  of  the  belly  is  only  a  por- 
tion of  more  general  disease  of  the  same  kind,  and  limit  myself  at  present  to  that 
kind  of  passive  ascites  which  is  unattended  with  dropsy  elsewhere,  or  which  at  any 
rate  precedes  the  occurrence  of  serous  accumulation  in  other  parts. 

The  symptom  which  first  leads  us  to  suspect  ascites,  is  the  progressive  enlarge- 
ment of  the  abdomen.  But  the  abdomen  may  grow  gradually  large  and  prominent 
when  there  is  no  disease  whatever:  in  pregnancy,  for  example,  or  in  mere  obesity. 
It  is  necessary,  therefore,  to  search  for  more  definite  signs  of  peritoneal  dropsy. 

In  order  to  make  an  accurate  diagnosis  of  ascites,  we  must  know  what  are  the 
morbid  conditions  with  which  it  is  most  liable  to  be  confounded.  Solid  tumours  and 
simple  corpulency  are  readily  enough  distinguished.  But  there  are  certain  kinds 
of  encysted  dropsy  of  the  abdomen,  of  which  the  recognition  is  not  so  easy  and 
obvious.  Of  these,  what  is  called  ovarian  dropsy  is  the  chief.  In  some  of  its  symp' 
toms,  this  complaint  closely  resembles  ascites  ;  in  some,  it  differs  from  it  widely.  So, 
also,  the  treatment  of  the  two  disorders  is  alike  in  some  respects  ;  dissimilar  in  others. 
For  these  reasons,  and  because  I  am  more  solicitous  to  be  practical  than  to  be  me- 
thodical, I  shall  consider  these  two  maladies  together ;  turning  first  to  the  one,  and 
then  to  the  other,  and  marking,  as  I  go  on,  the  various  points  of  simihtude  and  con- 
trast which  they  mutually  offer. 

Recollect  that  ascites  signifies  the  accumulation  of  serous  liquid  in  the  bag  of  the 
peritoneum ;  whereas  ovarian  dropsy  consists  in  the  collection  of  fluid  in  one  or 
more  cells  within  the  ovary,  or  in  a  serous  cyst  connected  with  the  uterine  ap- 
pendages. 

One  source  of  distinction  between  the  two  is  furnished  by  the  condition  of  the 
abdomen  during  their  early  stages. 

In  ascites  the  enlargement  is  uniform  and  symmetrical,  in  reference  to  the  two 
sides  of  the  body.  When  the  patient  lies  on  her  back,  the  flanks  bulge  outwards, 
or  swag  over,  from  the  weight  and  lateral  pressure  of  the  augmenting  fluid.  This 
increased  breadth  of  the  trunk  is  not  observable  in  the  case  of  an  ovarian  tumour ; 
nor,  I  may  add,  in  pregnancy. 

When  we  are  able  to  trace  the  early  history  of  ovarian  dropsy,  we  find,  in  most 
instances,  that  the  abdominal  tumour  was  first  perceived  on  one  side  ;  in  one  or  the 
other  of  the  iliac  fossae,  or  somewhere  between  the  ribs  and  the  ilium.  But  when 
the  enlargement  of  the  abdomen  is  great,  the  distinction  between  ascites  and  encysted 
dropsy,  drawn  from  the  shape  of  the  swelling,  ceases.  The  ovarian  tumour  distends 
the  abdomen,  if  not  uniformly,  yet  nearly  or  quite  as  much  on  one  side  as  on  the 
other. 

The  next  thing  we  do,  when  the  visible  bulk  and  shape  of  the  abdomen  have 
suggested  a  suspicion  of  ascites,  is  to  employ  the  sense  of  touch. 

Examination  by  pressure  will  sometimes  suffice  to  assure  us  that  there  is  fluid  in 
the  peritoneum.  If  you  press  suddenly  with  the  tips  of  your  fingers,  in  a  direction 
perpendicular  to  the  surface,  you  will  often  become  aware  of  a  sensation  which  it  is 
difficult  to  describe  in  words,  yet  which  is  quite  decisive,  and  not  to  be  mistaken :  a 
.■sensation  of  the  displacement  of  liquid,  and  of  the  impinging  of  your  fingers  upon 


742  ASCITES. 

some  solid  substance  below.  So  that,  by  this  manoeuvre,  you  frequently  detect,  not 
merely  the  presence  of  the  liquid,  but  an  enlarged  liver,  or  spleen,  or  (it  may  be)  an 
ovarian  or  other  tumour;  ev-en  when  simple  palpation,  or  handling  in  the  ordinary 
wa}',  would  not  enable  you  to  ascertain  these  enlargements. 

A(ram, peratssion  of  the  abdomen  is  fertile  of  information  in  these  cases.  First, 
by  the  sense  of  fluctuation  which  it  causes  when  hquid  is  collected  within.  The 
left  hand  being  laid  flat  against  one  side  of  the  tumid  abdomen,  if  a  slight  blow  be 
struck  with  the  fingers  of  the  right  upon  the  opposite  side,  the  impulse  is  conveyed 
by  a  wave  of  the  liquid  to  the  open  flat  hand,  which  feels  a  little  shock  that  is  per- 
fectly distinctive.  The  larger  the  amount  of  the  accumulated  liquid,  and  the  thinner 
and  tighter  the  walls  within  which  it  is  confined,  the  more  sensible  and  decided  is 
this  fluctuation.  Even  when  the  quantity  is  small,  not  exceeding  a  few  ounces,  a 
little  practice  and  management  will  enable  you  to  detect  it.  Percuss  with  one  finger 
the  most  depending  part  of  the  cavit}^  and  apply  at  the  same  time  a  finger  of  the 
other  hand,  very  near  the  part  struck;  and,  if  liquid  be  there,  you  will  perceive  a 
limited  j'et  distinct  fluctuation.  In  the  same  way,  the  presence  of  liquid  in  a  small 
cyst  may  sometimes  be  ascertained.  Much  more  when  the  cyst  is  large.  And  the 
cyst,  in  ovarian  dropsy,  is  often  very  large,  and  the  liquid  it  contains  is  often  thin  and 
aqueous ;  and  then  the  fluctuation  ma}^  be  quite  as  perfect  and  perceptible  as  ever  it 
is  in  ascites. 

Hence,  mere  fluctuation  is  not  a  discriminating  symptom  between  ascites  and 
ovarian  dropsy. 

But,  secondly,  percussion  is  full  of  instruction  in  the  somids  it  elicits.  The  sense 
of  hearing  will  generally  supply  what  the  sense  of  touch  may  leave  wanting. 

In  true  ascites,  the  relative  place  of  the  liquid  and  of  the  intestines  is  determined 
by  the  posture  of  the  patient.  The  bowels,  which  always  contain  some  gas,  float 
to  the  upper  part  of  the  liquid,  and  there  give  out  (when  the  finger,  as  a  pleximeter, 
is  apphed  to  the  corresponding  surface,  and  struck)  their  peculiar  resonance.  Me- 
diate percussion  will  thus  follow  the  gravitating  fluid,  and  discover  always  a  dul. 
sound  in  the  lowermost,  and  a  hollow  sound  in  the  uppermost,  part  of  the  abdomen. 

But  it  is  not  so  in  ovarian  dropsy.  The  cyst,  in  a  diseased  and  enlarging  ovary, 
rises  in  front  of  the  intestines,  which,  being  tied  down  by  the  mesentery,  cannot 
embrace  the  tumour  so  as  to  reach  its  anterior  aspect,  but  are  in  fact  pressed  back  by 
it  towards  the  spine.  Hence,  if  there  be  any  resonance  produced  by  percussion,  it 
is  in  one,  or  the  other,  or  in  both,  of  the  flanks;  and  the  umbilical  region  yields  a 
dull  sound,  whatever  the  position  of  the  patient  may  be.  The  same  is  true  of  the 
enlarging  womb  in  pregnancy. 

The  simple  expedient,  then,  is  quite  decisive.  In  ascites  the  epigastric  and  umbi- 
lical regions'  are  tympanitic  on  percussion  ;  in  ovarian  dropsy  the  latter,  at  least,  is 
dull.  To  be  quite  sure  it  is  well  to  make  the  patient  assume  difll^rent  postures  in 
succession.  If  the  person  affl'Cted  with  ascites  turns  upon  her  side,  the  uppermost 
flank  will  become  resonant ;  the  umbilical  region  dull:  whereas  in  ovarian  dropsy, 
the  sounds  remain  severally  where  they  were  under  every  change  of  position.  In 
ascites,  with  a  little  care,  you  may  ascertain  the  exact  level  at  which  the  contained 
hquid  stands ;  and  measure  its  rise  or  fall  from  day  to  da3^ 

This  mode  of  diagnosis  is  scarcely  open,  under  ordinary  circumstances,  to  fallacy 
or  exception.  Yet  there  are  two  or  three  possible  conditions  in  which  it  may  fail ; 
and  these  it  is  right  that  I  should  briefly  mention. 

1.  The  distension,  in  true  ascites,  may  be  so  great,  that  the  mesentery  shall  not 
b(!  broad  enough  to  allow  the  buoyant  intestines  to  reach  the  surface,  when  the 
patient  is  supine.  This  impediment  to  the  efficacy  of  the  proposed  test  I  have  met 
with  in  practice.  A  woman  came  under  my  charge  in  the  hospital  with  ascites. 
Fluctuation  of  the  belly  was  unequivocal.  While  she  lay  on  her  back,  the  umbili- 
cal and  epigastric  regions  were  resonant  when  percussed  ;  the  flanks  were  dull. 
When  she  turned  upon  either  side,  the  other  side,  previously'-  dull,  gave  the  hollow 
sound;  the  umbilical  and  epigastric  regions,  previously  resonant,  gave  the  dull  flat 
sound.  Under  the  treatment  employed,  the  accumulated  liquid  was  removed,  and 
sne  lef^  the  hospital. 


ASCITES. 

Some  time  afterwards,  as  I  was  going  round  the  wards,  I  recognized  the  same 
iv'oman  among  the  patients  recently  admitted  by  my  colleague.  Dr.  Hawkins.  The 
ascites  had  returned.  The  abdomen,  enormously  distended,  projected  upwards, 
,  as  she  lay  on  her  back,  to  an  excessive  height.  I  found  that  fluctuation  was  very 
distinct,  as  before :  but  every  part  of  the  belly  yielded  a  dull  sound  when  struck  by 
the  lingers.  At  length  this  patient  died :  and  it  was  seen,  after  death,  that  there 
was  nothing  to  prevent  the  rising  of  the  intestines.  They  had  floated,  at  the  utmost 
tether  of  the  mesenter}',  as  high  as  they  could,  without  reaching  the  surface  of  the 
prominent  belly. 

2.  Another  occasional  source  of  fallacy  I  have  just  now  hinted  at.  The  intestines 
may  be  tied  down,  and  so  prevented  from  ascending  by  their  specific  lightness,  to 
the  upper  part  of  the  surrounding  liquid.  And  this  may  happen,  either  in  conse- 
quence of  the  adhesion  of  the  various  coils  of  the  intestines  to  each  other,  and  to  the 
parts  behind  them  :  which  is  not  an  uncommon  occurrence : — or  the  intestines, 
though  unadherent,  may  be  swathed,  as  it  were,  and  bandaged  down,  by  a  thickened 
and  diseased  omentum.  This  also  I  have  myself  seen.  A  man  died  in  the  hospi- 
tal, who  had  manifest  ascites.  Yet  his  whole  abdomen,  though  not  so  much  distended 
as  to  hinder  the  intestines,  had  they  been  free  to  rise,  from  reaching  its  walls, 
sounded  dull  on  percussion.  Ins])ection  of  the  body  explained  this  circumstance. 
When  the  peritoneum  was  opened  by  an  incision  carried  through  the  fore-part  of 
the  abdomen,  a  quantit}^  of  serous  liquid  gushed  out.  The  floor  of  the  cavity  which 
it  had  occupied  was  smooth  and  level ;  and  was  found,  on  further  examination,  to  be 
formed  by  a  tiiick  cake  of  omentum,  strapped  tightly  over  the  subjacent  intestines. 
Of  course,  the  same  diseased  condition  may  occur  in  the  female. 

8.  On  the  other  hand,  I  have  once  known  an  ovarian  cyst  to  exist,  when  the  um- 
bilical region  was  tympanitic  under  percussion.  The  case  furnished  just  that  kind  of 
exception  which  serves  to  prove  a  rule.  This  was  also  a  hospital-patient.  Her  his- 
tory  was  the  history  of  ovarian  dropsy.  Some  time  previously  she  had  discovered 
a  small  tumour  in  one  of  the  iliac  regions.  It  increased  without  much  disturbance 
of  her  general  health,  until  it  became  very  inconvenient  from  its  bulk.  She  was 
then  tapped  in  one  of  the  Borough  hospitals :  and  she  staled  distinctl}'-  that  it  was 
not  a  clear  watery  fluid  that  was  evacuated;  but  a  glutinous,  mixed,  and  grumous 
matter :  such  as  belongs  to  ovarian  disease.  No  doubt  could  be  entertained  that  the 
enlargement  of  the  abdomen  resulted  from  disease  of  that  kind.  Yet  the  umbilical 
region,  when  percussed,  always  rendered  a  hollow  sound.  Upon  the  death  of  the 
patient  the  mystery  was  solved.  Air  hissed  forth  from  the  opening  made  by  the 
scalpel  through  the  abdominal  parietes  :  and  the  source  of  it  being  traced,  an  ovarian 
cyst,  of  considerable  magnitude,  was  found  adhering  to  the  peritoneum  in  front  of 
the  belly,  and  containing  no  liquid,  but  some  yellowish  shreds  only ;  the  remains, 
apparently,  of  some  smaller  included  cysts.  This  ovarian  bag  had  been  filled  with 
air,  and  had  given  occasion  to  the  equivocal  sounds. 

These  sources  of  possible  mistake  or  obscurity  very  seldom  occur;  and  the  phy- 
sical diagnosis,  as  I  have  now  pointed  it  out,  is  very  sure  and  valuable.  So  com- 
pletely physical,  indeed,  are  these  tests,  that  we  recognize  ascites  by  them  as  readily 
and  certainly  in  the  dead,  as  in  the  living  body. 

Other  points  of  distinction  may  frequently  be  derived  from  the  history  and  progress 
of  the  two  disorders. 

The  equable  enlargement  of  the  abdomen,  on  both  sides,  in  ascites ,  and  its  une- 
qual prominence  on  one  side  in  the  early  stages  of  ovarian  disease ;  I  have  already 
mentioned. 

Again,  it  is  observable  that  in  true  ascites,  there  are  almost  always  manifest  indi- 
cations of  constitutional  suffering  and  disturbance  :  a  sallow  complexion  ;  debility  ; 
emaciation.  The  morbid  accumulation  results  (as  we  shall  see)  from  disease  in 
some  organ,  of  which  the  functions  cannot  be  impaired  without  injury  to  the  whole 
system. 

Ovarian  dropsy,  on  the  other  hand,  may  last  long,  and  be  extreme  m  degree, 
while  the  general  health  is  scarcely  affected.  The  very  bulk  and  weight  of  the 
swelHng,  produce,  indeed,  much  inconvenience  and  discomfort;  but,  in  other  re- 


/44  CHRONIC    ASCITES. 

spects,  the  patient  often  remains  in  good  health.  This  appears  to  be  owing  to  the 
circumstance  that  the  ovary  is  not  directly  necessary  to  the  life  or  well-being  of 
the  individual,  but  is  merely  subservient,  for  a  limited  time,  to  the  purpose  of  repro- 
duction. 

Among  the  symptoms  that  are  common  to  ascites  and  ovarian  dropsy  in  their 
advanced  stages,  are  all  those  which  are  occasioned  by  weight  and  pressure  :  viz., 
shortness  of  breath,  from  the  resistance  opposed  to  the  descent  of  the  diaphragm ; 
anasarca  of  the  legs  and  thighs,  from  pressure  upon  the  inferior  cava  and  its  branches ; 
and  a  peculiarity  of  carriage  and  gait,  like  those  of  a  woman  big  with  child,  and  de- 
pending upon  the  same  cause,  the  necessity  of  throwing  the  head  and  shoulders  back- 
wards, to  balance  the  weight  of  the  distended  abdomen  in  front. 

It  is  necessary  to  caution  you  against  mistaking  a  distended  bladder  for  dropsy  of  ■ 
the  abdomen.  An  old  Frenchman  was  brought  into  the  Middlesex  Hospital,  afdicted 
(so  his  friends  said)  with  dropsy.  He  had  been  treated  for  that  complaint.  The 
abdomen  was  large,  and  dull  under  percussion  from  the  pubes  to  above  the  umbili- 
cus. In  the  hypogastric  region  I  could  detect  an  obscure  sense  of  fluctuation.  I 
noticed  a  strong*  smell  of  urine  about  this  patient.  Being  interrogated,  he  said  that 
he  had  formerly  had  some  "stoppage,"  but  that  he  now  passed  plenty  of  water; 
that  it  'fven  ran  from  him.  It  was  obvious  that  his  bladder  was  enormously  distended, 
unabl*^  to  contract  upon  its  contents,  and  overflowing.  With  some  difficulty  a  cha- 
theter  was  introduced,  and  some  quarts,  I  forget  the  exact  quantity,  of  turbid  and 
stinking  urine  were  drawn  off.  The  patient  sunk  at  length,  and  the  bladder  was 
found  to  be  much  diseased.  I  have  known  similar  mistakes  occur  in  private  prac- 
tice. You  will  not  think  the  caution  I  am  now  giving  you  superfluous,  when  I  tell 
you,  on  the  authority  of  Sir  Everard  Home,  that  John  Hunter  once  actually  tapped 
a  distended  bladder,  in  the  belief  that  the  disorder  was  ascites. 

Encysted  dropsy,  in  the  abdomen,  is  not  always  ovarian  dropsy.  Omental 
dropsy  is  described  :  the  omental  cavity  alone  being  unfolded,  and  full  of  liquid. 
This  I  have  never  seen.  Cysts  containing  a  considerable  quantity  of  a  clear  thin 
liquid,  and  connected  with  the  liver,  are  common.  Probably  these  are  in  all  cases 
(they  certainly  are  in  many)  the  effects  of  the  growth  of  hydatids.  Dropsy  of  the 
Fallopian  tubes :  dropsy  of  the  uterus  :  large  serous  cysts  in  the  kidney :  constitute 
other  forms  of  abdominal  encysted  dropsy.  Such  states  must  be  discovered  by  their 
own  particular  circumstances.     None  of  them  are  very  common. 


LECTURE  LXVII. 

Pathology  of  Chronic  Jlscifes ;  of  Ovarian  Dropsy.  Treatment  of  these  two 
disorders.  Internal  remedies :  Extirpation  of  the  ovarian  sac :  Paracentesis 
Abdominis. 

In  my  last  lecture  I  pointed  out  the  means  we  possess  of  distinguishing  ascites 
from  ovarian  dropsy.  Continuing  the  parallel  between  these  two  disorders,  I  have 
still  to  consider  their  pathology ;  and  to  prescribe  their  treatment. 

I  mentioned  that  chronic  ascites  is  sometimes  the  sequel  of  acute  inflammation  of 
the  peritoneum.  In  such  cases,  the  abdomen  is  usually  uneasy,  and  tender  under 
pressure  ;  or  at  any  rate,  more  sensible  than  common  :  and  I  believe  more  hot  also 
than  common.  Whereas  when  ascites  is  passive  as  well  as  chronic,  you  may  make 
the  requisite  examination  without  causing  any  distress  to  your  patient.  There  is  no 
pain  produced  by  palpation,  by  pressure,  or  by  percussion.  Even  when  the  dropsy 
has  resulted  from  bygone  inflammation,  it  does  occasionally,  though  rarely,  happen^ 
that  no  other  trace  of  such  inflammation  is  discoverable  in  the  living  patient.  The 
absorbing  function  of  the  membrane  having,  however,  been  spoiled,  the  coflected 
iK^uid  remains.     Such  a  condition,  I  beheve,  I  have  witnessed.     The  history  of  siul- 


CHRONIC   ASCITES.  '  745 

den  and  sharp  pain,  and  tenderness  of  the  abdomen,  with  fever,  immediately  before 
the  dropsical  swelling  took  place,  made  it  probable  that  it  was  the  consequence  of 
inflammatory  effusion.  But  the  fever  had  entirely  subsided ;  no  tenderness  was 
left ;  no  large  veins  were  visible  on  the  surface  of  the  belly,  denoting  internal  ob- 
struction ;  and  the  general  health  was  good.     The  patient  had  no  other  dropsy. 

The  main  exciting  cause,  however,  of  true  and  uncombined  ascites,  Avhen  no 
inflammation  is,  or  has  been,  at  work,  is  some  impediment  to  the  venous  circulation 
in  the  abdomen.  Whereabouts,  and  of  what  kind,  is  this  impediment  ?  That  is  the 
question  which,  in  each  particular  instance,  we  ask  ourselves. 

The  old  doctrine  respecting  the  causes  of  ascites,  vaguely  referred  the  collection 
of  liquid  to  obstruction ;  and  to  organic  diseases  of  the  abdominal  viscera;  and, 
above  all,  to  hepatic  disease.  But  as  we  are  now  better  instructed,  and  know  that 
organic  diseases  produce  the  dropsy,  ultimately,  by  retarding  the  flow  of  blood  through 
the  system  of  the  vena  porlce,  we  see  that  the  truth  was  only  half  perceived  by  the 
ancient  pathologists.  We  can  now  understand  Avhy  some  organic  diseases  of  the 
abdomen  lead  to  dropsy  of  the  peritoneum,  and  others  (even  of  the  same  viscus)  do 
not.  And  we  have  no  difficulty  in  comprehending  why,  of  all  the  abdominal  viscera, 
the  liver  is  the  one  whose  diseases  are  the  most  frequently  connected  with  ascites: 
that  gland  being  traversed  by  the  converging  branches  of  the  venous  trunk,  through 
which  passes  by  far  the  greater  part  of  the  serosity  absorbed  from  the  surface  of  the 
vast  membrane  that  enwraps  most  of  the  abdominal  organs,  and  hnes  the  cavity  con- 
taining them.  It  is  plain  that  an  accumulation  of  serum  in  the  peritoneal  sac  may 
arise  from  a  mechanical  obstruction  in  the  trunk  of  the  vena  portJB,  or  in  some  of  the 
principal  branches  that  unite  to  form  that  vein ;  or  from  certain  diseases  of  the  hver 
itself.  But  we  know  that  disease  of  the  liver  is  of  very  common  occurrence,  and 
oftentimes  very  obvious,  while  there  is  no  ascites.  And  a  further  question  arises — 
With  what  kinds  of  disease  of  the  liver  is  hepatic  ascites  most  apt  to  be  associated  ? 

In  truth,  there  is  one  special  form  of  liver-disease  which,  though  not  the  sole,  is 
the  grand  cause,  of  passive  and  simple  ascites.  It  has  long  been  noticed  that  mere 
enlargement  is  not  the  most  common  condition  of  the  liver  met  with  in  hepatic 
dropsy ;  but  rather  the  small,  hard,  contracted  viscus.  Mere  increase  in  the  size 
of  the  organ  may  interfere  but  little  with  the  portal  circulation  ;  whereas  a  shrink- 
ing and  diminution  of  its  bulk  must  needs  do  so.  In  point  of  fact,  that  particular 
state  of  the  liver  which  the  French  have  termed  cirrhose,  and  which  is  familiar  to 
morbid  anatomists  in  this  country  as  the  hobnail  liver,  is  the  great  source  of  passive 
ascites. 

The  true  character  of  this  remarkable  condition  of  the  liver  is  of  modern  discovery. 
The  credit  of  correcting  the  erroneous  opinions  which  had  been  entertained  respect- 
ing it  is  due,  I  beheve,  to  Mr.  Kiernan.  The  change  undergone  by  the  organ  has 
also  been  clearly  described  by  Dr.  Carswell;  whose  delineations  of  its  physical 
appearance  are  now  before  you.  The  change  results  from  chronic  inflammation,  and 
chronic  thickening  (miscalled  hypertrophy)  of  Glisson's  capsule.  Since  Mr.  Kier- 
nan's  admirable  exposition  of  the  minute  anatomy  of  the  liver  has  been  given  to  the 
world,  few  can  be  ignorant  that  the  areolar  tissue,  termed  the  capsule  of  Glisson, 
accompanies  the  portal  vein,  the  hepatic  artery,  and  the  biliary  ducts ;  and  forms  a 
sheath  around  these  vessels  in  their  course  through  the  liver:  while  the  hepatic  vein 
and  its  branches  are  lodged  in  the  proper  substance  of  the  gland  without  any  such 
investing  membrane.  It  follows  that  a  general  thickening  of  this  tissue  must  produce 
a  general  pressure  upon  the  portal  veins,  and  hinder  the  return  of  the  venous  blood 
from  the  intestines.  Hence,  as  in  analogous  cases,  congestion  of  the  capillaries, 
arrested  absorption,  mechanical  transudation  of  serous  liquid.  The  pressure  affects 
also  the  nutrient  vessel,  the  artery  of  the  liver ;  so  that,  in  most  instances,  there  are 
atrophy  and  shrinking  of  the  organ.  And  sometimes,  but  not  always,  from  pressure 
upon  the  biliary  vessels,  there  is  jaundice  also.  By  degrees,  the  areolar  tissue 
itself  begins  to  shrink  ;  and  the  spaces  in  which  it  ramifies  on  the  surface  of  the  h  rer 
are  pulled  inwards;  the  lobules  appear  to  be  promment ;  and  the  surface  becomes 
irregular  and  knobby,  and  studded  with  little  roundish  eminences  like  the  head« 

3n 


74G  CHRONIC    ASCITES. 

of  nails.  Tlie  constricted  lobules  are  very  conspicuous  in  the  cut  surface  also  of  the 
liver. 

In  the  living  body  the  presence  of  this  hepatic  disease  is,  for  the  most  part,  a 
matter  of  inference  only.  It  is  rendered  probable  by  its  ascertained  frequency  in 
connection  with  ascites,  and  by  the  absence  of  any  other  obvious  cause  for  tho 
dropsy.  But  sometimes  the  irregular  surface  can  be  felt  through  the  walls  of  the 
abdomen. 

The  nature  of  this  morbid  change  affords  a  reason  for  the  intractable  and  unpro- 
mising character  of  ascites  in  general.  The  obstructed  blood  seeks,  indeed,  new 
channels ;  but  the  compensation  they  furnish  is  rarely  sufficient.  The  superficial 
veins  become  obvious,  numerous,  large ;  and  wander  with  many  inosculations  over 
the  surface  of  the  belly.  Large  veins,  significant  of  the  same  compensating  effort, 
have  been  met  with  also  in  the  adhesions  which  previous  inflammation  had  left  be- 
tween the  liver  and  the  diaphragm. 

Among  the  causes  to  which  the  thickening  of  the  capsule  of  Glisson  may  be  as- 
cribed, habitual  intemperance  holds  the  chief  place. 

But  this  condition  of  Glisson's  capsule,  though  it  is  the  principal,  and  by  far  the 
most  frequent,  is  not  the  only  cause  of  obstruction  to  the  current  of  the  blood  in  the 
portal  vessels,  and  of  consequent  ascites.  In  those  specific  forms  of  liver  disease  in 
which  separate  tumours  are  scattered  through  its  substance,  one  of  these  tumours 
may  be  so  placed  as  to  press  upon  the  trunk  of  the  vein.  So,  obviously,  may  ab- 
dominal tumours  of  any  kind  ;  enlarged  mesenteric  glands;  cancer  of  the  pylorus  ; 
cancer  of  the  head  of  the  pancreas ;  and  the  like. 

Ascites  is  found  to  be  not  unfrequently  associated  with  disease  and  enlargement 
of  the  spleen  also ;  but  in  most  instances  of  this  kind,  the  enlargement  of  the  spleen 
and  the  peritoneal  dropsy  are  not  connected  as  cause  and  effect ;  but  are  both  conse- 
quences of  portal  obstruction. 

When,  after  death  preceded  by  ascites,  the  cavity  of  the  abdomen  is  laid  open,  its 
contents  present  a  bleached  and  sodden  appearance.  It  has  been  made  a  question 
whether  this  be  the  result  of  the  long-continued  immersion  of  the  living  tissues  in 
the  accumulated  water ;  or  of  their  short  maceration  after  death.  The  question  has 
no  practical  importance. 

Dropsy  of  the  ovary,  in  its  ordinary  form,  consists  (I  believe)  in  disease  and 
enlargement  of  one,  or  more,  of  the  Graafian  vesicles ;  or  of  the  ova  which  they 
inclose. 

The  actual  condition  of  the  dropsical  ovary  is  subject  to  much  variety.  Sometimes 
there  is  but  one  cyst ;  and  this  may  be  no  bigger  than  a  pea ;  or  it  may  be  large 
enough  to  contain  many  gallons.  Its  walls  may  be  as  thin  and  flexible  as  those  of 
the  healthy  urinary  bladder;  or  they  may  be  firm,  and  half  an  inch  or  more  in  thick- 
ness. It  may  spring  from  a  small  pedicle,  and  he  free  and  unattached  to  the  cavity 
of  the  peritoneum ;  or  it  may  adhere,  partially  or  at  all  points,  to  the  contiguous 
parts  ;  or  it  rnay  be  tied  down  by  bands  of  coagulable  lymph.  Its  inner  surface  may 
be  smooih  and  even,  or  knobby  and  irregular.  Lastly,  the  fluid  contained  in  the 
cyst  may  be  thin,  or  consistent ;  limpid,  or  glutinous  ;  opaque,  or  transparent ;  and 
of  various  tints ;  so  that,  in  different  cases,  it  may  be  colourless,  green,  purple,  red  ; 
and  more  or  less  resemble  in  appearance  pure  water,  white  of  egg,  jelly,  glue,  bird- 
Hme,  or  treacle.  Most  commonly,  however,  wheri  the  cyst  is  single,  its  contents  are 
thin  and  aqueous. 

Again,  the  dropsical  ovary  may  be  multilocular,  composed  of  many  cysts,  which 
are  usually  distinct,  but  which  sometimes  communicate  together;  and  these  cysts, 
in  the  same  ovary,  while  they  vary  much  in  size,  may  differ  also  from  each  other  in 
any  or  all  the  particulars  just  enumerated  as  being  mcidental  to  a  solitary  C3'^st. 

Commonly  one  of  the  cysts  is  much  more  capacious  than  the  rest;  and  some  part 
ol  its  inner  surface  is  frequently  embossed,  as  it  were,  by  the  projecting  outline  of 
d.  group  of  small  nodules,  which  seem  to  lie  within  the  parietes  of  the  larg.'r  cyst, 
but  which,  in  truth,  are  cysts  of  similar  origin  with  it,  but  of  more  stunted  growth. 

The  externa!  surface  also  of  the  multilocular  ovary  is  generallj'-  lobulated  ;  and  its 


OVARIAN    DROPSY.  747 

inequalities  may  often  be  discovered  by  a  careful  examination  of  the  abdomen  in  the 
living  subject. 

Sometimes  the  tumour  is  sohd  throughout ;  in  which  case  the  term  dropsy  is  alto- 
gether misapplied. 

These  differences  are  not  without  occasional  importance,  in  reference  to  some 
points  in  the  treatment  of  the  disease. 

The  proa;ress  of  ovarian  dropsy  is  no  less  wanting  in  uniformity.  Sometimes  it 
is  very  rapid ;  sometimes  it  is  very  slow.  It  may  destroy  life  in  a  few  months  ;  it 
may  continue,  a  mere  burden,  with  scarcely  any  fatal  tendency,  for  many  years.  Not 
unfrequently,  after  a  period  of  active  increase  in  the  tumour,  the  morbid  process, 
without  any  obvious  cause,  suddenly  stops :  and  the  pause  may  be  final ;  or,  after 
an  uncertain  interval,  the  disease  may  j-esume  its  former  activity. 

Under  all  circumstances  the  malady  is  a  serious  one :  for  its  possible  grievances 
are  many ;  and  its  issue  is  precarious  and  unpromising.  Although,  in  some  cases, 
the  general  health  for  a  long  time  is  but  slightly  or  not  at  all  impaired,  in  others 
the  disease  runs  a  short  course;  the  tumour  increasing  rapidly  and  proving  ulti- 
mately fatal  by  its  bulk  and  pressure ;  or  embittering  and  abridging  the  unhappy 
patient's  existence  by  some  accident  of  growth  or  position.  Even  when  of  no  vast 
magnitude,  it  may  be  so  situated  as  to  impede  or  prevent  the  expulsion  of  the 
feces  from  the  bowel,  of  the  urine  from  the  bladder,  or  of  the  foetus  from  the  gravid 
uterus. 

The  single  cysts,  having  thin  parietes,  and  containing  a  serous  liquid,  are  not 
always  produced  by  disease  and  distension  of  a  Graafian  vesicle  ;  for  they  sometimes 
have  no  connection  with  the  ovary,  but  spring  from  some  other  part  of  the  uterine 
appendages. 

Neither,  perhaps,  can  it  be  demonslraled  that  the  complaint  originated  within  the 
Graafian  vesicles,  when  it  exists  in  its  more  complicated  form ;  when  the  cysts  are 
many,  and  their  contents  various.  But  the  shape  of  the  cysts,  which  are  more  or 
less  spherical,  their  number,  their  isolation  in  most  cases,  and  the  diversity  in  the 
matters  by  which  they  are  filled,  render  this  view  of  their  origin  at  least  a  probable 
one. 

This  form  of  the  disorder  has  been  considered  as  belonging  to  the  category  of 
malignant  diseases  ;  but,  in  my  judgment,  without  sufficient  reason.  It  is  true  tlia* 
the  tumour  does  sometimes  involve  one  or  more  of  those  morbid  conditions,  which 
have  been  denominated  scirrhus,  fungus  hsemalodes,  cerebriform  disease,  or  mela- 
nosis, and  which  all,  or  nearly  all,  appear  to  be  varying  results  of  the  same  morbid 
process,  and  to  be  referable  to  the  genus  carcinoma :  but  whenever  this  is  observed 
to  be  the  case,  other  structures  also  are  found  to  be  infested  with  analogous  changes. 
The  so-called  malignant  disease  occupies  the  ovary  in  common  with  other  parts  ;  and 
this  is  one  of  its  most  constant  characters,  namely,  that  proceeding  from  some  vice 
in  the  constitution,  or  disseminated  from  some  local  germ,  it  pervades  different  organs 
of  the  body  at  the  same  time,  or  in  succession  ;  whereas,  in  by  far  the  majority  of 
instances  of  ovarian  dropsy,  these  peculiar  products  are  met  with  neither  in  the 
diseased  gland,  nor  in  any  other  place.  It  has  already  been  remarked  that  many 
women,  labouring  under  ovarian  dropsy,  enjoy,  nevertheless,  in  all  other  respects, 
very  good  health,  even  for  many  years.  The  victims  of  malignant  disease  are  not 
so  fortunate.  They  either  are  soon  cut  off,  or  if  they  linger,  they  seldom  fail  to  ex- 
hibit, in  their  complexion  and  general  condition,  notable  indications  of  the  mischief 
which  is  in  progress,  and  gradually  undermining  the  powers  of  life. 

If  it  be  admitted,  as  a  reasonable  conjecture,  that  the  Graafian  vesicles,  or  the  ova 
they  contain,  are  the  seat  of  the  primary  changes,  we  may  push  our  speculations  a 
litUe  further.  These  ova  are  destined,  under  the  peculiar  stimulus  of  impregnation, 
10  Duild  up  the  fabric  of  the  body  in  all  its  parts  and  qualities.  And  we  may  sup- 
pose that,  in  consequence  of  some  unnatural  and  morbid  stimulus,  perverted  and 
erring  action  may  be  set  up,  and  strange  products  resuU.  It  is  not  uncommon  to 
find  fat,  hair,  cholesterine,  teeth,  and  other  bones,  in  the  diseased  ovaria,  even  of 
virgins. 

This  view  of  the  matter  is  strei  gthened  by  the  fact,  that  dropsy  of  the  ovary,  of 


748  TREATMENT  OF  OVARIAN  DROPSY. 

the  orJinary  kind,  has  not  been  known  to  commence  before  the  age  of  puberty ;  noi 
often  after  the  capability  of  child-bearing  had  ceased;  but  only,  or  chiefly,  during 
that  period  in  which  the  organ,  if  healthy,  is  susceptible  of  its  proper  and  temporary 
functions.  Virgins,  and  barren  and  fruitful  wives,  are  alike  subject  to  the  disease  ; 
but  in  what  relative  proportions,  statistical  inquiry  has  not  yet  (so  far  as  I  know) 
determined.     Where  it  accompanies,  it  may  also  account  for,  sterility. 

The  catamenia  during  the  progress  af  the  malady  sometimes  appear  with  more  oi 
less  of  regularity  and  quantity ;  sometimes  are  entirely  suspended.  This  function 
is  so  often  interrupted  under  other  circumstances,  that  its  derangements  shed  bui 
little  light  upon  cases  that  are  otherwise  obscure.  When  the  discharge  continues 
to  recur,  we  may  presume  that  one,  at  least,  of  the  ovaries  is  in  a  tolerably  healthy 
state :  when  both  are  sensibly  diseased,  the  catamenia  may  be  expected  to  be 
wanting. 

The  treatment  of  these  two  forms  of  abdominal  dropsy  must,  up  to  a  certain  point, 
at  which  the  operation  of  tapping  becomes  expedient,  be  considered  separately.  Of 
both  it  may  be  said,  that  their  cure  is  seldom  accomplished  ;  yet,  for  reasons  already 
assigned,  ascites  has,  upon  the  whole,  a  more  certain  progress  towards  the  destruc- 
tion of  life  than  ovarian  disease  :  while,  perhaps,  it  is  oftener  cured. 

In  passive  ascites,  when  the  distension  of  the  peritoneum  has  crept  on  without 
pain,  fever,  or  other  marks  of  inflammatory  action,  our  first  and  best  hope  of  evacuat- 
ing the  collected  liquid  will  rest  upon  diuretics.  Hepatic  ascites  and.  renal  disease 
may  be  sometimes  found  in  conjunction,  but  according  to  my  experience,  they  seldom 
are  so :  and  except  that  both  may  probably  owe  their  occasional  origin  to  habits  of 
intemperance,  there  appears  no  reason  why  they  should  be.  Diuretics  may  be  ad- 
ministered, therefore,  without  scruple.  The  hydragogue  purgatives  are  to  be  em- 
ployed, also,  when  diuretics  fail  to  act,  or  to  reduce  the  swelHng;  and  when  the 
disease  is  not  already  complicated  with  diarrhcea.  And  inferring  with  more  or  less 
certainty  the  existence  of  hepatic  disease — sometimes  from  palpation  of  the  enlarged 
or  altered  liver,  sometimes  from  the  coincidence  of  jaundice,  but  most  of  all  from  the 
result  of  accumulated  experience  respecting  the  morbid  anatomy  of  such  cases — we 
give  the  patient  the  chance  of  the  remedial  influence  of  mercury.  The  disorder 
being  chronic,  the  introduction  of  that  drug  should  be  gradual.  Th^  iodide  of  potas- 
s'um  is  held  by  some  physicians  to  be  especially  serviceable  in  hepatic  ascites. 
Compounds  of  mercury  and  iodine  may  be  applied,  by  inunction,  to  the  surface  of 
the  abdomen,  and  to  the  right  hypochondrium  m  particular.  In  Germany,  the 
muriate  of  ammonia  is  in  much  repute  as  a  therapeutic  agent.  This  diuretic  salt, 
though  seldom  administered  internally  in  this  country,  is  believed  by  some  practical 
men  who  have  employed  it,  to  exercise  the  same  beneficial  influence  upon  the  func 
lions  of  the  liver,  as  is  commonly  attributed  to  preparations  of  mercury ;  while  it  is 
less  prethictive  of  distress  or  inconvenience.  My  own  experience  upon  this  point  ia 
too  limited  to  justify  me  in  expressing  any  confident  opinion  about  it;  but  in  some 
recent  instances  I  certainl}^  have  noticed  a  remarkable  improvement  in  the  character 
of  the  biliary  excretion,  afier  the  daily  exhibition  of  sal-ammoniac  combined  with  the 
extract  of  taraxacum. 

You  will  generally  be  obliged  to  try,  in  their  turn,  all  the  diuretics  within  your 
reach,  and  frequently  to  no  purpose.  Our  efforts  to  remove  by  medicine  the  accu- 
mulated liquid,  or  to  cure  the  morbid  condition  on  which  the  accumulation  depends, 
are  too  often  made  in  vain.  The  distension  of  the  peritoneum  continues  to  augment ; 
the  distress  arising  therefrom  becomes  urgent  and  extreme ;  and  at  length,  to  aflbrd 
temporary  ease  to  the  patient,  and  in  the  faint  hope  also  of  giving  him  permanent 
relief,  we  resort  to  the  mechanical  expedient  oi  paracentesis. 

When  we  have  the  opportunity  of  treating  ovarian  dropsy  from  its  commence- 
ment, we  sometimes  find  that  the  enlarging  ovary  is  painful,  or  tender.  This  is  an 
indication  for  antiphlogistic  measures.  But  from  such  remedies,  or  from  any  reme- 
dies, little  more  than  temporary  relief  is  to  be  expected.  My  position  as  physician 
to  a  hospital,  has  brought  under  my  notice  several  cases  of  ovarian  swelling,  at  a  very 
early  period  of  its  development ;  when  all  that  could  be  detected  by  careful  exami 


TREATMENT  OF  OVARIAN  DROPSY.  749 

nation  of  the  abdomen  was  a  small  tumour,  not  larger,  perhaps,  than  an  egg,  and 
occupying  the  situation  of  the  ovary;  to  which  the  attention  of  the  patient  had  been 
drawn  by  some  pain  or  uneasy  feehng  in  that  part.  I  have  treated  such  cases  assi- 
duously, with  the  remedies  of  chronic  inflammation,  frequent  topical  bleedings,  and 
the  use  of  mercury  till  the  gums  were  affected  ;  with  the  remedies  of  ordinary  dropsy, 
diuretics  and  drastic  purgatives ;  and  with  remedies  accounted  specific,  the  liquor 
potassse,  the  various  preparations  of  iodine ;  and  I  must  honestly  confess  to  you  that 
I  am  unable  to  reckon  one  single  instance  of  success.  Yet  these  are  the  measures 
that  we  are  bound  to  try.  They  have  succeeded — as  we  are  assured  by  competent 
and  credible  w^itnesses  ;  they  may  therefore  succeed  again.  The  amount  of  my  own 
experience,  however,  tends  to  the  persuasion  that  medicine  has,  in  general,  very 
small  influence  over  the  progress  of  this  disorder.  The  cases  that  do  well,  do  well 
we  scarcely  know  how  or  w^hy  ;  the  cases  that  prove  fatal  run  their  course  in  spite 
of  us. 

Sometimes,  as  has  been  stated,  these  ovarian  tumours  reach  a  certain  magnitude, 
and  then  (wherefore  we  cannot  tell),  enlarge  no  more  ;  but  remain  a  mere  inconve- 
nience and  deformity,  for  many  years.  Occasionally,  either  spontaneously,  or  in 
consequence  of  some  accidental  violence,  they  burst  into  the  cavity  of  the  perito- 
neum, whence  the  effused  fluid  may  be  absorbed  ;  but  more  commonly  it  causes  fatal 
inflammation.  Or  the  bursting  tumour  may  empty  itself  harmlessly  (adhesion  having 
previously  taken  place),  through  some  channel  of  communication  with  the  bowels  or 
with  the  bladder;  or  externally  through  the  parietes  of  the  abdomen. 

Tumours,  supposed  to  be  ovarian,  do  sometimes  disappear  entirely.  It  may, 
however,  be  doubted  whether  all,  or  even  many,  of  the  enlargements  which  have 
had  this  fortunate  issue,  were  really  connected  with  the  ovary.  One  source  of  mis- 
take 1  have  myself  more  than  once  encountered,  and  I  believe  it  to  be  not  uncom- 
mon. A  brief  statement  of  the  circumstances  under  which  I  first  observed  the  falla- 
cious symptom,  will  show  you  at  once  what  1  mean.  Some  years  ago  I  was  sent 
for  by  a  lady,  who  for  many  days  had  been  labouring  under  an  ordinary  attack  of 
continued  fever.  While  examining  the  abdomen  by  pressure,  I  discovered,  on  the 
right  side,  between  the  ilium  and  umbilicus,  a  round,  hard,  painless  tumour,  as  big 
as  a  swan's  egg.  The  patient  was  aware  of  it ;  and  thought  it  had  existed  for  some 
time.  At  the  next  visit  it  was  gone.  In  the  interim,  very  abundant  discharges  from 
the  bowels  had  followed  the  administration  of  purgative  medicine.  The  tumour  had 
obviously  been  formed  by  the  accumulation  of  fecal  matters  in  the  csecum. 

Similar  collections  take  place,  less  frequently,  on  the  left  side,  just  above  the  sigmoid 
flexure. 

The  parts  concerned  in  this  disorder  are  not  essential  to  life,  or  to  the  enjoyment 
of  health.  On  some  of  the  lower  animals  the  operation  of  spaying  is  as  customary 
in  the  one  sex,  and  is  performed  with  as  little  risk,  as  that  of  castration  in  the  other. 
The  ovaries  have  in  several  instances  been  extracted  from  the  living  human  body, 
without  any  ill  consequences.  These  facts,  and  the  intractable  character  of  the  dis- 
ease, have  naturally  suggested  the  expediency  of  extirpating  the  tumour  in  cases  of 
ovarian  dropsy. 

But  although  the  ovary,  when  healthy,  or  when  not  much  enlarged,  may  be  re- 
moved without  much  difficulty  or  hazard,  the  operation  becomes  always  perilous,  and 
often  impracticable,  when  the  altered  gland  has  attained  any  considerable  magnitude. 
Yet  these  are  the  very  cases  for  which  the  remedy  is  needed.  A  large  ovarian 
tumour  is  usually  multilocular,  with  firm  parietes,  and  thick  internal  septa ;  and  is 
therefore  incapable  of  collapsing  much  when  punctured.  To  extirpate  such  a  tumour, 
the  abdomen  must  be  (as  it  frequently  has  been)  laid  open  from  the  sternum  to  the 
pubes.  Most  commonly,  also,  a  large  ovarian  swelling  is  adherent  to  the  contiguous 
parts  ;  a  circumstance  which  either  makes  the  proposed  removal  of  the  tumour  im- 
possible, or,  if  the  connections  admit  of  being  broken  down,  augments  in  a  fearful 
manner  the  jeopardy  of  the  patient.  It  is  not  surprising,  therefore,  that  the  results 
of  experience  have  been  so  discouraging  as  well  nigh,  in  most  minds,  to  prohibit 
such  attempts  in  future.  The  operation  has,  indeed,  in  several  authentic  cases, 
been  auite  successful.     In  other  instances,  the  surgeon,  after  exposing  the  adhereiu 

3n2 


750  TREATMENT  OF  OVARIAN  DROPSY. 

mass,  has  been  fain  to  replace  the  effused  bowels,  and  to  sew  up  the  abdomen,  a? 
speedily  as  possible;  and  the  patient,  having  suffered  all  this  in  vain,  has  sometimes 
been  fortunate  enough  to  escape  with  life  ;  but  not  always.  In  others,  the  adhering 
tumour  has  been  separated,  and  the  object  achieved  ;  and  the  woman  has  lived  there 
after  for  some  hours.  Three  times,  at  least  (one  of  the  cases  is  recorded  b}'^  Mr. 
Lizars,  another  by  Mr.  King,  the  third  fell  under  the  cognizance  of  Dr.  Richard 
Bright),  the  abdominal  muscles  and  the  peritoneum  have  been  slit  open,  for  the  pur 
pose  of  extracting  a  diseased  ovary, — when  no  disease  existed. 

But  of  late,  a  modification  of  the  process  of  excision  —  whereby  it  is  adapted  to 
certain  forms  or  conditions  of  the  disease  —  has  been  proposed  and  practised;  and 
holds  out  somewhat  more  of  promise. 

It  consists  in  making,  not  a  long,  but  a  small  incision  through  the  walls  of  the 
abdomen,  and  through  the  peritoneum,  so  as  to  bring  the  surface  of  the  diseased 
ovary  into  view.  The  cyst  is  then  secured,  by  means  of  a  tenaculum,  or  of  a  ligature, 
from  receding  inwards,  and  punctured,  and  its  contents  are  suffered  to  escape.  When 
the  sac  has  emptied  itself,  it  is  withdrawn  through  the  external  orifice  by  gentle 
traction,  until  its  stalk,  or  place  of  attachment  to  the  broad  ligament,  comes  near  the 
wound.  A  thread  is  tied  round  this  stalk,  the  cyst  is  cut  off",  the  uterine  appendages 
are  put  back  into  the  cavity  of  the  abdomen,  and  the  lips  of  the  wound  are  brought 
together. 

Although  this  method  does  not  appear  to  have  been  actually  performed  till  very 
recently,  it  had  been  suggested  as  long  ago,  at  least,  as  the  time  of  Dr.  William 
Hunter,  who,  in  a  paper  on  the  disease,  has  these  remarks  :  —  "If  it  be  proposed, 
indeed,  to  make  such  a  wound  in  the  belly  as  will  admit  only  two  fingers  or  so,  and 
then  to  tap  the  bag,  and  draw  it  out,  so  as  to  bring  its  root  or  peduncle  close  to  the 
wound  of  the  belly,  that  the  surgeon  may  cut  it  without  introducing  his  hand,  surely 
in  a  case  otherwise  so  desperate,  it  might  be  advisable  to  do  it,  could  we  beforehand 
know  that  the  circumstances  would  admit  of  that  treatment." 

In  these  few  words,  Dr.  William  Hunter  not  only  describes  the  mode  of  excision, 
but  alludes  to  circumstances  that  may  render  it  inadmissible,  as  well  as  to  the  uncer- 
tainty that  may  arise  about  the  existence  of  those  circumstances.  What  the  circum- 
stances are  is  sufficiently  obvious. 

However,  this  suggestion  has  been  carried  into  successful  practice  by  Mr.  West, 
Mr.  King,  and  others.  To  an  interesting  paper  on  the  subject,  published  by  Mr. 
Gorham,  in  the  Lancet,  is  appended  a  summary  account  of  ten  cases ;  by  which 
account  it  appears,  that  five  of  the  ten  patients  were  cured  by  the  operation ;  two 
recovered  from  the  attempt  to  extract,  which  wac  unsuccessful ;  two  died  very  soon 
after  the  operation,  and  evidently  in  consequence  of  it.  The  remaining  patient, 
whose  case  has  already  been  adverted  to,  recovered  also  from  the  incision  :  but  there 
was  no  diseased  ovary  to  amputate :  so  fallacious,  sometimes,  is  the  diagnosis. 

This  mode  of  operating  merits  careful  consideration,  and  further  trial.  Its  recom- 
mendations are — 

1.  That  the  first  steps  —  the  incision  and  the  puncture  —  are  the  same  in  kind  as 
the  first  steps  in  ordinary  paracentesis,  and  not  much  more  severe  or  dangerous  ;  the 
only  difl^erence  being  that  the  incision  requires  to  be  somewhat  larger  in  the  one  case 
than  in  the  other. 

2.  That,  when  successful,  it  affords  a  complete  and  permanent  cure,  which  can 
hardly  be  hoped  for  from  any  other  plan. 

The  objections  to  its  general  use  are — 

1.  That  the  single  sacs,  with  thin  and  flexible  walls,  do  not,  commonly,  reach  a 
very  large  size.  When  small,  or  of  moderate  dimensions,  they  produce  so  httle 
distress  or  inconvenience,  that  an  operation,  which  must  always  be  uncertain  and 
tentative,  ought  not  to  be  recommended. 

2.  That  the  multilocular  tumours,  with  solid  walls  and  partitions,  can  scarcely  be 
BO  drawn  through  the  opening  made  into  the  abdomen. 

3.  And  above  all,  that  adhesion  of  the  tumour  to  the  neighbouring  parts  would 
mterfere  with  and  prevent  the  success  of  the  operation. 

In  mosc,  nowerer,  of  the  five  cases  of  cure  referred  to  by  Mr.  Gorham,  the  sacs 


TREATMExNT   OF   OVARIAN    DROPSY.  75J 

thus  removed  were  large.  From  one  of  them  12  pints  of  fluid  were  let  3ut ;  from 
another,  27  pints  ;  from  a  third,  upwards  of  20  ;  and  from  a  fourth,  24  pints. 

It  is  difficult  to  guess  beforehand,  whether  the  tumour  be  attached  to  the  parts 
surrounding  it  or  no.  If  it  be  readily  movable  by  the  fingers  applied  to  the  surface 
of  the  belly,  so  as  to  admit  of  being  pushed  hither  and  thither  without  pain  or  dis- 
tress to  the  patient,  it  is  probably  unadherent.  In  one  of  the  same  five  cases,  the 
patient  being  in  labour,  Mr.  West  found  that  the  tumour  lay  between  the  uterus  and 
the  brim  of  the  pelvis.  By  gentle  pressure,  per  vaginam,  it  was  made  to  recede 
into  the  cavity  of  the  abdomen.  This  afforded  a  presumption  that  it  wa.s  free  from 
adhesion  ;  accordingly  the  sac  was  afterwards  easily  excised.  The  tumour  is  at- 
tached anteriorly  to  the  peritoneum  lining  the  front  of  the  abdomen  more  frequently 
than  to  any  other  part.  This  Mr.  Gorham  attributes  to  partial  inflammation  pro- 
duced by  the  puncture  in  the  operation  of  tapping;  hence  the  presumption  that  the 
cyst  is  loose  is,  cacferis  paribus,  the  stronger,  when  paracentesis  has  never  been 
performed. 

If  this  mode  of  excision  should  be  thought  advisable,  it  ought  to  be  attempted 
while  the  tumour  is  yet  of  moderate  bulk,  before  the  peritoneum  has  been  much 
stretched,  and  while  the  chance  of  adhesion  is  the  least.  When  any  distinct  history 
of  bygone  peritonitis  can  be  traced,  the  existence  of  adhesions  may  be  confidently 
reckoned  upon.* 

To  the  simpler  operation  of  tapping,  the  contrary  precept  applies.  Neither  in 
ascites,  nor  in  ovarian  dropsy,  should  paracentesis  be  resorted  to,  until  it  seems  abso- 
lutely indispensable.     To  this  rule  there  are,  in  my  opinion,  very  few  exceptions. 

The  operation  itself,  though  commonly  esteemed  a  trivial  one,  is  not  without  its 
dangers.  The  instances  are  not  few  in  which  it  has  been  followed  by  fatal  peritonitis, 
excited  either  by  the  mere  passage  of  the  lancet  or  trocar  through  a  previously  un- 
healthy membrane,  or,  (in  the  case  of  ovarian  dropsy,)  by  the  escape  of  some  portion 
of  the  contents  of  the  cyst  into  the  cavity  of  the  abdomen.  Formerly,  the  rapid 
evacuation  of  a  large  quantity  of  liquid  from  the  belly  was  often  attended  by  terrify- 
ing efl^ects ;  fainting,  convulsions,  almost  instant  death.  This  made  the  ancient 
physicians  afraid  of  the  operation :  and  when  they  could  no  longer  avoid  it,  they 
let  the  accumulated  fluid  out  by  little  and  httle,  and  at  short  intervals. 

The  cause  of  these  alarming  symptoms  is  now  well  understood,  and  easily  obviated. 
They  were  owing,  doubtless,  to  the  sudden  removal  of  the  pressure  to  which  the 
viscera  and  large  blood-vessels  had  been  for  some  time  submitted  and  accustomed. 
For  this  explanation  of  the  fact  we  are  indebted  to  the  sagacity  of  our  celebrated 
countrj'^man.  Dr.  Mead,  who  was  the  first  to  suggest  that  external  compression  should 
be  substituted,  in  lieu  of  the  tension  taken  off  by  the  operation.  The  complete 
success  of  that  expedient  fully  justified  his  ingenious  opinion.  We  now  drain  the 
cavity  of  its  liquid  contents  without  scruple  or  delay.  A  sheet,  or  broad  roller,  is 
thrown  round  the  patient's  body,  and  tightened  as  the  fluid  escapes,  so  as  to  main- 

•  Since  this  lecture  was  first  printed,  an  interesting  paper  by  Mr.  Phillips  vipon  the  ques- 
tion of  extirpating  ovarian  cysts  has  been  published  in  the  27th  volume  of  the  Mcdico-Ckirur- 
gical  Transactions. 

Mr.  Phillips  exhibits,  in  a  tabular  form,  "the  results  of  81  operations,  performed  for  the 
purpose  of  extracting  ovarian  tumours.  In  61  cases  the  tumour  was  extracted;  in  15  cases 
adhesions,  or  other  circumstances,  prevented  its  removal ;  in  5  instances  no  tumour  was 
found.  Of  the  cases  in  which  the  operation  was  completed,  the  tumour  being  extracted,  35 
terminated  favourably;  the  patient  recovered.  In  26  instances  the  termination  was  unfa- 
vourable ;  the  patient  died.  Of  the  five  cases  in  which  no  tumour  was  discovered,  all 
recovered.  5 

"Of  the  15  cases  in  which  adhesions  or  other  circumstances  prevented  the  extraction  of 
the  tumour,  9  recovered,  6  died." 

In  two  other  tables  Mr.  Phillips  collects  together : — 

I.  Cases  in  which  a  large  incision  was  made,  55  in  all :  and  among  these  cases  there  wi^ri? 
26  deaths,  23  cures,  and  6  recoveries  which  were  not  cures. 

II.  Cases  in  which  the  incision  was  small  (usually  under  six  inches),  amounting  in  all  to 
27.  Among  these  there  were  7  deaths,  13  cures,  and  7  recoveries  from  the  tmsuooessfui 
operation 


752  TREATMENT  OF  OVARIAN  DROPSY. 

tain  an  equable  pressure,  which  is  continued  for  a  while,  and  at  length  gradually- 
withdrawn. 

Other  casualties  occasionally  happen ;  the  trocar  has  sometimes  pierced  the  intes- 
tine. In  one  instance  wliich  I  myself  witnessed,  clear  serum  issued  for  some  time 
through  the  canula,  but  at  length  pure  blood ;  not  less  than  a  pint.  The  patient 
sank ;  and  no  opportunity  was  given  to  investigate  the  cause  of  the  bleeding.  In 
another  strange  but  well-authenticated  case,  the  almost  incredible  quantity,  twenty- 
six  pints,  of  blood  flowed  out  at  the  orifice  made  by  the  trocar,  and  afterwards  sepa- 
rated into  clot  and  serum.  To  the  wonder  of  those  who  saw  the  incident,  this 
patient  recovered  from  the  tapping ;  and  the  source  of  the  hemorrhage  is  still  a  mat- 
ter of  conjecture. 

And  apart  from  these  mischances — which,  after  all,  are  not  of  frequent  occurrence 
— you  must  bear  in  mind  that  paracentesis  can  seldom  be  contemplated  as  a  mode 
of  cure,  but  simply  of  temporary  relief  from  distress.  A  few  instances  have  hap- 
pened where  the  hquid  has  been  drawn  off',  and  has  not  again  collected  :  but  such 
cases  are  very  few.  So,  also,  according  to  my  experience,  are  those,  much  talked 
of  by  authors,  in  which  the  kidneys  resume  their  activity  upon  the  removal  of  the 
dropsical  fluid.  Ordinarily,  the  hquid  re-accumulates,  often  with  more  rapidity  than 
before ;  and  again,  and  again,  the  pain  and  the  hazard  of  the  operation  must  be 
repeated :  wherefore,  in  my  judgment,  paracentesis  in  abdominal  dropsy  ought 
seldom  to  be  performed,  unless  the  quantity  of  liquid  is  so  great  as  to  occasion  pain- 
ful distension  ;  or  causes  great  distress  of  breathing  by  its  upward  pressure  against 
the  diaphragm ;  or  gives  rise  to  some  positive  suffering  or  urgent  inconvenience, 
which  the  evacuation  of  the  water  may  be  expected  to  remedy. 

Acupuncture  of  the  dropsical  abdomen  has  of  late  been  recommended ;  and 
cures,  thus  efl^ected,  have  been  announced.  It  is  said,  or  supposed,  that  the  inclosed 
liquid,  oozing  gradually  into  the  areolar  tissue  of  the  integuments  of  the  abdomen, 
is  thence  removed,  gradually,  by  absorption.  Of  this  method  of  treatment  I  have 
no  practical  knowledge. 

It  is  seldom  that  tapping  is  many  times  performed  upon  the  same  person,  when 
the  complaint  is  mere  passive  ascites.  The  dropsy  returns  indeed,  and  again  the 
operation  is  required ;  meanwhile,  in  most  cases,  the  health  and  strength  rapidly 
deteriorate,  and  the  patient  sinks. 

The  same  speedy  declension  and  early  death  occur  sometimes  in  ovarian  dropsy 
ako ;  yet  the  operation  commonly  bears  to  be  repeated  more  often  than  in  ascites, 
without  serious  detriment  to  the  general  health.  Sometimes  the  liquid  re-accumu- 
lates in  the  cyst  very  quickly,  sometimes  slowly ;  in  a  very  few  instances  not  at  all. 
I  have  had  under  my  own  care  a  patient  who  had  been  tapped  for  this  disease  thirty- 
eight  or  thirtj^-nine  times.  Extraordinary  examples  of  a  similar  kind  are  on  record  ; 
one  or  two  I  may  mention  as  specimens. 

Dr.  Mead  narrates  the  case  of  a  lady,  who,  "  for  the  information  of  posterity, 
ordered  bj^  her  will  that  the  following  English  inscription  should  be  engraved  on  her 
monument,  in  Bunhill  Fields: — 

Here  lies  Dame  Mary  Page, 

Relict  of  Sir  Gregory  Page,  Bart. 

She  departed  this  life,  March  4,  1728, 

In  the  56th  year  of  her  age. 

In  G7  months  she  was  tapped  66  times : 

Had  taken  away  240  gallons  of  water, 

without  ever  repining  at  her  case, 

or  ever  fearing  the  operation." 

Among  authenticated  instances,  the  most  remarkable  that  I  have  met  with  )» 
detailed  in  the  Philosophical  Transactions  for  1784,  by  Mr.  Martineau,  who  was  at 
that  time  surgeon  to  the  Norfolk  and  Norwich  Hospital.  An  abstract  of  the  case  is 
given  in  the  printed  catalogue  of  the  Hunterian  Museum,  where  the  cyst  is  pre- 
served :  it  belonged  to  the  left  ovary  of  Sarah  Kippus,  a  w^idow,  fifty-five  years  old. 
"  The  complaint  began  after  a  miscarriage,  at  the  age  of  twenty-seven.  From  the 
year  1757,  to  August,  1783,  when  she  died,  she  had  been  tapped  eighty  times,  and 


ACUTE    GASTRITIS.  753 

had,  in  all,  had  taken  from  ber  6631  pints  of  fluid,  or  upwards  of  thirteen  hocrs- 
heads.  108  pints  was  the  largest  quantity  ever  taken  away  at  any  one  time.  But 
after  death  Mr.  Martineau  could  not  make  the  sac  contain  more  than  fifty  pints." 

Upon  the  whole,  it  may  be  stated  of  this  operation,  as  applied  to  ovarian  dropsy, 

1.  That  when  it  is  essential  to  the  comfort  and  continued  existence  of  the  patient, 
it  brings  sensible  rehef  to  her  distress,  and  often  materially  prolongs  her  life. 

But,  2.  That  when  it  is  performed  under  less  pressing  circumstances,  it  tends  to 
shorten  the  patient's  days.  Dr.  Bright  is  of  opinion  that  the  number  is  small  of 
those  who  survive  the  first  tapping  more  than  four  years.  A  respectable  woman 
having  very  large  ovarian  dropsy,  entered  the  Middlesex  Hospital,  under  my  care, 
for  the  express  purpose  of  being  tapped.  The  tumour  incommoded  her  by  its  bulk 
and  weight,  but  in  no  other  way ;  and  she  had  carried  it  for  thirteen  years.  I  felt 
that  I  should  not  be  justifi^^d  in  sanctioning  the  operation  in  such  a  case.  The 
patient  was  made  to  understand  that  the  performance  of  it  would  not  be  altogether 
free  from  immediate  danger:  and  that  if  she  went  through  it  safely,  the  swelling 
would  return,  and  the  same  kind  of  remedy  again  become  equally  necessary.  She 
was  instructed  how  to  suspend  the  heavy  overhanging  abdomen  by  a  sling  passing 
over  her  shoulders.  There  appeared  no  reason  why  she  should  not  continue  m 
good  health  for  another  period  of  thirteen  years. 

I  am  aware  of  another  instance,  in  which  a  woman,  similarly  burdened,  but  other- 
wise in  comfortable  health,  has  lived,  not  without  enjoying  Hfe,  between  twenty  and 
thirty  years.  Had  she  been  tapped  when  the  mere  enlargement  might  have  seemed 
to  justify  the  operation,  she  would  probably  have  been  for  twenty  years  in  her  grave. 


LECTURE  LXVIII. 

Acute.  Gastritis :  symptoms  ;  anatomical  characters  ;  treatment.  Chronic  Injlam 
mation  of  the  Stomach;  thickening  of  the  Mucous  Membrane;  Ulceration; 
symptoms  and  treatment  of  the  disorder.     Cancer  of  the  stomach. 

Acute  inflammation,  when  it  afTects  the  peritoneum,  usually  spreads  with  rapidity 
over  the  whole  surface  of  the  membrane.  This  is  characteristic  of  inflammation  of 
the  serous  membranes  generally.  But  it  is  not  so  with  the  other  tissues  that  com- 
pose the  alimentary  canal.  Inflammation  of  the  mucous  membrane  may  be,  and 
often  is,  very  limited  in  extent :  and  the  different  portions  of  the  intestinal  tube,  as 
they  differ  in  function,  so  also  they  differ  somewhat  in  their  diseases,  and  still  more 
in  the  symptoms  by  which  those  diseases  are  revealed.  Not  being  fettered  by  any 
artificial  system  of  arrangement,  I  shall  take  the  course  which  promises  to  be  prac- 
tically most  useful,  and  consider  separately  the  maladies  of  the  several  parts  of  ihe 
alimentary  canal  in  the  abdomen,  extending  my  remarks  occasionally  to  the  whole 
of  the  tube,  when  speaking  of  disorders  that  are  common  to  all  portions  of  it. 

Let  me,  then,  in  the  first  place,  draw  your  attention  to  the  organic  diseases,  and 
the  morbid  conditions,  of  the  stomach. 

It  is  remarkable,  all  things  considered,  how  seldom  the  stomach  is  affected  with 
acute  infianimation.  Scarcely  ever  do  we  find  either  the  organ  as  a  whole,  or  any 
one  of  its  tissues  separately,  the  subject  of  spontaneous  acute  inflammation.  What 
is  described  in  books  as  gastritis,  means  inflammation  of  the  mucous  membrane  of 
the  stomach ;  and  almost  all  that  we  know,  for  certain,  of  this  disease,  we  derive 
from  observation  of  the  effects  of  strongly  irritant  substances  upon  that  membrane. 
Idiopathic  gastritis,  in  an  acute  form,  I  never  saw.  Acute  gastritis,  fnjm  the  contact 
of  corrosive  or  acrid  poisons,  I  have  frequently  seen  :  and  a  highly  interesting  afl^ec 
tion  it  then  becomes.  This  is  a  subject  that  cannot  be  thoroughly  discussed  in  thjs 
course  of  lectures :  neither  may  it  be  altogether  omitted. 
4S 


754  ACUTE    GASTRITIS. 

When  an  irritant  poison  has  been  received  into  the  stomach  and  excites  inflam- 
mation there  —  or  when  acute  inflammation  arises  from  any  cause  —  the  symptoms 
which  mark  that  inflammation  are  pain,  usually  of  a  burning  character,  in  the  epi- 
gastrium; with  frequent  vomiting,  especially  upon  the  entrance  of  anything  into  the 
stomach  ;  and  often  with  hiccup,  and  with  tension  of  the  upper  part  of  the  abdomen. 
To  these  local  symptoms  are  added  fever  of  a  low  type  ;  and  a  small  and  weak  pulse. 
At  first,  indeed,  the  pulse,  although  small,  is  generally  sharp  and  hard ;  but  it  soon 
becomes  thready  and  feeble.  The  muscular  power  undergoes  a  corresponding  de- 
pression ;  the  patient  is  pale  and  faint,  with  collapsed  features,  cold  extremities,  and 
a  damp  skin. 

In  all  this  we  see  a  strong  tendency  to  death  by  asthenia.  It  is  clear  that  the 
subdued  state  of  the  circulation  is  dependent  upon  the  inflammation,  for  it  is  often 
relieved  by  the  remedies  of  inflammation.  In  acute  gastritis,  as  well  as  in  peritonitis, 
you  will  find  that  the  pulse  expands,  becomes  more  distinct  and  full,  under  early 
bleeding:  sometimes  even  while  the  blood  is  flowing. 

Upon  this  remarkable  sympathy  between  the  heart  and  the  stomach  I  have  fr& 
quently  had  occasion  to  insist.  You  are  aware  that  a  smart  blow  upon  the  epigas- 
trium may  put  a  sudden  stop  to  the  movements  of  the  heart,  and  induce  mortal 
syncope,  without  leaving  any  local  trace  of  its  operation.  On  the  other  hand,  a 
person  in  a  state  of  extreme  exhaustion  and  faintness,  will  sometimes  revive  at  once, 
upon  swallowing  into  the  stomach  an  ounce  or  two  of  brandy,  and  recover  his  pulse 
and  colour  much  too  speedily  to  allow  of  our  ascribing  these  effects  to  the  absorption 
of  the  alcohol  into  the  blood.  Dr.  Alison  suggests  that  the  depression  of  the  circu- 
lation may  be  attributable  to  the  peculiar  sickening  pain  which  accompanies  inflam- 
mation or  sudden  injury  of  the  stomach.  It  appears,  however,  more  probable  (as 
has  been  intimated  to  me  by  an  obliging  correspondent)  that  the  remarkable  sympathy 
in  qttestion  is  governed  by  the  nerves  of  organic  life.  The  great  solar  plexus  of  the 
ganglionic  system  lies  upon  the  spinal  column  immediately  behind  the  stomach. 
The  heart  is  largely  supplied  with  nervous  filaments  from  the  same  system.  Hence 
we  might  almost  expect  that  any  sudden  stimulus  applied  to  this  important  plexus 
would  excite,  and  that  any  sudden  depressing  influence  would  subdue,  the  natural 
action  of  the  heart.  Upon  the  same  principle  may  be  explained  the  facts  that  deadly 
faintness  and  nausea  are  apt  to  result  from  injury  of  the  testes,  which  are  also 
abundantly  endowed  with  influence  from  the  nerves  of  organic  life.  Be  this  as  it 
may,  it  is  important  for  you  to  know  that  the  mode  of  dying  in  these  cases  is  pre- 
cisel}'-  what  Bichat  describes  as  death  beginning  at  the  heart. 

The  pain  that  accompanies  gastritis  is  augmented  by  pressure  upon  the  epigas- 
trium. It  is  increased  also  by  the  full  descent  of  the  diaphragm,  and  the  breathing 
IS  consequently  short  and  constrained.  In  the  most  exquisite  cases  of  gastritis,  pro- 
duced by  chemical  or  mechanical  irritants  applied  to  the  interior  of  the  stomach,  the 
inflammation  probabl}  reaches  and  involves,  more  or  less,  the  peritoneum.  The 
patients  speak  of  the  pain  as  a  pricking  and  burning  sensation ;  it  is  attended  with 
great  anxiety  and  restlessness.  The  sufferer  is  tormented  with  extreme  thirst,  while 
all  that  he  drinks,  even  cold  water,  is  almost  instantly  rejected  by  vomiting. 

Hiccup  does  not  always  accompany  acute  gastritis.  It  sometimes  occurs  early  ; 
but  more  generally  it  comes  on  late  in  the  disease,  when  the  patient  is  sunk  and 
much  debilitated. 

The  bowels,  in  this  complaint,  are  sometimes  bound  :  sometimes,  on  the  contrary — 
uspeciaUy  when  the  inflammation  has  been  caused  by  corrosive  poison — dysenteric 
diarrhoea  ensues,  with  much  griping  and  tenesmus. 

Such,  then,  are  the  symptoms  that  indicate  the  existence  of  acute  gastritis ;  but 
you  ought  to  be  aware  that  they  occur  in  varying  combinations,  and  with  different 
degrees  of  severity  ;  and  consequently  that  the  course  of  the  disease  is  not  uniformly 
the  sanr>e  in  all  cases.  When  the  symptoms  are  the  most  violent,  and  the  progress 
of  th'j  complaint  is  the  most  rapid,  the  peritoneal  coat  of  the  stomach  is  usually,  I 
belie /e,  more  or  less  implicated. 

Intense  inflammation  of  the  stomach  may  be  expected  to  be  rapid  in  its  progress. 
I'  mav  destroy  Hfe  within  twenty -four,  or  even  twelve  hours.     When  it  is  fatal,  it 


GASTRITIS.  755 

generally  is  so  within  a  few  days ;  and  death  takes  place  by  fainting :  with  a  remis- 
sion of  the  pain,  sometimes  verj  sudden,  and  sometimes  occurring  only  just  before 
dissolution.  But  as  idiopathic  gastritis  is  rave,  fatal  idiopathic  gastritis  is,  of  course, 
still  more  so.  Louis  states,  that  during  six  years'  experience  at  La  Charite,  in  which 
period  he  noted  the  details  of  6000  cases  of  disease,  and  of  500  dissections,  he  did 
not  meet  with  a  single  instance  of  fatal  idiopathic  gastritis.  The  subject  derives 
almost  all  its  importance,  therefore,  from  its  connection  Avith  poisoning ;  and  the  many 
mteresting  points  of  inquiry  which  arise  out  of  that  connection  will  be  brought  before 
you  by  the  Professor  of  Forensic  Medicine.  This  consideration  is  a  great  satisfac- 
tion and  relief  to  me  ;  because  I  find  that  the  limits  of  my  own  course  will  not 
permit  me  to  go  into  any  detail  in  this  matter. 

The  morbid  appearances  to  be  looked  for  after  death  by  acute  gastritis,  are  redness 
of  the  mucous  membrane,  softening,  sloughing,  and  even  (after  the  action  of  strongly 
corrosive  poisons)  perforation  of  all  the  coats  of  the  stomach. 

I  wish  particularly  to  caution  you  against  being  misled  by  mere  redness  of  the 
interior  of  the  stomach  ;  or  of  the  inner  surface  of  the  alimentary  canal  in  general ; 
or  of  any  mucous  membrane  ;  and  indeed  I  may  add,  of  any  serous  membrane  also. 
Redness  and  inflammation  have  been  made,  too  often,  convertible  terms.  Persons 
finding  the  inner  surface  of  the  stomach  red,  have  instantly  concluded,  from  that  cir- 
cumstance, that  suspicions  of  poisoning,  which  had  arisen,  were  well  founded.  We 
are  indebted  to  Dr.  Yclloly,  in  the  first  instance,  and  to  M.  Billard  and  some  other 
Frenchmen,  in  the  second,  for  correcting  this  error — an  error  which  not  only  was  of 
importance  in  questions  of  imputed  poisoning,  but  has  run  through  and  vitiated 
almost  the  whole  of  pathology,  both  lately  and  heretofore.  iVIistaking  mere  redness 
for  evidence  of  inflammation,  Cullen  divided  gastritis  into  two  species — one  of  which 
he  called  gastritis  erythematica ;  and  he  inferred  from  the  observation  of  cases  in 
which  redness  of  the  membrane  had  been  met  with  after  death,  that  this  peculiar 
kind  of  inflammation  of  the  mucous  coat  of  the  stomach  might  take  place,  without 
fever,  pain,  or  vomiting,  or  any  other  symptom  indicative  of  gastritis :  whereas  it  is 
almost  certain  that,  in  the  cases  to  which  he  refers,  there  really  was  no  inflammation 
at  all.  So  also  Morgagni,  puzzled  by  intestinal  vascularity,  was  disposed  to  attribute 
the  absence  of  pain,  in  what  he  beheved  to  have  been  inflammation  of  the  bowels, 
to  a  paralytic  afl!ection,  which  blunted  the  sensibility  of  the  parts ;  and  Haller  con- 
ceived, from  so  constantly  meeting  with  this  vascularity  in  his  inspections  of  the  body, 
that  inflammation  of  the  bowels  was  almost  always  present  in  fevers  of  all  kinds  ; 
and  was  frequent  in  every  other  complaint.  And  the  same  doctrine  has  been  strenu- 
ously inculcated  of  late  years,  as  I  dare  say  you  know,  by  Broussais,  in  France,  and 
adopted  by  a  Tast  host  of  his  disciples.  Finding  the  lining  membrane  of  the  stomach 
and  intestines  red  and  vascular  in  most  of  the  bodies  of  patients  who  had  died  of 
fever,  Broussais  concluded  that  fever  depends,  in  all  cases,  upon  inflammation  of  the 
gastro-enteric  mucous  membrane.  You  will  perceive  that  this  doctrine  must  exer- 
cise a  vast  influence  upon  the  practice  of  those  who  entertain  it.  If  inflammation 
constitute  an  essential  part  of  any  disorder,  it  follows  that  the  remedies  of  inflamma- 
tion will  be  adapted  to  that  disorder ;  and  thus,  even  so  slight  a  mistake  as  that  may 
appear  to  be,  against  which  I  am  now  cautioning  you,  of  regarding  every  surface 
which  is  red  as  being  inflamed  also,  may  lead  to  very  mischievous  views  in  respect 
to  treatment. 

The  redness  that  is  zndependent  of  inflammation  may  be  of  various  kinds ;  but 
the  principal  cause  of  it  is  venous  congestion.  "  The  appearances  of  vascular  full- 
ness (says  Dr.  Yelloly)  in  the  villous  coat  of  the  stomach,  whether  florid  or  dark- 
coloured,  in  distinct  vessels,  or  in  extravasations  of  difl^erent  sizes,  are  not  to  be 
regarded  as  unequivocal  marks  of  disease,  inasmuch  as  they  occur  in  every  variety 
of  degree  and  character,  under  every  circumstance  of  previous  indisposition,  and  in 
situations  where  the  most  heakhy  aspect  of  the  organ  may  be  expected."  To  the 
truth  of  this  statement  I  can  bear  witness,  having  at  one  time  of  my  hfe  carefully 
examined,  with  a  view  to  this  matter,  a  great  number  of  stomachs  in  succession,  iu 
the  dead-housG  )f  a  large  hospital.  "  The  vascularity  (according  to  Dr.  Yelloly)  is 
entirely  vennus,  and  depends  on  a  power  capable  of  being  exercised  on  the  artery 


756  GASTRITIS. 

itself  at  the  close  of  life,  which  carries  on  the  blood  to  the  veins,  after  the  further 
supply  of  fresh  blood  from  the  heart  is  stopped.  The  branched  or  stellated  form  of 
vessels,  under  which  the  vascularity  usually  appears,  is  capable  of  being  imitated, 
either  by  injecting  the  veins  with  fine  injection,  or  by  forcing  back  with  the  finger, 
or  the  back  of  a  scalpel,  the  blood  from  the  larger  branches  of  veins  into  the  smaller." 
"  And  this  vascularity  soon  becomes  difl^used  redness,  by  transudation  of  the  blood 
through  the  coats  of  the  containing  vessels,  just  as  happens  with  the  bile  in  the  gall 
bladder." 

Redness,  from  mere  repletion  of  the  smaller  veins,  is  usually  extensive  and  unde- 
fined ;  except  that,  being  influenced  by  the  force  of  gx-avity,  it  settles  into  the  most 
depending  parts  of  the  organ,  which  are  either  its  exclusive  seat,  or,  at  any  rate,  are 
of  a  deeper  colour  than  the  parts  more  elevated.  It  is  attended  with  an  empty  state 
of  the  arteries,  and  with  a  full  state  of  the  larger  veins.  Hence,  the  condition  of  the 
venous  and  arterial  trunks,  and  especially  of  the  vena  portse,  should,  in  doubtful 
cases,  be  ascertained  before  the  main  blood-vessels  are  laid  open  and  drained  of  their 
contents. 

The  redness  that  belongs  to  inflammation  is  generally  circumscribed,  and  of  limited 
extent ;  it  occupies  indiscriminately  the  upper  or  the  lower  side  of  the  tube  (for  these 
remarks  apply  alike  to  the  stomach  and  to  the  intestines) ;  it  is  attended  with  some 
fullness  of  the  corresponding  arterial  trunks:  and  it  may  or  may  not  be  coincident 
with  comparative  emptiness  of  the  venous  system  within  the  abdomen.  Much  will 
depend,  in  this  respect,  upon  the  mode  of  dying,  as  I  have  fully  explained  to  you 
on  a  former  occasion. 

You  will  please  to  remember,  then,  in  all  your  future  investigations  into  morbid 
anatomy,  that  it  is  generally  difficuk,  and  often  impossible,  to  determine,  from  the 
aspect  of  the  vessels  of  a  dead  part,  from  its  redness,  that  inflammation  had  been 
present  in  that  part  during  life,  unless  the  unequivocal  products  or  effects  of  inflam- 
matory action  are  present  also. 

A  much  more  certain  evidence  of  inflammation  of  the  mucous  membrane  of  the 
stomach  and  intestines,  is  its  softening.  This  can  be  attributed  to  nothing  else, 
except  it  be  to  decomposition ;  and  it  is  well  known  that  this  membrane  is  slow  and 
late  in  passing  into  the  state  of  putrefaction  after  death.  To  certain  questions  respect- 
ing perforations  of  the  stomach,  I  shall  by  and  by  return. 

I  say  that  gastritis  is  most  commonly  the  eflect  of  poisons  applied  to  the  mucous 
surface  of  the  stomach  ;  but  I  must  include  under  that  head  certain  substances  which, 
to  most  people,  are  not  poisonous  or  injurious  at  all,  and  which  only  become  so  to 
some  persons  under  particular  circumstances.  Thus,  large  draughts  of  cold  drink, 
taken  when  the  body  is  hot,  and  rapidly  parting  with  its  heat,  and  especially  large 
draughts  of  cold  sour  liquors,  as  cider  or  stale  beer,  are  apt  to  give  rise  to  acute  gas- 
tritis. Another  occasional  cause  of  gastritis  is  the  ingestion  of  very  large  quantities 
of  food  at  one  time,  especially  during  convalescence  from  any  serious  disorder.  It 
is  an  exceedingly  curious  fact,  too,  but  one  which  I  merely  mention  without  dwelling 
upon,  that  certain  poisons  introduced  into  the  body  through  some  other  channel,  will 
cause  mflammation  of  the  mucous  membrane  of  the  stomach,  with  which  they  have 
not  been  in  contact.  Corrosive  subhmate  and  arsenic  excite  inflammation,  with 
ulceration  or  sloughing  of  the  mucous  membrane,  even  when  they  are  merely 
rubbed,  in  a  certain  quantity,  upon  the  skin,  or  when  they  are  inserted  into  the 
rectum. 

The  treatment  of  acute  gastritis  is  simple.  The  chief  nicety  respects  the  employ- 
ment of  blood-letting.  Early  in  the  disease,  if  the  pain  be  severe,  you  must  trylhe 
fiffect  of  venesection,  notwithstanding  the  smallness  and  feebleness  of  the  pulse. 
How  much  blood  you  are  to  abstract  cannot  be  told  beforehand.  Take  away  a  small 
teacupful,  keeping,  meanwhile,  your  finger  on  the  wrist.  If  the  beat  of  the  artery 
does  not  grow  weaker,  and  still  more  if  it  becomes  fuller  and  stronger,  go  on  with 
the  bleedmg,  and  take  another  cupful,  and  another,  according  to  the  circumstances 
of  the  case  and  to  the  effects  produced.  Apply  leeches  to  the  epigastrium,  and  cover 
ihe  bleeding  bites  with  a  soft,  light  pouUice.  Keep  the  patient  as  strictly  as  you  can 
in  the  horizontal  posture ;  in  other  words,  see  thft  thr  depressing  influence  of  tbn) 


CHRONIC  INFLAMMATION  OF  THE  STOMACH.         757 

Msi  lise  upon  the  action  of  the  heart  is  not  aided  and  augmented  by  the  position  of 
the  body.  If  cold  water  is  retained,  that  is  the  best  medicine  which  you  can  give  by 
the  mouth;  purgatives  so  administered  would  be  almost  sure  to  be  rejected,  and,  if 
nut  rejected,  they  would  be  likely  to  increase  the  existing  inflammation  of  the  organ. 
En-imata  are,  however,  extremely  useful:  of  warm  water,  if  the  bowels  are  not 
mu(,h  confined ;  of  purgative  materials,  if  they  are.  After  the  intestines  have  been 
thuij  cleared — or  when  they  are  loose  and  irritable — opiate  injections  (thirty  or  forty 
drops  of  laudanum,  with  three  or  four  ounces  of  starch  or  gruel)  do  much  good. 
They  often  have  a  very  tranquillizing  effect  upon  the  irritable  stomnch,  and  check 
the  vomiting.  These  measures  are  to  be  pursued  until  the  inflammation  has 
subsided. 

When  any  corrosive  substance  has  been  swallowed,  I  scarcely  need  say  that  painj 
should  be  taken  to  remove  it  as  speedily  as  possible  from  the  stomach,  or  to  admin- 
ister such  remedies  as  are  known  to  be  capable  of  decomposing  the  poison,  or  of 
affording  a  specific  antidote  to  it.  Not  that  the  stomach-pump  should  be  employed 
in  such  cases,  as  it  too  often  is.  These,  however,  are  points  that  must  be  fully  treated 
of  in  the  lectures  on  forensic  medicine,  and  therefore  I  shall  dwell  upon  them  no 
longer  here. 

Chronic  inflammation  of  the  stomach  is  probably  a  very  common  disorder.  It 
does  not  put  life  in  immediate  jeopardy,  and  it  is  often  recovered  from.  It  deranges, 
however,  the  functions,  and  perverts  the  feelings  of  the  stomach :  it  gives  rise  to  the 
manifold  and  multiform  symptoms  of  dyspepsia.  But  dyspepsia,  with  its  manifold 
and  multiform  symptoms,  may  be,  and  often  is,  entirely  independent  of  inflamma- 
tion. You  see,  then,  why  the  efTects  of  chronic  gastritis  are  various,  and  why  the 
symptoms  that  are  supposed  to  denote  its  presence  are  apt  to  be  obscure,  uncertain, 
and  equivocal.  I  intend,  before  I  quit  the  subject  of  the  stomach,  to  investigate  the 
principal  circumstances  that  mark  its  functional  disorders,  and  to  describe  the  means 
which  we  sometimes  find  effectual  for  their  relief.  I  shall  therefore  restrict  myself 
at  present  to  a  kw  points  which  seem  to  have  been  fairly  ascertained  respecting 
chronic  gastritis. 

We  know  that  chronic  inflammation  had  been  going  on  in  the  stomach  when,  after 
death,  we  see  that  its  coats  are  thickened,  or  when  we  perceive  that  a  portion  of  one 
or  more  of  them  has  been  removed  by  ulceration. 

It  is  not  at  all  uncommon  to  find  the  mucous  membrane  of  the  stomach,  over  a 
larger  or  smaller  space,  thick,  granular,  uneven,  and  of  an  unnatural  colour.  Gray, 
or  slate-coloured,  it  often  is.  This  slate-colour  is  much  dwelt  upon  by  the  French 
writers,  as  being  a  sure  and  unequivocal  impress  of  chronic  inflammation.  The 
colour  proceeds,  I  believe,  from  the  operation  of  the  gastric  acids  upon  the  blood, 
which,  under  habitual  congestion  or  slow  inflammation,  is  detained  in  the  vessels  of 
the  altered  part.  The  ulcers  that  result  from  chronic  inflammatory  action  are  usually 
small,  varying  from  the  size  of  a  split  pea  to  that  of  a  shilling;  sometimes  with  no 
surrounding  vascularity  or  thickening  at  all,  but  looking  exactly  as  though  a  piece 
of  the  mucous  membrane  had  been  struck  out  by  a  stamp ;  sometimes  with  rounded 
and  elevated  edges  only;  and  sometimes  they  occupy  patches  of  thickening  and 
induration  of  the  parietes  of  the  stomach.  There  may  be  one  solitary  ulcer,  or  a 
few,  or  many.     It  is  seldom,  however,  that  they  are  numerous. 

Ulcerative  disease  of  the  stomach  may  prove  fatal  in  various  ways.  The  ulcer 
may  penetrate  as  far  as  the  peritoneum,  and  excite  inflammation  of  that  membrane, 
whereby  the  stomach  becomes  adherent  to  the  neighbouring  parts.  In  these  cases, 
prior  or  subsequently  to  adhesion,  death  may  at  length  ensue,  from  gradual  ex- 
haustion and  protracted  suffering. 

If  an  ulcer  happen  to  lie  over  the  track  of  a  large  blood-vessel  in  the  stomacn,  it 
may  eat  its  way  into  that  vessel,  and  give  rise  to  fatal  hemorrhage. 

Or  the  ulcer  may  perforate  the  walls  of  the  stomach,  without  any  previous  adho 
sion,  and  suffer  the  food,  or  the  secretions  of  the  stomach,  to  pass  into  the  peritoneal 
cavity,  where  intense  inflammation  is  lighted  up,  and  the  patient  soon  perishes 

So 


758  CHRONIC    INFLAMMATION 

Or  the  ulcers  may  at  length  heal.  Of  this  we  are  certain,  because,  we  sometimes 
find  cicatrices  marking  the  spots  which  the  ulcers  had  occupied. 

The  symptoms  of  chronic  gastritis  are  pain  or  uneasiness  in  the  epigastrium, 
increased  by  pressure ;  increased  also  on  the  introduction  of  food,  or  perhaps  fell 
only  while  digestion  is  in  progress;  flatulence  and  eructation;  vomiting  of  mucus,  and 
of  the  meals;  loss  of  sleep;  languor  and  debility. 

Not  that  even  these  symptoms  are  constant  in  all  cases.  Sometimes  there  is  no 
actual  pain,  but  a  sense  of  heat  or  of  acidity.  The  vomiting,  too,  in  the  outset,  is  occa- 
sional only  ;  and  is  then  attributable,  often,  to  some  error  or  imprudence  in  respect 
to  diet.  And  sometimes  the  complaint  may  run  nearly  its  whole  course,  up  to  one 
of  the  fatal  terminations  just  now  mentioned,  with  scarcely  any  other  sign  of  its  ex- 
istence than  uneasiness  after  meals,  which  subsides  in  two  or  three  hours  entirely. 
With  the  local  symptoms  I  have  been  describing  there  are  often  conjoined  some 
acceleration  and  hardness  of  the  pulse  :  more  or  less  thirst :  a  dry  skin  :  scanty  and 
deep-coloured  urine:  a  red  tongue;  red  especially  at  its  tips  and  edges;  patchy  and 
fissured  perhaps  ;  or  smooth  and  glossy,  like  a  slice  of  raw  meat.  The  throat  is  also 
frequently  tender;  and  the  phaiynx  and  palate  unnaturally  vascular. 

In  attempting  to  relieve  or  cure  chronic  gastritis  we  have  to  guard  against  apply- 
ing anything  to  the  inflamed  surface  which  may  be  likely  to  add  to  the  existing 
mischief,  or  which  has  been  found,  upon  trial,  to  give  pain.  We  employ  at  the 
same  time  the  ordinary  remedies  of  chronic  inflammation.  Leeches  may  be  put 
upon  the  epigastrium,  and  repeated  day  by  day,  or  every  other  day,  in  small  num- 
bers, so  long  as  there  is  much  tenderness  on  pressure.  When  the  tenderness  is  less, 
counter-irritation  is  very  useful:  repeated  blisters;  or  friction  with  the  tartar  emetic 
ointment  over  the  region  of  the  stomach.  But,  after  all,  the  main  dependence  must 
be  placed  in  the  due  regulation  of  the  food,  which  should  be  mild  and  unstimulating 
in  quality,  and  sparing  in  quantity.  The  well-known  farinaceous  substances  which 
figure  in  the  bill  of  fire  of  a  sick  chamber :  arrow-root ;  sago  ;  tapioca ;  gruel ;  milk 
also ;  and  jellies.  And  even  these  bland  articles  of  nourishment  must  be  given  in 
moderation,  so  as  neve  to  distend  the  stomach  or  to  stretch  its  coats  by  their  bulk, 
or  to  overtask  its  power  of  digestion.  It  is  difficult,  in  such  cases,  to  give  precise 
rules  for  the  management  of  the  diet,  which  must  be  left  to  the  common  sense  of  the 
practitioner. 

With  respect  to  internal  medicines,  they  must  be  such  as  appear  to  be  called  for 
by  ])arlicular  symptoms.  Of  these,  which  are  in  fact  the  symptoms  of  dyspepsia,  I 
postpone  the  further  consideration.  Appropriate  means  must  be  used  for  the  regu- 
lation of  the  bowels :  mild  laxatives  by  the  mouth ;  emollient  or  purgative  enemata 
by  the  rectum. 

When  I  say  that  a  good  deal  must  be  left,  in  these  cases  of  chronic  disease  o-f  the 
stomach,  to  the  judgment  and  good  sense  of  the  practitioner,  I  am  forcibly  reminded 
of  a  most  striking  and  instructive  case,  beautifully  told  by  the  celebrated  Dr.  Wm. 
Hunter,  in  the  sixth  volume  of  the  Medical  Observations  and  Inquiries.  The 
perusal  of  that  history  has  afforded  me  hints  upon  which  I  have  ofien  acted  with 
great  advantage  to  my  patients,  and  with  some  credit  to  myself.  As  I  doubt  whether 
many  of  you  would  find  immediate  opportunity  or  leisure  for  referring  to  the  narra- 
tive, and  as  I  should  spoil  it  by  attempting  to  give  you  an  abstract  of  it,  I  am  tempted 
to  read  it  here  in  Dr.  Hunter's  own  words. 

"  Many  years  ago  (he  says)  a  gentleman  came  to  me  from  the  eastern  part  of  the 
city,  with  his  son,  about  eight  or  nine  years  old,  to  ask  my  advice  for  him.  The 
complaint  was  pain  in  the  stomach,  frequent  and  violent  vomitings,  great  weak|[iess, 
and  wasting  of  flesh.  I  think  I  hardly  ever  saw  a  human  creature  more  emaciated, 
or  with  a  look  more  expressive  of  being  near  the  end  of  all  the  miseries  of  life.  The 
disorder  was  of  some  months'  standing,  and  from  the  beginning  to  that  time  had  been 
daily  growing  more  desperate.  He  was  at  school  when  first  taken  ill, and  concealed 
nis  disorder  for  some  time  :  but  growing  much  worse  he  was  compelled  to  complain, 
and  was  brought  home  to  be  more  carefully  attended.  From  his  sickly  look,  his 
v?tal  loss  of  appetite,  besides  what  he  said  of  the  pain  which  he  suffered,  but  espe 


OF    THE    STOMACH.  759 

cially  from  his  vomiting  up  almost  everything  which  he  swallowed,  it  was  evident 
that  his  disorder  was  very  serious. 

"Three  of  the  most  eminent  physicians  of  that  time  attended  him  in  succession  : 
and  tried  a  variety  of  medicines  without  the  least  good  effect.  They  had  all,  as  the 
father  told  me,  after  sufficient  trial,  given  the  patient  up,  having  nothing  further  to 
propose.  The  last  prescription  was  a  pill  of  solid  opium ;  for  in  the  fluid  state, 
though  at  first  the  opiate  had  stayed  some  time  upon  his  stomach,  and  brought  a 
temporary  relief,  it  failed  at  length,  and  like  food,  drink,  and  every  medicine  which 
had  been  given,  was  presently  brought  up  again  by  vomiting.  The  opiate  ^;z7/  was 
therefore  given  in  hopes  that  it  would  elude  the  expulsive  efforts  of  the  stomach.  It 
did  so  for  a  time ;  but  after  a  little  use,  that  likewise  brought  on  vomiting.  Then  it 
was  that  his  physician  was  consulted  for  the  last  time,  who  said  that  he  had  nothing 
further  to  propose. 

♦'  Though  at  first  the  boy  professed  that  he  could  assign  no  cause  for  his  complaint, 
being  strictly  interrogated  by  his  father,  if  he  had  ever  swallowed  anything  that 
could  hurt  his  stomach,  or  received  any  injury  by  a  blow,  or  otherwise,  he  confessed 
that  the  usher  in  the  school  had  grasped  him  by  the  waistcoat  at  the  pit  of  the  sto- 
mach, in  a  peevish  fit,  and  shaken  him  rudel}^  for  not  having  come  up  to  the  usher's 
expectation  in  a  school-exercise.  That  though  it  was  not  very  painful  at  the  time, 
the  disorder  came  on  soon  after.  This  account  disposed  the  father  to  suspect  that  the 
rude  grasp  and  shake  had  hurt  the  stomach.  With  that  idea  he  brought  him  to  me, 
as  an  anatomist,  that  an  accurate  examination  might  if  possible  discover  the  cause  or 
nature  of  the  disorder. 

"  He  was  stripped  before  the  fire,  and  examined  with  attention  in  various  situa- 
tions and  postures;  but  no  fulness,  hardness,  or  tumour  whatever  could  be  discovered  ; 
on  the  contrary,  he  appeared  everywhere  like  a  skeleton  covered  with  a  mere  skin  ; 
and  the  abdomen  was  as  flat,  or  rather  as  much  drawn  inwards,  as  if  it  had  not  con- 
tained half  the  usual  quantity  of  bowels. 

"Having  received  all  the  information  that  I  could  expect,  and  reflected  some  little 
time  upon  the  case,  I  wished  to  speak  with  the  father  alone,  in  another  room  ;  and 
to  give  my  patient  some  employment  as  well  as  refreshment,  asked  him  to  lake  a 
liule  milk  in  the  mean  time.  But  his  father  begged  that  taking  any  thing  into  his 
stomach  might  be  put  off  till  he  got  home,  because  he  was  certain  that  it  would 
make  him  sick ;  '  just  before  we  set  out  (said  he)  I  gave  him  a  little  milk ;  but  he 
was  sick,  and  brought  it  all  up  in  the  coach,  before  we  had  got  many  paces  from  the 
house.' 

"  In  the  adjacent  room  I  said  to  the  father.  This  case,  sir,  appears  to  me  so  despe 
rate,  that  I  could  not  tell  you  my  thoughts  before  your  son.  I  think  it  most  probable, 
no  doubt,  that  he  will  sink  under  it ;  I  believe  that  no  human  sagacity  or  experience 
could  pretend  to  ascertain  the  cause  of  his  complaint :  and  without  supposing  a  par- 
ticular or  specific  cause,  there  is  hardly  any  thing  to  be  aimed  at  in  the  way  of  a  cure. 
Yet,  dreadful  as  this  language  must  be  to  your  ear,  I  think  you  are  not  to  be  without 
hope.  As  we  do  not  know  the  cause,  it  may  happen  to  be  of  a  temporary  nature, 
and  may  of  itself  take  a  favourable  turn  ;  we  see  such  wonderful  changes  every  day, 
in  cases  that  appear  the  most  desperate,  and  especially  in  young  people.  In  them 
the  resources  of  nature  are  astonishing. 

"Then  he  asked  me  if  T  could  communicate  any  rules  or  directions,  for  givincr 
l.im  a  better  chance  of  getting  that  cure  from  nature,  which  he  saw  he  must  despair 
of  from  art. 

"  I  told  him  that  there  were  two  things  which  I  w^ould  recommend.  The  first  was 
not  so  important  indeed,  yet  I  thought  it  might  be  useful,  and  certainly  could  do  no 
harm.  It  was  to  have  his  son  well  rubbed,  for  half  an  hour  together,  with  warm  oil 
and  a  warm  hand,  before  a  fire,  over  and  all  around  his  stomach,  every  morning  and 
evening.  The  oil,  perhaps,  would  do  little  more  than  make  the  friction  harmles;-;, 
as  well  as  easy ;  and  the  friction  would  both  soothe  pain,  and  be  a  healthful  exercise 
to  a  weak  body, 

"The  second  thing  that  I  had  to  propose,  I  imagined  to  be  of  the  utmost  conse- 
quence     It  was  something  which  I  had  particularly  attended  to  in  the  disorders  o ' 


760  CHRONIC    INFLAMMATION 

the  stomach,  especially  vomitings.  It  was,  carefully  to  avoid  offending  a  very  weak 
stomach,  either  with  the  quantity,  or  quality,  of  what  is  taken  down  ;  and  yet  to  get 
enough  retained  for  supporting  life.  I  need  not  tell  you,  sir,  said  I,  that  your  son 
cannot  live  long,  without  taking  so7ne  nourishment ;  he  must  be  supported  to  allow 
of  any  chance  m  his  favour.  You  think  that  for  some  time  he  has  kept  nothing  of 
what  he  has  swallowed ;  but  a  small  part  must  have  remained,  else  he  could  not 
have  lived  till  now.  Do  you  not  think,  then,  that  it  would  have  been  better  for  him 
if  he  had  only  taken  the  very  small  quantity  which  remained  with  him,  and  was 
converted  to  nourishment  '.  It  would  have  answered  the  end  of  supporting  life  as 
well,  and  perhaps  have  saved  him  such  constant  distress  of  being  sick,  and  of  vomit- 
ing. The  nourishment  which  he  takes  should  not  only  be  in  very  small  quantity  at 
a  time,  but  in  quantity  the  most  inoffensive  to  a  weak  stomach  that  can  be  found. 
Milk  is  that  kind  of  nourishment.  It  is  what  Providence  has  contrived  for  support- 
ing animals  in  the  most  tender  stage  of  life.  Take  your  son  home,  and  as  soon  as 
he  has  rested  a  httle,  give  him  one  spoonful  of  milk.  If  he  keeps  it  some  time, 
without  sickness  or  vomiting,  repeat  the  meal,  and  so  on.  If  he  vomits  it,  after  a 
little  rest,  try  him  with  a  smaller  quantity,  viz.,  with  a  dessert,  or  even  a  leaspoonful. 
If  he  can  but  bear  the  smallest  quantity,  you  will  be  sure  of  being  able  to  give  him 
nourishment.  Let  it  be  the  sole  business  of  one  person  to  feed  him.  If  you  succeed 
in  the  beginning,  persevere  with  great  caution,  and  proceed  very  gradually  to  a 
greater  quantity,  and  to  other  ^uid  food,  especially  to  what  his  own  fancy  may  invite 
him ;  such  as  smooth  gruel,  or  panada,  milk  boiled  with  a  little  flour  of  wheat  or 
rice  ;  thin  chocolate  and  milk  ;  any  broth  without  fat,  or  with  a  little  jelly  or  rice  or 
barley  in  it,  (fee.  &c. 

"  We  then  went  in  to  our  patient  again  ;  and  that  he  might  be  encouraged  with 
hope,  and  ac\  his  part  with  resolution,  I  repeated  the  directions  with  an  air  of  being 
confident  of  success.  The  plan  was  simple,  and  perfectly  understood.  They 
left  me. 

"  I  heard  nothing  of  the  case  till,  I  believe,  between  two  and  three  months  after. 
His  father  came  to  me  with  a  most  joyful  countenance,  and  with  kind  expressions 
of  gratitude  told  me,  that  the  plan  had  been  pursued  with  scrupulous  exaclrness,  and 
with  astonishing  success  ;  that  his  son  had  never  vomited  since  I  had  seen  him;  that 
he  was  daily  gaining  flesh,  and  strength,  and  colour,  and  spirits,  and  now  grown 
very  importunate  to  have  more  substantial  food.  I  recommended  a  change  to  be 
made  by  degrees.  He  recovered  completely  ;  and  many  years  ago  he  was  a  healthy 
and  a  very  strong  young  man." 

[Acute  gastritis  is  a  disease  of  by  no  means  unfrequent  occurrence  during  infancy,  and 
then  frequently  causes  a  softening  of  the  mucous  membrane  of  the- stomacli,  to  which  much 
attention  has  of  late  years  been  directed  by  the  observations  of  Cruveilheir,  Louis,  Laisne, 
Billard,  and  others;  by  several  of  whom  it  is  described  as  a  specific  disease.  It  is  to  this 
particular  lesion  that  we  wish  to  direct  attention  in  the  pfresent  note,  referring  the  reader  fur 
information  on  the  subject  of  the  inflammatory  affections  of  the  stomach  generally,  that  occur 
during  the  early  period  of  life,  to  the  Editors  Treatise  on  the  Diseases  of  Children. 

The  symptoms  of  the  particular  form  of  acute  gastritis,  to  which  we  have  reference,  are 
■'ery  accurately  described  by  Billard.  The  disease  commences  with  tlie  phenomena  of  a 
violent  inflammation  of  the  stomach  ;  as  tension  of  the  epigastrium,  which  is  painful  to 
tlie  touch  ;  frequent  vomiting,  not  only  of  the  milk  and  drinks  taken,  but  also  of  a  green  or 
yellow  fluid;  the  vomiting  occurring  every  moment,  without  any  reference  to  the  period 
when  the  child  has  taken  food  or  drink.  There  is,  sometimes,  diarrha'a,  varying  in  diflerent 
subjects,  and  returning  after  having  ceased  for  a  day  or  two;  the  matters  discharged  from 
the  bowels  being  often  green,  and  similar  to  those  brought  up  from  the  stomach  by  vomiting. 
The  extremities  are  cold;  the  pulse  is  generally  irregular ;  the  countenance  has  a  permanent 
expression  of  sufiering,  the  face  remaining  furrowed,  as  if  the  infant  were  crying;  the  cry 
is  expressive  of  pain ;  the  respiration  is  interrupted,  and  the  general  agitation  so  great  that 
Ihe  existence  of  a  cerebral  affection  might  be  suspected.  At  the  end  of  six,  eight,  or  fifteen 
(lays  'he  patient  sinks  exhaiisted  from  the  want  of  sleep,  constant  vomiting,  and  pain :  in 
very  young  infants  the  disease  is  attended  with  little  or  no  fever. 

Dr.  Iselin,  of  IMuhlheim,  who  had  an  opportunity  of  studying  the  disease  during  its  exten- 
sive prevalence  as  an  epidemic  at  Gottingen,  gives  the  following  description  of  its  phe- 
ocmena : 

Previous  to  the  attack,  the  child  is  often,  for  several  days,  unusually  restless  and  fretful  — 


OF   THE    STOMACH.  761 

finally,  a  decided  febrile  attack  occurs,  attended  with  a  quick  pulse,  hot  and  dry  skin,  intense 
thirst,  sleeplessness,  and  constant  vomiting,  increased  upon  food  or  drink  being  taken  into  the 
stomach.  To  these  symptoms  is  speedily  added  a  copious  diarrhoea  —  the  dejections  being, 
at  first,  of  a  grayish  colour,  and  of  some  degree  of  consistence,  but  subsequently  of  a  yellow- 
ish or  greenish  serum,  decidedly  acid.  The  evacuations  are  usually  preceded  by  contortions 
of  the  countenance  indicative  of  pain,  which  are  likewise  induced  by  pressure  on  the  abdo 
men.  The  latter  is  always  much,  often  enormously  distended,  and  its  temperature,  especially 
at  the  epigastrium,  is  often  considerably  elevated,  while  the  extremities  are  cool,  or  even  de- 
cidedly cold.  The  patient  exhibits  great  prostration  of  strength,  and  a  profuse  partial  per- 
spiration soon  breaks  out,  particularly  about  the  head. 

The  disease  varies  in  its  duration — proving  fatal,  in  some  cases,  within  twenty-four  hours, 
and  in  others,  not  until  after  a  continuance  of  several  days,  or  even  weeks. 

In  the  more  violent  cases,  its  onset  is  very  sudden — and  it  is  attended  with  frequent  faint- 
ing, and  an  irregular  and  very  quick  pulse — the  eyes  and  features  are  sunken — the  body  is 
bathed  in  a  profuse  perspiration.  Convulsions,  more  or  less  severe,  often  attended  with  stra- 
bismus, sooner  or  later,  occur  ;  the  face  becomes  of  a  bluish  tint;  the  diarrhoea  or  vomiting, 
or  both,  soon  become  suspended ;  the  accessions  of  fainting  and  convulsions  become  more 
frequent,  and  during  one  of  these,  death  usually  takes  place. 

The  intumescence  and  augmented  heat  of  the  abdomen,  particularly  of  the  epigastric 
region,  and  the  coldness  of  the  extremities,  are,  according  to  Dr.  Iselin,  to  be  considered  a3 
among  the  most  constant  and  characteristic  symptoms  of  the  disease.  The  agonized  expres- 
sion of  countenance,  and  sunken  appearance  of  the  eyes,  are  likewise  almost  invariably  pre- 
sent, even  from  its  earliest  stages. 

The  age  at  which  this  form  of  gastritis  usually  occurs  is  within  the  first  year ;  it  is 
not,  however,  necessarily  restricted  to  this  period  of  life. 

The  most  constant  lesion  discovered  after  death  is  a  softening  of  the  mucous  membrane 
of  the  stomach,  and  often  of  the  small  and  great  intestines;  the  membrane  being  reduced  to 
a  disorganized  and  gelatinous  pulp  ;  or,  the  softening  may  extend  to  all  the  tissues  of  the 
stomach,  rendering  them  liable  to  be  perforated  by  the  slightest  force.  In  the  stomach  these 
softenings  occur  especially,  according  to  Baron,  Billard,  and  Iselin,  at  the  great  curvature,  sel- 
dom extending  beyond  the  most  depending  parts.  Distinct  traces  of  inflammation  are  occa- 
sionally observed,  surrounding  the  softened  parts,  and  patches  of  inflammation  often  exist, 
also,  in  diflerent  portions  of  the  intestinal  canal,  especially  in  the  small  intestines.  The  pa- 
rietes  of  the  stomach  frequently  present  a  serous  infiltration. 

Carswell,  Burns,  Gairdner,  Carwell,  Hope,  and  other  pathologists,  deny  the  connection  in 
tliese  cases,  of  the  softening  of  the  gastro-intestinal  mucous  membrane  and  inflammation,  and 
maintain  that,  in  general,  it  is  to  be  viewed  as  a  cadaveric  phenomenon,  resulting  from  the 
action  of  the  gastric  juice  upon  the  tissues  of  the  stomach ;  others,  with  Jaeger,  Zeller,  and 
Camerer,  refer  it  to  a  paralysis  of  the  nerves  of  the  stomach,  with  increased  acidity  of  the 
gastric  juices,  by  which  the  tissues  of  the  organ  are  dissolved  during  the  lifetime  of  the  pa- 
tient. A  somewhat  similar  opinion  is  entertained  by  Laisne,  Chaussier,  Desbarreaux,  Ber- 
nard, and  others.  Without  denying  that  the  softening  observed  after  death  in  the  stomachs 
of  children  may  be,  in  many  cases,  strictly  a  cadaveric  phenomenon,  and  that,  in  other  cases, 
it  may  result,  during  the  lifetime  of  the  patient,  from  other  causes  than  inflammation,  we  are, 
nevertheless,  well  convinced  from  the  result  of  repeated  and  cautious  observations,  that  the 
gelatinous  softening  so  frequently  met  with  in  the  stomach  of  those  infants  who  die  after 
exhibiting  all  the  symptoms  of  acute  gastritis,  is  invariably  the  efl'ect  of  an  intense  inflamma- 
tion commencing  in  the  mucous  tissue  of  the  organ. 

Softening  of  the  parietes  of  the  stomach,  as  well  as  of  the  intestines,  unquestionably  often 
takes  place  previously  to  the  death  of  the  patient,  in  cases  where  it  cannot  be  sujjposed  to  be 
trie  result  of  inflammation.  Thus,  we  not  unfrequently  observe  in  infants  brought  up  by  the 
hand,  or  improperly  fed  subsequently  to  weaning,  a  loss  of  appetite,  peevishness,  great  rest- 
lessness, and  want  of  sleep  ;  the  tongue  becomes  coated  with  a  layer  of  white  or  yellowish 
mucus  ;  and  in  some  instances  aphthte  appear  upon  the  parietes  of  the  mouth,  and  the  breath 
has  usually  a  decidedly  acid  odour.  There  are  a  constant  diarrhcea,  and  intense  thirst.  The 
diarrhcea,  after  a  time,  frequently  diminishes,  or  entirely  ceases — but  soon  returns  again  with 
increased  violence — the  discharges  being  a  thin  serous  fluid  of  a  yellow  or  greenish  hue,  and 
having  a  very  strong  acid  smell ;  great  emaciation  and  exhaustion  soon  ensue  ;  the  face  and 
extremities  become  cold ;  the  pulse  small  and  irregular ;  the  resjiiration  quick  and  short. 
The  child  utters  continually  a  low  piteous  moan,  or  lies  upon  his  back  with  the  eyes  fixed, 
glassy,  and  half  closed.  No  pain  or  tenderness  is  indicated  upon  gentle  pressure  of  the  ab- 
domen ;  the  latter  is,  however,  often  greatly  swollen  and  tyuipanitic.  The  child  becomes 
more  and  more  exhausted,  and,  finally,  expires  quietly,  and  without  convulsions. 

This  train  of  symptoms,  with  slight  variations,  marks  that  form  of  disease  described  by 
Camerer,  Pommer,  Hergt,  Romberg,  Droste  and  others,  as  gastro-malacia,  and  in  which  the 
stomach,  and  often  the  intestines  likewise,'  present  a  gelatinous  softening  of  their  parietes,  to 
a  greater  or  less  exter  t,  but  without  the  slightest  indication  of  inflammation ;  the  soitenirg 

3o2 


7C2  CARCINOMA  OF  THE  STOMACH. 

appearing  to  depend  upon  a  diminished  cohesion  of  the  tissues  —  the  result  probably  of  dis* 
ordered  or  suspended  nutrition. 

Acute  gastritis  as  it  occurs  in  the  infant,  is  under  all  circumstances,  and  throughout  all  its 
stages,  difficult  to  manage,  and  but  little  luider  the  control  of  remedies.  At  its  very  onset 
leeches  to  the  epigastrium,  followed  by  warm  fomentations  or  soft  emollient  poultices,  assi 
duonsly  applied,  will  be  found  advantageous.  Internally,  minute  doses  of  calomel  vi'il  often 
remain  upon  the  stomach  and  allay  the  excessive  irritability  of  that  organ;  we  have  occa- 
.■sionally  combined  the  calomel  with  the  acetate  of  lead;  one-fotirth  of  a  grain  of  the  first 
■with  half  a  grain  to  a  grain  of  theN  second,  will,  in  a  large  number  of  instances,  very  speedily 
control  the  vomiting  and  purging,  and  atibrd  us  time  to  reduce  the  local  inflammation  by 
leeches  to  the  epigastrium,  followed  by  blisters,  kept  on  for  one  or  two  hours,  and  then  re- 
placed by  an  emollient  poultice.  The  thirst  of  the  child  should  be  allayed  by  small  quanti 
ties  of  some  bland  mucilaginous  fluid,  given  cold,  and  repeated  at  short  intervals.  Slightly 
astringent  and  bitter  infusions  are  recommended  by  some  practitioners  during  the  period  of 
convalescence,  and  we  think  that  we  have  seen  very  decided  benefit  result  at  this  period 
from  the  j^roto-carbonate  of  iron  in  moderate  doses. — C] 

The  stomach  is  very  frequently  the  seat  of  specific  inahgnant  disease ;  of  cancer, 
in  its  various  forms  and  denominations.  The  fatal  nature  of  this  complaint ;  the 
obscurity  in  which  it  is  sometimes  wrapped  ;  the  possibility  of  overlooking  it  alto- 
gether, or  of  confounding  it  with  disease  of  a  more  innocent  character,  combine  to 
invest  it  with  peculiar  interest. 

Carcinoma  of  the  stomach  has  sometimes  no  symptoms  at  all,  or  none  which  the 
most  sagacious  practitioner  would  refer  to  the  organ  affected.  Not  long  since  I  saw, 
in  consultation,  an  elderly  clergyman,  m4io  complained  of  pains  in  his  back,  which 
were  brought  on  or  aggravated  by  certain  movements  of  the  body.  His  bowels 
were  costive  ;  and  purgatives  always  relieved  his  pains.  He  was  passing  lithic  acid 
gravel.  The  pains  were  felt  in  or  near  the  renal  region.  Several  years  before  he 
had  suffered  in  a  similar  manner;  and  had  then  been  cured  by  being  cupped  in  the 
loins.  What  was  the  matter  here  ?  Was  it  lumbago  ?  Was  there  a  calculus  in  one  of 
his  kidneys  ?  These  were  the  best  guesses  that  I  could  make.  The  eminent  phy- 
sician whom  I  met,  and  a  surgeon  of  no  less  eminence,  Avho  had  seen  the  patient 
previously,  had  not  been  able  to  obtain  any  more  exact  diagnosis.  Upon  this  gen- 
tleman's death,  which  occurred  not  long  afterwards,  his  disorder  was  discovered  to 
have  been  cancer  of  the  stomach.  Excepting  slight  sickness  a  day  or  two  before  he 
died,  there  had  been  no  symptom  to  direct  attention  to  that  part. 

A  young  woman  came  into  the  xMiddlesex  Hospital,  under  one  of  my  colleagues, 
with  a  pulsating  tumour  in  her  epigastrium.  It  was  thought,  at  first,  to  be  an  aneu- 
rism, and  the  case  attracted,  on  that  account,  a  good  deal  of  notice.  But  the  tumour 
subsided  very  much  after  free  purgation.  This  led  some  to  suppose  that  it  was  formed 
by  accumulated  feces  in  the  transverse  colon.  There  was  no  sickness;  nor  indaed 
any  one  symptoin  referable  to  the  stomach.  She  died.  The  tumour  was  cancerous; 
and  in  the  stomach.  Lying  in  front  of  the  abdominal  aorta,  it  had  been  hfted  by  its 
pulsations. 

Cases  to  the  same  effect  are  related  by  Dr.  Seymour  in  the  Medico-Chirurgical 
Transactions  ;  and  by  M.  Andral  in  his  Cliniqiie  Medicale. 

But  even  when  the  stomach  is  the  organ  pointed  out,  by  the  symptoms,  as  the 
probable  seat  of  the  malady,  those  symptoms  fail,  often,  to  indicate  with  any  cer- 
tainty its  nature.  The  effects  of  the  carcinomatous  disease  exhibit  no  uniformity. 
The  ingestion  of  food  is  apt  to  produce  great  distress ;  but  differently  in  different 
cases :  sometimes  as  soon  as  the  food  is  swallowed ;  sometimes  not  for  an  hour 
or  two  afterwards.  Some  cases  are  attended  with  much  pain  ;  some  with  none 
at  all.  One  patient  vomits  continually:  another  has  httle  or  no  vomiting  from  first 
to  last. 

Can  the.?e  differences  be  in  any  way  accoimted  for  ?  Partly  they  may.  By  ana- 
•yzmg  case  after  case,  we  approximate  to  a  knowledge  of  their  causes.  But  this 
knowledge  is  yet  far  from  being  complete. 

One  circumstance  that  has  a  considerable  influence  upon  the  symptoms,  is  the 
situation  of  the  disease.  In  respect  to  this. point  there  are  certain  general  rules 
which  are  for  the  most  part  true.  Still  we  can  speak  of  them  only  as  applicable  on 
the  average;  they  are  not  absolute  or  infalhble. 


CARCINOMA    OF   THE    STOMACH.  763 

The  rules  I  mean  are  these  : 

1st.  That  there  is  more  suffering,  caeteris  paribus,  when  the  cancerous  disease  is 
situated  at,  or  very  near,  either  extremity  or  orifice  of  the  stomach,  than  when  it 
occupies  the  intermediate  parts  ;  whether  in  the  greater  or  in  the  lesser  curvature. 

2d.  That  when  the  cardia,  and  its  immediate  neighbourhood,  is  the  part  solely  or 
principally  diseased,  the  food  and  drink  find  a  hinderance  in  passing  into  the  sto- 
mach ;  but  being  once  there,  the  distress  is  over.  The  symptoms  are  very  like  those 
of  stricture  of  the  oesophagus.  The  morsel  reaches  the  bottom  of  that  tube,  and  there 
causes  uneasiness,  till  at  length  it  is  brought  up  again  through  the  mouth,  or  passes 
gradually  in  the  natural  direction. 

8d.  That  when,  on  the  other  hand,  the  disease  is  limited  to  the  pyloric  end  of  the 
stomach,  the  food  enters  that  bag  readily  enough,  and  remains  there  for  a  certain 
time ;  then  uneasy  sensations  arise,  and  the  imperfectly  digested  meal  is  apt  to  be 
rejected  by  vomiting. 

It  is  the  difficulty  of  passing  the  doorway  in  these  cases,  that  gives  rise  to  the 
principal  suffering;  the  difficulty  of  getting  into,  or  the  difficulty  of  getting  out  of 
the  stomach.  But  when  the  disease  is  confined  to  the  intermediate  space,  no  such 
difficulty  occurs  ;  and  therefore  little  or  no  pain. 

You  must  expect,  I  say,  to  meet  with  individual  variations  from  these  rules.  A 
remarkable  example  of  such  variation  was  presented  by  one  of  my  hospital  pa- 
tients, in  the  year  1837.  I  have  the  notes  of  that  case  before  me,  which  I  will  read 
sJiort. 

Simon  Ailes,  aged  thirty-six,  admitted  March  14.  His  main  complaint  was  of  pain 
in  the  epigastrium,  always  present,  but  augmented  in  frequent  paroxysms,  to  an  ex- 
treme degree  of  severity.  At  first,  pressure  gave  him  some  relief.  The  pain  was 
most  violent  an  hour  or  two  after  he  ate.  He  was  troubled  also  with  flatulence,  and 
with  sour  eructations.  Occasionally  a  clear  tasteless  fluid,  looking  like  water,  rose 
into  his  mouth.     His  bowels  were  costive. 

At  this  time  his  countenance  was  natural  and  placid  ;  but  it  gradually  assumed 
that  pinched  and  anxious  expression,  and  that  peculiar  yellowish  hue,  which  are  so 
significant  of  organic  visceral  disease.  He  wasted  fast.  At  length  the  epigastrium 
became  tender  as  well  as  painful:  but  no  tumour,  except  the  left  edge  of  the  liver, 
could  be  felt  there.  He  died  on  the  11th  of  May,  about  eight  months  from  the 
commencement  of  the  pain.  A  week  before  his  death  he  vomited  some  dark, 
grumous,  offensive  fluid,  evidently  containing  blood.  With  this  exception  he  had 
CO  vomiting. 

Many  remedies  were  tried,  which  I  do  not  specify,  for  none  of  them  gave  him  any 
sensible  or  continued  relief. 

In  the  smaller  curvature  of  the  stomach  we  found  a  ragged,  sloughy  surface,  as 
big  as  the  palm  of  one's  hand,  and  extending  to  within  half  an  inch  from  the  pylorus. 
A  section  of  this  diseased  portion  exhibited  the  characters  of  true  scirrhus:  a  white 
and  hard  mass,  nearly  half  an  inch  across  at  its  thickest  part.  The  mucous  mem- 
brane of  the  duodenum  was  congested,  and  dark-coloured.  The  I'est  of  the  intestines 
VA'ere  healthy  except  the  rectum,  which  was  surrounded,  towards  the  anus,  by  scir- 
rhus and  thickened  areolar  tissue,  intermixed  in  laminas.  The  gut  itself  was  not 
affected. 

The  diseased  stomach  was  removed,  and  examined  by  Mr.  Kiernan,  who  found, 
upon  careful  dissection,  that  the  trunk  of  the  gastric  branch  of  the  par  vagum  run 
directly  into,  and  was  lost  in,  the  scirrhous  mass.  This  sufficiently  accounted  for 
the  dreadful  sufferings  of  the  patient. 

And  I  am  here  reminded  that,  with  regard  to  the  structural  akeration  itself,  there 
are  some  circumstances  well  worth  attending  to. 

Andral  places  all  these  organic  affections  of  the  stomach  in  the  class  of  chronio 
gastritis.  But  it  is  clear  that  he  is  wrong :  and  you  will  perceive  at  once  that  it  •'» 
of  immense  importance  to  recognize  the  specific  disease  from  the  mere  result  of 
common  inflammation. 

But  though  cancer  is  not,  in  any  case,  a  mere  product  of  common  inflammation 
neither  is  all  that  is  called  cancer  really  such.     Specimens  of  morbid  texture,  nus* 


764  CARCINOMA    OF   THE    STOMACH. 

named  scirrhus  of  the  pylorus,  are  not  uncommon  in  anatomical  museums.  I  shciv 
you  some  from  our  own  ;  not  so  denominated,  however.  The  correct  labeling  would 
be  hypertrophy.  You  may  perceive  that  the  areolar  and  the  muscular  tissues  near 
the  p3-lorus,  are  very  much  thickened.  A  section  of  the  thickened  parts  presents 
an  appearance  somewhat  like  horn  ;  and  is  crossed  by  whitish  Hnes  that  run  nearly 
parallel  to  each  other.  The  morbid  structure  is  quite  definite  and  uniform ;  and 
ver}"  dissimilar,  in  that  respect,  to  the  irregular  masses  of  scirrhus,  and  to  the  amor- 
phous deposits  of  encephaloid  cancer.  Neither  does  it  at  all  resemble  that  of  the 
colloid  variety  of  carcinoma.  Changes  of  this  kind  are  liable  to  occur  in  the  mus- 
cular tissue  of  this,  as  of  other  organs,  whenever  a  permanent  obstacle  is  opposed  to 
the  onward  progress  of  the  contents  of  the  hollow  viscus.  The  impediment  may 
have  been  originally  produced  by  inflammatory  thickening  of  the  textures  composing 
the  pylorus  ;  and  then  the  hypertrophy  may,  in  a  certain  sense,  be  accounted  a  con- 
sequence of  inflammation.  To  that  extent  alone  is  M.  Andral  right.  He  has  un- 
questionably pushed  his  theory  on  this  subject  too  far.  Whatever  narrows  the 
pyloric  orifice  leads  to  increased  effort  of  the  propelling  muscle,  and  to  augmenta- 
tion of  its  bulk  and  power.  Now  cancer  itself,  situated  at,  or  close  upon,  the  pylorus, 
may  impede  the  exit  of  the  digested  aliment ;  and  then  it  causes  a  gradual  hyper- 
trophy of  the  muscular  coat.  In  these  cases  there  is  a  mixture  of  the  two  changes  ; 
of  the  cancerous  growth,  with  the  muscular  hypertrophy :  and  this  is  one  reason 
why  they  have  been  confounded  together.  Here  are  several  preparations,  exhibiting 
true  cancer  of  the  stomach.  At  the  bottom  of  each  bottle  may  be  seen  a  sort  of 
whitish  powder,  or  sediment,  consisting  of  some  of  the  matters  peculiar  to  cancer. 
This  fact  has  been  pointed  out  to  me  by  Mr.  Kiernan  in  the  numerous  specimens 
contained  in  his  private  collection.  But  there  is  no  such  deposit  when  the  hyper- 
trophy is  not  combined  with  malignant  disease. 

It  has  long  been  thought  and  asserted,  that  cancer  of  the  stomach  is  not  so  apt  to 
be  attended,  as  cancer  of  other  parts,  with  a  disposition  to  present  itself  in  various 
organs  of  the  body  at  the  same  time,  or  in  succession.  Now  I  believe — and  I  am 
glad  to  add  the  weight  of  Mr.  Kiernan's  authority  to  my  statement — that  this  is  not 
really  so.  Cancer  is  a  constitutional  affection:  or,  if  local  and  solitary  in  the  outset, 
is  prone  to  disseminate  itself.  The  error  has  arisen  out  of  that  confounding  of  one 
morbid  condition  with  another,  against  which  I  have  been  warning  you.  Instances 
are  not  at  all  uncommon  of  thickening  of  the  areolar  and  mucous  tissues  about  the 
pylorus,  producing  first  a  mechanical  impediment  to  the  passage  of  the  food,  then 
more  energetic  muscular  efforts  towards  its  expulsion  from  the  stomach,  and  at  last 
hypertrophy  of  the  muscular  tunic.  In  these  cases,  you  do  not  find  cancer  in  other 
organs :  because,  in  fact,  there  is  no  cancer  in  the  stomach. 

You  may  say  that  as  both  forms  of  disease  are  alike  fatal,  it  signifies  nothing 
whether  there  be  really  cancer  or  not.  But  it  is  always  satisfactory  to  clear  away 
an  apparent  anomaly,  and  to  show  that  it  has  no  real  existence.  Besides,  you  know 
with  how  much  anxiety  the  relatives  of  the  dead  inquire  concerning  these  matters. 
That  cancer  "runs  in  families"  is  well  understood  even  by  the  public:  and  the  dis- 
tinctions I  have  been  pointing  out  are  surely  worth  learning,  if  they  do  no  more  than 
enable  us  to  comfort  the  minds  of  survivors,  and  to  relieve  them  from  the  apprehen- 
sion that  they  also  may  be  doomed  or  likely  to  become  the  victims  of  cancer. 

Notwithstanding  what  I  have  now  been  saying,  it  must  be  allowed  that  genuine 
cancer  of  the  stomach  is  accompanied  less  frequently  than  some  other  modes  of  car- 
cinomatous disease,  by  cancer  elsewhere.  In  fact  cancer  of  the  stomach  is  most 
often  of  the  scirrhous  variety,  which  until  it  softens  is  not  so  readily  disseminated  as 
the  others,  and  which  is  apt  to  prove  fatal  before  it  softens. 

When  primary  cancer  of  the  stomach  is  of  the  encephaloid  kind,  or  when,  being 
scirrhous,  it  begins  to  grow  soft, — you  would  expect,  after  what  was  stated  respecting 
suppurative  phlebitis,  that  its  secondary  manifestation  should  occur  chiefly  in  the 
liver.  And  it  is  so:  the  reason  being  that  the  veins  of  the  stomach  conuTiunicate 
with  the  general  system  not  directly,  but  through  the  hepatic  capillary  system. 

But  to  return  to  the  symptoms  of  carcinoma  of  the  stomach.  In  some  cases,  I  say, 
the  food  is  rejected  by  vomiting :  in  some  cases  it  is  not.     Now  it  has  been  argued 


CARCINOMA    OF   THE    STOMACH.  765 

that  this  difference  depends  upon  the  condition  of  the  pyloric  outlet ;  whether  it  be 
free  and  open,  or  contracted  and  shut.  The  explanation  is  more  plausible  than 
sound.  It  is  not  strictly  consistent  with  facts.  Vomiting  of  the  food  has  been  an  ur 
gent  symptom,  when  there  was  no  mechanical  bar  to  its  passage  into  the  duodenum, 
The  pylorus  is  a  sphincter  muscle,  of  which  the  natural  and  habitual  state  is  that  of 
contraction.  It  yields,  however,  in  health,  to  the  pressure  of  the  digested  aliment, 
whicn  is  driven  forwards  by  the  muscular  fibres  that  surround,  and  compress  by  their 
action,  the  pyloric  end  of  the  stomach.  If  there  be  a  mechanical  impediment,  that 
affords  a  sufficient  reason  why  the  food  should  be  thrown  up  again.  But  sometimes, 
I  repeat,  the  orifice  is  wide  open,  and  yet  the  food  is  rejected :  and  it  is  rejected  be- 
cause the  disease  so  involves  the  pyloric  end  of  the  stomach,  that  the  propelling  force 
cannot  be  exercised. 

When  there  is  a  mechanical  obstacle,  the  disposition  to  hypertrophy  of  the  mus- 
cular coat  is  conservative.  But  in  feeble  and  delicate  persons,  the  baffled  muscles 
may  never  acquire  strength  enough  to  overcome  the  impediment ;  and  then  the  very 
opposite  condition  is  apt  to  take  place  :  the  coats  all  become  very  thin  ;  meal  after 
meal  is  retained  ;  the  stomach  is  enormously  distended,  and  relieves  itself  now  and 
then,  at  distant  intervals,  by  copious  vomiting  ;  until  at  last  it  is  unequal  to  that  efTort, 
and  the  patient  dies. 

Sometimes  the  sickness  and  vomiting  are  urgent  even  when  the  stomach  contains 
no  food  :  and  the  matters  rejected  are  of  various  character  and  appearance.  They 
often  resemble  coffee-grounds,  and  consist,  no  doubt,  of  altered  blood.  Vomiting  of 
this  kind  is  a  vexy  pregnant  sign  of  organic  mischief  in  the  stomach. 

Emaciation  is  another  ugly  circumstance  in  these  cases  ;  and  forms  a  strong  grouno* 
of  presumption  that  the  symptoms  depend  upon  structural  disease.  Yet  it  is  not  a 
uniform  consequence,  even  of  malignant  disorganization  of  the  stomach.  Napoleon 
Bonaparte  was  very  fat  when  he  died.  His  omentum  is  described  as  having  been 
"remarkably  fat;"  and  the  "fat  was  upwards  of  an  inch  thick  upon  his  sternum, 
and  one  inch  and  a  half  upon  his  abdomen." 

The  existence  of  a  palpable  tumour  strengthens  the  unfavourable  diagnosis.  But 
this  is  far  from  being  a  constant  phenomenon.  It  is  not  even  pathognomonic  when 
it  does  occur.  The  diseased  head  of  the  pancreas  has  been  mistaken  for  a  thickened 
pylorus.  The  stomach  is  liable  also  to  be  dragged  much  out  of  its  place  ;  and  then 
a  thickened  pylorus  may  be  mistaken  for  something  else.  Sometimes  the  form  of 
the  stomach  may  be  distinctly  traced.  In  the  person  of  a  medical  practitioner  who 
died  lately  in  this  neighbourhood,  the  shape  of  the  organ,  its  occasional  peristaltic 
motions,  and  the  irregular  and  hardened  pylorus,  were  plainly  to  be  felt.  They 
might  indeed  almost  be  seen,  in  the  hollow  and  attenuated  abdomen.  When  a 
tumour  is  ascertained  to  belong  to  the  stomach,  it  indicates  disease  of  the  pylorus 
rather  than  of  the  cardia. 

It  is  a  curious  feature  in  these  malignant  diseases  of  the  stomach,  that  the  symp- 
toms sometimes  remit,  in  a  remarkable  manner,  so  as  to  excite  a  hope  in  the  mind 
of  the  patient,  and  in  that  of  his  medical  attendant,  that  the  nature  of  the  malady 
had  been  mistaken,  and  that  recovery  is  about  to  take  place.  But  the  truce  is  not 
for  long.  Frightful  disorganization  is  at  length  produced,  ragged  ulceration,  perfora 
tion  of  the  coats  of  the  stomach,  adhesion  to  the  parts  adjacent,  which  thus  are  con 
stituted  adventitious  walls ; — and  inevitable  death  at  last. 

The  treatment  of  this  dreadful  complaint  can  only  be  palliative.  If  there  be  pain, 
we  are  driven,  sooner  or  later,  to  opium.  Anodyne  enemata  have  often  as  good  an 
effect  in  relieving  the  pain  as  opium  given  by  the  mouth ;  and  they  have  this  advan- 
tage, that  their  constipating  properties  are  more  easily  obviated  than  when  that  drug 
is  put  into  the  stomach.  Nutritive  injections  are  proper  when  food  taken  through 
the  natural  channel  is  not  retained. 

Other  palliative  measures  may  be  aimed  at  particular  symptoms ;  of  these  I  pro- 
pose to  speak  when  I  come  tc  the  symptoms  and  remedies  of  dyspepsia. 


766  H^MATEMESIS. 


LECTURE  LXIX. 

Hemorrhage  from  the  Stomach:  sometimes  from  a  large  vessel,  usually  by  exha 
lation.  Idiopathic  Hxmatemesis.  Vicarious  Hxrnatemesis :  Hsematemesis 
from  Gastric  disease  or  injury:  from  disease  in  other  organs.  Melxna. 
Ila^matemesis  from  a  morbid  state  of  the  blood.  General  phenomena  of  Haema- 
temesis.     Diagnosis.     Treatment. 

Hemorrhage  from  the  stomach,  to  which  I  wish  next  to  direct  your  attention,  is 
of  much  more  frequent  occurrence  than  acute  gastritis.  It  is  a  complaint,  or  a  symp- 
tom, that  presents  several  points  of  interest  and  importance.  I  use  the  phrase 
"hemorrhage  from  the  stomach,"  rather  than  the  single  term  "  hasmatemesis,"  be- 
cause that  term,  signifying  strictly  a  vomiting  of  blood,  does  not  necessarily  imply 
hemorrhage y)'om  the  stomach;  nor,  indeed,  does  it  always  accompany  such  hemor- 
rhage, although  it  is  one  of  its  most  common  and  most  striking  symptoms. 

What  I  have  so  frequently  mentioned  in  respect  to  hemorrhages  from  me  mucous 
membranes  generallj',  viz.,  that  the  efllux  of  the  blood  is  seldom  jwing  to  tne  rupture 
of  a  large  blood-vessel,  holds  true  in  this.  It  can  rarely  happen  tnat  any  vein  or 
artery  belonging  to  the  stomach  is  divided  or  laid  open  by  accidental  injury,  so  as  to 
pour  forth  its  blood.  When  hemorrhage  does  proceed  from  one  or  more  of  the 
larger  blood-vessels,  the  opening  by  which  the  blood  escapes  is  commonly  the  result 
of  chronic  ulceration  ;  such  as  I  spoke  of  yesterday.  1  have  not,  myself,  met  with 
an  instance  of  that  kind.  Andral  states,  that,  ai  most,  there  are  but  five  or  six  such 
eases  to  be  found  in  the  records  of  medicine.  Since  his  work  on  Pathological 
Anatomy  was  published,  another  example  of  the  same  lesion  has  been  detailed  in 
the  Journal  Hebdomadairz  for  May,  1S30.  I  show  you  a  drawing  after  Dr.  Cars- 
well,  representing  an  ulcer  which  Idid  open  the  coronary  artery  of  the  stomach,  ana 
caused  fatal  hemorrhage.  In  these  cases,  we  have,  first,  the  symptoms  of  chronic 
gastritis ;  next,  faintness,  or  actual  syncope,  from  the  sudden  abstraction  of  a  large 
quantity  of  the  vual  fiuid ;  and  lastly,  the  visible  eruption  of  the  blood  itself;  foi 
vomiting  seldom  occurs  until  a  large  quantity  of  blood  has  accumulated  in  the  sto- 
mach. 

As  this  variety  of  gastric  hemorrhage  is  rare,  I  will  briefly  relate  an  instance  of  it, 
which  occurred  in  the  year  1831,  at  St.  Bartholomew's  Hospital.  Dr.  Latham,  who 
had  charge  of  the  case,  was  good  enough,  some  time  ago,  to  give  me  the  following 
history  of  it.  The  subject  of  the  disorder  was  a  man  thirty-eight  years  old.  He  was 
admitted  on  tne  19th  Januarj'.  His  countenance  was  dusky,  but  exsanguine ;  his 
pulse  100,  and  weak  ;  his  tongue  pale,  and  shghtly  furred.  He  made  no  complaint 
of  pain  anywhere. 

He  had  been  ailing  for  two  years ;  had  suffered  much  pain  across  the  epigastric 
region ;  and  had  frequently  vomited  his  meals.  Two  days  before,  he  had  been 
suddenly  attacked  with  faintness  and  giddiness,  and  then  vomited  about  two  quarts 
0^  blood.     He  was  an  habitual  spirit  drinker. 

In  the  afternoon  of  the  day  on  which  he  entered  the  hospital,  he  was  again  seized 
with  giddiness ;  and  fell  into  a  state  of  syncope,  in  which  he  remained  for  several 
minutes.  Upon  recovering,  he  vomited  a  large  quantity  of  blood,  not  less  than 
three  pints.  The  next  morning,  early,  he  brought  up  a  like  quantity,  under  similar 
circumstances ;  and  he  passed  three  evacuations  from  the  bowels,  all  of  them  black. 
He  w'as  gradually  sinking  during  the  whole  of  that  day,  the  20th.  Towards  the 
evening,  he  vomited  about  half  a  pint  more  blood.  He  died  quietly  the  next 
morning. 

When  the  abdomen  was  laid  open,  the  stomach  was  seen  to  be  distended.  The 
intestines  had.  in  several  places,  a  black  appearance,  from  the  colour  of  their  con 
tents.  The  siomach  contained  about  two  pints  of  coagula,  and  of  a  dirty  red  liquid. 
At  the  upper  part  of  its  lesser  arch  was  a  small  excavated  ulcer,  with  hardened 


HiEMATEMESIS.  767 

edges.  In  the  centre  of  this  ulcer  there  were  visible  the  orifices  of  three  or  four 
arteries,  filled  with  minute  clots  of  blood. 

Tt  would  seem  as  if  gastric  hemorrhage,  having  this  origin,  were  capable  of  being 
stanched  by  some  natural  process  ;  and  as  if  the  injury  done  to  the  stomach  were 
susceptible  of  repair.  Andral  describes  a  curious  case,  in  which  an  open  blood- 
vessel was  found  in  an  ulcer  of  the  stomach ;  but  no  hemorrhage  had  occurred. 
That  mere  ulcers  in  the  stomach  may  heal,  there  can  be  no  doubt :  two  or  three 
scars  of  healed  ulcers  are  represented  in  Dr.  Carswell's  drawing.  The  patient 
whose  case  is  related  in  the  Journal  Hebdomadaire  had  vomited  considerable 
quantities  of  blood  for  eight  days  in  succession,  five  years  previously  to  the  attack 
which  terminated  his  life.  So  that  hsematemesis  from  this  cause  is  not  absolutely 
hopeless. 

But  (as  I  have  already  said)  hemorrhage  from  the  mucous  membrane  of  the  sto- 
mach, and  from  that  of  the  alimentary  canal  generally,  takes  place  far  more  com- 
monly by  exhalation.  The  evidence  that  the  blood  really  does  ooze  from  the 
membrane  is  the  same  as  that  to  which  I  have  so  often  had  occasion  to  advert ;  and 
it  is  very  satisfactory  and  conclusive  in  these  cases,  because  we  are  able  to  scrutinize 
closely  the  whole  extent  of  the  mucous  surface.  This  cannot  so  well  be  done  in 
regard  to  the  mucous  membrane  of  the  lungs.  When  death  has  followed  imme- 
diately upon  the  hemorrhage,  and  has  indeed  been  its  rapid  effect,  the  membrane 
has  been  found  quite  entire,  and  of  its  natural  consistence  and  texture  throughout. 
Sometimes  partially  red  and  pulpy,  and  vascular;  sometimes  universally  so,  the 
submucous  capillary  net-work  of  vessels  being  still  gorged  with  blood ;  sometimes 
quite  pale,  the  same  system  of  vessels  having  been  completely  emptied  by  the  last 
attack  of  hemorrhage  ;  and  sometimes  studded  with  minute  dark  points,  which  could 
be  made,  by  slight  pressure,  to  start  from  the  surface,  and  looked  like  grains  of 
black  sand.  This  latter  appearance,  as  I  once  before  remarked,  is  very  corroborative 
of  the  opinion  that  the  blood  escapes  through  the  natural  pores  or  channels :  which 
it  cannot  enter  so  long  as  the  solids  and  fluids  of  the  body  retain  their  healthy  con- 
dition. These  sand-like  bodies  are,  doubtless,  small  portions  of  blooa,  which  have 
coagulated  in  the  exhalant  orifices  of  the  membrane,  and  received  from  them  their 
shape. 

This  kind  of  hemorrhage  happens  under  various  circumstances ;  and  is  attended 
with  different  degrees  of  danger.  1.  The  bleeding  may  be  idiopathic.  2.  It  may 
bo  vicarious  of  some  other  habitual  hemorrhage.  3.  It  may  depend  upon  disease 
or  injury  of  the  stomach  itself.  4.  It  may  be  the  consequence  of  disease  situated 
elsewhere,  and  producing,  mechanically,  a  plethora  of  the  veins  of  the  stomach. 
5.  It  may  result  from  a  morbid  condition  of  the  blood,  and  form  one  sjariptom  of  a 
more  general  disease ;  as  in  the  passive  hemorrhages  of  purpura  and  sea-scurvy. 
Each  of  these  varieties  requires  a  short  notice. 

1.  Hemorrhage  strictly  idiopathic  —  i.  e.,  independent  of  any  apparent  change 
of  texture,  whether  in  the  surface  itself,  or  in  any  part  obviously  capable  of  influ- 
encing its  blood-vessels — is  as  rare,  I  believe,  from  the  mucous  membrane  of  the 
stomach,  as  from  that  of  the  lungs.  I  have  never  seen,  nor  do  I  recollect  to  have 
read  of,  any  instance  of  hsematemesis  analogous  to  the  epistaxis  which  is  so  common 
in  children  and  young  persons  ;  and  which  affords  the  most  familiar  example  of  idio- 
pathic hemorrhage. 

2.  But  hemorrhage  from  the  stomach,  occurring  in  connection  with  other  consti- 
tutional hemorrhages,  or  in  their  stead — and  above  all,  occuring  vicarioiislt/  of  men- 
struation— is  abundantly  common.  It  is  the  most  common,  indeed,  of  all  the  species 
of  hemorrhage  by  deviation.  I  told  you,  in  a  former  lecture,  that  patients  will 
sometimes  menstruate  for  years  together  through  the  lungs  ;  without  any  apjxirent 
injury  to  their  general  health.  More  commonly  still  do  they  menstruate  through 
the  stomach.  I  will  mention  one  concise  but  singular  example  of  this  which  I  had 
from  Dr.  Latham,  and  which  came  within  his  own  knowledge.  A  young  woman 
became  the  subject  of  haematemesis,  recurring  at  monthly  periods,  about  the  age  of 
fourteen.  She  had  never  menstruated.  This  continued  until  she  married,  and  in 
due  time,  fell  with  child.     Thereupon  the  hsematemesis  ceased.     She  brought  forth 


768  HiEMATEMESIS. 

and  suckled  her  infant.  During  lactation  tlie  hennorrhage  did  not  recur.  It  came 
on  again  soon  after  she  ceased  to  nurse  the  child ;  no  regular  menstruation  by  the 
uterus  having  ever  happened.  This  was  the  woman's  own  account,  and  there  ap- 
peared no  reason  to  question  its  accurac3\ 

Gastric  hemorrhage  of  this  kind,  vicarious  of  regular  menstruation,  is  not  generally 
thought  to  have  any  tendency  to  shorten  the  existence  of  those  who  are  afflicted  with 
it.  Cujlen  states  broadly  that  this  species  of  hsmatemesis  is  hardly  ever  a  dangerous 
disorder:  and  this  is  true.  Yet  it  is  not  so  entirely  free  from  peril  as  to  preclude 
the  necessity  of  some  caution  and  qualification  in  stating  the  prognosis.  The  ex- 
haustion from  the  mere  loss  of  blood  is  sometimes  so  great  as  to  create  serious  alarm 
for  the  patient's  safety.  And  Mr.  North  has  recorded  (in  the  London  Medical  and 
Physical  Journal)  two  instances  in  which  suppressed  menstruation  was  followed  by 
repeated  and  at  length  fatal  hsematemesis.  In  neither  of  these  women  was  the 
health  seriously  deranged ;  nor,  previously  to  the  hemorrhage,  did  there  exist 
debility,  or  any  other  symptom  calculated  to  excite  the  apprehension  of  danger.  In 
fact,  in  both  of  these  cases,  a  strongly  favourable  prognosis  was  given  by  experienced 
physicians,  a  very  short  time  only  before  the  fatal  event. 

3.  Gastric  hemorrhage,  by  the  w^ay  of  exhalation,  is  often  a  consequence  of  dis- 
ease or  injury  of  the  stomach  itself.  It  is  sometimes  one  of  the  earliest  declaratory 
symptoms  of  scirrhus  or  cancer  of  that  organ — occurring  long  prior  to  ulceration. 
Hsematemesis  attends,  also,  very  commonly,  the  ultimate  stages  of  that  fatal  disease  : 
and  then  it  may  be  owing  to  the  erosion  of  some  vessel  of  notable  magnitude,  in  the 
course  of  the  process  of  disorganization,  as  in  the  examples  already  spoken  of:  or 
(what  I  believe  is  far  more  common)  it  may  result  from  a  kind  of  general  oozing  or 
exhalation  from  the  ulcerating  surface.  Blood  is  often  vomited  soon  after  the  recep- 
tion of  strongly  irritant  poisons  into  the  stomach.  I  show  you  again  Dr.  Roupel's 
plate,  representing  the  crimson  surface  of  a  portion  of  the  stomach  of  a  dog  which 
had  been  killed  shortly  after  the  administration  of  a  dose  of  alcohol.  The  intense 
congestion  thus  produced  is  doubtless  active  congestion  ;  congestion  belonging  to 
inordinate  arterial  action.  Pushed  a  degree  further,  such  congestion  passes  into 
hemorrhage. 

4.  On  the  other  hand,  intense  passive  congestion — congestion  arising  from  the 
detention  of  blood  in  the  veins  by  some  mechanical  obstacle  to  its  progress — is  a  very 
common  source  of  gastric  hemorrhage.  Hfematemesis  is  therefore  an  occasional 
symptom  of  obstructive  disease  of  the  heart.  Much  more  frequently,  however,  it 
depends  upon  abdominal  changes.  The  hemorrhage  is  symptomatic  of  disease 
situated  not  in  the  stomach  itself,  but  elsew'here.  And  the  viscera,  with  the  diseases 
or  morbid  conditions  of  which,  bleeding  from  the  stomach  is  most  often  connected, 
are  the  liver  and  the  spleen. 

All  this  is  well  known  :  and  it  is  easy  to  see,  from  the  peculiar  construction  of  thff 
venous  apparatus  in  the  abdomen,  how  disease  of  one  or  both  of  these  viscera  may 
produce  mechanical  congestion  of  the  submucous  capillary  tissue;  and  how  chai 
congestion  may  be  relieved,  under  certain  circumstances,  by  the  effusion  of  seious 
fluid  on  the  one  or  the  other  surface,  constituting  ascites  or  diarrhoea,  as  the  case 
may  be ;  or  under  other  circumstances,  not  perhaps  easily  discriminated  or  well 
understood,  by  the  extravasation  of  the  collected  blood  itself.  It  would  be  saper- 
fluous  to  describe  the  peculiar  distribution  and  functions  of  the  vessels  which  leturn 
the  main  portion  of  the  venous  blood  from  the  stomach  and  intestines  towards  thd 
'heart.  It  seems  to  m''.  highly  probable  that  one  at  least  of  the  offices  of  the  spleen 
is  to  provide  a  receptacle  or  reservoir  for  this  blood  when  its  free  passage  through 
the  portal  vessels  is  temporarily  obstructed.  It  then  becomes  a  sort  of  safety-valve 
(if  such  an  illustration  be  allowable),  which  obviates  the  danger  that  might  otherwise 
arise  to  more  vital  parts  from  any  great  or  sudden  disturbance  of  the  venous  circu- 
lation. The  stress  of  the  congestion  is  continually  feh  in  the  submucous  capillary 
system  ;  and  the  hemorrhage,  which  is  apt  in  such  cases  to  occur  from  the  loaded 
membrane,  receives  a  simple  solution  upon  principles  almost  purely  mechanical. 
Nay,  the  very  circumstances  which  lead  to  the  effiision  of  the  blood  from  the  mucous 
eurface  on  the  one  side,  rather  than  from  the  serous  on  the  other,  may  perhaps  (as  I 


HiEMATEMESIS.  760 

Stated  more  at  large  in  an  early  part  of  the  course)  be  themselves  susceptible  or 
mechanical  explanation. 

Gastric  hemorrhage,  symptomatic  of  hepatic  disease,  is  chiefly  to  be  looked  for  in 
those  morbid  conditions  of  the  liver  which  imply  obstruction  of  the  portal  vein  and 
of  its  ramifications.  We  are  not  surprised,  therefore,  to  find  it  coincident,  often, 
with  a  contracted  and  shrunken  state  of  that  organ.  The  state  of  the  spleen,  on  the 
contrary,  for  reasons  that  must  be  obvious  to  you,  is  uniformly,  in  the  cases  we  are 
now  considering,  a  state  of  enlargement.  And  the  augmentation  of  bulk  is  not  so 
much  to  be  ascribed  to  disease  inherent  in  its  proper  texture,  as  to  distension  by  the 
mere  quantity  of  blood  which  it  holds.  The  internal  structure  of  the  spleen  furnishes 
a  credible  presumption  in  favour  of  that  view  of  one  of  its  uses  to  which  I  just  now 
alluded  ;  and  this  structure,  and  this  presumed  function,  when  considered  together, 
throw  a  strong  light  upon  some  of  the  pathological  relations  of  the  spleen  which  well 
deserve  attention. 

Numerous  instances  are  on  record  of  hsematemesis  going  along  with  evident 
enlargement  of  the  spleen ;  and  in  some  of  them  that  organ  has  been  observed  to 
diminish  in  bulk,  in  proportion  as  blood  was  poured  out  by  the  stomach.  If  I  am 
not  greatly  mistaken,  I  have  more  than  once  seen  this  myself.  In  such  lases  the 
tumid  condition  of  the  spleen  may  be  regarded  as  an  evidence  of  venous  obstruction 
elsewhere;  and,  as  depending,  sometimes  at  least,  upon  disease  of  a  less  striking 
and  prominent  character  in  the  liver,  impeding  the  progress  of  the  blood  through  the 
vena  portaa.  Of  this  kind  would  seem  to  have  been  a  case  related  by  Morgagni, 
wherein,  after  repeated  attacks  of  haematemesis,  under  which  the  patient  sank  at 
last,  the  spleen  was  found  to  weigh  four  pounds,  and  to  be  gorged  with  dark  blood  ; 
while  the  liver  was  pale  and  exsanguine.  Frank  gives  the  history  of  a  patient,  who 
had  vomitings  of  blood,  and  whose  spleen,  taken  from  the  body  after  death,  weighed 
sixteen  pounds:  the  ordinary  weight  of  the  spleen  in  a  healthy  adult  being  from 
eight  to  ten  ounces.  In  Latour's  work  on  Hemorrhage,  which  is  remarkable  for  the 
number  of  examples  it  contains,  collected  from  various  sources,  and  amounting  to 
nearly  a  thousand,  several  instances  are  detailed  of  this  combination  of  splenic  en- 
largement with  hasmatemesis.  One  of  these  occurred  in  the  person  of  a  friend  of 
his,  who  had  been  living  in  a  malarious  district,  and  who  had  laboured  for  nearly 
iwo  years  under  obstinate  intermittent  fever.  This  was  followed  by  an  immense 
enlargement  of  the  spleen — a  great  ague-cake — which  came  to  occupy  almost  tht 
whole  of  the  abdomen.  Latour's  experience  enabled  him  to  predict  that  hasmate- 
mesis would  probably  supervene  upon  this  condition  of  the  spleen ;  and,  accord- 
ingly, one  night  he  was  called  in  a  hurry  to  his  friend,  and  found  that  he  had 
vomited  an  enormous  quantity  of  clotted  blood.  A  great  deal  passed  away  through 
the  bowels  also.  The  hemorrhage  recurred  from  time  to  time,  till  in  the  course 
of  a  month  the  spleen  was  so  far  reduced  in  bulk,  that  it  could  no  longer  be  felt  in 
the  belly ;  and  the  patient  lived  and  enjoyed  good  health,  for  twenty-five  yeara 
afterwards. 

It  is  necessary,  therefore,  in  marking  the  connection  which  frequently  subsists 
between  hsematemesis  and  enlargement  of  the  spleen,  to  guard  ourselves  against  con- 
cluding that  these  two  circumstances  hold  always  the  relation  of  cause  and  effect. 
In  many  such  cases,  probably  in  most  of  them,  they  are  simply  concurrent  effects  of 
one  common  cause  ;  and  that  cause  is  chiefly  to  be  sought  in  such  morbid  conditions 
of  the  liver  —  or  of  other  parts  within  the  abdomen  —  as  are  competent  to  produce  a 
considerable  impediment  to  the  free  transmission  of  blood  through  the  system  of  tha 
vena  portse. 

When  gastric  hemorrhage  results  from  hepatic  obstruction,  there  is  almost  always 
intestinal  hemorrhage  also.  At  any  rate  there  are  almost  always  black  alvme 
evacuations,  like  tar  or  dark  paint.  This  form  of  disease  has  there^'ore  been 
called  mdxna.  The  ancients  supposed  that  the  unnatural  stools  consisted  of  black 
bile. 

Hemorrhage  from  the  stomach,  independent  of  disease  in  that  or  any  other  part, 
sometimes  happens  in  the  advanced  periods  of  utero-gestation.     Yet,  though  it  does 
not  result  in  these  cases  from  disease,  it  is  difficult  to  class  it  among  idiopatUl 
49  3p 


770  HiEMATEMESIS. 

hemorrhages.  The  want  of  periodical  recurrence,  and  the  absence  of  the  hemor- 
rhage during  the  earlier  months  of  pregnancy,  are  circumstances  which  sufficiently 
refute  the  old  notion,  that  this  form  of  hoematemesis  depends  also  upon  the  suspen- 
sion of  the  catamenia.  It  is  caused,  no  doubt,  b}^  the  pressure  of  the  gravid  uterus, 
which  impedes  mechanically  the  venous  circulation  in  the  abdomen. 

5.  Gastric  hemorrhage,  resulting  from  changes  in  the  blood  itself,  occurs  in  sea- 
scurvy,  in  purpura  hemorrhagica,  and  in  the  yellow  fever.  Being  merely  a  symp- 
tom in  these  cases,  it  requires  no  separate  consideration  here. 

When  a  large  quantity  of  blood  is  poured  into  the  stomach,  whatever  may  have 
been  its  source,  it  appears  to  have  a  nauseating  and  emetic  effect.  At  least  the  blood 
ejected  in  hcematemesis  is  almost  always  considerable  in  amount.  The  vomiting 
may,  for  aught  I  know,  be  dependent  on  the  m.ere  distension  of  the  stomach,  which 
appears  to  be  tolerant  of  the  presence  of  the  blood  up  to  a  certain  point,  but  no  further. 
A  small  quantity  may,  doubtless,  pass  all  of  it  onwards  through  the  pylorus,  after 
undergoing,  more  or  less  completely,  the  process  of  digestion  in  the  stomach;  and  a 
portion  of  the  blood  pursues  that  course  in  most  instances.  But  when  it  is  vomited, 
it  comes  up  in  large  quantities,  usually  of  a  dark  colour,  and  more  or  less  coagulated. 
Sometimes  the  coagula  have  evidentl}''  been  moulded  in  the  stomach  ;  and  sometimes 
clots  are  thrown  up,  partially  deprived  of  the  colouring  matter  of  the  blood,  and  re- 
sembling the  fibrinous  polypi  so  often  met  with  in  the  cavities  of  the  heart.  Of  course 
the  degree  of  coagulation  of  the  blood,  and  of  its  separation  into  serum  and  crassa- 
mentum,  will  depend  upon  the  time  that  it  remains  in  the  stomach ;  and  this  again 
would  seem  to  bear  a  proportion  to  the  rate  of  its  effusion. 

The  blood  that  is  vomited  is  almost  always  of  a  dark  colour ;  while  that  Avhich  is 
coughed  up  is  most  frequently  florid  and  bright.  Why  is  this  ?  We  are  told  that 
the  blood  which  comes  from  the  lungs  is  rendered  florid  by  the  admixture  of  atmo- 
spheric air.  But  this  is  not  the  Avhole  of  the  matter.  Neither  can  we  saj''  that  the 
dark  hue  of  the  blood  ejected  in  hoematemesis  is  always,  or  solely  due  to  some  morbid 
alteration  effected  in  that  fluid  while  yet  circulating  in  its  proper  vessels.  There  is 
another  cause,  which  till  of  late  years,  was  much  overlooked,  but  which  frequently 
changes  the  colour  and  appearance  of  the  blood  after  it  has  been  extravasated  into  the 
stomach  ;  and  that  in  so  great  a  degree  as  sometimes  to  render  doubtful,  or  to  disguise 
altogether,  the  real  nature  of  the  fluid  vomited.  I  mean  the  chemical  agency  of  the 
gastric  acid.  The  effect  of  acids  in  blackening  the  blood  out  of  the  body  is  well 
known  ;  and  it  is  somewhat  singular  that  the  ascertained  existence  of  an  acid  secre- 
tion in  the  stom.ach,  varying  in  quantity  at  different  times  and  under  different  circum- 
stances, was  not  sooner  apphed  in  explanation  of  the  dark  colour  of  the  blood,  and 
its  occasional  blackness,  when  vomited.  The  degree  of  blackness  will  be  in  propor- 
tion to  the  relative  quantity  of  acid  which  it  meets  with  in  the  stomach,  and  the  inti- 
macy of  the  admixture.  Sometimes  the  blood  is  clotted  and  not  very  much  altered 
in  colour;  sometimes  it  is  grumous,  brown,  of  a  chocolate  tint,  or  like  coffee-grounds. 
This  generally  denotes  the  existence  of  organic  disease;  and  the  appearance  of  the 
blood  is  probably  modified  in  some  degree  by  the  morbid  process  that  leads  to  its 
effusion.  There  is  good  reason  for  believing  that  in  the  black  vomit  of  the  yellow 
fever,  the  colour  of  the  blood  undergoes  alteration,  even  while  it  is  yet  circulating 
through  the  blood-vessels :  but  that  the  black  appearance  of  the  matter  vomited  is  in 
great  part  owing  to  the  chemical  action  of  the  gastric  acid,  may  be  inferred  from  the 
fact,  that  the  fluid  so  discharged  is  always  (so  I  am  informed)  intensely  acid.  Andral 
has  described  an  eff^usion  of  black  liquid  into  the  stomach,  as  an  example  of  mela- 
nosis. He  states  at  the  same  time  that  an  accurate  analysis  of  the  liquid  showed 
its  composition  to  be  very  nearly  the  same  with  that  of  the  blood.  May  we  not  sus- 
pect that  this  inky  fluid  really  consisted  of  blood  that  had  been  blackened,  subse- 
quently to  its  extravasation,  by  the  acid  with  which  it  mixed  in  the  stomach  ?  Upon 
the  same  principle  may  be  explained  the  dark  brown  or  almost  black  colour  of  the 
spots  which  are  sometimes  seen  (I  presume  when  there  has  been  a  great  predomi- 
nance of  acid)  in  the  substance  of  the  mucous  membrane  of  the  stomach,  or  even 
Deneath  it ;  and  which  have  also  been  set  down  as  melanotic.     They  are  so  like,  in 


DIAGNOSIS   OF   GASTRIC   HEMORRHAGE.  771 

all  circumstances,  except  in  the  single  particular  of  colour,  to  the  crimson  spots  which 
are  obviously  formed  by  minute  extravasations  of  blood  in  the  same  parts,  that  we 
can  scarcely  refer  them  to  any  other  source.  The  slate-coloured  patches,  which  I 
spoke  of  yesterday  as  being  vestiges  of  chronic  gastritis,  depend  likewise  upon  the 
blackening  effect  of  the  gastric  acid  upon  the  congested  surface.  We  have  the  same 
dark  colour  of  the  effused  blood,  in  many  cases,  when  it  is  poured  out  in  the  intes- 
tines. Here,  of  course,  its  colour  is  not  referable  to  the  gastric  juice  ;  but  it  is  black- 
ened by  some  of  the  intestinal  gases :  probably  b}''  the  sulphuretted  hydrogen,  for 
example,  or  the  carbonic  acid  that  enters  into  their  composition. 

There  can  be  no  doubt  that  this  gastric  acid,  when  intense  in  strength,  or  copious 
in  quantity,  is  capable  of  changing  the  colour  of  the  blood,  after  death,  even  while 
it  is  contained  in  the  sub-mucous  blood-vessels.  In  these  cases  it  must  be  conveyed 
to  the  blood  by  imbibition.  And  the  very  same  thing  takes  place  when  strong  acids 
are  introduced  into  the  stomach  from  without.  When,  for  instance,  the  sulphuric 
acid,  or  what  is  perhaps  more  to  our  present  purpose,  the  vegetable  oxalic  acid,  has 
been  taken  as  a  poison,  it  has  the  effect  of  blackening,  and,  as  it  were,  charring  the 
blood,  with  which  the  membrane  becomes  loaded  in  consequence  of  the  irritation 
produced  by  the  poison.  It  does  this  when  no  destruction  of  the  mucous  membrane 
has  been  produced. 

It  is  but  justice  to  observe,  that  the  credit  of  having  been  the  first  to  perceive,  and 
to  explain,  this  cause  of  the  blackened  state  of  the  blood,  while  yet  remaining  in  its 
proper  vessels,  is  due  to  Dr.  Carswell. 

When  the  blood  is  injected  through  the  oesophagus  and  mouth,  we  have  demon- 
strative evidence  of  the  existence  of  hemorrhage  ;  and  the  diagnosis  of  hsematemesis 
may  appear  to  be  so  simple  as  to  admit  of  neither  mistake  nor  doubt.  The  diagno- 
sis of  hemorrhage  from  the  stomach,  however,  is  really  oftentimes  difficult  and  ob- 
scure, and  to  be  established  by  presumptive  evidence  alone. 

In  the  first  place,  bleeding  may  take  place  from  the  mucous  membrane  of  the 
stomach,  and  no  hcematemesis  ensue,  especially  when  the  blood  is  poured  forth  in 
small  quantities  and  slowly.  In  these  cases  the  blood  becomes  visible  only  in  the 
stools,  where  it  may  not  be  looked  for,  and  where,  if  seen,  it  may  not  always  be 
recognized,  in  consequence  of  the  changes  it  has  undergone  during  its  passage 
through  the  intestinal  canal.  And  even  supposing  that  its  presence  is  detected  in 
the  alvine  evacuations,  it  will  remain  uncertain  in  what  part  of  that  long  canal  it 
was  effused.  The  hemorrhage  may  even  be  profuse,  and  the  patient  may  die,  with- 
out any  escape  of  the  blood  externally.  There  is  a  case  related  by  Frank,  in  which 
death  took  place  from  hemorrhage  of  the  stomach  without  hsematemesis;  and  both 
the  stomach  and  the  intestines  were  found  distended  by  an  enormous  coagulum  of 
blood  which  had  assumed  their  form. 

Even  when  the  blood  is  ejected  by  the  mouth,  the  exercise  of  some  care  and 
sagacity  is  occasionally,  though  not  always  required,  in  order  to  determine  the  part 
from  which  it  was  originally  poured  out. 

Thus  blood  may  be  swallowed,  and  afterwards  vomited :  and  so  we  may  have 
hsematemesis  without  hemorrhage  from  the  stomach ;  just  as  we  may  have  hemor- 
rhage from  the  stomach  without  hsematemesis.  There  are  cases  of  slow  bleeding 
from  the  lungs,  the  fauces,  the  mouth,  or  the  nasal  cavities,  where  the  blood,  col- 
lecting in  the  pharynx,  provokes,  from  time  to  time,  an  instinctive  and  involuntary 
act  of  deglutition;  and  thus  is  gradually  accumulated  in  the  stomach  up  to  that 
point  at  which  the  organ  becomes  impatient  of  its  contents,  and  ejects  them  by  vo- 
miting. This  is  very  apt  to  happen  during  sleep,  and  especially  to  young  children : 
and  as  the  blood,  ivhen  vomited,  is  coagulated,  and  in  considerable  quantity,  it  is 
scarcely  possible  to  conclude,  from  its  mere  appearance,  that  it  has  proceeded  frono 
any  other  source  than  the  stomach  itself.  If,  however,  we  mistake  such  cases,  our 
error  is  likely  to  produce  much  needless  alarm,  and  to  lead  us  to  unnecessary  acti 
vity  in  treating  them.  We  are  assisted  towards  forming  a  right  judgment  (when 
our  attention  happens  to  be  directed  to  this  source  of  fallacy),  partly  by  the  general 
history  and  symptoms,  and  partly  by  an  examination  of  the  mouth,  fauces  and  nos- 


772  DIAGNOSIS   OF   GASTRIC   HEMORRHAGE. 

trils,  to  ascertain  whether  any  coagula,  or  other  marks  of  hemorrhage,  are  visible  on 
the  mucous  membrane  belonging  to  those  parts. 

But  blood  may  be  swallowed  knowingly  and  purposely  by  impostors,  and  after- 
waids  vomited.  Hsematemesis  is  one  of  the  complaints  which  have  frequently  been 
feigned ;  either  for  the  sake  of  avoiding  some  imminent  punishment,  or  distasteful 
service ;  or  with  the  view  of  exciting  compassion,  and  of  profiting  by  the  contribu' 
lions  of  the  charitable  and  the  credulous ;  or  sometimes  from  a  kind  of  wilful  per- 
versity, akin  to  insanity.  In  treatises  on  forensic  medicine,  you  will  generally  find 
reference  made  to  an  instance  of  this  kind  recorded  by  Sauvages,  in  his  Nosology. 
A  young  girl,  who  was  anxious  at  all  hazards  to  escape  the  constraints  of  a  convent, 
pretended  that  she  was  suffering  from  violent  heematemesis.  In  fact  she  did,  for 
several  days  in  succession,  vomit  large  quantities  of  blood  in  the  presence  of  the 
physician  who  had  been  summoned  to  her  assistance.  It  Avas  afterwards  discovered 
that  on  each  of  those  days  she  had  swallowed  blood  which  had  been  secretly  con- 
veyed to  her  from  the  neighbouring  shambles.  A  case  of  precisely  the  same  kind 
occurred  (as  I  was  informed  by  a  gentleman  who  witnessed  it)  in  the  Bristol  Infirm- 
ary some  years  ago.  A  girl  had  long  been  a  patient  there,  labouring  (as  was  sup- 
posed) under  hsematemesis ;  but  it  was  at  length  discovered  that  she  was  a  mahn- 
gerer.  She  was  in  the  habit  of  assisting  the  nurses  in  their  work  ;  and  this  afforded 
her  opportunities — of  which  she  availed  herself — of  drinking  the  blood  which  had 
been  drawn  from  the  veins  of  other  patients:  and  this  blood  she  afterwards  vomited. 

And  even  where  no  fraud  is  attempted,  nor  any  blood  swallowed,  it  occasionally 
becomes  a  nice  matter  to  determine  the  origin  of  the  hemorrhage,  when  blood  is 
ejected  in  large  quantities  from  the  mouth:  to  decide,  namely,  whether  the  blood 
has  come  originally  from  the  lungs  or  from  the  stomach.  In  copious  hsemoptysis, 
the  blood  issues  from  the  mouth  in  gushes  as  it  does  in  hcematemesis  ;  and  the  reflux 
of  the  blood  into  the  phar}-nx,  the  tickling  sensation  it  there  produces,  and  the  cough 
(which  we  know,  even  when  the  expectoration  is  not  of  blood,  frequently  excites 
retchings);  these  causes,  acting  singly,  or  together,  occasion  sometimes  a  convulsive 
contraction  of  the  muscles  of  the  thorax,  which  looks  like  the  effort  of  vomiting :  and 
they  often  indeed  give  rise  to  actual  vomiting.  On  the  other  hand,  in  sudden  and 
profuse  hsematemesis,  the  irritation  caused  by  the  blood  as  it  passes  over  the  upper 
part  of  the  larynx,  is  apt  to  provoke  a  paroxysm  of  choking  cough. 

Now  when  I  was  speaking,  some  lectures  back,  of  hcemoptysis,  I  promised  that  I 
would  point  out  the  means  of  distinguishing  it  from  hasmatemesis,  when  I  came  to 
the  consideration  of  the  latter  complaint.  I  have  now  therefore  to  redeem  my 
promise. 

However  equivocal  certain  cases  may  be  at  first  sight,  we  may  generally  guide 
ourselves  to  a  correct  decision  by  a  careful  investigation  of  the  circumstances  that 
precede,  accompany,  and  folloiv  the  hemorrhage.  Vomiting  of  blood  is  commonly 
preceded  by  a  sensation  of  weight  and  uneasiness  in  the  epigastrium  ;  and  by  nausea. 
Ilsematemesis  is  also,  more  frequently  than  htemoptysis,  ushered  in  by  paleness  of 
the  face,  dimness  of  vision,  and  an  approach  to  syncope,  or  even  actual  fainting. 
These  symptoms  are  not  to  be  regarded  (I  apprehend)  as  premonitory  of  the  hemor- 
rhage, although  they  have  been  so  considered  by  some ;  they  are  rather  a  sign  that 
it  has  already  taken  place ;  and  yet  they  are  preliminary  of  the  hsematemesis. 
Occurring  before  the  blood  comes  up,  they  cannot  be  ascribed  to  alarm  at  the  sight 
of  it.  On  the  other  hand,  haemoptysis  is  wont  to  be  announced  by  dyspnoea,  cough, 
tickling  in  the  throat,  and  a  sensation  as  if  of  bubbling  within  the  thorax.  Most 
commonly,  too,  before  the  expulsion  of  much  blood  from  the  lungs,  some  sputa  are 
coughed  up,  composed  more  or  less  of  that  fluid.  The  symptoms  that  usually  suc- 
ceed the  hemorrhage,  in  either  case,  afford  equallv  valuable  assistance  to  our  judg- 
ment, in  cases  that  might  otherwise  be  doubtful.  Generally  copious  hsemoptysis 
goes  on,  in  a  succession  of  mouthfuls,  for  some  time  :  whereas  there  is,  mostly,  only 
one  access  of  full  vomiting.  At  any  rate,  at  the  close  of  abundant  pulmonary  he- 
morrhage, the  patient  manifestly  coughs  up,  and  expectorates,  smaller  quantities  of 
blood  ,  while  we  usually  may  observe  that,  a  few  hours  after  hsematemesis  has 


DIAGNOSIS    OF    GASTRIC  HEMORRHAGE.  773 

occurred,  slight  griping  pains  come  on  in  the  abdomen,  and  a  portion  of  blood  is  got 
rid  of  from  the  bowels. 

Other  questions,  often  of  much  importance  in  regard  to  the  ultimate  diagnosis, 
when  the  blood  is  traceable  with  certainty  to  the  stomach,  are,  whether  it  be  idio- 
pathic, if,  indeed,  it  ever  be  so  :  whether  it  be  supplemental  of  some  other  discharge  : 
whether  it  depend  on  disease  of  the  stomach  itself;  of  one,  or  more,  of  the  contigu- 
ous viscera ;  or  of  the  system  at  large.  Certainly,  in  a  very  great  majority  of  ca.es, 
gastric  hemorrhage  is  symptomatic;  and  the  nature  and  seat  of  the  disease  of  which 
the  bleeding  is  a  symptom,  may,  in  many  instances,  be  determined  without  much 
difficulty.  That  which  depends  upon  incipient  cancer  of  the  stomach,  while  it  is 
by  no  means  of  rare  occurrence,  is  also,  (I  think,)  more  frequently  than  other  forms 
of  hemorrhage  from  that  organ,  obscure.  It  must  be  obvious  to  you,  and  therefore 
I  need  not  dwell  upon  this  part  of  the  subject,  that  a  httle  attention  to  the  symptoms 
and  past  history  of  the  patient  will  usually  suffice  to  elucidate  the  nature  of  the  case, 
where  hsematemesis  supervenes  immediately  upon  the  introduction  of  corrosive  poi- 
sons, or  within  a  certain  interval  after  they  have  been  swallowed :  where  it  depends 
upon  the  bursting  of  a  large  aneurism :  where  it  breaks  forth  among  other  symp- 
toms of  scurvy  or  purpura :  where  it  is  the  result  of  an  advanced  stage  of  cancer  of 
the  stomach :  where  it  accompanies  organic  disease  of  the  liver,  spleen,  or  heart : 
where  it  occurs  as  a  symptom  of  yellow  fever :  where  it  takes  the  place  of  suppressed 
or  imperfect  menstruation ;  or  where  it  is  occasioned  by  the  pressure  of  the  gravid 
uterus.  In  all  these  cases,  there  is,  ordinarily,  no  room  for  mistaking  the  one  dis- 
ease for  the  other;  or  for  regarding  the  hemorrhage  as  idiopathic. 

With  respect  to  the  treatment  that  should  be  adopted  in  cases  of  hemorrhage  from 
the  stomach,  it  must  be  apparent,  from  what  has  just  been  said  of  the  many  different 
morbid  conditions  u]5on  which  it  may  depend,  or  with  which  it  may  be  essentially 
connected,  that  remedies  are,  in  most  cases,  rather  to  be  directed  against  the  disease 
of  which  the  ha^matemesis  is  a  symptom,  than  against  that  symptom  itself.  But 
sometimes  we  are  obliged  to  treat  the  symptom,  either  because  we  are  not  certain  of 
the  exact  nature  of  its  cause,  or  because  the  condition  out  of  which  it  springs  is  not 
within  our  reach. 

Cases  0^  melxna  (I  have  told  you  what  is  meant  by  that  term)  require  hard  purg- 
ing ;  and  many  patients  recover  thoroughly  under  that  mode  of  treatment.  You 
may  prescribe  five  grains  of  calomel  every  night,  and  a  black  dose  every  morning, 
till  the  stools  lose  their  pitchy  colour.  Do  not  be  afraid  of  purging  your  patients  in 
such  cases.  If  they  are  curable  at  all,  that  is  the  way  to  cure  them.  I  have  pur- 
sued that  plan  with  perfect  success,  even  with  patients  whom  the  previous  hemor- 
rhages had  blanched,  and  whose  pulse  was  feeble  and  irregular.  You  may  sustain 
them,  at  the  same  time,  by  a  full  allowance  of  nourishing  broths.  The  portal  system 
is  drained  and  unburdened  by  this  active  depletion.  And  if  there  be  no  irremediable 
change  of  texture  in  the  liver,  the  recurrence  of  the  hemorrhage  may  often,  by  a 
proper  regulation  of  the  habits  and  diet,  be  obviated.  The  ancients  had  learned  by 
observation  the  efficacy  of  treatment  of  this  kind ;  but  they  used  a  different  form  of 
medicine,  and  purged  away  the  atra  bilis  with  hellebore. 

It  is  plain  that  for  melcena,  dependent  on  mechanical  congestion,  styptic  substances 
would  be  worse  than  useless.  They  are  more  adapted  to  those  cases  (could  w^e  but 
surely  distinguish  them)  in  which  the  hemorrhage  proceeds  from  a  bleeding  vessel. 
This  is  indeed  the  mode  whereby  w^e  often  succeed  in  stanching  external  hemor- 
rhages ;  namely,  by  applying  astringents  to  the  very  part.  Similar  means  may  bv^ 
employed  when  ha^matemesis,  of  a  purely  passive  character,  depends  upon  some 
modification  of  the  circulating  blood.  There  is  one  remedy  which  is  thought  to 
have  a  sort  of  specific  eflt^ct  upon  hemorrhages  of  the  gastro-intestinal  canal  •  I  mean 
the  oil  of  turpentine,  given  in  small  doses;  from  twenty  minims  to  half  a  drachm, 
every  four  or  six  hours.  I  cannot  say  that  I  have  had  much  experience  of  it.  Of 
course  the  patient  must  be  kept  cool  and  quiet;  whatever  he  drinks,  he  should  drink 
cold  ;  even  ice  is  often  both  grateful  and  effectual.  If  ordinary  measures  fail,  recourse 
may  be  had  to  the  acetate  of  lead  ;  or  even  to  the  quack  medicine,  Ruspini's  styptic 
Not  that  I  think  you  will  often  find  the  latter  expedient  successful,  when  mor« 

3p2 


774  DYSPEPSIA. 

rational  treatment  has  failed ;  but  in  obstinate  and  dangerous  cases  it  ought  to  be 
tried.  If,  with  the  hasmatemesis,  there  be  any  fever,  it  may  be  proper  and  necessary 
to  abstract  blood  from  a  vein,  and  to  employ  refrigerant  substances  as  remedies ;  and 
if,  with  or  without  much  fever,  there  be  tenderness  at  the  epigastrium,  leeches,  or  a 
bhster,  should  be  applied.  In  cases  where  the  catamenia  desert  their  natural  chan- 
nel, and  seek  an  outlet  through  the  mucous  membrane  of  the  stomach,  it  will  be 
well,  while  means  are  taken  to  discourage  the  hcematemesis,  as  iced  drintt  and  so 
forth,  to  endeavour  to  solicit  the  discharge  in  the  right  direction.  And  we  often  sue 
ceed  in  this  object  by  placing  leeches  upon  the  groins  of  these  patients  immediate^ 
before  the  period  when  the  vicarious  menstruation  is  expected,  and  by  putting  theii 
feet  at  the  same  time  into  hot  water,  or  even  laying  them  in  a  warm  hip  bath. 


LECTURE  LXX. 

Dyspepsia.     Physiology  of  Digestion.     Symptoms  of  Dyspepsia.     Treatment 
and  Prevention,  Dietetic  and  Medicinal. 

It  is  my  intention  to  appropriate  this  evening's  lecture  to  a  cursory  account  of 
dyspepsia;  by  which  I  mean  some  evident  derangement  in  the  natural  process  of 
digesting  and  assimilating  our  food,  and,  more  especially,  a  faulty  performance  of  the 
functions  of  the  stomach.  Indigestion  is  the  prevailing  malady  of  civilized  hfe. 
We  are  more  often  consulted  about  the  disorders  that  belong  to  eating  and  drinking, 
than  perhaps  about  any  others ;  and  I  know  of  no  medical  topic  concerning  which 
there  is  afloat,  both  within  and  beyond  the  profession,  so  much  ignorant  dogmatism 
and  quackery. 

Cullen,  in  his  definition  of  dyspepsia,  enumerates  the  various  symptoms,  by  the 
occurrence  of  more  or  fewer  of  which  that  complaint  is  most  commonly  manifested : 
"Anorexia,  nausea,  vomitus,  inflatio,  ructus,  ruminatio,  cardialgia,  gastrodynia  :  pau- 
ciora  saltem  vel  phira  horum  simul  concurrentia,  plerumque  cum  alvo  adstricta,  et 
sine  alio  vel  ventricuh  ipsius,  vel  aliarum  partium,  morbo." 

The  variety  in  the  actual  presence  and  combinations  of  these  symptoms  is  very 
great ;  and  any  attempt  to  give  a  perfect  or  complete  history  of  dyspepsia  in  these 
lectures  is  quite  out  of  the  question.  But  I  will  endeavour  to  draw  such  a  general 
outline  of  the  disorder  as  may  assist  and  direct  your  observation  of  it  hereafter. 

I  shall  first  take  a  brief  view  of  the  pathology  of  indigestion,  so  far  as  it  is  under- 
stood ;  and  to  make  this  intelligible,  it  will  be  necessary  to  interweave  something  of 
the  physiology  of  the  subject.  To  these  preliminary  considerations,  I  shall  ad»^  a 
short  comment  upon  the  several  symptoms  of  dyspepsia,  enumerated  in  Cullen's 
definition ;  and,  lastly,  I  shall  state  what  I  know  respecting  the  means  of  curing  and 
preventing  this  familiar  disorder. 

The  conditions  of  healthy  digestion  are  these  :  that  the  food  should  be  masticated, 
mixed  with  saliva,  and  swallowed  into  the  stomach ;  that  in  the  stomach  it  should  be 
reduced  to  a  semi-fluid  consistence,  and  converted  into  a  uniform  pulp,  called  chyme  ; 
that  the  chyme  should  be  transmitted  through  the  pylorus  into  the  duodenum,  and 
there  mixed  with  the  bile,  the  pancreatic  secretion,  and  the  intestinal  mucus :  in 
consequence,  as  it  would  seem,  of  which  admixture,  the  whole  is  separated  into  two 
parts,  viz. :  the  chyle,  or  the  nutritive  portion  of  the  food,  now  in  a  fit  state  to  be 
taken  up  by  the  lacteals  which  open  upon  the  mucous  surface  of  the  intestines,  and 
to  be  carried  by  them  into  the  blood ;  and  the  excrementitious  portion,  which  at 
length  is  conveyed  out  of  the  body. 

The  food  js  dissolved  and  transformed,  in  the  stomach,  by  the  chemical  agency 
of  the  gastric  juice.  This  is  a  secretion  peculiar  to  the  stomach.  All  that  need  be 
stated  of  it  h'^re — almosi  all,  indeed,  that  is  known — is,  first,  that  it  oozes  forth  in 
minute  drop*  from  the  mucous  surface ;  but  only  when  food  (or  some  solid  sub* 


DYSPEPSIA.  775 

stance)  is  present  in  the  stomach;  and,  secondly,  that  it  is  always  aclJ.  It  appears 
to  owe  its  solvent  power  to  a  special  principle,  which  chemists  have  named  pepsin. 

The  food,  having  arrived  in  the  stomach,  is  moved  about  by  a  sort  of  churning  or 
revolving  movement,  and  mixed  with  the  gastric  juice,  and  gradually  changed  into 
chyme,  which  also  is  acid.  Finally,  the  chyme  is  propelled  by  degrees  into  the 
duodenum  by  the  pressure  of  the  transverse  band  of  muscular  fibres  which  embraces 
the  pyloric  extremity  of  the  stomach.  The  time  in  which  the  whole  operation  is 
completed  varies  from  two  to  four  or  five  hours. 

Liquids  introduced  into  the  stomach  disappear  much  more  speedily ;  either  by 
direct  absorption,  or  through  the  pylorus. 

All  this  we  know,  not  from  mere  speculation  on  the  anatomy  and  uses  of  the 
organ,  but  from  actual  observation.  An  American  physician  had,  for  several  months 
in  succession,  the  curious  privilege  of  looking,  whenever  he  pleased,  into  a  healthy 
human  stomach,  and  of  watching  its  condition,  its  movements,  and  its  contents,  during 
the  process  of  digestion.  A  young  Canadian  had  a  portion  of  the  skin,  muscles 
and  ribs  of  the  left  side  of  the  body  blown  away  in  a  gunshot  wound,  which  laid 
open  the  stomach  also.  He  recovered  from  this  frightful  injury  with  a  permanent 
aperture  in  the  side,  communicating  directly  wiih  the  stomach.  Through  this  loop- 
hole Dr.  Beaumont  was  allowed  to  introduce  various  articles  of  food  ;  and  to  with- 
draw from  time  to  time  the  gastric  secretions  ;  and  the  aliment,  in  the  different  stages 
of  its  digestion.  He  has  published  a  very  interesting  account  of  these  experiments, 
which  have  set  at  rest  some  points  in  the  physiology  of  the  stomach  that  were  pre- 
viously uncertain.  I  shall  embody  his  deductions  in  what  I  have  further  to  say  on 
the  subject. 

In  order  that  digestion  may  be  perfect  and  easy,  it  is  requisite  that  the  food  be  irj 
a  state  of  minute  division.  This  object  is  attained  by  mastication.  A  weak  dys- 
peptic stomach  acts  slowly,  or  not.at  all,  on  solid  lumps  and  tough  masses  of  food. 
The  delayed  morsels  undergo  spontaneous  changes,  promoted  by  the  mere  warmth 
and  moisture  of  the  stomach  :  gases  are  extricated :  acids  are  formed  :  perhaps  the 
half-digested  mass  is  at  length  expelled  by  vomiting ;  or  it  passes  undissolved  into 
the  duodenum,  and  becomes  a  source  of  irritation  and  disturbance  during  the  whole 
of  its  journey  through  the  intestines.  Here  then  we  have  one  common  cause  of 
dyspepsia  ;  and  an  easy  and  obvious  preventive.  Dyspeptic  persons  should  not  eat 
in  a  hurry,  as  busy  men,  and  studious  and  solitary  men,  are  apt  to  eat.  They  are 
to  be  cautioned  against  bolting  their  food :  it  must  be  well  ground  in  the  mill  that 
nature  has  provided  for  that  purpose.  I  am  not  at  all  sure  that  the  increased  lon- 
gevity of  modern  generations  is  not,  in  some  degree,  attributable  to  the  capability 
of  chewing  their  food  which  the  skill  of  the  dentist  prolongs  to  persons  far  advanced 
in  life. 

There  are  certain  things  upon  which  the  gastric  juice  has  no  power.  The  green 
colouring  matter  of  certain  vegetables  ;  the  husks  of  seeds  ;  the  rinds  of  many  fruits. 
You  may  perhaps  have  observed  that  dry  currants,  and  the  pips  of  apples,  swallowed 
entire,  reappear,  unchanged,  among  the  egesta.  Whatever  passes  the  stomach  un- 
touched by  the  gastric  liquor,  passes  undissolved  through  the  whole  of  the  alimentary 
canal ;  provoking  disorder  sometimes  in  its  transit;  forming  sometimes  a  nucleus  for 
intestinal  concretions.  These  substances  are  therefore  unfit  for  a  weak  stomach. 
When  the  digestive  powers  are  active,  and  the  bowels  slow,  they  may  perhaps  ccca- 
sionally  be  even  useful.  Thus  brown  bread  —  i.  e.,  the  indigestible  bran,  or  tegu- 
ment of  the  kernel  of  wheat  —  stimulates  the  peristaltic  motions  of  the  intestines, 
and  averts,  in  certain  persons,  the  necessity  of  more  direct  purgatives.  Unbruised 
mustard-seed,  once  so  much  in  vogue,  owed  much  of  whatever  virtue  it  possessed  to 
this  principle.  But  if  these  intractable  substances  fail  to  excite  the  proper  action 
of  the  bowels,  they  are  apt  to  accumulate,  and  to  lay  the  foundation  of  serious 
disease. 

Indigestible  matters,  to  which  the  pylorus  refuses  a  passage,  may  remain  in  the 
stomach,  and  disturb  its  functions,  for  days,  or  even  sometimes  for  weeks,  together. 
If  we  could  ascertain  their  presence,  an  emetic  would  be  the  remedy.  And  sooner 
or  later  vomiting  is  set  up,  and  the  offending  substance  expelled.     I  lately  saw  h 


776  DYSPEPSIA. 

mass  of  hard  curd  —  a  small  cream  cheese  in  respect  to  consistence  —  which  was 
thrown  up  after  several  days  of  severe  gastric  pain  and  disorder.  The  relief  was 
immediate  and  complete.  The  patient  had  been  taking  large  quantities  of  cream 
with  his  tea  and  coffee.  In  another  person  a  similar  fit  of  indigestion  terminated  m 
the  ejection  of  a  mass  of  snuff".  This  is  no  unusual  source  of  derangement  of  the 
stomach  among  those  who  use  lavishly  that  nasty  luxury. 

The  essential  change  which  the  chyme  undergoes  after  leaving  the  stomach,  ap- 
pears to  consist  in  its  separation  into  two  parts  :  namely,  into  chyle,  which  is  taken 
up  by  the  lacteals ;  and  into  excrement,  which  is  discharged  from  the  body.  Any 
undissolved  portions  of  the  food  become  attached  to  this  last  part.  We  do  not  know 
exactly  what  is  the  function  or  agencjr  of  the  pancreatic  liquor ;  but  with  regard  to 
the  bile  our  knowledge  is  somewhat  more  definite.  The  acid  developed  in  the 
stomach  combines  in  the  duodenum  with  the  alkali  of  the  bile,  and  is  more  or  less 
neutralized.  Dr.  Prnut  conjectures  that  in  a  healthy  state  of  the  organs  it  is  entirely 
neutrahzed.  Bile  is,  moreover,  the  natural  stimulus  of  the  intestines:  when  its 
secretion  is  stopped,  or  its  passage  into  the  duodenum  prevented,  digestion  and  assi- 
milation may  go  on,  but  the  bowels  are  usually  sluggish.  The  hepatic  secretion  has, 
doubtless,  other  important  uses  ;  but  with  these  we  are  not  at  present  concerned.  It 
is  pretty  evident  that  the  state  of  the  biliary  functions  can  have  no  direct  influence  in 
the  production  of  mere  dyspepsia.  When  the  constituents  of  the  bile  are  imper- 
fectly eliminated  from  the  blood,  various  parts  of  the  body  may  suffer  detriment. 
And  when  the  functions  of  the  stomach  and  the  functions  of  the  liver  are  both  disor- 
dered, it  may  be  that  the  former  organ  sympathizes  indirectly  with  the  morbid  state 
of  the  latter :  or  it  may  be  that  one  and  the  same  cause  operates  in  producing  the 
derangement  of  both  organs. 

Let  us  now  review  the  symptoms  of  dyspepsia  which  are  mentioned  in  Cuilen's 
definition.  The  first  of  these  is  anorexia:  want  of-  the  natural  appetite.  Sometimes 
this  is  almost  the  only  symptom  observable.  The  patient  is  warned,  by  loss  of  appe- 
tite, not  to  take  too  much  food ;  he  refrains  instinctively  from  certain  kinds  of  food ; 
or  he  feels  perhaps  absolute  repugnance  and  disgust  at  the  very  thought  of  eating. 
Various  have  been  the  speculations  respecting  the  immediate  cause  ot  hunger.  It 
has  been  ascribed  to  the  action  of  the  gastric  juice  upon  the  surface  of  the  empty 
stomach.  But  during  health  the  gastric  juice  is  never  present  in  an  empty  stomacli. 
Neither  can  the  appetite  depend  upon  contraction  of  the  muscular  fibres  of  the 
3tomach  ;  for  the  emptj^  stomach,  during  health,  is  always  contracted  upon  itself.  No 
doubt  the  sensation  of  hunger,  like  all  other  sensations,  arises  from  some  particular 
condition  of  the  nerves  of  the  part.  It  returns  periodically,  acknowledging  in  this 
respect  the  influence  of  habit.  It  is  sensibly  aff'ected  by  agencies  which  operate  upon 
and  through  the  nervous  system.  The  receipt  of  a  piece  of  bad  news  Avill  destroy, 
in  a  moment,  the  keenest  appetite. 

Sometimes  there  is  no  anorexia.  The  appetite  may  even  be  morbidly  craving  and 
ravenous  ;  or  capricious  and  uncertain. 

When  defect  of  appetite  is  the  only  symptom,  it  may  be  remedied,  often,  by  the 
employment  of  bitters,  or  of  the  mineral  acids,  taken  twice  or  thrice  daily,  for  some 
lime  together.  It  would  be  out  of  place  for  me  to  speak  in  detail  of  particular  me- 
Jicines  of  this  kind  ;  it  is  enough  if  I  indicate  quina,  columbo,  gentian,  quassia  ;  the 
Jiluie  sulphuric  and  nitric  acids;  or  a  mixture  of  the  nitric  and  muriatic. 

Nausea — vomitus.  These  are,  in  some  instances,  the  most  distressing  results  and 
ligns  of  the  dyspepsia.  Sometimes  nausea  comes  on  soon  after  the  food  is  swal- 
lowed. Sometimes  there  is  no  nausea ;  but  after  the  lapse  of  a  certain  period,  an 
liour  or  two  generally,  the  food  is  rejected  by  vomiting.  The  matters  thus  thrown 
up  are  most  frequently  sour.  Not  seldom  they  are  mixed  also  with  bile,  especially 
if  the  rutching  has  been  violent,  or  long  continued ;  and  then  the  patient  is  apt  to 
ascribe  the  whole  of  his  complaint  to  "an  overflow  of  bile,"  although  in  fact  the 
secretions  of  the  liver  have  nothing  whatever  to  do  with  it;  the  appearance  of  bile 
in  the  fluids  ejected  from  the  stomach  proceeding  from  an  inverted  action  of  the 
duodenum.  The  effort  of  vomiting,  however  induced,  will,  if  often  repeated,  be 
nllended  with  the  expulsion  of  yellow  bile.    I  have  more  than  once  referred  you,  fur 


DYSPEPSIA.  777 

an  illustration  of  this  fact,  to  the  phenomena  of  sea-sickness.  The  fallacy  I  now 
point  out  has  been  one  cause  of  the  notion  that  is  prevalent  among  patients,  and  the 
pubHc  —  and  not  unfrequently  perhaps  among  practitioners  —  that  dyspepsia  very 
commonly  depends  upon  a  disordered  state  of  the  biliary  organs. 

The  vomiting  which  occurs  in  dyspepsia  is  often  connected  with  a  morbid  irrita- 
bility of 'the  stomach;  and  it  is  sometimes  a  very  troublesome  symptom  to  treat. 
The  carbonic  acid  has  certainly  a  marked  effect  in  allaying  it,  in  many  cases.  We 
give  it,  as  you  know,  in  the  effervescing  saline  draught,  made  wiih  the  carbonate  of 
potash,  or  soda,  and  lemon-juice.  Sometimes  the  mineral  acids  answer  better.  Some- 
times, on  the  other  hand,  alkalies — the  liquor  potasses,  for  example — or  hme-water, 
are  more  effectual.  In  these  latter  cases  we  may  presume  that  there  is  a  morbid 
acidity  of  the  stomach.  Small  doses  of  opium  are  occasionally  successful  when 
other  means  fail.  Opiates  thrown  into  the  rectum — opium  plasters  to  the  epigastri- 
um— blisters  to  the  same  part :  these  are  measures  which  you  will  sometimes  have 
to  try  one  after  another.  There  are  two  special  remedies  which  have  been  greatly 
extolled  for  their  virtue  in  abating  sickness :  the  hydrocyanic  acid  is  one  of  them ; 
creasote  is  the  other.  The  hydrocyanic  acid  I  have  found  exceedingly  useful  in 
obstinate  cases.  It  may  be  given  alone — or  mixed  with  the  effervescing  draught-  — 
or  combined  with  a  few  grains  of  the  sesquicarbonate  of  soda.  The  creasote  has 
disappointed  me  oftener  than  it  has  answered  my  hopes  from  it.  Yet  it  has  a  de- 
cided influence  in  checking  some  forms  of  nausea ;  and  it  is  the  more  likely  to  suc- 
ceed, in  proportion  as  the  condition  of  the  stomach  is  remote  from  inflammation. 

But  after  all,  the  grand  principle  on  which  to  treat  chronic  vomiting — not  depend 
ent  upon  disease  in  other  parts,  as  the  head,  the  kidney,  or  the  uterus — is  that  laid 
down  by  Dr.  William  Hunter ;  of  reducing  the  quantity  of  food  to  that  amount, 
whatever  it  may  be,  which  the  stomach  is  able  and  willing  to  retain,  and  of  making 
its  quality  as  bland  and  nutritious  as  possible.  The  most  satisfactory  case  which  I 
have  had  to  treat  upon  this  principle  occurred  some  years  ago,  in  the  person  of  one 
of  my  hospital  patients.  She  was  brought  out  of  Kent  by  her  father.  She  had 
been  under  the  care  of  several  medical  men,  one  of  whom  had  been  a  pupil  at  the 
hospital,  and  recommended  her  as  a  proper  patient  for  admission  there.  Her  age 
was  sixteen.  She  and  her  father  both  agreed  in  the  same  story  ;  viz.,  that  she  con 
stantly  vomited  her  meals  ;  the  food  generally  coming  up  again  immediately  after  it 
was  swallowed,  and  never  remaining  longer  in  her  stomach  than  ten  minutes.  The 
vomiting  was  described  as  being  easy ;  and  was  neither  preceded  nor  accompanied 
by  nausea. 

She  had  been  ill  for  four  years :  ever  since  a  severe  attack  of  scarlet  fever.  At 
first  she  vomited  her  meals  now  and  then — three  or  four  times  a  week — but  the 
vomiting  gradually  became  more  and  more  frequent ;  and  at  the  time  of  her  admis- 
sion she  had  vomited  after  every  meal,  for  three  months  in  succession.  She  had 
grown  considerably  in  the  four  years  ;  and  was  tolerably  plump  ;  and  looked  healthy ; 
and  the  catamenia  had  begun  to  appear,  though  scantily,  in  the  same  period :  but 
they  had  been  altogether  suspended  for  a  year. 

It  was  clear  that  a  good  deal  of  her  food  must  have  remained  ;  and,  bearing  Wil 
liam  Hunter's  case  in  mind,  I  directed  that  she  should  have  a  very  small  quantity  of 
roast  meat  for  dinner,  and  a  coffee  cup  of  milk  occasionally  during  the  day ;  and  no 
other  food.  I  prescribed  also  some  pills  consisting  of  aloes  and  soap,  to  act  mode- 
rately on  the  bowels.  I  expected  to  have  been  obliged  still  further  to  limit  her  food; 
but  she  never  vomited  again,  from  that  time.  This  distressful  and  protracted  disor- 
der, after  long  and  fruitless  treatment  previously,  yielded  thus  at  once  and  easily  to 
very  simple  means. 

Injlalio — ruclus.  Flatulence,  and  belching.  The  gas  that  produces  these  symp- 
toms is  sometimes  extricated  from  undigested  food  detained  in  the  stomach,  and'  in  a 
state  of  fermentation :  sometimes  secreted,  apparently,  by  the  stomach  itself ;  for  the 
flatulence  comes  on  when  the  stomach  is  empty  of  food.  It  is  apt  to  arise,  in  dys- 
peptic persons,  if  a  meal  happens  to  be  delayed  beyond  the  accustomed  hour.  Pa- 
tients complain  grievously  of  these  symptoms,  and  accuse  the  "  wind  in  their  stomach," 
as  being  at  once  the  essence  and  the  cause  of  all  their  complaint^.     They  ask  tor 


778  DYSPEPSIA. 

medicines  to  get  rid  of  the  wind ;  and  its  escape  may  indeed  be  promoted  by  warm 
aromatics,  and  carminatives,  as  they  are  called :  the  relief  thus  afforded  to  the  dis- 
tended stomach  being  so  sudden,  and  for  the  time  so  complete,  that  the  sufferer 
ascribes  to  the  medicine  vi7n  curminis,  the  power  of  a  charm.  One  of  the  most 
effectual  and  popular  of  these  carminatives  is  peppermint  water.  A  due  regulation 
of  the  periods  for  taking  food  will  often  suffice  to  obviate  the  flatulence  that  belongs 
to  emptiness.  That  which  follows  eating  may,  in  many  cases,  be  prevented,  by 
swallowing,  immediately  before  the  meal,  five  or  six  grains  of  the  extract  of  rhubarb, 
with  or  without  a  grain  of  cayenne  pepper.  If  the  ascending  wind  brings  into  ihe 
throat  and  mouth  a  portion  of  the  solid  contents  of  the  stomach,  the  patient  is  said 
to  ruminate.  The  regurgitated  matters  are  often  intensely  acid  ;  and  then  an  alkali 
may  remedy  the  flatulence  ;  a  teaspoonful  of  sal  volatile,  for  example. 

Indigestion  is,  in  many  instances,  attended  with  scarcely  any  pain;  while  in 
others  the  pain  is  very  tormenting.  Cullen  speaks  of  it  under  the  terms  car  dial gia  ; 
and  gastrodynia.  Cardialgia  is  that  less  violent  and  more  permanent  uneasiness 
which  in  popular  language  is  called  heart-burn.  Gastrodynia  is  that  more  severe,  and 
usually  more  transient  pain,  which  is  commonly  denominated  spasm  or  cramp  of 
the  stomach. 

Dr.  Abercrombie  has  some  useful  practical  observations  in  respect  to  pain  of  the 
stomach.  He  speaks  of  it  as  occurring  under  four  different  forms,  and  I  am  able  to 
bear  witness  to  the  reality  of  the  distinctions  that  he  has  drawn.  In  the  first  place, 
some  persons  suffer  pain,  occasionally,  when  the  stomach  is  empty,  even  when  there 
is  no  flatulence  ;  and  they  are  comforted  and  relieved  by  taking  food.  It  is  reason- 
able to  suppose  that  this  kind  of  pain  depends  upon  some  degree  of  acrimony  of  the 
fluids  of  the  stomach  itself.  It  is  often  removed  at  once  by  alkalies,  or  absorbent 
medicines.  A  teaspoonful  of  the  aromatic  spirit  of  ammonia,  or  a  tablespoonful  of 
the  liquid  magnesia,  in  a  wineglass  of  camphor  julep,  will  still  the  whole  uneasiness 
sometimes  in  a  moment,  as  if  by  magic. 

A  second  form  of  pain  in  the  stomach  is  when  it  occurs  immediately  after  taking 
food,  and  continues  during  the  whole  process  of  digestion,  or  until  vomiting  ensues, 
which  gives  instant  ease.  In  such  cases  we  have  reason  to  suspect  the  existence 
of  chronic  inflammation,  or  of  some  undue  sensibility  of  the  mucous  membrane  of 
the  stomach.  The  suitable  remedies  are  such  as  I  spoke  of  in  the  last  lecture.  I 
might  have  mentioned  a  form  of  medicine  which  Dr.  James  Johnson  has  found  espe- 
cially serviceable  against  this  morbid  sensibility ;  I  mean  the  nitrate  of  silver,  in 
small  doses. 

In  a  third  species  of  painful  disorder  of  the  stomach  the  pain  does  not  begin  till 
from  two  to  four  hours  after  a  meal,  but  continues  for  several  hours.  This  is  a  very 
common  form  of  complaint.  Dr.  Abercrombie  is  of  opinion  that  the  pain  is  seated 
in  the  duodenum,  and  connected  with  inflammatory  action,  or  with  morbid  sensitive- 
ness of  the  mucous  lining  of  that  bowel.  He  says  it  is  frequently  accompanied  by 
pain  and  tenderness  of  the  right  hypochondrium ;  and  that  the  hver  is  often  blamed 
when  it  really  is  not  in  fault.  This  last  remark  I  well  believe  ;  but  I  am  not  so 
easily  persuaded  that  the  pain  is  duodenal.  I  believe  it  depends  upon  acidity  in  the 
prinice  vias.  It  has  been  ascertained  by  several  chemists,  that  the  acid  which  is  pre- 
sent in  the  gastric  juice  is  the  muriatic.  Dr.  Prout  holds  that  the  source  of  this 
muriatic  acid  is  the  common  salt  which  exists  in  the  blood,  and  that  the  decomposi- 
tion of  this  salt  is  owing  to  the  immediate  agency  of  some  modification  of  electricity; 
and  he  conceives  that  the  principal  digestive  organs  represent  a  kind  of  galvanic 
apparatus,  of  which  the  mucous  membrane  of  the  stomach  and  intestinal  canal  may  be 
considered  as  the  acid  or  positive  pole,  while  the  hepatic  system  is  the  alkaline  or 
negative  pole.  However  this  may  be,  it  is  certain  that  the  muriatic  acid  contained 
in  the  stomach  is  often  in  excess :  other  acids  are  ako  found  there — the  acetic,  and 
more  especially  the  lactic;  and  when  the  food,  now  converted  into  chyme,  passes 
into  the  duodenum,  the  remaining  superfluous  acid  teazes  the  stomach.  I  think  this 
explanation  of  the  cause  of  the  pain  is  a  more  probable  one  than  Dr.  Abercrombie's, 
because  jou  may  generally  mitigate  or  remove  the  pain  by  introducing  an  alkan  mto 
the  stomach,  whereby  the  acid    is    neutralized  :    even   the  swallowing  a  cup  of 


DYSPEPSIA.  779 

warm  tea,  by  which  the  acid  is  diluted  or  w^ashed  away,  often  stops  the  pain.  And 
I  have  in  numerous  instances  succeeded  in  preventing  the  recurrence  of  this  pain, 
by  directing  the  patient  to  take  a  small  quantity  of  alkali,  in  some  aromatic  water, 
immediately  after  his  dinner.  According  to  Dr.  Abercrombie's  theory,  the  pain 
ought  not  to  be  so  immediately  allayed  by  these  remedies ;  and,  since  the  food  is  gra- 
dually propellea  into  the  duodenum  as  it  is  digested,  the  pain  should  begin,  I  think 
(supposing  him  right),  earlier  than  it  does.  Dr.  Abercrombie  has  found  nothing  of 
more  general  utility  in  these  cases  than  the  sulphate  of  iron,  combined  with  one 
grain  of  aloes,  and  five  grains  of  aromatic  powder,  taken  three  times  a  day.  He 
praises  lime-water,  also,  and  small  opiates,  and  a  combination  of  bismuth  and  rhu- 
barb. What  its  modus  operandi  is  I  know  not,  but  I  am  sure  that  bismuth  is  a  very 
effectual  remedy  for  some  kinds  of  gastric  distress. 

Cases  now  and  then  occur  in  which  this  pain,  succeeding  a  meal,  and  the  deposit 
of  lithates  in  the  urine,  would  seem  to  indicate  the  propriety  of  an  alkaline  treatment, 
but  which  really  are  more  benefited  by  the  mineral  acids.  How  to  distinguish  these 
exceptional  cases,  unless  by  trial,  1  have  not  yet  learned.  Any  detected  admixture 
of  phosphates  might  perhaps  furnish  the  requisite  clue. 

Pain  in  the  stomach  occurs  in  a  fourth  form,  coming  on  at  uncertain  intervals  in 
most  violent  paroxysms,  and  properly  called  gastrodynia.  It  is  often  accompanied 
by  a  sensation  of  distension,  much  anxiety,  and  extreme  restlessness.  In  females  it 
is  frequently  combined  w^ilh  hysterical  symptoms.  This  form  Dr.  Abercrombie 
supposes  to  depend  upon  over  distension  of  the  stomach  ;  and  it  may  be  so;  certainly 
great  quantities  of  air  are  sometimes  extricated ;  and  the  pain  is  not  confined  to  the 
stomach,  but  shoots  through  to  the  back  and  between  the  shoulders.  I  suspect  that 
the  pain  is  sometimes  neuralgic.  It  is  often  very  intractable  ;  occasionally  it  yields 
to  carminatives,  •  Dr.  Abercrombie  states  that  he  has  observed  ihe  most  effectual 
relief  in  such  cases  to  have  been  obtained  from  exciting  a  brisk  action  of  the  bowels  by 
means  of  a  strong  purgative  enema.  He  makes  this  practical  remark,  which  is 
worth  attending  to.  From  the  facilities  with  which  such  affections  often  yield  to  the 
remedy  just  mentioned,  it  appears  not  improbable  that  the  pain  may  be  sometimes 
situated  in  the  arch  of  the  colon.  Wherever  its  seat  may  be,  I  know  that  it  is  fre- 
quently removed  by  a  mustard  poultice  laid  upon  the  epigastrium.  Opium  also  is 
of  eminent  use  in  many  of  these  cases  ;  and  bismuth  ;  and  cordials  :  but  I  have  seen 
more  rapid  and  decided  rehef  afforded  by  the  prussic  acid  than  by  anything  else ; 
and  the  cure  so  wrought  is  often  permanent.  It  does  not  bring  ease  in  all  cases,  nor 
is  it  a  medicine  that  is  any  particular  favourite  of  mine,  yet  its  good  effect  is  in  some 
instances  so  striking,  that  if  this  were  its  only  virtue  I  should  esteem  the  hydrocyanic 
acid  a  most  valuable  remedy. 

You  will  meet  sometimes  with  what  is  called  spasm  of  the  stomach  (and  I  sup- 
pose it  is  such)  in  gouty  people ;  who  are  then  said  to  have  gout  in  the  stomach. 
The  pain  comes  on  in  sudden  and  severe  paroxysms ;  and  is  removable  in  general 
by  laudanum  and  stimulants,  brandy,  for  example;  or  by  the  mustard  poultice. 
On  these  cases,  however,  we  look  with  jealousy  and  apprehension.  In  some  in- 
stances the  attack  is  really  inflammatory,  and  would  then  be  aggravated  by  a  stimu- 
lant treatment. 

There  is  yet  another  modification  of  uneasiness  and  disorder  of  the  stomach,  of 
which  the  distinguishing  characteristic  is  the  vomiting,  or  rather  the  eructation  of  a 
thin  watery  liquid,  sometimes  sourish,  but  usually  insipid  and  tasteless,  and  often 
described  by  the  patients  themselves  as  being  cold.  This  is  what  Cullen  calls 
pyrosis,  the  water-brash.  It  is  a  disorder  much  more  frequent  in  the  lower  ranks 
of  society  than  in  others.  It  is  particularly  common  in  Scotland,  and  is  there  ascribed 
to  the  large  employment  of  farinaceous  substances  as  food,  and  especially  of  oat-meal. 
But  it  is  said  to  be  still  more  common  in  Lapland.  Dr.  Cullen,  w^ho  saw  a  great 
deal  of  it,  says  that  its  paroxysms  "  usually  come  on  in  the  morning  and  forenoon, 
when  the  stomach  is  empty.  The  first  symptom  of  it  is  a  pain  at  the  pit  of  tho 
stomach,  with  a  sense  of  constriction,  as  if  the  stomach  was  drawn  towards  Hie  back. 
The  pain  is  increased  by  raising  the  body  into  an  erect  posture,  and  tnerefore  tnc 
body  is  bended  forward.     The  pain  is  often  very  severe  ;  and  after  continuing  for 


780  DYSPEPSIA. 

some  time,  it  brings  on  an  eructation  of  a  thin  watery  fluid  inconsiderable  quantity." 
Such  is  Cullen's  description  of  pyrosis.  He  states  that  the  complaint  often  occurs 
without  other  evidence  of  dj^spepsia ;  but  this  is  not  consistent  with  the  experience 
of  subsequent  observers.  It  is  a  symptom  sometimes  of  organic  disease  of  the 
stomach.  In  one  remarkable  case  of  pyrosis  which  I  saw,  and  in  which  not  less 
than  three  pints  of  this  thin  tasteless  liquid  was  brought  up  every  day,  the  stomach, 
after  death,  was  found  to  all  appearance  healthy  ;  but  it  had  been  pressed  upon  by 
an  enormous  liver.  I  mention  these  facts  that  you  may  not  suppose  pyrosis  to  be 
ahvays,  as  Cullen  has  described  it,  a  substantive  and  idiopathic  malady. 

When  pyrosis  is  not  caused  by  organic  disease  in  the  stomach  or  in  the  liver,  it 
will  yield  in  general  to  opium,  and  especially  to  opium  in  combination  with  astrin 
gents.  The  pulvis  kino  compositiis  of  the  Pharmacopoeia  is  an  admirable  remedy 
for  it.  But  we  often  have  to  contend  with  this  difficulty,  that  the  bowels,  in  case.s 
of  pyrosis,  are  generally  confined,  and  that  the  opium  tends  to  aggravate  this  unna- 
tural condition;  so  that  it  becomes  necessary  to  administer  some  aperient  daily 
while  the  kino  and  opium  are  given:  castor  oil,  or  confection  of  senna,  or  cathartic 
extract. 

Cosliveness  is,  in  fact,  a  very  frequent  concomitant  of  dj-spepsia,  as  Cullen's  defi- 
nition affirms  (plerumque  cum  alvo  adstricta).  And  this  sluggish  state  of  the  bowels 
often  aggravates,  if  it  does  not  produce,  the  dyspepsia.  At  anj''  rate  the  defective 
powers  and  uneasy  sensations  of  the  stomach  are  rectified,  in  many  instances,  by 
measures  which  promote  the  regular  and  healthy  evacuation  of  the  intestines. 
AVithout  professing  to  go  into  detail  in  this  matter,  I  may  state  that,  in  our  remedial 
attempts,  we  should  imitate,  as  much  as  we  can,  the  processes  of  nature.  The 
mixed  contents  of  the  small  intestines  furnish  the  natural  stimulus  of  their  peristalic 
movements  ;  and  the  excrement  excites  the  larger  bowels.  When  this  natural  stimu- 
lus is  insufficient,  the  want  may  be  supplied  by  some  substance  which  is  involved  in 
the  food,  and  accompanies  it  in  its  progress  —  as  the  bran  of  brown  bread,  already 
mentioned,  or  a  few  grains  of  rhubarb  or  of  aloes  swallowed  immediately  before 
dinner.  In  adjusting  the  proper  quantity  of  the  drug  the  patient  must  assist  the 
physician.  It  should  be  just  so  much  as  suffices  to  effect  what  nature  neglects  to 
do,  and  no  more.  With  some  persons  an  aperient  pill  acts  more  comfortablj^  and 
opportunely  if  taken  at  bed-time.  Sometimes  diarrhoea  is  associated  with  indigestion. 
This  is  usually  connected  with  an  excess  of  acid  in  the  primse  vise.  The  principle 
of  treatment  in  such  cases  is  obvious. 

There  are  innumerable  sympathies  of  distant  parts  with  a  dyspeptic  stomach,  .n 
respect  to  which  lean  do  little  more  than  barely  enumerate  a  few.  Thus  indigestion 
is  often  accompanied  by  pain  in  the  head,  with  some  confusion  of  thought :  or.  at  all 
events,  with  a  loss  of  mental  energy^  and  alertness.  Together  with  a  violent  headache 
there  are  frequently  nausea  and  vomiting ;  and  the  complaint  is  popularly  known  by 
the  name  of  the  sick-headache :  or,  in  the  fashionable  jargon  of  the  da}',  as  a  bilious 
headache.  I  must  refer  you  to  a  paper  of  Dr.  Fothergill's,  in  the  sixth  volume  of 
the  Medical  Observations  and  Inquiries,  for  a  very  good  account  of  this  troublesome 
complication. 

I  shall  hereafter  have  a  good  deal  to  say  respecting  certain  morbid  conditions 
of  the  urine,  which  take  their  rise  sometimes  from  faulty  digestion  in  the  stomach, 
sometimes  from  faulty  assimilation  of  the  digested  aliment  in  the  more  advanced 
stages  of  the  process  of  nutrition.  These  conditions  of  the  urine,  indicating  grave 
derangements  of  the  whole  system,  furnish  the  characters  and  the  names  of  several 
distinct  maladies. 

I  told  j'ou,  in  a  former  lecture,  that  certain  affections  of  the  viscera  of  the  thorax 
are  liable  to  be  produced  by  mere  indigestion.  Palpitations  of  the  heart,  irregulari- 
ties of  the  pulse,  fits  of  asthma,  are  no  uncommon  accompaniments  of  a  disordered 
stomach.  This  is  partly  to  be  ascribed  to  that  reflex  sympathy  between  the  parts 
concerned,  which  I  have  so  frequently  mentioned  ;  partly  to  the  effect  of  flatulence, 
which,  by  resisting  the  descent  of  the  diaphragm,  impedes  the  free  working  of  the 
lungs  and  of  the  heart.  I  told  you,  at  the  same  time,  that  these  symptoms  torment 
mnny  persons  with  the  belief  that  they  spring  from  organic  disease.     This  notion  is 


DYSPEPSIA.  781 

particularly  apt  to  infest  the  minds  of  medical  students.  I  suppose  most  teachers  in 
our  profession  partake  of  that  sort  of  experience  which  Dr.  James  Gregory,  of  Edin- 
burgh, used  to  speak  of  in  his  lectures.  He  said  that  scarcely  a  winter  passed  over 
in  which  several  of  his  pupils  did  not  apply  to  him  on  account  of  palpitations  sup- 
posed by  them  to  depend  upon  structural  disease  of  the  heart :  and  in  no  single  in- 
stance were  their  apprehensions  well  founded.  They  were  all  cases  of  mere  dys- 
pepsia and  hypochondriasis. 

D3'^spepsia  is  often  connected  with  phthisis,  with  leucorrhoea,  with  amenorrhosa 
and  chlorosis :  and  some  persons  imagine  that  these  diseases  are  caused  by  the 
dyspepsia.  Indigestion  may  lead  indirectly  to  the  development  of  consumption,  by 
producing  debihty ;  but  the  truer  view  of  the  matter  seems  to  be  that  the  dyspepsia 
is  a  consequence,  rather  than  an  exciting  cause,  of  these  complaints.  When,  for 
instance,  leucorrhoea  is  cured  by  topical  astringents,  as  it  often  may  be,  the  indiges- 
tion frequently  is  cured  too. 

One  of  the  worst  occasional  concomitants  of  dyspepsia  is  that  peculiar  state  of  the 
mind  to  which  I  just  now  alluded  under  the  term  hypochondriasis.  This  is,  in  truth, 
a  species  of  insanity :  but  it  is  so  often  connected  with  disorder  of  the  digestive 
organs,  that  Cullen,  whose  descriptions  of  disease  are  admirably  clear  and  true, 
however  faulty  many  of  his  theories  may  be,  defines  hypochondriasis  to  be  ^^Dys- 
pepsia —  cum  languore,  ma^stitia,  et  metu,  ex  causis  non  sequis."  In  the  following 
short  paragraph  he  completes  the  picture.  "  In  certain  persons  there  is  a  state  of 
mind  distinguished  by  the  concurrence  of  the  following  circumstances.  A  languor, 
listlessness,  or  want  of  resolution  and  activity  with  respect  to  all  undertakings  :  a 
disposition  to  seriousness,  sadness,  and  timidity :  as  to  all  future  events,  an  appre- 
hension of  the  worst  or  most  unhappy  state  of  them ;  and  therefore,  often  upon 
slight  grounds,  an.  apprehension  of  great  evil.  Such  persons  are  particularly  atten- 
tive to  the  state  of  their  own  health,  to  every  the  smallest  change  of  feeling  in  their 
bodies  :  and  from  any  unusual  feeling  perhaps  of  the  slightest  kind,  they  apprehend 
great  danger,  and  even  death  itself.  In  respect  to  all  these  feelings  and  apprehen- 
sions, there  is  commonly  the  most  obstinate  belief  and  persuasion." 

Now  when  the  attention  of  the  hypochondriac  is  thus  morbidly  fixed  upon  the 
states  and  sensations  of  his  digestive  organs  (as  it  is  very  apt  to  be)  the  patient  be- 
comes a  plague  to  his  physicians  as  well  as  to  himself. 

There  are  a  few  simple  rules  which  ought  always  to  be  kept  in  mind  in  our  treat' 
rnent  of  dyspepsia ;  although  we  can  seldom  enforce  them,  as  they  ought  to  be  en- 
forced, upon  our  padents.  What  patients  want,  in  general,  is  some  medicine  that 
will  relieve  them  from  their  discomfort  and  uneasy  feelings,  and  allow  them,  at  the 
same  time,  to  go  on  in  the  indulgence  of  those  habits  which  have  generated  the  dis- 
comfort.    And  such  remedies  have  not  yet  been  discovered. 

One  great  and  indispensable  principle  in  the  treatment  of  indigestion,  is  that  of 
restricting  the  quantity  of  food  taken  at  any  one  time.  The  gastric  juice  is  probably 
secreted  in  a  tolerably  uniform  quantity.  The  muscular  contractions  of  the  stomach 
must  needs  be  impaired  or  impeded  by  much  distension  of  thai  organ.  For  both 
these  reasons  the  amount  of  food  introduced  into  the  stomach  should  be  kept  within 
the  limits  of  its  capacity  and  powers.  The  great  good  which  the  late  Mr.  Abernethy 
unquestionably  did  to  a  host  of  dyspeptic  patients,  was  owing  much  more,  I  am  per- 
suaded, to  the  rules  of  diet,  and  the  restrictions  as  to  quantity,  which  he  laid  down, 
than  to  his  eternal  blue  pill. 

Again,  as  Dr.  Abercrombie  has  well  remarked,  and  as  Dr.  Beaumont  actually  saw, 
various  articles  of  food  are  soluble  in  the  stomach  with  various  degrees  of  readine.'s. 
Therefore,  when  the  digestion  is  liable  to  be  easily  impaired,  it  is  of  great  import- 
ance, not  only  to  refrain  from  those  substances  which  are  known  to  be  soluble  with 
difficulty,  but  also  to  avoid  mixing  together  in  the  stomach  different  substances  which 
are  of  different  degrees  of  solubility.  Hence  there  are  two  reasons  why  it  is  salutary 
to  dine  off  one  dish.  1st.  Because  we  avoid  the  injurious  admixture  just  adverted 
to ;  and,  2dly,  because  we  escape  that  appetite,  and  desire  to  eat  too  larjge  a  quantit},, 
which  is  provoked  by  new  and  various  flavours. 

3q 


782  DYSPEPSIA. 

And  another  very  important  principle,  f^reatly  insisted  on  by  Mr.  Abernetliy,  is, 
that  the  stomach  should  have  time  to  perforna  one  task  before  another  is  imposed 
upon  it.  He  always  made  his  patients  (at  least  he  always  strongly  exhorted  them) 
to  interpose  not  less  than  six  hours  between  one  meal  and  another.  Allowing  from 
threy  to  five  hours  for  the  digestion  of  a  meal,  and  one  hour  over  for  the  stomach  to 
rest  in,  Mr.  Abernethy's  rule  seems  as  much  founded  in  reason  as  it  is  justified  by 
experience.  But  we  preach  in  vain  on  these  topics.  Mr.  Abernethy  was  in  the 
habit  of  saying  that  no  person  could  be  persuaded  to  pay  due  attention  to  his  digestive 
organs,  till  death,  or  the  dread  of  death,  was  staring  him  in  the  face.  I  have  now 
in  my  mind  a  family  consisting  of  a  mother  and  three  grown-up  daughters,  who  are 
continually  ailing  and  valetudinary.  They  profess  to  have  great  respect  for  my  pro- 
fessional advice  :  yet  I  never  can  induce  them  to  think  that  their  plan  of  eating  is  a 
bad  one.  They  are  not  early  risers.  They  get  to  breakfast  about  half  after  ten  or 
eleven.  At  two  they  think  it  absolutely  necessary  to  eat  luncheon,  which  consists 
of  a  mutton  chop  or  some  hashed  meat,  with  vegetables.  At  six  they  dine :  and  at 
eight  they  drink  tea :  and  then  they  eat  no  more  till  the  next  breakfast.  And  this 
is  just  a  picture  of  the  habits  of  scores  of  famihes.  They  huddle  all  their  food  into 
the  stomach,  at  four  periods,  within  seven  or  eight  hours ;  and  leave  it  idle  for  six- 
teen or  seventeen. 

D3'speptic  patients  are  very  importunate  to  know  ivhat  they  may  eat,  and  (more 
so  still)  what  they  ma}^  drink.  It  is  of  course  impossible  to  lay  down  any  general 
rules  which  will  suit  every  case.  The  stomach  has  its  idiosyncrasies.  I  remember 
seeing  a  publication  some  years  ago,  one  section  of  which  had  this  startling  title, — 
"  Cases  of  poisoning  by  a  Mutton  Chop."  Dr.  Prout  knew  a  person  who  could  not 
eat  mutton  in  any  form.  He  was  thought  to  be  whimsical,  and  mutton  was  frequently 
served  up  to  him  under  some  other  guise,  without  his  knowing  it ;  but  it  invariably 
caused  violent  vomiting  and  diarrhosa.  Yet,  for  the  average  of  stomachs,  mutton  is 
probably  the  most  digestible  of  all  meats.  And  for  the  average  of  stomachs  some 
useful  general  directions  may  doubtless  be  given. 

In  fevers  and  inflammatory  disorders,  experience  has  taught  us  to  forbid  or  limit 
the  use  of  flesh  meat  on  account  of  its  stimulating  qualities.  And  when  the  stomach 
itself  is  affected  with  chronic  inflammation,  or  with  morbid  sensibility,  a  diet  restricted 
to  farinaceous  substances,  and  milk,  is  sometimes  attended  with  the  happiest  conse- 
quences. I  suspect  that  a  false  analogy  has  led  some  into  the  mistake  of  supposing 
that  animal  food  ought  to  be  refrained  from,  or  taken  in  a  scanty  proportion,  in  merely 
dyspeptic  complaints.  Animal  food  is  easier  of  digestion,  in  the  human  stomach, 
than  vegetable  food.  It  is  nearer,  in  its  composition,  to  the  textures  into  which  it  is 
to  be  incorporated  by  assimilation.  There  is  less  of  "  conversion"  requisite.  Indeed 
we  may  look  upon  the  appropriation  of  vegetable  matter,  by  granivorous  and  grami- 
nivorous animals,  as  one  stage  of  the  process  by  which  such  vegetable  matter  is 
prepared  for  the  sustenance  of  carnivorous  animals :  even  as  one  great  end  of  vege- 
table life  seems  to  be  that  of  generating  or  concocting  matter  for  the  nutrition  of  the 
former  class,  out  of  inorganic  materials,  not  fitted  for  that  purpose.  A  more  elaborate 
digesting  apparatus  is  provided  for  the  vegetable  eaters.  Man,  indeed,  is  omnivorous. 
But  his  organs  of  digestion  are  more  like  those  of  the  carnivorous  than  of  the  grani- 
vorous races.  And  it  is  notorious  that  vegetable  food,  when  the  stomach  is  weak,  is 
followed  by  more  flatulence,  that  is,  is  digested  with  niore  tardiness  and  difficulty, 
ihan  animal  food.  Nevertheless,  a  mixture  of  the  two,  of  well  roasted  or  boiled  flesh 
or  fowl,  with  a  moderate  portion  of  thoroughly  cooked  vegetables,  is  better  suited, 
in  my  opinion,  for  a  feeble  stomach,  than  a  rigid  adhesion  to  either  kind  of  aliment 
singly  Each  of  the  four  great  classes  of  alimentary  principles  specified  by  Dr. 
Prout  should  be  represented;  the  aqueous,  the  saccharine,  the  albuminous,  and  the 
oleaginous.  All  meats  that  have  been  hardened  by  culinary  art,  or  by  condiments, 
should  be  avoided  by  him,  who,  as  the  vulgar  express  it,  has  "a  bad  digester;"  all 
cured  meats  I  mean — ham,  tongue,  sausages,  and  so  forth.  Mutton  is  thought  to  be 
..lore  readily  digestible  than  beef.  Pork,  its  lean  part  at  least,  is  much  less  so  than 
either.  All  raw  vegetables  also  must  be  eschewed ;  salads,  cucumbers,  pickles. 
But  if  we  press  our  prohibitions  much  more  strictly  than  this,  we  incur  the  risk  of 


DYSPEPSIA.  783 

fixing  the  patient's  attention  too  curiously  upon  his  diet,  and  upon  the  sensations  of 
his  stomach ;  and  of  rendering  him  hypochondriacally  ahve  to  the  miserable  subject 
of  his  feeding. 

Again,  you  will  be  continually  asked  whether  you  recommend  malt  liquor  or 
wine,  wine  or  brandy  and  water,  vvhite  wine  or  port,  sherry  or  madeira.  Now  it 
would  be  very  easy  to  propound  some  positive  rules  in  this  matter,  but  it  would  not 
be  so  easy  to  vindicate  them.  Some  allowance  must  be  made,  no  doubt,  for  custom. 
I  believe,  however,  that  most  dyspeptic  persons  would  be  better  without  any  of  these 
drinks.  But  it  is  very  difficult  to  persuade  them  that  the  habitual  use  of  strong- 
liquors  in  small  quantities  can  have  any  injurious  effects.  "It  is  not  easy  (says 
Cullen)  to  engage  men  to  break  in  upon  established  habits,  or  to  renounce  the  pur- 
suits of  pleasure ;  and  particularly  to  persuade  men  that  those  practices  are  truly 
hurtful,  which  they  have  often  practised  with  seeming  impunity."  They  are  too 
ready  to  believe  that  it  is  unsafe  to  abandon  their  accustomed  indulgence.  A  friend 
of  mine,  who  visited,  some  years  since,  many  of  the  American  prisons,  tells  me  that 
the  health  of  even  the  most  inveterate  spirit-drinkers  improves,  instead  of  suffering, 
upon  the  sudden  and  total  abstinence  from  spirits,  which  the  regulations  of  those 
prisons  enforce.  There  certainly  are  cases  in  which  the  digestion  seems  to  be  helped 
by  a  moderate  quantity  of  wine,  or  beer,  or  spirits ;  yet  no  one  can  say  before-hand 
— at  least  I  cannot — which  of  them  is  to  be  preferred.  Upon  these  points  patients 
should  interrogate  their  own  sensations  and  experience,  instead  of  seeking  the  oracu- 
lar counsel  of  a  physician.  Drinks  which  are  followed  by  evident  disturbance  and 
discomfort  are  manifestly  unfit.  And  even  when  a  favourable  effect,  for  the  time, 
appears  to  be  produced,  there  is  always  a  risk  of  ultimate  detriment  to  the  powers  of 
the  stomach  from  this  habitual  excitement. 

There  are  states  of  mind  and  habits  of  life,  which,  having  no  direct  relation  to  the 
organs  of  digestion,  yet  exercise  a  material  influence  over  their  functions.  Mental 
distress;  mental  solicitude  ;  mental  toil ;  over-much  study  ;  Avant  of  exercise  :  these 
are  all  prohfic  sources  of  dyspepsia.  Sedentary  habits,  when  their  injurious  effects 
are  known,  may  be  altered  :  excessive  intellectual  labour  may  be  abandoned  :  but  it 
is  seldom  that  we  can  minister  to  a  wounded  or  an  anxious  spirit.  Our  task  is 
hardest  of  all  when  the  patient's  anxiety  relates  to  his  own  complaints ;  when  he  is 
morbidly  engrossed  by  his  bodily  feelings,  and  despondent  about  its  recovery.  The 
management  of  the  mind  of  a  hypochondriac  is  peculiarly  nice  and  difficult.  It  wilt 
not  do  to  treat  him  as  if  his  ailments  were  imaginar}^  He  disbelieves  you,  contemns 
your  judgment,  and  deserts  you:  to  be  fleeced  perhaps  by  some  villanous  quack. 
You  must  hear  what  he  has  to  say ;  show  an  interest  in  his  case ;  and  prescribe  for 
him  :  assuring  him  that  you  understand  his  malady,  that  it  is  curable,  and  that  he 
will  be  cured  provided  he  follows  your  directions.  If  you  can  succeed  in  gaining 
his  confidence,  and  in  persuading  him  of  this,  the  battle  is  half  won.  To  tell  such  a 
person,  however,  not  to  think  of  his  grievances  would  be  worse  than  useless.  The 
very  effort  to  drive  a  subject  from  our  thoughts  fixes  it  there  more  surely.  But  you 
must  endeavour  to  turn  his  attention  to  other  things ;  and  to  awaken  in  him  some 
new  interest.  Prescribe  change:  change  of  air;  change  of  place  and  of  scenery; 
change  of  society.  Get  him  to  travel  in  search  of  health  ;  and  the  chances  are  in 
favour  of  his  finding  it.  A  tour,  in  fine  weather,  and  through  a  pleasant  country, 
combines  almost  all  the  ingredients  which  are,  seperately  even,  desirable  :  the  with- 
drawal of  the  mind  from  its  ordinary  pursuits  and  cares ;  the  diversion  of  the  atten- 
tion from  one's  self,  by  new  and  varied  objects  ;  exercise  carried  on  in  the  open  air ; 
a  holiday  from  intellectual  toil.  Six  weeks  among  the  mountains  of  Switzerland,  or 
upon  the  rivers  of  Germany,  Avill  often  do  more  towards  restoring  a  dyspeptic  hypo- 
chondriac than  a  twelvemonth's  regimen  and  physicking  at  home. 

With  these  disjointed  hints,  gentlemen,  I  must  request  j^ou  to  be  satified  in  respect 
to  the  principles  upon  which  dyspepsia — and  the  hypochondriasis,  which  is  in  gene- 
ral so  closely  linked  with  dyspepsia — are  to  be  managed.  A  full  discussion  of  "the.<=« 
subjects  in  detail  would  furnish  matter  for  several  lectures. 


784  ENTERITIS. 


LECTURE  LXXI. 

Enteritis:  its  symptoms  ;  causes;  treatment.  Mechanical  occlusion  of  the  Intes 
tinal  Tube.  Culic.  Colica  Fictonum :  its  symptoms,  complications,  treatment, 
and  prevention. 

Some  of  the  diseased  states  of  the  intestinal  canal,  while  they  difTer  a  good  deal  in 
their  essential  nature,  have  yet  many  characters  in  common.  Colic  ;  ileus  ;  enteritis  ; 
mechanical  obstruction  of  the  tube.  It  will  be  convenient,  therefore,  to  consider  these 
disorders  in  succession,  and,  in  some  degree,  in  connection  with  each  other. 

In  colic  we  have  pain  of  the  abdomen  ;  pain  of  a  twisting  or  wringing  kind,  occu- 
pying generally  the  umbilical  region  ;  vomiting ;  and  costive  bowels.  Similar  pains 
are  apt  to  occur  in  diarrhoea ;  but  they  are  transitory,  and  are  then  termed  gripings, 
or  more  learnedly,  tormina.  When  they  are  violent,  and  more  permanent,  and 
above  all,  when  attended  with  constipation,  they  constitute  colic. 

You  have  not  forgotten  the  symptoms  of  peritonitis.  They  are,  briefly,  pain  in 
the  abdomen,  increased  on  pressure  ;  and  fever. 

Now,  if  to  the  symptoms  of  colic,  you  add  the  symptoms  of  peritonitis,  you  have 
the  symptoms  of  enteritis :  by  which  word  I  desire  to  express  the  disease  that  is 
commonly  called  inflammation  of  the  bowels.  The  term  has  lately  been  extended 
so  as  to  signify  any  and  every  form  of  inflammation  which  any  portion  or  tissue  of 
the  intestinal  canal  within  the  belly  may  suffer;  but  I  use  it  in  the  old-fashioned 
meaning.  Cullen  makes  two  species  of  enteritis.  One  of  these  consists  in  inflam- 
mation of  the  mucous  membrane  of  the  intestinal  tube :  he  calls  it  enteritis  erythe 
matica.  That  is  not  the  disorder  I  am  about  to  speak  of;  but  the  other  of  his  spe- 
cies, the  enteritis  phlegmonodea.  I  say  that  in  colic,  we  have  abdominal  pain, 
constipation,  and  vomiting.  In  peritonitis,  the  functions  of  the  stomach  and  intestines 
are  not,  necessarily,  affected  :  in  enteritis  they  are.  There  is  inflammation,  not 
merely  of  the  peritoneal  coat,  but  of  the  areolar  tissue  uniting  the  several  tunics, 
probably  of  the  muscular  tissue  also,  and  often  of  the  whole  substance  of  the  bowel 
at  the  inflamed  part. 

When  the  intestinal  channel  is  any  how  closed  up,  and  a  bar  placed  to  the  pass- 
age of  its  contents,  the  symptoms  of  coHc  are  very  apt  to  ensue ;  and  at  length,  the 
obstacle  continuing,  fatal  inflammation  is  set  up. 

The  term  ileus  is  applied,  I  believe,  to  those  cases,  whether  inflammatory  or  not, 
in  which,  by  an  inverted  action  of  the  intestines,  their  contents  are  carried,  in  3 
retrograde  course,  into  the  stomach,  and  thence  out  of  the  body  by  vomiting. 

Having  made  these  explanations,  I  shall  now  address  myself  more  especially  to 
Jhe  consideration  of  enteritis. 

It  is  of  much  practical  importance  to  discriminate  between  enteritis  and  the  dis- 
orders that  resemble  it ;  and  particularly  to  distinguish  it  from  colic.  When  it  com- 
mences, as  it  sometimes  does,  with  distinct  rigors,  and  is  attended  by  thirst,  a  hot  skin, 
and  a  hard  and  frequent  pulse,  there  is  no  room  for  doubt.  But  it  often  begins  in- 
sidiously, with  mere  colicky  symptoms  ;  the  pain,  at  first,  is  not  much  augmented, 
It  may  even  be  somewhat  eased,  by  steady  pressure.  If  we  mistake  colic  for  enteritis, 
the  error  is  of  no  great  moment ;  but  the  opposite  mistake,  which  is  more  common, 
may  be  fatal.  Blood-letting,  and  the  other  remedies  of  enteritis,  will  not  aggra- 
vate the  mere  colic ;  they  may  even,  though  unnecessary,  relieve  the  patient. — 
Some  of  the  remedies  of  mere  cohc  are,  however,  highly  dangerous  when  there  is 
inflammation  of  the  bowel.  Physicians  may  fall  into  this  error  :  patients  who  choose 
to  prescribe  for  themselves,  commonly  do  so.  They  take  stimulants,  cordials,  car- 
minatives— the  pleasantest  and  nearest  at  hand  is  a  glass  of  brandy,  or  of  gin.  And 
in  true  colic  these  means  are  frequently  of  great  service ;  but  they  exasperate  the 
6>yniptoms,  and  increase  the  mischief  when  the  disease  is  enteritis.  Indeed,  treat- 
ment of  this  kind  will  sometimes  urge  colic  into  enteritis.     If  the  case  be  ambiguous, 


ENTERITIS.  78o. 

you  must  act  upon  the  most  unfavourable  supposition,  and  treat  the  complaint  as  if 
you  were  sure  that  inflammation  was  present. 

The  pain  of  enteritis  is  increased  by  pressure.  The  pain  of  coHc  is  not  only  not 
made  worse,  but  it  is  actually  mitigated  often,  by  pressure  ;  and  it  usually  intermits 
entirely.  I  know  that  when  there  is  simply  flatulent  distension  of  the  intestines, 
pressure  does  sometimes  increase  the  patient's  uneasiness ;  but  the  uneasy  sensation 
is  very  different  from  that  acute  sensibility  which  belongs  to  inflammation  of  their 
peritoneal  covering.  In  enteritis  there  are  also  paroxysms  of  severe  pain,  determined, 
probably,  by  the  peristaltic  movements,  or  by  the  temporary  distension  of  the  inflamed 
parts  of  the  bowel ;  and  the  pain  has  frequently  a  twisting  character :  but  there  is 
not  any  thorough  intermission.  There  is  a  duller  abiding  pain  between  the  sharper 
fits.  It  is  to  be  observed  also,  as  a  diagnostic  circumstance,  that,  as  in  peritonitis,  the 
patient  lies  on  his  back,  with  his  knees  drawn  up,  and  is  fixed  in  that  position,  and 
for  the  very  same  reasons.  If,  in  his  agony,  he  tosses  about  his  arms,  the  trunk  is 
kept  motionless,  and  the  respiration  is  thoracic :  whereas  in  mere  colic  the  mode  of 
breathing  is  not  altered,  and  the  patient  is  apt  to  be  turning  and  writhing  in  all  pos- 
tures, and  out  of  one  posture  into  another. 

The  nausea  and  vomiting  are  often  most  distressing.  The  patient  not  only  rejects 
immediately  whatever  food,  drink,  or  medicine  he  swallows,  but  he  has  fits  of  retch- 
ing when  the  stomach  is  empty.  In  some  instances,  matters  are  cast  up  having  the 
appearance,  and  something  of  the  odour,  of  liquid  feces :  or  resembling,  at  any  rate, 
the  offensive  fluids  which  are  found  in  the  small  intestines  after  death  in  these  cases. 
I  cannot  say  that  I  have  ever  seen  genuine  excrement  ejected,  unequivocal  ordure: 
yet  this  may  well  happen  if  it  be  true  that  clysters,  introduced  into  the  rectum,  have 
been  voided  through  the  mouth.  Such  a  phenomenon  would  show  that  the  whole 
tube  was  pervious ;  that  there  was  no  mechanical  obstruction. 

Although  the  fever,  in  the  outset,  may  be  high,  and  the  pulse  strong  and  hard,  it 
soon  becomes  (as  in  all  acute  abdominal  inflammations)  small  and  wiry  ;  or  weak, 
and  like  a  thread.  In  bad  cases,  as  the  disease  proceeds,  the  abdomen  begins  to 
swell,  becomes  tympanitic  ;  hiccup  sometimes  comes  on  ;  the  pulse  intermits  or  beats 
irregularly ;  the  extremities  grow  cold ;  the  features  are  sharpened  and  ghastly ; 
cold  sweats  break  out ;  the  pain  ceases  perhaps ;  and  the  sphincters  relax.  The 
head  is  generally  unaffected.  Now  and  then  delirium  occurs  late  in  the  disease ; 
but  much  more  frequently  the  intellect  remains  clear  to  the  very  last.  Death  begins 
at  the  heart,  and  takes  place  in  the  way  of  asthenia. 

You  may  probably  have  observed  that  the  symptoms  which  I  have  been  describ- 
ing are  just  the  symptoms  which  the  surgeon  so  frequently  encounters  in  cases  of 
strangulated  hernia.  The  symptoms  of  that  surgical  complaint  are,  in  truth,  most 
commonly  at  least,  the  symptoms  of  enteritis,  caused  by  the  forcible  closure  of  the 
bowel.  Obstruction  to  the  passage  of  the  contents  of  the  gut  gives  rise  to  its  inflam 
mation.  And  we  often  find,  after  death  preceded  by  the  signs  of  enteritis,  an  internal 
mechanical  obstruction — an  internal  strangulated  hernia.  In  some  cases  bands  or 
strings  of  coagulable  lymph,  the  products  of  bygone  inflammation,  have  formed 
snares  (so  to  speak)  for  the  gut,  which  at  length  they  catch  and  constrict.  They  do 
no  harm  till  some  coil  of  intestine  gets  beneath  or  beyond  them;  and  then  they 
strangle  it,  as  the  phrase  is.  I  have  twice  seen  (as  I  think  I  formerly  stated)  the 
appendix  vermiformis  prove  the  immediate  cause  of  fatal  internal  hernia.  In  one  of 
these  cases,  the  person  had  been  a  private  patient  of  Dr.  Macmichael ;  and  I  went 
with  him  to  examine  the  body.  The  free  end  of  the  appendix  had  become  adherent 
to  the  mesocolon  ;  and  so  a  loop  was  made,  through  which  a  portion  of  the  gut  had 
passed.  In  the  other  instance,  which  I  saw  in  Edinburgh,  the  appendix  was  lite- 
rally tied  round  a  piece  of  the  intestine.  Sometimes,  again,  there  is  intussusception  : 
the  upper  part  of  the  tube  slips  into  the  lower,  fills  it  up;  obstructs  it;  and  inflam- 
mation fixes  it  there.  Or  it  may  be  that  a  chronic  thickening  of  the  coats  of  the  in- 
testine has  narrowed  its  channel ;  or  a  tumour  presses  upon  the  intestine  from  with- 
out ;  or  some  foreign  substance,  or  morbid  accumulation,  plugs  it  up  within  ;  in  all 
which  cases  a  chronic  dfsorder  passes  at  length  into  acute  inflammation.  A  very 
small  hernia  at  one  of  the  usual  orifices — not  large  enough  to  manifest  itself  ext^r 
50  3  Q  2 


786  ENTERITIS. 

nally — is  sometimes  the  cause  of  the  obstruction  ;  even  though  only  a  portion  of  one 
side  of  the  gut  may  be  nipped  in  the  aperture. 

Sometimes,  but  according  to  my  experience  less  frequently,  there  is  no  mechanical 
impedime>it  to  account  for  the  constipation.  In  all  cases,  whether  there  be  mechanical 
obstruction  or  not,  the  inflamed  portion  of  the  gut  is  of  a  red  or  dark  colour ;  distended 
by  its  gaseous  or  liquid  contents ;  covered  often,  on  its  peritoneal  surface,  with  co- 
agulable  lymph  ;  or  adherent  to  the  contiguous  organs.  When  the  gut  is  mechani- 
cally closed,  the  part  which  lies  on  this  side  the  obstacle,  as  we  follow  the  natural 
course  of  the  channel,  is  inflamed  ;  the  part  which  lies  beyond  it  is  pale,  contracted, 
and  to  all  appearance,  healthy.  The  line  of  demarcation  is  abrupt  and  strong;  and 
it  is  determined  by  the  obstacle.  And  the  distinction  between  the  healthy  and  in- 
flamed portions  is  usually  as  sudden  and  decided,  when  there  is  no  apparent  obstacle. 
I  mean  that  up  to  a  certain  spot  the  intestine  is  red  like  a  cherry,  or  dark  like  a  grape, 
large,  and  smeared  (perhaps)  -with  lymph  or  with  pus ;  while  immediately  beyond 
that  point,  and  throughout  the  remainder  of  its  course,  it  is  white,  empt}',  and  shrunk 
up  into  the  semblance  of  a  cord.  The  pathology  of  these  last  forms  of  the  disease 
is  full  of  difficulty.  Some  have  held  that  the  contracted  part  was  the  original  seat 
of  disease,  namely,  of  spasm;  and  that  the  upper  adjoining  portion  of  intestine  be- 
cime  distended  and  inflamed  in  consequence  of  such  spasm.  Without  attempting 
to  explain  these  phenomena,  which  are  comparatively  unfrequent,  I  content  myself 
with  observing  that  it  is  the  distended  part  which  is  ihe  really  inflamed  part,  and 
that  its  muscular  coat  appears  to  have  lost  its  natural  contractile  power — not  (I  fanc}-^) 
from  over-stretching,  as  now  and  then  happens  to  the  urinary  bladder — but  from  the 
efl^ect  of  the  inflammation. 

The  inflamed  portion  of  bowel  is  often  of  a  very  dark  colour,  and  even  almost 
black,  from  the  great  congestion  of  blood  in  its  tissues.  Now  this  black  colour  has 
sometimes  been  erroneously  set  down  as  an  evidence  of  gangrene.  You  must  not 
trust  to  the  mere  colour,  however.  If  the  coats  of  the  bowel  be  firm,  and  if  the  pe- 
culiar odour  of  gangrene  be  wanting,  you  are  not  to  conclude  that  mortification  has 
taken  place,  simply  from  the  dark  appearance  of  the  intestine. 

Enteritis,  not  dependent  upon  any  mechanical  occlusion  of  the  bowel,  may  arise 
under  the  operation  of  the  ordinary  causes  of  internal  inflammation  :  cold  and  wet, 
for  instance,  applied  externally,  and  especially  to  tha  feet  and  legs.  Cold  is  thought 
to  be  particularly  injurious  in  this  way  when  the  exposure  happens  soon  after  a 
meal :  probably  because  at  that  time  the  digestive  organs,  being  in  activity,  receive 
a  more  copious  supply  of  blood. 

The  mechanical  impediments  that  occur  within  the  bowel,  are  still  more  various 
in  kind  than  those  which  constrict  it  from  withotd.  Hardened  fecal  matters:  intestinal 
concretions.  Some  of  these  are  curious,  and  I  shall  hereafter  have  a  word  or  two 
to  say  respecting  their  composition.  Persons  who  are  in  the  habit  of  taking  a  good 
deal  of  magnesia,  or  of  chalk,  to  relieve  acidity  and  heartburn,  are  liable  to  have 
these  substances  accumulate,  and  become  indurated  in  the  intestines.  They  generally 
begin  to  collect,  I  believe,  around  some  accidental  nucleus :  and  such  a  nucleus  may 
very  readily  be  supplied.  A  cherry-stone,  a  fish-bone,  a  gall-stone  that  has  found 
its  way  into  the  bowei.  Even  a  pill,  prescribed  to  cure,  may  thus  come  to  kill  one's 
patient.  Dr.  Prout  was  asked  to  analyze  certain  odd-shaped,  triangular  bodies  which 
had  been  voided  at  stool,  and  were  supposed  to  be  gall-stones:  but  he  found  that 
they  were  specimens  of  Plummer's  pill,  which  had  defied  the  solv>!nt  action  of  the 
gastric  juice,  and  had  passed  into,  and  lingered  in,  the  bowels.  Unbruised  mustard- 
seed,  and  carbonate  of  iron,  are  other  remedial  substances  which,  injudiciously  ad- 
ministered, have  collected  in  hard  masses,  and  caused  intestinal  disease.  It  is  seldom 
that  we  can  discover,  during  life,  what  is  the  exact  nature  of  the  mechanical  obstacle : 
but  I  have  observed  this  peculiarity  in  most  of  the  cases  in  which  I  have  known  it 
produced  by  intussusception,  that  after  severe  and  sudden  symptoms  of  obstruction 
and  inflammation,  blood  has  been  passed  by  stool.  Sometimes  the  included  portion 
of  bowel  itself  sloughs  away,  and  is  expelled  ^;er  anum. 

Inflammation  of  the  bowels  requires  very  much  the  same  kind  of  treatment  as 
penionitis :  indeed,  the  disease  is  in  most  cases  peritonitis  and  something  more.   The 


ENTERITIS.  ,  '  787 

patient  must  strictly  abstain  from  every  sort  of  stimulus,  and  confine  himself  as  much 
as  possible  to  the  horizontal  position.  He  must  lose  blood  also  from  the  arm,  and 
the  earlier  the  better.  The  lancet  is  not  to  be  withheld  merely  because  the  pulse 
is  small.  If  the  artery  becomes  fuller,  and  its  beating  more  distinct,  under  venesec- 
tion— nay,  if  the  patient  does  not  become  faint — the  first  bleeding  should  be  a  large 
one.  This  is  not  only  the  safer  plan,  but  in  the  long  run  it  is  the  most  economical 
of  the  blood  and  strength  of  the  patient.  As  in  simple  peritonitis,  the  abdomen  must 
be  covered  with  leeches,  and  afterwards  with  fomentation  cloths.  Should  one  spot 
or  region  be  more  painful  and  tender  than  another,  on  that  part  the  leeches  are  to  be 
accumulated.  It  may  be  requisite  to  repeat  the  venesection  and  the  leeching  once, 
or  twice,  or  many  times ;  the  propriety  of  such  repetition  depending  upon  the 
urgency  and  obstinacy  of  the  symptoms,  and  upon  the  age  and  state  of  the  patient. 
I  am  speaking  of  idiopathic  enteritis,  and  of  its  earher  stages.  In  the  advanced 
periods,  when  feebleness  of  the  pulse  is  associated  with  tympany  of  the  belly  and 
coldness  of  the  surface,  it  betokens  weakness  and  sinking,  and  the  tendency  to  death 
by  asthenia;  and,  consequently,  it  then  indicates  support  rather  than  depletion.  So 
also  when  the  enteritis  is  not  idiopathic,  but  consecutive — when  we  have  reason  to 
believe  that  it  arises  out  of  a  firm  mechanical  impediment — our  employment  of  blood- 
letting must  needs  be  modified  by  that  circumstance. 

One  point  in  the  management  of  enteritis,  requiring  great  caution  and  judgment, 
relates  to  the  exhibition  of  purgative  medicines.  The  costive  state  of  the  bowels  is 
apt  to  be  looked  upon  as  the  main  evil,  and  their  evacuation  as  the  chief  indication 
of  treatment;  but  great  mischief,  I  apprehend,  is  likely  to  arise  from  the  exclusive 
pursuit  of  that  indication.  I  am  still  speaking  of  the  idiopathic  disease,  where  it  is 
presumable  that  no  mechanical  obstacle  exists  to  render  the  passage  of  the  feces  im- 
possible. Purgatives  given  by  the  mouth  are  often  rejected  by  the  stomach,  with 
great  distress  to  the  patient.  If  they  are  retained,  and  fail  to  operate,  they  must  do 
more  harm  than  good.  Certainly  they  should  not  precede  the  venesection.  I  well 
remember,  though  it  is  now  many  years  ago,  being  myself  badly  treated  for  enteritis. 
Being  ill,  in  a  strange  place,  I  sent  for  the  nearest  practitioner,  who  happened  to  be 
a  very  ignorant  man.  Finding  that  I  was  sick,  and  that  my  bowels  did  not  act,  he 
gave  me,  for  two  or  three  days  in  succession,  strong  drastic  purges,  with  no  other 
effect  than  that  of  increasing  my  sickness,  and  adding  to  the  abdominal  pain  I  suf- 
fered. I  was  then  seen  by  a  most  intelligent  physician  (this  was  before  I  had  paid 
miy  attention  to  physic  myself),  and  the  first  thing  he  did  was  to  have  me  copiously 
bled ;  and  the  immediate  effect  of  that  bleeding  was  to  send  me  to  the  night-chair. 
And  I  am  persuaded  that  when  evacuations  follow  the  administration  of  purgatives  in 
such  cases,  they  are  often  owing  to  the  blood-letting  and  other  antiphlogistic  measures 
that  are  employed  at  the  same  time.  These  are  the  opinions  of  Dr.  Abercrombie 
also,  who  says,  "  I  confess  my  own  impression  distinctly  to  be,  that  the  use  of  pur- 
gatives makes  no  part  of  the  treatment  of  the  early  stages  of  enteritis ;  on  the  con- 
trary, that  they  are  rather  likely  to  be  hurtful  until  the  inflammation  has  been  sub- 
dued." It  is  an  instructive  fact,  that  when  purgative  medicines  do  operate  during 
the  height  of  the  inflammation,  the  stools  they  produce  are  merely  watery  ;  and  it  is 
only  after  the  inflammation  has  been  reduced  that  feces  are  discharged,  and  then  in 
such  quantity  sometimes  as  to  show  that  they  must  have  been  shut  up  in  the  bowels 
during  the  period  of  active  inflammation. 

You  should  wait,  then,  for  the  effect  of  other  measures,  blood-letting,  leeching, 
fomentation,  before  you  give  active  purgatives  by  the  mouth;  and  in  all  stages  of  the 
disease,  whatever  laxatives  are  given  should  be  of  the  mildest  kind,  such  as  are  least 
likely  to  excite  irritation  of  either  the  stomach  or  bowels. 

The  same  objections  do  not  apply  to  enemata,  which  soothe  while  they  evacuate 
the  lower  parts  of  the  canal.  You  will  read  or  hear  of  great  service  done  by  an 
infusion  of  tobacco,  or  by  the  smoke  of  tobacco,  thrown  into  the  bowels  Uhrough  the 
rectum.  Dr.  Abercrombie  speaks  of  a  weak  infusion  of  the  leaves  as  being  a  remedy 
of  very  general  utility.  It  should,  I  apprehend,  be  a  weak  infusion  to  be  at  all  safe; 
but,  of  my  own  knowledge,  I  can  tell  you  little  or  nothing  about  it.  I  do  Know, 
however,  that  the  injection  of  a  large  quantity  of  merely  warm  water  is  often  of  mucl- 


788  MECHANICAL   OCCLUSION   OF   THE   INTESTINAL   TUBE. 

use  :  from  two  to  six  pints,  for  example,  thrown  up  gradually  and  gently.  Indurated 
feces  are  softened  and  brought  away  in  this  manner,  and  the  warm  water  acts  as  an 
internal  fomentation. 

Of  internal  medicines  I  believe  the  best  you  can  give  is  a  combination  of  calomel 
and  opium,  in  such  proportions  as  will  restrain  the  purgative  qualities  of  the  calomel. 
The  opium  allays  pain,  and,  perhaps,  relaxes  spasm ;  mercury  tends  to  arrest  the 
inflammatory  action ;  and  the  more  immediate  effects  of  this  combination  are  often 
found  to  be,  a  setthng  of  the  irritable  stomach,  a  disposition  to  diaphoresis,  and  an 
improved  pulse. 

To  sum  up,  then,  bleeding,  and  calomel  and  opium  are  to  be  resorted  to  for 
checking  the  inflammation  :  and  when  that  is  in  great  measure  abated  (and  probably 
not  before),  it  will  be  right  to  give  some  mild  laxative  to  clear  out  the  bowels. 
There  can  be  none  more  suitable  or  convenient  than  castor  oil.  But  before  we  ven- 
ture upon  purgatives  by  the  mouth  it  will  be  proper  to  wash  out  the  bowels  by 
lavements  of  tepid  water.  These  injections  may  sometimes  have  mechanically  a 
beneficial  effect  upon  the  parts  concerned  in  the  inflammatior) ;  untwisting,  for  ex- 
ample, a  twisted  bowel ;  or  setting  free  the  half-incarcerated  intestine.  It  is  often 
expedient  to  administer  them  through  a  long  tube  passed  as  far  as  possible  into  the 
rectum. 

There  is  one  very  important  point  in  the  treatment  of  enteritis  that  I  have  yet  to 
mention.  I  have  told  you  that  in  the  advanced  stage  of  the  disease  symptoms  of 
sinking  often  come  on ;  a  total  cessation  of  pain,  failure  of  the  vital  powers,  and 
coldness  of  the  body.  These  symptoms,  this  collapse  and  approach  to  syncope,  are 
generally  considered  to  denote  grangrene,  and,  therefore,  a  hopeless  state  of  disease. 
Yet  in  many  cases  which  have  proved  fatal  after  similar  symptoms,  not  a  trace  of 
gangrene  has  been  discoverable.  So  that  this  unpromising  change  in  the  symptoms 
does  not  always  indicate  a  morbid  condition  which  is  necessarily  mortal.  And  if  the 
patients  are  to  be  saved  at  ail,  they  are  to  be  saved  by  wine  and  support.  We  must 
combat  the  obvious  tendency  to  death  by  asthenia. 

"  A  man,  aged  forty,  was  affected  with  enteritis  in  the  usual  form,  for  which  ho 
was  treated  in  the  most  judicious  manner  by  a  respectable  practitioner.  On  the  fifth 
day  the  pain  ceased:  the  pulse  was  140,  and  extremely  feeble  and  irregular;  his 
face  was  pale,  the  features  were  collapsed,  and  his  whole  body  was  covered  with 
cold  perspiration ;  his  bowels  had  been  moved.  In  this  condition  (says  Dr.  Aber- 
crombie,  from  whom  I  quote  the  case)  I  saw  him  for  the  first  time.  Wine  was  then 
given  him,  at  first  in  large  quantities,  and  upon  the  whole,  to  the  extent  of  from  two 
to  three  bottles  during  the  next  twenty-four  hours.  On  the  following  day  his  ap- 
pearance was  improved;  his  pulse  120,  and  regular;  the  wine  was  continued  in 
diminished  quantity.  On  the  third  day  his  pulse  was  112,  and  of  good  strength,  and 
in  a  few  days  more  he  was  well." 

Dr.  Abercrombie  relates  other  cases  to  the  same  effect ;  and  most  physicians,  I 
suppose,  have  occasionally  seen  such.  They  teach  us  that  we  must  not  abandon  our 
patients  in  despair,  even  under  the  most  adverse  circumstances.  If  diarrhoea  should 
supervene  with  this  state  of  collapse,  opiates  must  be  joined  with  the  wine.  External 
warmth  is  also  a  powerful  auxiliary. 

I  know  of  no  cases  of  disease  more  painful  to  witness  or  to  treat  than  those  which 
result  from  invincible  obstruction  of  the  intestinal  lube.  They  are  usually  attended, 
at  length,  with  enteritis ;  but  they  differ  much  in  some  respects  from  what  I  have 
called  idiopathic  enteritis.  The  inflammation  is  an  accident  or  consequence  of  the 
obstruction  ;  or  of  the  means  used  to  overcome  it.  They  happen  usually  somewhat 
in  this  manner.  A  person  thinks  it  expedient  to  take  some  aperient  medicine.  It 
has  no  effect.  He  repeats  the  dose.  It  causes  pain  and  gripings,  and  probably  sick- 
ness also ;  but  still  the  bowels  are  not  moved.  Enemata  are  employed.  They 
bring  away,  perhaps,  some  hardened  feces,  but  there  is  no  further  relief.  Mean- 
while' i-ne  patient  may  have  a  clean  tongue,  a  quiet  pulse,. a  cool  and  soft  skin,  and  a 
supple  and  painless  abdomen.  Purgatives  of  a  more  drastic  kind  are  tried,  but  tried 
.n  vain ;  and  the  physician  is  summoned. 


MECHANICAL    OCCLUSION    OF    THE    INTESTINAL    TUBE.  789 

Now  the  first  thing  which  you  have  to  do,  when  called  to  a  case  of  "  obstruction 
of  the  bowels,"  is  to  search  narrowly  whether  there  be  not  some  unsuspected  exter- 
nal hernia.  All  delicacy  must  be  waived  ;  and  every  part  of  the  body,  where  hernia 
may  possibly  show  itself,  must  be  submitted  to  inspection.  If  none  be  found,  the 
rectum,  and  in  women  the  vagina,  must  be  severally  explored.  Stricture,  or  a 
quarry  of  impacted  feces,  may  possibly  be  detected  in  the  one :  a  uterine  or  other 
tumour,  pressing  upon  the  bowel,  may  perchance  be  felt  through  the  other.  I  shall 
never  forget  the  shock  I  once  experienced  on  being  sent  for  to  see  a  woman,  of  mid- 
dle age,  who  was  in  articulo  mortis,  and  who,  as  I  was  told,  had  for  some  days  been 
labouring  under  sickness,  pain  in  the  abdomen,  and  constipation.  In  her  left  groin 
there  was  a  large  palpable  strangulated  hernia,  which  had  not  been  detected  by  the 
practitioner  in  attendance,  simply  because  it  had  not  been  looked  for ;  and  which  was 
discovered  only  when  it  was  too  late. 

Remember,  therefore,  that  in  every  case  of  obstinate  costiveness,  with  signs  of 
inflammation  within  the  abdomen,  it  is  absolutely  necessary,  for  y,our  own  credit  and 
subsequent  comfort,  as  well  as  for  your  patient's  safety,  to  make  diligent  and  thorough 
inquiry  after  such  hernia  as  may  be  recognized  externally. 

But  often  you  find  nothing  of  the  sort,  and  then  you  are  at  liberty  to  prosecute 
with  more  energy  and  decision  the  purgative  plan  ,of  treatment.  You  prescribe 
strong  doses  of  jalap  and  calomel ;  black  draughts.  The  stomach  being  irritable, 
you  give  pills  of  cathartic  extract,  and  repeat  them  at  short  intervals  ;  or  large  doses 
of  calomel,  ten  grains  or  a  scruple,  three  or  four  times  in  succession.  You  inject 
stimulating  clysters.  Then  you  are  driven  to  croton  oil :  and  at  last,  in  some  vague 
hope  of  relaxing  spasm,  to  opiates.  If  symptoms  of  inflammation  spring  up,  you 
put  fairly  in  force  the  remedies  of  inflammation  ;  and  especially  blood-letting.  But 
all  is  in  vain.  The  medicines  are  vomited  ;  or,  if  retained,  they  serve  but  to  aug- 
ment the  patient's  distress,  producing  or  renewing  the  pain  and  the  nausea.  It  is 
extraordinary  how  comfortable  the  patient  sometimes  becomes  upon  the  intermission 
of  these  active  attempts.  Now  and  then  he  suffers  tormina,  or  has  fits  of  retching; 
but  in  the  intervening  periods  his  sensations  and  outward  condition  may  be  those  of 
perfect  health ;  only  there  is  no  alvine  discharge. 

Now,  under  these  afflicting  circumstances,  the  question  will  force  itself  upon  you 
—-how  long  am  I  to  pursue  the  purgative  system?  Common  sense,  and  commorr 
humanity,  answer — you  must  stop  it  the  instant  you  are  convinced  that  there  is  a 
mechanical  obstacle,  which  cannot  be  overcome.  To  persist  in  the  use  of  drastic 
purgatives  after  that  conviction,  is  to  inflict  wanton  and  needless  torture  upon  the 
patient.  But  how  are  you  to  know  this  ?  That  is  one  difficulty.  And  how  are 
you,  beheving  that  it  is  so,  to  satisfy  the  patient's  friends  that  his  disorder  is  irreme- 
diable ;  and  to  resist  their  importunity  to  try  this  and  that :  how  persuade  them  to 
look  passively  on,  while  their  relative  is  slowly  perhaps,  but  surely,  perishing? 
These  are  great  and  terrible  difficulties. 

You  will  be  urged  by  all  imaginable  suggestions  :  even  the  most  absurd.  Crude 
mercury  may  perhaps  be  one.  Pounds  of  this  metal  have  been  swallowed  in  such 
cases ;  in  the  hope,  I  suppose,  that  it  would  force  a  passage  by  its  weight.  But  the 
obstacle  may  be  in  an  ascending  coil  of  intestine.  And  if  not,  experience  does  not 
teach  us  to  put  any  faith  in  this  rude  mechanical  remedy.  It  has  often  done  mis- 
chief, and  seldom  or  never  done  any  good.  The  metal  is  apt  to  become  oxidized  in 
the  body,  and  then  to  produce  very  distressing  salivation.  This  is  an  evil  which  I 
have  known  to  occur,  and  to  trouble  the  patient  greatly,  some  time  after  the  ineffect- 
ual exhibition  of  large  doses  of  calomel. 

Dashing  cold  water  over  the  abdomen,  and  the  lower  extremities,  is  another  i-nugii 
expedient,  which  is  sometimes  successful  in  producing  evacuations.  It  was  adopted, 
after  various  other  measures  had  failed,  in  the  case  in  which  the  bowel  was  tied 
down  by  the  adherent  appendix  vermiformis  ;  and  it  caused  the  empiymgot  that  part 
of  the  canal  which  lay  beyond  or  below  the  internal  hernia.  It  is  plain  that  this 
partial  success  can  be  of  little  or  no  use  ;  certainly  of  none  that  can  compensate  for 
the  shock  and  annoyance  of  the  cold  affusion. 

Let  me  not,  however,  be  misunderstood.     I  do  not  say  that  you  are  to  aDanaon  ail 


790     MECHAMCAL  OCCLUSION  OF  THE  INTESTINAL  TUBE. 

hope  when  purgatives  (and,  if  need  be,  blood-letting)  have  failed,  after  a  fe\v  trials, 
to  obtain  evacuations  from  the  bowels.  Nor  even  that  you  are  necessarily,  for  that 
reason,  to  give  up  the  use  of  purgatives.  The  intestines  may  be  torpid  and  insen- 
sible to  ordinary  stimuli,  and  really  require  strong  rousing.  Dr.  Abercrombie  men- 
tions the  case  of  a  gentleman  whose  bowels  were  locked  up  by  an  accumulation,  as 
the  result  showed,  of  black  hardened  feces.  The  obstruction,  which  had  resisted 
the  most  active  purgatives,  and  was  accompanied  by  an  evident  and  painful  disten- 
sion of  a  part  of  the  abdomen,  yielded  at  once  to  the  repeated  application  of  galva- 
nism to  that  part :  each  application  being  immediately  followed  by  a  copious  evacua- 
tion. Here  the  flagging  muscular  action  was  restored  apparently  by  the  galvanic 
stimulus.  Very  lately  I  attended  an  elderly  lady,  who  from  Wednesday  morning 
to  the  next  Monday  noon,  had  had  no  alvine  relief,  notwithstanding  the  employment 
of  the  most  active  cathartics.  She  suffered  frequent  paroxysms  of  pain  and  vomiting  : 
but  the  abdomen  was  scarcely,  if  at  all,  distended  ;  nor  was  it  tender.  At  length  she 
complained  that  what  she  vomited  was  stercoraceous — to  use  her  own  words,  "what 
came  upwards  ought  to  have  passed  the  other  way."  It  was  a  thin,  brown-coloured, 
ill-smelling  fluid.  Dr.  Mayo  and  Mr.  Arnott  were  now  associated  with  me  in  this 
case,  and  they  touched  and  felt  the  abdomen  as  I  had  previously  done.  The  lady 
observed  that  their  hands  were  heavy;  and  she  fancied  that  the  pressure  they  made 
had  displaced  something  within.  And  I  believe  that  it  was  so:  for  before  our  consul- 
tation in  the  next  room  was  over,  word  was  brought  us  that  the  bowels  had  acted. 
She  had  passed  a  liquid  motion  precisely  resembling  the  stuff  she  had  last  vomited. 
The  next  day,  with  one  of  several  similar  stools,  a  hard  lump  was  voided,  which 
proved  to  be  a  gall-stone,  as  big  as  a  small  walnut. 

As  large  quantities  of  warm  water  had  without  difficulty  been  injected,  I  infer  that 
the  concretion  had  been  impacted  high  up  in  the  bowel,  probably  at  the  valve  of  the 
cajcum.  Some  years  previously  the  lady  had  suffered  severe  abdominal  pains, 
which  at  the  time  were  ascribed  to  the  passage  of  a  biliary  calculus  through  the 
gall-ducts. 

In  this  instance  there  was  no  evidence  of  any  strong  contractile  efforts  of  the  bowel 
above  the  place  of  obstruction. 

Large  enemata — as  much  as  the  intestines  will  patiently  receive — gradually  and 
gently  introduced,  and  repeated  three  or  four  times  a  day,  may  sometimes  succeed 
in  breaking  down  and  washing  away  masses  of  hardened  excrement.  And  if  these 
enemata  are  composed  of  milk  or  beef-tea,  and  are  suffered  to  remain  as  long  as  they 
will,  they  may  answer  another  important  purpose;  they  may  contribute  sensibly  to 
the  nourishment  of  a  patient  who  cannot  retain  food  in  his  stomach.  They  are 
generally  very  soothing  and  comfortable ;  allaying  tormina,  and  abating  sickness : 
and  they  are  adapted  to  every  stage  and  variety  of  the  complaint. 

There  are,  however,  cases  in  which  we  arrive  at  the  melancholy  but  sure  convic- 
tion that  some  mechanical  impediment  has  rendered  the  bowel  absolutely  and  hope- 
lessly impassable.  We  fear  this  when,  the  constipation  being  obstinate,  we  discover 
a  tumour,  or  hardness,  in  some  part  of  the  belly :  or  when  we  receive  a  history  of 
some  former  inflammatory  attack,  since  which  the  bowels  have  been  habitually  diffi- 
cult to  regulate.  Our  fears  are  strengthened  when  the  patient  feels  that  the  injec- 
tions reach  a  certain  spot,  and  there  always  stop ;  and  that  the  intestines  rumble, 
and  roll,  and  propel  their  contents  downwards  to  the  same  spot,  and  no  further. 
And  this  is  the  distinctive  symptom  upon  which  I  desire  to  fix  your  attention.  The 
abdomen  gradually  enlarges,  especially  if  the  patient  is  able  to  retain  food.  The 
intestines  fill  up  above  the  obstacle ;  and  then  throes  of  pain  occur,  spasms  the  suf- 
ferers usually  call  them,  attended  with  sickness ;  and  during  these  pangs  you  may 
feel,  and  if  the  abdomen  be  uncovered,  you  may  see,  immense  coils  of  intestine,  as 
big  perhaps  as  one's  arm,  rise  and  roll  over,  like  some  huge  snake,  with  loud  roar- 
ings and  flatulence.  When  this  takes  place,  the  time  for  giving  purgatii-es  is  cer- 
tainly over.  The  distended  bowel  requires  no  stimulus  ;  it  acts,  and  strives  with  all 
its  power,  but  strives  in  vain,  to  overcome  the  opposing  barrier.  If  you  would  con- 
sult your  patient's  ease,  if  you  would  not  embitter  and  abbreviates  his  slender  rem- 
nant of  life,  harass  him  no  further  with  active  remedies.     In  some  cases  violent 


COLIC.  791 

.nflammation  quickly  supervenes,  and  death  arrives  in  a  few  days :  in  others,  the 
patient  survives,  without  any  evacuation  from  his  bowels,  but  with  long  intervals 
of  ease  and  comfort,  for  four,  or  five,  or  six  weeks.  Even  a  brief  respite  may  be  of 
infinite  value ;  giving  time  for  the  arrival  of  distant  friends — for  the  settlement  of 
worldly  concerns — and  for  preparation  of  the  spirit  against  the  inevitable  hour. 

It  is  to  these  circumstances  of  irremediable  disease  that  opiates  are  eminently 
adapted.  Even  when  the  symptoms  are  less  desperate,  they  are  not  without  their 
use.  I  cannot  better  express  what  I  think  upon  this  point  than  in  the  words  of  the 
first  Heberden,  who  says :  "  The  probability  of  advantage  from  anodynes  has  deter- 
mined me  to  recommend  them;  and  experience  has  strongly  confirmed  this  judg- 
ment. Under  the  protection  of  an  opiate  I  have  successfully  given  more  and  stronger 
purges  than  v/ould  have  stayed  without  its  help.  The  patient's  strength  has  been 
kept  up  by  some  refreshing  sleeps :  and  even  in  hopeless  cases,  in  which  the  dying 
person  is  harassed  by  unspeakable  inquietude,  he  may  be  lulled  into  some  compo- 
sure ;  and  without  dying  at  all  sooner,  may  be  well  enabled  to  die  more  easily. 
Lord  Verulam  blames  physicians  for  not  making  the  euthanasia  a  part  of  their 
studies :  and  surely,  though  the  recovery  of  the  patient  be  the  grand  aim  of  their 
profession,  yet,  where  that  cannot  be  obtained,  they  should  try  to  disarm  death  of 
some  of  its  terror :  and  if  they  cannot  make  him  quit  his  prey,  and  the  life  must 
be  lost,  they  may  still  prevail  to  have  it  taken  away  in  the  most  merciful  manner." 

1  have  spoken  of  these  cases  as  being  irremediable :  but  perhaps  I  have  spoken 
somewhat  too  absolutely.  Life  may  sometimes  be  saved  by  a  surgical  operation. 
The  gut  may  be  punctured  above  the  seat  of  obstruction,  and  suffered  to  discharge 
its  contents  through  what  is  called  an  artificial  amis.  This  expedient  is  feasible, 
however,  in  those  cases  07ily  in  which  the  obstacle  is  situated  near  the  termination 
of  the  large  intestine ;  i.  e.,  in  the  rectum,  or  in  the  lower  part  of  the  descending 
colon  :  for  here  only  can  we  ascertain,  with  any  thing  like  certainty,  the  exact  place 
of  the  impediment,  and  here  only  may  the  colon  be  pierced,  from  behind,  without 
injury  to  the  peritoneum.  Under  no  other  circumstances,  in  my  opinion,  would  an 
attempt  to  reheve  the  patient,  by  cutting  down  upon  and  opening  the  bowel,  be  justi- 
fiable. An  artificial  outlet  in  the  loin  would  probably  be  less  disgusting  to  the  pa- 
tient, and  less  offensive  to  others,  than  if  it  were  in  front  of  the  body.  I  am  not 
aware  that  the  operation  has  ever  been  done  in  this  country.  It  has  been  practised 
successfully  in  France.  The  mode  of  performing  it  I  am  not  competent  to  teach 
you.  In  an  appropriate  case  I  should  think  it  right  to  mention,  though  I  should  be 
slow  to  recommend,  this  anceps  remedium.  The  risk  of  failure,  and  the  penalty  of 
success,  should  both  be  set  fairly  before  the  patient.  The  choice  between  certain 
death,  on  the  one  hand,  and  the  chance  of  living  with  a  very  loathsome  bodily 
infirmity,  on  the  other,  must  be  made  by  himself. 

For  further  information  upon  this  subject,  I  would  refer  you  to  an  interesting  essay, 
by  Mr.  Erichsen,  published  in  the  28th  volume  of  the  Medical  Gazette. 

It  remains  that  I  should  say  something  more  respecting  colic:  which  may  exist 
independently  of  enteritis,  and  of  mechanical  occlusion  of  the  bowel ;  although  the 
three  are  very  often  combined  and  intermixed  in  the  course  of  the  same  disease. 

In  colic  there  is  pain  in  the  abdomen,  constipation  of  the  bowels,  vomiting  often  : 
and  these  are  symptoms  which  occur  also  in  enteritis.  The  pain  is  a  twisting  or 
wringing  pain  generally,  round  the  navel ;  and  such  is  the  character  of  the  exacer- 
bations of  pain  experienced  when  the  bowels  are  inflamed.  These  are  the  points 
of  resemblance  between  the  two  maladies :  and  it  is  of  much  importance,  as  1  told 
you  before,  to  observe  their  differences  ;  and  to  note  the  marks  by  which  the  one 
may  be  distinguished  from  the  other.  It  is,  then,  an  essential  difference  that  enteritis 
is  attended  with  fever,  and  with  tenderness  of  the  belly.  The  pain  is  increased  by 
all  kinds  and  every  degree  of  pressure  ;  and  the  patient,  fixed  in  the  supine  position, 
breathes  with  the  intercostal  muscles  only,  and  carefully  avoids  any  movement  whicli 
would  call  the  abdominal  muscles  into  action,  and  so  "^rimpress  the  inflamed  bowel. 
In  colic,  on  the  other  hand,  the  circulation  is  tranquil ;  there  Js  no  fever ;  and  the 
pain  is  even  mitigated  by  pressure.     The  patient  will  lie  on  his  belly  lor  ease  :  nay, 


792  COLICA    PICTONUM 

he  will  press  it,  with  the  whole  weight  of  his  body,  across  the  back  of  a  chair,  and 
obtain  comfort  by  that  manoeuvre.  During  the  paroxysms  the  pain  is  often  most 
violent :  what  the  old  writers  call  dolor  atrox — atrocious  pain  :  but  there  are  inter- 
vals of  complete  ease.  Even  when  the  pain  is  worst,  the  patient  tosses  and  shifts 
from  one  posture  to  another  in  search  of  relief:  and  he  does  not  wear  that  anxious 
and  apprehensive  aspect  which  we  see  in  those  who  are  labouring  under  enteritis. 
The  pain  arises,  I  imagine,  from  the  distension  of  the  bowel,  here  and  there,  by  gas  ; 
or,  it  may  be,  from  spasm ;  or  from  both  these  states  at  once.  At  any  rate,  it  is 
often  associated  with  audible  flatulence,  and  with  evident  outward  spasm.  The 
abdomen  is  hard,  and  drawn  spasmodically  inwards  towards  the  vertebral  column ; 
and  its  muscles  are  partially  and  strongly  contracted,  gathered  up  into  lumps  and 
knots.     None  of  these  circumstances  belong  to  enteritis. 

However,  there  is  good  reason  for  believing  that,  even  in  mere  colic,  the  pain  may 
sometimes  be  augmented  by  pressure.  When  a  portion  of  the  gut  has  become 
rapidly  distended,  considerable  uneasiness  may  result  from  its  forcible  compression; 
although,  as  Dr.  Abercrombie  states,  the  kind  of  pain  can  generally,  by  attention, 
be  distinguished  from  the  sensitive  tenderness  of  an  inflamed  peritoneum. 
Luckily,  if  such  pain  on  pressure  should  lead  us  to  mistake  a  case  of  pure  colic  for 
a  case  of  enteritis,  the  error  is  on  the  safe  side  :  and  we  must  always  bear  in  mind 
the  tendency  remarked  in  colic,  when  the  complaint  is  neglected,  or  badly  treated, 
to  run  into  actual  inflammation.  In  fact,  as  any  obstacle  to  the  passage  of  the  ali- 
mentary matters  through  the  bowels  may  give  rise  to  colic,  colic  is  sometimes  merely 
the  first  step  towards  acute  inflammation  arising  out  of  a  continuance  of  the  obstruc- 
tion. And  having  told  you  that  colic  may  be  thus  produced,  I  have  at  once  intro- 
duced you  to  a  large  class  of  its  causes  which  have  already  been  spoken  of  in  the 
present  lecture  as  frequent  causes  of  inflammation  also. 

But  colic,  like  inflammation  of  the  bowels,  sometimes  arites  without  any  appa- 
rent or  detectable  obstruction,  of  a  mechanical  kind,  to  the  free  transit  of  the  contents 
of  the  alimentary  tube.  And  there  is  one  particular  form  of  colic  that  requires  a 
separate  notice.  The  colica  Pictonum — so  called  from  its  great  frequency,  hereto- 
fore, among  the  Pictones,  or  inhabitants  of  Poictou — is  produced  by  the  slow  intro- 
duction of  the  poison  of  lead  into  the  system.. 

Now,  the  colic  which  has  this  origin  is  not  to  be  distinguished,  in  its  ordinary 
symptoms,  from  any  other  kind  of  colic.  But  the  abdominal  pain  is  usually,  in  such 
cases,  a  part  only  of  more  general  disease.  It  has  received,  in  different  places,  a 
variety  of  names — colica  Pictonum,  the  painter's  colic,  the  Devonshire  colic,  the 
bfUain  of  Derbyshire,  the  dry  belly-ache  of  the  West  Indies.  In  all  cases  it  acknow- 
ledges the  same  cause — the  gradual  entrance  of  lead  into  the  body. 

In  this  country,  we  see  the  disease  more  often  in  painters  than  in  any  other  per- 
sons. They  use,  as  you  know,  white  lead  in  the  preparation  of  their  colours ;  and 
they  are  perfectly  familiar  with  this  terrible  cohc.  We  see  it,  also,  in  all  workmen 
whose  occupations  bring  them  habitually  into  contact  with  preparations  of  lead.  No 
doubt  there  are  very  great  differences  in  the  susceptibility  of  this  effect  of  the  poison 
of  lead.  Persons  have  been  known  to  suffer  colica  Pictonum,  in  consequence  of 
their  sleeping  for  a  night  or  two  in  a  recently  painted  room.  On  the  other  hand,  I 
have  myself  seen  a  patient  who  became  affected  with  the  disease,  for  the  first  time, 
after  working  with  white  lead  for  nineteen  years.  Generally  the  first  attacks  of  colic 
are  well  recovered  from.  The  obstinate  constipation  of  the  bowels  is  at  length  over- 
come ;  the  patient  obtains  ease,  and  forthwith  recurs  to  his  previous  habits ;  and  after 
a  period,  which  varies  in  different  individuals,  he  is  again  laid  up  with  the  cohc. 
Even  the  primary  attacks  are  usually  attended  with  pains  in  the  head,  and  in  the 
limbs ;  sometimes  with  cramps ;  sometimes  even  with  epilepsy  and  coma.  At 
length,  in  one  of  these  attacks  of  colic,  or  after  one  of  them,  when  the  violence  of 
:he  pain  and  the  costiveness  have  yielded  to  treatment,  the  patient  finds  that  he  has 
lost  the  full  power  of  using  one  or  both  of  his  hands.  The  wrists,  as  the  patients 
express  it,  drop.  You  see  at  once  what  is  the  matter,  by  the  characteristic  state  of 
the  arms  and  hands.  The  extensor  muscles  of  the  hands  and  fingers  are  palsied ; 
so  that,  when  the  arms  are  stretched  out,  the  hands  hang  dangling  down  by  their 


COLICA    PICTONUM.  793 

own  weight,  and  the  patient  is  unable,  by  any  effort  of  his  will,  to  raise  them.  The 
palsy  is  local ;  it  does  not  proceed  from  any  diseased  condition  of  the  nervous  cen- 
tres. The  affected  muscles  waste,  and  the  atrophy  is  very  remarkably  seen  in  the 
bundle  of  muscles  composing  the  ball  of  the  thumb.  Even  from  this  condition,  the 
patients  often  are  capable  of  complete  recovery.  But  if  they  persist  in  following  their 
former  calling — or  if,  without  knowing  it,  they  continue  to  be  habitually  exposed  to 
the  exciting  cause  of  the  disease — they  become  miserable  cripples,  fall  into  a  state 
of  general  cachexia,  and  sink  at  length  under  some  visceral  disease.  The  poison 
accumulates  in  the  body,  and  saps  the  powers  of  life.  Francis  Citois,  a  native  of 
Poictou,  who  published  an  excellent  and  one  of  the  earliest  accounts  of  the  disease, 
in  the  year  1617,  has  drawn  the  follovving  graphic  picture  of  its  effects.  Its  cause 
was  not  at  that  time  suspected.  Speaking  of  the  wretched  sufferers,  he  says,  "Per 
vicos,  veluti  larvos,  aul  arte  progredientes  statuse,  pallidi,  squalidi,  macilenti  conspici- 
untur;  manibus  incurvis,  et  suo  pondere  pendulis,  nee  nisi  arte  ad  os  et  coeteras 
supernas  partes  sublatis,  et  pedibus  non  suis  sed  crurum  musculis,  ad  ridiculum  ni 
miserandum  incassum  compositis,  voce  clangosa  et  strepera." 

The  course  of  the  disease  is  usually  such  as  I  have  just  described  it.  The  colic 
happens  first,  perhaps  several  times,  and  then  arrives  the  palsy.  But  in  a  few 
instances  I  have  known  this  order  reversed.  The  wrists  have  dropped,  when  there 
tiad  been  no  preceding  colic. 

The  great  cause  of  this  fearful  malady  Avas  first  made  out  by  our  distinguished 
countryman.  Sir  George  Baker.  He  set  on  foot  an  inquiry  into  the  origin  of  what 
was  called  the  Devonshire  colic,  so  common  was  it  in  that  county.  He  found,  first, 
that  it  occurred  chiefly  in  persons  who  drank  the  cider  manufactured  there ;  and,  by 
degrees,  he  traced  the  source  of  the  malady  to  the  admixture  of  lead  with  the  cider ; 
cither  designedly,  for  the  purpose  of  sweetening  it,  or  by  the  inadvertent  employment 
of  lead  in  the  construction  of  the  cider-mills  and  vats.  It  was  under  circumstances 
of  the  same  kind  that  the  colic  of  Poictou  originated.  Preparations  of  lead  were 
used — not  fraudulently,  but  openly  and  honestly — to  prevent  the  wines  of  the  coun- 
try from  turning  sour;  the  injurious  influence  of  lead  upon  the  human  body  not 
having  then  been  ascertained.  So,  also,  equally  convincing  proofs  of  the  adultera- 
tion of  rum  by  means  of  lead,  giving  rise  to  frequent  attacks  of  dry  belly-ache,  in 
the  West  Indies,  are  given  by  Dr.  John  Hunter,  in  the  Medical  Transactions.  I 
invite  your  attention  to  his  papers,  and  to  Sir  George  Baker's,  on  this  subject.  They 
afford  a  capital  specimen  of  medical  research  and  reasoning.  Various  causes,  as  you 
may  suppose,  had  been  assigned  for  this  disorder.  These  are  one  by  one  investi- 
gated and  set  aside,  until,  by  this  method  of  exclusion,  the  real  source  of  all  the  mis- 
chief is  detected.  Sir  George  Baker's  papers  contain  a  great  deal  of  curious  and 
useful  information  in  respect  to  the  various  modes  in  which  this  poison  of  lead  may 
find  its  way,  without  being  suspected,  into  the  animal  economy.  The  subject  is  one 
of  vast  importance  in  its  relation  to  medical  police ;  but  my  limits  will  not  allow  me 
to  follow  it  beyond  the  point  where  it  ceases  to  be  directly  connected  with  the  prac- 
tice of  physic. 

Colica  Pictonum  is  seldom  fatal  as  colic,  or  during  the  persistence  of  the  abdomi- 
nal symptoms ;  yet  instances  enough  of  death  occurring  while  the  colic  was  present, 
but  from  other  accidental  causes,  have  now  been  collected,  to  enable  us  to  say,  that 
no  appearances  have  been  met  with  in  the  intestinal  canal,  calculated  to  explain  the 
pain  or  the  constipation.  Andral  relates  five  cases,  in  which  the  body  was  carefully 
examined  after  death  preceded  by  the  painter's  colic.  He  found  neither  inflamma- 
tion, nor  any  remaining  trace  of  spasm.  The  intestines  were  neither  dilated  no' 
contracted,  but  of  their  natural  texture  and  appearance.  Merat,  who  has  written  t. 
good  treatise  on  this  form  of  colic,  gives  the  dissections  in  four  fatal  cases  :  fatal,  as  I 
mentioned  that  they  sometimes  are,  by  the  supervention  of  coma.  There  was  no 
discoverable  mark  of  disease  ;  the  alimentary  canal  was  -empty,  and  the  large  bowels 
contracted  ;  as  they  were  also  found  to  be  in  rabbits  which  had  died  of  lead  colic. 
For  animals  are  susceptible  of  the  disease,  and  it  ma}''  be  produced  in  them  by  the 
slow  impresrnation  of  their  bodies  with  the  specific  poison.  Dogs,  cats  and  rats,  thai 
inhabit  houses  and  manufactories  wherein  lead  is  much  used  or  prepared,  are  known 

3r 


7D4  COLICA    PICTONUM. 

to  be  attacked  both  with  colic  and  with  palsy.  With  respect  to  the  contraction  of  tiie 
large  intestines  in  these  cases,  we  must  not  be  too  ready  to  attribute  it  to  spasm ;  for 
the  bowel,  when  empty,  is  apt  to  be  contracted. 

When  the  palsy  has  been  of  any  continuance,  the  affected  muscles  not  only  shrink 
and  waste,  but  undergo  a  structural  change,  which  is  obvious  to  the  sight.  They 
become  pale,  almost  white,  dry.  John  Hunter  examined  the  muscles  of  the  hand 
and  arm  of  a  house-painter,  who  died,  while  thus  paralytic,  in  St.  George's  Hospital. 
He  found  them  of  a  cream  colour,  and  opaque,  instead  of  being  of  a  purplish  red, 
and  semi-transparent.  And,  since  his  time,  lead  has  been  detected  in  the  palsied 
muscles,  and  in  the  brain,  by  chemical  analysis.  It  is  doubtless  conveyed  by  the 
blood  to  all  parts  of  the  body.  Why  it  fastens  solely  or  chiefly  on  particular  mus- 
cles or  particular  nerves,  nobody  knows.  The  pain  it  occasions,  whether  in  the 
abdomen  or  in  the  hmbs,  is  generally  thought  to  be  neuralgic.  It  is  one  of  the  poi- 
sons that  do  not  appear  to  find  a  ready  exit  from  the  body.  Very  recently,  a  most 
curious  symptom,  pathognomonic,  I  believe,  of  the  presence  of  lead  in  the  system,  has 
been  pointed  out  by  Dr.  Burton  ;  and  now  that  it  has  been  pointed  out,  one  can 
hardly  understand  how  it  escaped  discovery  so  long.  It  is  a  blue  or  purplish  line 
running  along  the  edges  of  the  gums,  just  where  they  meet  the  teeth.  Dr.  Burton 
first  noticed  this  six  years  ago,  but  wisely  refrained  from  making  his  observations 
public  until  he  had  had  time  and  opportunity  enough  to  satisfy  his  mind  that  he  was 
not  mistaken.  A  paper  of  his  on  the  subject  was  read  at  the  Medical  and  Chirur- 
gical  Society  last  January  (1840).  I  cannot  resist  the  temptation  to  read  to  you  the 
notes  of  a  case  which  has  subsequently  occurred  to  me  in  the  hospital.  Mary  Anne 
Davis,  a  middle-aged  woman,  presented  herself  with  dropped  wrists.  It  was  an 
exquisite  example  of  palsy  of  the  extensor  muscles  of  the  hands  and  fingers.  She 
could  raise  her  arms,  but  her  hands  hung  down  like  the  talons  of  a  bird,  or  like  the 
fore  paws  of  an  erect  kangaroo.  This  began  nine  weeks  before.  She  complained 
of  pain,  beginning  under  the  nails,  stretching  up  the  backs  of  her  hands,  and  reach- 
ing sometimes  to  the  elbows.  The  bottoms  of  her  feet  had  also  been  tender,  and  at 
night  were  burning  hot. 

Seeing  the  dropped  wrists,  we  thought  immediately  of  the  poison  of  lead.  But 
the  patient  was  a  female.  We  do  not  often  see  these  effects  of  that  poison  in  women  ; 
for  obvious  reasons.  At  first  we  could  get  no  clue  to  the  mode  in  which  lead  could 
have  found  its  way  into  her  system.  Her  husband  was  a  broker.  She  had  not 
been  living  in  a  newly-painted  house :  and  had  (she  said)  no  concern  with  lead  in 
any  way.  Lead  often  creeps  in,  however,  through  undetected  channels,  and  I  could 
not  help  suspecting  it  here.  Mr.  Pyper,  my  clinical  assistant,  soon  elicited  another 
part  of  her  history,  which  added  to  our  suspicions ;  namely,  that  before  the  palsy 
occurred,  she  had  had  pains  in  the  abdomen,  and  costive  bowels,  for  five  days  toge- 
ther. Nay,  she  had  a  recurrence  of  colic  after  her  admission.  This  was  a  strongly 
corroborating  fact;  but  what  clenched  the  proof  was  the  discovery  of  a  decided  blue 
rim  along  the  edges  of  nearly  ail  her  gums.  This  conclusive  evidence  led  to  further 
cross-examination ;  and  at  last  it  came  out  that  some  of  her  sons  (she  had  seven)  had 
occupied  their  leisure  time  in  the  preceding  summer  with  making  bird-cages,  and 
painting  them  green,  in  the  one  room  in  which  she  habitually  lived.  The  case  alto- 
gether was  a  very  neat  one. 

Mr.  Tomes  pointed  out  to  me  some  interesting  circumstances,  which  led  him,  at 
one  time,  to  think  it  probable  that  the  colour  might  be  produced  by  some  chemical 
action  between  the  tartar  that  forms  on  the  teeth,  where  they  meet  the  gums,  and 
the  lead  which  pervades  the  system.  This  woman's  teeth,  like  those  of  man)^  in 
her  rank  of  life,  were  loaded  with  tartar.  In  one  place  was  visible  a  stump,  level 
with  the  gum,  and  surrounded  by  a  ring  of  tartar;  and  there  was  also  a  correspond- 
ing border  of  blue.  In  other  places  there  were  gaps,  where  teeth  once  were ;  here 
there  was,  of  course,  no  tartar;  and  here  there  was  no  blue  line  on  the  edge  of  the 
gum  The  blueness  may  however  appear  when  there  is  no  tartar  at  all.  I  do  not 
know  exactly  m  what  manner  the  chemical  union  arises,  but  the  colour  depends,  I 
beheve,  upon  a  sulphuret  of  lead,  formed  somehow  by  the  action  of  sulphuretted 
hydrogen  upon  the  metal.     It  is  curious  that  the  edge  of  the  gum  should  always  be 


COLICA    PICTONUM.  795 

the  part  thus  marked ;  that  very  part  which  first  exhibits  the  influence  of  another 
metal,  mercury,  when  ptyalism  is  about  to  ensue. 

This  discovery  of  Dr.  Burton's  is  not  a  mere  piece  of  curiosity,  but  is  likely  to 
be  of  use  in  various  ways.  In  the  first  place,  it  may  settle  the  nature  and  cause  of 
many  doubtful  cases;  as  it  did,  indeed,  of  the  one  just  narrated.  The  poison  of 
lead  produces  pains  which  resemble,  und  no  doubt  are  sometimes  mistaken  for,  the 
pains  of  rheumatism;  it  has  other  obscure  consequences  too:  and  an  inspection  of 
the  gums  may  often  greatly  elucidate  such  cases.  Dr.  Burton  finds  that  small 
quantities  of  lead  given  as  a  medicine  will  produce  the  phenomenon.  In  two  in- 
stances it  occurred  within  two  days.  One  of  these  patieiid^iad  taken  fifteen  grains 
of  the  acetate  of  lead  in  that  time ;  the  other  twenty-four  grains.  A  correspondent 
of  his  produced  the  blue  rim  in  twenty-four  hours  ;  viz.,  by  four  doses,  of  five  grains 
each,  exhibited  every  six  hours.  He  finds  too  that  the  line  remains  distinct  after 
death  ;  even  more  so  than  during  life.  It  may  atford  valuable  inibrraution  therefore 
to  the  medical  jurist  in  cases  of  suspected  poisoning  with  the  salts  of  lead.  It  is,  I 
say,  an  early  consequence  of  the  absorption  of  lead.  It  will  teach  us,  as  the  mercu- 
rial affection  of  the  gums  teaches  us,  that  the  medicine  is  pervading  the  system  ;  and 
admonish  us  to  look  out  for,  and  guard  against,  colic.  It  may  apprise  workers  in 
lead  that  their  caution  has  been  insufficient ;  that  the  poison  has  entered  ;  and  that 
they  are  in  peril  of  belly-aches  and  palsy.  It  is  a  capital  diagnostic  sign  also  be- 
tween colic  so  arising,  and  colic  from  other  causes ;  and  between  cohca  Pictonum, 
and  the  pain  of  inflammation  of  the  bowels. 

[The  symptoms  of  colica  pictonum,  or  lead  colic,  are  in  some  respects  different  from  those 
of  ordinary  colic.  There  is  usually,  at  first,  a  loss  of  appetite,  ^vith  some  degree,  more  or 
less  in  different  cases,  of  nausea,  and  very  commonly  an  increased  discharge  of  saliva.  The 
patient's  sleep  is  disturbed,  or  more  frequently,  there  is  an  inability  to  sleep  ;  according  to 
M.  Ranque,  of  Orleans,  he  exhibits  various  other  symptoms  of  a  disordered  condition  of  the 
nervous  system.  The  attack  of  colic  usually  commences  with  vomiting ;  the  matter  dis- 
charged being,  at  first,  whatever  has  been  taken  into  the  stomach  mixed  with  bile  and  the 
gastric  secretions,  very  generally  changed  from  their  healthy  condition;  if  the  vomiting  con- 
tinue, these  latter  are  alone  discharged.  Pain  of  the  abdomen  is  next  complained  of;  it  is 
most  severe  about  the  navel,  the  epigastrium,  the  hypochondria,  the  loins,  and  above  the  crest 
of  the  ileum.  The  pain,  in  general,  commences  at  the  hypogastric  region,  or,  as  a  cramp,  at 
the  pit  of  the  stomach,  and  from  thence  extends,  in  a  short  time,  over  the  rest  of  the  abdo- 
men. The  pain  is  at  first  paroxysmal,  with  intervals  of  ease ;  these  intervals  being  the 
longest  at  the  commencement  of  the  attack.  More  commonly  there  occur  remissions  ratlier 
than  intermissions  of  the  pain;  and  it  is  remarked,  that  both  the  remissions  and  exacerba- 
tions are  much  longer  than  those  of  ordinary  colic.  As  the  disease  advances  the  pain  is 
almost  constant,  but  is  usually  most  severe  at  night.  It  is  not  increased  by  pressure;  on  the 
contrary,  pressure  very  generally,  but  not  invariably,  affords  relief,  provided  it  be  not  made 
upon  the  epigastrium  ;  according  to  Merat,  patients  have  been  known  to  bear,  with  relief  JD 
tlie  paroxysms,  the  weiglit  of  two  or  tliree  persons  standing  on  the  belly.  The  abdomen  is 
almost  invariably  hard  and  flat  from  a  contraction  of  its  niuscles ;  the  navel  is  sometimes 
drawn  in  so  as  almost  to  approach  the  spine;  in  a  kw  instances  there  exists  some  fiUlness  of 
the  abdomen,  and  occasionally  it  has  an  irregular,  knotty  feel.  There  generally  occur,  within 
the  first  day  or  two,  sometimes  within  the  first  few  hours  of  the  attack,  headache,  and  a  dull, 
anxious,  or  depressed  expression  of  the  countenance ;  to  these  symptoms  are  soon  added, 
pains  of  the  limbs,  especially  of  the  inside  of  the  thighs,  calves  of  the  legs,  ankles,  and  soles 
of  the  feet;  these  pains  are  worst  at  night;  they  are  often  accompanied  with  cramps,  and 
according  to  Tanquerel,  are  relieved  by  pressure.  The  disease  is  seldom  attended  with  febrile 
excitement.  The  skin  is  of  a  dull,  dirty  cadaverous  appearance ;  it  is  frequently  hot,  and 
almost  invariably  bedewed  with  irregular,  clammy,  and  often  cold,  perspiration.  The  pulse, 
according  to  SIM.  Ranque  and  Merat,  is  rarely  accelerated,  but  often  below  G0°  in  a  minute ; 
others,  however,  notice  a  considerable  acceleration  of  the  pulse,  which  we  have  remarked  in 
many  cases,  the  pulse  being  at  the  same  time  hard,  and  communicating  to  the  finger  a  pecu- 
liar thrill.  Obstinate  constipation  of  the  bowels  is  an  almost  invariable  symptom;  although 
it  does  not  always  occur  at  the  very  commencement  of  the  attack ;  in  a  few  instances,  it  is 
said  that  the  attack  has  been  attended  with  diarrhcea;  such  an  occurrence,  howe'  er,  we  have 
never  observed.  On  the  contrary,  in  all  the  cases  that  have  fallen  under  our  -otice,  either 
no  discharge  has  taken  place  from  the  bowels,  or  a  scanty  stool  has  occurred  composed  of  a 
few  lumps  of  dry,  hardened  feces,  passed  with  much  straining  and  pain.  The  urine, 
though  generally  natural  in  appearance,  is  often  diminished  in  quantity. 

From  an  attack  of  colica  pictonum,  particularly  a  first  attack,  the  patient  may,  under  a 


796  COLICA    PICTONUM. 

judicious  and  timely  treatment,  recover  perfectly ;  and  with  a  careful  avoidance  of  any  oi 
its  exciting  causes,  and  of  the  poison  of  lead,  he  may  remain  ever  after  free  from  a  recur 
rence  of  the  disease.  When  the  disease,  however,  is  neglected,  or  badly  managed,  or  the 
patient  is  constantly  or  repeatedly  exposed  to  the  influence  of  lead,  he  becomes  affected  either 
with  a  peculiar  form  of  partial  palsy,  which  is  well  described  by  Dr.  Watson  in  the  text;  or, 
instead  of  this  gradual  loss  of  voluntary  motion  in  the  muscles  of  the  extremities,  there  occur 
another  set  of  symptoms,  which  very  generally  terzninate  speedily  in  death.  The  patient 
after  a  few  days  becomes  affected  with  giddiness,  great  debility,  torpor,  and  sometimes  deli- 
rium :  as  the  torpor  advances,  the  pains  in  the  abdomen  and  extremities  abate ;  at  length 
convulsions,  and  a  comatose  condition  ensue,  from  which  very  few  recover.  Cases  are 
recorded  by  Louis  and  others,  in  which  death  suddenly  occurred  during  the  first  stage  of  the 
disease,  without  the  occurrence  of  any  symptoms  that  would  cause  such  a  result  to  be  sus- 
pected. Drs.  Elliotson  and  Copland  each  relate  a  case  in  which  death  was  caused  by  per- 
foration of  the  stomach.  To  a  paralytic  affection  of  the  muscles  of  the  extremities,  as  a 
very  common  eftect  of  repeated  attacks  of  colica  pictonum,  we  have  already  referred ;  and 
two  cases  are  related  by  Dr.  Alderson,  of  Hull,  England,  in  which  the  disease  was  attended 
with  paralysis  of  the  nerves  of  vision ;  Tanquerel  states  that  this  is  not  uncommon  in  Paris, 
the  paralysis  being  attended  with  dilated  and  immovable  pupils ;  he  met,  also,  with  one  in- 
stance in  which  deafness  was  present,  no  doubt  from  paralysis  of  the  auditory  nerve. — C  ] 

In  the  treatment  of  colic — and  especially  of  the  lead  colic — the  great  indication  is 
to  get  the  bowels  to  act.  If  the  pain  of  the  belly  be  increased  on  pressure,  if  the 
pulse  be  at  all  accelerated,  if  the  face  be  flushed,  and  there  be  the  shghtest  approach 
to  fever,  it  will  be  right  to  take  blood  from  the  arm.  It  is  a  measure  of  safety  as 
regards  the  possible  existence  of  inflammation :  and  if  there  be  no  inflammation  pre- 
sent or  impending,  it  will  tend  to  remove  the  spasmodic  state  of  the  muscles  which 
goes  along  with,  and  perhaps  chiefly  constitutes,  the  disease.  External  warmth 
should  also  be  applied  ;  dihgent  friction,  with  some  stimulating  liniment ;  or,  what 
is  much  better,  a  mustard  poultice,  or  a  turpentine  stupe.  My  colleague.  Dr.  Wil- 
son, has  been  very  successful  in  relieving  these  patients,  by  putting  them  into  a  hot 
bath,  and  having  a  large  quantity  of  the  water  in  which  they  are  immersed,  thrown 
gradually  into  their  bowels  by  means  of  a  proper  syringe.  The  bath  presently  be- 
comes polluted,  to  the  great  satisfaction  and  refreshment  of  the  patient.  It  will 
generally  be  expedient  to  give  a  full  dose  of  calomel  and  opium ;  ten  grains  of  the 
one  with  two  of  the  other.  Sometimes  the  effect  of  the  opiate  is  to  suffer  the  bowels 
to  empty  themselves  ;  showing  that  the  previous  difficulty  was  probably  spasmodic. 
Usually  the  calomel  and  opium  will  soothe  the  vomiting,  the  restlessness  and  the 
pain ;  and  then  a  full  dose  of  neutral  salts,  or  of  castor  oil ;  or  (if  these  do  not  suc- 
ceed) of  the  last  named  remedy,  castor  oil,  quickened  by  one  or  two  drops  of  the  oil 
of  croton,  will  produce  free  evacuations  from  the  bowels;  and  the  patient  soon  re- 
turns to  his  ordinary  state  of  health.  It  is  sometimes  necessary  to  repeat  this  prac- 
tice, this  alternation  of  purgatives  and  anodynes:  but  when  once  the  bowels  have 
been  freely  moved,  the  disease,  in  general,  becomes  very  tractable. 

At  La  Charite,  in  Paris,  there  is  what  is  called  a  specific  mode  of  treatment  fol- 
lowed. It  is  complicated  and  rough,  bu't  not  a  whit  more  successful  than  the  simpler 
plan  which  is  universally  adopted  in  this  country.  You  may  see  it  described,  if 
you  are  curious  on  the  subject,  in  most  of  the  French  books.  I  think  it  is  given  in 
detail  in  Ratier's  Formulary  of  Hospital  Practice. 

Some  have  recommended  salivation  for  the  cure  of  the  painter's  colic,  on  the 
principle,  I  conjecture,  of  driving  out  one  metallic  poison  by  another.  But  the  two 
may  combine,  for  aught  I  know,  to  plague  the  patient.  The  practice  is  quite  unne- 
cessary. 

You  will  be  consulted  about  the  palsy  which  arises  from  lead,  and  especially  to 
remedy  the  dropped  wrists,  which  render  the  patient  incapable  of  earning  his  liveli- 
hood. Now  in  the  early  stages  of  the  palsy,  and  in  its  primary  attacks,  you  may 
often  succeed  in  effecting  a  cure.  Electricity  has  long  been  thought  useful,  apphed 
in  the  way  of  sparks  at  first,  and  of  shght  shocks  afterwards,  along  the  muscular 
parts  of  the  extensors  of  the  fingers.  It  accelerates  the  recovery  to  give  the  hand 
and  fingers  the  mechanical  support  of  a  splint,  made  for  that  express  purpose,  and 
so  contrived  that  the  hand  and  fingers  are  kept  extended  through  the  greater  part  of 
the  day.     Patients  labouring  under  this  kind  of  palsy  resort  to  the  Bath  waters  for 


COLICA    PICTONUM.  797 

a  cure  :  and  I  learn  from  a  gentleman  who  once  held  the  office  of  house-surgeon  to 
the  hospital  there,  that  the  physicians  have  much  more  faith  in  the  use  of  the  baths, 
with  shampooing,  and  in  splints  and  blisters  to  the  palsied  muscles,  than  in  electricity. 
The  warm  douche  is  a  promising  expedient :  the  electro-magnetic  apparatus,  per- 
haps, still  more  so. 

According  to  Andral  and  others,  who  have  had  more  experience  of  that  drug  than 
I  have,  there  is  no  form  of  palsy  so  Hkely  to  be  benefited  by  strychnine  as  this  which 
proceeds  from  the  poison  of  lead.  I  should  recommend  you  to  try  the  safer  methods 
of  binding  the  hand  to  a  splint,  and  stimulating  the  muscles  by  friction,  shampooing, 
or  electricity,  before  you  resort  to  that  active  poison. 

It  is  observable  of  this  disease,  as  of  many,  and,  indeed,  of  most  others,  except 
certain  contagious  febrile  diseases,  that  when  once  it  has  occurred,  it  is  much  more 
liable  to  occur  again,  upon  a  repetition  of  the  exciting  cause,  than  before.  It  is  of 
very  great  moment,  therefore,  that  they  who  are  necessarily  exposed  to  the  poison 
of  lead — as  painters,  plumbers,  printers  (who  handle  leaden  types),  colour-grinders, 
potters,  and  glass-blowers  (who  use  the  oxide  of  lead  in  their  respective  manufacto- 
ries), shot-makers,  workers  in  lead  mines,  and  so  on — it  is  of  great  importance  that 
these  persons  should  be  made  aware  of  the  means  which  are  best  adapted  for  their 
protection  against  the  injurious  agency  of  the  poison  :  and  we  ought  to  be  able  to 
give  them  advice  in  that  matter.  The  rules  for  their  guidance  are  short  and  simple  ; 
and,  if  carefully  observed,  I  believe  they  will  generally  prove  successful.  They 
resolve  themselves  into  cautions  against  the  admission  of  the  metal  or  its  compounds 
into  the  body  through  any  channel. 

1.  To  prevent  its  introduction  through  the  skin  minute  attention  to  cleanliness  is 
necessary.  The  face  and  hands  should  be  washed,  the  mouth  rinsed,  and  the  hair 
combed,  several  times  in  the  day  ;  and  bathing  and  ablution  of  the  whole  body  should 
be  frequently  performed :  also,  the  working-clothes  should  not  be  made  of  woolen, 
but  of  strong  compact  linen  ;  and  they  should  be  washed  once  or  twice  a  week  at 
least ;  and  they  should  be  worn  as  little  as  possible  out  of  the  workshop :  and  some 
light  impervious  cap  mi^ht  protect  the  head  while  the  person  is  at  work. 

2.  Care  should  be  taken  that  none  of  the  poison  be  admitted  into  the  system  with 
the  food.  The  workmen,  therefore,  should  not  take  their  meals  in  the  workroom, 
and  should  be  scrupulous  in  cleansing  their  hands  and  lips  before  eating. 

3.  The  entrance  of  the  poison  into  the  air-passages  during  respiration  should  be 
guarded  against  as  much  as  possible.  Masks  have  been  recommended  for  this  pur- 
pose :  none,  probably,  would  be  more  convenient  or  more  effectual,  than  Mr.  Jeffrey's 
orinasal  respirator. 

There  is  a  notion  prevalent  in  some  places,  which  apparently  has  some  founda- 
tion, that  the  free  use  of  fat,  and  of  oily  substances,  as  food,  is  a  preservative  against 
the  colic.  A  physician,  near  Breda,  informed  Sir  George  Baker  that  the  village  in 
which  he  lived  contained  a  great  number  of  potters,  among  whom  he  did  not  witness 
a  single  case  of  lead  colic  in  the  course  of 'fifteen  years;  and  he  attributed  their 
immunity  to  their  having  lived  very  much  on  butter  and  bacon,  and  other  fat  kinds 
of  food.  De  Haen  also  was  told  by  a  physician,  the  proprietor  of  a  lead  mine  in 
Styria,  that  the  labourers  there  were  once  very  subject  to  colic  and  palsy ;  but  that 
after  they  were  exhorted  by  a  quack  doctor  to  eat  a  good  deal  of  fat,  especially  at 
breakfast,  they  were  exempt  from  these  disorders  for  three  years.  This  is  a  kind 
of  prophylaxis  that  is  very  easily  adopted. 

More  recently  Liebig  has  asserted  that  "  the  disease  called  painter's  colic  is  un- 
known in  all  manufactories  of  white  lead  in  which  the  workmen  are  accustomed  to 
take,  as  a  preservative,  sulphuric  acid  lemonade,  a  solution  of  sugar  rendered  acid 
by  sulphuric  acid." 

If  this  be  so,  the  lemonade  must  protect  the  system  by  converting  any  other  salt 
of  lead,  which  might  find  entrance,  into  an  insoluble  sulphate :  solubility  being 
requisite  to  give  efficacy  to  any  poisonous  substance. 

Mr.  Benson,  the  manager  of  the  British  white-lead  works,  in  Birmingham,  states 
(in  the  Lancet)  that  he  has  tried  this  method  of  prevention.  Under  his  direction 
sulphuric  acid  was  first  added  to  the  treacle-beer,  used  as  a  beverage  by  the  work- 

3r2 


798  DIARRHCEA. 

men,  in  the  summer  of  1841.  Lead  colic,  which  had  prevailed  before  "  to  a  dis 
tressmg  extent,"  soon  began  to  diminish  in  frequency :  and  from  October  in  the 
same  year,  up  to  the  date  of  Mr.  Benson's  communication  in  December,  1842 — a 
period  of  fifteen  month? — not  a  single  instance  of  the  disorder  had  occurred  amongst 
them.     This  is  very  encouraging. 


LECTURE  LXXII. 

Diarrhoea.     Sporadic  Cholera,     Epidemic  Cholera 

Tke  morbid  fluxes  which  proceed  from  the  long  tract  of  mucous  membrane  that 
lies  between  the  stomach  and  the  anus  are  many  in  number:  and  they  vary  much 
both  in  kind  and  in  cause.  Hemorrhages  are  not  uncommon.  I  have  already  de- 
scribed the  disease  called  melsena,  which  is  characterized  by  the  discharge  of  black 
semifluid  matters,  resembling  tar,  from  the  bowels,  and  in  most  instances  from  the 
stomach  also  by  vomiting.  The  matters  vomited,  and  the  matters  passed  by  stools, 
are  composed  principally  of  blood,  Avhich  has  been  rendered  black,  and  otherwise 
modified  in  appearance,  during  its  progress  onwards  in  the  one  direction  and  in  the 
other.  Again,  hemorrhage  from  the  bowels  is  apt  to  occur  in  continued  fever ;  as  I 
shall  show  j'ou  when  we  come  to  that  disease.  Hemorrhage  takes  place  also  from 
the  rectum  in  hsemorrhois,  or  bleeding  piles :  a  malady  that  falls  chiefly  to  the  care 
of  the  surgeon.  Blood  comes  awa}^,  too,  mixed  with  a  greater  or  less  quantity  of 
mucus,  in  dysentery. 

The  remaining  forms  of  profluvia  from  the  intestinal  canal  I  shall  proceed  to  con- 
sider seriatim  ;  at  least  the  most  important  of  them. 

There  are  several  very  different  affections  classed  together  under  the  head  of 
diarrhcea:  by  which  term  is  usually  signified  the  occurrence  of  frequent,  loose  or 
liquid  alvine  evacuations.  Thus  diarrhcea  is  a  very  common  sj-mptom  of  pulmo- 
nary phthisis  ;  and  this  form  of  the  disorder  has  been  already  mentioned.  It  is  very 
oiten  met  with  also  in  continued  fever,  and  during  the  decline  of  the  febrile  exanthe- 
mata, of  which  I  have  yet  to  speak.  But  diarrhcea  is  not  unfrequently  the  main 
symptom  of  the  illness  under  which  the  patient  labours;  and  constitutes,  at  any  rate 
the  chief  object  of  our  treatment.     I  shall  touch  briefly  on  some  of  its  varieties. 

In  the  first  place,  there  is  that  common  form  of  the  complaint  which  proceeds 
from  over-repletion  of  the  stomach ;  or  from  the  ingestion  of  food  that  is  not  whole- 
some :  food  that  disagrees  (as  the  phrase  is)  with  the  patient's  stomach  and  bowels 
at  that  particular  time.  We  may  call  it,  with  Cullen,  by  way  of  distinction,  diarrhoea 
crapnlosa:  in  which  feces  are  discharged  in  a  more  liquid  state,  and  more  copiously, 
and  more  often,  than  is  natural.  These  cases  are  in  truth  slight  cases  of  irritant 
poisoning.  The  ingesta  irritate  the  mucous  surface,  and  probably  the  muscular  coat 
also ;  the  secretions  of  the  inner  membrane  are  poured  forth  in  unusual  abundance, 
and  the  peristaltic  motions  of  the  intestines  become  more  strong  and  active ;  the  ob- 
ject of  these  changes  being  that  of  getting  rid  of  the  offending  substances:  a  salutary 
and  conservative  effort,  which  we  assist  and  imitate  in  our  treatment  of  this  form  of 
diarrhoea. 

The  symptoms  by  which  this  species  of  diarrhoea  is  marked,  must  be  well  known 
to  us  all.  There  are  often  nausea;  flatulence;  griping  pains  in  the  bowels,  suc- 
ceeded by  stools  of  unnatural  appearance  and  odour,  and  of  fluid  or  watery  consist- 
ence. There  are  often,  also,  a  furred  tongue  and  a  foul  breath :  but  the  disorder  is 
attended  with  little  or  no  fever ;  the  pulse  remains  of  the  ordinary  frequency ;  and 
the  temperature  of  the  body  does  not  rise. 

There  are  certain  things  which,  more  than  others,  tend,  when  taken  into  the  sto- 
mach, to  cause  this  crapulous  diarrhoea :  and  there  are  certain  circumstances  which 
increase  the  disposition  to  be  affected  by  the  ordinary  exciting  causes. 


DIARRHCEA.  799 

We  frequently  see  this  disorder  supervene  upon  a  debauch,  in  which  case  the 
mixture  of  various  articles  of  food,  and  of  drink,  each  of  which  in  itself  might  have 
been  perfectly  innocent — and  the  actual  quantify  of  the  mixed  ingesta — have  occa- 
sioned the  irritation  and  disturbance,  Byjt  Avhere  there  has  been  no  intemperance  in 
eating  or  drinking,  some  kinds  of  food  are  more  likely  than  others,  cxteris  paribus, 
to  provoke  diarrhoea.  I  do  not  speak  of  idiosyncrasies,  which  show  the  truth  of  the 
old  proverb,  that  what  is  one  man's  meat  is  another  man's  poison,  and  which  cannot 
be  reckoned  upon  beforehand ;  but  I  refer  to  the  average  of  systems  and  stomachs. 
And  among  these  indigestible  and  irritating  substances  we  may  place  raw  vege- 
tables of  many  kmds ;  such  as  cucumbers  and  salads,  sundry  kinds  of  fruit,  espe- 
cially if  they  be  hard,  immature  and  acid ;  plums,  melons,  pine-apples,  nuts,  and  so 
forth.  Mushrooms  may  be  added  to  the  hst,  even  when  they  are  cooked.  Putrid 
food,  or  food  which,  in  the  more  refined  phraseology  of  gastronomers,  is  termed 
high,  has  the  same  effect  upon  some  persons :  and  so,  in  a  particular  manner,  have 
some  kinds  oafish  ;  shell-fish,  crabs  and  muscles,  for  instance,  in  this  country ;  and 
in  other  countries,  in  the  West  Indies,  there  are  several  species  of  fish  which  are 
actually  poisonous,  and  cannot  be  safely  eaten  at  all.  And  similar  disorder  is  fre- 
quently  produced  in  children  by  any  sort  of  food,  other  than  the  natural  sustenance 
furnished  by  the  mother.  The  new  kind  of  nutriment  disagrees  with  them :  and  the 
very  same  thing  is  apt  to  occur  in  adult  persons.  An  article  of  diet  which  is  per- 
fectly wholesome  and  digestible,  and  which  the  stomach  bears  well  after  a  little  habit, 
will  sometimes  cause  griping  and  purging,  when  it  is  taken  for  the  first  time.  It  is 
upon  this  principle  that  the  diarrhoea  to  which  Englishmen  are  subject  upon  first 
visiting  the  towns  upon  the  continent,  is  to  be  explained.  I  do  not  know  that  it  is 
so,  but  I  think  it  very  likely  that  Frenchmen,  and  Germans,  and  Italians,  suffer 
in  the  same  way  when  they  first  come  to  this  country,  and  adopt  our  habits  and 
regimen. 

Another  curious  exciting  cause  is  to  be  found  in  certain  mental  emotions,  and 
especially  the  depressing  passions;  grief,  and  above  all,  fear.  A  sudden  panic  will 
operate  on  the  bowels  of  some  persons  as  surely  as  a  black  dose,  and  much  more 
speedily.  Among  the  circumstances  which  predispose  most  persons  to  this  kind  of 
malady,  we  may  particularly  specify  season — the  hot  weather  of  summer  and  au- 
tumn. And  it  is  probably  consistent  with  the  experience  of  most  of  you,  that  the 
atmosphere  of  the  dissecting-room  has  a  similar  tendency. 

Now  this  diarrhoea,  from  occasional  irritation,  produced  by  the  presence  of  sub- 
stances that  offend  the  stomach  or  bowels,  will  generally  cease  of  itself.  The  purging 
is  the  natural  way  of  getting  rid  of  the  irritant  cause.  We  may  favour  the  recovery 
by  diluent  drinks,  and  by  making  the  patient  abstain  from  all  further  use  of  food 
which  is  not  perfectly  easy  of  digestion ;  and  we  may  often  accelerate  the  recovery 
by  sweeping  out  the  alimentary  canal  by  some  safe  purgative,  and  then  soothing  it 
by  an  opiate.  Or  we  may  give  the  aperient  and  the  anodyne  together,  and  the  one 
will  not  interfere  with  the  operation  of  the  other.  A  table-spoonful  of  castor-oil, 
wAh.  six  or  eight  minims  of  laudanum  dropped  upon  it :  or  from  fifteen  grains  to  a 
scruple  of  powdered  rhubarb,  with  half  as  much  of  the  pulvis  cretse  cumpositus  cum 
opio.  By  some  such  medication  as  this,  emptying  the  bowels,  and  quieting  them, 
the  cure  is  generally  accomplished  with  ease,  and  speedily:  tutd,  cito,  etjucunde. 

We  sometimes,  however,  meet  with  cases  in  which  diarrhoea  runs  on  ;  the  stooL< 
being  composed  of  fecal  matter  in  an  unnaturally  fluid  state ;  and  the  precise  condi 
tion  on  which  this  disposition  to  an  over-loose  slate  of  the  bowels  depends,  escaping 
detection.  If  the  disorder  be  slight,  it  will  often  yield  to  the  astringent  and  bitter 
medicines.  The  infusion  of  cusparia,  with  the  tincture  of  cinnamon,  supplies  a  con- 
venient formula.  If  it  be  more  severe,  or  obstinate,  we  have  recourse  to  a  chalk 
mixture,  which  neutralizes  acidity ;  com-bined  with  catechu,  which  is  a  direct  astrin- 
gent of  the  tissues ;  and  with  laudanum,  which  calms  irritation.  And  in  extreme 
cases  the  sulphate  of  copper  has  been  found  to  have  a  powerful  efiect  in  restraining 
the  flux.  It  is  apt  to  gripe,  and  should  be  combined  therefore  with  opium.  A  quar 
ter  of  a  grain  of  each,  in  a  pill,  given  three  or  four  times  a  day,  I  have  frequently 
found  successful,  when  previous  attempts  to  remove  the  diarrhoea  had  failed. 


800  DIARRHOEA. 

[A  much  more  effectual  remedy  is  the  acetate  of  lead,  combined  with  opium  and  ipecacu- 
anha ;  one  grain  of  the  first,  from  a  fourth  to  the  half  of  a  grain  of  the  second,  and  from 
half  a  grain  to  a  grain  of  the  latter,  combined  in  the  form  of  a  pill,  or  in  a  powder,  mixed 
with  a  little  simple  syrup,  may  be  given  to  an  adult,  and  repeated  every  three  or  four  hours 
according  to  circumstances. 

Diarrhrea  in  a  chronic  form  is  that  which  the  practitioner  will  be  the  most  frequently 
called  upon  to  treat  in  the  adult;  and  it,  in  general,  requires  for  its  complete  removal  a  cau- 
tious and  judicious  course  of  treatment  persevered  in  for  a  length  of  time.  The  slightest 
deviation  from  the  strict  diet  and  regimen  required  in  each  case,  will  often  very  considerably 
protract  the  cure ;  while  a  too  early  abandonment  of  the  appropriate  remedies  ■will  fre 
quently  be  quickly  followed  by  a  return  of  all  the  worst  symptoms  of  the  disease. 

In  chronic  diarrhoea  there  exists  a  morbid  excitability  of  the  intestinal  canal,  so  that  almost 
everything  taken  into  the  stomach,  as  food  or  drink,  brings  on  quickly  repeated  discharges  by 
stool  consisting  of  the  ordinary  secretions  of  the  digestive  tube,  more  or  less  changed  in  cha- 
racter, mixed  with  portions  of  half  digested  aliment ;  and  the  looseness  continues,  often  un- 
attended with  griping,  or  any  other  uneasy  sensation  save  those  connected  with  the  debility 
and  emaciation  produced  by  the  interruption  to  the  digestive  and  nutritive  functions  generally, 
which  the  rapid  passage  of  the  aliment  through  the  bowels  occasions.  There  is  no  doubt, 
that  frequently  the  morbid  excitability  of  the  digestive  canal  is  due  to  a  chronic  inflamma- 
tion, often  follicular,  and  attended  with  ulceration  of  some  portion  of  its  mucous  membrane; 
when  this  is  the  case,  we  have  repeated  discharges  by  stool  without  apparently  any  exciting 
cause  other  than  the  morbid  secretions  of  the  liver,  pancreas,  or  of  the  stomach  and  intes- 
tines themselves.  The  discharges  are,  in  general,  dark-coloured  and  offensive,  very  fluid,  and 
small  in  quantity,  and  are  often  preceded  and  accompanied  by  griping  pains  more  or  less 
severe.  There  is,  very  commonly,  some  degree  of  nausea,  and  occasionally  vomiting,  the 
appetite  for  food  is  generally  destroyed,  though  in  many  cases  it  continues  unimpaired.  The 
patient  becomes  more  and  more  emaciated  and  debilitated  ;  his  skin  assumes  a  dirty  sallow 
hue  and  a  dry  harsh  feel;  the  palms  of  the  hands  become  hot  and  dry;  the  countenance  has, 
in  many  cases,  a  dull,  desponding  expression;  the  features  acquire  considerable  sharpness, 
and  the  eyes  become  sunken  and  surrounded  by  a  broad  leaden-coloured  ring.  The  abdo- 
n^n  is  frequently  flaccid,  and  exhibits  no  tenderness  upon  moderate  pressure;  occasionally, 
however,  it  becomes  swollen  and  tympanitic,  and  is  now  and  then  decitledly  tender  to  the 
touch.  We  have  known  in  cases  of  chronic  diarrhcea,  an  effusion  of  serum  to  occur  within 
the  peritoneal  cavity,  and  to  produce  a  very  decided  intumescence  of  the  abdomen.  In  pro- 
tracted cases,  the  body  exhales  a  peculiar  sickly  odour,  the  tongue  becomes  of  a  dark  maho- 
gany hue,  and  often,  together  with  the  parietes  of  the  mouth,  is  covered  with  aphthas.  The 
pulse  is  usually  small  and  feeble,  often  quick  and  frequent.  Febrile  symptoms  are  not  gene 
rally  present;  in  many  cases,  however,  there  is  observed  some  degree  of  febrile  excitement 
towards  evening — very  protracted  cases  we  have  repeatedly  known  to  be  accompanied  with 
well-marked  hectic  symptoms  —  more  or  less  pufliness  of  the  face,  and  cedematous  swelling 
of  the  extremities,  very  commonly  occur  in  the  course  of  the  disease.  The  discharges  by 
'jtool,  while  they  are  always  fluid  and  vitiated,  exhibit  considerable  variety  in  their  appear- 
ance;  most  gencraUy  they  are  dark-coloured,  and  exhale  a  rancid  or  fetid  odour;  occasion- 
ally, however,  they  have  a  jelly-like  consistence,  and  very  little  smell;  at  other  times  they 
consist  of  a  small  quantity  of  a  dirty  yellow  fluid,  and  when  they  contain  solid  matter  this 
will  generally  be  found  to  consist  of  portions  of  half-digested  aliment.  All  these  changes  in  the 
character  of  the  discharges  may  present  themselves  in  the  same  case,  and  often  within  a  very 
short  period.  In  protracted  cases,  the  discharges  would  appear  to  acquire  an  acrid  property,  pro- 
ducing an  erythematous  inflammation  of  the  verge  of  the  anus,  and  often  of  the  nates.  The 
frequency  of  the  stools  varies  very  much  in  different  cases,  and  at  different  periods  in  the 
same  case.  Occasionally,  the  diarrhoea  takes  place  only  after  the  ingestion  of  food  or  drinks, 
or  of  particular  kinds  of  food,  and  the  discharges  from  the  bowels  continue  to  recur  at  short 
intervals  until  the  offending  matters  are  got  rid  of;  in  many  cases,  repeated  stools  occur  in 
the  course  of  the  day,  whether  food  is  taken  or  not,  and  are  suspended  during  the  night ;  in 
other  instances  the  evacuations  from  the  bowels  often  cease  for  a  day,  or  even  longer,  and 
then  return,  and  for  a  short  period  with  increased  frequency. 

The  duration  of  chronic  diarrhoea  is  very  various ;  unless  arrested  by  a  proper  course  of 
treatment  —  its  spontaneous  cessation  being  a  thing  of  very  rare  occurrence  —  it  will  run  on 
for  weeks,  often  for  months,  and  the  patient  finally  sinks  from  extreme  exhaustion.  Occa- 
sionally perforation  of  the  intestines  occurs  from  ulceration  or  softening,  and  the  fatal  event 
is  preceded  by  peritonitis. 

Tne  causes  of  chronic  diarrhoea  are  the  same  as  those  of  the  acute  or  simple  form  of  the 
disease ;  frequent  attacks,  within  a  short  period,  of  an  ordinary  bowel  complaint,  will  very 
commonly  induce  a  chronic  affection. — Improper  articles  of  diet,  and  acescent  drinks,  habit 
ually  mdulged  in  ;  exposure  to  a  cold,  and,  at  the  same  time,  humid  atmosphere ;  the  abuse 
*f  purgatives,  and  intemperate  habits  generally,  are  among  the  most  common  causes  of 


DIARRHCEA.  801 

chronic  diarrhoea.  It  is  an  affection  much  more  readily  induced  in  those  of  a  lax,  and  feeble, 
excitable  and  broken-down  constitution,  than  in  tho.se  of  an  opposite  condition. 

The  state  of  the  intestinal  tube  in  those  who  have  fallen  victims  to  the  disease  is  very 
various.  In  some  cases,  the  mucous  coat,  particularly  of  the  large  intestines,  is  somewhai 
thickened,  spongy,  and  pale  —  in  others  its  anatomical  characters  are  entirely  changed,  large 
portions  of  it  presenting  a  smooth,  glassy,  mottled  appearance,  as  though  its  surface  had  been 
covered  with  a  thin  coating  of  dirty  varnish.  Occasionally  large  patches  of  the  mucous  mem- 
brane of  the  colon  or  rectum  are  of  a  dark  mahogany  or  of  a  slate  colour  — •  the  traces  of 
follicular  inflammation,  or  of  ulcerations,  more  or  less  extensive,  are  not  unfrequently  met 
with,  especially  in  the  ileum  and  colon.  Dr.  Stokes  notices  a  form  of  chronic  diarrhcBa  as 
of  common  occurrence,  dependent  upon  ulcers  situated  close  to  the  verge  of  the  anus ;  these 
ulcers  occur  chiefly  in  persons  of  a  broken-down  constitution,  and  those  who  have  taken  a 
great  deal  of  mercury  ;  we  have  repeatedly  observed  them,  also,  in  individuals,  who  have 
been  in  the  habit  of  using  almost  daily  the  various  pills  composed  chiefly  of  aloes,  soap,  and 
Bcamniony,  or  gamboge,  vast  quantities  of  which  are  vended  in  the  United  States  as  a  popu- 
lar remedy  for  almost  every  ailment.  The  ulcers  situated  just  within  the  anus  produce  irri- 
tation in  the  colon,  tenesmus,  griping,  frequent  discharges  by  stool,  and  most  commonly  dur- 
ing the  straining  a  little  blood  is  passed.  The  presence  of  the  ulcers  may  be  at  once  detected 
by  an  examination  of  the  rectum  ;  which  examination,  as  Dr.  Stokes  very  correctly  remarks, 
should  invariably  be  made  in  all  cases  where  the  diarrhoea  has  been  of  long  standing,  and 
has  resisted  a  great  variety  of  treatment ;  where  it  is  attended  with  tenesmus,  and  a  desire 
of  sitting  on  the  night  chair  after  a  stool  has  been  passed  ;  and,  finally,  where  the  patient's 
health  does  not  appear  to  be  so  much  affected  as  it  naturally  would  be  from  long-continued 
disease  of  a  large  portion  of  the  great  intestine. 

In  the  treatment  of  chronic  diarrhoea  our  leading  indications  are,  to  control  the  morbid 
irritability  or  excitability  of  the  intestinal  mucous  membrane,  and  restore  it  as  quickly  as 
possible  to  its  healthy  condition  and  functions.  To  effect  these  objects  is  not  always,  how- 
ever, a  very  easy  task,  and  always  demands  considerable  judgment  on  the  part  of  the  prac- 
titioner, and  considerable  patience,  and  an  implicit  obedience  on  the  part  of  the  patient  to 
the  medicinal  direc^tions  and  dietetic  rules  laid  down.  The  first  and  all-important  considera- 
tion is  that  of  diet  —  so  that,  while  the  patient  is  supplied  with  aliment  caleulateii  for  his 
support,  as  little  irritation  as  possible  of  the  intestines  shall  be  excited  by  it.  The  food  taken 
by  an  individual  labouring  under  chronic  diarrhcEa  should  be  easy  of  digestion,  of  the  mildest 
quality,  and  such  as  leaves,  after  undergoing  digestion,  but  a  small  quantity  of  excrementi- 
tious  matter ;  and  even  of  such  food  but  a  small  portion  shoiHd  be  taken  at  a  time.  Rice  is 
probably  the  best  article  of  diet  in  the  generality  of  cases  of  chronic  diarrhoea;  when  well 
boiled,  with  the  addition  of  a  little  salt,  while  it  is  sufficiently  nourishing  it  is  extremely  mild 
and  unirritating,  by  no  means  difficult  of  digestion,  and  scarcely  affords  any  excrementitious 
matter  to  be  transmitted  along  the  intestines.  It  may,  generally,  be  eaten  mixed  with  a 
very  moderate  quantity  of  plain  beef  or  mutton  broth ;  plain  meat  broths  prepared  whh  the 
addition  of  a  large  amount  of  rice,  will  often  furnish  a  very  suitable  food  in  chronic  diarrhoea, 
and  are  to  many  stomachs  more  palatable  ;  rice,  also,  boiled  with  milk  and  sweetened,  but 
not  too  heavily,  with  the  best  of  loaf  sugar,  or  fresh  milk  thickened  with  rice  flour,  may  be 
occasionally  given.  Should  either  preparation,  however,  be  found  to  disagree  with  the 
patient,  or  to  augment  or  keep  up  the  diarrhoea,  it  should  be  at  once  relinquished.  We  have 
indeed,  in  numerous  instances,  found  plain  broths,  when  well  prepared,  or  the  juice  of 
roasted  meats  with  a  portion  of  stale  bread  or  cracker  broken  into  it,  agree  better  than  any 
preparation  of  rice.  Tapioca,  sago,  or  arrow-root,  we  have  seldom  found  an  appropriate  ali- 
ment for  persons  labouring  under  the  chronic  form  of  diarrhcEa.  As  soon  as  it  can  be  borne, 
and  this  can  only  be  ascertained  by  a  cautious  trial,  a  small  portion  of  tender  chicken,  tur- 
key, or  mutton,  plainly  boiled  or  roasted,  may  be  eaten  with  rice.  Pure  water,  toast  water, 
or  rice  water,  taken  cold  and  in  very  moderate  quantities  at  a  time,  should  be  the  only  drink 
allowed. 

Next,  or  more  properly  perhaps,  equal  in  importance  to  a  well-regulated  diet,  is  an  atten 
tion  to  the  clothing  and  regimen  of  the  patient.  Individuals  affected  with  chronic  diarrhosa 
are  particularly  susceptible  to  the  influence  of  a  cold  and  damp  atmosphere  —  a  slight  ex- 
posure to  which  will  often  increase  their  disease,  or  when  we  have  succeeded  in  diminish- 
ing the  frequency  of  the  discharges,  causes  them  to  return  as  before.  It  is  essential,  thens- 
fore,  that  independent  of  cautiously  avoiding  every  species  of  exposure,  the  patient  should  bo 
suitably  lodged  and  clothed.  The  chamber  he  occupies  at  night,  as  well  as  during  the  day, 
iiliould  be  dry,  of  a  comfortable  and  equable  temperature,  perfectly  clean,  and  well  ventilated  ■ 
his  clothing  should  be  adapted  to  the  season  and  state  of  the  weather — flannel  next  the  skin 
should  always  be  worn;  a  belt  of  flannel  around  the  abdomen,  or  enveloping  this  part  with 
a  flannel  roller  nicely  adjusted,  and  renewed  daily,  will  always  be  found  advantageous.  In 
obstinate  and  protracted  cases,  the  removal  of  the  patient  from  a  cold,  damp,  and  changeable, 
to  a  more  equable,  warmer,  and  drier  climate,  whenever  praoiicable,  is  a  measure  fioiv. 
51 


802  DIARRHCEA. 

which  the  very  best  results  are  to  be  anticijiated ;  it  has,  in  numerous  instances,  been  known 
to  effect  a  speedy  cure,  when  all  other  means  have  failed. 

In  regard  to  exercise,  even  the  gentlest  kind,  whether  passive  or  active,  cannot  sometimes 
Le  undertaken,  from  the  frequent  and  pressing  calls  to  evacuate  the  bowels  which  occasion- 
ally are  found  to  be  excited  by  motion  of  every  kind  :  in  other  cases,  short  walks  in  the  open 
air,  in  suitable  weather,  or  a  gentle  ride  in  an  open  carriage,  or  sailing  in  a  boat,  are  advan- 
tageous, and  should  be  repeated  daily  if  the  patient's  strength  will  admit  of  it. 

The  warm  bath,  followed  by  brisk  friction  of  the  surface,  is  a  remedy  from  whicli  the  best 
effects  are  to  be  anticipated  in  most  cases  of  chronic  diarrhoea;  it  maybe  repeated  daily,  the 
temperature  of  the  water  being  carefully  graduated  by  the  condition  of  the  patient's  surface; 
when  this  is  dry  and  warm,  a  tepid  bath  should  be  preferred,  but  if  the  surface  is  cool,  or 
its  heat  is  not  well  sustained,  the  water  should  be  decidedly  warm.  The  temperature  of 
the  bath  should  never  be  so  low  as  to  cause  the  patient  when  innnersed  in  it  the  slightest 
sensation  of  chilliness  on  the  one  hand,  nor  so  high  on  the  other,  nor  the  continuance  in  it 
so  long,  as  to  produce  profuse  perspiration. 

By  a  few  physicians  the  effects  of  leeches  to  the  abdomen  or  to  the  anus,  in  cases  of  chro- 
nic diarrhoea,  are  spoken  of  in  the  highest  terms  of  commendation.  Drs.  Crampton  and 
Forbes,  in  their  very  excellent  essay  on  the  disease  under  consideration,  contained  in  the 
Cyclopsedia  of  Practical  Medicine,  {Philadelphia  Edition,  vol.  i.,  p.  640,)  speak  of  leeclies  ap- 
plied to  the  anus,  as  a  remedy  "  possessed  of  remarkable  powers — often  working,''  according 
to  the  common  expression,  "like  a  charm,  even  in  cases  of  diarrhcEa  of  vej'y  long  standing, 
and  of  different  external  characters.  Combined  with  proper  diet,  indeed,  we  are  per- 
suaded," tliey  remark,  "that  the  greater  number  of  diarrheas,  both  acute  and  chronic,  will 
yield  to  this  method,  with  little  or  no  aid  from  other  medicine.''  —  "Although,  in  our  prac- 
tice, we  always,"  they  add,  "combine  with  the  use  of  leeches,  in  the  cases  where  they  are 
indicated,  a  proper  diet,  yet  we  have  had  ample  evidence  of  their  unassisted  powers  in 
checking  or  removing  diarrhcea  of  great  severity  and  obstinacy." 

It  is  certain  that  many  of  the  most  obstinate  cases  of  chronic  diarrhoea  are  kept  up  by  a 
subacute  inflammation  of  some  portion  of  mucous  membrane  of  the  large  intestines,  and  in 
such  cases  a  well-timed  application  of  leeches  to  the  anus  will  be  productive  of  the  best 
effects.  In  such  cases,  the  earlier  the  leeches  are  applied  the  better.  In  detectinT;  the  cases 
in  which  leeching  is  indicated,  will  demand  a  good  deal  of  tact,  and  close  habits  of  observa- 
tion on  the  part  of  the  practitioner — his  judgment  must  be  made  up  from  an  inquiry  into  the 
history,  and  a  careful  analysis  of  all  the  circumstances  of  each  case,  for  we  know  of  no  lead- 
ing phenomena  by  which  those  cases  where  leeches  are  calculated  to  do  good  can  be  distin- 
guished from  those  to  which  they  are  not  adapted  ;  as  a  general  rule,  however,  we  are  per- 
suaded that  in  well-marked  cases  of  chronic  diarrhcea,  particularly  when  the  disease  has 
existed  for  any  length  of  time,  leeches  are  at  best  a  doubtful,  if  not  an  improper  remedy. 

Blisters  to  the  abdomen  will,  we  apprehend,  be  found  more  generally  advantageous  than 
leeches ;  we  have  found  them  to  produce  a  speedy,  marked,  and  prompt  amelioration  in  the 
l^rominent  symptoms  of  the  case;  the  frequency  of  the  stools,  under  their  use,  being  siseedily 
diminished,  and  the  discharges  assuming  a  more  natural  appearance.  In  many  instances, 
however,  we  confess  that  no  benefit  whatever  has  resulted  from  repeated  blisters.  They  are 
a  remedy,  nevertheless,  which  so  generally  do  good  that  they  should  not  be  overlooked. 
Keeping  on  the  blister  for  a  few  hours,  and  then  replacing  it  by  a  soft  emollient  poultice; 
repeating  it  as  soon  as  the  vesicated  surface  has  healed,  is  a  preferable  plan  to  allowing  the 
blister  to  remain  on  until  complete  vesication  is  produced,  and  keeping  up  the  irritation  thus 
produced  by  stimulating  dressings. 

The  principal  internal  remedies  from  which  any  good  effects  are  to  be  anticipated  are, 
opiates  and  astringents.  Opium,  either  by  the  mouth,  or  introduced  into  the  rectum,  in  the 
form  of  an  injection,  acts  beneficially  by  quieting  the  pain  and  other  uneasy  sensations  under 
which  the  patient  labours,  as  well  as  by  allaying  the  irritability  of  the  bowels,  and  thus  sus- 
pending the  frequency  of  the  stools  ;  it  aids  in  this  manner  the  efficacy  of  whatever  astringent 
is  r,«.ade  use  of.  The  Dover's  powder  will  frequently  be  the  best  form  in  which  the  opium 
can  be  administered  ;  or,  if  this  be  found  to  disagree  with  the  stomach,  as  will  sometimes 
be  the  case,  the  opium  may  be  given  in  the  form  of  a  pill;  combining  it  with  a  small  por- 
tion of  ipecacuanha,  we  have  generally  found  advantageous  :  or  the  opium  may  be  given  as 
an  enema  rubbed  up  with  starch.  The  dose  of  the  opium,  and  the  period  of  its  repetition, 
must  be  left  to  the  judgment  of  the  practitioner. — We  have  not  derived  the  same  advantage 
in  cases  of  chronic  diarrhoea,  from  the  salts  of  morphium  as  from  the  opium  itself. 

Of  astringents,  nearly  the  whole  list,  both  vegetable  and  mineral,  has  been  recommended, 
and  each  one  is  praised  by  different  practitioners  as  particularly  efficacious  in  the  disease 
under  consideration.  The  vegetable  astringents  most  deserving  of  attention  are,  the  catechu, 
kino,  galls,  logwood,  blackberry  root,  and  the  root  of  the  geranium  maculatum.  The  first 
may  "up  given  in  t'.s  form  cf  the  infus.  catechu  comp.  Dr.  Pemberton  prefers  the  kino  tc  all 
other  astringents,  in  chrome  diarrhoea;  he  gave  it  in  doses  cf  a  scruple  made  in  a  bolus  with 
opiate  confection  (on  Diseases  of  jib  dam.  Viscera').     More  recently,  an  extensive  series  of  ex 


DIARRHCEA.  803 

periinents  on  the  effects  of  kino  in  diarrhoea  were  made  in  the  hospital  La  Pitie,  in  Paris,  by 
M. Bally.  In  chronic  diarrhoea,  unaccompanied  by  fever  or  marks  of  inflammation  in  the 
mucous  membrane,  the  continued  use  of  the  remedy,  even  for  a  short  time,  was  found  almost 
invariably  to  be  effectual  in  stopping  the  diarrhoea.  In  one  case  of  three  years  standing  it 
effected  a  cure.  But  the  most  remarkable  result  of  M.  Bally's  experiments  is  the  alleged 
fact — that  the  kino,  given  in  doses  of  twelve  or  fifteen  grains,  for  several  days  in  succession, 
succeeded  in  curing  diarrhoea  attended  by  febrile  and  inflammatory  symptoms.  (Crampton 
and  Forbes,  from  Med.  Gazette,  v.  70D.)  We  have  repeatedly  employed  both  the  catechu  and 
kino  in  cases  of  chronic  diarrhoea  where  astringents  were  evidently  indicated,  and  although 
their  beneficial  effects  were  often  promptly  exhibited,  they  have,  nevertheless,  repeatedly 
failed  in  diminishing  the  frequency  of  the  discharges ;  we  have  found  the  galls,  either  in 
powder  —  combined  with  camphor  or  opium,  and  not  unfrequently  with  both  —  or  in  decoc- 
tion, a  much  more  effective  astringent  in  protracted  and  obstinate  cases  of  diarrhoea,  than 
either  the  kino  or  catechu.  The  logwood  in  decoction  is  a  favourite  remedy  with  many  prac 
titioners ;  we  have,  however,  been  disappointed  in  its  effects ;  it  may  serve  as  a  useful  vehi 
cle  for  more  active  remedies.  The  dewberry-root  is  unquestionably  a  very  powerful  astrin 
gent,  and  well  adapted  to  the  disease  under  consideration;  in  infusion  or  decoction  it  is 
extensively  employed  by  the  physicians  of  the  United  States,  as  is  also  the  root  of  the  gera- 
nium maculatum,  the  efi'ects  of  which  latter,  in  chronic  discharges  from  the  bowels,  are  very 
highly  spoken  of  by  many  practitioners. 

Of  the  mineral  astringents,  we  know  of  none  superior,  in  cases  of  chronic  diarrhcEa,  to  the 
acetate  of  lead  ;  in  the  dose  of  one  grain,  combined  widi  a  quarter  of  a  grain  of  opium  and 
the  same  quantity  of  ipecacuanha,  repeated  every  three  hours,  it  will,  in  a  large  number  of 
cases,  promi^tly  arrest  the  disease.  The  alum  will,  also,  be  found  a  good  astringent  in  chro- 
nic diarrhoea;  it  may  be  administered  in  the  form  of  alum  whey,  or  in  substance,  combined 
with  opium.  We  have  given  it  in  conjunction  with  powdered  galls  and  with  the  best  effects. 
The  sulphate  of  copper,  which  has  been  employed  in  combination  with  opium  by  Dr.  Elliots 
son  with  the  most  decided  success,  has  repeatedly  succeeded  in  our  hands  in  arresting  the 
disease  under  circumstances  the  most  unpromising.  The  mode  in  which  we  have  generally 
employed  it,  has  been  in  a  quarter  or  one-third  of  a  grain  doses  combined  with  two  grains 
of  extract  of  quina  and  a  fourth  of  a  grain  of  opium  every  three  hours.  The  protocarbonate 
of  iron,  the  tincture  of  the  chloride  of  iron,  and  the  solution  of  the  persesquinitrate  of  iron, 
we  have  repeatedly  employed,  and  in  cases  of  long  standing  have  found  them,  especially  the 
first  two,  very  efficacious.  They  are  particularly  well  adapted  to  protracted  cases  of  the  dis- 
ease, attended  with  great  prostration,  and  more  or  less  infiltration  of  the  subcutaneous  cellu- 
lar tissue. 

The  balsam  copaiba  and  spirits  of  turpentine  are  among  the  remedies  from  which,  in  nu- 
merous cases  of  chronic  diarrhoea,  the  very  best  eflects  may  be  anticipated.  When  the  dis- 
charges from  the  bowels  are  small  in  quantity,  and  resemble  in  consistence  thin  starch  or 
mucilage,  or  when  they  are  dark-coloured  and  of  a  rank  offensive  odour,  we  are  acquainted 
with  no  remedies  from  which  the  same  amount  of  good  may  be  anticiiJated.  They  may  be 
combined  with  opiates  and  astringents  where  these  are  considered  necessary.  The  sjiirits 
of  turpentine  we  employ  more  frequently  than  the  copaiba;  it  is,  we  believe,  equally  effica- 
cious, while  it  is  more  easily  taken  by  the  patient,  and  agrees  better  with  the  stomach;  it 
may  be  combined  widi  simple  syrup  and  water,  by  adding  a  few  grains  of  magnesia. 

A  variety  of  other  remedies  are  recommended  by  different  writers,  the  eflicacy  of  which 
is  highly  extolled.  The  most  prominent  are  Hope's  Mixture,  which  is  a  mixture  of  nitrous 
acid,  camphor  water  and  laudanum — the  nux  vomica  and  its  active  principle ;  the  ferrocya- 
nuret  of  iron  ;  the  nitrate  of  silver,  and  the  resinous  extract  of  the  artemisia  vulgaris.  Of  the 
effects  of  these  we  have  had  no  experience. 

In  those  cases  in  which  the  diarrhoea  appears  to  be  kept  up  by  ulceration  seated  just 
within  the  verge  of  the  anus,  very  speedy  and  permanent  relief  will  always  be  obtained  by 
touching  the  ulcers  with  nitrate  of  silver. 

We  have  given  above  an  outline  of  the  treatment  demanded  in  the  chronic  form  of  diar- 
rhoea;  in  conclusion,  we  would  remark,  that  the  management  of  this  disease  ahvays  requires 
the  exercise  of  great  judgment  and  discretion  on  the  part  of  the  practitioner.  Nothing  would 
appear  more  easy  tlian  by  opiates  and  astringent  remedies  to  arrest  the  inordinate  discharges 
from  the  bowels,  and  thus  to  effect  the  cure  of  the  patient,  but  it  will  be  found  that,  in  many 
cases,  when  astringents  are  too  early  resorted  to,  the  disease,  instead  of  being  removed,  is 
aggravated ;  or  if  by  our  astringents  we  do  succeed  in  suspending  the  discharges  from  tlie 
bowels,  a  swollen  and  painful  state  of  the  abdomen  quickly  succeeds,  producing  greater  dis- 
tress to  the  patient,  and  terminating  more  promptly  in  death,  than  had  the  diarrhoea  been 
allowed  to  run  its  course.  In  numerous  instances,  chronic  diarrhoea  may  be  very  effectually 
cured  by  a  proper  regulation  of  diet  and  regimen,  the  warm  bath,  blisters  to  the  abdomen, 
and  internally  the  blue  pill  or  calomel  combined  with  opium  and  ipecacuanha,  and,  pei haps, 
the  use,  at  the  same  time,  of  moderate  doses  of  copaiba  or  turpentine,  without  astrint;ento. 
There  are,  however,  unquestionably,  many  cases,  in  the  course  of  which  astringents,  az.u  al' 


804  SPORADIC    CHOLERA. 

the  most  powerful  kind,  are  demanded  in  order  to  effect  a  removal  of  the  disease,  and  others, 
in  Mdiich  mild  astringents,  early  administered,  will  very  materially  shorten  its  duration;  and 
it  is  in  rightly  determining  the  cases  and  period  of  the  disease,  in  which  astringents  are  in- 
dicated, that  the  success  of  the  practitioner  in  effecting  its  cure  will  frequently  depend. — C] 

I  have  alluded  to  the  influence  of  hot  weather  in  predisposing  the  system  to  be 
affected  by  the  exciting  causes  of  diarrhcEa.  And  there  is  a  complaint  of  which 
diarrhcea  is  one  prominent  symptom,  but  which  is  sopiething  more  than  mere  diar- 
rhoea— that  shows  itself  in  this  country  more  or  less,  every  autumn,  and  prevails 
extensively  in  some  years,  as  a  minor  epidemic.  It  is  rightly  enough  named  cho' 
lera  ;  for  it  is  attended  with,  and  consists  mainly  of,  a  remarkable  flux  of  bile.  Sy- 
denham held  that  the  disease  is  limited  to  the  month  of  August ;  and  that  bowel  affec- 
tions, with  vomiting,  occurring  at  other  times,  are  not  genuine  cases  of  cholera.  But 
this  was  one  of  that  great  man's  crotchets.  The  symptoms  that  mark  this  complaint 
are  vomiting  and  purging  of  liquid  matter,  deeply  tinged  with,  and  principally  com- 
posed of,  bile  ;  violent  pains  in  the  stomach  and  bowels ;  cramps  of  the  legs  and  of 
the  abdominal  muscles ;  a  great  depression  of  the  vital  powers,  and  a  tendency  to 
syncope  or  collapse. 

The  attack  is  generally  sudden.  At  first  the  contents  of  the  alimentary  canal  are 
evacuated;  and  then  a  quantity,  an  enormous  quantity  sometimes,  of  a  turbid,  yel- 
lowish, acrid  fluid,  is  expelled  with  violence  both  from  the  bowels,  and  by  vomiting. 
The  patients  complain  of  a  burning  sensation  in  the  epigastrium.  As  the  vomiting 
and  purging  go  on,  clonic  spasms  of  the  lower  extremities,  and  especially  of  the 
gastrocnemii,  occur ;  the  surface  of  the  belly  is  drawn  up  into  knots :  and  after  a 
while,  the  patient,  exhausted  by  the  pain  and  the  spasms,  and  still  more  so  by  the 
copious  discharges,  grows  cold  and  faint.  Sometimes  actual  syncope  happens :  and 
sometimes  death. 

Death,  however,  is  an  uncommon  event  of  this  form  of  cholera,  in  this  country. 

The  chief  cause  of  cholera,  such  as  has  now  been  described,  appears  to  be  casual 
exposure  to  cold,  after  a  continued  high  temperature  of  the  atmosphere :  and  the 
great  irritation  of  the  stomach  and  bowels  evinced  by  the  symptoms,  proceeds 
from  the  presence  of  bile  in  the  intestines  in  undue  quantity,  and  rendered  more 
acrid  than  usual  by  some  morbid  alteration  of  its  quality.  The  attack  seems  to 
be  often  determined  by  some  of  those  causes  of  irritation  which  I  just  now  men- 
tioned when  speaking  of  simple  diarrhoea;  and  particularly  by  imprudence  in  eating 
and  drinking. 

I  believe  that  no  better  treatment  can  be  followed  in  this  disease  than  that  long 
ago  laid  down  by  Sydenham.  He  observes  that  any  attempt  to  stop  the  purging  and 
vomiting  by  strong  drastic  aperients,  under  the  notion  of  expelling  the  irritant  matter, 
would  be  like  endeavouring  to  extinguish  fire  by  pouring  oil  upon  it;  and  that  to 
try  to  lock  up  the  acrid  discharges  in  the  ahmentary  canal  by  means  of  narcotics  or 
astringents,  would  be  equally  hurtful.  He  therefore  was  accustomed  to  dilute  the 
contents  of  the  stomach  and  bowels  by  emollient  drinks,  and  injections,  especially  by 
chicken  broth ;  and  so  to  favour  their  expulsion  ;  and  when  any  faintness  or  sign  of 
sinking  began  to  show  itself,  to  administer  laudanum  in  full  doses.  We  are  seldom 
summoned  to  these  cases  in  the  outset.  Generally  the  vomiting  and  diarrhoea  have 
continued  for  some  hours  before  we  see  the  patient :  so  that  it  is  expedient  to  give 
the  opiate  as  soon  as  we  can.  If  the  stomach  be  very  irritable,  solid  opium  in  the 
form  of  pill  may  be  preferable  to  laudanum  ;  or  an  opiate  clyster — or  an  opiate  sup- 
pository— may  be  introduced  into  the  rectum. 

[In  such  cases  we  know  of  no  remedy  more  effectual  than  a  pill  composed  of  opium, 
eamphor  and  acetate  of  lead,  in  the  proportion  of  one  grain  each.  When  the  stomach  is  sa 
Ijritable  that  the  pill  is  quickly  rejected,  a  solution  of  acetate  of  lead,  eight  grains  ta 
two  ounces  of  water,  with  the  addition  of  one  grain  of  the  acetate  of  morphia,  in  the  dosa 
of  a  teaspoonful,  repeated  at  proper  intervals,  will  very  generally  be  retained. — C] 

When  the  skin  is  cold,  and  the  pulse  sinking  or  irregular,  carbonate  of  ammonia, 
or  brandy  and  water,  may  be  given  by  the  mouth ;  and  a  mustard  poultice,  or  a  bag 
of  hot  salt,  or  a  moist  and  hot  flannel  sprinkled  with  oil  of  turpentine,  should  be 
applied  to  the  abdomen.     The  cramps  of  the  extremities  may  be  relieved  by  dili 


EPIDEMIC    CHOLERA.  805 

gent  friction  with,  the  hand ;  or  some  stimulating  liniment  may  be  rubbed  upon  the 
affected  muscles.  When  the  collapse  is  great,  the  patient  should  not  be  allowed  to 
raise  himself  out  of  the  horizontal  posture,  lest  fatal  syncope  should  follow.  Opium, 
however,  is  our  sheet-anchor  in  this  complaint :  it  sustains  the  flagging  powers,  while 
it  quiets  the  gastro-inteslinal  irritation. 

After  an  attack  of  severe  cholera,  the  patient  is  apt  to  be  left  extremely  feeble ; 
with  soreness  of  the  muscles  of  the  trunk  and  limbs  :  and  sometimes,  symptoms  of 
viflammation  of  the  mucous  membranes  will  supervene  ;  pain  and  tenderness  of  the 
belly,  a  white  tongue,  thirst,  and  fever.  And  these  symptoms  may  require  some  of 
the  remedies  of  inflammation. 

Such  is  the  disease  which  has  long  been  familiar  to  English  practitioners,  as  cho- 
lera :  but  about  twelve  or  thirteen  years  ago,  this  country  was  visited  by  a  severe 
epidemic  disorder,  which  was  also  called  cholera ;  or  by  way  of  emphasis,  the  cho- 
lera ;  or  sometimes  spasmodic  cholera ;  or  Jlsialic  cholera ;  or  malignant  cholera. 
The  symptoms  of  this  new  disease  resembled,  in  some  points,  those  of  the  old- 
fashioned  cholera :  but  differed  from  them  in  more,  and  in  more  important,  particu- 
lars. So  that  the  application  of  the  term  cholera,  or  cholera  morbus,  to  both  these 
morbid  affections,  is  very  much  to  be  regretted,  for  it  has  produced  a  great  deal  of 
confusion  and  inconvenience. 

I  scarcely  know  how  to  name  the  newer  and  severer  disorder.  I  have  no  right 
to  alter  the  received  nomenclature ;  and  choosing  from  among  the  many  appella- 
tions which  have  been  given  to  the  complaint,  that  epithet  which  seems  the  least 
objectionable,  I  may  call  it  epidemic  cholera :  although  this  term  is  objectionable, 
since  the  other  malady,  the  English  or  sporadic  cholera,  is  sometimes  also  epi- 
demic. 

The  epidemic  cholera  so  far  resembled  the  sporadic,  that  it  was  attended  by  pro- 
fuse vomiting  and  purging,  by  extreme  prostration  of  strength,  and  by  cramps.  But 
it  differed  remarkably  in  these  respects;  in  the  circumstance  that  the  matters  ejected 
from  the  stomach  and  bowels  contained  no  bile  (and  this  alone  is  a  good  reason 
against  calling  the  disease  cholera) ;  in  the  early  supervention  of  the  symptoms  of 
collapse ;  and  in  the  great  mortality  of  the  disorder. 

The  amount  of  the  fluid  matters  thrown  up  from  the  stomach  and  discharged  by 
the  bowels,  was  really  in  many  cases  wonderful.  At  first,  perhaps,  the  j)atient  would 
have  so  copious  a  stool — a  consistent  dejection  it  might  be,  but  so  large  in  quantity — 
as  to  lead  him  to  conclude  that  the  whole  contents  of  the  intestines  had  been  evacu- 
ated at  once.  Yet  soon  afterwards  a  turbid  whitish  liquid  would  again  and  again 
pour  from  his  bowels  in  streams  ;  and  be  spouted  from  his  mouth  as  if  from  a  puuip  : 
not  in  general  with  much  effort,  but  easily  and  abundantly.  The  matters  thus  dis- 
charged were  thin,  and  for  the  most  part  of  a  whitish  colour,  like  water  in  which  rice 
has  been  boiled  ;  without  fecal  smell ;  and  containing  small  white  albuminous  flakes. 
There  were  some  varieties  in  the  evacuations,  but  the  kind  I  have  mentioned,  resem- 
bling rice-water,  was  the  most  common  and  the  most  characteristic :  and  however 
else  their  sensible  qualities  might  vary,  this  circumstance  was  universal,  that  they 
contained  no  bile. 

With  all  this  there  was  early  sinking,  and  collapse,  as  it  was  called.  This  term 
collapse  expressed  a  general  condition,  made  up,  in  the  most  exquisite  cases,  of  the 
following  particulars : — A  remarkable  change  took  place  in  the  circulation,  and  a 
striking  alteration  in  the  appearance  of  the  patient.  The  pulse  became  frequent, 
very  small  and  feeble,  and  at  last,  even  for  hours,  sometimes,  extinct  at  the  wrists. 
The  surface  grew  cold  ;  and  in  most,  or  in  many  instances,  blue  as  well  as  cold.  The 
lips  were  purple;  the  tongue  was  of  the  colour  of  lead,  and  sensibly  and  unplea- 
sandy  cold  to  the  touch,  like  a  frog's  belly ;  and  the  breath  could  be  felt  to  be  cold. 
With  this  coldness  and  blueness  there  were  a  manifest  shrinking  and  diminution  of 
the  bulk  of  the  body.  The  eyes  appeared  sunk  deep  in  their  sockets;  the  cheeks 
fallen  :  in  short,  the  countenance  became  as  withered  and  ghastly  as  that  of  a  corpse. 
The  cadaverous  aspect  that  sometimes  precedes  death  in  long-standing  aiseases, 
would  come  on  in  the  course  of  an  hour  or  two,  in  this  complaint.     11  the  physi 

3s 


806  EPIDE3IIC    CHOLERA. 

cian  left  his  patient  for  half  an  hour,  he  found  him  visibly  thinner  on  his  return. 
The  finger  nails  became  blue ;  the  hands  and  fingers  shriveled,  white,  corrugated, 
and  sodden,  like  those  of  a  washerwoman  after  a  long  day's  work.  The,  skin  was 
bathed  in  a  cold  sweat.  The  voice  became  husky  and  faint.  So  peculiar  was  this 
change,  that  the  sound  was  spoken  of  as  the  vox  cholerica.  These  are  the  symp- 
toms which  the  single  word  collapse  was  meant  to  express. 

Another  very  striking  feature  of  the  disorder  was  the  muscular  cramp ;  affecting 
the  muscles  of  the  thighs  and  calves  of  the  legs,  rendering  them  as  hard  and  rigid 
as  wood  ;  and  drawing  up  into  kno'ts  the  muscles  of  the  abdomen.  These  spasmodic 
contractions  were  attended  with  severe  pain,  and  constituted  the  greater  part  of  the 
patient's  suffering.  During  the  continuance  of  the  symptoms  that  I  have  been  en- 
deavouring to  describe,  not  a  drop  of  urine  was  passed  or  secreted.  One  man,  who 
was  under  my  own  observation  and  care,  and  who  recovered,  did  not  void  a  drop  of 
water  from  Sunday  morning  till  the  afternoon  of  the  following  Wednesday. 

Even  in  the  extreme  state  of  collapse  the  intellect  remained  quite  clear :  the 
patients  would  continue  to  talk  rationally  to  the  last  moment  of  their  lives ;  and, 
for  the  most  part,  they  seemed  singularly  indifferent  and  apathetic  about  their 
condition. 

In  the  fatal  cases — and  a  very  fearful  proportion  of  the  whole  number  were  fatal — 
death  took  place  sometimes  in  the  course  of  two  or  three  hours ;  and  it  was  seldom 
delayed  beyond  twelve  or  fifteen.  In  those  that  recovered,  the  favourable  symptoms 
were  the  cessation  of  the  vomiting,  purging,  and  cramp;  the  return  of  the  pulse,  and 
of  warmth  to  the  surface ;  the  disappearance  of  the  blueness  of  the  skin,  and  of  the 
hippocratic  countenance;  the  re-appearance  of  bile  in  the  al vine  evacuations;  and 
the  restoration  of  the  secretion  of  urine. 

The  course  of  the  symptoms  varied  a  good  deal  in  different  persons  Sometimes 
the  vomiting  and  purging  soon  ceased,  and  sometimes  there  was  neither  sickness  nor 
diarrheea  at  all,  but  rapid  collapse  and  sinking.  These  were  thought  the  most  formi- 
dable cases.  However,  the  peculiar  secretions  were  poured  forth,  in  some,  at  least, 
of  the  instances  in  which  none  of  them  were  eject-ed  from  the  body.  A  patient  died 
of  cholera  in  the  Middlesex  Hospital  without  any  vomiting  or  purging :  but  on  ex- 
amming  the  dead  body,  we  found  the  intestines  quite  full  of  the  rice-water  serous 
fluid.  Sometimes  the  cramps  were  not  very  troublesome.  The  cutaneous  bluen^'ss 
was  not  a  universal  phenomenon.  The  patients  were  in  general  tormented  by  thirst: 
and  when  attempts  were  made  to  bleed  them,  the  blood  was  found  dark  and  thick, 
like  treacle,  and  scarcely  moving,  if  moving  at  all,  in  the  veins :  in  some  cases  it 
could  not  be  made  to  flow  out.  Considerable  hurry  and  anxiety  of  the  breathing 
were  also  symptoms  that  I  omitted  to  mention  before. 

Examination  of  the  dead  bodies  threw  no  light,  that  I  know  of,  upon  the  nature 
of  this  frightful  disease.  The  alimentary  canal  generally  was  found  to  contain  a 
white  liquid,  having  whiter  flakes  in  it ;  such  as  had  previously  issued  from  the 
bowels:  and  the  mucous  glands  of  the  intestines,  both  the  solitary  and  the  agmi- 
nated,  were  usually  large  and  conspicuous.  The  veins  were  loaded  with  thick,  black, 
far-hke  blood  ;  and  the  urinary  bladder  was  always  found  empty,  and  contracted  into 
the  size  of  a  walnut.  Even  when  the  blue  colour  had  existed  in  a  marked  degree 
during  life,  it  often  quickly  disappeared  after  death.  And  another  most  singular 
phenomenon  was  occasionally  remarked  in  the  dead  body.  A  quarter  or  half  an 
hour,  or  even  longer,  after  the  breathing  had  ceased,  and  all  other  signs  of  animation 
had  departed,  slight,  tremulous,  spasmodic  twitchings  and  quiverings,  and  vermicular 
motions  of  the  muscles  would  take  place  ;  and  even  distinct  movements  of  the  limbs, 
n  consequence  of  these  spasms. 

The  disease,  of  which  I  have  drawn  but  a  faint  outline,  was  not  known  in  this 
country  till  the  autumn  of  the  year  1831.  There  are  persons,  I  am  aware,  who  hold 
that  it  has  always  existed  among  us ;  only  not  in  such  numerous  instances  as  at  that 
period ;  and  they  appeal  to  Morton,  and  other  early  writers  on  the  diseases  of  this 
country,  in  support  of  their  opinion.  But  the  malady  was  too  striking  to  be  over- 
looked, or  ever  forgotten,  by  any  one  who  had  once  seen  it.  Certainly,  till  that  year 
1  never  saw  anything  hke  it.     To  be  sure,  I  had  not  at  that  time  been  very  many 


EPIDEMIC    CHOLERA.  807 

years  in  practice  here.  The  late  Dr.  Babington,  however,  told  me  that  it  was  quite 
new  to  him.  He  had,  for  a  very  long  period,  been  in  extensive  practice,  in  those 
parts  of  the  metropolis  and  its  vicinity  where  the  epidemic  cholera  raged  most ;  and 
when  it  first  came  among  us  he  had  the  curiosity  to  ask  every  medical  man  whom 
he  met,  whether  he  had  seen  any  case  of  the  cholera  ;  and  if  the  answer  was  "yes," 
he  went  on  to  inquire,  whether,  before  that  year,  the  person  had  ever  met  with  the 
same  complaint;  and  the  reply  was  always,  without  a  single  exception,  "no."  Yet 
I  say  there  were,  and  are,  a  few  practitioners  who  denied,  and  deny,  that  it  was  any- 
thing more  than  the  common  and  well-known  English  complaint,  raging  with  unusual 
frequency  and  violence. 

But  we  have  evidence  of  a  different  kind  of  the  newness  of  the  epidemic  cholera 
to  these  kingdoms.  Its  approach  was  discerned  afar  off,  as  distinctly  as  a  storm  is 
foreseen  by  the  rising  of  the  clouds  from  the  horizon  in  the  direction  of  the  wir>d. 
The  disorder  began  to  rage  with  terrible  severity,  in  India,  in  the  year  1817.  I  do 
not  mean  that  it  then  broke  out  there  for  the  first  time.  It  had  visited  those  regions 
again  and  again  before.  But  from  its  eruption  in  the  year  I  have  mentioned,  when 
it  committed  frightful  devastation  in  the  armies  in  the  north-eastern  districts  of  India, 
its  course  can  be  distinctly  traced  to  our  own  thores ;  towards  which  it  approached 
with  slow  and  hailing,  but  with  sure  steps,  in  a  north-western  direction.  From  India 
it  spread  to  Persia  ;  and  thence  to  Russia ;  and  across  through  Poland  to  Germany  : 
and  at  length  it  was  found  at  Hamburgh.  It  was  predicted  before  that  time,  that  the 
distemper  would  at  length  reach  Great  Britain.  (Dur  government  had  even  sent  two 
physicians  into  Russia  to  investigate  its  nature,  in  the  fearful  anticipation  that  its 
march  across  the  earth  would  continue  progressive  ;  and  accordingly,  at  the  expira- 
tion of  fourteen  years,  it  made  its  appearance  on  the  eastern  coast  of  this  country ; 
in  Sunderland  :  and  in  due  time  extended  over  every  part  of  these  islands.  I  say 
its  arrival  had  been  foreseen  and  foretold ;  and  it  is  absurd  to  suppose  that  a  vast 
number  of  persons  would  fall  sick  and  die,  with  symptoms  quite  strange  to  the  great 
mass  of  practitioners  here,  merely  to  fulfil  this  prediction. 

The  progress  of  the  disorder  did  not  end  here.  Crossing  the  Atlantic,  it  invaded 
America  ;  turning,  at  the  same  time,  in  a  south-easterly  direction,  it  ravaged  France 
and  Spain,  and  the  north  coast  of  Africa,  and  Italy. 

Moving  thus  onward,  as  it  did,  in  defiance  of  all  natural  or  artificial  barriers, 
under  opposite  extremes  of  temperature  and  climate,  in  the  teeth  of  adverse  winds, 
over  lofty  mountain  chains,  across  wide  seas,  through  "  hot,  cold,  moist,  and  dry" — 
in  what  manner,  you  will  probably  ask,  was  this  wasting  pestilence  propagated? 

Upon  this  point  various  and  discordant  opinions  are  entertained.  Many  persons 
believe  that  the  complaint  spread  by  contagion ;  more,  however,  that  it  was  not  con- 
tagious at  all,  but  arose  from  some  deleterious  cause  with  which  the  general  atmo- 
sphere of  the  place  was  pregnant.  Now  1  cannot  reconcile  the  phenomena  of  the 
appearance  and  extension  of  the  malady  with  either  of  these  hypotheses  exclusively. 
It  must,  I  think,  be  granted  that  the  complaint,  in  every  instance,  was  excited  by  the 
apphcation  of  some  noxious  material  to  the  body,  some  positive  poison.  It  is  certain, 
also,  whichever  hypothesis  may  be  chosen,  that  many  more  individuals  were  exposed 
to  the  agency  of  this  poison,  than  were  injuriously  affected  by  it.  This  exemption 
from  the  disease  no  more  invalidates  the  doctrine  of  contagion,  than  it  invalidates  the 
doctrine  of  some  diffused  atmospheric  influence  ;  nay,  it  is  more  explicable  upon  the 
former  than  upon  the  latter  supposition  ;  for  while  many  may  avoid  a  specific  conta- 
gion, all  are  immersed  in,  and  all  breathe,  the  common  atmosphere.  But  the  ex- 
emption shows  this:  that  the  exciting  cause,  to  be  effective,  required  a  fit  recipient: 
that  the  susceptibility  of  being  hurt  by  the  poison  in  its  ordinary  dose  and  intensity 
varied  much  in  different  persons;  and  in  the  majority  was  very  faint,  or  wanting. 
It  is  clear  that  the  poison  travelled.  It  is  equally  clear  to  my  mind,  that  it  was 
portable  ;  and  therefore  communicable  from  person  to  person.  I  even  believe  thai 
it  was  capable  of  being  conveyed,  and  was  actually  conveyed,  from  one  spot  to 
another,  by  persons  who  were  themselves  proof  against  its  effects.  The  innumerable 
authentic  instances  of  coincidence,  in  point  of  time,  between  the  first  outbreak  of  th«' 
disorder  in  a  particular  place,  and  the  arrival  at  that  place  of  some  person  or  persona 


808  EPIDEMIC    CHOLERA. 

from  an  infected  locality,  prove  that  the  poison  could  be  thus  carried.  Of  this  direct 
importation  of  the  disorder  into  new  and  distant  places,  by  infected  individuals,  and 
of  its  subsequent  extension  from  those  individuals  to  others  who  had  intercourse  with 
them,  you  may  see  a  vast  number  of  examples,  collected  by  Dr.  James  Simpson,  in 
the  4yth  volume  of  the  Edinburgh  Medical  and  Surgical  Journcd.  The  evidence 
there  adduced  of  the  portability  of  the  poison  is  abundant,  and  to  my  mind,  irresist- 
ible. Whether  the  malady  was  contagious  in  the  same  sense  in  which  small-pox  is 
contagious — whether,  I  mean,  the  cholera  poison  had  the  power  of  multiplying  and 
reproducing  itself  in  the  human  body,  as  yeast  multiplies  itself  during  the  fermenta- 
tion of  beer — is  a  ditTerent  and  a  much  more  doubtful  question.  A  disorder  may  be 
contagious,  without  this  property  of  reproduction  in  the  animal  fluids.  The  itch  is 
contagious.  The  itch  is  produced  by  a  minute  parasitic  animalcule,  whose  existence 
has,  of  late  years  only,  been  assured  to  us  by  the  microscope.  Suppose  that  these 
iich  insects  could  fl)',  or  were  capable  of  being  wafted  through  the  air — they  would 
then  represent  what  is  conceivable  enough  of  the  subtle  exciting  cause  of  cholera. 
Between  the  two  epidemic  distempers,  influenza  and  cholera,  there  were  numerous 
and  striking  points  of  similitude  or  analogy.  They  have  observed  the  same,  or  very 
nearly  the  same,  geographical  route.'  Both,  issuing  from  their  cradle  in  the  east, 
have  traversed  the  northern  countries  of  Europe,  till,  arriving  at  its  western  boundary, 
they  have  divided  into  two  great  branches ;  the  one  proceeding  onwards,  across  the 
Atlantic,  the  other  turning  in  a  retrograde  direction,  towards  the  south  and  east. 
The  main  difierences  between  them  have  been,  that  whereas  the  poison  of  influenza 
spared  very  few  of  the  community,  inflicting  a  disease  which,  of  itself,  was  seldom 
fatal — the  poison  of  cholera,  on  the  contrary,  smote  very  few,  but  with  so  deadly  a 
stroke  that  as  many  sank  beneath  it,  probably,  as  recovered.  Both  were  general 
disorders,  affecting  the  whole  system,  but  in  both  the  most  prominent  of  the  symp- 
toms had  reference,  in  the  majority  of  cases,  to  the  mucous  membranes ;  to  those  of 
the  air-passages  in  the  influenza  ;  to  those  of  the  alimentary  passages  in  the  cholera. 
Now  this  strong  analogy  has  been  made  use  of  as  an  argument  that  the  cholera 
was  not  contagious.  "  The  influenza  (say  the  objectors)  had  no  contagious  proper- 
ties ;  therefore  it  is,  a  priori,  likely  that  the  cholera  had  none."  But  1  demur  to  the 
major  proposition.  Cuilen  thought  the  influenza  was  contagious,  and  I  adverted,  in 
a  former  lecture,  to  some  facts  which  favour  that  belief.  Supposing  it,  however,  to 
be  so,  the  proof  of  its  contagious  property  must,  from  the  very  nature  of  the  case,  be 
extremely  difficult.  Its  visitations  are  so  rapid,  widely  spread,  and  multitudinous, 
that  there  is  no  time  for  its  transference  from  house  to  house,  or  from  person  to  per- 
son ;  yet  it  may  be  nevertheless  transferable.  Its  inherent  rate  of  locomotion  outstrips 
and  precludes  the  tardier  conveyance  of  ihe  poison  by  man.  Its  contagious  qualities 
(granting  them  to  exist)  are  hidden  in  its  universality,  and  can  seldom  be  traced  but 
by  accident.  I  therefore  esteem  this  argument  from  analogy  as  worthless ;  and  my 
own  creed  respecting  the  cholera  is,  that  it  u'as  contagious,  in  the  hmited  sense 
already  explained ;  but  that  its  contagious  power  was  not  very  great :  that  a  com- 
paratively small  part  of  the  population,  of  this  country  at  least,  was  susceptible  of  its 
operation ;  and  that  few  were  in  much  danger  of  suffering  from  exposure  to  the 
physical  cause  of  the  disease,  except  under  circumstances  of  predisposition.  At  the 
san)e  time  I  believe  that  a  great  majority  of  the  cases  of  cholera  were  not  attributable 
to  direct  contagion,  but  to  the  poison  diffused  through  the  atmosphere.  There  is  no- 
thing inconsistent  in  the  supposition  thot  this  noxious  matter  travelled  sometimes  by 
its  own  peculiar  powers,  sometimes  made  use  of  vehicles. 

[During  the  prevalence  of  the  cholera  in  Philadelphia,  in  1832,  we  closely  investigated 
every  fact  calculated  to  throw  light  upon  the  question  of  its  contagious  or  non-contagious 
character,  and  for  this  investigation,  our  position  in  the  Board  of  Health  and  as  chief  of  a 
large  hospital,  afibrded  us  ample  opportunities — hut  we  were  unable  to  discover  the  slightest 
evidence  of  the  disease  having  been  in  any  one  instance  comraunicated  from  the  sick  to  the 
well.— C] 

This,  I  say,  is  my  creed  upon  the  vexed  question  of  contagion.  Respecting  the 
special  nature  of  the  poison  I  can  only  guess ;  and  my  guessing,  as  you  may  have 
perceived,  takes  the  same  direction  as  before.     I  adverted,  when  speaking  of  the 


EPIDEMIC    CHOLERA.  809 

influenza,  to  what  Dr.  Holland  has  called  "  the  hypothesis  of  insect  life  as  a  cause 
of  disease."  I  shall  not  repeat  the  observations  I  then  made  ;  but  I  would  refer  you, 
for  much  curious  thought  and  information  upon  the  subject,  to  Dr.  Holland's  very 
interesting  essay.  The  hypothesis  in  question  squares  more  readily  than  any  other 
that  I  know  of,  with  the  ascertained  history  of  the  disorder:  with  its  origin,  after  an 
unusually  wet  season,  in  the  low  marshy  country,  and  hot  atmosphere  of  Bengal : 
with  its  irregular  but  continuous  migrations  :  with  its  dying  away  after  a  while,  and 
its  occasional  and  partial  revivals.  But  still,  remember  that  we  are  deahng  merely 
with  an  hypothesis. 

Whatever  obscurity  may  overhang  the  exciting  causes  of  the  epidemic  cholera, 
we  are  quite  sure  that  certain  circumstances  exercised  a  strong  predisposing  influence 
upon  the  human  body,  to  render  it  more  than  usually  susceptible  of  the  disease. 
The  predisposing  causes,  as  might  well  be  imagined,  were  such  as  tended  to  debili- 
tate the  system :  and  therefore  poverty,  which  implies  scanty  nourishment,  and 
frequently  also  the  confinement  of  several  persons  to  a  narrow  space,  and  want  of 
fresh  air;  poverty, which  includes  these  and  other  evils,  was  found  to  predispose  the 
body  to  a  ready  reception  of  the  malady.  But  to  intemperance,  more  than  to  any 
other  single  cause,  may  the  proclivity  to  become  affected  by  this  species  of  cholera 
be  ascribed ;  and  especially  to  the  intemperate  and  habitual  use  of  distilled  spirits. 
This  fact  was  peculiarly  manifested  in  the  selection,  by  the  disease,  of  its  victims  in 
this  country  ;  and  it  has  been  remarked  almost  everywhere  else. 

I  have  all  along  spoken  of  the  visitation  of  epidemic  cholera  in  the  past  tense, 
because,  for  the  last  eleven  or  twelve  years,  we  have  heard  but  httle  of  it.  Yet  we 
can  scarcely  venture  to  hope  that  the  stranger  pest  has  altogether  forsaken  us,  for  we 
have  had  slight  sprinklings  of  the  disease  in  and  near  London,  every  summer,  I  be- 
lieve, since  1832;  but  it  has  never  again  been  extensively  prevalent  or  epidemic. 
Certainly  it  dealt  lightly,  upon  the  whole,  with  our  country.  It  was  much  more 
general,  and  more  widely  fatal,  in  France,  which  it  visited  subsequently  to  its  arriving 
here :  it  was  very  destructive  also  in  its  subsequent  course,  both  westward  and  to- 
ward the  south-east. 

The  epidemic  cholera  made  its  attack  in  two  different  modes,  [n  one  it  seized 
upon  the  patient  suddenly,  and  without  warning.  This  was  comparatively  rare. 
Much  more  commonly  the  specific  symptoms  were  preceded,  for  some  little  time, 
even  for  some  days  perhaps,  by  diarrhcEa.  And  this  I  take  to  be  the  most  important 
practical  fact  that  was  ascertained  during  its  prevalence  among  us.  When  the  dis- 
ease was  once  fairly  formed,  medicine  had  very  httle  power  over  it ;  but  in  the  pre- 
liminary stage  of  diarrhcsa  it  was  easily  manageable.  Unfortunately  people  are 
inclined  (especially  those  classes  of  the  community  among  whom  the  cholera  most 
raged),  to  regard  a  loose  state  of  the  bowels  as  salutary  ;  and  to  make  no  complaint 
of  it,  and  to  do  nothing  for  it :  or,  in  other  cases,  they  conceive  it  to  proceed  from 
some  peccant  matter  within,  which  requires  to  be  carried  off,  and  they  take  purgative 
medicines  to  get  rid  of  it.  Both  of  these  are  serious  and  often  fatal  mistakes.  Mere 
neglect  of  the  diarrhoea  frequently  permitted  it  to  run  into  well-marked  and  uncon- 
trollable cholera;  and  the  employment  of  purgatives  hastened  or  insured  that  cata- 
strophe. The  proper  plan  of  proceeding,  I  am  convinced,  was,  to  arrest  the  diarrhoea 
as  soon  as  possible  after  its  commencement,  by  astringents,  aromatics,  and  opiates. 
You  may  object,  perhaps,  that  the  cases  that  were  cured  in  this  way  were  not  cases 
of  cholera  at  all,  and  never  would  have  been;  but  simple  ordinary  diarrhoea.  It  is 
impossible  to  prove  the  contrary,  no  doubt;  but  the  presumption  is  strong  that  the 
diarrhoea  would  in  many,  and,  perhaps,  in  most  instances,  have  run  on,  if  not  check- 
ed, into  the  more  perilous  form  of  the  disease.  In  many  places,  when,  taught  by 
experience,  the  authorities  estabhshed  diarrhcea  dispensaries,  to  which  those  attacked 
by  looseness  of  the  bowels  were  warned  and  invited  to  apply,  that  the  looseness 
might  forthwith  be  corrected  ;  in  many  such  places  the  cholera,  which  had  before 
been  cuiting  the  inhabitants  off  by  scores,  and  hundreds,  began  instantly  to  declinv) 
in  frequency.  I  venture  to  advise  you,  supposing  the  disease  should  reappear,  of 
whenever  in  the  autumn  a  suspicion  arises  that  this  form  of  cholera  is  pr"  ^cnt  in  the 

3s2 


810  EPIDEMIC    CHOLERA. 

community,  not  to  try,  in  cases  of  diarrhoea,  to  carr)^  off  the  presumed  offending 
matter,  but  to  quiet  the  irritation,  and  stop  the  flux  as  soon  as  you  can. 

But  when  the  regular  symptoms,  peculiar  to  the  severe  form  of  cholera,  had  set 
in,  medicine,  I  repeat,  had  very  little  influence  upon  it :  and  accordingly,  as  might 
have  been  expected,  a  hundred  different  cures  of  the  disease  were  announced,  most 
of  them  all  but  infallible.  Some  persons  held  that  timely  bleeding  would  save  the 
patient ;  others  relied  confidently  upon  mustard  emetics.  Hot  air  baths  were  manu- 
factured, and  sold  to  a  great  extent,  to  meet  the  apprehended  attack  in  that  manner 
without  delay.  Certain  practitioners  maintained  that  the  disease  was  to  be  remedied 
by  introducing  into  the  system  a  large  quantity  of  neutral  salts,  which  were  to  liquefy 
and  redden  the  blood,  and  to  restore  the  functions  of  the  circulation.  But  of  this 
practice  it  was  said  in  a  sorry  but  true  jest,  that  however  it  might  be  with  pigs  or 
herrings,  salting  a  patient  in  cholera  was  not  always  the  same  thing  as  curing  him. 
In  a  great  number  of  the  sick  the  blood  was  mechanically  diluted  by  pouring  warm 
water,  or  salt  and  water,  into  their  veins.  Some  physicians  put  their  trust  in  brandy, 
some  in  opium,  some  in  cajeput  oil,  which  rose  to  I  know  not  what  price  in  the 
market ;  some  again,  in  calomel  alone. 

Now,  I  would  not  willingly  mislead  or  deceive  you  on  this  point,  by  speaking 
with  a  confidence  which  I  really  have  no  warrant  for,  of  the  success  or  propriety  of 
any  of  these  expedients.  I  believe  that  each  in  some  cases  did  good,  or  seeincd  to  do 
so ;  but  I  cannot  doubt  that  some  of  them  did  sometimes  also  harm.  I  had  not  more 
than  six  severe  cases  under  my  own  charge :  and  I  congratulated  myself  that  the 
mortality  among  them  was  not  greater  than  the  average  mortality.  Three  died,  and 
three  (I  will  not  say  were  cured,  but)  recovered.  The  three  that  died  I  was  called 
in  to  see  w^ien  the  disorder  was  at  its  height :  and  in  each  case  it  went  on  with 
frightful  rapidity,  in  spite  of  all  the  means  adopted,  and  proved  fatal  a  few  hours 
afterwards.  The  three  that  recovered  I  saw  somewhat  earlier,  but  still  not  till  the 
specific  symptoms  were  present :  one  was  a  girl  in  the  hospital.  They  all  recovered 
under  large  and  repeated  doses  of  calomel.  Yet  (as  I  said  before)  I  do  not  venture 
to  affirm  that  the  calomel  cured  them.  In  the  first  case  which  was  treated  in  that 
way,  I  merely  followed  up  the  plan  that  had  been  begun  by  Dr.  Latham,  who  had 
visited  the  patient  for  me  when  I  was  accidentally  absent.  I  found  that  he  had  fell 
better,  less  sick  and  less  faint,  after  taking  half  a  drachm  of  calomel  at  a  dose  ;  and  I 
repeated  the  same  dose  many  times,  for  after  every  dose  his  pulse  rose  somewhat, 
and  he  appeared  to  rally.  This  was  the  same  man  whom  I  mentioned  before  as 
having  made  no  urine  from  the  Sunday  to  the  Wednesday :  all  that  time  he  kept 
discharging  rice-water  stools.  At  last,  on  the  fourth  day  he  passed  a  little  water, 
and  his  alvine  evacuations  became  rather  more  consistent,  and  began  to  look  green: 
and  from  that  time  he  graduall}-  got  well.  Afterwards  I  treated  my  hospital  patient 
in  the  same  way,  and  with  the  same  event.  Yet  I  will  not  pretend  to  sa\'  that  these 
persons  might  not  have  done  quite  as  well  if  they  had  been  left  entirely  to  them 
selves. 

[Soon  after  the  appearance  of  the  cholera  in  Philadelphia,  we  were  persuaded  that  had 
we  a  remedy  capable  of  arresting  the  inordinate  serous  discharge,  which  in  this  disease  is 
poured  out  by  the  mucous  membrane  of  the  alimentary  canal,  we  should  very  readily  suc- 
ceed in  its  cure.  We  were,  therefore,  induced  to  try  the  effects  of  the  acetate  of  lead,  with 
the  remedial  powers  of  which  in  a  somewhat  analogous  disease,  the  cholera  of  infants,  we 
'vere  familiar.  We  administered  it  in  pills,  combined  with  opium  and  camphor,  or  when 
ihe  stomach  rejected  it  in  this  form,  in  solution  with  the  acetate  of  morphia,  and  at  the  same 
ttrne,  by  the  rectum,  in  injections  composed  of  a  strong  solution  with  the  addition  of  lauda- 
num. Under  this  plan  of  treatment,  the  discharges  were  in  numerous  instances  promptly 
arrested,  and  the  patients  recovered,  even  after  the  stage  of  collapse  had  ensued.  From  our 
subsequent  experience  with  this  plan  of  treatment,  we  are  convinced,  that  had  the  remedy 
been  generally  resorted  to  from  the  commencement  of  the  epidemic,  the  mortalit}'  of  the 
disease  would  have  been  materially  reduced.  Since  1832  many  cases  of  the  cholera  have 
occurred  every  year:  all  that  have  fallen  under  our  notice  were  treated  by  the  acetate  of 
l^ad,  and  we  have  lost  ftone. — Dr.  Graves  has  subsequently  recommended  the  same  remedy, 
auii  speaks  of  its  effects  in  the  highest  terms. — We  usually  administer  the  acetate  of  lead  in 
the  dose  of  one  grain,  combined  with  one  of  opium  and  the  same  quantity  of  camphor, 
«very  hour,  or  two,  or   three,  according   to  the  violence  of  the   attack.     The   thirst  of  tb« 


CHOLERA    INFANTUM.  811 

patient  was  assuaged  by  small  portions  of  ice  held  in  the  mouth  and  allowed  slowly  i«>  dis 
solve — large  and  frequent  draughts  of  cold  water  we  always  found  to  be  injurious. — Cups  to 
the  abdomen  were  frequently  employed,  and  we  have  reason  to  believe  always  with  advan 
tage.  —  From  warm  bathing,  dry  heat  to  the  surface,  sinapisms,  stimulating  pediiuvia,  we 
never  saw  any  good  effects  result. — C] 

Some  of  the  expedients  recommended  had  certainly  a  very  marked  and  immediate 
effect  upon  the  condition  of  the  patients,  especially  the  injection  of  warm  water  into 
the  veins.  Many  instances  of  this  were  related  at  the  time.  One  I  myself  saw. 
The  patient  was  a  young  man,  who  was  nearly  moribund  apparently.  His  pulse 
had  almost,  if  not  quite  disappeared  from  the  wrist ;  he  was  very  blue,  and  his  visage 
was  ghastly  and  cadaverous :  in  one  word,  he  was  in  an  extreme  state  of  collapse. 
Out  of  this  he  was  brought  in  a  few  minutes  by  injecting  warm  water  into  one  of 
the  veins  in  the  arm.  The  pulse  again  became  distinct  and  full ;  and  he  sat  up,  and 
looked  once  more  like  one  alive,  and  spoke  in  a  strong  voice.  But  he  soon  relapsed*, 
and  a  repetition  of  the  injection  again  rallied  him,  but  not  so  thoroughly :  and  in  the 
end  he  sunk  irretrievably.  Dr.  Babington  told  me  of  a  patient  whom  he  saw  speech- 
less, and  all  but  dead,  and  whose  veins  were  injected.  He  then  recovered  so  as  to 
sit  up,  and  talk,  and  even  joke,  with  the  bystanders:  but  this  amendment  did  not 
last  either.  Yet  even  this  temporary  recovery  might  sometimes  be  of  great  import- 
ance :  might  allow  a  dying  man  to  execute  a  will  for  example.  And  some  of  the 
persons  thus  revived  got  ultimately  well.  We  had  for  some  time  a  woman  in  the 
Middlesex  Hospital  acting  as  nurse,  who  had  been  rescued,  when  at  the  verge  of 
death  in  cholera,  by  the  injection  of  warm  water  into  her  veins. 

It  was  remarked  of  those  who  recovered  that  some  got  well  rapidly,  and  at  once  ; 
while  others  fell  into  a  state  of  continued  fever,  which  frequently  proved  fatal  some 
time  after  the  violent  and  peculiar  symptoms  had  ceased.  Some,  after  the  vomiting 
and  purging  and  cramps  had  departed,  died  comatose ;  over-drugged  sometimes,  it 
is  to  be  feared,  by  opium.  The  rude  discipline  to  which  they  were  subjected  might 
account  for  some  of  the  cases  of  fever.  And  the  process  of  artificially  replenishing 
the  veins  was  certainly  attended  with  much  danger.  The  injection  of  air  with  the 
water — inflammation  of  the  vein  from  the  violence  done  to  it — an  over-repletion  and 
distension  of  the  vessels  by  the  hquid  —  might,  any  one  of  them,  and  sometimes,  I 
suppose,  did,  occasion  the  death  of  the  patient.  Never,  certainly,  was  the  artillery 
of  medicine  more  vigorously  plied  —  never  were  her  troops,  regular  and  volunteer, 
more  meritoriously  active.  To  many  patients,  no  doubt,  this  busy  interference  made 
all  the  difference  between  life  and  death.  But  if  the  balance  could  be  fairly  struck, 
and  the  exact  truth  ascertained,  I  question  whether  we  should  find  that  the  agorecrate 
mortality  from  cholera  in  this  country,  was  any  way  disturbed  by  our  craft.  Except- 
ing always  the  cases  in  which  preliminary  diarrhnea  was  checked,  just  as  many, 
though  not,  perhaps,  the  very  same  individuals,  would,  probably,  have  survived  had 
no  medication  whatever  been  practised. 

I  do  not  know  that  I  have  any  thing  more  to  say  that  could  be  of  any  use  to  you, 
in  respect  to  the  epidemic  cholera. 

[Of  the  diseases  to  which  children  are  liable  in  the  middle  and  southern  portions  of  tno 
United  States,  k-w  produce  a  greater  amount  of  mortality  than  Cholera  Infantum,  or 
the  Summer  Complaint.  It  is  an  endemic  of  all  our  larger  cities,  during  the  season  of  the 
greatest  heat;  attacking  children  between  four  and  twenty  months  of  age,  or  at  the  period  of  the 
first  dentition.  So  generally  is  it  confined  to  this  period,  that  an  infant's  second  summer  ia 
considered  by  mothers  as  one  of  unusual  peril,  and  should  it  escape  an  attack  at  diis  period, 
or  pass  safely  through  the  disease,  it  is  considered  to  have  a  fair  chance  of  surviving  the 
period  of  infancy. 

The  first  symptom  of  the  disease  is  usually  a  profuse  diarrhoea,  the  stool  being  very  fluid, 
generally  of  a  very  light  colour,  though  often  of  a  pale  yellow  or  green;  to  the  diarrhoea  is 
soon  added  an  extreme  irritability  of  the  stomach,  everything  taken  into  it  being  rejected 
immediately,  and  with  violence.  The  irritability  of  stomach,  in  most  cases,  continues  through 
out  the  attack,  and  in  many  frequent  spontaneous  vomiting  is  a  pronrinent  symptom. 

After  the  disease  has  continued  for  a  short  time,  the  discharges  from  the  bowels  are  ordi 
narily  composed  entirely  of  a  perfectly  colourless  and  inodorous  fluid,  containing  often  minutu 
mucous  flocculi,  and  are  disch-arged  without  the  least  eflbrt.    They  are  occasionaMv  .however, 


812  CHOLERA    INFANTUM. 

very  small  in  quantity,  and  squirted,  as  it  were,  from  the  anus.  Li  these  cases,  there  is  usually 
more  or  less  tormina  and  tenesmus. 

Very  frequently  the  vomiting  becomes  suspended,  even  at  an  early  period  of  the  attack, 
■while  the  discharges  froin  the  bowels  continue,  or  augment  in  frequency  and  in  quantity, 
the  irritability  of  the  intestinal  canal  being  often  such,  as  to  cause  whatever  food  or  drink 
is  taken  to  pass  off  rapidly,  without  having  undergone  the  slightest  change. 

The  infant  becomes  quickly  afl'ected  with  extreme  langour  and  prostration,  and  is  rapidly 
emaciated  —  being  reduced  in  a  few  days,  often  hours,  to  an  extent  that  would  scarcely  be 
credited  by  those  unacquainted  with  the  disease. 

The  pulse,  from  the  very  commencement  of  the  attack,  is  usually  quick,  frequent,  small, 
and  often  tense.  The  skin  is  dry  and  harsh,  the  head  and  abdomen  are  often  hot,  while  the 
extremities  retain  their  natural  temperature,  or  are  even  decidedly  cold.  The  tongue  ia 
moist,  and  covered  with  a  white  slimy  mucus.  There  is  always  intense  thirst  —  whatever 
fluid  is  taken  being  almost  immediately  ejected  from  the  stomach.  The  child  sulfers  more 
or  less  pain  in  the  abdomen,  as  indicated  by  its  fretful ness,  low  moaning  cries,  frequent 
change  of  posture,  the  drawing  up  of  its  knees,  and  its  occasional  acute  screams.  The  abdo- 
men is  sometimes  tumid,  and  generally  tender  to  the  touch.  Towards  evening,  there  occurs, 
in  most  cases,  a  decided  febrile  reaction. 

In  many  cases,  some  degree  of  delirium,  with  an  injected  and  wild  appearance  of  the 
eyes,  and  a  tossing  of  the  head  backwards  and  forwards,  is  early  manifested.  When  this  is  the 
case,  we  have  frequently  seen  the  patient  attemjot  to  bite  or  scratch  his  attendants. 

The  disease  usually  runs  a  protracted  course.  The  discharges  from  the  bowels  continue 
to  be  frequent  and  profuse,  but  dark-coloured,  like  dirty  water,  or  the  washings  of  stale  mea^ 
and  often  very  offensive.  They  not  unfrequently,  however,  are  small  in  quantity,  and  composed 
entirely  of  a  dark-coloured  mucus,  mixed  with  the  food  and  drinks  that  have  been  taken. 
The  emaciation  of  the  patient  becomes  extreme;  his  eyes  are  languid,  hollow,  and  glassy;  his 
countenance  pale  and  shrunken;  his  nose  sharp  and  pointed;  and  the  lips  thin,  dry  and 
shrivelled.  The  surface  of  the  body  becomes  cool  and  clammy,  of  a  dirty  brownish  hue,  and 
often  covered  with  petechiffi.  The  tongue  is  dark-coloured,  smooth  and  shining,  or  covered, 
as  well  as  the  parieties  of  the  mouth,  with  aphtha.  In  many  cases  the  child  lies  constantly 
in  an  imperfect  doze,  with  half-closed  eyelids,  and  so  insensible  to  external  impressions,  that 
flies  will  frequently  light  upon  the  half-closed  eyeballs  without  the  patient  exhibiting  the 
least  consciousness- of  their  presence.  The  abdomen  becomes  more  or  less  tympanitic,  and 
tlie  hands  and  feet  of  a  leaden  hue,  or  pallid  and  cedematous.  The  fauces,  becoming  dry, 
causes  a  sense  of  uneasiness,  which  induces  the  patient  to  thrust  his  hand  deep  in  the  mouth, 
as  if  to  remove  some  offending  substance. 

In  many  of  the  protracted  cases,  an  eruption  of  very  minute  white  vesicles  occurs  upon 
the  neck  and  breast.  This  Dr.  Dewees  considered  to  be  invariably  a  fatal  symptom  ;  but  we 
have  seen  many  patients  recover,  even  when  this  eruption  has  been  the  most  extensive  and 
distinct. 

The  patient,  unless  relieved  from  his  suffering  by  a  judicious  treatment,  becomes  daily 
more  and  more  exhausted,  rolls  his  head  about  when  awake,  and  utters  constantly  short, 
plaintive,  scarcely  audible  cries.  He  falls  at  length  into  a  state  of  complete  coma,  death  being 
frequently  preceded  by  a  convulsive  attack.  Not  unfrequently,  at  a  much  earlier  period  of 
tlie  disease,  the  brain  becomes  affected,  and  the  child  dies  with  all  the  symptoms  of  acute 
meningitis. 

Cholera  infantum  is  of  very  variable  duration.  In  violent  attacks,  the  prostration  which 
suddenly  ensues  is  occasionally  so  extreme,  that  the  patient  is  destroyed  within  the  first 
twenty-four  hours.  Usually,  however,  the  disease  is  of  many  days,  or  even  weeks'  con- 
tinuance, and  the  patient  generally  sinks,  apparently  from  a  total  cessation  of  the  nutrition 
of  the  system. 

The  lesions  exhibited  by  the  post-mortem  examination  of  those  who  have  died  from  cholera 
infantum,  vary  according  to  the  period  of  the  disease  when  death  takes  place.  When  the  dis- 
ease has  been  of  short  continuance,  the  mucous  membrane  of  the  alimentary  canal  presents 
often  an  abnormal  paleness,  and  the  liver  is  more  or  less  congested.  When  the  case  has  been 
of  a  more  protracted  character,  increased  redness  in  points  or  patches,  in  different  parts  of  the 
stomach  and  intestines,  is  often  present.  The  red  points  are  sometimes  very  minute  and 
isGiated,  and  spread  over  a  considerable  portion  of  the  stomach  and  duodenum,  or  over  the 
fcmall  intestines  only.  They  have  the  appearance,  generally,  of  minute  extravasations  of 
blood.  In  the  lower  intestines  the  points  occur  in  clusters,  so  as  to  form  patches  of  redness, 
varying  in  size,  though  never  of  any  great  extent,  and  often  slightly  elevated,  from  a  thick- 
ening of  the  mucous  tissue  at  the  parts  occupied  by  them.  Occasionally,  portions  of  the 
mucous  membrane  are  more  or  less  softened — often  witliout  the  slightest  inflammation.  In 
other  instances,  increased  redness  of  some  portion  of  the  intestines  exists,  with  contractions, 
often  extreme,  of  its  calibre. 

The  mucous  follicles  of  the  intestines  are  very  generally  enlarged,  often  in  a  state  of 
inflammation,  and  occasionally  of  ulceration.     Dr.  Horner  describes   the   appearance  of  the 


CHOLERA    INFANTUM.  813 

enlarged  follicles,  as  resembling  a  sprinkling  of  white  sand  upon  the  surface  of  the  mucous 
membrane.  The  intestines  are  generally  empty,  or  contain  merely  a  small  amount  of  thick 
tenacious  mucus.  Drs.  Page  and  Lindsly  describe  an  appearance  of  dark  spots  upon  the 
mucous  membrane  of  the  stomach,  above  its  pyloric  oriiice.     We  have  never  detected  it. 

The  liver  is  almost  invariably  enlarged,  and  more  or  less  congested  ;  while  the  gall-bladder 
is  filled  with  dark-green  bile,  or  a  pale  and  almost  colourless  fluid.  Dr.  Page  tlescribes 
the  liver  as  being  in  some  cases  large,  soft,  and  spongy ;  and  Dr.  Horner,  as  being  usually  of 
a  light  yellow  or  mottled  colour. 

In  the  more  protracted  cases,  indications  of  inflammation  of  the  meninges  of  the  brain  are 
very  frequently  present. 

The  prognosis  in  cholera  infantum  will  depend  very  much  upon  our  ability  to  remove  the 
patient  from  the  influence  of  the  impure  and  heated  air  by  which  the  disease  has  been  pro- 
duced and  is  kept  up,  as  well  as  upon  the  period  of  the  attack  at  which  the  treatment  is  com- 
menced. Without  this  removal,  it  is  scarcely  possible  to  effect,  in  any  case,  a  permanent  cure  ; 
while  in  most  cases — in  their  commencement,  at  least — little  else  is  required  to  arrest  the  dis- 
ease: even  at  a  later  period,  its  effects  are  often  strikingly  evinced  in  the  rapid  improvement 
of  the  patient,  from  almost  the  very  moment  the  removal  takes  place.  In  cases  where  the  dis- 
ease has  continued  for  many  days,  and  reduced  the  patient  to  a  state  in  which  a  fatal  termina- 
tion would  seem  inevitable,  by  removal  to  the  free  open  air  of  the  country,  and  an  appropriate 
course  of  treatment,  a  very  rapid  recovery  is  often  effected. 

Cholera  infantum  is  evidently  produced  by  the  action  of  a  heated,  impure,  and  stagnant 
atmosphere,  directly  upon  the  skin,  and  indirectly  upon  the  digestive  mucous  surface,  at  an 
age  when  the  latter  is  strongly  predisposed  to  disease  from  the  effects  of  dentition,  and  fiom 
the  increased  development  and  activity  of  the  muciparous  follicles  which  takes  place  at  that 
period. 

The  dependence  of  cholera  infantum  upon  a  high  degree  of  atmospheric  temperature  is 
shown  by  the  fact,  that  its  prevalence  is  always  in  proportion  to  the  heat  of  the  summer ; 
the  disease  increasing  and  becoming  more  fatal  with  the  rise  of  the  thermometer,  and 
declining  with  the  first  appearance  of  cool  weather  in  the  autumn.  That,  however,  the  dis 
ease  is  not  produced  by  heat  alone,  in  its  more  aggravated  forms,  is  proved  by  its  occurring 
almost  exclusively  in  the  larger  and  more  crowded  cities  of  the  Middle  and  Southern  States, 
and  by  its  especially  prevailing,  and  being  most  destructive  to  life,  among  the  children  of  the 
poorer  classes,  inhabiting  small,  ill-ventilated  houses,  situated  in  narrow,  confined  lanes, 
courts,  and  alleys,  or  in  situations  abounding  with  accumulations  of  filth.  When  it  occurs  m 
the  country,  which  is  rarely  the  case,  it  is  almost  exclusively  in  low,  damp,  and  otherwise 
unhealthy  situations. 

The  process  of  dentition  is  unquestionably  a  predisposing  cause  of  the  disease ;  while 
premature  weaning  and  errors  in  diet  act  often  as  exciting  causes. 

In  regard  to  the  treatment  of  the  disease,  this  is  very  simple,  and  generally  successful, 
whenever  we  are  able  to  remove  the  patient  from  the  heated,  confined,  and  impure  atmo- 
sphere by  which  the  disease  has  been  generated,  to  a  situation  where  he  may  enjoy  the 
advantages  of  a  cool  air  and  free  ventilation. 

The  infant  should  be  confined  to  the  breast,  or,  if  weaned,  to  a  diet  of  fresh  rennet-whey, 
with  the  addition  of  gum  acacia,  rice-water,  tapioca,  or  plain  meat  broths,  with  some  cool, 
perfectly  bland,  and  sliglitly  mucilaginous  fiuid  for  drink.  He  should  be  immersed  daily  in 
a  bath,  warm  or  tei:)id,  according  as  the  temperature  of  the  skin  is  deficient  or  increased. 

If  the  removal  of  the  patient  is  impracticable,  he  should  be  placed  in  as  pure,  cool,  and 
free  an  atmosphere  as  possible,  and  carried  frequently  abroad  in  any  open  and  healthy  situa- 
tion in  the  neighbourhood  of  his  residence,  in  a  carriage,  or  in  the  arms — or  where  his  resi- 
dence is  near  a  large  river,  he  should  be  taken  on  the  water  in  a  boat.  His  clothing  should 
be  perfectly  clean  and  dry,  and  sufficient  to  guard  against  the  influence  of  sudden  changes 
of  temperature,  but  not  so  warm  as  to  overheat  tlie  patient :  flne  soft  flannel,  or  soft,  coarse 
■muslin,  worn  next  the  skin,  will  be  proper  in  all  cases.  His  sleeping  apartment  should  be, 
if  possible,  large  and  airy.  He  should  sleep  upon  a  mattrass,  or  on  a  blanket  folded  and 
laid  upon  the  sacking-bottom  of  the  bedstead,  or  upon  the  floor  of  the  crib,  his  body  being 
defended  by  a  light,  loose  covering. 

The  gums  should  be  carefully  examined,  and  if  they  are  hot,  swollen  and  inflamed,  they 
should  be  freely  lanced. 

When  the  disease  commences  as  a  simple  diarrhoea,  the  warm  bath,  repeated  daily,  or 
even  night  and  morning,  and  followed  by  gentle  friction  over  the  surface  of  the  body,  with 
a  hand  or  soft  dry  cloth  ;  cold  mucilaginous  drinks,  and  a  combination  of  a  sixth  of  a  grain 
of  calomel,  about  four  grains  of  prepared  chalk,  and  a  half  a  grain  of  acetate  of  lead, 
repeated  every  three  or  four  hours,  will  ordinarily  arrest  it. 

To  subdue  the  irritability  of  the  stomach,  from  a  sixth  to  a  fourth  of  a  grain  of  calomel, 
rubbed  up  with  a  little  dry  loaf-sugar,  and  sprinkled  npon  the  tongue,  will  very  generally  bo 
found  suiRcient.  When,  however,  this  fails,  a  few  drops  of  the  spirits  of  turpentine,  <v  a 
solution  of  camphor  in   sulphuric  asther,  repeated   at  short  intervals,  will  usually  succeed 


814  DYSENTERY. 

Wlien  tlie  vomiting  is  violent  and  frequent,  particularly  if  there  is  any  pain  or  tenderness 
of  the  abdomen,  a  few  leeches  to  the  epigastrium,  followed  by  a  light  emollient  cataplasm 
or  warm  fomentations,  will  be  found  decidedly  beneficial.  The  eflects  of  fomentations  to 
the  abdomen,  with  a  strong  decoction  of  hops,  have  been  spoken  of  by  many  practitioners  as 
peculiarly  soothing. 

A  teaspoonful  of  cold  water  may  be  allowed  every  fifteen  or  twenty  minutes  ;  it  is  grate- 
ful to  the  f)atient,  and  will  assist  in  allaying  the  gastric  irritability. 

When  the  irritability  of  the  stomach  is  so  far  quieted  as  to  allow  of  the  remedy  being 
retained,  the  disordered  action  of  the  bowels  will  in  most  cases  be  promptly  restrained  by  a 
combination  of  a  fourth  of  a  grain  of  calomel,  three  grains  of  prepared  chalk,  one  grain  of 
acetate  of  lead,  and  a  fourth  of  a  grain  of  ipecacuanha,  given  every  three  hours.  Under  the 
use  of  this  prescription,  the  inordinate  discharges  will  be  quickly  suspended,  and  replaced 
by  regular,  natural  stools.  The  acetate  of  lead  should  be  omitted  as  soon  as  the  watery  dis- 
charges are  arrested,  and  the  calomel,  prepared  chalk,  and  ipecacuanha,  in  the  same  pro- 
portion as  above,  continued  until  regular  and  healthy  stools  are  procured.  The  use  of  some 
one  of  the  liglit  vegetable  astringents  will  complete  the  cure.  The  full  restoration  of  the 
patient  to  strength  will  be  greatly  promoted  by  a  mild  unirritating  diet,  daily  exercise  in  the 
open  air,  and  the  most  scrupulous  cleanliness  of  person  and  clothing. 

In  cases  where  much  heat  of  the  head,  a  wild  injected  state  of  the  eyes,  aversion  from 
light,  with  delirium,  or  other  symptoms  of  cerebral  disease  ensue,  leeches  should  be  applied 
to  the  temples  or  behind  the  ears,  cold  lotions  to  the  scalp,  and  warm  sinapisms,  pediluvia,  or 
some  stimulating  embrocation  to  the  lower  extremities.  In  these  cases,  blisters  behind  the 
ears,  kept  open  by  the  use  of  some  irritating  ointment,  will  often  be  found  beneficial. 

In  the  chronic  stage  of  cholera  infantum,  the  most  efiicacious  remedies  are  the  warm  bat'.!, 
repeated  daily;  blisters  to  the  abdomen,  kept  on  until  the  skin  is  reddened  and  then  removed, 
the  part  being  covered  with  a  soft  emollient  poidtice ;  injections  composed  of  starch  and  a 
few  drops  of  laudanum  ;  small  doses  of  Dover's  powder  at  night,  with  light  astringents,  as 
kino,  decoction  of  dewberry-root  or  of  the  geranium  maculatum,  with  change  of  air,  and  a 
diet  of  boiled  milk  thickened  with  rice-flour,  or  of  plain  meat  broths  with  the  addition  oi 
rice.  A  solution  of  die  tartrate  of  iron,  twenty  grains  to  the  ounce  of  water,  with  the  addi 
tion  of  a  drachm  or  two  of  ginger  syrup,  or  the  persesquinitrate  of  iron,  maybe  administered 
with  good  eflects.  In  many  cases  the  sulphate  of  quinia  in  solution,  besides  exeriing  a  bene 
ficial  influence  upon  the  disordered  condition  of  the  bowels,  will  be  found  useful  in  restoring 
strength  to  the  patient,  who  is  always  in  a  state  of  extreme  prostration. 

When  the  stools  are  thin,  small  in  quantity,  dark-coloured,  and  highly  offensive,  with  flatu- 
lence, and  a  tendency  to  a  tympanitic  condition  of  the  abdomen,  or  when  frequent  griping 
pains  are  experienced,  the  best  effects  will  be  derived  from  the  use  of  turpentine.  It  may 
be  given  in  the  following  mixture:  —  H.  Mucil.  g.  acaciip  S'ij- j  sacch.  alb.  pur.  5ij. ;  spir. 
tether  nit.  3iij-  j  spir-  terebinth. 3ij- ;  magnes.  calc.  gr.  xiij. ;  lavend.  spir.  comp.  3ij- — M.  The 
dose  of  which  is  a  teaspoonful  three  times  a  day  —  or  oftener,  when  the  child  is  over  two 
years  of  age.  The  addition  of  3'^-  of  the  tincture  of  kino,  and  the  same  quantity  of  the 
camphorated  tincture  of  opium,  will  be  proper  in  cases  attended  with  great  irritability  of  the 
bowels. 

When  the  discharges  are  acrid,  offensive,  and  dark-coloured,  we  have  administered  with 
advantage  pulverized  charcoal,  two  to  eight  grains,  in  combination  with  two  or  three  grains 
of  powdered  rhubarb,  a  fourth  to  a  half  a  grain  of  ipecacuanha,  and  a  grain  of  extract  of 
hyosciamus  every  three  or  four  hours. 

The  umost  attention  must  be  paid  to  the  diet  of  the  patient ;  he  should  be  confined  to  meat 
broths  —  the  juice  of  roasted  meats,  with  boiled  rice  —  rice  milk  and  tapioca  in  moderate 
quantities  at  a  time — with  toast  or  rice  water,  or  rennet-whey,  with  the  addition  of  a  portion 
C'f  gum  acacia,  for  drink. — C] 


LECTURE  LXXIII. 

Dysentery.     Diarrhoea  Adiposa.     Intestinal  Concretions.     Worms. 

Another  of  the  morbid  fluxes  from  the  alimentary  tube,  of  which  I  have  yet  to 
epeak,  is  dysentery. 

Its  characteristic  symptoms  are,  griping  pains  in  the  abdomen,  followed  by  fre- 
quent, mucous  or  bloody  stools,  straining  and  tenesmus.  In  chronic  cases  pus  is 
sometimes  discharged  from  the  bowels.  The  acute  form  or  stage  of  the  disease  is 
attended  with  fever. 


DYSENTERY.  815 

The  difTerences  between  dysentery  and  diarrhoea  are  obvious  enough.  Both  of 
them  may  be  accompanied  by  griping  pains :  in  both  the  stools  are  frequent  and 
loose :  but  in  diarrhoea  they  are  fecal ;  in  dysentery  there  is  retention  of  the  natural 
feces,  or  they  are  expelled  from  time  to  time,  in  small,  hard,  separate  lumps,  termed 
scybala.  Again,  straining,  and  tenesmus,  and  the  excretion  of  mucus,  which  is  often 
tinged  with  blood,  form  no  necessary  features  in  diarrhoea ;  whereas  in  dysentery 
these  symptoms  are  prominent  and  constant.  These  nosological  distinctions  are  true 
and  useful,  although  in  our  actual  intercourse  with  the  sick,  we  do  not  find  them 
always  or  strictly  observed.  Some  of  the  worst  forms  of  dysentery  commence  with 
the  ordinary  symptoms  of  diarrhoea. 

Dysentery  consists,  essentially,  in  inflammation  of  the  mucous  membrane  of  the 
large  intestines;  yet  not,  I  apprehend,  of  the  whole  of  that  long  surface  indiscrimi- 
nately. Observation  of  the  course  of  the  disorder,  during  life,  and  of  the  morbid 
appearances  visible  after  death,  leads  to  the  conclusion  that  in  simple  dysentery, 
marked  by  tormina  and  tenesmus,  and  frequent  dejections  of  sanguinolent  mucus 
without  fecal  matter,  the  inflammation  chiefly  affects  the  rectum  and  the  descending 
colon.  When  the  earlier  portions  of  the  large  mtestines  are  involved  in  the  diseased 
process,  the  stools  at  the  outset  are  often  composed,  in  great  measure,  of  excrement 
in  an  unnaturally  fluid  state,  and  mmgled  with  blood  and  slime.  We  generally 
speak  of  these  circumstances  as  constituting  dysenteric  diarrhoea. 

Slight  and  simple  dysentery  may  occur  and  run  its  course  with  very  httle  or  no 
disturbance  of  the  circulation.  When  it  is  acute  and  severe,  it  is  attended  with  more 
or  Jess  pyrexia.  The  acute  disease  may  terminate  in  recovery  ;  or  in  early  death  ; 
or  in  chronic  dysentery,  which  usually,  in  the  end,  is  fatal. 

The  wards  of  our  metropolitan  hospitals  place  frequently  under  our  notice  severe 
cases  of  chronic  dysentery  in  the  persons  of  soldiers  and  sailors,  who  bring  the  dis- 
ease home  with  them  from  hot  climates.  With  these  exceptions,  dysentery  is,  now- 
a-days,  neither  a  very  common,  nor  a  verj''  serious  disorder  in  this  country,  I  say 
now-a-days,  for  the  time  was  when  it  raged  in  London  like  a  plague.  The  present 
Dr.  Heberden,  in  his  valuable  essay,  On  the  Increase  and  Decrease  of  different 
Diseases.,  shows,  that  in  the  seventeenth  century  the  number  of  deaths  set  down,  in 
the  weekly  bills  of  mortality,  under  the  titles  bloody  Jliix,  and  griping  in  the  guts, 
was  never  less  than  1000  annually,  and  in  some  years  exceeded  4000,  For  five- 
and-twenty  years  together,  viz.,  from  1667  to  1692,  they  every  year  amounted  to 
above  2000.  During  the  last  century,  the  number  gradually  dwindled  down  lo 
twenty.  Dysentery  is  one  of  the  pests  of  hot  climates.  In  all  tropical  regions,  at 
certain  seasons  of  the  year,  it  is  very  prevalent  and  destructive.  But  it  is  in  fleets 
and  armies,  and  especially  among  troops  in  actual  service,  that  the  distemper  most 
displays  its  terrible  power.  There  is  no  single  malady  which  is  so  crippling  to  an 
army  in  the  field  as  this.  Sir  James  M'Grigor,  to  whom  was  entrusted  the  superin- 
tendence of  the  medical  department  of  the  army,  on  "the  two  greatest  services  on 
which  the  military  force  of  this  country  has,  of  late  years,  been  employed,  namely, 
that  in  Walcheren,  and  that  in  the  Peninsula,"  calls  dysentery  "the  scourge  of 
arimes,"  and  the  "  most  fatal  of  all"  their  diseases.  In  two  years  and  a  half,  the 
British  army  in  Spain  lost  no  less  than  4717  men  by  this  complaint. 

How  are  these  facts  lo  be  explamed  1  Wherefore  is  dysentery,  which  was  so 
familiar  to  our  ancestors,  so  happily  rare  among  us  ?  Why  does  it  thus  wait  upon 
and  afflict  the  march  of  armies  ?  •  Upon  what  depends  its  frequency  in  hot  climates  ? 
We  may  expect  to  obtain  some  answer  to  these  questions  by  searching  into  the 
causes  of  the  disorder. 

It  has  been  ascribed  to  exposure  to  wet  and  cold  ;  to  the  use  of  unwholesome 
food  ;  to  the  agency  of  malaria ;  to  contagion. 

Weather  and  season  have  a  manifest  influence  in  tlie  production  of  dysentery.  In 
temperate  chmates,  Hke  our  own,  it  is  an  autumnal  disorder.  In  tropical  countries 
it  is  observed  to  be  more  common  and  more  severe  when  rains  succeed  to  long- 
continued  drought.  In  respect  to  this,  as  to  other  bowel  affections,  a  high  diurnal 
temperature  of  the  air  appears  to  be  the  predisposing,  and  exposure  to  cold  the  ex- 
citing cause,     I  stated,  on  a  former  occasion,  that  great  vicissitudes  of  temperature 


816  DYSENTERY. 

are  very  frequent  and  very  pernicious,  even  under  the  torrid  zone.  Scorching  days 
are  followed  by  extremely  cold  nights.  The  dysentery  which  arises  under  these 
circumstances  is  apt  to  run  on  into  the  ensuing  winter.  Soldiers  in  the  field  against 
an  enemy  are  peculiarly  obnoxious  to  the  agencies  which  favour  or  generate  the 
complaint.  Marching,  or  engaged  in  actual  conflict,  during  the  day ;  bivouacking 
at  night,  often  in  the  open  air,  and  under  every  variety  of  weather;  ill-provided,  too 
often,  with  clothes  and  bedding;  their  food  scanty,  precarious,  or  of  bad  quality; 
seizing  the  many  opportunities  which  their  dreadful  trade  supplies  of  license  and 
intemperance;  depressed,  it  may  be,  by  disaster  or  defeat;  we  need  not  w^onder 
either  at  the  prevalence  of  dysentery  among  them,  or  at  its  untractableness  while 
they  remain  subject  to  the  same  morbid  influences.  Neither  can  the  causes  be 
warded  off  from  the  patient,  nor,  in  general,  can  the  patient  be  removed  from  the 
causes.  Yet  occasions  do  arise  which  show  distinctly  enough  this  alleged  relation 
of  cause  and  effect.  Frxsens  morbiim  facit — sublata  tollit.  Take,  on  the  one 
side,  the  following  facts  from  Sir  John  Pringle's  book  On  the  Diseases  of  the  Army. 
The  men  who  had  fought  at  Dettingen  lay  that  night  on  the  field  of  battle,  w-ithoul 
tents,  exposed  to  a  heavy  rain.  For  the  next  night  or  tw^o  they  encamped  on  better, 
but  still  wet  ground  ;  and  they  w^anted  straw.  Nearly  half  of  these  troops  were 
soon  after  affected  with  dysentery ;  while  three  companies  which  had  not  been  engaged 
in  the  battle,  nor  exposed  to  rain,  nor  lain  wet,  escaped  the  complaint  entirely. 
Take  this  converse  fact,  related  by  Desgenettes.  Four  hundred  of  the  French 
"arm}?-  of  Egypt,"  reduced  to  a  state  of  extreme  weakness  and  emaciation  by  dysen- 
tery there  contracted,  embarked  at  Alexandria  on  their  return  towards  France;  were 
carried  away,  in  short,  from  the  alleged  causes  of  their  disorder.  Nineteen  died  at 
the  very  outset  of  the  voyage ;  which,  had,  however,  so  good  an  effect,  upon  all  the 
rest,  that  before  they  reached  Malta  they  were  thoroughly  convalescent. 

The  very  frequent  coincidence  or  alternation,  in  some  places,  of  dysentery  w-ith 
intermittent  poison,  has  given  rise  to  the  opinion  that  both  these  diseases  are  alike 
attributable  to  the  malarious  poison..  But  dysentery  prevails  where  there  is  no  other 
evidence  of  the  presence  of  malaria.  You  may  recollect  that  when  we  were  upon 
the  subject  of  ague,  I  showed  you  that  its  repeated  paroxysms  were  attended  with 
extreme  and  increasing  congestion  of  blood  in  the  internal  organs  ;  of  which  conges- 
tion the  tumid  spleen,  the  ague-cake,  was  an  effect  and  a  token.  Now,  whatever 
gorges  the  splenic  vein,  gorges  its  tributary,  the  inferior  mesenteric,  which  carries 
the  blood  from  the  rectum  and  the  descending  colon.  Upon  such  congestion  of  the 
mucous  membrane,  inflammation  is  readily  engrafted  ;  and,  in  this  indirect  way, 
dysentery  may  be  said  to  result  from  the  marsh  effluvia.  Ague  is  an  effect  of  ma- 
laria, and  dysentery  is  sometimes  a  sequela  of  ague.  In  precisely  the  same  manner, 
dysentery  is  apt  to  supervene,  in  hot  chmates  especially,  upon  hepatic  congestion 
and  disease. 

That  dysentery  is,  in  itself,  a  contagious  malady,  we  have  no  satisfactory  evi- 
dence. In  its  sporadic  form,  in  this  country,  we  never  see  it  spread  from  person  to 
person.  But  it  is  a  prominent  symptom  in  some  epidemic  visitations  of  continued 
fever,  which  undoubtedly  is  contagious.  To  this  fact  I  am  inclined  to  attribute  the 
notion,  formerly  much  more  common  than  it  now  is,  that  simple  dysentery  is 
catching. 

The  remarkable  decline  of  dysentery  in  this  metropolis  has  been  cotemporary  with 
that  of  other  disorders,  and  is  due  to  the  same  combination  of  causes.  For  nearly 
two  centuries  we  have  had  no  plague  among  us.  Agues,  formerly  very  rife  in  Lon- 
don, have  almost  disappeared.  Continued  fevers,  wdiich  used  to  break  out  annually 
m  hot  weather,  are  comparatively  unfrequent.  I  believe  that  we  may  trace  these 
great  blessings  to  an  event  which  was  regarded,  at  the  time,  as  a  national  judgment ; 
[  mean  the  great  fire  that,  in  1606,  consumed  everything  between  Temple  Bar  and 
the  Tower.  The  streets  and  houses  thus  destroyed  had  been  filthy  in  the  extreme, 
close,  densely  crowded,  and  consequently  most  unhealthy.  The  impurity  of  the  air 
excited,  perhaps,  some  maladies ;  and  it  certainly  predisposed  those  who  dwelt  in  it 
10  various  kinds  of  diseases,  "the  seeds  of  which  (says  Dr.  Heberden)  like  those  of 
vegetables,  will  only  spring  up  and  thrive  when  they  fall  upon  a  soil  convenient  fo! 


DYSENTERY.  817 

their  growth."  To  the  better  construction  of  the  houses  and  of  the  streets  in  the 
rebuilt  cit)' ;  to  the  increased  means  of  ventilation  ;  to  the  general  formation  of  drains 
and  sewers;  to  the  more  copious  supply  of  water;  and  to  the  more  temperate  and 
cleanly  habits  of  the  people  ;  we  may  fairly  ascribe  our  present  exemption  from 
dysentery,  from  ague  and  continued  fever,  which  are  often  the  parents  of  dysentery, 
and  from  the  plague  itself.  In  too  many  parts  of  this  overgrown  place,  there  is  still 
much  room  for  improvement. 

The  pyrexia  that  accon?panies  dysentery  sometimes  begins  before  the  local  symp- 
toms declare  themselves ;  more  frequently  it  succeeds  their  manifestation.  Occa- 
sionally the  fever  runs  high,  the  pulse  is  hard  and  frequent,  the  skin  hot,  the  face 
jflushed,  and  the  tongue  furred ;  and  the  patient  complains  of  headache  and  thirst. 
But  in  this,  as  in  other  abdominal  diseases,  the  pulse  soon  becomes  small  and  weak, 
the  strength  rapidly  declines,  and  the  temperature  of  the  body  sinks. 

In  acute  cases,  the  pain  is  often  severe  ;  but  it  is  subject  to  remissions  and  exacer- 
bations. It  occupies  the  hypogastrium,  or  some  part  of  the  course  of  the  colon, 
where  there  is  usually  more  or  less  tenderness  on  pressure.  The  patient  is  tormented 
by  a  sensation  as  if  there  were  some  excrement  ready  to  be  dislodged,  goes  perpe- 
tually to  the  night-chair,  and  is  irresistibly  impelled  to  strain  violently  to  get  rid  of 
the  irritation.  But  the  efforts  are  ineffectual ;  he  discharges  but  little  ;  and  what  is 
voided  is  either  altogether  a  jelly-like  mucus  (in  which  case  the  complaint  has  been 
called  the  dysenteria  alba,  and  the  morbus  mucosus),  oi  more  commonly  it  is  mucous 
and  bloody  (the  bloody  flux  of  our  old  authors),  mixed  with  films,  and  membranous 
shreds,  and  morsels  that  resemble  flesh.  In  many  of  the  dejections  there  is  no 
genuine  fecal  matter  at  all;  or  the  small  indurated  balls  which  I  just  now  mentioned 
come  away  occasionally.  Frequently  the  ejected  mucus  is  variegated  in  colour, 
green,  or  black,  or  reddish,  like  the  washings  of  meat,  and  horribly  fetid.  Some- 
times pain  and  difficulty  in  making  water  are  added ;  there  is  dijsuria,  the  irritation 
of  the  rectum  being  reflected  upon  the  bladder  through  the  lower  portion  of  the 
spinal  cord.  Sometimes  the  stomach  sympathizes,  and  nausea  and  vomiting  ensue. 
With  all  this  local  suffering  there  is  a  continuance  of  febrile  distress ;  the  patient 
passes  sleepless,  or  dreamy  and  disturbed  nights,  and  is  low-spirited  and  desponding. 
in  the  fatal  cases,  the  pulse  becomes  very  smaU  and  rapid,  the  features  sharpen,  and 
the  surface  grows  cold.     Death  begins  at  the  heart. 

Inspection  of  the  dead  body  discloses  more  or  less  ulceration,  chiefly  of  the  large 
■■sitestine.  The  glands  that  are  scattered  over  its  surface  are  enlarged  and  prominent, 
:!Ooking  somewhat  like  small-pox  pustules,  for  which  indeed  they  have  been  mis- 
taken. They  probably  form  the  foci  of  most  of  the  ulcers,  which  are  sometimes 
narrow  and  oblong,  lying  across  the  gut;  sometimes  very  large  and  irregular,  with 
here  and  there  islands  or  ridges  of  thickened  mucous  membrane.  In  the  worst 
cases,  the  whole  extent  and  circumference  of  the  bowel  present,  internally,  one  irre- 
gular, confused,  and  tattered  mass  of  disorganization. 

[In  tbe  ordinary  cases  of  dysentery,  the  morbid  appearances  detected  after  death  are,  in- 
flammation witli  thickening  of  the  mucous  membrane  of  the  colon  and  rectum  ;  occasionally, 
mortification  and  slougliing  of  this  membrane,  but  more  generally,  in  protracted  cases,  deep 
and  extensive  ulcerations,  in  the  course  of  the  transverse  bands  of  the  colon,  or  enlargement 
and  ulceration  of  the  follicles  of  the  large  intestines.  In  the  more  violent  forms  of  the  dis- 
ease, especially  those  which  occur  in  hot  and  intertropical  climates,  in  addition  to  the  inflam 
mation.  ulceration,  mortification,  or  sloughing  of  the  inner  coat  of  the  large  intestines,  there 
is  often  morbid  vascularity  of  the  mesocolon,  mesentery  and  omentum,  with  adhesions  of  the 
omentum  to  the  adjacent  viscera,  and  of  contiguous  portions  of  the  intestines  to  each  other. 
The  latter  usually  happen  only  when  ulcers  have  perforated  nearly  all  the  coats  of  the 
bowels.  The  glands  of  the  mesocolon  and  mesentery  are  often  enlarged,  sometimes  in 
flamed,  and  more  rarely  in  a  state  of  suppuration ;  the  corresponding  portion  of  the  intestine 
being  usually  the  seat  of  a  deep  and  extensive  ulcer.  The  omentum  occasionally  adheres  to 
these  diseased  glands,  forming  a  band  by  which  a  portion  of  intestine  may  become  strangu 
lated  and  be  the  cause  of  death. 

The  ulcerations  of  the  large  intestines  are  commonly  most  numerous  and  extensive  in  the 

caecum  and  upper  portion  of  the  colon.    The  ileo-ctpcal  valve  has,  in  some  eases,  been  found 

entirely  destroyed  by  the  ulceration  ;  the  lower  portion  of  the  ileum  forming  then  an  intus- 

su.sception  into  the  caecum,  and  becoming  there  strangulated  has  caused  death.     In  a  lb'* 

53  3t 


818  DYSENTERY. 

more  fortunate  instances,  the  strangrulated  portion  of  the  ileum  sloughs  off,  after  adhesion  has 
taken  place  between  the  adjacent  parts,  so  as  to  maintain  the  continuity  of  the  canal,  when 
the  patient  may  recover.  The  right  portion  of  the  omentum  is  not  unfrequently  found  ad- 
hering to  the  ctecum,  and  this  morbid  attachment  gives  rise  to  symptoms  which  may  be  mis- 
taken for  hepatic  abscess.  Sometimes,  in  the  whole  course  of  the  colon,  we  find  not  more 
than  eight  or  ten  deep  ulcerations,  with  sloughing,  thick,  abrupt,  raised  edges,  surrounded  by 
an  extensive  thickened  base,  into  which  sinuses  arid  undermining  cavities  are  seen  to  pene- 
trate. These  appearances,  Mr.  Twining  states,  (opera  citat.)  have  reminded  him  of  the  foul 
ulceration  at  the  centre  of  a  small  carbuncle ;  he  has  seen  several  patients  die  with  only  six 
or  eight  of  these  idcers  in  the  colon.  The  patients  had  a  flushed  face,  restlessness,  and 
symptoms  of  continued  fever,  which  were  with  difficulty  controlled  by  any  course  of  treat- 
ment. 

The  last  three  or  four  inches  of  .the  ileum  are  generally  studded  with  superficial  ulcera- 
tions, and  have  a  rough  appearance  from  the  enlarged  follicles  and  glandular  bodies ;  with 
this  exception,  we  rarely  meet  with  any  traces  of  disease  in  the  small  intestines  in  those 
who  die  of  d3'sentery — excepting  in  those  cases  in  which  the  dysenteric  symptoms  occur 
towards  the  tennination  of  protracted  fevers. 

In  a  few  instances  the  coats  of  the  colon  are  so  much  thickened,  that,  when  a  transverse 
section  is  made,  its  canal  stands  open  like  a  thick  leathern  tube,  the  interior  of  the  intestine 
being  covered  with  numerous  large  ragged  ulcers,  in  the  intervals  of  which  the  mucous 
membrane  is  partly  destroyed,  and  hangs  in  shreds.  In  several  of  these  cases,  Mr.  Twining 
(o?i  tJie  Diseases  of  Bengal),  has  observed  the  caecum,  and  lower  portion  of  the  ascending 
colon,  to  be  nearly  covered  with  a  thick  layer  of  coagulable  lymph,  deposited  beneath  the 
peritoneal  coat,  and  extendii^g  a  considerable  distance  along  the  iliacus  muscle;  in  some  in- 
stances an  unusual  amount  of  fat  is  found  at  the  same  jiart  mixed  with  the  lymph.  In  other 
cases,  when  the  disease  has  been  more  protracted,  the  whole  of  the  great  intestines  are  con- 
tracted in  diameter,  resembling  a  cord,  their  mucous  coat  being  at  the  same  time  covered 
with  numerous  small  superficial  ulcers.  In  such  cases,  also,  the  internal  surface  of  the 
caecum,  and  of  four  or  five  inches  of  the  colon,  will  now  and  then  be  of  a  livid  red  colour 
inclining  to  brown,  having  a  fleshy  appearance,  as  if  from  a  growth  of  granulations.  Mr. 
Twining  (opera  citat.)  has  met  with  this  condition  but  seldom,  but  when  it  has  existed.,  he 
has  found  it  to  extend  also  to  a  small  part  of  the  sigmoid  flexure  of  the  colon.  The  patients 
in  these  cases  had  become  much  emaciated,  with  flat  contracted  abdomen,  dry  skin,  tongue 
of  a  slate  colour,  glossy  and  morbidly  clean,  as  if  skinned  ;  the  stools  consisted  of  an  opaque 
dirty-brown  water. 

When  death  takes  place  after  protracted  suffering  from  dysentery,  ■we  often  find  the  cel- 
lular structure  at  the  root  of  the  mesentery  and  mesocolon,  and  across  the  bodies  of  the 
lower  lumbar  vertebrae,  deprived  of  its  usual  elasticity  and  pliability,  and  to  a  certain  degree 
indurated ;  and  in  many  cases  entirely  devoid  of  fat.  This  change  is  probably  the  result 
of  a  previous  inflammation  at  this  part — giving  rise  to  an  exudation  of  coagulable  lymph  into 
the  interstices  of  the  cellular  substance. — C] 

When  submitted  to  early  treatment,  and  when  its  exciting  causes  can  be  averted, 
or  avoided,  dysentery  is  not  an  intractable  disorder.  Sir  James  M'Grigor  remarks 
of  the  camp  dysentery  in  the  Peninsula,  that  it  had  two  stages,  which  it  was  of  con- 
sequence to  note,  because  they  required  different  and  almost  opposite  modes  of  treat- 
ment :  the  inflammatory  stage,  and  the  stage  of  ulceration.  A  plan  proposed  by  Dr. 
Somers  appeared  to  Sir  James  so  judicious,  and  proved  so  successful,  in  the  first  at- 
tacks of  the  pure  unmixed  disease,  that  he  recommended  its  general  adoption  in  the 
army.     It  was  this  : 

First,  the  patient  was  freely  bled.  Immediately  afterwards  twelve  grains  of  Do- 
ver's powder  were  administered.  This  dose  was  repeated  three  times,  at  intervals 
of  one  hour.  Plenty  of  warm  barley-water  was  at  the  same  time  given,  and  profuse 
sweating  encouraged  for  six  or  eight  hours.  A  pill,  contaming  three  grains  of  calomel 
and  one  of  opium,  was  exhibited  every  second  night;  and  in  the  intervening  days 
two  drachms  of  Epsom  salts  dissolved  in  a  quart  of  light  broth.  The  venesection 
was  repeated,  while  the  strength  and  the  pulse  permitted  it,  until  the  stools  were 
free  or  nearly  free  from  blood  ;  and  Dover's  powder  as  a  sudorific,  was  always  given 
after  the  blood-letting.  When  the  pains  were  great,  and  attended  with  much  tenes- 
mus, the  warm  bath  gave  instantaneous  relief.  "  This  plan  being  steadily  persevered 
in  for  a  few  days,  the  inflammatory  diathesis  of  the  intestinal  canal,  which  had  ex- 
cited symptomatic  fever  throughout  the  general  system,  was  found  gradually  to  yield, 
and  make  way  for  returning  health." 

If  the  disease  was  not  cut  short  by  this  method,  but  advanced  into  the  second 


DYSENTERY.  819 

stage,  and  became  chronic,  the  most  effectual  remedies  appeared  to  be  laxatives,  and 
opiates,  given  alternately  ;  and  combined  vpith  such  medicines  as  promote  perspira 
tion.  The  abdomen  should  be  swathed  with  flannel,  or  covered  by  a  warm  adhesive 
plaster.  Much  benefit  may  be  obtained  from  the  employment  of  clysters,  if  there  be 
not  too  much  tenesmus  to  admit  of  the  introduction  of  the  pipe  of  the  injecting  syringe 
Warm  starch,  with  laudanum  in  it — not  exceeding  in  quantity  a  couple  of  ounces, 
lest  the  irritable  bowel  should  expel  it  again — will  sometimes  afford  signal  relief. 
Or  if  the  pain  and  tenesmus  are  so  great  that  a  clyster-pipe  cannot  be  used — or  the 
enema  is  not  retained — a  grain  or  two  of  solid  opium  inserted  into  the  rectum  beyond 
the  sphincter  ani,  will  often  allay  the  distress.  The  food  should  be  farinaceous  and 
simple  ;  and  great  care  must  be  taken  during  the  convalescence  to  prevent  a  return 
to  improper  diet,  and  a  fresh  exposure  to  cold. 

There  is  one  important  point  in  the  treatment  of  dysentery,  concerning  which  a 
striking  discrepancy  of  opinion  exists,  even  amongst  practitioners  who  have  had  large 
experience  of  the  disease  :  I  allude  to  the  employment  of  mercury  as  a  remedy.  I 
have  no  data  for  settling  the  question :  but  the  amount  of  evidence  appears  to  be 
against  its  indiscriminate  use.  It  seems  (as  we  might  expect)  to  be  powerful  both 
for  good  and  for  evil.  Sir  James  M'Grigor  has  probably  hit  the  distinction  which 
should  guide  us  to  prescribe  or  to  withhold  this  drug.  It  was,  he  tells  us,  when  the 
dysentery  was  complicated  with  disease  or  disorder  of  the  liver,  that  mercury  proved 
so  highly  useful :  when  along  with  the  dysenteric  symptoms  there  were  present  a 
dull  pain  in  the  hepatic  region,  and  in  the  right  shoulder,  a  yellowish-brown  colour 
of  the  skin,  and  of  the  conjunctiva,  and  uneasiness  when  the  patient  lay  in  any  other 
posture  than  on  the  right  side.  He  adds  :  "  In  the  early  stage  of  the  acute  and  un- 
mixed disease,  and  before  venesection  has  been  performed,  mercury  will  aggravate 
the  symptoms.  In  the  more  advanced  stage  of  the  disease,  particularly  when  there 
is  hectic  fever,  Avith  extensive  erosion  or  ulceration  of  the  intestine,  it  is  invariably 
found  to  hurry  it  on  to  a  fatal  termination." 

The  sporadic  dysentery  which  we  chiefly  see  in  this  country  seldom  requires  the 
lancet.  Leeches,  however,  are  to  be  applied,  in  the  track  of  the  colon,  wherever 
there  is  much  tenderness  or  pressure.  A  full  dose  of  castor  oil  may  then  be  given  ; 
and  after  that  an  opiate.  It  is  the  practice  of  some  physicians  to  prescribe  laxatives 
and  opium  together;  but  in  this  complaint  it  is  better  to  alternate  them.  Opiate 
enemata  are  of  service  for  relieving  tenesmus.  These  remedies  will  be  much  as- 
sisted by  the  warm  bath ;  by  hot  fomentations  to  the  abdomen  ;  and  by  such  means 
as  promote  the  natural  secretions  of  the  skin.  If  there  be  any  reason  to  suspect  that 
the  portal  system  is  gorged  with  blood,  complete  relief  to  the  dysenteric  symptoms 
may  often  be  obtained  by  the  practice  which  I  recommended  as  proper  in  melaena; 
viz.,  the  exhibition  of  five  grains  of  calomel  at  bed-time,  and  of  a  senna  draught  the 
next  morning,  for  two  or  three  days  in  succession.  Should  the  symptoms  still  drag 
on,  it  may  be  necessary  to  give  mercury,  even  to  the  extent  of  making  the  gums 
tender;  but  it  should  be  introduced  gradually.  Equal  parts  of  hydrargyrum  cxmi 
cretd  and  of  Dover^s  powder,  constitute  a  very  good  combination  either  in  pill  or 
powder  for  such  forms  of  the  complaint.  But  in  the  milder  cases  of  simple  sporadic 
dysentery  there  is  no  occasion,  I  had  almost  said  there- is  no  excuse,  for  giving  your 
patient  a«sore  mouth  by  the  lavish  employment  of  mercurial  remedies. 

[There  are  few  cases  of  dysentery  in  which  the  lancet,  or  the  application  of  leeches  or 
cups  to  the  abdomen  can  be  dispensed  with,  witliout  endangering  ulceration,  thicliening,  or 
other  structural  changes  in  the  mucous  membrane  of  the  intestines — by  wliich  the  sufferings 
of  the  patient  are  prolonged  and  his  life  endangered.  When  we  consider  that  the  disease 
consists  in  fact  in  an  inflammation  of  the  lining  membrane  of  the  great  intestines,  proceed- 
ing on,  more  or  less  rapidly,  to  ulceration,  and  in  the  more  violent  cases  to  gangrene  and 
sloughing,  but  little  doubt  can  be  entertained  of  the  propriety  of  blood-letting  in  its  early 
stage  ;  even  in  the  mildest  cases,  the  application  of  leeches  or  cups  to  the  abdomen  will  very 
generally  be  attended  with  marked  relief,  and  will  materially  shorten  the  duration  of  the 
attack.  The  more  violent  forms  of  the  disease  can  be  successfully  managed  only  by  the 
prompt,  free,  and  even  repeated  use  of  the  lancet,  and  the  application  at  tlie  same  time  of 
leeches  upon  that  portion  of  the  abdomen  where  pressure  causes  the  most  pain ;  and  tnis 
Bystem  of  active  depletion  must  be  continued,  so  long  as  fever  or  tenderness  of  the  abdomeu 


820  DYSENTERY. 

continues,  more  especially  if  the  stools  continue  to  be  bloody.  The  use  of  the  warm  bath, 
in  a  few  hours  after  the  bleeding,  and  its  daily  repetition,  will  always  be  attended  with 
benefit;  or  when  there  is  no  convenience  for  the  employment  of  the  warm  bath,  the  abdo- 
men may  be  enveloped  with  cloths  wrung  out  of  warm  water,  and  repeated  as  they  lose 
their  heat,  or  covered  with  a  light,  soft  and  warm  poultice.  A  large  number  of  cases,  if 
treated  at  their  commencement  by  bleeding,  and  the  warm  bath  or  fomentations,  with  per- 
haps a  dose  of  Dover's  powder  at  night,  to  ensure  repose,  will  be  very  readily  and  speedily 
cured  by  these  means  alone. 

There  exists  much  discrepancy  of  opinion  in  regard  to  the  employment  of  purgatives  in 
dysentery. — Some  practitioners  insisting  that  they  should  be  early  commenced  with  and  re- 
peated at  short  intervals  until  natural  stools  are  procured.  While  we  cannot  perceive  any 
indication  that  purgatives  are  calculated  to  fulfil,  which  cannot  be  as  effectually  met  by 
other  less  exceptionable  remedies,  we  are  convinced  that  the  operation  of  purgatives  cannot 
fail  to  increase,  in  most  cases,  the  irritation  of  the  bowels,  and  to  augment  considerably  the 
sufferings  of  the  patient.  In  cases  where  ulceration  of  the  intestines  is  suspected  to  exist, 
we  consider  that  purgatives  are  altogether  inadmissible. 

Subsequent  to  bleeding,  the  internal  remedy  from  which  we  have  derived  the  most  ad- 
vantage in  nearly  all  the  forms  of  dysentery  that  have  fallen  under  our  notice,  is  the  ipe- 
cacuanha; we  usually  administer  it  in  doses  of  half  a  grain,  combined  with  the  blue  mass 
and  extract  of  hyoscyamus,  of  each  one  grain,  repeated  every  three  hours — ten  grains  of  the 
Dover's  powder  being  given  at  night.  After  the  discharges  from  the  bowels  have  lost  in 
some  measure  their  slimy,  bloody  appearance,  and  though  still  small,  liquid,  and  frequent, 
have  acquired  more  of  a  fecal  character,  combining  the  ipecacuanha  with  acetate  of  lead 
and  a  small  portion  of  opium,  will  be  found  in  general  to  quickly  diminish  the  tormina  and 
tenesmus,  and  to  afford  marked  and  often  very  great  relief  to  the  patient. 

Blisters  are  not  a  remedy  from  which  any  advantage  can  be  anticipated  until  after  the  more 
acute  symptoms  of  the  disease  have  been  reduced  by  bleeding — previously  they  will  often 
do  harm,  but  at  this  period  they  will  be  often  serviceable.  We  have  repeatedly  observed 
very  great  relief  to  follow  their  application. 

To  remove  the  painful  affection  of  the  bladder,  with  suppression  of  urine,  that  so  frequently 
attends  violent  cases  of  dysentery,  Mr.  Twining  recommends  injectiors  of  cold  water  into 
the  rectum  as  a  remedy  the  most  prompt  and  certain  in  its  effects.  These  injections  will  also 
be  found  an  excellent  remedy  for  the  copious  discharges  of  blood  which  frequently  occur  ; 
these  discharges  will  in  general,  however,  be  promptly  arrested  by  an  injection  of  ten  grains 
of  acetate  of  lead  in  six  ounces  of  water. 

In  cases  where  the  tenesmus  is  severe  during  the  night,  an  injection  of  sixty  drops  of  lau- 
danum in  two  ounces  of  cold  water  will  usually  remain  in  the  rectum  until  morning,  and 
promote  greatly  the  comfort  of  the  patient. 

The  intense  sufferings  which  the  patients  often  experience  from  the  severe  tormina  and 
almost  constant  and  distressing  tenesmus  attendant  upon  many  cases  of  the  disease,  tempt  the 
inexperienced  practitioner  to  resort  at  once  to  opiates  for  their  relief.  But  the  use  of  opium 
in  dysentery  requires  the  utmost  caution  ;  until  the  violence  of  the  inflammation,  in  the  more 
severe  forms  of  the  disease,  is  reduced  by  active  depletion,  they  are,  in  general,  inadmis- 
sible ;  they  are  apt  to  mask  the  more  prominent  symptoms,  and  by  the  calm  they  thus  pro- 
duce may  lead  the  physician  into  a  false  security  as  to  the  condition  of  his  patient  while  a 
fatal  disorganization  is  taking  place  in  the  intestines.  After,  however,  bleeding,  either  gene- 
ral or  local,  or  both,  according  to  the  violence  of  the  case,  has  been  carried  to  a  proper  extent, 
an  opiate  at  night  in  the  form  of  Dover's  powder,  or  during  the  day  time  opium  combined 
with  ipecacuanha  and  tlie  blue  mass,  will  often  be  demanded  to  quiet  the  tormina  and 
tenesmus,  and  in  this  manner  will  give  great  relief  to  the  patient  and  contribute  materially 
in  shortening  the  duration  of  the  most  distressing  symptoms  of  the  disease.  Opiate  injeo 
tions  are  certainly  one  of  the  most  prompt  and  efficacious  means  we  possess  of  relieving  the 
distressing  tenesmus,  which  often  continues  to  torment  the  patient  after  the  violence  of  the 
attack  has  been  reduced.  As  an  injection,  we  prefer  the  solid  opium  rubbed  up  with  olive 
oil,  flaxseed  tea  or  thin  starch.  The  tenesmus  is  usually  dependent  on  ulcerations  low  down 
in  the  rectum  ;  and  may  frequently  be  relieved  by  introducing  within  the  anus,  three  times 
a  day,  a  portion  of  the  size  of  an  hazelnut  of  an  ointment  composed  of  thirty  grains  of  acetate 
of  lead,  mixed  with  an  ounce  and  a  half  of  fresh  lard.  When  tenesmus  remains  after  the 
more  prominent  symptoms  of  the  disease  have  been  removed,  an  injection  of  one  drachm  of 
acetate  of  lead  dissolved  in  eight  ounces  of  tepid  water  was  a  favourite  prescription  with 
Masely,  and  in  many  cases  it  will  afford  prompt  relief 

The  utmost  caution  should  be  observed  in  regard  to  the  nature  and  amount  of  the  food  and 
drinks  allowed  to  the  patient  as  well  during  the  disease,  as  in  the  stage  of  convalescence.  It 
is  all  important  to  keep  the  colon  as  nearly  as  possible  empty  so  long  as  any  degree  of  in- 
flammation exists. — The  practice  followed  by  some  practitioners  of  exhibiting  to  the  patient 
large  quantities,  daily,  of  flaxseed  tea  and  other  mucilaginous  fluids,  under  the  notion  that  by 
»0  doing  we  soothe  the  inflamed  intestine,  is  productive  of  far  more  injury  than  good.     Whilst 


DYSENTERY.  821 

the  disease  continues  the  mildest  diluents  only  should  be  allowed,  and  theso  only  in  moderate 
portions  at  a  time.  Even  after  convalescence  has  been  fully  established,  the  patient  should 
be  restricted  to  the  blandest  and  most  unirritating  food,  and  this  in  very  moderate  quantity. 
Errors  in  diet,  as  Mr.  Twiningr  very  properly  remarks,  are  among  the  principal  causes  of  a 
tardy  recovery  and  frequent  relapses. 

In  describing  the  post-mortem  appearances  in  fatal  cases  of  dysentery,  we  noticed  various 
morbid  conditions  of  the  CEecum  as  of  occasional  occurrence ;  to  these  Mr.  Twining,  in  his 
work  on  the  Diseases  of  Bengal,  (page  69,)  directs  especial  attention.  No  particular  change 
in  the  general  treatment  of  the  case,  however,  is  demanded.  All  that  is  necessary  is  for  the 
practitioner  to  bear  in  mind  the  possibility  of  the  occurrence  of  more  or  less  violent  inflam- 
mation of  the  caecum,  and  by  the  most  undeviating  perseverance  in  the  employment  of  the 
remedies  demanded  for  its  removal,  especially  the  local  application  of  leeches,  to  prevent 
the  disorganization  of  the  intestine,  and  the  death  of  the  patient.  "  When,"  remarks  Mr.  T., 
"  a  considerable  enlargement  of  the  ccecum  takes  place,  during  dysentery,  it  is  usually  first 
noticed  about  ten  or  fourteen  days  after  the  commencement  of  the  attack.  There  is  not 
usually  so  much  pain  as  to  make  the  patient  complain,  particularly  of  the  part  affected ;  and 
unless  the  practitioner  habitually  examines  the  abdomen  of  those  he  is  treating  for  dysen- 
tery, he  will  be  occasionally  told  of  the  swelling  at  a  period  of  the  disease  when  the  patient 
is  past  recovery :  or  he  will  find.  Upon  dissection,  such  a  mass  of  disease  and  inflammation, 
with  induration,  in  the  right  iliac  region,  that  he  will  be  surprised  how  it  could  have  escaped 
his  notice  during  life.  Excepting  in  fat  persons,  the  rounded,  doughy,  inelastic  tumefaction 
of  the  CEecum  is  easily  detected  by  examination  with  the  hand ;  and,  in  fact,  is  often  visible 
on  inspection. 

The  inflammation  of  the  ccecum  is  to  be  treated  by  the  daily  application  of  leeches  to  the 
right  iliac  region  ;  the  discharge  of  blood  being  promoted  by  warm  fomentations  or  poultices. 
When  by  this  means  the  morbid  sensibility  is  removed,  and  the  tumefaction  considerably 
reduced,  a  blister  should  be  applied  and  kept  open  by  some  stimulating  dressing.  Mr. 
Twining  recommends  as  a  means  of  reducing  the  remaining  induration,  "  a  course  of  Plum- 
mer's  pill,  and  extract  of  colocynth,  at  night,  followed  by  the  compound  powder  of  jalap  in 
the  morning."  "We  must  remember,"  he  adds,  "that  no  part  of  the  disease  can  be  left 
unsubdued  without  hazard  to  the  patient's  life." 

In  chronic  dysentery,  there  is  frequent  watery  purging,  attended  often  with  tormina,  and 
very  generally  with  tenesmus,  by  which  the  patients  are  much  distressed  and  soon  greatly 
exhausted.  The  discharges  are  mostly  of  a  pale  gray  colour,  often  mixed  with  more  or  Less 
cf  a  mucous  or  white  slimy  substance,  and  not  unfrequently  portions  of  undigested  food. 
They  sometimes  consist  of  a  copious  paste-like  brown  mass,  in  a  state  of  fermentation  ;  occa- 
sionally, they  are  frothy,  with  a  whitish  or  pale  gray  sediment  like  a  mixture  of  chalk  and 
beer ;  in  a  few  very  protracted  cases,  the  discharges  are  very  frequent  and  copious,  quite 
Watery,  and  varying  in  colour,  from  a  dark-brown  to  a  bright-orange,  or  from  a  dirty  yellow 
to  a  pale  straw.  They  are  in  some  cases  inodorous,  or  nearly  so;  in  others  they  have  a 
peculiar  sickening  odour,  and  in  others  again  they  are  more  or  less  fetid.  Blood  is  rarely 
present  in  the  stools,  and  the  patients  suffer  from  fever  only  in  those  cases  in  which  there  is 
extensive  disease  of  the  mesenteric  gland — when  they  occasionally  presented  a  well-marked 
fever  of  a  hectic  character.  The  abdomen  is  generally  flat,  inelastic,  and  somewhat  retracted; 
occasionally,  however,  tympanitis  is  a  troublesome  symptom.  The  skin  is  usually  dry,  shri- 
veled, and  desquamating,  and  of  a  dirty  brown  or  sallow  hue. 

The  treatment  of  chronic  dysentery  differs  but  little  from  that  proper  in  cases  of  chronic 
diarrhoea.  During  the  continuance  of  the  disease,  and  for  some  period  after  it  has  been 
removed,  the  patient  is  to  be  strictly  confined  to  a  mild,  i^nirritating  diet,  taken  in  very 
moderate  quantity,  and,  for  drink,  to  some  bland  mucilaginous  fluid,  as  toast  or  rice  water — 
and  even  this  only  in  such  portions  as  are  necessary  to  allay  his  thirst.  He  should  be 
shielded  from  the  influence  of  cold  and  damp,  and  all  sudden  atmospherical  changes,  by 
flannel  next  his  skin  and  appropriate' clothing,  and  by  a  careful  attention  to  the  temperature 
of  the  chamber  he  occupies. 

Leeches  or  cups  to  the  abdomen  will  frequently  be  found  of  service  —  but  their  use  will 
require  judgment,  and  a  close  scrutiny  of  each  case  in  order  that  any  latent  or  chronic  inflam- 
mation may  be  at  once  detected.  Whenever  indurations  within  the  abdomen  can  be  felt, 
and  they  are  attended  by  morbid  sensibility  on  pressure  or  the  least  degree  of  febrile  excite- 
ment, the  application  of  leeches  or  cups  should  not  be  neglected.  When  the  indurations  are 
without  sensibility,  or  after  this  has  been  removed,  blisters  are  generally  very  importatit 
remedies.  The  daily  use  of  the  warm  bath  and  warm  fomentations  to  the  abdomen  assidu- 
ously employed,  are  means  from  which,  in  cases  of  chronic  dysentery,  the  most  decided 
advantage  will  invariably  result.  Small  doses  of  ipecacuanha  combined  with  extract  of 
byosciamus  and  the  blue  mass,  and  repeated  every  three  hours,  with  a  dose  of  Dover's  pow- 
der at  night,  will  generally  be  found  to  aid  very  effectually  in  restoring  the  capillary  v,ircu 
lation  to  its  healthy  state,  in  quieting  the  morbid  irritability  of  the  mucous  membrane  of  tho 
intestines,  in  moderating  the  profuse  morbid  discharges,  and  in  rendering  the  stools  less  frt^ 

3x2 


822  DIARRHCEA    ADIPOSA. 

qiient  and  of  a  more  natural  character.  The  balsam  of  copaiba  and  turpentine  will  often 
be  found  of  equal  advantage  in  many  cases  of  the  present  affection,  as  in  chronic  diarrhcea. 
In  regard  to  the  period  proper  for  the  employment  of  astringents,  and  the  articles  of  this 
kind  that  are  best  adapted  to  the  disease,  the  same  remarks  may  be  repeated  as  were  made 
in  our  note  on  chronic  diarrhcea. — C] 

The  fluxes  of  which  I  have  hitherto  spoken  have  all  consisted  in  an  immoderate 
discharge  of  some  of  the  usual  contents  or  secretions  of  the  alimentary  tube,  in  an 
altered  and  unnatural  state.  But  matters  are  sometimes  voided  from  the  bowels, 
totally  unlike  atiy  of  the  healthy  discharges.  Adeps  is  not  an  intestinal  excretion, 
yet  it  is  sometimes  passed  in  great  abundance  by  stool.  Many  unquestionable 
instances  of  this  are  on  record,  both  in  ancient  and  in  modern  literature.  I  have  not 
seen  more  than  one,  and  therefore  have  but  little  to  say  upon  the  subject ;  yet  I  must 
not  pass  it  over  altogether.  A  certain  quantity,  sometimes  it  has  been  a  large  quan- 
tit)'^,  of  oil,  or  liquid  fat,  has  been  poured  forth,  in  a  sort  of  diarrhoea.  Sauvages 
was  aware  of  the  disorder,  and  calls  it,  in  his  Nosology,  diarrhcea  adiposa.  In  a 
paper  in  the  Medico-Cldrurgical  Transactions  upon  this  affection.  Dr.  Elliotson 
refers  to  an  example  of  it  described  by  Tulpius,  in  which  a  woman  discharged  every 
day,  for  fourteen  months,  a  considerable  quantity  of  yellow  fat,  that  lay  upon  the  feces 
like  melted  butter.  When  voided  into  a  vessel  of  water,  it  floated,  like  oil,  upon 
the  surface  ;  and  when  cold  it  assumed  the  consistence  and  appearance  of  fat.  Like 
fat,  it  was  very  inflammable,  and  burned  with  a  bright  flame.  With  all  this  there 
was  no  kind  of  distress,  nor  any  wasting  of  the  body ;  and  the  patient  was  in  excel- 
lent health  sixteen  years  afterwards.  Dr.  Elliotson  had  a  case  of  this  kind  under 
his  own  care.  The  man  had  also  diabetes  and  phthisis.  The  symptoms  were  pre- 
cisely the  same  as  those  described  by  Tulpius.  Dr.  Prout  and  Dr.  Faraday  ana- 
lyzed portions  of  the  adipose  matter,  and  they  pronounced  it  to  be  genuine  fat.  Mr. 
Lloyd,  of  St.  Bartholomew's  Hospital,  has  given  us  the  details  of  a  case  in  which  the 
evacuation  of  grease  was  associated  with  jaundice.  The  excretion  looked  like  melted 
fat,  but  when  cool  had  the  consistence  of  butter.  Tt  swam  on  the  surface  of  water, 
melted  at  a  moderate  heat,  and  burned  readily.  In  this  instance  the  head  of  the  pan- 
creas, and  the  duodenum,  were  involved  in  a  mass  of  scirrhous  disease.  And  this  is 
a  very  curious  fact :  for  Dr.  Bright  also  states  that  in  three  different  persons,  each  of 
whom  he  had  known  to  pass  fat  from  the  bowels  during  life,  and  whose  bodies  he 
had  the  opportunity  of  examining  after  death,  he  found  scirrhous  disease  of  the  pan- 
creas, and  fungus  disorganization  of  the  duodenum. 

The  remarkable  coincidences,  occurring  so  often,  of  these  fatty  discharges  with 
cancerous  disease  of  the  pancreas  and  duodenum,  is  well  worthy  of  being  borne  in 
mind  ;  although  it  may  not,  as  yet,  afford  any  explanation  of  the  phenomenon. 

The  single  case  of  which  I  have  had  any  cognizance  is  that  of  a  tradesman  now 
living  in  my  neighbourhood,  who  from  October  1843  to  August  1844,  suffered  fre- 
quent attacks  of  this  kind.  First,  he  had  severe  pain  in  the  epigastrium  and  right 
hypochondrium,  with  little  or  no  fever,  nor  acceleration  of  pulse.  Occasionally, 
when  the  pain  was  extreme,  it  was  accompanied  by  nausea  and  vomiting.  After 
the  pain  came  jaundice  and  white  stools  ;  and,  lastly,  a  discharge  from  the  bowels  of 
a  quantity  of  white  fragments,  looking  exactly  like  coarse  chewings  of  walnuts. 
Sometimes  much  larger  lumps  of  the  same  sort  were  voided.  These  lumps  and 
fragments  were  found  to  be  composed  of  adeps.  They  floated,  many  of  them  at 
least,  for  a  while  upon  the  surface  of  the  water.  They  fek  greasy ;  and  burned,  like 
fat,  with  a  flame. 

After  this  series  of  symptoms,  the  patient  would  recover  perfectly,  save  that  the 
attacks  reduced  his  strength  somewhat.  They  occurred  about  once  a  fortnight,  so 
that  he  had  about  a  score  of  them  in  ten  months. 

The  symptoms  resembled  those  which  declare  the  passage  of  gall-stones :  and 
upon  one  occasion  two  concretions  were  detected  among  the  fragments  of  fat.  One 
of  these  was  yellowish  ;  the  other  black,  hke  a  cinder.  Once  also,  a  considerable 
portion  of  what  seemed  membrane  came  away.  My  neighbour,  Mr.  Francis  E. 
Hicks,  (to  whose  kindness  I  am  indebted  for  the  opportunity  of  seeing  this  patient,) 
is  of  opinion  that  a  cyst,  which  secreted  the  fat,  existed  in  the  liver,  and  di?- 


INTESTINAL    CONCRETIONS.  823 

charged  its  contents  periodically ;  and  that  the  membranous  fragment  was  a  part  of 
this  cyst. 

Projecting  a  little  into  the  epigastric  notch,  I  could  feel  what  appeared  to  be  the 
edge  of  the  left  lobe  of  the  liver.  This  spot  was  slightly  tender  and  dull  under  per- 
cussion. 

I  had  previously  been  consulted  by  the  same  patient  for  a  chronic  and  obstinate 
cough,  which,  after  harassing  him  for  three  or  four  years,  ceased  suddenly,  upon  the 
occurrence  of  the  first  of  these  strange  seizures.  On  that  occasion,  he  voided  at  least 
a  quart  of  the  fat.  Since  August,  1844,  he  has  experienced  only  two  or  three  slight 
threatenings  of  an  attack ;  but  lo,  his  old  cough  has  returned. 

Mr.  Hicks  tells  me  that  a  female  relative  of  his  own  laboured  for  four  or  five 
years  under  a  perpetual  dry  cough,  which  was  most  distressing  to  herself,  and  very 
irksome  to  the  hearers  of  it.  A  pint  of  fatty  matter  was  then  passed  by  stool,  and 
the  cough  ceased  at  once,  entirely  and  permanently.  This  happened  more  than  ten 
years  ago. 

All  that  we  know  of  the  disease  seems  to  amount  to  this :  that  it  is  not  a  common 
complaint ;  and  that  it  is  not  necessarily  a  /a/a/ complaint.  Persons  who  have  passed 
great  quantities  of  fat  in  that  way  have  Hved  in  good  health  for  many  years  after- 
wards. Yet  though  not  necessarily  fatal,  it  has  frequently  been  found"  associated 
with  incurable  malignant  disease  in  the  duodenum  and  pancreas.  Dr.  Prout  informs 
us  also  that  in  cases  in  which  a  similar  oily  fluid  has  been  passed  through  the  wre//im, 
the  kidneys  have  been  found  in  a  state  of  organic  malignant  disease. 

With  respect  to  the  treatment  of  such  cases,  all  the  hints  I  can  give  you  are  such 
as  are  furnished  by  the  two  following  facts  : — 

Mr.  Howship,  in  his  book  on  morbid  anatomy,  mentions  the  instance  of  a  lady 
who  was  affected  with  this  diarrhoea  adiposa,  and  parted  with  vast  quantities  of  fat ; 
and  who  was  cured  upon  the  principle  of  similia  similibus  curantur,  for  she  reco- 
vered after  swallowing  a  pint  of  sweet  oil.  And  Dr.  Elliotson,  acting  on  this  hint, 
gave  his  patient,  who  was  labouring  at  the  same  time  under  diabetes,  a.  quarter  of  a 
pint  of  olive  oil ;  and  the  voiding  of  fat  greatly  diminished  from  that  time,  and  soon 
ceased  entirely. 

Whether  these  were  really  cures,  or  whether  they  were  coincidences,  is  a  question 
which  we  want  larger  experience  to  help  us  to  determine. 

When  I  was  speaking  of  the  causes  of  enteritis,  I  adverted  to  the  presence 
0^  foreign  substances,  ^s  they  are  called,  in  the  bowels,  and  to  intestinal  concre- 
tions. 

There  are  some  points  connected  with  these  subjects  which  I  had  not  then  leisure 
to  pursue,  but  which  you  ought  not  to  be  ignorant  of. 

Intestinal  concretions  are  very  common  in  some  of  the  lower  animals  —  in  horses 
and  oxen  especially.  Most  of  you  have  seen,  I  dare  say,  immense  intestinal  calculi 
of  this  kind,  and  great  numbers  of  them,  in  the  Museum  of  the  College  of  Surgeons. 
The  old  remedies  called  bezoars  were  of  the  same  nature. 

They  occur,  also,  these  intestinal  calculi,  in  the  human  entrails,  and  in  various 
parts  of  them  ;  chiefly,  however,  in  the  caecum  and  large  intestines,  but  sometimes  in 
the  stomach :  indeed,  very  large  ones  have  occasionally  been  met  with  in  the  latter 
organ.  Bonetus  describes  one  which  weighed  nine  ounces,  and  was  as  big  as  a  hen's 
eg^.  Generally  they  are  few  in  number  in  the  same  person :  one  only,  perhaps, 
exists  ;  or  two,  or  three.  Yet  as  many  as  thirty  have  been  found  together  in  thfi 
stomach  in  one  case  ;  and  in  another  case  nine.  One  of  the  Monros  of  Edinburgh 
(Monro  primus)  detected  twelve  in  the  colon  of  a  boy,  during  life,  by  the  touch. 
Monro  secundis  took  a  concretion  that  weighed  four  pounds  from  the  colon  of  a 
woman.  They  have  been  known  to  measure  as  much  as  eight  inches  in  circum- 
ference. In  the  twenty-fourth  volume  of  the  Edinburgh  Medical  and  Surgical 
Journal  is  an  account  of  one  long  one,  or,  perhaps,  of  three  that  had  become  united 
together,  weighing  twelve  ounces.  Mr.  Turner,  of  Keith,  has  very  lately  published 
the  case  of  a  man  who  passed  fourteen  large  intestinal  concretions. 

Now,  what  are  these  substances,  and  how  do  they  get  there?     What  is  the  patno- 


824  INTESTINAL  CONCRETIONS. 

logy  of  the  malady  ?  Why,  they  seem  to  be  formed,  in  many  instances,  by  the 
deposit  of  saline  particles,  intermixed  with  animal  matter,  upon  and  around  some, 
accidental  nucleus  which  has  entered  the  alimentary  canal,  and  there  stopped. 
Sometimes  a  gall-stone  forms  the  nucleus :  the  centre  of  the  calculus  has  several 
times  been  found  to  consist  of  pure  cholesterine.  Those  matters  over  which  the 
gastric  juice  has  no  power,  and  which  pass  the  pylorus  unchanged — such  as  the 
stones  of  fruit,  husks  of  grain,  many  unbroken  seeds,  portions  of  bone,  and  the  like. 
Other  of  these  intestinal  concretions  are  evidently  composed  of  a  mass  of  short  fibres, 
matted,  or  interwoven  together,  after  the  manner  oifelt.  These  calculi  have  a  some- 
what soft  and  velvety  feel,  yet  are  too  hard  to  be  much  compressed.  Sometimes 
they  involve  a  nucleus,  and  sometimes  they  do  not.  Their  composition  has  been 
discovered  in  rather  a  curious  manner.  Mr.  Clift,  who,  as  you  know,  has  long  had 
the  main  charge  of  the  Hunterian  Museum,  after  attentively  examining  some  of  the 
specimens  there  collected,  fancied  that  they  might  be  formed  somehow  of  the  beard 
of  oats ;  and  the  late  Dr.  Wollaston,  at  Mr.  Chft's  suggestion,  I  beheve,  undertook  to 
analyze  them  somewhat  more  rigidly;  and  he  found  that  Mr.  Clift's  conjecture  was 
well  founded.  If  you  have  ever  looked  closely  into  the  structure  of  an  oat  which 
has  been  separated  from  its  husk,  you  may  have  noticed  that  one  end  of  it  is  formed 
somewhat  like  a  tiny  brush  ;  madt  up  of  very  minute  needles  or  beards.  Dr.  Wol- 
laston found  that  these  ends  were  identical  in  their  shape  and  composition  with  the 
fibres  of  the  intestinal  concretions. 

The  accuracy  of  the  result  of  this  analysis  is  singularly  confirmed  by  the  fact  that 
this  particular  kind  of  intestinal  calculus  is  almost  peculiar  to  the  bowels  of  Scottish 
people  ;  among  whom,  as  you  know,  oats  form  a  verj'  common  article  of  diet,  in  the 
shape  of  oat-meal. 

Concretions  of  the  same  species  have  also  been  found  in  the  intestines  of  Lan- 
cashire persons;  and  they  also  use  oatmeal  a  good  deal  as  food.  Mr.  Children 
gives  an  account  of  some  in  the  Philosophical  Transactions  for  1822.  The  fibres 
were  cemented  together  by  mucus ;  and  the  concretions  contained  also  albumen, 
phosphate  of  lime  and  soda,  and  common  salt. 

I  mentioned  formerl)^  the  danger  which  attends  the  incautious  or  excessive  use  of 
magnesia,  whether  for  stomach  complaints  or  for  urinary  disorders.  When  this 
substaMce  is  taken  habitually,  and  when  due  care  is  not  used  to  ensure  its  habitual 
expulsion  from  the  intestines,  it  is  liable  to  accumulate  and  concrete  there,  especially 
in  the  ccecum  and  colon.  Large  masses  of  this  kind  have  been  met  with,  composed 
almost  entirely  of  carbonate  of  magnesia. 

And  the  habitual  use  of  any  other  indigestible  substance  may  have  the  same  ill 
consequence.  The  seeds  of  figs ;  unbruised  mustard  seeds,  which  (as  I  mentioned 
before)  are  taken  daily  by  some  persons;  the  woody  knots  found  in  certain  pears; 
all  these  have  been  known  to  form  the  material  of  concretions,  or  of  hard  injurious 
masses  in  the  bowels. 

Now  concretions  of  this  kind  come  at  length  to  produce  symptoms  by  the  pressure 
and  distension  they  occasion,  by  the  ulceration  to  which  they  sometimes  give  rise, 
and,  above  all,  bj'  the  obstacle  they  oppose  to  the  passage  of  the  contents  of  the 
intestines.     They  generally  cut  the  patient  off' by  exciting  inflammation. 

But  they  may  exist  for  a  long  time  without  producing  any  definite  symptoms. 
And  when  symptoms  do  arise,  or  when  we  ascertain  that  such  concretions  have 
formed,  we  are  often  at  a  loss  for  a  remedy.  From  the  colon  we  may  hope  at  last  to 
dislodge  them:  by  mechanical  means  when  they  are  near  the  outlet;  by  frequent 
mjections  of  warm  water,  or  soap  and  water,  whereby  thty  may  be  softened  or  broken 
down,  and  washed  out,  when  they  are  beyond  the  reach  of  the  finger,  or  of  instru- 
ments passed  into  the  rectum. 

We  have  an  illustration  of  the  patience  of  the  alimentary  canal  under  the  presence 
>i  these  masses,  in  what  often  happens  when  foreign  bodies  of  some  magnitude  are 
•wallowed  and  remain  in  the  tube. 

In  one  of  the  earlier  volumes  of  the  Medico-Chirurgiccd  Transactions  you  may 
iead  the  history  of  a  celebrated  knife-eater.  A  sailor,  in  a  drunken  bravado,  swal- 
lowed a  clasp-knife.     This  was  followed  by  no  immediate  bad  consequences,  and 


WORMS.  825 

he  used  to  brag  of  the  feat  he  had  performed.  And  afterwards,  either  to  satisfy  the 
scruples  of  those  who  did  not  believe  his  assertions,  or  for  the  sake  of  rewards 
which  some  people  were  thoughtless  and  cruel  enough  to  offer,  or  to  win  wagers,  he 
stupidly  repeated  his  folly,  till  he  had  swallowed  (I  think)  thirteen  knives  of  various 
kinds  and  sizes.  They  killed  him  at  last ;  and  their  remains  were  found  in  various 
parts  of  the  alimentary  tract.     But  he  had  no  serious  symptoms  for  some  time. 

Mr.  Wakefield  has  given  us  an  account  of  a  culprit,  confined  in  the  Cold  Bath 
Fields  Prison,  who  had  swallowed  seven  half-crowns  before  his  incarceration.  One 
day  out  they  all  clattered  into  the  pan  of  his  night-chair. 

I  saw  a  prisoner  myself,  last  autumn,  in  the  Penitentiary,  who,  after  some  sick- 
ness, and  tenderness  of  the  belly,  voided  a  half-crown  from  the  rectum.  This  was 
in  November,  1839.  He  had  swallowed  the  piece  of  money  two  years  and  a  half 
before — viz.,  in  March,  1837;  and,  until  within  a  week  of  his  passing  it,  he  had 
enjoyed  excellent  health. 

Before  I  proceed  to  any  of  the  other  viscera  of  the  abdomen,  I  may  as  well  take 
fcuch  notice  as  the  nature  and  hmits  of  these  lectures  admit  and  require,  of  the  sub- 
ject of  tvorms ;  in  which  subject  the  intestinal  canal  is  more  concerned  than  any 
other  part  of  the  body.  It  seems  a  strange  as  it  is  a  somewhat  humiliating  fact,  that 
the  human  body  should  furnish  food  and  a  habitation  for  many  of  the  inferior  crea- 
tures ;  not  only  after  death,  but  while  it  is  yet  alive.  The  parasitic  animals  which 
thus  prey  upon  man  have  been  much  studied  from  time  to  time,  and  especially  of 
kte,  in  their  relations  to  natural  history :  and  some  of  the  facts  that  have  been  ascer- 
tained respecting  them  you  ought  to  be  acquainted  with.  But  I  shall  pursue  the 
subject  no  further  in  this  place  than  it  concerns  us  as  pathologists  and  physicians. 
Its  natural  history  will,  no  doubt,  be  fully  taught  you  by  the  professor  of  comparative 
anatomy. 

First,  then,  it  is  a  notorious  fact  that  numerous  parasites  do  crawl  over  our  surface, 
burrow  beneath  our  skin,  nestle  in  our  entrails,  .nd  riot,  and  propagate  their  kind,  in 
every  corner  of  our  frame :  produ  iu  oftentimes  such  molestation  and  disturbance 
as  require  the  interference  of  medicine.  Nearly  a  score  of  animals  belonging  to  the 
interior  of  the  human  body  have  been  already  discovered  and  described  :  and  scarcely 
a  tissue  or  an  organ  but  is  occasionally  profaned  by  their  inroads.  Each,  also,  has 
its  special  or  its  favourite  domicile.  One  species  of  strongJe  chooses  the  heart  for  its 
dwelling-place,  another  inhabits  the  arteries,  a  third  the  kidney.  Myriads  of  minute 
worms  lie  coiled  up  in  the  voluntary  muscles,  or  in  the  areolar  tissue  that  connects 
the  fleshy  fibres.  The  gxcinea-worm  and  the  chigoe  bore  through  the  skin,  and 
reside  in  the  subjacent  reticular  membrane.  Hydidids  infest  various  parts  of  the 
body,  but  epecially  the  liver  and  the  brain.  A  Httle  fluke,  in  general  appearance 
much  like  a  miniature  flounder,  lives,  steeped  in  gall,  in  the  biliary  vessels.  If  you 
squeeze  from  the  skin  of  your  nose  what  is  vulgarly  called  a  maggot — the  contents, 
namely,  of  one  of  the  hair-follicles, — it  is  ten  to  one  that  you  find,  in  that  small 
sebaceous  cylinder,  several  animalcules,  extremely  minute,  yet  exhibiting  under  the 
microscope  a  curious  and  complicated  structure.  Even  the  eye  has  its  living  in- 
mates. But  it  is,  I  repeat,  in  the  alimentary  tube  that  we  are  most  apt  to  be  plagued 
with  these  vermin. 

Independently  of  minute  scientific  divisions  into  genera  and  species,  there  are 
some  broad  lines  of  distinction  between  these  creatures.  Thus  some  kinds  of  worms 
occupy,  as  I  have  said,  the  interior  of  our  bodies ;  these  are  called,  accordingly, 
entozoa:  some  dwell  externally,  and  are  named  ectozoa;  or,  more  properly,  per- 
haps, epizoa. 

There  are  five  sorts  of  intestinal  worms,  sufficiently  common  to  make  it  likeiy 
that  you  will  meet  with  some  or  most  of  them  in  your  future  practice.  I  shall,  on 
that  account,  direct  your  attention  first  of  all  to  them. 

1.  A  frequent  tenant  of  the  human  intestines  is  the  round  worm,  so  like  in  shape, 
bize,  and  general  appearance  to  the  common  earth-worm.  It  is  from  tnis  species,  no 
doubt,  that  the  whole  class  are  called  worms.     This  round  worm  is  ofien  denonni- 


826  ROUND   WORMS. 

nated  a  lumbricus ;  but  that  is  erroneous :  it  is  a  species  of  ascaris,  and  it  has  been 
named  by  naturalists  the  ascaris  lumbricoides — the  ascaris  that  is  hke  a  lumbricus. 

2.  The  ascaris  vermictdaris ;  or  the  oxyuris  vermicidaris.  These  animals 
resemble  slender  maggots  rather  than  worms.  They  are  often  called  simply  asca- 
Hdes:  or,  in  the  vernacular, //n-e«(/-i6'orms ;  and  they  are  very  much  like  bits  of 
white  thread. 

3.  The  tricocephalus  dispar ;  also  a  small  worm,  but  longer  than  the  last ;  its 
vulgar  denomination  is  accordingly  the  long  thread-worm. 

4  and  5.  Two  species  of  tmnia  ;  long,  flat,  articulated  animals,  resembling  pieces 
of  tape.  The  txnia  solium,  or  common  tape-worm  of  this  country  ;  and  the  taenia 
lata,  or  broad  tape-worm. 

Of  all  these  I  proceed  to  mention  a  few  more  particulars. 

The  ascarides  lumbricoides,  or  round  worm,  is,  I  say,  very  hke  the  common  earth- 
worm, and  used  to  be  thought  identical  with  it.  It  runs  from  five  or  six  inches  to 
about  a  foot  in  length,  and  it  is  of  a  reddish-brown  colour,  with  a  tinge  of  yellow. 
The  female  worm  (for  they  are  of  both  sexes)  is  much  more  common  than  the 
male,  which  is  smaller  also,  and  may  be  distinguished  by  a  curved  state  of  its  tail, 
and  by  the  genital  organs.  Sometimes  young  ones  are  met  with,  about  an  inch  and 
a  half  long. 

I  shall  not  go  into  any  minute  description  of  the  anatomy  of  these  worms.  You 
cannot  mistake  them,  except  for  earth-worms ;  and  the  points  of  distinction  between 
the  two,  when  known,  are  easily  perceived.  The  earth-worm,  then,  is  redder  than 
the  intestinal  worm,  and  less  pointed  at  its  two  ends.  The  mouths  of  the  two  differ 
much.  That  of  the  earlh-worm  is  a  short  longitudinal  fissure,  or  slit,  placed  on  the 
under  surface  of  its  small  rounded  head.  In  the  ascaris  lumbricoides,  the  mouth  is 
situated  at  the  extremity  of  the  worm,  is  of  a  triangular  shape,  and  is  surrounded  by 
three  tubercles. 

It  is  curious  that  similar  differences,  only  reversed,  exist  in  respect  to  the  other 
aperture  of  the  alimentary  canal,  the  anus.  In  the  earth-worm  this  is  terminal,  at 
the  very  end  of  the  cylinder :  in  the  ascaris  it  is  a  transverse  sht  near  the  extremity, 
and  on  the  other  surface  of  the  animal. 

Again,  the  earth-worm  has  rows  of  Httle  projections,  like  bristles,  upon  its  under 
surface ;  feet  they  may  be  called,  for  they  appear  to  serve  the  purposes  of  locomo- 
tion.    In  the  parasite  there  is  nothing  resembling  this. 

By  attending  to  these  plain  marks,  you  may  avoid  being  deceived  by  impostors, 
who  pretend  that  they  are  afflicted  with  worms,  and  to  prove  their  case  bring  you  an 
earth-worm  or  two  in  a  bottle. 

The  habitat  of  these  worms  is  in  the  small  intestines.  They  may,  and  do,  pass 
upwards  into  the  stomach,  or  downwards  into  the  large  bowel :  in  either  case  they 
are  generally  soon  voided.  Sometimes  they  are  vomited  up:  but  they  have  been 
known  to  creep  into  the  oesophagus,  and  thence  into  the  nostrils.  Andral  states  that 
he  saw  a  case  in  which  a  child  was  strangled  by  one  of  these  worms,  which  had 
turned  back  and  become  e-ntangled  in  the  larynx.  They  have  been  found  also  ni  the 
excretory  ducts  of  the  liver.  This  Andral  has  witnessed  ;  as  has  also  Dr.  Baron  in 
this  country. 

It  was  formerly  thought  that  these  animals  were  capable  of  perforating  the  coats 
ol  the  intestine:  but  that  opinion  is  now  generally  exploded.  They  do  not  appear 
to  have  the  means,  if  they  possess  the  inclination,  to  bore  through.  What  gave  rise 
to  this  notion  was  the  circumstance  of  their  sometimes  passing  out  of  the  bowel, 
through  ulcerated  or  other  openings,  into  the  peritoneal  sac ;  or  into  the  vagina  or 
bladder;  or  outwards  through  hernial  apertures. 

The  number  of  these  worms  existing  at  the  same  time  in  the  same  person  is  very 
variable.  The  late  Dr.  Hooper  mentions  a  girl,  eight  years  ok',  who  voided  upwards 
of  200  in  the  course  of  one  week.  An  instance  is  recorded  of  a  soldier  who  passed 
3G7  in  six  days.     Another  patient  got  rid  of  400  in  a  fortnight. 

Fifty  or  sixty  have  been  found  in  the  same  dead  body.  They  often  lie  in  packets. 
The  corresponding  portion  of  mucous  membrane  has  in  some  cases  been  red,  in 


THREAD-WORMS — TAPE   WORMS.  827 

Others  quite  natural.  Sometimes  two  are  met  witii ;  sometimes  one  only.  So  that 
we  cannot  infer  with  certainty  that  because  one  such  worm  has  been  voided,  more 
remain  behind ;  although  that  is  always  probable. 

This  worm  is  more  common  in  the  early  periods  of  life  than  afterwards. 

The  other  species  of  ascaris,  the  ascaris  vermicularis  or  thread-worm,  resembles 
the  former  in  some  respects,  but  it  differs  from  it  remarkably  in  size.  Here  also  the 
female  is  longer  and  larger  than  the  male ;  the  one  being  perhaps  half  an  inch  in 
length,  the  other  not  two  lines,  and  very  slender. 

The  thread-worms  hve  principally  in  the  rectum,  and  sometimes  exist  there  in 
vast  numbers ;  thousands :  and  they  pass  out,  or  are  ejected,  matted  together  with 
mucus  in  the  shape  of  balls,  or  entangled  in  portions  of  excrement.  Sometimes  they 
emerge  of  their  own  accord,  and  crawl  about  the  neighbourhood,  getting  into  the 
vagina  in  females,  and  even  into  the  urethra,  and  causing  intolerable  irritation,  itch- 
ing, and  distress. 

They  are  seen,  when  recently  expelled,  to  be  very  lively ;  moving  their  anterior 
extremity  about  continually.  To  this  restlessness  and  activity  the  animal  owes  its 
name,  which  is  derived  from  the  Greek  word  asxapc^nv,  to  leap.  The  Germans  call 
it  springwurm. 

This  worm  also  belongs  chiefly  to  infancy  and  childhood.  It  does  sometimes  infest 
adults ;  but  generally  as  the  patient  grows  older  the  animals  cease  to  trouble  him, 
whether  curative  means  are  employed  or  not.  Bremsen,  however,  knew  a  person 
eighty  years  old,  who  was  nearly  killed  by  them. 

[We  have  met  with  these  worms  nearly  as  often  in  the  adult  as  in  the  chikl. — According 
to  our  experience,  the  female  adult  is  much  more  liable  to  them  than  the  male. — C] 

The  third  kind  of  these  round  worms  is  the  long  thread-worm ;  the  tricocephalus 
dispar!  It  is  from  an  inch  and  a  half  to  two  inches  in  length.  One  extremity,  that 
to  which  the  head  belongs,  is  extremely  fine  and  small ;  and  then  suddenly  bulges 
out  into  a  thicker  body.  The  thinner  portion  is  about  twice  as  long  as  the  thicker. 
Its  name  is  derived  from  this  variation  of  size.  Spi-I,  a  hair,  and  xs^axyj,  the  head  ; 
the  portion  to  which  the  head  is  appended  being  as  fine  as  a  hair.  At  one  time  the 
head  was  mistaken  for  the  tail,  and  then  the  animal  was  called  tricuris,  from  i9p(.|, 
and  ovpa,  the  tail.  The  thicker  or  body  part  is  rolled  up  in  a  spiral  form,  especially 
in  the  male,  the  female  being  straighter.  This  worm  is  of  a  white  colour,  unless 
tinged  by  its  food.  It  also  affects  the  large  intestine  as  its  place  of  abode  ;  but  the 
opposite  end  of  that  gut,  the  ccecum,  is  its  favourite  spot.  It  is  sometimes  met  with 
in  great  numbers,  attached  to  the  mucous  membrane  by  its  head ;  the  body  hanging 
loose. 

Although  jjenerally  overlooked,  it  is  said  to  be  extremely  common,  and  to  occur  in 
most  bodies.  I  have  seldom  seen  it ;  but  then  I  have  never  hunted  for  it.  It  infests 
the  dog,  the  fox,  the  monkey,  and  other  mammalia. 

This  species  of  entozoon  attracted  a  good  deal  of  attention  about  seventy  or  eighty 
years  ago ;  it  being  then  first  observed  in  Germany  d'uring  the  prevalence  of  an  epi- 
demic fever,  which  was  characterized  by  a  profuse  mucous  diarrhoea.  Rcedererand 
Wagler  have  given  an  excellent  account  of  this  disorder,  under  the  title  of  morbus 
mucosus.  It  was  thought  to  have  been  excited  by  these  worms,  which  were  found 
in  abundance  in  the  caecum  after  death.  This  opinion  must  have  been  erroneous,  for 
the  animals  were  known  in  other  places,  long  before ;  and  they  produce,  in  general, 
no  inconvenience. 

The  two  taenicB  are  more  formidable  beasts.  With  a  general  resemblance  between 
them,  there  are  strong  particular  distinctions. 

The  tfenia  solium,  or  common  tape-worm,  has  a  minute  hemispherical  head,  and  a 
long  flat  body  of  a  whitish  colour,  composed  of  many  pieces  curiously  articulated 
together.  The  articulated  pieces  are  quadrilateral,  very  short  and  small  in  the  crea- 
ture's neck  ;  they  become  gradually  square  as  the  distance  from  its  head  increases  ; 
and  at  length  are  longitudinally  oblong.  These  portions,  ox  joints  as  they  are  called, 
have  foramina  on  their  margins,  leading  to  ovaries  within.    The  foramina,  which  are 


828  TAPE- WORMS. 

very  conspicuous,  are  placed  alternately  on  the  one  side  of  the  ctnimal  and  on  the 
other:  on  the  right  edge  of  one  joint,  on  the  left  of  that  next  to  it.  This  arrange- 
ment is,  however,  subject  to  occasional  irregularities.  Each  joint  is  let  in,  as  it  were, 
to  that  immediately  in  front  of  it,  and  the  connection  between  them  is  not  very  firm. 
It  is  less  firm  in  proportion  as  the  animal  is  older,  and  as  we  approach  its  posterior 
extremity  :  so  that  the  segments  are  apt  to  come  away,  by  stool,  separately.  They 
have  somewhat  the  appearance  of  the  seeds  of  cucumbers  or  gourds ;  and  the  para- 
sites, for  that  reason,  are  sometimes  called  cucurbitine  worms.  Blumenbach  and 
others  have  supposed  that  each  articulated  piece  was  a  distinct  worm  :  but  that  is  not 
the  case.  The  head  of  the  animal,  and  i-ts  peculiar  terminal  segment,  forbid  this  belief. 

The  common  tape-worm  is  very  narrow  and  thin  towards  its  anterior  extremity ; 
one-third  or  one-quarter  of  a  hne  perhaps  in  breadth.  At  its  broadest  part  it  may  be 
from  three  to  six  lines  wide. 

The  young  taeniae  see?n  to  be  merely  wrinkled ;  but  they  are  really  articulated. 
The  question  has  been  started,  whether  the  lost  joints  are  ever  reproduced.  It  is 
beheved  that  no  new  joints  are  formed,  but  that  the  original  ones  are  gradually  more 
and  more  developed.     The  animal  is  hermaphrodite. 

Specimens  of  this  worm  are  preserved,  upwards  of  twenty  feet  in  length.  Much 
exaggeration  seems  to  have  existed  formerly  about  its  size.  It  has  been  said  to  mea- 
sure ISO,  and  even  300  feet.  In  all  probability  separate  portions  of  several  have 
been  estimated  as  forming  parts  of  one  and  the  same  worm.  There  is  one  case  well 
authenticated  (it  is  cited  by  Bremser  from  Robin)  in  which  a  tape-worm  was  found 
to  extend  from  the  pylorus  to  within  seven  inches  of  the  anus ;  adhering  firmly  to 
the  mucous  membrane  all  the  way.  The  animal  has  the  power  of  motion.  Its 
movements  are  felt  by  the  patients,  within  them.  When  recently  expelled,  and 
placed  in  tepid  water,  it  may  be  seen  to  shorten  itself;  nay,  portions  protruding 
many  feet  from  the  anus  have  been  known  to  draw  themselves  back  again. 

This  kind  of  worm  is  more  frequent  in  adults  than  in  children :  yet  it  is  some- 
times met  with  even  in  the  fcetus.  It  is  exceedingly  common  in  dogs.  It  has  been 
badly  named  ver  solitaire,  for  it  is  not  always  single.  It  is  not  only  found  in  com- 
pany with  different  worms,  but  also  with  others  of  its  own  species.  Its  natural 
place  of  abode  is  the  small  intestines :  but  it  extends  sometimes  into  the  large,  and 
sometimes  into  the  stomach.  Vandoverer  declares  that  after  an  emetic  one  of  his 
patients  vomited  forty  Dutch  ells  of  the  worm,  and  might  have  got  rid  of  more 
"if  he  had  not  been  afraid  of  puking  out  all  his  guts,  and  for  that  reason  bit  the 
worm  off." 

The  taenia  lata,  or  broad  tape-worm,  has  often  been  confounded  with  the  taenia 
solium;  yet  there  are  striking  differences  between  them;  respecting  which,  for  all 
practical  purposes,  it  is  enough  to  say  that  the  heads  (as  viewed  through  a  micro- 
scope) are  very  dissimilar;  that  the  joints  of  the  tasnia  lata  are  shorter  and  broader, 
and  adhere  together  in  a  different  manner ;  and  that  the  pores  leading  to  the  oviducts 
are  situated  not  on  the  edge  of  each  joint,  but  in  the  centre  of  its  fiat  surface.  This 
variety  is  not  so  easily  broken  across  as  the  former;  and  therefore  its  segments  are 
less  liable  to  be  voided  in  a  separate  form.  It  is  probably  shorter  also  than  the  tasnia 
sohum.  Fifteen  feet  have  been  supposed  its  average  length.  Marvellous  stories, 
however,  are  told  on  this  head.  Boerhaave  declares  that  he  effected  the  expulsion 
of  one,  which  Avas  300  ells  long,  from  the  bowels  of  a  Russian. 

The  geographical  distribution  of  these  two  species  of  taenia  forms  a  curious  part 
of  their  history,  and  throws  some  light  upon  the  doubtful  question  of  their  origin. 
In  England,  Holland,  and  Germany,  the  taenia  solium  is  common,  and  the  taenia  lata 
very  rare.  In  Russia,  Poland,  and  Switzerland,  it  is  just  the  reverse  ;  the  taenia  lata 
prevails ;  the  taenia  solium  is  seldom  seen ;  while  in  France  the  one  species  is  nearly 
as  fre(|uenl  as  the  other. 


HYDATIDS.  829 


LECTURE  LXXIY. 

Entozoa  continued.  Hydatids.  Trichina  Spiralis.  The  Guinea-Worm.  Stron- 
gidiis  Gigas.  Origin  of  Entozoa.  Question  of  Spontaneous  Generation. 
General  symptoms  of  the  presence  of  Intestinal  Worms.  Particular  symp- 
toms, and  remedies,  of  the  common  Round  Worm,  of  Thread-worms,  of  Tape- 
Worms. 

At  our  last  meeting  I  gave  a  summary  description,  sufficient,  however,  for  our 
purposes  as  medical  practitioners,  of  the  five  kinds  of  vermes  which  are  most  com- 
mon in  the  human  intestinal  canal.  There  are  yet  a  few  more  of  these  entozoa 
which  are  curious  and  interesting  enough  to  deserve  a  brief  notice. 

Hydatids  —  animals  like  bags  or  bladders  of  water  —  are  of  very  frequent  occur- 
rence in  various  parts  of  the  body.  They  are  also  called  acephalo cysts,  headless 
bags.  These  are  not  to  be  confounded  with  enlarged  Graafian  or  other  vesicles,  nor 
with  morbid  serous  cysts  in  general.  They  look  like,  or  rather  they  are,  spherical 
sacs  having  one  aperture  only,  and  containing  a  thin  colourless  liquid.  They  are 
usually  found  congregated,  sometimes  in  vast  numbers,  w^ithin  a  large  cavity  or  cyst, 
to  which  they  are  not  attached.  This  is  a  consequence  of  the  pecuHar  manner  in 
which  the  animals  are  propagated.  The  wall  of  the  cyst  is  laminated,  and  the  youncr 
hydatids  bud  forth  from  between  its  layers.  In  the  species  which  most  commonly 
infests  the  human  frame,  they  are  born  into  the  cavity  of  the  parent :  in  some  other 
species  they  are  detached  externally.  We  find  therefore  a  parent  bag,  full  of  other 
smaller  bags ;  which,  again,  are  pregnant,  as  it  were,  with  their  own  offspring,  the 
grandchildren  of  the  primary  cyst :  and  so  on,  somewhat  after  the  manner  of  a  nest 
of  pill-boxes.  Minute  in  their  origin,  these  parasites  may  thus  increase  and  multiply 
till  the  original  cyst  attains  an  immense  size,  and  at  length  destroys  life  by  its  bulk 
and  pressure.  Of  course  the  immediate  consequences  of  such  pressure  will  depend 
greatly  upon  the  parts  occupied  by  the  hydatids.  You  may  readily  imagine  what 
kind  of  symptoms  are  likely  to  ensue,  when  they  are  lodged  within  the  abdomen, 
within  the  less  yielding  thorax,  within  the  unyielding  skull.  They  are  more  com- 
mon in  the  liver  than  in  any  other  single  organ.  I  lately  mentioned  the  case  of  a 
woman,  Harriet  Baldwin,  who  died  in  the  Middlesex  Hospital,  and  whose  liver  con- 
tained thousands  of  these  globular  bodies.  The  enlarged  gland  had  completely  sealed 
up,  by  its  pressure,  a  portion  of  the  inferior  cava. 

We  can  seldom  tell  that  hydatids  exist  in  the  body  until  we  see  them;  nor,  if  we 
knew  of  their  presence,  could  we  propose  any  rational  method  of  cure.  It  has  been 
fancied  that  a  galvanic  current,  or  an  electric  shock,  passed  through  the  organ  con- 
taining'these  creatures,  might  kill  them,  and  so  at  least  prevent  their  increase ;  or 
that  they  might  be  poisoned  by  drugs  that  are  not  seriously  prejudicial  to  man,  such 
as  mercury  or  iodine.  But  these  are  mere  dreams  of  our  baffled  art.  They  some- 
limes  open  a  way  for  themselves  to  the  surface,  and  escape  through  an  ulcerated 
outlet :  and  sometimes  they  are  let  out,  to  the  surprise  perhaps  of  the  operator,  who 
only  knew  that  he  was  dealing  with  an  abscess  which  required  puncturing.  Mr. 
Arnott  put  a  lancet  into  a  fluctuating  tumour  in  the  epigastrium  of  one  of  my  patients; 
very  offensive  pus  issued,  with  the  shriveled  skins  of  sundry  defunct  hydatids.  The 
cyst  was  situated,  I  believe,  in  the  liver.  Although  the  orifice  was  slow  to  heal,  the 
patient  ultimately  got  well. 

There  are  single  cyst-like  bodies,  with  short  retractile  necks,  bearing  the  generic, 
name  of  cysticercus.  One  species  of  this  kind,  the  cysticercus  cellulosus,  inhabits 
the  interfascicular  areolar  tissue  of  the  muscles.  It  is  rare  in  the  human  subject,  but 
frequent  in  the  pig ;  giving  rise  to  that  condition  of  the  muscles  which  is  famiharly 
known  as  measly  pork.  This  is  one  of  the  internal  parasites  with  which  the  organ 
of  vision  is  liable  to  be  infested.     A  most  remarkable  instance  occurred  a  few  years 

3u 


830  TRICHINA    SPIRALIS. 

ago,  in  Glasgow.  In  the  eye  of  a  child,  who  had  suffered  repeated  attacks  of  ophthal- 
mia, Mr.  Logan  discovered  one  day,  to  his  extreme  astonishment,  a  semi-transparent 
body,  about  two  lines  in  diameter,  fk)ating  unattached  in  the  anterior  chamber.  It 
seemed  almost  perfectly  spherical,  except  that  from  its  lower  edge  there  proceeded  a 
slender  process,  of  a  white  colour,  with  a  shghtly  bulbous  extremity,  which  appeared 
to  be  heavier  than  the  globular  part,  for  it  was  always  turned  downwards.  This 
head  or  neck  was  seen  to  project  or  elongate  itself  from  time  to  time ;  and  occasion- 
ally it  was  drawn  up  and  completely  hidden  in  the  cystic  portion.  When  the  patient 
sat  still,  in  a  moderate  light,  the  animal  covered  the  two  lower  thirds  of  the  pupil. 
"  Watching  it  carefully  (says  the  gentleman  who  has  recorded  the  case),  its  cystic 
portion  was  seen  to  become  more  or  less  spherical,  and  then  to  assume  a  flattened 
form ;  while  its  head  I  saw  at  one  moment  thrust  suddenly  down  to  the  bottom  of 
the  anterior  chamber,  and  at  the  next  drawn  up  so  completely  as  to  be  scarcely 
visible."  The  child's  head  was  now  turned  gently  back,  and  instantly  the  hydatid 
revolved  through  the  aqueous  humour,  so  that  its  head  feli  to  the  upper  edge  of  the 
cornea,  now  the  more  depending  part.  Upon  the  child  again  leaning  forwards,  it 
settled,  like  a  little  balloon,  in  its  former  position  ;  preventing  the  patient  from  seeing 
objects  directly  before  her. 

The  animal  was  carefully  watched  for  three  weeks ;  and  no  other  change  was 
noticed  than  a  slight  increase  in  the  bulk  of  its  cystic  portion.  In  six  weeks  it  had 
evidently  grown  bigger,  the  eye  became  injected,  and  the  iris  less  free  in  its  move- 
ments ;  and  pain  ensued.  Extraction  of  the  hydatid  was  attempted  ;  but  the  patient 
was  unruly ;  the  lens  was  forced  out,  and  the  animal  ruptured  and  expelled  in 
shreds :  the  iris  became  entangled  in  the  wound  of  the  cornea,  and  vision  in  that  eye 
was  spoiled. 

There  is  a  very  singular  microscopic  parasite,  the  trichina  spiralis,  dwelling  in 
myriads,  sometimes,  in  the  rhuscles  of  the  living  human  body.  It  was  first  de- 
scribed, I  believe,  by  Mr.  Hilton,  of  Guy's  Hospital,  and  afterwards  more  fully 
by  Professor  Owen,  in  1835.  Mr.  Wormald,  the  Demonstrator  of  Anatomy  at  St. 
Bartholomew's  Hospital,  sent  to  that  gentleman  a  portion  of  human  muscle,  which 
presented  a  singular  speckled  appearance,  as  if  it  were  mouldy.  Mr.  Owen  found 
that  each  speck  was  a  shuttle-shaped  cyst,  containing  a  very  minute  cylindrical 
worm,  coiled  up  in  two,  or  two  and  a  half,  spiral  turns.  The  worm  measures, 
when  unrolled,  no  more  than  g^th  of  an  inch  in  length,  and  T^Joth  of  an  inch  in 
diameter ;  and  of  course  requires,  for  a  satisfactory  examination,  to  be  seen  through 
a  microscope.  The  longer  axis  of  the  containing  cyst  hes  between,  and  parallel  to, 
the  fibres  of  the  muscle.  Fourteen  similar  instances  have  since  come  to  Mr.  Owen's 
knowledge. 

This  is  a  very  strange  kind  of  parasite.  One  would  imagine  that  the  presence  ci 
innumerable  living  beings,  in  or  between  the  muscular  fibres,  would  be  likely  to  give 
rise  to  symptoms.  We  might  expect  pain,  or  muscular  debility,  or  embarrassed 
movements ;  yet  no  indication  of  the  presence  of  these  worms  seems  to  have  been 
afforded  in  those  instances  in  which  the  condition  of  the  subject  in  whom  they  were 
found  was  known,  during  life.  The  principal  points  that  have  hitherto  been  made 
out  appear  to  be  the  following : — 

1.  The  muscles  thus  beset  with  parasites  are  the  voluntary  muscles :  and  those 
which  lie  superficially  are  fuller  of  the  worm  than  the  deeper  seated.  The  pecto- 
ralis  major,  latissiraus  dorsi,  and  other  large  flat  muscles,  usually  present  them  in 
great  abundance.  They  have  been  detected  in  the  muscles  of  the  eye :  and  everi 
in  those  belonging  to  the  little  bones  of  the  ear,  and  of  whose  action  we  are  wholly 
unconscious.  They  occur  also  in  the  diaphragm,  in  the  muscles  of  the  tongue  and 
of  the  larynx,  in  those  of  the  soft  palate,  in  the  constrictors  of  the  pharynx,  in  the 
levator  ani,  in  the  external  sphincter  ani,  and  in  the  muscles  of  the  urethra.  They 
have  not  yet  been  seen  in  the  muscular  tunic  of  the  stomach  and  intestines,  in  the 
detrusor  urinas,  or  in  the  heart.  Mr.  Ow-en  makes  this  interesting  remark — that  all 
the  muscles  infested  by  the  trichina  are  characterized  by  the  striated  appearance  of 
'.heir  ultimate  fascicuU :  whereas  the  muscles  of  organic  life,  which  the  animal  does 


THE    GUINEA-WORM.  831 

not  inhabit,  have,  with  the  exception  of  the  heart,  smooth  fibres,  not  grouped  into 
fasciculi,  but  united  reticularly. 

2.  It  appears,  also,  from  what  has  been  hitherto  observed  of  these  entozoa,  that 
their  presence  in  the  body  is  unconnected  with  age,  sex,  or  any  particular  form  of 
disease.  They  have  been  concomitant  with  cancer  of  the  penis  ;  tubercles  of  the 
lungs  ;  exhaustion  of  the  vital  powers  by  extensive  ulceration  of  the  leg;  fever,  com- 
bined with  pulmonary  phthisis ;  aneurism  of  the  aorta ;  sudden  depression  or  col- 
lapse after  a  comminuted  fracture  of  the  humerus  ;  diarrhoea.  They  have  also  been 
met  with  in  the  muscles  of  a  man  who,  while  in  the  apparent  enjoyment  of  robust 
health,  was  killed  by  a  fracture  of  the  skull. 

The  Filaria  Medinensis — Dracuncidus — or  Guinea-worm — has  its  residence  in 
the  subcutaneous  areolar  tissue.  It  is  a  long,  slender,  round,  uniform  animal,  like  a 
fiddle-string,  or  a  piece  of  bobbin ;  as  you  may  see  in  the  specimens  before  you. 
Its  length  varies  from  five  or  six  inches  to  twice  as  many  feet.  Men's  lower  limbs, 
their  feet  and  legs,  are  the  parts  most  commonly  possessed  by  this  worm ;  but  it 
occurs  also  in  the  scrotum,  in  the  parietes  of  the  belly,  in  the  arms,  beneath  the  con- 
junctiva of  the  eye,  and  in  almost  every  superficial  situation.  It  is  sometimes  soli- 
tary ;  but  several  may  co-exist  or  succeed  each  other  in  the  same  individual ;  nine 
or  Ion  perhaps.  A  Dr.  Marrudri,  a  friend  of  the  celebrated  Clot  Bey,  had  suffered 
from  twenty-eight  of  them  in  succession. 

This  entozoon  is  epidemic  in  the  hot  intertropical  regions ;  in  Asia  and  Africa ; 
upon  the  coast  of  Guinea,  whence  its  trivial  name.  It  sometimes  abounds  after  the 
manner  of  an  epidemic.  Sir  James  M'Grigor  tells  us  that  the  86th  and  88th  regi- 
ments, stationed  at  Bombay,  were  much  plagued  by  this  pest.  The  86th  was  free 
from  it  upon  entering  the  fort,  in  September,  1799  ;  and  so  continued  till  the  setting 
in  of  the  monsoon  in  1800.  In  the  course  of  the  monsoon  nearly  300  of  the  men 
were  attacked.  The  88th  regiment  relieved  the  86th.  No  case  of  Guinea-worm 
appeared  among  them  for  nearly  a  month  after  their  coming  into  the  barracks  at 
Bombay,  in  October,  1800.  In  the  latter  end  of  November,  they  embarked  for  the 
Egyptian  expedition  ;  and  in  the  course  of  the  voyage  in  one  ship  alone  199  men 
out  of  360  were  crippled  and  laid  up  with  this  loathsome  disease.  It  was  thought 
to  be  infectious.  The  artillery-men,  who  were  kept  separate,  escaped.  Of  181 
instances,  of  which  Sir  James  M'Grigor  gives  a  tabular  account,  the  feet  were  the 
parts  affected  in  121. 

These  animals  sometimes  remain  for  a  long  while  in  the  areolar  tissue  without  pro- 
ducing inconvenience,  and  therefore  without  betraying  their  presence.  Hence  they 
are  sometimes  brought  over  to  this  country.  The  great  navigator,  Dampier,  had  no 
symptom  of  a  Guinea-worm  which  he  carried  about  with  him,  until  about  half  a 
year  after  he  left  the  place  in  which  he  contracted  it.  Sometimes  the  parasite  is 
quiet  and  harmless  for  a  still  longer  period ;  in  one  recorded  instance  it  was  latent 
and  dormant  for  three  years. 

The  symptoms  which  do  at  length  arise  are  the  following : — itching  of  the  part 
affected  ;  a  sensation  as  if  there  were  something  creeping  under  the  skin  ;  sometimes 
a  cord-like  ridge  can  be  felt  in  the  track  of  the  worm ;  at  length  a  vesicle,  or  a  pus- 
tule, or  a  little  boil  forms,  from  which,  when  it  breaks,  the  head  of  the  animal  pro- 
trudes. This  process  is  often  attended  with  fever ;  and  in  certain  parts  of  the  body 
the  local  suffering  is  considerable  :  the  areolar  tissue  sloughs  ;  and  sometimes  danger- 
ous hemorrhage  occurs. 

The  only  treatment  which  these  cases  appear  to  admit  of,  is  the  gradual  and  care- 
ful extraction  of  the  worm.  Lest  that  part  of  it  which  already  protrudes  should 
recede,  or  be  broken,  it  is  gently  wound,  day  by  day,  round  a  small  stick,  or  a  little 
roll  of  adhesive  plaster;  pains  being  taken  not  to  pull  upon  it  so  much  as  to  risk  its 
being  torn  asunder.  The  roll  is  protected  by  a  bandage.  Whenever,  by  accident, 
the  animal  is  broken,  very  serious  consequences  are  sai''  to  ensue  ;  violent  inflam- 
mation of  the  part,  abscesses  and  sinuses  and  high  irritative  fever.  This  mischief 
is  ascribed  by  some  to  the  presence  of  dead  animal  matter,  by  others,  of  young  fila 
riae,  in  the  subcutaneous  tissue :  for  I  should  have  mentioned  that  the  Guinea-worn; 


832  STRONGULUS    GIGAS. 

k  viviparous ;  and  although  neither  digestive  organs  nor  generative  organs  have  yet 
been  discovered  in  its  structure,  it  is  sometimes  found  stuffed  internally  with  a  count- 
less offspring.  The  extraction  is  tedious  work.  Where,  indeed,  the  areolar  tissue 
is  very  loose,  as  in  the  scrotum,  the  worm  is  occasionally  drawn  out  at  the  first 
attempt ;  but  the  process  sometimes  occupies  weeks ;  and  its  average  period  appears 
to  be  not  less  than  ten  days.  When  the  course  of  the  animal  is  quite  superficial  and 
obvious,  the  natives  are  accustomed  to  make  an  incision  in  the  skin,  at  about  the 
middle  point,  and  to  pull  the  worm  through  from  both  ends.  When  once  it  is  out, 
the  parts  presently  heal.  Ail  other  medication  (and  much  has  been  tried)  has  been 
found  useless;  except,  perhaps,  the  administration  of  assafetida ;  and  that  not  as  a 
means  of  cure,  but  of  prevention.  It  is  said  that  the  Brahmins  in  India,  who  are  in 
the  constant  habit  of  using  this  drug,  are  exempt  from  attacks  of  the  dracunculus. 
Cleanliness  was  also  found,  in  the  army,  to  be  a  considerable  protection. 

There  is  a  species  of  filaria  peculiar  to  the  eye,  and  another  to  the  bronchial 
glands  ;  but  these  are  extremely  rare. 

The  urinary  organs  have  their  parasites  also  ;  of  which  I  shall  specify  but  one,  and 
that  chiefly  on  account  of  its  strange  lurking-place,  and  remarkable  size.  I  alluded 
to  a  species  of  strongle  which  sometimes  occupies  the  human  kidney,  and  which  is 
no  uncommon  tenant  of  the  same  organ  in  various  animals ;  the  horse,  the  bull,  the 
dog,  the  wolf,  the  polecat,  and  the  otter.  In  the  human  subject,  its  length  varies 
between  five  inches  and  a  yard,  and  it  is  sometimes  half  an  inch  in  diameter.  There 
is  a  specimen  nearly  of  that  size  in  the  Hunterian  museum.  It  may  well  be  called 
the  giant  strongle,  strongiilus  gigas.  Fancy  a  creature  as  big  as  a  snake  coiled  up 
in  one's  kidney.  It  gives  rise  to  no  distinctive  symptoms,  although,  as  you  may 
suppose,  it  causes  much  renal  distress  ;  hematuria,  retention  of  urine,  and  great  suf- 
fering in  its  passage  out  of  the  body,  either  through  the  natural  urinary  channels,  or 
by  abscess  and  ulceration  through  the  back. 

With  respect  to  some,  at  least,  of  the  parasitic  animals  that  I  have  been  describing, 
those  I  mean  which  are  found  shut  up  in  close  chambers,  our  first  feeling  is  that  of 
wonder  how  they  came  there.  Into  all  parts  from  which  a  road  is  open  to  the  exter- 
nal surface,  we  can  conceive  that  living  creatures  may  enter,  or  their  eggs  be  carried. 
But  how  can  either  animals  or  ova  find  their  way  unperceived  into  the  substance  of 
the  liver  and  of  the  voluntary  muscles,  into  the  eye,  into  the  brain  ?  The  whole 
matter  is  obscure,  yet  interesting. 

With  respect  to  the  common  hydatids,  it  has  been  conjectured — and  the  conjecture 
does  not  seem  improbable — that  they  are  not  parasites,  nor  distinct  animals  in  any 
sense  ;  but  merely  certain  of  those  primitive  nucleated  cells — from  which  the  micro- 
scope asserts  that  all  the  varied  tissues  of  the  body  are  originally  formed — rendered 
gigantic  and  monstrous  by  some  erring  or  morbid  action  of  the  vital  forces.  Except 
in  size,  the  cell  and  the  hydatid  are  declared  to  be  alike:  alike  in  shape,  alike  in 
the  mode  of  their  growth  and  muhiplication.  But  this  view  of  the  matter,  granting 
it  to  be  the  true  one,  does  not  relieve  our  difficulty ;  for,  within  these  very  hydatids, 
distinct  living  animals  have  been  found  :  parasites  of  the  second  order,  entozoa  of  an 
entozoon,  if  the  hydatid  be  itself  a  separate  animal — tenants  of  a  formation-cell,  if 
the  hydatid  be  only  an  extravagant  development  of  the  primary  corporeal  structure. 

Within  several  of  the  transparent  hydatids  which  were  taken  from  the  liver  of  the 
woman  Baldwin,  a  number  of  small,  opaque,  white  grains,  were  visible.  These  were 
examined  by  Mr.  Tomes  and  myself,  under  the  lens  of  his  powerful  microscope. 
They  were  plainly  minute  animals:  baglike,  with  an  orifice  or  mouth  which,  in 
some  instances,  protruded  a  little  from  the  bag — in  others,  was  evidently  contracted 
and  drawn  inwards.  Around  this  orifice  was  arranged  a  circlet  of  small,  flat,  spear- 
shaped  rays,  somewhat  like  a  Vandyke  collar.  Many  of  these  rays,  or  spines  as 
they  have  been  called,  were  detached,  and  lying  loose  in  the  surrounding  hquid. 
Being  very  ill-informed  in  this  department  of  natural  history,  I  paid  less  attention  to 
these  creatures  than  they  deserved ;  fancying,  indeed,  that  they  might  be  common 
and  well-known,  or  rather  that  they  were  juvenile  hydatids.     I  have  become  aware 


ORIGIN    OF   ENTOZOA.  833 

of  my  mistake  through  perusing  a  paper,  by  Mr.  Curling,  in  the  twenty-third  volume 
of  the  Medico-Cliirur girnl  Transactions,  where  he  more  minutely  describes  pre- 
cisely similar  phenomena.  Mr.  Curling  shows  that  these  included  animalcules  are 
parasitic  vermin  which  infest  a  peculiar  species  of  hydatid,  called  the  Echiaocuccus 
Hominis.  Later  opinions  assert  that  what  we  call  the  ki/datids,  is  nothing  more 
than  a  nest,  or  habitation,  formed  by  or  for  the  small  indwellers. 

Now,  whatever  hypothesis  we  may  adopt  respecting  the  nature  of  hydatids  them- 
selves, the  puzzling  question  still  remains,  whence  originated  the  living  beings 
inclosed  within  them  ?     How  got  they  thither? 

It  was  the  opinion  of  Linnaeus,  and  of  other  natural  philosophers  of  his  time,  that 
the  intestinal  worms  were  really  terrestrial  or  aquatic  animals  which  had  been  acci- 
dentally swallowed,  either  while  young  and  small,  or  in  the  antecedent  state  of  ova. 
It  was  even  pretended  that  these  animals  had  been  recognised  and  detected  out  of 
the  body,  in  stagnant  waters.  But  later  inquirers,  especially  Bremser  and  Rudolphi, 
have  completely  disproved  this  notion.  After  dedicating  twelve  years  of  his  life  to 
the  observation  and  study  of  entozoa,  Bremser  was  satisfied  that  no  creatures  iden- 
tical in  structure  v^ith  the  intestinal  worms  are  ever  met  with  out  of  the  body, 
except  such  as  have  come  from  the  intestines  of  man,  or  of  some  other  animal ;  and, 
conversely,  that  no  terrestrial  or  aquatic  worms  are  ever  found  living  within  the  bodies 
of  men  or  of  animals,  unless  they  have  been  directly  or  plainly  received  from  without. 

But,  then,  is  it  not  possible  that,  as  Boerhaave  supposed,  aquatic  or  terrestrial  rep- 
tiles, casually  entering  the  bod}''  from  without,  being  placed  under  entirely  new  and 
unnatural  conditions,  may  have  attained  a  monstrous  growth,  and  undergone  meta- 
morphoses such  as  we  know  that  some  of  the  lower  animals,  by  change  of  circum- 
stance, do  undergo ;  as  the  tadpole  becomes  a  frog,  the  maggot  a  butterfly  ? 

To  this  theory  there  are  strontr  grounds  of  objection.  First,  there  is  no  ascertained 
relation  (as  in  the  other  cases)  between  the  structure  of  intestinal  worms,  and  of  ani- 
mals having  an  independent  existence  out  of  the  body ;  and  they  are  never  caught 
(as  they  would  surely  sometimes  be)  in  the  transition  state — the  intermediate  condi- 
tion. Secondly,  opposed  to  this  "accidental"  hypothesis  are  also  the  facts  that  cer- 
tain species  of  worms  infest  certain  species  of  animals  only  :  that  in  the  same  animal, 
different  species  of  worms  occupy  (as  we  have  seen)  special  parts  of  the  alimentary 
canal ;  have  each  their  peculiar  habitat :  that  worms  and  animals  of  external  origin 
mostly  die  as  soon  as  they  are  received  into  the  digestive  organs,  while  the  true 
mtestinal  worms  perish  whenever  they  are  delivered  therefrom.  Thirdly,  the  cir- 
cumstances that  these  worms  not  only  live,  but  breed  within  the  human  bowels,  and 
that  they  are  met  with  even  in  the  intestines  of  the  unborn  foetus,  are  very  adverse 
to  this  theory  of  an  accidental  error  loci. 

But,  to  give  up  the  notion  of  a  metamorphosis,  may  not  intestinal  worms  spring 
from  specific  germs  or  ova  introduced  from  without,  not  casually,  but  in  accordance 
with  a  natural  law:  germs  or  ova  which  find  in  the  interior  of  living  bodies  the 
only  conditions  that  admit  of  their  development,  the  only  soil  in  which  they  are 
capable  of  germinating,  the  only  nest  in  which  they  can  be  hatched  ?  I  confess  that 
si]ch  is  my  own  belief.  We  have  something  like  this,  at  least,  in  that  common  affec- 
tion of  horses  called  the  "  bots."  A  species  of  oestrus,  or  gadfl\',  deposits  its  egq-s 
upon  the  animal's  hide,  where  they  cause,  I  presume,  some  irritation,  which  induces 
the  horse  to  lick  that  part  with  his  tongue.  The  eggs  are  thus  conveyed  into  the 
mouth,  whence  they  reach  the  stomach.  There  they  are  converted  into  larvas,  and 
affix  themselves  to  the  parietes  of  the  stomach.  At  length,  when  they  are  ready  to 
undergo  their  final  metamorphosis,  they  are  detached  from  the  interior  of  the  sto- 
mach, pass  along  with  the  food  and  feces  through  the  intestines,  and  are  ejected  fron) 
the  rectum  with  the  dung. 

Why,  it  is  asked,  may  not  similar  phenomena  take  place  in  the  human  body  ' 

There  can  be  no  doubt  that  we  every  day  swallow,  inadvertently,  numerous  ova,  of 

/arious  kinds.     It  is  supposable  enough  that  sometimes  the  digestive  organs  may, 

ud  sometimes  they  may  not,  have  the  power  of  decomposing  or  expelling  the^se  ova. 

It  is  quite  certain  that  what  are  generally  called  spurious  worms  may  have  that 
mode  of  origin  in  the  body.  Thus,  Ft.  Eiliotson  states  that  he  had  once  a  patient, 
53  ^  3u2 


834  SPONTANEOUS    GENERATION. 

an  infant,  who  discharo-ed  from  the  bowels  a  dozen  live  larvge,  or  maggots,  of  the 
common  fly.  The  child  had  eaten  part  of  a  high  pheasant  some  months  before. 
There  was,  in  that  case,  this  instructive  circumstance.  The  infant  had  been  sufTerinor 
under  a  chronic  cough,  but  as  soon  as  those  larvae  were  got  rid  of,  the  cough  ceased. 
Dr.  Elliotson  says  that  he  saw  them  in  the  napkin  moving  about  in  the  fecal  matter, 
iust  as  they  miglit  have  done  if  they  had  never  been  in  the  child's  body.  The  same 
physician  tells  us  that  he  has  twice  known,  in  two  different  patients  of  his,  a  living 
caterpillar  to  be  discharged  from  the  intestines.  One  of  the  patients  was  a  Avoman 
who  had  been  in  the  habit  of  eating  cabbage  stalks  while  she  was  washing  them  for 
the  pot.  The  moth  lays  its  eggs  on  cabbages,  and  she  no  doubt  had  swallowed  some 
of  them,  and  one  had  hatched  within  her.  In  the  ninth  volume  of  Dr.  Duncan's 
Medical  Commentaries  is  a  precisely  similar  case.  A  boy,  after  a  dose  or  two  of 
calomel  and  jalap,  discharged  from  the  rectum  very  many  caterpillars,  all  alive,  and 
full  of  activity.  He  had  been  in  the  habit,  when  in  the  garden,  of  eating  young 
cabbage  leaves.  Till  this  habit  began  he  had  enjoyed  good  health.  While  the 
animals  were  within  his  bowels  he  suffered  severely ;  had  locked-jaw ;  and  fell  into 
a  state  resembhng  coma.  Upon  their  expulsion  he  recovered  perfectly.  Centipedes 
have  in  like  manner  been  vomited,  and  voided  from  the  bowels.  But  the  most  won- 
derful instance  of  this  kind  that  ever  was  heard  of,  is  related  by  Dr.  Pickells  in  the 
Transactions  of  the  King  and  Queen'' s  College  of  Physicians  in  Ireland.  A  young 
woman  of  melancholic  disposition  and  chlorolic  appearance,  had  been  in  the  daily 
habit,  from  some  superstitious  motive,  of  drinking  water  mixed  u-ith  clay  taken  from 
the  graves  of  two  priests  who  lived  and  died  in  the  odour  of  sanctity.  In  this  way 
she  probably  imbibed  the  ova  of  the  insects  which  subsequently  issued  from  her 
body.  In  the  course  of  about  three  years  and  a  quarter,  she  discharged,  partly  by 
vomiting,  but  chiefly  per  anian,  upwards  of  2000  beetles,  and  their  larvae,  most  of 
them  alive.  Dr.  Pickells  counted  more  than  1300.  Larvs,  and  pupfe,  and  perfect 
insects,  all  came  forth  simultaneously.  Some  of  them  ran  off,  as  soon  as  they  were 
vomited,  into  holes  in  the  floor ;  and  two  large  winged  insects  were  so  lively  and 
vigorous  as  immediately  to  fly  away.  These  strange  births  were  preceded  and  at- 
tended by  a  complicated  and  distressing  train  of  symptoms  ;  a  gnawing,  and  sense 
of  something  creeping  at  the  pit  of  the  stomach,  vomiting  of  blood,  amenorrhoea, 
hysterical  convulsions,  headache,  retention  of  urine,  and  sometimes  a  decree  of  men- 
tal derangement.  She  was  at  length  freed  from  this  disgusting  malady  by  large 
doses  of  the  oil  of  turpentine. 

These  spurious  worms  differ  from  the  true  intestinal  parasites  in  this — that  the 
human  alimentary  canal  is  not  their  only,  but  their  accidental  and  unusual  nidus 
Nevertheless,  their  occasional  presence,  alive,  in  that  place,  adds  to  the  probability 
that  some  of  the  entozoa  may  be  originally  ectozoa. 

The  main  difficulty,  however,  respects  those  animals  which  occupy  shut  cavities 
within  us,  or  are  embedded  in  our  solid  organs  :  and  this  difficulty  forms  one  avowed 
ground  of  the  theory  of  equivocal  generation :  which  means  the  spontaneous  pro- 
duction of  living  creatures,  independently  of  any  germ,  or  egg^,  or  parent.  The  vul- 
gar suppose  that  dirt  engenders  fleas,  that  maggots  result  from  the  putrefaction  of 
flesh,  that  eels  arise,  of  themselves,  in  and  out  of  mud.  In  other  words,  they  infer 
the  spontaneous  origin  of  those  creatures,  of  which  they  cannot  or  do  not  trace  the 
procreation  by  pre-existing  parents:  and  philosophers  and  men  of  science  have  done 
ihe  same.  They  will  not  believe  that  which  they  cannot  see.  Now  this  doctrine 
of  equivocal  generation  shocks,  I  confess,  my  mind,  and  offends  my  reason.  If  well 
founded,  it  strikes  at  the  root  of  that  great  argument  of  Natural  Theology,  which 
deduces  the  existence  of  a  First  Intelligent  Cause,  from  the  marks  of  adaptation,  de- 
sign, and  contrivance,  so  manifest  throughout  the  visible  universe.  Observe  the 
demand  which  this  doctrine  makes  upon  our  faith.  In  defiance  of  all  experience 
and  analogy  m  respect  to  creatures  which  our  finite  senses  are  competent  to  examine, 
it  calls  upon  us  to  believe  that  living  beings,  of  complex  and  intricate,  yet  definite 
and  harmonious  structure  ;  provided  with  a  digestive  apparatus,  with  instruments  of 
locomotion,  with  generative  organs ;  of  various  species ;  in  many  instances  of  sepa- 
rate yet  answcrmg  sexes ;  that  not  one  or  two  of  these  beings,  nor  a  pair  or  two,  but 


I 


SPONTANEOUS    GENERATION.  835 

beings  and  pairs  innumerable,  are  daily  formed  by  the  casual  concourse  of  •'  organic 
molecules."  The  obscurity  that  hangs  over  the  origin  of  the  entozoa  is  not  indeed 
the  only,  nor,  I  think,  the  chief  ground  upon  which  the  notion  of_  spontaneous  gene- 
ration rests.  You  are  probably  aware  that  minute  animalcules,  so  minute  that  most 
of  them  cannot  be  seen  without  a  microscope,  soon  become  abundant  in  water  wherein 
vegetable  or  animal  matters  have  been  dissolved  by  infusion.  Such  animalcules  are 
therefore  called  Infusoria.  How  do  they  come  there  ?  There  are  two  suppositions 
open  to  us.  One  is,  that  they  are  formed  by  the  fortuitous  union  of  organic  atoms 
contained  in  the  infusion.  The  other  is,  that  they  proceed  from  ova  or  germs  exist- 
ing in  the  liquid,  or  floating  always  in  the  atmosphere,  and  ready  to  quicken  when- 
ever they  hght  upon  their  proper  element.  That  the  ova  of  animals  which  are 
themselves  visible  only  by  the  aid  of  a  microscope,  should  be  absolutely  invisible  by 
us,  is  not  surprising.  We  may  conclude  that  the  latter  supposition  is  the  most  true, 
if  we  can  show  that  when  these  ova  or  germs  are  excluded,  all  the  other  conditions 
of  the  production  of  infusoria  being  present,  no  animalcules  appear.  Now  Spallan- 
zani  long  ago  found,  by  careful  trials,  that  no  animalcules  were  discoverable  when 
the  access  of  air  to  the  infusion  was  completely  prevented.  But  it  has  been  objected 
to  his  experiments,  that  the  presence  of  atmospheric  air  may  be  one  of  the  essential 
conditions  upon  which  the  requisite  combination  of  the  organic  molecules  depends. 
Air,  solar  light  and  heat,  and  organic  matters  in  solution  being  given — does  animal 
(or  even  vegetable)  life  ever  result?  That  is  the  question.  The  experimentum 
crucis  has  been  made,  and  has  answered  "  No,"  as  I  lately  learned  from  one  of  Pro- 
fessor Owen's  admirable  introductory  lectures ;  by  whom,  I  am  glad  to  find,  this 
uncomfortable  doctrine  of  equivocal  generation  is  strongly  discountenanced.  The 
experiment  to  which  I  refer  was  conducted  by  M.  Schulze,  of  Berlin.  I  will  read 
5'^ou  his  own  account  of  it,  as  I  find  it  recorded  in  the  Edinburgh  New  Philosophical 
Journal. 

"The  difficulty  to  overcome  consisted  in  the  necessity  of  being  assured,  first,  that 
at  the  beginning  of  the  experiment  there  was  no  animal  or  germ  capable  of  develop- 
ment in  the  infusion ;  and  secondly,  that  the  admitted  air  contained  nothing  of  the 
kind.  For  this  purpose  I  filled  a  glass  flask  half  fall  of  distilled  water,  in  which  I 
mixed  various  animal  and  vegetable  substances ;  I  then  closed  it  with  a  good  cork, 
through  which  I  passed  two  glass  tubes  bent  at  right  angles,  the  whole  being  air 
tight.  It  was  next  placed  in  a  sand-bath,  and  heated  until  the  water  boiled  violently 
and  thus  all  parts  had  reached  a  temperature  of  212°.  While  the  watery  vapour  was 
escaping  by  the  glass  tubes,  I  fastened  at  each  end  an  apparatus  which  chemists 
employ  for  collecting  carbonic  acid  ;  that  to  the  left  was  filled  with  concentrated  sul- 
phuric acid,  and  the  other  with  a  solution  of  potash.  By  means  of  the  boiling  heat, 
everything  living,  and  all  germs  in  the  flasks  or  in  the  tubes,  were  destroyed;  and 
all  access  was  cut  off  by  the  sulphuric  acid  on  the  one  side,  and  by  the  potash  on 
the  other.  I  placed  this  easily  moved  apparatus  before  my  window,  where  it  was 
exposed  to  the  action  of  light,  and  also  (as  1  performed  my  experiment  during  the 
summer)  to  that  of  heat.  At  the  same  time  I  placed  near  it  an  open  vessel,  with  the 
same  substances  that  had  been  introduced  into  the  flask,  and  also  after  having  sub- 
jected them  to  a  boiling  temperature.  In  order  now  to  renew  constantly  the  air 
within  the  flask,  I  sucked  with  my  mouth,  several  times  a  day,  the  open  end  of  the 
apparatus  filled  with  solution  of  potash ;  by  which  process  the  air  entered  my  mouth 
from  the  flask  through  the  caustic  liquid,  and  the  atmospheric  air  from  without  entered 
the  flask  through  the  sulphuric  acid.  The  air  was  of  course  not  at  all  altered  in  its 
composition  by  passing  through  the  sulphuric  acid  in  the  flask,  but  if  sufficient  lime 
was  allowed  for  the  passage,  afl  the  portions  of  fiving  matter,  or  of  matter  capable  of 
becoming  animated,  were  taken  up  by  the  sulphuric  acid  and  destroyed.  From  the 
28lh  of  May  till  the  beginning  of  August,  I  continued  uninterruptedly  the  renewal 
of  the  air  in  the  flask,  without  being  able,  by  the  aid  of  the  microscope,  to  perceire 
any  hving  animal  or  vegetable  substance,  although  durijBg  the  whole  of  the  time  1 
made  my  observations  almost  daily  on  the  edge  of  the  liquid  :  and  when  at  last  I 
separated  the  difl<3rent  parts  of  the  apparatus,  7  could  not  find  in  the  whole  hquid  the 
slightest  trace  of  infusoria,  of  confervas,  or  of  mould.     But  aU  three  presented  thera 


836  INTESTINAL    WORMS. 

selves  in  great  abundance  a  few  daj^s  after  I  had  left  the  flask  standing  open.  The 
vessel  which  I  placed  near  the  apparatus  contained  on  the  following  day,  vibriones 
and  monads,  to  which  were  soon  added  larger  polygastric  infusoria,  and  afterwards 
rotatorise." 

This  experiment  confirms  the  belief  which  various  other  facts  had  suggested — that 
the  different  kinds  of  entozoa  are  not  parentless  animals,  and  that  they  somehow  find 
their  way  into  the  body  they  inhabit,  from  without.  The  lowest  of  the  infusoria  are 
of  fixed  and  determinate  species ;  and  Ehrenberg  states  that  even  the  minutest 
monads  possess  a  comphcated  organization.  It  may  be  asked,  concerning  both  them 
and  the  entozoa,  why,  if  they  ever  arise  spontaneously,  should  they  be  furnished 
with  a  generative  apparatus  ?  Again,  some  of  the  entozoa  abound  in  certain  places, 
and  strangers  coming  to  those  places  appear  to  contract  them  there.  The  dracun- 
culus  was  thought  by  the  soldiers  in  India  to  be  communicable  from  person  to  per- 
son, as  the  itch  insect,  and  the  chigoe,  to  both  of  which  it  has  some  analogy,  cer- 
tainly are.  The  infant  filaria  probably  creeps  in  through  the  skin  without  causing 
any  noticeable  pain.  Even  that  monster  among  the  entozoa,  the  tape-worm,  invades 
the  bodies  of  those  persons  who  visit  the  countries  to  which  it  belongs.  I  told  you 
before,  that  when  tape-worm  occurs  in  Germany,  it  is  always  the  tasnia  solium ; 
when  in  Switzerland,  almost  always  the  tsenia  lata.  Now  the  celebrated  Soemmer- 
ing was  afflicted  by  one  of  these  beasts ;  and  he  was  by  birth  a  German  :  yet  the 
worm  that  he  voided  was  of  the  foreign  species,  the  tasnia  lata.  He  had  resided, 
however,  for  some  time  in  Switzerland  ;  and  there,  we  can  scarcely  doubt,  he  caught 
the  ovum,  or  the  young  one,  of  the  parasitic  animal.  Mr.  Abernethy  once  told  me 
the  following  curious  story : — A  shepherd  had  to  drive  a  flock  of  healthy  sheep  to  a 
distant  part  of  the  country.  The  journey  occupied  two  or  three  days.  On  the  road 
one  of  the  animals  broke  its  leg,  and  was  carried  the  rest  of  the  way  on  horseback. 
All  the  flock,  except  this  hurt  individual,  was  turned  for  one  night  into  a  marshy  pas- 
ture. The  broken  limb  was  set,  and  the  patient  got  well ;  and  was  the  only  one  of 
the  whole  flock  that  did  not  subsequently  become  affected  with  the  rot;  the  only  one 
that  escaped  having  flukes  in  its  liver.  Is  it  not  presumable  that  the  ova  of  these 
parasites  were  swallowed  with  the  herbage  cropped  by  the  sheep  in  the  damp  mea- 
doAV  ?  The  germs  of  the  entozoa  which  dwell  in  closed  chambers,  and  within  the 
solid  viscera  of  the  body,  are  probably  carried  thither  by  the  blood. 

Upon  the  whole,  we  may  reject  the  hypothesis  of  equivocal  generation,  and  fall 
back  upon  the  Harveian  axiom,  taken  in  its  most  extended  sense,  of  omne  vivum  ex 
ovo.  If  I  have  digressed  somewhat  in  order  to  set  before  you  the  grounds  of  my 
own  beHef  in  this  matter,  the  interest  and  importance  of  the  subject  must  be  my 
excuse. 

What  I  have  further  to  say  will  relate  exclusively  to  the  intestinal  worms  of  the 
human  body :  their  predisposing  causes ;  the  symptoms  they  occasion ;  and  the 
modes  of  getting  rid  of  them. 

However  much  we  may  be  in  the  dark  as  to  the  exact  mode  in  which  these  para- 
sites reach  their  habitations,  we  do  know  something  of  the  circumstances  that  appear 
to  favour  their  production  and  muhiplication.  They  certainly  prevail  most  in  per- 
sons who,  from  whatever  cause,  are  weak  and  unhealthy  ;  and  particularly  in  scro- 
fulous children.  There  are,  however,  many  exceptions  to  this  :  they  are  not  uncom- 
mon in  individuals  who  are  robust  and  vigorous.  Intestinal  worms,  of  all  kinds,  are 
more  abundant  in  some  situations  than  in  others ;  especially  in  places  that  are  low 
and  moist.  They  are  accordingly  very  frequent  in  Holland,  and  in  some  parts  of 
Switzerland.  Wherever  there  is  much  debility  of  the  digestive  organs — in  k'uco 
phlegmatic  habits — in  persons  who  secrete  habitualh''  a  large  quantity  of  mucus — 
worms  are  apt  to  congregate.  The  children  of  the  Negroes  in  the  West  Indies  are 
wonderfully  infested  by  them. 

It  more  concerns  us  to  inquire  into  the  general  symptoms,  through  which  the 
existence  of  worms  in  the  alimentary  canal  may  be  ascertained,  or  suspected- 

Those  symptoms  are  very  multifarious;  and,  for  the  most  part,  very  e9ul vocal. 
1  know  of  none  that  can  be  reckoned  certain  or  pathognomonic,  except  the  actual 
appearance  of  one  or  more  of  the  animals,  or  of  portions  of  them,  in  the  exc/emcnt'i 


INTESTINAL    WORMS.  837 

of  the  body.  Yet  that  they  do  give  rise  to  a  variety  of  morbid  phenomena — which 
morbid  phenomena  are,  however,  Uable  to  be  produced  by  other  causes  also — there 
can  be  no  question. 

The  most  common  of  these  are  well  known  to  all  nurses  and  old  women ;  such 
as  colicky  pains,  and  swelling  of  the  belly;  picking  of  the  nose,  in  consequence  of 
itching  and  irritation  there  ;  itching  of  the  fundament ;  a  foul  breath  ;  grinding  of 
the  teeth  during  sleep  ;  a  variable  and  capricious  appetite,  sometimes  voracious  and 
insatiable,  sometimes  none  at  all;  and  irregular  bowels. 

Worms  sometimes  occasion  strange,  and  even  severe,  nervous  symptoms,  explain- 
able upon  the  principle  of  the  reflex  office  of  the  spinal  cord.  We  conclude  that 
the  symptoms  are  owing  to  worms  in  such  cases,  because  they  cease  when  the  crea- 
tures are  got  rid  of.  Some  examples  of  this  I  have  already  noticed.  Thus,  Dr. 
EUiotson's  infant  patient  lost  a  chronic  cough  upon  the  expulsion  of  the  live  larvae 
of  the  common  fly.  Bremser  gives  a  very  similar  case.  A  child  of  eleven,  afflicted 
with  taenia,  had  a  troublesome  dry  cough.  It  was  observed  that  the  cough  was  sus- 
pended for  two  months,  just  after  a  very  large  portion  of  the  worm  had  been  brought 
away  by  anthelmintic  medicines.  This  kind  of  coincidence  happened,  not  once 
only,  but  three  or  four  times  ;  and  at  length,  when  the  whole  of  the  worm  had  come 
away,  the  cough  was  permanently  cured.  I  mentioned,  some  time  ago,  the  frequent 
association  of  intestinal  worms  with  epilepsy,  which  is  then  of  the  eccentric  form: 
and  I  stated  that  a  certain  nobleman  voided  some  kind  of  worm  (a  tape-worm,  I  think) 
from  his  bowels,  and  was  thenceforward  free  from  epileptic  fits,  under  which  he  had 
long  laboured.  A  curious  circumstance,  illustrating  the  fact  that  irritation  of  the 
mucous  membrane  of  the  alimentary  tube  may  affect  distant  parts,  is  quoted  by  Dr., 
Joy  from  Albinus.  A  soldier  received  a  wound,  which  led  to  the  formation  of  an 
unnatural  anus,  in  front  of  the  abdomen,  and  in  the  track  of  the  colon.  Through 
this  opening  the  mucous  membrane  of  the  bowel  sometimes  protruded  ;  and  when- 
ever it  was  out,  and  exposed  to  the  contact  of  cool  air,  the  patient  began  to  cough ; 
and  continued  to  do  so  till  the  mucous  surface  was  warm  again.  Partial  palsy, 
amaurosis,  aphonia,  and  other  nervous  symptoms,  occasionally  depend  upon  the  pre- 
sence of  worms  in  the  intestines. 

[Dr.  Schleifer,  in  the  Austrian  Weekly  Journal  of  Medicine,  relates  the  case  of  a  child, 
nine  years  of  age,  who  became  dumb,  after  suffering  in  early  life  from  cutaneous  eruptions, 
engorgement  of  the  glands,  &.c.  The  loss  of  hearing  was  attributed  chiefly  to  a  fall,  and 
treated  accordingly.  The  child  became  emaciated,  pale,  with  a  dark  leaden  appearance  of 
the  contour  of  the  eyes.  The  tongue  was  white  and  loaded,  the  breath  offensive,  and  the 
abdomen  tumid  and  hard.  The  muscles  of  the  face  were  in  constant  motion,  and  the  patient 
moaned  incessantly.  Dr.  S.  suspected  the  presence  of  worms,  and  treated  the  patient  accord- 
ingly. In  three  weeks,  eighty-seven  lumbi-ici  were  discharged,  and,  during  five  weeks,  im- 
mense quantities  of  ascarides.  At  the  end  of  the  sixth  week,  the  child  had  recovered  his 
hearing  and  speech. 

In  the  Journal  of  Medicine  and  Surgery  of  Paris,  for  April,  1844,  a  case  is  quoted,  from 
the  Gazette  Medicales  of  Dijon,  of  a  young  man,  nineteen  years  of  age,  who  was  attacked 
with  all  the  symptoms  of  acute  pleurisy:  chill,  followed  by  fever;  severe  pain  in  the  left 
side;  difficult,  jerking  respiration  ;  paroxysms  of  dry  cough,  which  occasioned  the  patient  to 
scream  out,  &c. ;  all  of  which  symptoms  promptly  disappeared  after  the  discharge  of  seven- 
ty-five lunibrici. — C] 

But  let  us  examine  into  the  symptoms  which  are  more  or  less  proper  to  par- 
ticular species  of  intestinal  entozoa ;  and  into  the  treatment  which  they  severally 
require. 

A  variety  of  symptoms  are  ascribed  to  the  ascaris  lumbricbidcs.  Dr.  Bail  lie 
says  that  the  most  characteristic  are  a  tumid  belly,  enmciated  extremities,  offensive 
breath,  and  a  deranged  appetite.  To  these  may  be  added  colicky  pains  of  the 
abdomen.  When  these  animals  get  out  of  the  small  intestines,  and  ascend  into  the 
stomach  or  oesophagus,  they  may  occasion  pain,  nausea,  vomiting,  even  convulsions. 
They  have  caused  death,  as  I  mentioned  before,  by  crawling  into  the  biliary  ducts, 
and  into  the  chink  of  the  glottis.  Sometimes,  on  the  other  hand,  they  emerge  unex. 
pectedlj,  from  persons  who  had  received  no  previous  notice  of  their  prcsejir« 
within. 


838  THREAD-WORBIS — TAPE-WORMS. 

This,  the  commonest  parasitic  tenant  of  the  human  bowels,  is  also  a  troublesome 
one  to  eject.  A  great  variety  of  anthelmintics  have  been  cried  up  as  successful 
against  it;  but  brisk  purgatives,  and  bitter  medicines  in  the  intervals,  have  the  best 
evidence  in  their  favour.  These  animals  seem  not  to  like  steel;  and  my  own  plan 
of  assailing  them  is  that  of  purging  the  patient  from  time  to  time  by  calomel  and  jalap, 
and  administering,  three  times  a  day,  some  preparation  of  iron  ;  the  sulphate,  or  the 
muriated  tincture.  I  believe  that  most  of  the  patent  worm-medicines  consist  of  mer- 
cury, jalap,  and  scammon}^  given  in  strong  doses.  The  fetid  drugs,  assafetida,  gal- 
banum,  valerian,  are  often  used.  Cowhage,  also,  the  dolichos  pruriens,  which  is 
supposed  to  tease  the  skin  of  the  parasite  no  less  than  that  of  the  human  worm;  and 
tin-filings,  which  are  thought  to  bruise  or  lacerate  the  offenders,  are  favourite  reme- 
dies with  some  persons.  I  have  never  tried  them.  The  oil  of  turpentine  I  have  not 
found  so  successful  in  expelling  this  species  of  ascaris  as  I  shall  presently  show  you 
that  it  is  against  the  tape-worm.  Croton  oil  has  been  much  commended,  either  given 
by  the  mouth  or  rubbed  upon  the  abdomen.  Common  salt,  coloured  by  cochineal, 
and  exhibited  every  morning  in  half-drachm  doses,  was  found  by  Dr.  Rush  to  be 
very  successful. 

The  symptoms  produced  by  the  ascaris  vernncvhms  are  itching  and  irritation 
about  the  anus,  especially  in  the  evening,  and  aggravated  by  the  warmth  of  the  bed, 
and  by  whatever  overheats  the  body.  I  would  refer  j'ou  to  a  paper  by  Dr.  Heber- 
den  on  this  subject,  in  the  first  volume  of  the  Medical  Transactions.  The  case  he 
describes  is  the  more  valuable,  as  it  was  related  to  him  by  a  physician  who  \\-as  all 
his  life  plagued  by  these  thread-worms.  Generally,  however,  tney  infest  children; 
and  become  fewer,  and  at  length  disappear,  as  childhood  passes  into  youth.  When 
they  do  accompany  life  through  its  several  stages,  although  they  are  a  source  of 
serious  annoyance  and  suffering,  they  do  not  appear  to  shorten  the  duration  of  the 
patient's  existence. 

To  introduce  at  one  end  of  a  tube,  several  yards  long,  substances  which  are  in- 
tended to  act  upon  animals  that  live  quite  at  its  other  end,  would  be  a  very  round- 
about course.  Whether  a  purgative  efiiect,  or  a  specified  destructive  effect,  be  the 
object,  enemata  are  preferable  to  medicines  given  by  the  mouth.  Bitters  offend 
and  destroy  these  little  worms.  I  have  relieved  many  patients  from  their  tormentors 
by  prescribing  simply  the  infusion  of  quassia  as  an  injection.  Tobacco  clysters  are 
praised ;  but  the  remedy  is  a  hazardous  one.  Dr.  Darwall  says  of  an  enema  com- 
posed of  half  an  ounce  of  the  muriated  tincture  of  iron  mixed  with  half  a  pint  of 
water,  "  there  are  few  cases  so  obstinate  that  this  will  not  suffice  to  overcome."  Lime- 
water,  injected  into  the  rectum,  forms  another  effectual  remedy  for  ascarides,  and  (as 
pharmacologists  love  to  speak)  a  rather  elegant  one. 

Thread-worms  may  be  scooped  out  of  the  rectum  with  the  finger.  Old  women 
fish  for  them  with  a  piece  of  fat  meat,  or  a  candle,  wherewith  the  entangled  worms 
are  drawn  out  of  the  bowel.  Perhaps,  in  troublesome  cases,  the  plan  laid  down  by 
Martinet  is  as  good  as  any.  He  recommends  three  successive  injections:  the  first 
meiely  purgative ;  the  second  specific  (common  salt  in  solution,  cold  vinegar  and 
water,  lime-water,  some  bitter  infusion) ;  the  third,  oleaginous  and  soothing.  Oil 
often  alla3's  the  itching.  This  teazing  symptom  may  sometimes  be  quieted  by  ap- 
plying a  towel,  wetted  with  cold  water,  to  the  fundament,  while  in  bed. 

With  some  means  of  this  kind  for  expelling  the  worms,  appropriate  measures 
should  be  combined  for  improving  the  general  health. 

I  know  of  no  signs  by  which  the  presence  of  the  tricocephalus  dispar  is  revealed; 
and  I  am  equally  ignorant  of  any  remedies  for  it. 

That  a  tapr-icorm  is  within,  we  know  when  the  joints  of  it  are  voided.  Number- 
less symptoms  have  been  ascribed  to  this  huge  internal  parasite.  The  following  are 
probably  the  most  distinctive.  Uneasy  feelings  in  the  epigastrium,  which  often  abate 
or  arc  removed  by  eating ;  the  appetite  generally  craving,  but  sometimes  baa .  itching 


TAPE-WORMS.  839 

of  the  nose  and  of  the  anus  ;  nausea;  colic  ;  giddiness  ;  a  sour  breath.  Less  fre- 
quently loud  borborigmi  occur;  and  sometimes  convulsions. 

Louis  has  watched  and  recorded,  with  his  accustomed  minuteness,  the  symptoms 
of  ten  cases  in  the  wards  of  La  Charite.  Seven  of  the  patients  were  males,  and  three 
females.  The  youngest  was  a  boy  of  twelve,  the  son  of  another  of  the  patients  ;  the 
oldest  was  seventy-four.  Most  of  them  were  in  comfortable  circumstances,  and  had 
been  habitually  well  fed.  The  greater  number  of  them  had  for  some  time  been 
passing  fragments  of  tape-worm,  with  their  stools,  in  their  clothes,  and  in  their  beds. 
In  one  of  the  cases  the  articulations  had  been  twice  only  detected  in  the  stools,  and 
each  time  upon  the  operation  of  a  purgative. 

In  all  the  patients  but  two,  the  other  symptoms  commenced  when  the  evacuation 
of  the  fragments  commenced.  This  renders  it  probable  that  the  worms  begin  to  give 
annoyance  when  they  get  into  the  large  intestine.  The  temporary  relief  that  results 
from  the  expulsion  of  portions  of  the  animal  strengthens  that  supposition.  The  case 
is  mentioned  in  the  Aledico-Chinirgical  Journal  of  a  man  w^ho  was  in  the  habit  of 
freeing  himself  from  large  fragments  of  tape-worm  by  introducing  a  slick  into  his 
rectum,  and  twisting  the  worm  round  till  it  broke. 

The  chief  symptoms  observed  in  Louis's  cases  were  colicky  pains  of  the  abdo- 
men ;  itching  of  the  anus,  and  of  the  end  of  the  nose  ;  uneasiness  in  the  epigastrium  ; 
and  deranged  dicestion  and  appefite. 

Pain  in  the  abdomen  occurred  in  all  the  instances :  but  it  differed,  in  different 
cases,  both  in  degree  and  in  kind.  It  was  intermittent ;  and  mostly  felt  towards  the 
flanks. 

There  was  itching  at  the  margin  of  the  anus  in  seven  of  the  ten  cases ;  itching  of 
the  nose  in  four.  With  one  exception,  only,  itching  was  present  in  one  or  the  other, 
or  in  both  of  these  situations. 

The  appetite  was  craving  in  one  patient;  unaffected  in  four;  variable  or  bad  in  all 
the  rest.  In  all,  slight  emaciation  was  observed.  In  all,  the  pupil  of  the  ej^e  was 
of  its  natural  dimensions.  This  is  noticed,  because  dilatation  of  the  pupil  has  been 
set  down  as  one  of  the  symptoms  of  tsenia. 

Louis  thinks  that  the  following  combination  of  symptoms  indicates  with  tolerable 
certainty  the  presence  of  some  kind  of  worm  in  the  intestines.  Pain  in  the  belly; 
colic  of  various  degrees  of  intensity,  unaccompanied  by  diarrhoea;  itching  about  the 
anus,  and  at  the  end  of  the  nose.  If  pains  in  the  limbs,  lassitude,  and.  nervous  symp- 
toms exist  also,  the  diagnosis  is  strengthened. 

We  have  a  very  effectual  remedy  for  tsenia — at  any  rate  for  the  tape-worm  of  this 
country  —  in  oil  of  turpentine,  given  in  large  doses.  The  anthelmintic  virtues  of 
this  substance  were  not  generally  known  till  a  paper  on  the  subject,  by  Dr.  Fenwick, 
of  Durham,  was  published,  in  1811,  in  the  Medico-Chirurgical  Transactions.  A 
sailor,  plagued  by  this  parasite,  had  noticed  that  large  fragments  of  the  worm  were 
passed  whenever  he  had  swallowed  an  unusual  quantity  of  raw  gin.  Thinking  that 
a  stronger  spirit  might  have  a  stronger  effect  upon  his  internal  enemy,  he  tried  a 
glass  of  turpentine,  which  completely  cured  him.  This  practice  was  then  taken  up 
by  some  unprofessional  persons,  who  gave  turpentine,  with  similar  success,  in  several 
cases.  At  last  Dr.  Fenwick,  in  conjunction  I  believe  with  my  friend  Dr.  Southey, 
investigated  the  subject;  and  when  they  had  satisfied  themselves  of  the  value  of  the 
remedy,  the  result  of  their  inquiries  was  communicated  by  Dr.  Fenwick  to  the  late 
Dr.  Baillie,  in  a  letter  which  was  read  before  the  Medical  and  Chirurgical  Society. 
But  there  is  nothing  new  under  the  sun.  Fifty  years  ago,  Mr.  Maiden,  in  the 
Memoirs  of  the  London  Medical  Society,  recommended  the  same  remedy,  in  the 
same  doses,  for  the  same  purpose.  But  his  recommendation  had  been  neglected,  or 
forgotten. 

The  dose  of  turpentine  is  from  half  an  ounce  to  two  ounces.  It  may  be  given  i'l 
combination  with  castor  oil ;  or  castor  oil  may  be  administered  afterwards  to  assist 
its  })urgative  effect.  It  should  be  taken  in  the  morning,  fasting  :  and  no  drink  should 
be  admitted  into  the  stomach  until  the  medicine  begins  to  operafe,  lest  sickness  and 
vomiting  should  be  provoked.  The  worm  generally  is  voided,  dead,  within  an  how 
or  two. 


840  TAPE-WORMS. 

The  inconveniences  of  turpentine  as  a  remedy  are  its  nasty  taste,  the  sort  of  intojci- 
cation  it  is  apt  to  produce,  the  distressing  sickness  it  excites  in  some  persons,  and  the 
strangury  it  sometimes  occasions.  This  effect  of  it,  however,  is  less  common  from 
large  than  from  small  doses  of  the  oil.  The  bowels  should  be  kept  open  with  castor 
oil,  so  long  as  the  urine  retains  the  violet  smell,  which  indicates  the  presence  of  the 
turpentine  in  the  circulation. 

Upon  the  continent  a  celebrated  empyreumatic  oil,  called  Chabert's,  is  in  great 
repute.  It  contains  turpentine  ;  but  is  still  more  nauseous  than  it.  One  part  of  the 
empyreumatic  oil  of  hartshorn  is  mixed  with  three  parts  of  oil  of  turpentine.  Aflir 
the  mixture  has  stood  for  three  days,  three-fourths  of  it  are  to  be  distilled  over,  in 
glass  vessels,  by  means  of  a  sand  bath.  Chabert  was  a  veterinarj'^  surgeon,  and  had 
used  this  remedy  with  remarkable  success  upon  domestic  animals,  cow's,  dogs,  and 
sheep.  Bremser,  after  testing  its  safety  by  taking  it  himself,  administered  it,  he  tells 
us,  to  no  less  than  5(X)  individuals  troubled  with  taenia.  Among  these  were  two 
children,  a  year  and  a  half  old.  He  found  it  both  a  powerful  and  a  permanent  cure. 
Of  the  whole  number  treated  there  were  but  four  who  required  a  second  course  of 
the  remedy.  It  seems  to  kill  both  the  worms  and  their  ova.  The  dose  is  two  tea- 
spoonfuls,  night  and  morning,  until  four  or  six  ounces  have  been  taken  ;  a  purgative 
being  from  time  to  time  interposed.  If  that  dose  produces  any  confusion  of  head,  it 
must  be  diminished. 

Bremser  admits  that  this  curative  process  is  tedious,  but  affirms  that,  on  the  other 
hand,  it  is  safe,  and  but  little  inconvenient.  When  the  patient  has  continued  free 
from  any  symptoms  of  tape-worm  for  three  months,  he  concludes  that  the  cure  is 
absolute.  Other  practitioners  agree  with  him  in  attesting  the  efficacy  of  this  oil;  but 
are  not  so  confident  about  its  perfect  safety  and  convenience. 

Another  great  remedy  is  the  bark  of  the  pomegranate-root.  This  is  at  least  as  old 
as  the  time  of  Celsus.  It  has  long  been  employed  in  India.  Its  value  has  only 
been  recently  appreciated  in  France;  and  in  this  country  it  is  not  much  used,  I 
believe,  even  yet.  You  may  read  a  very  instructive  account  of  its  effects  in  a  paper 
communicated  to  the  Medical  and  Chirurgical  Society  by  Mr.  Breton.  He  boiled 
two  ounces  of  the  fresh  bark  of  the  root  in  a  pint  and  a  half  of  water,  till  the  decoc- 
lion  was  reduced  to  three  quarters  of  a  pint.  Two  ounces  of  this,  cold,  he  gave  to 
a  patient  who  had  tape-worm,  and  repeated  the  dose  every  half  hour  until  lour  doses 
had  been  swallowed.  About  an  hour  after  the  last  dose,  an  entire  taenia  was  voided 
alive. 

The  bark  dried  in  the  sun  he  found  still  more  active.  A  stout  man  forty  years 
old,  took  a  decoction  prepared  in  the  same  way  as  the  former,  only  with  the  dried 
instead  of  the  fresh  bark.  Three  hours  after  the  first  dose,  a  live  tape-worm  came 
away,  nineteen  feet  two  inches  long.  The  medicine  thus  prepared  seemed  to  be  too 
strong  ;  the  patient  was  sick,  giddy,  and  trembling  for  several  hours.  He,  also,  had 
taken  four  doses. 

To  two  boys,  of  seven  and  ten  years  of  age,  he  began  early  in  the  morning  to 
iidminister  one  ounce  of  a  decoction  made  of  half  the  previous  strength,  every  half 
hour,  for  six  times  ;  and  then  stopped.  In  the  middle  of  the  day  he  resumed  the 
medicine  in  half-ounce  doses.  Giddiness  and  faintness  soon  came  on ;  and,  about 
five  o'clock,  each  of  the  patients  passed  a  ta?nia  of  the  solium  kind. 

A  scruple  of  the  powder  was  given,  mixed  with  water,  every  hour  for  five  succes- 
sive hours,  to  a  boy  of  nine.  Forty  minutes  after  the  last  dose  a  living  tasnia  was 
expelled. 

The  same  quantity  was  given  to  a  girl,  ten  years  of  age  ;  beginning  at  eight,  and 
repealing  the  dose  hourly  till  twelve  o'clock.  At  twenty-four  minutes  past  one  she 
voided  a  living  taenia  lata;  and  the  next  morning,  at  nine  o'clock,  a  dead  taenia 
sohum.  This  curious  case  shows  that  the  two  species  may  exist  in  the  same  person 
at  the  same  time. 

Mr.  Breton  relates  other  examples,  but  those  which  I  have  cited  are  quite  suffi- 
cient to  demonstrate  the  power  of  this  substance.  The  bark  appears  to  act  upon  the 
worm  as  a  poison.  In  tepid  water  tjeniae  will  live  for  several  hours.  When  they 
are  plunged  into  the  aforesaid  decoction,  they  writhe  and  manifest  great  uneasiness^ 


INFLAMMATION    OF    THE    LIVER.  841 

Between  the  first  dose  of  the  medicine  and  the  expulsion  of  the  worm,  the  shortest 
period  appears  to  liave  been  three  hours,  the  longest  twenty-five. 

Louis's  ten  cases,  before  referred  to,  were  all  treated  by  a  nostrum  called  the  potion 
of  M.  Darbon.  It  proved  successful  in  all.  Eight  or  ten  ounces  of  it  were  taken 
in  the  morning,  before  breakfast ;  and  the  cure  was  accomplished  by  that  single  dose. 
It  is  said  to  be  quite  safe,  to  have  no  very  decided  taste,  and  to  cause  no  further  in- 
convenience than  a  slight  colicky  feeling,  and  uneasiness  in  the  epigastrium,  less 
than  is  produced  by  many  a  purgative  :  and  even  these  sensations  were  probably 
owing  to  the  movements  of  the  worm ;  for  when,  after  the  lapse  of  four  months, 
the  dose  was  repeated,  it  was  followed  by  no  inconvenience  at  all.  The  medicine 
is  not  strongly  cathartic,  and  sometimes  requires  the  aid  of  a  lavement.  In  each, 
of  these  cases  the  expelled  taenire  were  apparently  dead.  Their  Aeaf/s  were  detected 
in  the  evacuations  :  in  one  instance  seven  heads  were  seen.  Louis  says  that  within 
a  few  days  at  furthest  after  the  discharge  of  the  worms,  all  the  previous  symptoms 
of  their  presence  ceased  ;  and  the  patients  improved  in  respect  to  appetite,  digestion, 
complexion,  flesh,  and  strength.  They  all  remained  well  four  months  afterwards, 
and  then  the  potion  was  again  administered;  but  it  brought  away  no  more  worms. 
Some  of  the  patients,  who  had  previously  tried  other  modes  of  cure,  had  never 
enjoyed  so  long  an  interval  of  freedom. 

Various  other  remedies  have  been  employed,  and  employed  with  more  or  less 
success.  One  of  them,  the  root  of  the  male  fern,  formed  the  basis  of  a  nostrum, 
called  Madame  Nouffer's,  which  was  so  highly  thought  of,  that  in  1776  the  King 
of  France  gave  that  lady  some  hundred  pounds  sterhng  for  the  secret  of  its  com- 
position. I  think,  however,  you  will  find  the  oil  of  turpentine  equal  to  the  cure  of 
tape-worm  in  most  instances.  Should  it  fail,  or  should  circumstances  forbid  its  use, 
I  would  advise  you  to  resort  to  the  bark  of  the  pomegranate  root.  It  seems  pro- 
bable that  M.  Darbon's  remedy,  if  its  nature  were  divulged,  would  supersede  all 
others. 


LECTURE  LXXV. 

Diseases  of  the  Liver.  Acute  Inflammation.  Abscess  of  the  Liver.  Causes  and 
Treatment  of  Acute  Hepatitis.  Clironic  Hepatitis.  Jaundice.  Its  Symptoms, 
Causes,  and  Species. 

From  the  alimentary  canal  I  go  to  the  other  organs  directly  or  indirectly  con- 
cerned in  the  digestion  and  assimilation  of  our  food.  And,  first,  let  us  look  at  that 
large  gland,  the  liver,  of  which  the  main  office,  so  far  as  we  can  perceive,  is  the  se- 
cretion of  bile. 

The  liver  is  liable  to  various  forms  of  disease  :  but  it  is  not  so  frequently  in 
fault  as  many  would  have  us  believe.  It  is  often  blamed  most  gratuitously  and 
unjustly. 

The  researches  of  Mr.  Kiernan,  recently  published  in  the  Philosophical  Trans- 
actions, have  paved  the  way  for  a  better  understanding  in  future  of  its  pathology.  If 
I  did  not  feel  myself  too  much  circumscribed  by  the  remaining  limits  of  this  course 
of  lectures,  I  should  be  glad  to  attempt  to  assist  you  in  construing  Mr.  Kiernan's 
somewhat  difficult  and  very  valuable  paper.  But  doubtless  you  are  made  familiar 
with  the  anatomy  of  the  organ,  as  described  by  him,  in  other  lectures :  and  I  must 
content  myself  with  noticing,  as  we  go  along,  one  or  two  points,  in  respect  to  its  mor- 
bid appearances,  concerning  which,  before  Mr.  Kiernan  took  the  subject  up,  great 
mistakes  prevailed,  even  among  the  most  celebrated  pathologists. 

I  shall  follow  the  usual  order,  and  consider  first,  injiammation  of  the  liver,  which 
may  be  either  acute  or  chronic. 

Tht  se  are,  both  of  them,  diseases  that  are  much  more  common  in  warm  climates 
than  here. 

Of  well-marked  acute  hepatitis  the  symptoms  are  fever,  with  pain  and  a  sense  or 

3v 


842  INFLAMMATION    OF    THE    LIVER. 

tension  in  the  ri-^hl  hj-pochondrium,  inability  to  lie  on  the  left  side,  difficulty  of  breath 
ing,  a  dry  coujb,  vomiting,  hiccup. 

You  will  not  find  all  these  symptoms  present  in  every  case  :  yet  they  are  all  worth 
attending  to. 

The  pain  is  sometimes  sharp  and  pricking,  like  a  pleuritic  stitch:  sometimes  dull 
and  tensive.  In  the  former  case  the  peritoneal  covering  of  the  gland  is  supposed  to 
be  affected  ;  in  the  latter  its  parenchyma.  The  pain  sometimes  extends  to  the  right 
clavicle  and  to  the  top  of  the  right  shoulder.  This  circumstance  was  noticed  by 
Hippocrates  ;  and  I  have  referred  to  it  bel'ore  as  a  good  example  of  what  are  called 
sympathetic  sensations.  The  existence  of  this  pain  makes  it  probable  that  the 
inflammation  affects  the  convex  surface  of  the  hver.  Occasionahy  the  left  shoulder 
is  painful :  the  left  lobe  of  the  hver  being  involved  in  the  disease.  The  pain  in  the 
right  side  is  aggravated,  often,  by  the  movements  of  the  diaphragm  in  respiration ; 
and  this  explains  the  embarrassment  of  the  breathing,  and  the  short  dry  cough.  Why 
the  patient  cannot  well  he  on  the  left  side  is  obvious  enough :  all  the  connections  of 
the  inflamed  organ  are  then  put  upon  the  stretch  by  its  weight.  There  are,  how- 
ever, some  exceptions  to  this  rule.  On  the  under  or  concave  part  of  the  hver  lies  the 
pyloric  extremity  of  the  stomach  ;  and  that  viscus  often  s^-mpalhizes  with  the  hepatic 
inflammation :  nausea  and  vomiting  occur ;  and  hiccup.  The  thoracic  symptoms 
on  the  one  hand,  or  the  stomach  symptoms  on  the  other,  may  be  expected  to  predo- 
minate, according  as  the  convex  or  the  concave  surface  of  the  organ  is  chiefly  the 
seat  of  the  inflammation. 

The  situation  of  the  pain,  the  cough,  the  short  and  shallow  breathing,  used  to 
puzzle  the  older  observers :  and  they  confess  their  occasional  inability  to  determine 
whether  the  inflammation  was  situated  in  the  lower  lobe  of  the  right  lung,  or  in  the 
liver.  But  now-a-days  we  need  have  no  difficulty  in  making  the  diagnosis.  The 
ear  wilHell  us,  if  we  employ  auscultation  and  percussion,  whether  the  contents  of- 
the  chest  or  of  the  belly  are  suffering:  and  my  own  experience  has  taught  me  that 
sharp  pain,  with  feverishness,  occurring  in  the  debateable  ground  of  the  right  side, 
denotes  pleuritic  inflammation  far  more  often  than  it  denotes  hepatic. 

Jaundice  is  an  occasional,  but  by  no  means  a  necesaanj  effect  or  accompaniment 
of  hepatitis,  whether  acute  or  chronic :  and,  therefore,  what  I  have  to  say  of  that 
symptom  I  shall  give  under  a  separate  head. 

Acute  hepatitis  may  terminate  in  resolution  ;  or  it  may  terminate  in  diffused  sup- 
puration ;  or,  what  is  more  usual,  in  the  formation  of  a  circumscribed  abscess,  or  of 
abscesses,  in  the  liver.  In  this  climate  we  do  not  often  meet  with  hepatic  abscesses  ; 
but  they  are  very  common  in  hot  countries :  and  some  of  the  most  interesting  events 
of  the  disease  have  relation  to  the  progress  of  these  collections  of  matter.  When 
they  approach  the  surface  of  the  liver,  adhesions  generally  take  place  (in  virtue  of 
that  conservative  principle  of  which  we  so  constantly  discern  the  working)  between 
the  diseased  organ  and  the  neighbouring  parts.  If  no  such  adhesion  occurred,  ihe 
matter  would  at  length  burst  into  the  cavity  of  the  peritoneum ;  and  this  does  some- 
times happen.  The  peritonitis,  which  is  thus  suddenly  set  up,  is  almost  fatal.  I 
referred,  however,  in  a  former  lecture,  to  one  instance  in  which  it  was  recovered  from. 
Sometimes  the  adhesion  is  effected  between  the  liver  and  the  parietes  of  the  abdo- 
men, and  the  abscess  points  externally,  and  may  be  opened  by  the  surgeon.  Such 
a  case  occurred  in  my  neighbourhood  last  year.  Sometimes  the  liver  glues  itself  to 
the  stomach,  or  to  the  intestines  ;  and  then  the  abscess  breaks  into  the  alimen'.ary 
tube,  the  matter  is  evacuated  by  vomiting,  or  by  stool :  and  all  goes  on  tolerably 
well  again.  In  other  instances  the  agglutination  is  to  the  diaphragm,  which  is  per- 
forated, and  the  pus  makes  its  way  into  the  sac  of  the  pleura,  or  through  the  lung 
to  the  bronchi,  and  so  out  by  the  mouth.  I  have  seen  three  examples  of  this  my- 
self. In  one  the  abscesses  originated  in  the  formation  and  degeneration  of  hydatids 
in  the  liver ;  and  the  patient ^(a  woman,  she  was  under  Dr.  Macmichael's  cure  in 
the  Middlesex  Hospital)  spat  up  quantities  of  yellow  fluid,  consisting  partly  I  sup- 
pose of  pus,  but  chif^fly  of  pure  bile.  The  examination  of  the  dead  body  ultimately 
demonstrated  the  nature  of  that  case.  The  second  of  the  three  patients  got  well: 
yet  1  cannot  doubt  that,  bating  the  hydatids,  the  disease  ivas  essentially  of  the  same 


INFLAMMATION    OF    THE    LIVER.  843 

kind.  It  also  occurred  in  a  woman,  whom  I  admitted  into  th(5  hospital.  She  was  a 
kitchen-maid  at  the  Thatched  House  Tavern  in  St,  James's  Street ;  and  she  had 
received  a  violent  blow  at  the  back  part  of  the  right  hypochondriuin.  This  was  fol- 
lowed by  pain  there  and  by  fever ;  and  at  length  she  began  to  have  cough,  dyspncea, 
and  expectoration.  She  brought  up  an  abundance  of  frothy  mucus  of  a  bright  yel- 
low colour:  not  at  all  resembling  the  rusty  sputa  of  pneumonia,  but  exacily  of  the 
tint  which  bile  would  give  to  it.  At  the  same  time  large  crepitation  could  be  traced 
from  the  bottom  to  the  top  of  the  right  lang,  I  fully  expected  that  this  woman  would 
die  :  but  by  degrees  the  j^ellow  expectoration  ceased,  all  the  auscultatory  signs  gra- 
dually disappeared,  and  she  recovered  perfectly. 

It  is  plain  that  in  such  instances  as  this,  there  must  be  adhesion  of  the  Inng  to  the 
diaphragm  also:  but  cases  have  occurred  in  which  the  matter  burst  into  the  cavaly 
of  the  pleura,  and  presently  destroyed  the  patient  by  suffocation. 

The  event  of  the  third  case  is  still  s^^h  judice.  A  gardener,  of  forty-five  years 
old,  was  attacked,  four  weeks  before  he  came  under  my  care  in  the  hospital,  with 
severe  pain  in  the  right  loin.  Just  at  the  edge  of  the  short  ribs,  and  not  far  from  the 
vertebral  column,  on  the  right  side,  I  found  a  large  elastic  swelling,  very  tender,  and 
of  a  bluish  red  colour.  As  the  patient's  urine  was  most  remarkably  loaded  with 
amorphous  deposits,  my  iirst  suspicions  turned  towards  the  kidney.  It  soon,  how- 
ever, became  evident  that,  although  the  tumour  was  below  the  diaphragm,  the  parts 
above  that  muscle  were  involved  in  the  disease.  The  righl,  half  of  the  thorax  was 
dull  to  percussion  ;  no  vesicular  breathing  was  audible  there,  but  some  scattered  cre- 
pitation and  bronchophony.  Four  days  subsequently  to  his  admission  the  patient 
began,  during  an  effort  of  coughing,  to  discharge  almost  in  a  stream,  from  his  mouth, 
a  considerable  quantity  of  gray,  pultaceous  fluid,  of  the  consistence  of  gruel,  and  hor- 
ribly foslid.  Altogether  the  amount  of  matter  thus  expectorated  was  estimated  at 
two  quarts.  The  pain  then  ceased  ;  and  the  swelling  was  observed  to  be  less.  After 
three  days  more,  it  was  deemed  proper  to  puncture  the  tumour,  and  matter  was  let 
out  having  precisely  the  qualities  of  that  which  he  had  ejected  through  the  mouth. 
The  patient  remained  eleven  weeks  in  the  hospital,  the  expectoration  becoming  less 
unnatural,  and  the  discharge  from  the  abscess  gradually  diminishing.  He  then 
chose  to  depart.  Some  months  afterwards  he  applied  for  re-admission,  and  again 
stayed  with  us  a  week  or  two.  His  health  had  much  improved  during  the  interval: 
but  the  wound  in  his  back  was  still  open,  and  he  still  continued  to  expectorate  some- 
what :  and  yellow  bile  was  frequently  to  be  seen,  both  on  the  dressings  which 
covered  the  puncture,  and  in  the  vessel  into  which  he  spat.  I  think  it  probable  that 
this  man  may  eventually  recover,  at  the  expense,  however,  of  a  permanently  da- 
maged lung. 

Rigors  occurring  during  the  progress  of  hepatitis  should  make  us  suspect  that 
suppuration  is  taking  place :  if  the  pain  is  thenceforward  mitigated,  or  exchanged 
for  a  sense  of  \veight,  and  hectic  fever  sets  in,  we  may  be  tolerably  certain  that  pus 
has  formed. 

Of  the  several  courses  taken  by  an  hepatic  abscess,  that  towards  the  surface  of  the 
body  is  the  most  common  ;  and  it  is  the  only  one  with  which  w'e  are  able  to  interfere. 
And  the  chief  thing  we  have  to  look  to,  is  not  to  interfere  too  soon.  The  adhesion 
of  the  inflamed  organ  to  the  wall  of  the  abdomen  is  the  indispensable  condition,  not 
of  success  only,  but  of  safety,  where  the  question  arises  of  puncturing  the  tumour. 
Without  such  adhesion  the  pus  will  be  transferred  from  the  cyst  to  the  cavity  of  the 
peritoneum ;  or  if  the  abscess  be  not  reached  by  the  scalpel,  that  cavity  will  be  laid 
open.  Now  it  is  not  easy  to  ascertain  whether  there  be  adhesion  or  not.  Certainly 
the  operation  ought  not  to  be  attempted  until  the  parts  above  the  abscess  are  very 
thin,  and  are  verging  to  a  point;  and  even  then,  unless  there  were  some  distinc 
purpose,  besides  that  of  saving  a  little  time,  some  urgent  distress  or  danger  to  relieve, 
I  think  such  abscesses  might  be  more  prudently  left  to  themselves.  Dr.  Gregory, 
of  Edinburgh,  used  to  mention  a  case  in  which,  as  fluctuation  was  palpable,  and  the 
tumour  pointed,  it  was  proposed  to  open  it ;  but  the  patient  died,  somewhat  suddenly, 
before  the  operation  could  be  performed;  and  inspection  of  the  dead  body  showed 
that  no  adhesion  existed.     Mr.  Malcolmson  has  lately  published,  in  the  3Iedico-Chi- 


844  ACUTE    HEPATITIS. 

riirgircd  Tranaactions,  two  or  three  instances  of  a  like  kind.  These  are  circum- 
stances which  teach  us  to  be  cautious  about  recommending  the  operation. 

A  case  is  recorded  of  the  bursting  of  an  hepatic  abscess  into  the  pericardium; 
another  into  the  vena  cava.  Facts  of  this  kind  constitute  mere  medical  curiosities, 
and  have  no  practical  bearing. 

It  is  clear,  both  from  the  size  of  the  organ,  and  from  its  situation  in  the  body,  that 
an  abscess  in  the  liver  can  never  be  otherwise  than  gravely  hazardous.  Yet  many 
recover  from  them.  Much  evidently  depends  upon  the  manner  and  direction  in 
which  the  pus  seeks  a  vent.  The  most  desirable  road  for  its  exit  is  one  which  it 
sometimes  takes,  but  which  I  have  not  yet  mentioned.  It  occasionally  flows  out  into 
the  duodenum  through  the  excretory  ducts  of  the  liver,  when  these  happen  to  have 
been  laid  open  by  the  suppurating  process.  Next  to  this  we  may  hope  for  its  dis- 
charge through  the  adhering  parietes  of  the  abdomen ;  next  by  a  breaking  of  the 
abscess  into  the  ahmentary  canal.  The  escape  of  the  matter  through  the  air-pas- 
sages is  fearfully  perilous ;  and  its  entrance  into  the  shut  serous  sacs,  or  into  the 
great  blood-vessels,  almost  necessarily  fatal. 

I  have  spoken  of  an  abscess  in  the  liver,  as  an  event  of  acute  inflammation  of  that 
organ.  Such  inflammation  is  apt  to  arise,  in  tropical  countries,  after  exposure  to  cold. 
In  any  climate  it  may  be  excited  by  a  blow,  or  other  mechanical  injury.  But  abscess 
in  the  liver  seems  to  be  far  more  frequently  the  result  of  other  remote  causes.  You 
will  call  to  mind  those  collections  of  matter  which  form  in  the  liver,  as  well  as  else- 
where, in  consequence  of  suppurative  phlebitis.  There  is,  moreover,  acknowledged 
connection  between  hepatic  suppuration  and  dysentery.  In  hot  chmates  the  two  are 
often  found  coincident.  It  has  commonly  been  thought  that,  in  these  cases,  the  affec- 
tion of  the  liver  happens  first,  in  the  order  of  time  ;  that  the  hepatic  disease,  inter- 
fering with  the  freedom  of  the  portal  circulation,  occasions  congestion  of  the  submu- 
cous capillary  blood-vessels,  and  so  disposes  the  membrane  to  take  on  inflammation 
under  the  influence  of  any  slight  exciting  cause.  In  some  recent  lectures,  however, 
dehvered  before  the  College  of  Physicians,  Dr.  Budd  has  proved,  by  a  careful  colla- 
tion of  a  large  number  of  authentic  instances,  that  the  relation  of  these  two  morbid 
conditions  to  each  other,  is  exactly  the  reverse :  that  the  dysentery  is  the  primary 
disorder,  and  the  hepatic  abscess  the  secondary ;  the  link  of  connection  between 
them  being  the  same  as  between  suppurative  inflammation  of  a  vein,  and  the  forma- 
tion of  pus  in  parts  more  or  less  remote.  The  blood,  in  its  return  through  the 
veins  which  are  tributaries  of  the  vena  porta,  carries  with  it,  if  not  pus,  yet  some 
vitiating  ingredient  from  the  inflamed  membrane :  and  this  vitiating  ingredient  pro- 
vokes inflammation  in  the  capillary  vessels  of  the  liver. 

This,  to  the  best  of  my  knowledge,  is  a  new,  and  certainly  it  is  an  important  view 
of  the  pathology  of  hepatic  abscess.  I  trust  that,  ere  long.  Dr.  Budd  will  lay  before 
the  public  the  evidence  upon  which  it  is  founded. 

Acute  hepatitis,  when  it  occurs,  requires  vigorous  treatment  in  the  outset.  Our 
object  is,  if  possible,  to  prevent  suppuration.  Blood  should  therefore  be  freely  taken 
from  the  system  by  venesection,  and  from  the  neighbourhood  of  the  inflamed  part 
by  leeches.  I  will  not  weary  you  by  going  over  the  old  ground  that  we  have  so 
often  trodden  already,  nor  repeat  observations  which  have  been  many  times  made 
respecting  the  methods,  and  the  requisite  amount,  of  this  great  antiphlogistic  remedy. 
Depletion  of  the  portal  vessels  may  also  be  indirectly  obtained  by  purgatives;  espe- 
cially by  such  purgatives  as  produce  copious  and  watery  stools.  The  neutral  salts 
are  therefore  proper  in  this  disorder.  It  may  be,  as  some  suppose,  that  they  operate 
beneficially,  as  counter-irritants,  upon  the  duodenum;  but  their  eWecl  in  draining 
the  veins  that  feed  the  vena  porta,  and  thereby  relieving  the  hepatic  congestion,  is 
more  obvious  and  more  intelligible.  These  saline  medicines  should  be  much  dilutea; 
and  their  action  may  be  quickened,  if  that  be  necessary,  by  adding  the  infusion  of 
senna. 

After  blood-letting  has  been  duly  performed,  and  the  force  of  the  inflammatory 
action  has  been  broken,  blisters  may  be  applied  to  the  right  hypochondriuni :  and  I 
lielieve  that  repeated  blistering  is  more  serviceable  than  a  single  bUster  kept  open  by 
sjivme  ointment. 


I 


CHRONIC   HEPATITIS.  845 

Some  diff^^rence  of  opinion  prevails  among  medical  men  in  regard  to  the  employ- 
ment of  mercury  in  the  outset  of  acute  hepatitis.  I  cannot  pretend  to  offer  you  the 
results  of  my  own  observation  on  this  point,  but  I  find  that  the  best  authorities, 
among  those  who  have  had  to  treat  the  disease  in  hot  climates,  are  against  its  use  at 
the  very  first,  as  being  stimulating  to  the  liver.  I  suspect  that  this  is  a  piece  of 
theory :  but  at  all  events,  after  the  first  violence  of  the  inflammation  has  abated,  that 
remedy  is  not  to  be  omitted,  either  in  the  acute,  or  in  the  chronic  form  of  the  disorder, 
to  be  mentioned  presently :  only  in  the  one  case  it  should  be  so  administered  as  to 
affect  the  system  as  speedily  as  possible;  in  the  other  it  is  to  be  introduced. with  a 
slowness  which  bears  a  proportion  to  the  pace  of  the  disease. 

When  suppuration  has  taken  place,  or  is  unavoidable,  when  the  patient  ceases  to 
complain  of  pain,  but  has  in  its  stead  a  feeling  of  weight  in  the  hypochondrium, 
and  becomes  distinctly  hectic,  a  corresponding  change  must  be  made  in  the  treatment. 
Active  depletion  is  no  longer  admissible  ;  you  must  sustain  the  strength  by  a  more 
nourishing  diet,  and  prescribe  some  tonic  remedies ;  the  sulphate  of  quina,  with 
sulphuric  acid  ;  or  the  nitro-muriatic  acid,  which  enjoys  a  considerable  repute,  greater 
perhaps  than  it  merits,  for  the  relief  of  liver  complaints. 

Acute  inflammation  of  the  liver  is  apt  to  degenerate  into  chronic.  Chronic  in- 
flammation may  also  arise  under  the  circumstances  that  give  birth  to  the  acute  form. 
Chronic  hepatitis,  again,  is  not  unfrequently  produced  by  the  presence  of  specific 
disease  in  the  liver  ;  of  carcinoma  ;  of  scrofulous  tubercles.  JVIelanosis  and  hydatids 
are  both  of  them  of  common  occurrence  in  the  same  part ;  and  they  may  give  rise 
to  symptoms,  or  they  may  not :  and  when  these  morbid  conditions  do  declare  them- 
selves by  external  signs,  those  external  signs  are  very  much  the  same  as  belong  to 
chronic  hepatitis.  The  precise  diagnosis  is  exceedingl)''  obscure ;  the  symptoms 
point  distinctly  to  the  fiver  as  the  seat  of  the  disorder ;  but  as  to  its  exact  nature,  we 
must  often  be  content  with  probabilities  alone. 

The  symptoms  of  chronic  hepatitis— or  of  the  chronic  forms  of  disease  to  which  I 
have  alluded,  when  they  show  themselves  by  symptoms  —  are  (I  give  you  them  in 
Cullen's  words)  "some  fullness  and  some  sense  of  weight  in  the  right  hypochon- 
drium; some  shooting  pains  felt  at  times  in  that  region;  some  uneasiness  or  pain 
felt  on  pressure  in  that  part ;  some  discomfort  from  lying  upon  the  left  side;  perhaps 
some  degree  of  jaundice  ;  and  sometimes  a  certain  amount  of  fever  coinbining  itself 
with  more  or  fewer  of  these  symptoms."  In  short,  they  are  just  the  symptoms  of 
acute  hepatitis  occurring  in  a  minor  degree. 

Chronic  affections  of  the  liver  are  sometimes  attended  with  an  increase,  and  some- 
times with  a  diminution,  of  its  size.  When  it  is  augmented  in  bulk,  its  place  and. 
enlargement  may  be  ascertained  by  palpation  and  percussion ;  nay,  the  magnified 
gland  may  sometimes  be  seen,  extending  beyond  its  proper  situation  in  the  hypo- 
chondrium, and  passing  far  down  into  the  abdomen.  I  have  known  the  liver  reach 
to  the  right  groin  :  and  when  its  left  lobe  is  affected,  it  will  sometimes  stretch  across 
towards  the  lower  part  of  the  left  side  of  the  belly.  On  the  other  hand,  the  liver 
may  shrink  into  a  much  smaller  space  than  it  naturally  occupies.  These  small  livers 
are  usually  hard.  Interfering  more  with  the  portal  circulation  than  many  enlarged 
livers  do,  they  are  more  frequently  attended  with  dropsj''  of  the  peritoneum. 

The  "hobnail"  liver,  the  cirrhose  of  modern  French  writers,  is  nodulated  as  well 
as  hard.  The  irregularity  of  its  surface  may  be  so  great  as  to  be  perceptible  to  the 
touch.  I  fully  described  this  condition  of  the  liver  when  I  was  upon  the  subject  of 
passive  ascites,  of  which  it  is  the  most  common  cause. 

I  mentioned,  also,  some  time  ago,  the  "  fatty"  liver,  so  frequently  found  associated 
with  pulmonary  consumption.  The  liver  in  this  state  is  soft,  enlarged,  smooth  on  its 
surface,  and  of  a  buff  or  tawny  colour  throughout.  Mr.  Bowman  has  lately  shown 
that  these  changes  are  owing  simply  to  the  unwonted  abundance  of  certain  small 
granules  of  fat,  of  which,  in  the  healthy  organ,  each  lobule  contains  a  few  only.  If 
in  a  phthisical  patient  we  find  the  liver  palpably  enlarged,  we  may  guess  that  it  is 
encumbered  with  this  interstitial  fat :  but  there  are  no  symptoms  peculiar  to  the  fatty 
liver.  As  to  its  cure,  we  are  quite  helpless  :  and  the  same  may  be  said  of  the  hobnail 

3v2 


846  CHRONIC    HEPATITIS. 

liver,  as  well  as  of  all  those  forms  of  disease  in  which  the  organ  is  loaded  with  specific 
deposits. 

Dark  masses  of  extravasated  blood  are  sometimes  found  interspersed  through  this 
gland,  and  then,  by  an  absurd  perversion  of  language,  the  patient  is  said  to  have  had 
"apoplexy"  of  the  liver. 

The  same  causes  which  produce  acute  hepatitis,  acting  in  a  less  intense  degree, 
will  excite  chronic  inflammation  of  the  same  textures.  Intemperance,  also,  and  par- 
ticularly the  habitual  and  excessive  use  of  alcoholic  liquors,  certainly  tends  to  generate 
hepatic  inflammation,  especially  in  its  more  chronic  form.  We  see  this  even  here, 
and  it  is  still  more  strikingly  perceptible  in  v^^arm  climates,  as  you  may  learn  by 
reading  the  works  of  those  persons  who  have  had  experience  of  the  diseases  of  India. 
Dr.  William  Ferguson,  for  example,  who  was  for  some  time  chief  of  the  medical 
staff  of  the  windward  and  leeward  islands  in  the  West  Indies,  observed  that  there  was 
a  regular  increase  and  aggravation  of  these  chronic  affections  of  the  hver  among  the 
troops  after  they  received  their  monthly  pay,  when  they  drank  great  quantities  of 
ardent  spirits ;  arrack  in  the  East  Indies,  and  rum  in  the  West. 

There  has  long  been  supposed  to  be  what  is  called  a  gin-drinker' s  liver,  in  which 
a  section  of  that  gland  presents  an  appearance  very  closely  resembling  the  section 
of  a  nutmeg;  and  a  good  deal  of  useless  speculation  has  been  employed  as  to  the 
nature  of  the  change  which  has  taken  place  in  such  cases.  Mr.  Kiernan  has  clearly 
shown  that  the  nutmeg  aspect  of  the  liver  is  produced  by  mere  congestion  of  blood. 
Congestion  of  the  liver  is,  indeed,  very  likely  to  arise  under  the  daily  stimulus  of 
distilled  spirits,  but  it  arises  under  various  other  circumstances  besides ;  and  there- 
fore it  is  no  safe  test  of  the  intemperate  habits  of  the  party.  And  of  this  we  had 
sufficient  evidence  before  Mr.  Kiernan's  observations  were  published.  Again  and 
again  have  I  met  with  the  nutmeggy  liver,  strongly  marked,  when  there  was  reason 
to  believe  that  the  possessor  of  it  had  never  transgressed  the  strictest  rules  of  tem- 
perance in  drinking:  in  young  persons,  for  example,  of  both  sexes,  who  certainly 
never  had  been  dram-drinkers.  Disease  of  the  heart  is  a  very  obvious,  and  a  very 
common  cause  of  hepatic  congestion. 

You  are  aware  that  the  congestion  occurs  under  two  forms,  according  as  the 
branches  of  the  hepatic  vein,  or  of  the  vena  portge,  are  gorged.  If  both  these  sets 
of  vessels  are  full,  the  liver  is  universally  red.  If  the  hepatic  vein  alone  be  the  seat 
of  the  congestion,  then  in  the  centre  of  each  lobule  we  see  a  red  speck,  surrounded 
by  yellowish  matter;  the  specks  are  isolated,  the  yellow  colour  is  arranged  in  a  sort 
of  net-work.  Whereas,  if  the  portal  system  be  greatly  engorged,  the  red  streaks 
will  be  continuous,  and  the  yellow  portions  hemmed  in  by  them,  and  isolated.  I 
show  you  these  distinctions  in  some  specimens  prepared  by  Mr.  Kiernan  himself. 

I  should  have  stated,  when  speaking  of  the  signs  of  chronic  hepatitis,  what  is  sin- 
gularly true  of  chronic  hver  affections  in  general,  that  they  are  apt  to  be  attended 
with  much  languor  and  lassitude,  and  a  remarkable  depression  of  spirits ;  and  with 
that  sort  of  dread,  and  apprehension  of  impending  evil,  which  I  mentioned  as  being 
a  striking  feature  of  hypochondriasis:  the  very  derivation  of  which  term  marks  its 
frequent  connection  with  hepatic  disorder.  There  is  sallowness  of  the  complexion 
also  ;  and  sometimes  emaciation. 

The  same  rem.edies  are  adapted  to  the  chronic  as  are  proper  for  the  acute  inflam- 
mation of  the  liver:  the  comparative  mode  of  their  exhibition,  however,  differs 
somewhat. 

Blood-letting  is  not  often  necessary  or  advisable,  except  when  more  violent  aggra- 
vations than  usual  of  the  inflammatory  symptoms  supervene.  Topical  bleeding,  and 
blistering,  are  more  expedient. 

But  the  two  main  remedies  to  be  tried  in  this  complaint  are  mercury,  and  the 
sahne  puriratives,  given  in  small  doses,  and  repeated  for  a  long  time  together.  Five 
grains  of  biue-pill  every  night,  or  every  night  and  morning ;  and  as  much  of  the 
sulphate  of  magnesia  as  will  produce  one  or  two  watery  stools  every  day,  for  weeks, 
perhaps,  in  succession.  Patients  are  not  so  well  content  to  bear  this  discipline  when 
it  is  administered  in  boxes  and  phials,  as  physic;  but  they  have  more  faith  in  the 
natural  mineral  waters :  so  that  a  residence  at  Cheltenham,  or  some  such  place,  is 


JAUNDICE.  847 

exceedingly  proper  to  be  recommended  in  these  cases ;  where  the  daily  use  of  tho 
waters  may  keep  up  a  continual  drain  on  the  system  of  the  vena  portse ;  and  where 
relaxation  from  business,  the  amusements  that  are  constantly  going  on,  with  change 
of  scene  and  of  society,  may  contribute  to  dissipate  the  hypochondriacal  feelings 
which  are  so  apt  to  render  the  subjects  of  chronic  hepatic  disease  supremely 
wretched. 

Moderate  exercise,  in  the  open  air,  on  horseback  and  on  foot,  should  be  encouragea 
There  is  no  doubt  that  hepatic  as  well  as  gastric  derangements  are  fostered  by 
sedentary  habits.  Tepid  bathing  is  another  expedient  from  which  benefit  may  be 
hoped.  In  many  instances  it  will  be  proper  to  make  trial  of  Scott's  nitro-muriatic 
bath. 

Iodine  has  been  thought  of  much  use  in  certain  kinds  of  hepatic  disease  ;  in  those 
kinds  especially  which  are  connected  with  enlargement  of  the  viscus.  The  iodide 
of  potassium,  or  a  mixture  of  the  iodide  and  of  iodine,  or  some  of  the  combinations 
of  iodine  and  mercury,  may  be  given  in  such  cases;  or  the  iingiienfum  iodinii 
composifum,  or  the  unguentum  hydrargyri  iodidi  of  the  Pharmacopoeia,  may  be 
rubbed  night  and  morning  upon  the  hypochondrium.  I  have  not  seen  much  benefit 
from  these  forms  of  medicine  myself,  in  such  cases ;  but  they  are  said,  by  persons 
of  experience  and  credit,  to  have  been  successful  in  their  hands. 

Tantxacnm  is  also  a  drug  which  has  been  much  employed  in  liver  complaints, 
since  Dr.  Pemberton's  book  on  the  diseases  of  the  abdomen  was  published  ;  but  it 
is  very  doubtful,  in  my  mind,  whether  it  ever  does  much  good.  The  Germans  are 
very  fond  of  giving  the  rauriate  of  tnnmonia  in  small  and  frequent  doses.  They 
have  the  same  belief  in  the  virtues  of  this  salt,  in  various  disorders,  as  the  English 
practitioners  have  in  those  of  mercury  ;  and,  what  is  curious,  they  attribute  to  it 
some  specific  agency  upon  the  functions  of  the  liver. 

In  the  account  which  I  have  now  given  of  the  principal  diseased  conditions  of  the 
liver,  I  have  not  included  nor  dwelt  upon  all  the  changes  of  structure  and  appear- 
ance to  which  that  organ  is  liable.  There  are  various  conditions  which  disclose 
themselves  by  no  intelligible  symptoms  during  life,  of  which  the  nature  has  not  yet 
been  determined,  and  of  which  the  cure  still  remains  to  be  discovered.  At  this 
advanced  period  of  the  course,  and  with  no  time  to  spare,  I  do  not  think  it  necessary 
or  right  to  trouble  you  with  the  unprofitable  discussion  of  matters  that  are  not  strictly 
practical. 

I  have  mentioned  jaundice  as  an  occasional  symptom  both  of  acute  and  of  chronic 
inflammation  of  the  liver.  But  jaundice  is  spoken  of,  in  general,  as  constituting, 
itself,  a  distinct  form  of  disease.  If  we  consider  it  in  that  light,  its  diagnosis  is  most 
easy.  We  have  only  to  look  upon  our  patient  to  know  what  is  the  matter  with  him. 
But  jaundice  depends  upon  various  and  very  different  morbid  conditions  ;  and,  look- 
ing to  those  conditions  as  the  true  objects  of  diagnosis,  we  find  that  the  real  nature 
of  a  given  case  of  jaundice  is  often  involved  in  very  great  obscurity. 

Let  us  first  consider  the  constituent  features  of  jaundice,  whether  it  be  regarded 
as  a  disease,  or  as  a  sign  of  disease.  They  are,  yellowness  of  the  skin  and  of  the 
eyes;  whitish  feces;  urine  having  the  colour  of  saffron,  and  communicating  a  bright 
yellow  tinge  to  white  linen. 

The  characteristic  yellow  hue  is  owing,  no  doubt,  to  the  presence  of  bile,  or  at  any 
rate  of  the  colouring  matter  of  the  bile,  in  the  circulating  blood.  And  the  deep  tint 
of  the  urine  is  evidently  derived  from  the  same  source.  On  the  other  hand,  the 
paleness  of  the  feces  is  to  be  ascribed  to  the  want  of  bile,  which  always  exists  in 
healthy  and  natural  excrement.  This  last  symptom  is  not,  however,  a  constant  one  ; 
there  may  be  jaundice  while  bile  appears  in  the  stools.  I  shall  explain  how  this  is 
supposed  to  happen,  presently. 

It  has  been  made  a  question  how  the  bile,  or  its  colouring  matter,  comes  to  be 
visibly  present  in  the  blood,  or  rather  in  many  of  the  tissues  supplied  by  the  blood, 
and  in  several  of  the  other  fluids  of  the  body.  The  general  opinion,  and  probably 
the  true  one,  is,  that  the  bile,  after  being  secreted  in  the  liver,  is  reabsorbed,  and  car- 
ried into  the  circulation,  and  so  conveyed  to  the  surface,  and  to  the  parts  in  which 


848  JAUNDICE. 

the  change  of  colour  is  observed.  This  explanation  is  consistent  with  the  pheno- 
mena wnicl)  we  notice  in  the  disorder. 

But  another  theory  has  been  broached  on  this  subject;  first,  I  believe,  in  this 
country,  by  Darwin.  It  has  been  more  recently  revived  by  M.  Chevreul,  who  is 
followed  by  Mr.  Maj'^o.  These  pathologists  are  of  opinion  that  the  bile  is  formed, 
not  b}"^  the  hver,  but  in  the  blood  :  that  the  office  of  the  liver  is  to  strain  ofiT  or  with- 
draw the  bile  from  the  circulation,  constantly,  as  fast  as  it  is  formed;  just  as  the  per- 
petual elimination  of  urea  from  the  blood  appears  to  be  one  great  purpose  of  the 
kidneys.  They  hold,  therefore,  that  jaundice  manifests  itself  whenever  the  due 
separation  of  the  bile  from  the  blood  is  suspended  or  imperfect.  Failing  of  its  natu- 
ral vent,  this  peculiar  substance  accumulates  in  the  blood,  seeks  other  outlets,  is 
deposited  in  various  places,  and,  in  fact,  partly  escapes  through  unaccustomed  chan- 
nels. They  speak  of  jaundice  as  a  symptom  of  suppression  of  bile,  while  others 
consider  it  as  a  sign  of  retention;  using  these  words,  suppression  and  retention,  in 
the  sense  in  which  they  are  applied  to  the  secretion  of  urine.  They  maintain  that 
the  proper  function  of  the  liver,  the  abstraction  of  bile  from  the  blood,  may  be 
arrested  by  alterations  of  the  substance  and  structure  of  that  gland  ;  or  by  the  oblite- 
ration or  obstruction  of  the  gall-bladder  or  ducts,  impeding  or  forbidding  the  removal 
of  the  bile  already  formed  ;  or  by  some  obscure  influence  of  the  nervous  system 
upon  these  organs.  They  introduce  the  last  kind  of  cause  with  the  view  of  explain- 
ing those  cases,  which  certainly  occur,  in  which  jaundice  is  the  result  of  severe 
bodily  pain,  or  strong  mental  emotion.  Nay,  on  their  supposition,  we  might  even 
suppose  that  the  yellowness  is  sometimes  due  to  a  spontaneous  and  unwonted  abun- 
dance of  the  elements  of  bile  in  the  blood ;  in  which  case,  we  need  not  wonder  that 
jaundice  should  go  along  with  perfect  integrity  of  the  biliary  apparatus. 

The  advocates  of  the  first-mentioned  supposition  are  aware  of  the  difficulties 
opposed  to  its  reception,  by  the  occasional  absence,  even  in  cases  of  well-marked 
jaundice,  of  all  organic  disease  or  apparent  obstruction  to  the  excretion  of  the  bile. 
They  show  that  in  verj^  many  cases  there  is  some  obvious  mechanical  obstacle  to  the 
efflux  of  the  secreted  fluid ;  and  in  those  instances  in  which  none  can  be  discovered 
after  death,  they  conceive  either  that  the  ducts  of  the  hver  had  been  temporarily 
plugged  up  by  inspissated  bile,  or  a  sort  of  biliary  sand — or  that  they  were  closed 
for  a  time  by  spasm — or  by  some  morbid  condition  of  the  duodenum. 

Now,  of  these  two  hypotheses,  that  which  ascribes  the  yellowness  to  the  reabsorp- 
tion  of  secreted  bile  is,  to  my  mind,  the  most  probable  and  the  simplest;  and  I  can- 
not see  that  it  is  attended  with  more  difficulty  than  the  other.  But  you  may  choose 
for  yourselves  between  them ;  and  I  pass  from  this  digression  to  a  somewhat  closer 
examination  of  the  principal  circumstances  noticeable  in  the  complaint.  Its  technical 
appellation,  I  should  observe,  is  icterus.,  which  is  the  Greek  name  for  a  bird  with  a 
yellow  plumage,  the  galbula,  or  golden  thrush  ;  the  sight  whereof,  by  a  jaundiced 
person,  was  death  (Pliny  tells  us)  to  the  bird,  and  recovery  to  the  patient.  Various 
other  terms  have  been  applied  to  the  disorder,  most  of  them  having  reference,  like 
jaundice  itself  (from  the  French  Jo?/?2e),  to  the  unnatural  colour.  Morbus  arqiiatics, 
from  its  exhibiting  some  of  the  bright  hues  of  the  rainbow ;  aurigo,  from  its  resem- 
bling gold  ;  and  we  hear  the  common  people  say,  now-a-days,  such  a  one  is  as  yel- 
low as  a  guinea.  The  Latins  spoke  of  it,  also,  under  the  title  of  morbus  regius. 
Why  they  so  called  it,  we  learn  from  the  following  curious  passage  in  Celsus,  giving 
an  account  of  the  pleasant  regimen,  fit  for  royalty  itself,  to  be  adopted  by  those  who 
labour  under  the  malady:  "Per  omne  vero  tempus  utendum  est  exercitatione,  fric- 
lione :  si  hiems  est,  balneo;  si  asstas,  frigidis  natationibus ;  lecto  etiam  et  concla/i 
cultiore,  lusu,  joco,  ludis  lascivia,  per  quae  mens  exhilaretur:  ob  quce  regius  morbus 
dictus  videtur." 

The  whiteness  of  the  stools  I  have  mentioned  as  being  a  very  common,  but  not  a 
..onstant  appearance.  It  clearly  depends  upon  the  absence  of  bile.  But  sometimes 
•.here  IS  bile  in  the  discharged  feces,  and,  at  the  same  time,  the  yellow  colour  of  the 
^km  and  eyes.  This  probably  depends  upon  the  circumstance  that  some  branches 
of  the  hepatic  ducts  are  obstructed,  while  the  others  are  free ;  and  thus  the  bile  that 
is  secreted  is,  in  part,  reabsorbed  into  the  blood,  and  in  part  carried  off  into  the  intes- 


JAUNDICE.  840 

tines.  In  a  former  lecture,  I  stated  that  one  of  the  uses  of  the  bile  appeared  to  be 
that  of  stimulating  the  bowels  to  action  ;  it  is  the  natural  purgative.  Accordingly, 
in  most  cases  of  jaundice,  the  bowels  are  costive.  But  neither  is  lids  uniform.  In 
some  of  the  worst  cases,  wherein  the  jaundice  depends  upon  hepatic  disease,  which 
is  connected  with  disease  also  of  the  mucous  coat  of  the  intestmes,  there  is  constant 
iiarrhcea. 

In  some  instances  the  yellowness  of  the  skin  is  at  first  attended  with  itching,  which 
is  occasionally  so  intolerable  as  to  require  the  employment  of  opiates  to  allay  it.  In 
most  cases  there  is  no  itching  at  all.  The  bile  never  fails  to  appear  in  a  deep  vessel, 
even  black ;  and  which  tinges  any  white  substance  that  is  dipped  into  it  of  a  bright 
yellow.  The  urine  which  thus  sometimes  seems  black,  may  be  proved  to  derive 
that  appearance  merely  from  concentration  of  the  yellowness,  by  pouring  a  little  of 
it  into  a  shallow  white  dish,  or  by  diluting  it  with  water ;  when  the  brilliant  yellow 
tint  will  become  manifest.  Bilious  sweat  sometimes  occurs,  staining  the  patient's 
linen  yellow.  The  saliva,  in  some  jaundiced  persons,  has  the  same  yellow  tinge, 
and  a  distinctly  bitter  taste.  It  has  been  said  that  the  milk  of  women  who  are  nursing 
is  made  yellow  in  this  disorder.  Dr.  Heberden,  however,  states  that  he  never  wit- 
nessed this ;  and  he  had  known  a  woman  with  a  very  deep  jaundice  upon  her, 
suckle  her  infant  for  six  weeks  together  with  no  apparent  bad  effects  upon  its  health. 
One  man  assured  him  that  his  tears  were  yellow.  You  are  aware  of  the  vulgar 
notion,  that  to  a  jaundiced  eye  all  things  appear  yellow.  It  is  an  old  notion,  for  we 
find  it  expressed  by  Lucretius  :  —  "Lurida  prteterea  fiunt  qusecunque  tuentur  Ar- 
quati."  Heberden  was  disposed  to  regard  this  as  a  mere  poetical  fiction.  But  cer- 
tainly it  is  sometimes,  though  very  rarely,  indeed,  a  fact.  Two  women,  whom  he 
considered,  however,  to  be  of  little  credit,  told  Heberden  that  objects  appeared  yellow 
to  them.  I  have  been  assured  of  the  same  thing  by  a  medical  man  who  experienced 
it  in  his  own  person.  If  I  do  not  mistake.  Dr.  Mason  Good  saw  all  things  yellow 
when  he  was  jaundiced.  Dr.  EUiotson  has  had  some  very  interesting  cases  of  this 
phenomenon.  One  of  his  icteric  patients  declared  that  objects  seemed  yellow  when 
looked  at  with  one  eye,  but  not  with  the  other ;  and  in  the  eye  that  perceived  the 
yellow  tint  he  observed  two  large  red  vessels  running  towards  the  cornea.  And  in 
one  or  two  instances,  which  he  met  with  afterwards  of  yellow  vision  with  both  eyes 
in  jaundiced  patients,  he  found  inflammation,  or  distended  blood-vessels  in  both  eyes. 
This  very  morning  I  saw  in  the  hospital  a  patient  of  Dr.  Wilson's,  a  middle-aged 
woman,  affected  with  jaundice.  She  affirms  that  all  objects  seem  yellow  to  her 
vision.  In  both  eyes  there  are  several  varicose  and  singularly  tortuous  vessels,  pro- 
ceeding across  the  sclerotica  towards  the  cornea,  and  some  of  them  reaching  its 
margin.  It  seems  probable  therefore  that  ttie  ophthalmic  vessels,  in  their  natural 
state,  do  not  permit  the  colouring  matter  of  the  bile  to  pass  through  them ;  but  that 
when  they  become  enlarged  by  disease,  so  as  to  admit  the  colouring  particles  of  the 
blood,  they  may  also  give  a  passage  to  the  yellow  colouring  matter,  which  tinges 
the  humours  of  the  eye :  and  in  that  case  the  objects  seen  through  the  yellow  fluids 
would  appear  like  those  viewed  through  a  piece  of  yellow  stained  glass.  This  is  a 
point  which  is  worth  your  attention  in  future. 

The  shades  of  yellowness  are  different  in  different  patients.  Those  who  are  pale 
and  fair  present  a  bright  lemon  colour.  But  in  those  who  are  florid,  or  whose  cheeks 
and  skin  are  flushed  with  fever,  the  tint  will  more  resemble  that  of  the  Seville  orange 
Again,  if  the  patient  be  naturally  swarthy,  or  if  his  visage  is  livid  or  dusky  through 
imperfect  arterialization  of  his  blood,  the  superaddition  of  jaundice  will  give  him  a 
greenish  hue.  These  differences  resuU  from  natural  or  acquired  difl!erences  of  com 
plexion  antecedent  to  the'  icterus.  But  sometimes  the  bile  that  is  reabsorbed  is 
vitiated  and  dark ;  and  we  may  have,  for  that  reason,  as  Dr.  Bail  lie  has  pointed  oui, 
cases  of  green  or  black  jaundice.  You  will  remark  that  from  whichever  cause  the 
green  or  dark  colour  proceeds,  whether  from  a  mingling  of  the  yellowness  of  the 
bile  with  the  blueness  of  lividity,  or  from  the  circulation  of  green-coloured  bile,  such 
cases  are  especially  unpromising  cases. 

Icterus  depends,  as  1  have  said,  upon  various  and  different  internal  causes :  and 
frequently  we  cannot  determine  at  all,  until  death  affords  us  the  means  of  inspecting 
54 


8r»0  JAUNDICE. 

tht!  parts  concerned  in  its  production,  what  the  precise  exciting  cause  may  be ;  even 
when  it  is  simply  mechanical.  Any  kind  of  pressure  made  upon  the  excretory  ducts 
of  the  hver  will  produce  it ;  and  such  pressure  may  be  exercised  b}''  tumours  seated 
in  the  liver  itself;  or  by  a  scirrhous  pylorus;  or  by  specific  disease  situated  in  the 
head  of  the  pancreas,  of  which  I  have  seen  several  examples ;  or  by  a  diseased  con- 
dition of  the  duodenum :  and  these  possible  causes  of  a  detention  of  the  bile  in  its 
receptacle  should  always  be  borne  in  mind  when  we,  are  investigating  an  obscure 
case  of  jaundice. 

The  impediment,  in  the  cases  just  supposed,  is  external  to  the  ducts ;  but  they 
may  be  obstructed  within,  plugged  up  by  inspissated  bile,  or  by  a  biliary  calculus. 
This  forms  one  of  CuUen's  species  of  icterus — the  icterus  culculosus.  The  concre- 
tion is  most  commonly  situated,  I  believe,  in  the  ductus  choledochus ;  sometimes, 
however,  in  the  cystic,  and  sometimes  in  the  hepatic  duct.  The  pain  that  attends 
the  passage  of  a  gall-stone  through  these  ducts  is  often  dreadful.  Perhaps  there  is 
no  pain  to  which  the  body  is  subject  that  is  more  severe.  You  will  not  wonder  at 
this,  when  you  consider  that  through  a  tube,  of  which  the  natural  size  scarcely  ex- 
ceeds that  of  a  goose-quill,  there  sometimes  passes  a  stone  as  big  as  a  walnut.  The 
common  duct  has  been  found  so  dilated  as  readily  to  admit  one's  finger.  CuUen's 
definition  of  this  species  is  "Icterus,  cum  dolore  in  regione  epigastricil,  acute,  post 
pastum  aucio,  et  cum  dejeclione  concretionum  biliosarum."  INow  the  last  of  these 
circumstances,  the  voiding  of  biliary  calculi  by  stool,  may  happen  over  and  over 
again,  without  its  being  noticed,  and  it  does  not  help  us  at  all  to  judge  of  the  nature 
of  the  complaint  at  its  commL-ncement,  while  the  gall-stone  is  still  in  the  ducts.  With 
the  pain,  which  is  not  constant,  but  comes  and  goes,  there  are  much  nausea  and 
vomiting ;  and  sometimes  hiccup ;  and  the  matters  vomited  are  usually  very  sour. 
The  patient  is  flatulent  and  dyspeptic;  languid  and  gloomy.  At  length  the  concre- 
tion passes  into  the  intestines ;  the  pain  suddenly  ceases,  and  all  is  soon  well  again. 
Attacks  of  this  kind,  having  happened  once,  are  very  apt  to  be  repeated. 

Now  this  pain  you  might  readily  mistake  for  the  pain  of  inflammation,  were  it  not 
marked  by  these  two  circumstances — the  absence  of  tenderness  and  the  absence  of 
fever.  Pressure,  instead  of  augmenting,  usually  mitigates  it.  The  patient  keeps 
his  hand  firmly  applied  to  his  epigastrium  ;  or  rests,  perhaps,  the  weight  of  his  body 
upon  some  hard  substance  placed  beneath  his  stomach.  1  speak  now  of  the  begin- 
ning of  the  attack,  before  there  has  been  much  retching ;  for  a  degree  of  tenderness 
of  the  abdominal  muscles  is  often  produced  by  repealed  straining  and  vomiting.  The 
pulse  is  unaffected,  or  I  should  rather  say  it  is  not  accelerated,  during  the  pain : 
occasionally  it  is  even  slower  than  natural,  and  the  skin  cold.  Though  there  be  no 
inflammation,  rigors  may  occur ;  just  as  they  sometimes  happen  when  a  solid  sub- 
stance— a  bougie  to  wit — is  passing  through,  and  distending  the  urethra. 

Nevertheless,  inflammation  does  sometimes  arise,  and  then  the  pulse  becomes 
frequent,  and  the  skin  hot,  and  thirst  and  headache  are  complained  of,  and  the  epi- 
gastrium IS  tender;  and  if  blood  be  drawn  it  exhibits  the  buffy  coat.  Sometimes  the 
gall-stone  makes  its  way,  by  ulceration,  through  the  contiguous  structures,  and  so  is 
discharged  outwardly,  or  into  the  bowels.  In  such  cases  there  must  have  been 
inflammation. 

As  jaundice  often  occurs  without  any  pain,  so  a  gall-stone  may  enter  and  pass 
through  the  ducts,  and  produce  pain,  when  there  is  no  jaundice.  The  cystic  duct 
alone  may  be  blocked  up,  and  that  portion  only  of  the  bile  be  prevented  from  escaping 
which  is  accumulated  in  the  gall-bladder.  It  is  probable  that  re-absorption  of  the 
contents  of  that  cistern  is  not  very  active.  Or  a  calculus  of  an  angular  shape  may 
stick  in  the  common  duct,  and  thus  impede,  without  entirely  stopping,  the  egress  of 
the  bile.  Dr.  Heberden  thought  that  gastrodynia  was  not  unfrequently  owing  to 
biliary  concretions :  founding  his  opinion  upon  the  fact  that  many  persons  sufler,  for 
months  or  years,  under  occasional  attacks  of  epigastric  pain,  which  is  at  last  asso- 
ciated with  jaundice.  But  after  all,  this  might  happen  from  progressive  disease  in 
the  stomach  itself;  and  it  is  a  pity  that  Dr.  Heberden's  views  were  not  fortified  by 
diaseclioQ. 

Wiief  ')nce  a  large  calculus  has  forced  its  way  through  the  natural  channels  of 


JAUNDICE.  85 

the  bile,  they  remain  permanently  dilated ;  and  smaller  stones  may  be  afterwards 
voided  without  pain  or  other  notice  of  their  passage.  There  are  persons  who  get 
rid  of  scores  of  them  in  this  way,  during  the  course  of  their  lives. 

Sometimes  a  large  concretion,  after  its  extrication  from  the  biliary  passages,  lodges 
in  the  more  capacious  intestines,  and  gives  rise  to  serious  obstruction  there.  I  men- 
tioned, recently,  one  case  of  this  kind  which  had  fallen  under  my  own  notice.  But 
in  general  the  concretions  are  presently  voided  with  the  stools :  and  they  should 
always  be  looked  for.  The  patient  is  much  gratified  by  seeing  that  his  enemy  has 
been  expelled;  and  also  by  the  proof  he  thus  obtains  of  the  sagacity  and  judgment 
of  his  physician.  The  feces  should  be  mixed  with  water,  upon  the  surface  of  which 
any  gall-stones,  since  they  are  specifically  hghter  than  that  fluid,  will  float.  I  never 
but  once  succeeded  in  thus  catching  a  concretion  in  the  evacuations  of  a  patient, 
whose  symptoms  had  led  me  to  search  for  it. 

We  often  find  gall-stones,  even  in  vast  numbers,  in  the  gall-bladders  of  persons 
who,  during  their  lifetime,  had  never  been  known  to  suffer  pain  about  the  fiver,  or 
to  have  jaundice,  or  to  exhibit  any  token  of  the  presence  of  such  concretions.  We 
infer  from  this  that,  while  they  remain  in  the  reservoir  of  the  bile,  they  are  harm- 
less ;  and  that  the  suffering  and  the  hazard  they  occasion  are  mechanical  conse- 
quences of  their  transit  through  the  gall-ducts.  I  have  heard  of  an  instance  in  which 
upwards  of  1,300  gall-stones  were  taken  from  a  human  gall-bladder  after  death. 

These  gall-stones  are  not,  as  you  might  suppose,  mere  lumps  of  inspissated  bile. 
There  are,  I  believe,  concretions  of  that  kind,  but  they  are  very  rarely  met  with  in 
the  human  subject.  The  ordinary  calculi  consist,  in  a  great  measure,  of  a  peculiar 
substance,  cholesterine,  which  exists  in  a  state  of  solution  in  healthy  bile,  but  which, 
in  some  morbid  conditions  of  that  fluid,  being  released  from  its  solvent,  assumes  its 
proper  crystalline  form.  Very  fittle  is  knovvn  respecting  the  circumstances  under 
which  the  change  lakes  place.  Cholesterine,  Dr.  Prout  tells  us,  is  the  product  of 
some  modification  of  the  oleaginous  principle.  Biliary  concretions  seldom  form  in 
children.  They  are  much  more  common  in  women  than  in  men.  They  occur 
most  frequently  in  persons  who  are  corpulent,  lead  sedentary  lives,  use  generous 
fare,  sleep  much,  and  neglect  their  bowels:  all  which  things  foster  or  denote  a  torpid 
and  congested  state  of  the  hepatic  system.  Cattle  are  said  to  be  subject  to  bihary 
calculi  when  shut  up  in  stalls  during  the  winter,  and  to  lose  the  complaint  when 
they  are  again  turned  out  into  the  pastures  in  the  spring.  Hence  the  absurd  notion, 
countenanced  even  by  Van  Swieten,  that  grass  is  a  good  remedy  for  jaundice. 

Another  variety  of  jaundice,  also  noticed  by  Cullen,  is  supposed  to  depend  upon 
mere  spasm  of  the  gall-ducts.  ^^ Icterus  spasmodicus,  sine  dolore,  post  morbos 
spasmodicos,  et  pathemata  mentis." 

Now  the  existence  of  this  cause  is  hypothetical.  The  gall-ducts,  though  not  dis- 
tinctly muscular,  possess  a  vital  power  of  contraction.  I  am  not  aware  that  the 
disease  has  ever  been  clearly  traced  to  a  connection  with  "morbi  spasmodici."  It  is 
an  alleged  cause  which  we  can  neither  prove  nor  disprove.  Certainly  the  "  pathe- 
mata mentis"  play  their  assigned  part:  fits  of  anger,  and  of  fear,  and  of  alarm,  have 
been  presently  followed  by  jaundice  ;  and  it  has  also  been  produced  by  great  bodily 
suffering,  by  a  severe  surgical  operation,  or,  perhaps,  by  the  dread  which  attended 
it.  Mr.  North  witnessed  a  case  in  which  an  unmarried  female,  on  its  being  acci- 
dently  disclosed  that  she  had  borne  children,  became  in  a  very  short  time  yefiow.  A 
young  medical  friend  of  mine  had  a  severe  attack  of  intense  jaundice,  which  could 
be  traced  to  nothing  else  than  his  great  and  needless  anxiety  about  an  approachino- 
examination  before  the  Censor's  Board  at  the  College  of  Physicians.  There  are 
scores  of  instances  on  record  to  the  same  effect:  and  tJiis  is  observable  of  such  cases, 
that  they  are  often  fatal,  with  head  symptoms :  convulsions,  delirium,  or  coma,  super- 
vening upon  the  jaundice.  But  with  respect  to  the  immediate  cause  of  the  icteric 
symptoms,  they  may,  I  say,  depend  'upon  a  spasmodic  constriction  of  the  gall-ducts. 
Mr.  Mayo  has  suggested  another  cause,  viz.,  the  sudden  formation  of  bile  in  unusually 
large  quantity  in  the  blood,  by  some  influence  propagated  through  the  nerves. 

Jaundice  sometimes  supervenes  upon  violent  and  long-continued  vomiting;   in 


852  JAUNDICE. 

which  case  the  extremity  of  the  gall-ducts  is  supposed  to  have  been  compressed  by 
the  coats  of  the  duodenum. 

Jaundice  may  also  occur,  as  I  stated  before,  as  a  symptom  of  acute  or  chronic 
inflammation  of  the  liver ;  and  then  its  treatment  will  merge  in  that  of  the  primitive 
disease  which  occasioned  it. 

Icterus  occasionally  comes  on  during  pregnancy ;  and  disappears  after  childbirth 
The  pressure  of  the  gravid  uterus  may  thrust  other  organs,  a  loaded  colon  for  ex- 
ample, against  the  liver,  and  so  impede  the  passage  of  the  bile.     The  little  exercise 
that  pregnant  women  are  apt  to  take,  and  the  costiveness  that  frequently  attends 
their  condition,  may  have  some  influence  in  causing  the  icterus  gravidarum. 

All  systematic  writers  follow  Cullen  in  making  jaundice  a  common  disorder  among 
newly-born  children.  The  icterus  neonatoruin  occurs,  they  say,  a  few  days  after 
birth ;  is  not  attended  with  any  suffering,  or  obvious  disturbance  of  the  bodily  func- 
tions ;  and  soon  disappears.  Now  there  seems  reason  to  beheve  that  this  is  not 
icterus  at  all ;  and  has  no  relation  to  the  biliary  organs.  The  surface  of  the  infant, 
at  its  birth,  is  frequently  of  a  deep  red,  from  hyperemia  or  congestion  of  blood  ;  pre- 
senting a  condition  which  falls  little  short  of  a  mild  but  universal  bruise.  By  degrees 
the  redness  fades,  as  bruises  fade,  through  shades  of  yellow  into  the  genuine  flesh- 
colour.  Such,  1  am  assured  by  those  who  are  more  conversant  with  these  matters 
than  myself,  is  the  pathology  of  the  icterus  infantum.  Of  course  true  jaundice  may, 
as  well  as  most  other  complaints,  befall  the  earliest  period  of  life ;  but  I  conceive 
that  it  seldom  does. 

The  prognosis  in  jaundice  is  generally  favourable ;  except  when  it  depends  upon 
structural  disease  of  the  liver,  or  supervenes  suddenly  upon  some  great  mental  or 
bodily  shock.  In  both  these  cases  the  prognosis  is  bad,  or  doubtful.  It  is  better,  in 
that  variety  connected  with  hepatic  disease,  if  the  disease  proceeds  from  some  known 
cause,  by  which  a  low  degree  of  inflammation  has  been  produced ;  and  the  cause  is 
such  as  can  be  avoided  for  the  future.  Just,  indeed,  as  in  chronic  hepatitis,  of  which 
the  icterus  is  simply  an  occasional  symptom.  The  prognosis  is  worst  of  all  in  old 
persons,  when  the  constitution  is  impaired,  and  there  is  no  obvious  cause  for  the 
disease ;  and  particularly  when  the  colour  of  the  skin  is  greenish,  or  approaching  to 
black. 

[Mr.  Twining,  in  his  work  on  the  Diseases  of  Bengal,  has  presented  some  very  interesting 
and  important  views  in  relation  to  the  patliology  of  jaundice. 

Mr.  T.  has  found  that  jaundice,  not  only  during  its  early  stage,  but  for  a  long  period  subse- 
quently, while  the  discoloration  of  the  skin  remains,  is  very  generally  attended  with  some 
morbid  sensibility  when  pressure  is  made  over  the  situation  of  the  gall-bladder  and  capsule 
of  Glisson,  though  the  uneasiness,  during  the  absence  of  pressure,  is  most  generally  referred 
to  the  epigastrium. 

When  the  disease  occurs  in  plethoric  subjects,  and  the  stools  are  of  a  pale  clay  colour,  Mr. 
T.  has  found  it  almost  always  attended  with  fever,  and  in  some  cases  he  has  known  robust 
patients  to  die,  with  symptoms  of  oppressed  brain,  within  thirty-six  hours  after  the  sudden 
appearance  of  intense  jaundice,  for  the  accession  of  which  no  cause  could  be  assigned. 

In  consequence  of  the  acknowledged  obscurity  which  exists  in  regard  to  the  true  pathology 
of  the  disease,  he  was  anxious  to  ascertain  the  exact  condition  of  the  liver  and  biliary  ducts 
in  persons  labouring  under  jaundice.  The  almost  invariable  existence  of  pain,  increased 
upon  pressure,  confined  to  a  circumscribed  spot  on  the  right  side,  just  below  the  centre  of  a 
line  drawn  from  the  right  nipple  to  the  umbilicus,  led  him  early  to  suspect  circumscribed 
inflammation  of  some  part  of  the  liver  as  the  most  frequent  cause  of  the  disease.  This 
opinion  he  believed  to  be  confirmed  by  the  good  effects  which,  in  the  majority  of  cases,  are 
produced  by  a  systematic  course  of  depletion:  nevertheless,  if  circumscribed  inflammation 
be  the  efficient  cause  of  jaundice,  he  found  it  difficult  to  explain  why  the  disease  was  so 
freqtiently  absent  during  the  progress  of  the  most  unequivocal  and  intense  inflammations  of 
large  portions  of  that  organ.  The  examination  of  individuals  who  had  recovered  from  jaun 
dice  only  a  short  time  before  death  occurred  from  other  diseases,  exhibited  no  appearances 
in  the  liver  indicative  of  any  circumscribed  portion  of  it  having  been  the  seat  of  recent 
inflammation.  In  the  course  of  his  dissections,  however,  Mr.  T.  found  that  albuininous  infil- 
tration into  the  cellular  structure  of  the  capsule  of  Glisson  was  sometimes  present.  Within 
this  capsule  are  situated  two  small  bodies,  which,  from  their  structure,  appearance,  and  uni- 
formitv  of  situation,  he  is  inclined  to  believe  are  absorbent  glands :  one  of  them  is  situated 


JAUNDICE.  ^  853 

'^ear  the  termination  of  the  gall-bladder  in  the  cystic  duct,  the  other,  at  the  upper  part  of  tha 
ductus  communis;  the  superior  gland  is  sometimes  very  small,  and  occasionally,  it  is  more 
closely  attached  to  the  side  of  the  gall-bladder  than  to  the  cystic  duct;  the  lower  one 
is  more  uniform  in  bulk,  being  usually  half  the  size  of  a  small  bean;  it  is  always  placed 
just  at  the  common  biliary  duct.  Irritations  affecting  the  absorbent  vessels  passing  through 
this  gland  may,  Mr.  T.  conceives,  cause  in  it  such  a  degree  of  swelling  as  would  produce 
transient  compression  and  closure  of  the  common  duct,  and  thus  prevent  the  passage  of  the 
bile  into  the  intestines,  and  give  rise  to  the  phenomena  of  jaundice.  So  long  as  the  obstruc- 
tion is  complete,  the  stools  will  be  nearly  white,  or  of  a  very  pale  gray  colour;  when,  how- 
ever, the  jaundice  is  attended  with  severe  fever  and  symptoms  of  intense  gastro-enteritis,  the 
stools  will  very  often  be  coloured  by  the  blood  which  is  poured  out  by  the  capillary  vessels 
of  the  intestinal  mucous  membrane,  as  well  as  by  other  morbid  secretions. 

When  previous  inflammatory  disease  of  the  capsule  of  Glisson  has  caused  an  infiltration 
of  coagulable  lymph  into  the  cellular  structure  of  that  part,  at  a  remote  period,  and  its  sub- 
sequent absorption  has  left  a  degree  of  induration  and  constriction,  Mr.  T.  believes  that  a 
very  slight  enlargement  of  the  lower  gland  will  effectually  compress  the  common  biliary 
duct ;  he  has  seen  its  canal  obliterated,  from  this  cause,  exactly  at  the  point  of  contact  with 
the  swollen  and  indurated  gland.  He  has,  also,  seen  the  cystic  duct  obliterated  where  it 
was  in  contact  with  the  upper  gland,  in  consequence  of  the  enlarged  and  diseased  condition 
of  the  latter ;  but  he  does  not  believe  that  this  could  have  any  influence  in  the  production 
of  jaundice. 

Mr.  T.  does  not  deny  the  agency  which  biliary  calculi — tumours  of  the  pancreas,  liver  or 
spleen,  or  scirrhous  pylorus  may  occasionally  have  in  the  production  of  the  phenomena  of 
jaundice,  nor  that,  in  some  rare  cases,  the  disease  may  have  been  excited  simply  by  mental 
emotion  ;  nor  is  he  willing  to  place  undue  importance  on  the  observations  upon  which  his 
views  of  the  most  frequent  cause  of  the  disease  are  based.  Should  these,  upon  more  ample 
investigation,  be  found  to  be  correct,  they  will  have  an  important  influence  upon  the  treat- 
ment of  the  disease. 

According  to  Mr.  T.,  the  most  sticcessful  plan  of  treatment  in  those  cases  of  jaundice  ac- 
companied  with  pain,  augmented  upon  pressure,  of  the  right  side  of  the  abdomen,  is  by 
depletion  by  the  lancet  and  leeches — active  purgation — the  daily  use  of  the  warm  bath — and 
sudorifics,  aided  by  low  diet  and  perfect  rest,  in  the  commencement  of  the  disease;  followed 
by  milder  purgatives,  and  a  small  blister  over  the  region  of  the  gall-bladder,  kept  open  for 
a  long  time.  Subsequently,  a  course  of  Cheltenham  salts,  or  small  doses  of  rhubarb  and  sal, 
polychrest,  with  gentle  exercise,  and  frictions  with  camphorated  liniment  over  the  right  hypo- 
chondrium  are  advisable  :  at  the  same  time,  it  may  be  proper  to  allow  a  mild  unirritating 
diet,  in  such  quantities  as  shall  improve  the  patient's  strength.  The  disease  may  sometimes 
occur  under  circumstances  that  forbid  depletion.  This  Mr.  T.  considers  an  unfortunate  cir- 
cumstance, as  he  has  but  little  confidence  in  other  modes  of  treatment. 

In  those  cases  in  which  the  stools  indicate  the  entire  absence  of  bile  from  the  intestmes, 
Mr.  T.  considers  the  use  of  mercurials  to  be  of  doubtful  propriety;  but,  when  bile  does  pass 
into  the  dtiodenum,  he  admits  that  calomel  may  be  useful,  in  conjunction  with  the  remedies 
already  detailed.  Excepting  in  cases  where  there  is  pretty  positive  evidence  of  the  exist- 
ence of  biliary  calculi,  which  he  believes  to  be  less  frequently  a  cause  of  jaundice  than  is 
generally  imagined,  he  doubts  the  propriety  of  having  recourse  to  opiates. 

Whether  the  views  of  Mr.  Twining  in  regard  to  the  pathology  of  jaundice  be  or  be  not 
correct,  must  be  determined  by  the  result  of  future  and  more  extended  observations ;  they 
are  sufficiently  plausible  and  important,  however,  to  demand  the  attention  of  the  physician 
and  to  influence  him  in  his  treatment  of  the  disease.  In  respect  to  the  plan  of  treatment  re- 
commended by  Mr.  T.,  we  believe  it  will  be  found,  with  one  exception  only,  to  be,  in  a  large 
number  of  cases,  the  only  proper  and  successful  one.  The  exception  to  which  we  allude,  ia 
the  indiscriminate  admimslTaXion  of  active  purgatives  :  jaundice  is,  not  unfrequently,  connected 
with  more  or  less  extensive  inflammation  of  the  stomach  and  small  intestines,  and  in  these 
casRS,  the  employment  of  active  purgatives  to  the  extent  racommended  by  Mr.  T.  would  un- 
questionably be  decidedly  injurious. — C] 


3w 


854  JAUNDICE. 


LECTURE  LXXVI. 

Treatment  of  the  variotts  Species  of  Jaundice.  Diseases  of  the  Gall-bladder ;  of 
the  Spleen  ;  of  the  Pancreas.  Diseases  of  the  Kidneys.  Nephritis  and  Neph- 
ralgia. Phenomena  constituting  a  ''fit  of  the  Gravel.''^  Different  kinds  oj 
Gravel.  Diseased  states  of  the  Urine.  Description  and  remedies  of  the  Lithic, 
Phosphatic  and  Oxalic  Diatheses. 

In  the  last  lecture,  after  describing  the  symptoms,  causes  and  treatment  of  acute 
and  chronic  inflammation  of  the  liver,  and  after  pointing-  out  various  other  forms  of 
chronic  disease  to  which  that  organ  is  obnoxious,  I  spoke  of  jaundice.  I  offered 
)''ou  some  comments  upon  its  phenomena;  and  I  indicated  several  different  internal 
conditions  upon  which  it  may,  in  different  cases,  depend  :  and  the  lecture  was  closed 
with  some  brief  hints  respecting  the  prognosis  of  icterus.  I  have  yet  to  consider  the 
plans  of  treatment  best  adapted  to  the  several  varieties  of  the  complaint. 

Some  kinds  of  jaundice  are  obviously  and  absolutely  irremediable.  From  others 
the  patients  recover,  whatever  treatment  may  be  adopted,  or  without  any  treatment 
at  all.  Hence,  as  is  customary  in  such  circumstances,  remedies  the  most  worthless 
and  absurd  are  extolled  for  their  efficacy  against  jaundice.  The  patient  gets  well, 
and  the  drug  last  tried  is  held  to  have  cured  him.  Post  hoc,  ergo  propter  hoc,  is  an 
argument  more  often  applied  I  believe  to  the  variations  of  disease,  than  to  any  other 
class  of  events. 

In  that  species  of  icterus  which  occurs,  sometimes,  in  connection  with  acute  or 
chronic  inflammation  of  the  liver,  the  treatment  must  be  such  as  I  yesterday  recom- 
mended for  acute  and  chronic  hepatitis.  Mercury  forms  an  essential  part  of  that 
treatment;  and,  unless  the  disease  yielded  sooner,  I  should  urge  the  remedy  until 
its  effect  upon  the  gums,  and,  therefore,  its  presence  in  the  circulating  blood,  was 
apparent. 

But  to  the  icterus  calculosus,  mercury  is  not  so  well  adapted.  What  we  want  is, 
not  a  more  plentiful  or  a  more  healthful  secretion  of  bile,  but  to  get  rid  of  the  me- 
chanical impediment  to  its  excretion  :  or,  at  any  rate,  if  that  cannot  be  accomplished, 
to  ease  the  acute  sufferings  of  the  patient.  Should  fever  attend  the  passage  of  a 
gall-stone,  or,  should  the  epigastric  pain  become  epigastric  tenderness,  leeches  may 
be  applied,  or  a  vein  may  be  opened.  The  abstraction  of  blood  may  prevent  any 
thickening  of  the  distended  gall-ducts ;  or  it  may  perhaps  relax  their  spasmodic 
closure  around  the  calculus.  But,  in  general,  blood-letting  is  not  of  service  nor 
requisite  in  this  variety  of  jaundice.  Our  great  resource,  for  relieving  the  pain,  and 
for  loosening  the  presumed  spasms,  is  opium,  given  in  full  doses:  and  I  can  add 
but  little,  with  any  advantage,  to  the  directions  laid  down,  on  this  head,  by  Dr.  He- 
berden.  "This  pain  (says  he)  can  only  be  assuaged  by  giving  and  repeating  opium 
and  its  preparations,  as  often  as  the  continuance  of  the  pain  requires  them ;  and  be- 
cause this  pain  is  very  apt  to  return,  the  patient  should  always  be  advised  to  keep 
by  him,  as  long  as  the  distemper  lasts,  pills  of  pure  opium,  each  weighing  one  grain 
— or  what  is  equivalent  to  them — that  no  time  may  be  lost  in  quieting  a  sensation 
which  is  so  difficult  to  endure.  One  of  these  pills  may  be  taken  as  soon  as  the  pain 
comes  on,  and  it  may  be  repeated  once  or  twice  in  the  course  of  two  hours,  if  the 
pain  require  it ;  and  I  have  often  found  it  both  safe  and  necessary  to  give  much 
more." 

This  plan,  of  giving  opium  in  the  form  of  pills,  is  the  more  judicious,  because, 
from  their  small  bulk,  they  are  more  hkely  to  be  retained  than  draughts  Avould  be. 
Sometimes  the  stomach  is  so  irritable  as  to  reject  even  a  pill.  I  would  add,  there- 
fore, to  Dr.  Heberden's  recommendations,  that  of  throwing  an  opiate  injection  into 
the  rectum ;  half  a  drachm  or  a  drachm  of  laudanum,  mixed  with  a  small  quantity 
of  warm  gruel.     Another  very  useful  expedient  is  the  warm  bath.     If  this  cannot 


THE    GALL-BLADDER.  855 

be  readily  procured,  hot  fomentations  to  the  epigastrium,  the  mustard-poultice,  the 
turpentine  stupe,  are  valuable  substitutes  for  it.  Dr.  Prout  states  that  he  has  seen 
more  alleviation  afforded  by  large  draughts  of  hot  water,  containing  the  carbonate 
of  soda  in  solution  (one  or  two  drachms  to  a  pint),  than  by  any  other  means.  "  The 
alkali  counteracts  the  distressing  symptoms  produced  by  the  acidity  of  the  stomach ; 
while  the  hot  w^ater  acts  like  a  fomentation  to  the  seat  of  the  pain.  The  first  por- 
tions of  w'ater  are  commonly  rejected  almost  immediately ;  but  others  may  be 
repeatedly  taken  ;  and  after  some  time  it  will  usually  be  found  that  the  pain  becomes 
less,  and  the  water  is  retained.  Another  advantage  of  this  plan  of  treatment  is,  that 
the  water  abates  the  severity  of  the  retching,  which  is  usually  most  severe  and 
dangerous  where  there  is  nothing  present  upon  which  the  stomach  can  react.  This 
plan  does  not  supersede  the  use  of  opium,  which  may  be  given  in  any  way  deemed 
most  desirable ;  and  in  some  instances  a  few  drops  of  laudanum  may  be  advan- 
tageously conjoined  with  the  alkaline  solution,  after  it  has  been  once  or  twice 
rejected."  The  pain  having  been  quelled,  the  bowels  should  be  swept  out  by  a 
brisk  purgative. 

When  the  jaundice  appears  to  have  been  suddenly  engendered,  by  moral  causes, 
the  rationale  of  its  production  is  obscure;  and  the  treatment  has  a  corresponding 
uncerlaint)'-.  The  bile,  retained  or  readmitted  into  the  blood,  is  supposed  to  operate 
as  a  poison  upon  the  nervous  system.  But  the  mental  state  which  precedes  and 
seems  to  occasion  the  jaundice,  may  possibly  be  itself  the  cause  of  the  nervous  symp- 
toms that  follow.  In  other  forms  of  the  malady  patients  remain  intensely  yellow, 
often  for  a  long  time  together,  without  becoming  comatose,  delirious,  or  convulsed. 
Not  that  this  is  conclusive.  We  know  that  a  given  poison  may  influence  different 
persons  very  differently.  The  same  dose  of  opium  that  will  put  one  man  to  sleep, 
will  stimulate  a  second  to  madness,  and  will  have  no  sensible  effect  upon  a  third.  In. 
the  very  complaint  before  us,  one  patient  is  tormented  with  a  universal  itching,  which 
we  attribute  to  bile  in  his  blood  ;  and  ten  others  remain  free  from  that  disagreeable 
feeling.  If  we  were  sure  that  the  bile  was  the  material  cause  of  all  the  cerebra' 
symptoms,  we  might  hope  to  draw  some  of  the  poison  off  by  blood-letting :  but  we 
are  not  sure  of  this ;  and  reasoning  upon  the  matter  helps  us  not  much  towards  the 
cure.  The  lesson  which  experience  has  furnished  amounts  to  no  more  thaa  this : 
that  active  purging  is  sometimes  followed  by  evident  amendment,  and  ultimate 
recovery.  I  would  bleed  also,  if  the  ^jwZse  warranted  venesection,  but  not  otherwise. 
In  all  the  varieties  of  what,  from  its  intensity  and  rapid  accession,  I  may  call  acute 
jaundice,  purging  is  strongly  indicated  :  and  we  sometimes  succeed  in  rectifying  the 
whole  morbid  condition  by  thus  applying  a  sudden  lurench  (so  to  speak)  to  the 
biliary  organs;  by  giving,  for  instance,  half  a  scruple  or  a  scruple  of  calomel,  and, 
a  few  hours  afterwards,  half  an  ounce  of  castor  oil,  with  half  an  ounce  of  spirit  of 
turpentine. 

When  green  jaundice  arises  from  hepatic  disease,  we  can  only  palhate.  Mild 
laxatives  and  anodynes  comprise  all  that  such  a  state  admits  of.  For  the  icterus 
gravidarum,  delivery  is  the  natural  cure:  it  may  sometimes  be  removed  by  the 
careful  employment  of  aperients. 

The  gall-bladder  has  its  own  diseases,  which  I  do  not  stop  to  investigate,  foi  they 
seldom  become  the  objects  of  specific  treatment.  Sometimes  it  is  found  shrivelled 
up,  and  nearly  empty :  sometimes  enormously  distended  ;  sometimes  ruptured. 
Of  these  conditions,  the  distension  of  the  gall-bladder  is  the  only  one  that  we  can 
ever  expect  to  recognize  in  the  living  body.  The  bag  then  projects  beyond  the 
edge  of  the  liver,  and  is  palpable  externally,  forming  an  elastic  tumour  in  the  right 
side.  Authors  lay  down  marks  for  distinguishing  a  distended  gall-bladder  from 
abscesses  of  the  liver,  and  from  an  hydatid  cyst ;  but  they  are  not  much  to  be  trusted 
to ;  nor  is  the  precise  diagnosis  of  any  great  moment.  The  practical  rule  seems  to 
be  that,  when  the  swelhng  is  adherent  to  the  parietes  of  the  abdomen  we  may  punc- 
ture It,  whatever  is  its  nature :  but  under  no  other  circumstances. 

I  have  already,  incidentally,  described  most  of  the  morbid  states  of  the  sphen 


856  THE    SPLEEN — NEPHRITIS   AND   NEPHRALGIA. 

which  are  susceptible  of  relief  from  medicine :  especially  the  enlargement  of  that 
body  constituting  the  ague-cake  of  the  fens,  and  occuring  in  connection  with  inter- 
mittent fever ;  and  that  other  kind  of  enlargement  which  sometimes  goes  along  with 
hsematemesis  and  melsena.  The  spleen  is  liable  to  tubercles  also ;  to  deposits  of 
other  specific  tumoui-s,  and  of  bone  ;  and  to  softening  of  its  substance. 

The  best  remedy  for  the  ague-cake  is  the  remedy  for  intermittent  fever,  qidna. 
Purgatives  also  have  the  effect  of  reducing  hypertrophy  of  that  curious  organ.  One 
caution  enforced  by  Dr.  Abercrombie,  is,  that  in  splenic  disease,  mercury  should  be 
sedulously  avoided,  or  rather  such  an  employment  of  mercury  as  would  risk  tender- 
ness of  the  gums.  Dr.  Williams,  of  St.  Thomas's  Hospital,  states  in  a  recent  pub- 
lication, that  he  has  made  many  trials  of  the  bromide  of  potassium  as  a  remedy  in 
various  disorders  :  but  that  he  has  satisfied  himself  of  its  utility  only  in  cases  of  dis- 
eased spleen.     Of  this  I  know  nothing. 

Again,  it  may  seem  a  slight  to  the  pancreas  to  pass  it  over  without  noticing  the 
diseases  to  which  it  is  subject.  But  really  those  diseases  appear  to  be  but  few ;  and 
they  do  not  signify  their  existence  by  any  plain  or  intelligible  signs.  I  have,  nine 
or  ten  times  perhaps  in  my  life,  met  with  carcinomatous  deposits  in  the  pancreas. 
In  every  instance  the  head  of  the  gland,  that  extremity  which  lies  next  to  the  bowel, 
has  been  the  exclusive  or  the  principal  seat  of  the  disease.  I  have  known  this 
change  in  the  pancreas  to  cause  jaundice,  by  obstructing  the  bile-ducts :  I  have 
known  it  in  the  same  way  to  occasion  very  great  enlargement  of  the  liver  itself;  and 
I  have  known  it  to  produce  enormous  and  slowly  fatal  distension  of  the  stomach  by 
compressing  the  duodenum,  and  so  preventing  the  free  passage  of  the  aliment 
through  that  gut.  As  to  remedies  for  pancreatic  diseases  or  disorders,  I  do  not  know 
of  any. 

Diseases  of  the  kidneys — and  disorders  of  their  function — and  alterations  in  the 
fluid  they  secrete — require  more  consideration.  And  I  proceed  at  once  to  the  sub- 
ject of  their  inflammation;  to  nejihritis :  and  it  will  be  practically  convenient  to 
lake  nephralgia,  or  pain  of  the  kidney,  into  the  account  at  the  same  time.  Nephral- 
gia is  commonly,  but  not  always,  produced  by  the  transit  of  a  urinary  calculus  from 
the  pelvis  of  the  kidney,  through  the  ureter,  towards  the  bladder.  This  constitutes 
what  is  called,  in  common  parlance,  a  fit  of  the  gravel.  The  symptoms  are  these: — 
pain,  sometnnes  dull,  but  more  frequently  very  severe,  in  the  loins,  usually  on  one 
side,  and  descending  often  along  the  track  of  the  ureter  of  the  same  side ;  numbness 
of  the  corresponding  thigh  ;  in  the  male,  retraction,  and  perhaps  pain,  of  the  testicle; 
a  frequent  desire  to  make  water,  which  is  generally  high  coloured  ;  nausea  and 
vomiting. 

If  to  these  symptoms  there  be  added  pyrexia,  we  learn  the  important  fact  that  in- 
flammation is  present :  we  have  the  symptoms  of  acute  nephritis.  The  passage  of 
gravel  from  the  kidney  sometimes  does,  and  sometimes  does  not,  provoke  inflamma- 
tion of  the  gland.  Nephritis  is  very  seldom  idiopathic.  It  may  sometimes  arise 
under  the  influence  of  cold  :  more  frequently  it  is  excited  by  calculous  matter  lodged 
in  the  kidney ;  by  a  blow  or  fall  upon  the  loins;  by  the  internal  administration  of 
cantharides,  or  of  turpentine.  It  is  to  the  presence  of  fever  that  we  look,  to  establish 
the  inflammatory  character  of  the  renal  affection 

Nephralgic  pains  require  to  be  distinguished  on  the  one  hand  from  rheumatic,  and 
on  the  other  from  colic  pains.  In  lumbago  there  is  pain  in  the  back,  and  it  may  or 
may  not  be  attended  with  fever ;  but  the  pain  usually  aflects  both  sides,  and  is  ag- 
gravated by  such  movements  of  the  body  as  call  the  muscles  of  the  loins  into  action, 
particularly  by  stooping.  It  originates,  frequently,  in  some  strain  or  efTort,  of  which 
the  patient  is  made  painfully  conscious  at  the  time.  It  is  seldom  accompanied  by 
any  notable  trouble  of  the  urinary  functions.  When  rheumatic  pain  extends  from 
the  back  into  the  thigh,  it  mostly  follows  the  course  of  the  great  sciatic  nerve,  and  is 
felt  down  the  outer  part  of  the  limb  ;  whereas  the  pain  that  accompanies  nephritis  or 
nephralgia  shoots  rather  along  the  track  of  the  anterior  crural  nerve.  Lastly,  lumbar 
(tain,  depending  upon  rheumatism,  is  not  attended  with  nausea  and  vomiting. 

Thf  pain  of  colic  is  often  associated  with  sickness  and  retching ;  and  it  may  occupy 


NEPHRITIS   AND   NEPHRALGIA.  857 

(hose  parts  of  the  abdomen  which  correspond  to  the  place  of  the  ureters.  I'he  uri- 
nary functions  are  undisturbed ;  and  this  is  a  capital  point  of  distinction.  The 
numbness  of  the  thigh,  and  drawing  up  of  the  testicle,  are  sufficiently  characteristic 
when  they  happen ;  but  they  are  frequently  altogether  absent. 

Some  years  ago  I  was  sent  for  by  an  exceedingly  intelligent  surgeon,  who  had 
been  one  of  the  house-surgeons  at  the  Middlesex  Hospital.  I  found  him  in  bed.  He 
told  me  he  had  pain  in  the  abdomen.  It  had  begun  in  the  morning  in  the  situation 
of  the  right  kidney,  and  soon  extended  round  to  the  right  side  of  the  abdomen  and 
the  groin.  Two  days  before,  he  had  experienced  a  similar  attack  of  pain  in  the 
renal  region,  stretching  round  into  the  hypogastrium.  When  I  saw  him,  he  de- 
scribed the  pain  as  lying  more  round  the  umbilicus  than  elsewhere  ;  and  he  expressed 
a  strong  persuasion,  from  the  feelings  which  attended  it,  that  it  would  be  removed  by 
free  action  of  the  bowels.  But  he  felt  nausea,  and  had  vomited  some  medicine 
which  he  had  taken.  He  had  no  fever,  no  retraction  of  the  testicle  or  numbness  of 
the  thigh,  and  the  pain  was  not  increased  by  pressure.  Neither  had  there  been  any 
marked  irritation  of  the  bladder.  He  said,  indeed,  when  I  questioned  him  on  that 
point,  that  he  thought  he  had  made  water  rather  more  frequently  than  usual  the 
day  before.  I  mention  this  case  to  show  you  the  occasional  obscurity  of  the  symp- 
toms. Here  a  well-instructed  medical  man  believed  that  nephralgia,  existing  in  his 
own  person,  was  colic.  To  my  judgment,  however,  it  seemed  most  probable  that  a 
small  calculus  had  been, passing  from  his  kidneys,  towards  and  perhaps  into  his 
bladder.  I  may  as  well  tell  you  the  event  of  the  case,  which  interested  me  a  good 
deal-;  for  it  exhibits  the  train  of  symptoms  that  are  apt  to  ensue  after  nephritic 
attacks,  although  in  this  instance  they  were  but  slightly  pronounced.  His  bowels 
were  well  acted  on  by  a  purgative,  and  the  next  day  he  was  free  from  pain,  and 
apparently  well. 

Two  days  after  this,  he  had  more  frequent  calls  to  pass  urine  than  were  usual  with 
him,  and  having  done  so  on  one  occasion,  he  presently  felt  the  want  again,  and  then 
passed  a  little  blood.  The  urine  had  been  of  a  clear  amber  colour  throughout.  At 
the  expiration  of  two  or  three  days  more  he  called  upon  me  to  say  that,  after  making 
water,  he  had  perceived  in  the  vessel  a  small  crystallized  mass,  which  he  took  out, 
supposing  it  to  be  (what  it  very  much  resembled)  a  fragment  of  sugar  candy.  In 
fact,  he  had  been  eating  sugar  candy,  and  thought  some  portions  of  it  had  fallen 
down  between  his  waistcoat  and  shirt,  and  afterwards  into  the  chamber-pot.  He  had 
the  curiosity,  he  said  (some  misgiving  he  must  have  had,  too,  for  I  had  told  him  my 
own  opinion  of  the  nature  of  his  attack),  to  put  a  small  crystal  from  this  fragment 
into  his  mouth;  and  as.it  neither  tasted  sweet  nor  dissolved,  he  suspected  it  might 
be  a  urinary  concretion,  and  brought  it  to  me.  And  sure  enough  it  was  so ;  a  piece 
of  very  pure  oxalate  of  lime,  which  he  had  been  fortunate  enough  thus  to  get  rid  of. 
It  was  a  quarter  of  an  inch  in  length,  and  less  than  one-eighth  of  an  inch  broad, 
consisting  of  an  aggregation  of  small  crystals.  It  was  exactly  similar  in  appearance 
and  colour  to  a  piece  of  brown  sugar-candy  of  the  same  size.  It  would  pass,  long- 
ways, into  a  large  crow-quill. 

That  it  was  oxalate  of  lime,  was  proved  in  this  manner.  A  little  separate  crystal 
was  heated  to  redness  on  a  piece  of  platinum  foil,  by  means  of  a  spirit-lamp  and 
blowpipe.  By  these  means  the  oxalic  acid  was  destroyed,  and  quick-lime  left.  This 
residue,  moistened,  and  pressed  into  a  powder  on  a  piece  of  turmeric  paper,  gave 
the  characteristic  brown  colour. 

You  see,  then,  that  a  nephritic  affection  may  be  mistaken  for  an  attack  of  colic. 
In  reference  to  practice,  it  would  indeed  be  a  mistake  of  no  great  importance,  smce 
the  remedies  that  are  proper  in  the  one  case  are  generally  proper,  or  not  improper 
in  the  other.  If  the  pain  be  attended  with  fever,  antiphlogistic  measures  are  alike 
indicated  in  each  of  the  two  diseases. 

The  numbness  of  the  thigh,  and  the  drawing  up  of  the  testicle,  are  analogous 
phenomena  to  the  pain  which  affects  the  shoulders  in  hepatic  disorders.  Irritation 
of  one  extremity  of  a  nerve,  situated  internally,  and  belonging  to  an  organ  which 
is  not  endowed  with  a  high  degree  of  sensibility,  causes  sympathetic  sensations  in 

3  w2 


858  NEPHRITIS    AND   NEPHRALGIA. 

the  sentient  extremities  of  other  branches  of  the  same  nerve,  or  of  communicating 
nerves. 

And  this  sympathetic  afTection  of  distant  parts  is  sometimes  attended  (as  I  formerly 
observed)  not  merely  with  pain,  but  with  some  degree  of  inflammation  also.  The 
testicle  occasionally  swells,  and  becomes  tender  during  a  nephritic  attack.  On  the 
other  hand,  as  the  nerves  which  communicate  with  those  of  the  testicle  or  thigh,  may 
or  may  not  be  implicated  in  the  renal  disorder,  so  we  see  how  it  happens  that  these 
curious  symptoms,  so  instructive  when  they  do  occur,  may  frequently  be  wanting, 
as  they  were  in  the  example  I  just  now  detailed  to  you. 

When  the  symptoms  I  specified  in  the  outset  are  attended  with  fever,  we  conclude 
that  we  have  to  deal  with  nephritis  ;  and  when  inflammation  of  the  kidney,  how- 
ever produced,  lasts  for  a  certain  period,  without  abatement,  suppuration  is  to  be 
dreaded.  Such  suppuration  is  marked,  sometimes,  by  the  supervention  of  rigors, 
by  throbbing,  perhaps,  and  it  may  be  by  a  remission  of  the  pain  :  but  I  beheve  it 
may  take  place  without  throwing  out  any  such  signals.  Nay,  I  think  it  probable 
that  inflammation,  confined  to  the  parenchymatous  substance  of  the  kidney,  may 
arise,  and  run  through  all  its  stages,  without  denoting  its  presence  or  progress  by 
any  noticeable  local  signs  ;  and  that  the  sharp  and  peculiar  symptoms  ascribed  by 
authors  to  acute  nephritis  manifest  themselves  only  when  the  investing  membrane 
of  the  gland,  or  its  pelvis  and  excretory  tubes,  are  involved  in  the  inflammator}^  pro- 
cess. However  this  may  be,  suppuration  leads  to  ulceration,  to  the  formation  of 
renal  fistulse,  to  the  establishment  of  a  purulent  discharge,  and  hectic  fever;  and 
finally,  in  most  cases,  to  a  fatal  event ;  whether  the  inflammation  was  at  first  idiopa- 
thic, or  dependent  on  a  calculus. 

I  may  illustrate  these  remarks,  by  stating  the  heads  of  a  case  which  has  occurred 
to  me  since  this  course  of  lectures  began.  I  admitted  Caroline  Barnard,  a  married 
woman,  forty  years  old,  into  the  hospital,  on  the  18th  of  October.  Among  other 
things  she  complained  of  pain  in  the  situation  of  the  right  kidney.  She  had  been  ill 
SIX  weeks,  and  at  the  commencement  of  her  illness  her  urine  had  been  very  turbid, 
as  indeed  it  still  was :  and  she  had  experienced  much  pain  and  difficulty  in  passing 
it,  and  after  it  had  passed.  From  that  time  she  had  frequent  nausea  and  retching, 
and  occasional  numbness  of  the  right  thigh.  She  had  been  losing  flesh  fast ;  and 
her  pulse  was  frequent.  There  was  some  tenderness  discoverable  in  the  right  renal 
region  ;  and  after  a  time  a  manifest  fulness  there,  and  hardness  ;  and  at  length  oedema 
of  the  integuments  and  extreme  tenderness.  She  suffered  also  well  marked  hectic 
fever,  and  had  severe  and  repeated  rigors.  On  the  4th  of  November,  after  a  careful 
examination  of  the  right  loin,  we  satisfied  ourselves  of  the  presence  of  matter.  I  got 
Mr.  Arnott,  therefore,  to  see  her,  and  put  a  lancet  into  the  abscess ;  and  a  large 
quantity  of  faint-smelling  pus  came  out.  She  was  greatly  relieved  by  the  operation ; 
and  a  purulent  discharge,  mixed  \\\\\\  shreds  of  cellular  membrane,  came  away  in 
abundance  for  some  days :  but  in  time  the  discharge  ceased,  the  swelling  subsided, 
and  the  opening  healed.  We  began  to  hope  that  it  had  been  merely  an  abscess  in 
the  neighbourhood  of  the  kidney,  irritating  it  and  affecting  its  functions.  But  in 
three  weeks  after  the  abscess  was  punctured,  the  swelling  was  found  to  have  re- 
curred ;  and  she  again  began  to  suffer  much.  The  tumour  was  again  opened,  and 
pus  of  a  more  offensive  character  than  before  evacuated.  In  the  early  part  of  De- 
cember she  sank. 

We  found  the  right  kidney  small,  collapsed  and  hollow ;  in  some  parts  a  mere 
flabby  bag.  On  its  posterior  surface  there  w^as  an  opening,  which  formed  a  commu- 
nication between  the  interior  of  the  kidney,  and  the  abscess  in  the  areolar  tissue, 
which  had  pointed  externally.  The  pelvis  of  the  kidney  was  much  dilated ;  and 
the  substance  of  the  gland  destroyed  to  a  considerable  extent,  by  suppuration  and 
ulceration.  The  ureter,  where  it  left  the  pelvis  of  the  kidney,  was  found  to  be  im- 
pervious. 

The  other  kidney  was  much  enlarged,  but  of  quite  healthy  and  sound  structure. 
That  kind  of  compensation  had  occurred  which  I  formerly  mentioned  as  not  unusual 
when,  of  double  organs,  one  has  been  rendered  incapable  of  its  natural  functions,  and 
ine  other  takes  up  its  duty  and  performs  a  twofold  amount  of  work.     The  organ  of 


NEPHRITIS    AND   NEPHRALGIA.  859 

which  the  function  is  thus  increased,  becomes  hypertrophied.  This  woman  did  not 
die  because  there  was  not  urine  enough  secreted ;  but  she  sank  under  the  wasting 
punlent  drain,  the  irritation  and  pain  she  suffered,  and  the  protracted  hectic  fever. 
in  this  instance  the  inflammation  and  suppuration  occurred  independently  of  the  for- 
mation of  calculous  matter. 

Sometimes  the  pus  finds  its  way  out  of  the  body  through  the  natural  passages,  and 
appears  in  the  urine.  This  woman's  urine  was  thought,  by  some  of  the  pupils,  to 
contain  pus.  Tt  was  quite  thick,  and  of  a  yellowish  colour.  But  heat  rendered  it 
transparent.  You  must  not  judge  by  a  cursory  look  at  the  water.  The  effect  of 
heat  proved  that  the  yellow  material  was  not  pus :  the  impervious  condition  of  the 
ureter  showed  afterwards  that  it  could  not  have  been. 

When  calculi  exist  in  the  kidney,  they  often  betray  their  presence  there,  by 
causing  bloody  urine.  But  bloody  urine  may  proceed  from  various  causes  ;  and  in 
conformity  with  my  usual  custom,  I  shall  by  and  by  offer  you  some  general  remarks 
on  hsematuria,  as  one  of  the  hemorrhages. 

I  showed  you,  at  our  last  meeting,  that  gall-stones  might  inhabit  the  gall-bladder 
in  considerable  numbers,  and  be  quite  harmless,  unless  they  atteinpted  to  escape  from 
their  prison,  through  the  very  narrow  channel  of  egress  from  it;  and  I  intimated  that 
the  same  observation  was  often  applicable  to  urinary  concretions.  Renal  calculi  do, 
indeed,  in  many  cases,  produce  abiding  uneasiness,  or  frequently  recurring  pain,  in 
the  situation  of  the  affected  kidney,  bloody  urine,  and  gastric  disturbance;  especially 
when  the  concretions  are  shaken  or  displaced  by  sudden  jolts,  or  jarring  movements 
of  the  body  ;  or  when  the  system  is  deranged  by  intemperate  habits.  But  in  many 
other  instances  these  calculi  cause  no  pain  or  annoyance,  so  long  as  they  remain  in 
the  kidney ;  although  they  inflict  horrible  suffering,  in  general,  while,  for  the  first 
time,  they  are  forcing  their  way  along  the  narrow  ureter.  A  concretion  cannot  be 
formed  in  a  moment ;  3'et  the  attack  of  pain  often  comes  on  in  a  moment,  without 
any  previous  warning.  After  a  while  it  remits,  perhaps,  as  suddenly'- ;  the  calculus 
having  passed  (it  may  be  presumed)  from  the  ureter  into  the  bladder;  and  then  in- 
dications, more  or  less  palpable,  usually  begin  to  declare  themselves  of  its  presence 
in  that  reservoir.  Moreover,  it  is  not  uncommon  to  find  calculi  in  the  kidney 
alter  death,  of  the  existence  of  which  there  had  been  no  symptom  manifested  during 
hfe. 

The  /reo/menf  of  nephritis — or  of  the  nephralgia  calculosa,  when  accompanied  by 
fever,  or  occurring  in  young,  strong,  and  plethoric  persons — is  just  such  as  would  be 
proper  in  cases  of  severe  colic,  or  enteritis  :  and  therefore  it  is  that  any  mistake  between 
these  disorders  at  the  outset  is  not  of  so  much  practical  consequence.  The  objects  of 
treatment  are,  to  arrest  the  inflammatory  process ;  to  quiet  existing  irritation  ;  and  to 
obviate  any  fresh  causes  of  irritation.  Venesection,  therefore,  in  proportion  to  the 
strength  of  the  patient  and  the  violence  of  the  symptoms,  will  sometimes  be  proper: 
and  it  will  always  be  advisable  to  take  away  blood  freely  from  the  neighbourhood  of 
the  suffering  part  by  cupping.  Warm  fomentations  ;  the  warm  bath  ;  the  injection 
of  warm  water  into  the  bowel ;  these  are  all  expedients  of  which  practical  men  ac- 
knowledge the  value.  The  warm  enemata  not  only  clear  out  from  the  large  intes- 
tines any  irritating  matters  they  might  contain,  but,  from  the  proximity  of  the  colon  to 
the  kidney,  they  perhaps  have  the  effect  of  an  internal  fomentation.  It  is  desirable 
also  to  get  the  bowels  well  acted  upon  by  purgative  medicines  as  soon  as  possible: 
the  relief  that  follows  free  alvine  discharges  is  often  very  marked.  There  is  some- 
times a  difficulty,  from  the  irritability  of  the  stomach,  in  administering  purgatives  by 
the  mouth.  Calomel,  however,  will  often  be  retained,  when  other  substances  are 
rejected.  It  is  generally  considered  of  importance  to  give  those  purgatives  only 
which  are  not  likely,  after  being  absorbed  into  the  blood,  to  irritate  the  urinary  pas- 
sages. On  this  account  the  saline  purgatives  are  to  be  avoided.  Nothing  is  so 
good  as  castor  oil,  if  the  stomach  will  bear  it ;  or  infusion  of  senna,  with  manna,  may 
be  used  ;  or,  if  the  stomach  be  very  quesisy,  pills,  composed  of  cathartic  extract,  and 
calomel. 

When  there  is  no  fever,  i.  e.,  when  the  case  is  one  of  nephralgia,  and  a  calculus 
IS  passing,  after  the  intestinal  canal  has  been  cleared  by  a  purgative,  't  will  be 


860  GRAVEL. 

necessary  to  give  opium  in  full  doses  to  allay  the  pain :  and  it  may  either  bo 
adiTi  mistered  in  the  form  of  pill  through  the  stomach  ;  or  introduced  into  the  rectum. 

When  a  person  suffers  what  is  called  a  fit  of  the  gravel,  the  pain,  I  saj?^,  is  at  length 
very  suddenly  relieved,  in  general,  in  consequence  of  the  calculus  having  emerged 
from  the  ureter  and  entered  the  bladder.  We  judge  that  this  has  taken  place,  first, 
by  the  cessation  of  the  pain ;  and  secondly,  by  the  supervention,  sooner  or  later,  of 
symptoms  indicative  of  stone  in  the  bladder ;  viz.,  a  more  than  usually  frequent  in- 
clination to  make  water;  pain,  referred  to  the  extremity  of  the  urethra,  especially 
just  after  passing  urine  :  and  stoppages  and  renewals  of  the  stream  of  water  while  the 
patient  is  endeavouring  to  void  it. 

The  time  which  a  calculus  takes  in  travelling  from  the  kidney  to  the  bladder 
varies  a  good  deal.  The  painful  journey  may  be  over  in  a  few  hours;  or  it  may 
last  two  or  three  days.  More  rarely  the  symptoms  continue,  with  irregular  intervals 
of  comparative  quiet,  for  weeks.  And  sometimes,  notwithstanding  the  peculiar  pain, 
which  amounts  to  torment,  all  morbid  symptoms  cease,  and  yet  no  calculus  has 
passed,  apparently,  into  the  bladder :  none,  i.  e.,  of  the  symptoms  of  stone,  ensue  ;  no 
calculus  is  voided  by  the  urethra ;  and  none  found  in  the  bladder  when  the  patient 
at  length  dies. 

What  is  the  explanation  of  these  circumstances  ?  Why,  as  calculi  have  been 
discovered  in  such  cases  in  the  kidney,  it  has  been  supposed  that  a  concretion  may 
get  into  the  very  beginning  of  the  ureter,  where  it  is  a  little  larger  than  elsewhere, 
and  give  rise  to  the  peculiar  symptoms,  yet  never  pass  fairly  into  that  narrow 
tube  ;  but  at  length  fall  back  again  into  the  pelvis  of  the  kidney  ;  when  the  symptoms 
cease. 

But  the  same  symptoms  undoubtedly  occur,  occasionally,  when  there  is  no  cal- 
culus at  all.  Sir  B.  Brodie  has  referred  to  this  form  of  complaint.  In  people  who 
live  intemperate  and  luxurious  lives,  pain  is  apt  to  seize  upon  one  renal  region,  and 
to  extend  round  and'downwards  into  the  groin  :  and  these  symptoms  will  be  followed 
by  frequent,  difficult,  and  painful  micturition,  the  urine  being  unusually  acid,  high- 
coloured,  and  sometimes  turbid.  The  whole  irritation  appears  to  be  produced 
by  this  unhealthy  urine :  at  least  the  complaint  vanishes  after  cupping  the  loins, 
purging,  the  warm  bath,  and  two  or  three  full  doses  of  colchicum  given  at  short  in- 
tervals. 

Sometimes  the  little  stone  becomes  immovably  wedged  in  the  canal  of  the  ureter. 
If  it  completeljr  shuts  the  tube,  the  urine  accumulates  behind  it,  and  that  portion  of 
the  ureter  dilates.  The  obstruction  usually  proves  fatal,  by  its  influence  upon  the 
functions  of  the  kidney,  and  thereby  upon  the  whole  economy.  But  if  the  urine 
finds  a  passage  by  the  side  of  the  impacted  concretion,  this  danger  is  averted,  or  post- 
poned. 

When  we  have  reason  to  believe,  from  the  nature  and  course  of  the  symptoms, 
that  a  calculus  has  come  down  from  the  kidney,  and  lodged  in  the  bladder,  then  it 
becomes  an  object  of  deep  interest  to  the  practitioner,  and  of  fearful  importance  to 
the  patient,  to  try  all  means  to  bring  about  its  expulsion  before  it  grows  too  large  to 
be  voided.  For  grow  it  almost  surely  will,  by  the  continual  accretion  of  earthy 
matter  upon  its  surface,  if  it  remains  long  in  the  bladder.  We  know  that  it  may,  af 
first,  be  voided,  provided  the  urethra  be  in  a  healthy  and  natural  state  ;  that  what- 
ever has  passed  through  the  ureter,  may  pass  through  the  urethra  also. 

The  objects  to  be  kept  in  view  are  these :  first,  to  procure  a  plentiful  secretion  of 
bland  urine,  wherewith  the  bladder  may  become  filled  ;  secondly,  by  lulling  the  sen- 
sibility of  the  parts  concerned,  to  prevent  or  lessen  that  spasmodic  effort  of  the 
sphincter  of  the  bladder,  which  the  presence  of  the  calculus  is  apt  to  provoke  ;  and, 
thirdly,  to  ascertain  that  the  channel  of  the  urethra  is  open  and  unimpeded. 

To  effect  the  first  of  these  purposes,  the  patient  should  be  instructed  to  drink  freely 
of  diluent  liquors;  such  as  barley-water,  or  linseed-tea,  in  which  may  be  mixed  a 
small  quantity  of  the  sweet  spirits  of  nitre.  To  fulfil  the  second,  he  should  take  a 
full  dose  of  opium  at  bed-time.  By  these  means  the  pain  and  irritation  which  may 
have  been  produced  by  the  calculus,  will  be  soothed  ;  and  the  bladder  will  gradually 
fill      He  should  then  make  water,  having  first  placed  himself  in  such  a  position 


GRAVEL.  861 

that  the  outlet  of  the  bladder  shall  be  at  the  lowest  part  of  that  receptacle.  He  may 
etand  up,  and  lean  forwards ;  or  it  may  be  well  to  make  wator  while  kneeling,  in  a 
warm  bath.  If  these  expedients  are  not  presently  successful,  the  urethra  may  be 
cautiously  expanded,  and  habituated  to  the  contact  of  a  solid  body,  by  the  daily  in- 
troduction of  a  full-sized  bougie.  Sometimes  the  calculus  will  follow  the  bougie, 
as  it  is  withdrawn,  through  the  urethra.  In  this  way  the  patient  will  have  a  fair 
chance  of  getting  rid  of  the  stone.  In  this  way  a  very  near  friend  of  my  own,  a 
physician  now  practising  in  this  town,  did  expel  a  formidable,  though  not  very  large, 
piece  of  rough  oxalate  of  lime  several  weeks  after  its  entrance  into  the  bladder. 
Out  it  came,  at  last,  with  a  smart  clink,  which  was  music  to  his  ear,  against  the 
chamber-pot.  A  gentleman  was  not  long  since  sent  up  to  me  from  Kent,  by  a  former 
pupil  of  this  College,  with  the  following  history.  About  a  month  before  he  had  been 
suddenly  attacked  with  acute  pain  in  the  loins,  extending  forwards  into  the  left  flank 
and  pelvis,  with  nausea  and  vomiting.  For  nearly  ten  days  these  symptoms  con- 
tinued to  occur  at  intervals ;  then  they  ceased  :  and  then  he  began  to  be  troubled  by 
a  frequent  and  very  urgent  inclination  to  make  water,  and  by  pain  after  voiding  it, 
just  above  the  arch  of  the  pubes.  I  gave  him  directions,  in  accordance  with  the 
plan  just  now  mentioned  ;  and  wished  him  to  allow  some  surgeon  to  explore  the 
contents  of  his  bladder.  To  this  he  would  not,  as  yet,  he  said,  consent.  I  saw  him 
on  the  2d  of  August.  He  returned  into  Kent  the  next  day.  On  the  5th,  while 
taking  a  walk,  he  was  seized  with  a  most  imperative  desire  to  make  water,  but  found 
that  he  could  part  with  none.  Concluding  that  a  calculus  had  entered,  and  stopped 
up  the  urethra,  he  was  proceeding  homewards,  but  was  soon  constrained  again  to 
try  to  empty  his  bladder :  and  then  he  had  the  satisfaction  of  feeling,  and  seeing,  a 
stone  fly  out  with  great  force :  but,  as  he  had  turned  towards  a  hedge,  he  could  not 
find  it.     From  that  moment  he  was  quite  easy. 

When  a  calculus  of  a  certain  size  has  once  traversed  the  tubes  that  lead  respect- 
ively to  and  from  the  bladder,  others  sometimes  follow  it  with  more  ease.  I  show 
you  here  a  large  concretion  which  was  passed,  or  pissed  if  you  will,  by  a  patient  of 
mine  without  his  knowing  it.  He  is  subject  to  epilepsy,  which  is  probably  eccen- 
tric, and  excited  by  renal  disease.  He  is  closely  and  anxiously  watched  by  his  wife. 
One  day  last  year  she  noticed  that  the  urine  he  had  just  voided  was  shghtly  tinged . 
with  blood  :  and  she  then  found  this  oblong  stone,  which  is  composed  of  hthic  acid, 
in  the  vessel. 

If  the  renal  calculus,  after  it  has  reached  the  bladder,  cannot  be  got  rid  of  by  the 
expedients  I  have  been  recommending,  the  question  arises,  whether  medicine  can  do 
any  further  good,  or  whether  the  patient  is  to  be  delivered  over  to  the  surgeon. 

Most  of  these  small  concretions  admit  of  being  mechanically  crushed  into  smaller 
fragments,  which  are  then  readily  washed  out  by  the  stream  of  urine.  Larger  stones 
are  extracted  entire,  through  incisions  of  the  bladder.  Yet  there  are  many  cases  in 
which,  for  various  reasons,  surgery  declines  to  attempt  the  removal  of  vesical  calcuh. 
Medicine  still  offers  to  these  unfortunate  patients  the  means  of  mitigating,  at  least, 
their  sufferings.  But  it  often  can  do  more  than  this.  It  is  very  important  for  you 
to  know  that  judicious  medical  treatment  may  retard  or  prevent,  and  that  injudicious 
medical  treatment  may  promote  and  hasten  the  enlargement  of  such  calcuh.  Let  ns 
briefly  consider  the  principles  by  which  our  judgment  and  our  practice,  in  this  serious 
matter,  must  be  guided. 

I  have  described  a  fit  of  the  gravel.  We  say  that  a  patient  has  the  gravel  when 
he  passes  concrete  matter  with  his  urine,  whether  in  the  form  of  powder,  of  grit  or 
sand,  or  of  more  massive  calculi.  We  do  not  apply  that  term  to  the  cases  in  which 
the  urine  is  clear  when  recently  voided,  and  warm  ;  but  throws  down  an  earthy  sedi 
ment  as  it  cools  :  which  sediment  redissolves  if  the  urine  be  again  artificially  heated 
Now,  besides  the  different  forms  which  the  gravel  assumes,  of  powder,  sand,  and 
little  stones,  there  are  (as  you  may  have  guessed  from  certain  terms  that  I  have  been 
obliged  to  employ)  several  kinds  of  gravel ;  differing,  I  mean,  in  their  chemical  com 
position.  The  main  signs — the  pain,  the  sickness,  the  affection  of  the  testicle,  the 
subsequent  bladder  symptoms — are  much  the  same,  whatever  be  the  nature  of  the 
solid  matter  that  descends  from  the  kidney,  and  fingers  in  the  bladder.     But  other 


862  LITHIC    DIATHESIS. 

circumstances  difTer  widely.  The  qualities  of  the  water  previously  to  the  formation, 
and  to  the  discharge,  of  the  sabulous  matter  ;  the  state  of  the  system  at  large.  And 
it  is  quite  impossible  to  treat  cases  of  calculus  in  the  kidney,  or  of  stone  in  the  bladder, 
v.'ith  propriety,  or  safety,  without  constant  reference  to  the  condition  of  the  urine. 
The  morbid  states  of  that  secretion  are  of  the  greatest  interest.  I  cannot  undertake 
to  enter  upon  the  subject  in  much  detail.  Yet  some  outline  of  it  I  must  attempt, 
especially  where  it  touches  upon  points  of  practice. 

You  know,  probably,  that  the  urine  voided  by  a  person  in  health  alwaj's  exhibits 
acid  properties,  always  turns  Htmus  paper  red.  Not  that  healthy  urine  contains  a 
free  acid  ;  but  only  (according  to  Dr.  Prout,  who  is  the  great  authority  in  these  things), 
that  certain  of  the  alkaline  and  earthy  bases  are  not  exactly  neutralized,  but  exist 
in  the  state  of  supersalts.  The  pure  lithic  acid  is  nearly  insoluble  ;  but  the  lithate 
of  ammonia  is  very  readily  soluble  :  and  it  is  this  which  reddens  the  vegetable  blues. 
Now,  whether  out  of  the  body,  or  within  it,  the  lithate  of  ammonia  will,  of  course, 
be  decomposed,  if  any  acid  be  present  in  the  urine,  for  which  ammonia  has  a  stronger 
affinity  that  it  has  for  the  lithic  acid  :  and  the  latter  will  be  thrown  down,  in  the  form 
of  a  red  sand  :  little  crystals,  in  point  of  fact,  they  are  very  much  like,  in  shape,  size, 
and  colour,  to  the  particles  of  Cayenne  pepper.  I  show  you  some  collected  by  one 
of  my  out-patients  at  the  hospital.  He  must  have  passed  a  peck  of  it  while  under 
my  observation  :  and  I  am  sorry  (having  lately  lost  sight  of  him)  that  I  did  not 
procure  a  large  quantity  for  the  museum. 

Now  this  lithic  acid,  or  red  sand,  or  gravel,  is  liable  to  form  in  the  kidney,  if  not 
in  the  bladder,  and  to  concrete  into  calculi ;  and  the  calculi  once  formed,  or,  indeed, 
any  solid  substance,  will  constitute  a  nucleus,  upon  and  around  which  a  further  and 
repeated  incrustration  of  a  similar  nature  is  almost  sure  to  take  place.  You  will  at 
once  perceive  the  importance  of  doing  nothing  to  aggravate  this  disposition  to  deposit 
lithic  acid ;  but  of  trying  to  prevent,  or  stop  it.  If  there  be  symptoms  of  stone  in 
the  kidney,  or  in  the  bladder,  and  we  have  reason  to  believe  that  it  consists  of  lithic 
acid,  there  are  medicines  which  would  tend  to  render  matters  worse,  and  there  are 
others  of  which  the  effect  would  be  to  correct  the  lithic  acid  diathesis,  as  it  is  called. 
But  how  are  we  to  know  whether  the  presumed  calculus  be  of  that  kind  or  not  ? 
or,  rather,  how  are  we  to  know  that  the  lithic  diathesis  exists  ?  Why,  we  learn  that 
it  exists  by  noticing  the  habitual  qualities  of  the  urine,  and  the  habitual  state  of  the 
patient's  general  health. 

In  the  urine  of  persons  who  have  the  lithic  diathesis,  you  will  find  that  there  are 
frequent  deposits,  after  it  has  become  cool,  of  reddish  sediments,  looking  like  brick- 
dust,  and,  therefore,  called  lateritious.  These  sediments  consist  chiefly  of  the 
lithate  of  ammonia,  tinged  with  certain  colouring  matters  in  the  urine.  Sometimes 
pure  lithic  acid  appears,  in  the  shape  of  fine  sand,  or  in  larger  crystals.  The  urine 
itself  is  bright,  of  a  dark  coppery  colour,  hke  brown  sherry.  It  is  more  acid  than 
the  urine  of  health,  and  gives  to  litmus  paper  a  deeper  shade  of  red.  It  is  apt,  too, 
to  fall  below  the  average  quantity. 

The  presence  of  this  diathesis  is  likewise  accompanied,  and  so  far  denoted,  by  a 
tendency  to  feverish  and  inflammatory  complaints.  The  patients  are  troubled  with 
acidity  of  stomach  and  heartburn  ;  many  of  them  are  subject  to  gout  or  rheumatism. 
They  are  mostly  also  indolent  and  luxurious,  or  intemperate  in  their  mode  of  fife. 
Adults  are  peculiarly  obnoxious  to  this  condition  of  the  system  after  the  age  of 
forty.  But  children,  up  to  the  period  of  puberty,  are  very  liable  to  have  lithic  acid 
gravel. 

Whenever  a  paroxysm  of  nephritic  pain  befalls  a  person  whose  time  of  life,  whose 
habits,  the  characters  of  whose  health,  and  the  habitual  qualities  of  whose  urine,  are 
such  as  I  have  been  describing,  you  may  conclude  that  the  concretion  which  has 
occasioned  the  symptoms  is  of  the  Hthic  acid  kind :  and  you  may  expect  that  such 
attacks  will  recur;  for  it  is  observed  of  these  lithic  acid  renal  calcuii",  that  they  are 
generally  numerous  in  the  same  individual.  I  speak  of  the  habitual  —  or  of  the 
fiequently  recurring  —  qualities  of  the  urine :  for  a  deposit  of  lithic  acid  gravel,  or 
of  superabundant  lithates,  may  occur  to  the  healthiest  individual,  under  accidental 
and  transient  disturbing  causes.  Many  persons  will  tell  you  that  their  water  becomej 


Iffi 


LITHIC   DIATHESIS.  863 

turbid  with  red  sand  whenever  they  have  a  cold.  Febrile  and  inflammator}  aihnents 
will  produce  the  sediment :  even  too  full  a  meal:  or  exercise  taken  immediately- 
after  a  full  meal.  In  all  such  cases  it  seems  probable  that  the  customary  evolution 
of  lactic  acid  through  the  skin  is  somehow  prevented :  in  consequence  either  of  a 
check  given  to  the  perspiration,  or  of  imperfect  assimilation  of  the  food.  The  lactic 
acid,  thus  diverted  from  its  natural  emunclory — or  some  other  acid  generated  within 
the  system — is  determined  to  the  urine,  and  precipitates  the  lithic. 

Now  the  formation  of  lithic  acid,  and  of  the  lithates,  may  be  controlled  by  the 
exhibition  of  alkaline  remedies.  You  will  find  that  free  livers  use  alkalies  to  neutralize 
the  excess  of  acid  which  results  from  their  intemperate  habits  ;  the  carbonates  of  soda, 
or  of  potass.  They  do  this,  without  any  reference  to  the  appearance  of  their  urine, 
to  prevent  or  appease  the  uneasy  feelings  produced  by  a  debauch.  But  it  is  of  im- 
portance to  be  aware  that  one  of  these  alkalies  is  preferable,  for  the  purpose  of 
obviating  the  lithic  acid  diathesis,  to  the  other.  Soda  will  sometimes  combine  with 
the  Hthic  acid,  and  form  an  insoluble  salt,  as  hard,  and  as  pernicious,  when  deposited 
around  a  nucleus,  as  the  lithic  acid  itself.  With  potass  there  is  no  such  danger.  If 
it  should  combine  with  the  lithic  acid,  the  resulting  sak  is  perfectly  soluble,  and  will 
pass  away  dissolved,  in  the  urine.  Magnesia  is  also  a  good  medicine  in  such  cases ; 
but  it  has  this  disadvantage,  as  I  showed  you  indeed  before,  that  it  is  apt,  when  taken 
habitually,  to  cause  intestinal  concretions :  and  these  may  be  as  dangerous  as  the 
urinary  ones.  One  of  the  best  modes  of  giving  the  bicarbonate  of  potass  is  in  the 
common  saline  draught.  The  stomach  has  the  power  apparently  of  destroying  the 
vegetable  acids;  and  the  remedial  properties  of  the  bicarbonate  become  thus  equally 
certain  with  those  of  the  pure  alkali,  while  it  is  much  less  likely  to  derange  or  dis- 
agree with  the  stomach.  Of  course  the  mode  of  living  ought  to  be  changed  when 
the  lithic  diathesis  prevails  ;  the  patients  should  dine  moderately  and  plainly,  eating 
of  one  dish,  and  avoiding  acids,  and  all  articles  of  diet  likely  to  generate  acid  in  the 
stomach;  saccharine  substances,  therefore,  and  fermented  liquors.  But,  as  I  men- 
tioned in  a  former  lecture,  they  will  not,  if  they  can  help  it,  give  up  their  accus- 
tomed indulgences :  and  they  attempt,  and  we  attempt,  but  the  attempt  is  often 
made  in  vain,  to  remedy  disorders,  which  might  with  ease  and  certainty  have  oeen 
prevented. 

You  must  take  care  not  to  give  these  alkaline  remedies  too  long ;  nor  in  too  great 
quantity.  You  must  not  push  them  to  such  an  extent  as  entirely  to  destroy  the 
acidity  of  the  urine  :  for  if  you  do,  your  patient  is  exposed  to  the  same  danger  as 
before,  but  from  an  opposite  cause.  A  white  sand  or  gravel  will  be  apt  to  form  in 
the  alkaline  or  neutral  urine  :  and  this  will  collect  itself,  by  the  force  of  aggregation, 
around  any  existing  calculus,  or  foreign  substance.  The  white  deposits  consist 
mainly  of  the  triple  phosphate  of  ammonia  and  magnesia;  and  if  you  examine 
collections  of  urinary  calculi,  you  will  find  that  they  are  sometimes  made  up  of 
concentric  layers ;  and  one  layer  may  be  composed  of  lithic  acid,  and  the  next  of 
the  triple  phosphates  ;  and  so  on,  as  the  condition  of  the  urine  has  alternated.  You 
must  test  the  urine,  therefore,  and  see  that  it  still  reddens  litmus,  though  perhaps 
famtly.  Indeed  it  may  do  so,  without  containing  any  free  acid :  so  that  urine  which 
only  slightly  reddens  litmus  paper  may  nevertheless  be  capable  of  depositing  the 
triple  phosphate.  The  saline  draught  has  always  a  tendency  to  make  the  urine 
alkaline  ;  and  thus  it  is,  probably,  that  it  proves  of  use  in  febrile  disorders :  but  it  is 
an  absolute  poison  to  those  whose  urine  is  already  alkaline.  Colchicum  has  a  similar 
tendency  to  diminish  the  acid  reaction  of  the  urine.  So  has  mercury.  And  I  may 
tell  you  —  speaking  generally  of  morbid  states  of  the  urine  —  that  it  is  much  more 
easy  to  correct  too  great  acidity  than  to  rectify  the  opposite  condition.  We  can  almost 
always  make  acid  urine  neutral  or  alkaline  :  but  to  render  alkahne  urine  acid  is  often 
beyond  our  power. 

It  is  scarcely  less  important  to  attend  to  the  functions  of  the  skin,  in  persons  having 
the  Hthic  acid  diathesis,  than  to  the  functions  of  the  stomach.  The  warm  bath  is 
often  an  excellent  adjuvant,  in  their  treatment.  In  cold  weather,  warm  clothing  must 
be  enjoined  ;  and  the  avoidance,  in  all  weathers,  of  such  exposure  to  cold  as  mighl 
suppress  or  materially  lessen  the  amount  of  healthy  perspiration. 


864  PHOSPHATIC    DIATHESIS. 

You  will  have  gathered,  from  what  I  have  already  said,  that  there  is  a  morbid 
condition  of  the  system,  the  opposite  of  that  in  which  the  lithic  diathesis  prevails. 
The  phosphatic  diathesis,  namely ;  in  which  there  is  a  readiness  to  deposit  ivliite 
gravel ;  composed  of  minute  shining  crystals  of  a  triple  salt,  the  phosphate  of  ammo- 
nia and  magnesia.  The  way  in  which  this  is  formed,  according  to  Dr.  Prout,  is  as 
follows.  Healthy  urine  contains  the  phosphate  of  magnesia,  which  is  very  soluble ; 
and,  therefore,  is  dissolved  in  that  fluid.  But,  under  certain  circumstances,  the  urea 
of  the  urine  becomes  decomposed  in  the  kidneys,  and  ammonia  is  extricated,  which 
combines  with  the  phosphate  of  magnesia,  and  forms  an  insoluble  triple  salt.  Some- 
times with  the  triple  phosphate  just  mentioned,  there  is  also  an  admixture  of  phos- 
phate of  lime. 

It  is  a  fact  of  great  practical  importance,  that  the  tendency  to  the  formation  of  the 
phosphates  goes  along  with  a  debilitated  condition  of  the  system.  Persons  who  have 
been  rendered  weak  and  feeble  by  overmuch  toil,  by  mental  anxiety,  by  insufficient 
nourishment,  are  very  apt  to  pass  water  that  is  alkalescent  or  but  faintly  acid,  and 
to  exhibit  the  tokens,  in  their  urine,  of  the  phosphatic  diathesis.  They  are,  for  the 
most  part,  cachectic,  sallow,  languid,  spiritless,  exhausted.  The  urine  itself  is  pale, 
copious,  slightly  turbid  or  opaline,  of  a  low  specific  gravity,  and  it  does  not  smell 
like  healthy  urine  :  sometimes  it  has  somewhat  the  faint  odour  of  weak  broth.  It 
IS  occasionally  alkalescent  when  voided ;  never  more  than  slightly  acid.  As  the 
urine  cools,  the  white  sand  is  thrown  down ;  and  in  many  cases  a  sort  of  film  is 
formed  upon  the  surface  of  the  water,  exhibiting,  as  you  see  it  in  different  hghts,  all 
the  colours  of  the  rainbow :  an  iridescent  pellicle.  This  has  been  found  to  consist 
of  the  triple  phosphate.  If  you  skim  the  pellicle  off,  by  placing  a  bit  of  paper  under 
it,  and  then  suffer  the  paper  to  dry,  you  may  distinctly  see  the  little  crystals.  Urine 
of  this  kind  speedily  grows  putrid  and  highly  offensive.  Sometimes  it  has  a  strong 
ammoniacal  smell.  You  may  estimate  the  intensity  of  the  phosphatic  disposition  by 
the  rapidity  with  which  the  urine  becomes  alkalescent.  Occasionally  the  salt  is  so 
abundant  that  it  is  thrown  down  while  the  urine  is  still  in  the  bladder ;  and  the  last 
portions  of  the  issuing  stream  look  milky. 

Anything  which  tends  further  to  depress  the  powers  of  the  system  will  aggravate 
the  phosphatic  diathesis.  When  you  find  that  your  patient  passes  urine  such  as  1 
have  been  last  describing,  which  does  not  redden  litmus  paper,  but  on  the  contrary 
turns  litmus  paper  that  has  been  reddened  by  a  weak  acid,  blue  again,  or  even  in 
some  cases  is  alkaline  enough  to  make  turmeric  paper  brown  —  in  such  cases  you 
must  cautiously  abstain  from  all  remedies  that  are  calculated  to  lower  the  vital 
powers ;  from  saline  draughts,  and  alkalies  of  every  kind  ;  from  mercury  and  col- 
chicum ;  from  bleeding ;  and  even  from  active  purgation :  or  j^ou  will  add  to  the 
patient's  dangerous  weakness ;  and  promote  the  more  abundant  deposit  of  the  alka- 
line phosphates.  But  you  may  do  more  than  abstain  from  what  is  hurtful :  you 
may  counteract  the  phosphatic  tendency  by  a  generous  diet  and  by  the  exhibition 
of  tonic  medicines  ;  bark,  wine,  and  acids ;  the  muriatic  acid,  or  the  nitric,  or  both 
too-ether,  may  be  given  in  such  cases  with  vast  advantage  sometimes.  Opium  is 
also  a  remedy  to  be  employed  in  this  form  of  disease.  No  single  drug  probably 
has  so  much  power  in  rendering  alkahne  urine  acid,  as  opium.  And  it  is  indicated 
for  other  reasons  ;  it  composes  the  nervous  anxiety  to  which  these  patients  are  mostly 
a  prey.  Mental  relaxation — freedom  from  care — the  relinquishment  of  all  exhaust- 
ing habits  and  pursuits — these,  too,  are  points  of  vast  importance,  whenever  they  are 
attainable. 

I  should  state  that  the  tendency  to  deposit  the  mixed  phosphates,  though  sometimes 
idiopathic,  is  much  more  often  consequent  upon  local  disease  in  some  part  of  the  uri- 
nary organs,  especially  in  the  bladder  and  prostate  gland.  It  is  also  a  frequent  result 
of  certain  injuries  of  the  back. 

There  is  yet  another  diathesis  sufficiently  common  and  important  to  claim  your 
best  attention.  I  mean  the  oxalic  ;  in  which  there  is  a  tendency  to  the  formation, 
in  the  kidney,  of  the  oxalate  of  lime,  or  mulberry  calculus  ;  an  epithet  derived  from 
the  occasional  resemblance  of  the  concretion  to  that  fruit,  in  respect  to  colour  and 


OXALIC    DIATHESIS.  865 

inequality  of  surface.  This  diathesis  is  not  so  obvious  as  the  other  two,  but  it  is  no 
less  real. 

The  urine  differs  much  in  its  sensible  qualities  from  that  of  both  the  precedino- 
varieties.  Unlike  the  urine  of  the  phosphatic  diathesis,  it  is  bright  and  clear;  un- 
like that  of  hthic,  it  is  remarkably  free  from  sediment.  The  mulberry  calculus  is 
soUtary  also ;  or  recurs  at  long  intervals ;  and  the  diathesis  prevails  chiefly  durincr 
the  prime  of  hfe.  In  both  these  particulars  the  contrast  with  the  lithic  diathesis  is 
striking. 

The  persons  who  manifest  this  disposition  are  usually  dyspeptic ;  sometimes 
very  much  so;  sometimes  very  slightly.  They  are  uneasy  during  the  assimilation 
of  their  meals  ;  suffer  flatulence  when  the  stomach  is  empty  ;  prefer  vegetable  diet 
to  animal ;  are  fond  of  sweets,  especially  of  sugar.  They  are  liable  to  boils  and 
carbuncles,  and  to  scaly  cutaneous  eruptions.  According  to  their  original  tempera- 
ment, they  are  nervous  and  irritable,  or  dejected  and  desponding  in  rnind.  A  neph- 
ritic attack  relieves  them  from  all  this  discomfort  for  years  perhaps.  When  the 
oxalic  diathesis  is  strongly  marked,  the  skin.  Dr.  Prout  says,  "is  apt  to  assume  an 
unnatural  appearance,  difficult  to  describe,  but  the  colour  of  which  may  be  said  to 
vary  from  dull  greenish  yellow  in  the  sanguine,  to  dark  olive  or  livid  in  the  melan- 
cholic temperament." 

The  formation  of  the  oxalate  of  lime  within  the  body  depends,  according  to  Dr. 
Prout,  either  upon  the  non-assimilation  of  oxalic  acid  taken  with  the  food,  or  upon 
the  mal-assimilation  of  saccharine  aliments.  Hence,  as  a  general  rule,  both  curative 
and  prophylactic,  sugar  and  other  saccharine  substances  should  be  rigidly  excluded 
from  the  diet  of  these  patients.  They  should  avoid,  also,  all  kinds  of  fermented 
liquor.  The  young  stalks  of  the  jV«<6ar6-plant,  which  of  late  years  have  come  into 
such  general  use  in  this  country  for  tarts  in  the  spring;  and  sorrel,  of  which  our 
neighbours,  the  French,  consume  a  good  deal  in  salads,  and  in  other  ways  ;  both  con- 
tain oxalic  acid  ;  and  hard  water  contains  lime.  Dyspeptic  persons  who  drink  such 
water,  and  eat  such  articles  of  food,  and  are  thus  daily  introducing,  without  suspect- 
ing it,  the  consthuent  ingredients  of  the  mulberry  calculus,  are  vexy  hkely  indeed  to 
incur  the  pain  and  the  exceeding  peril  of  a  renal  concretion  of  that  kind.  You  must 
see,  therefore,  the  great  importance  of  detecting  the  oxalic  diathesis ;  and  of  forbid- 
ding, to  those  who  have  it,  all  such  viands  as  contain  the  oxalic  acid,  and  of  recom- 
mending them  to  use  pure  water,  even  distilled  water,  for  drinking.  Animal  food, 
and  the  stronger  farinaceous  matters,  are  best  for  them. 

Dr.  Golding  Bird  refers  the  oxalate  of  lime  to  a  different  source  :  maintaining  that 
it  results  from  a  re-arrangement  of  the  elements  of  urea,  whereby  oxalate  of  ammo- 
nia is  formed  in  the  first  instance  ;  and  afterwards  oxalate  of  hme,  by  the  decompo- 
sition of  the  calcareous  salts  natural  to  the  urine. 

Agreeing  with  Dr.  Prout  that  the  mulberry  calculus  is  not  of  very  frequent  occur- 
rence— Dr.  Bird  nevertheless  finds  that  small  crystals  of  the  oxalate  of  lime  are 
extremely  common  :  although  from  their  transparency,  and  from  their  having  nearly 
the  same  specific  gravity  with  the  urine  in  which  they  exist,  they  do  not  "disclose 
themselves  to  the  naked  eye,  nor  sink  down  in  manifest  deposit.  They  are  made 
plainly  visible  by  the  microscope. 

The  same  writer  slates  that  the  persons  whose  urine  is  thus  charged  with  crystals 
of  oxalate  of  lime  are,  for  the  most  part,  highly  sensitive  and  irritable,  hypochon- 
drically  apprehensive  of  impending  evil,  full  of  gloomy  fears  concerning  their  bodily 
and  mental  powers,  dyspeptic,  weak,  and  usually  emaciated. 

With  respect  to  direct  remedies  for  this  diathesis,  Dr,  Prout  tells  us  that  he  has 
•«een  more  benefit  derived  from  the  mineral  acids,  alone  or  combined  with  tonics,  than 
from  any  other.  But  the  effects  of  these  acids  must  be  watched  :  and  when'  iney 
begm  to  produce  a  deposit  of  the  hthate  of  ammonia,  or  of  lithic  acid,  their  use  must 
be  suspended.  He  recommends  to  patients  who  happen  to  be  at  a  distance,  the 
muriatic,  or  nitro-muriatic  acid,  till  the  hthate  of  ammonia,  or  hthic  acid,  begins  to 
appear  in  the  urine  ;  or  for  a  month.  "  By  adopting,"  he  says,  "  such  a  course  of 
acids  tiinse  or  four  times  in  the  year,  and  by  carefully  regulated  diet,  I  have  seen 
55  3x 


866  SUPPRESSION    OF   URINE. 

the  diathesis  gradually  subdued,  and  at  length  removed  altogether."     Dr.  Bird  also 
testifies  to  the  efficacy  of  similar  measures. 

These  observations  will  serve,  I  hope,  in  some  degree,  as  landmarks,  to  guide 
your  treatment  of  patients  labouring  under  renal  or  vesical  calculi,  or  presenting 
symptoms  such  as  warrant  the  apprehension  that  disorders  so  fearful  may  occur.  It 
is  impossible  for  me  to  do  full  justice  to  this  interesting  subject  in  these  lectures;  and 
I  must  refer  you,  for  more  minute  information  respecting  it,  to  Dr.  Prout's  invaluable 
volume  ;  to  Sir  Benjamin  Brodie's  most  instructive  book  on  the  Diseases  of  the  Uri- 
nary Organs  ;  and  to  an  excellent  work  recently  published  by  Dr.  Golding  Bird,  on 
Urinary  Deposits. 


LECTURE  LXXVII, 


Suppression  of  Urine.     Diabetes :  Qualities  of  the  Urine  ;   Symptoms  ,   Anato- 
mical Appearances ;  General  Pathology  of  the  Disease  ;  Treatment.  Diuresis. 

Systematic  writers  have  adopted  the  term  Ischuria  to  express  that  condition  in 
which  no  urine  is  voided.  It  includes,  therefore,  those  cases  in  which  no  urine  is 
secreted ;  and  those  in  which,  although  secreted,  it  is  not  discharged  from  the  body. 
Now  these  two  conditions  are  exceedingly  different  from  each  other  in  most  respects  ; 
and  I  shall  prefer  making  use  of  the  two  plain  English  names,  suppression  of  urine, 
and  retention  of  urine.  Even  these  terms  are  sometimes  confounded  with  each 
other.  In  suppression,  the  secretion  is  suspended  :  in  retention  it  may  be  as  active 
as  ever.  Retention  of  urine  is  a  surgical  case ;  involving  points  of  great  practical 
interest.  Suppression  belongs  to  the  physician :  and  the  technical  term  for  it  is 
Ischuria  renalis.  It  is  sometimes  spoken  of  as  paralysis  of  the  kidney ;  a  phrase 
to  which  I  object,  because  I  think  palsy  is  a  word  which  ought  to  be  restricted  to  a 
loss  of  power  over  the  muscular  fibre. 

This  affection  usually  occurs  in  persons  who  are  advanced  in  hfe,  and  inclined  to 
corpulency.  Why  it  should  be  so  I  cannot  tell  you,  but  such  is  the  fact  as  stated 
by  most  observers.  Sir  Henry  Halford  has  related  one  of  five  instances  of  this  dis- 
ease that  he  had  met  with  in  the  course  of  seven-and-twenty  years.  He  says  it  was 
an  exact  copy  of  all  the  others  that  had  fallen  under  his  notice  :  and  as  his  account 
of  the  general  course  of  the  symptoms  coincides  with  the  statements  of  other  writers, 
I  may  give  you  his  narrative,  in  lieu  of  a  formal  description. 

"A  very  corpulent  robust  farmer,  of  about  55  years  of  age,  was  seized  with  a 
rigor,  which  induced  him  to  send  for  his  apothecary.  He  had  not  made  water,  it 
appeared,  for  24  hours.  But  there  was  no  pain,  no  sense  of  weight  in  the  loins,  no 
distension  in  any  part  of  the  abdomen  : — and  therefore  no  alarm  was  taken  till  the 
following  morning,  when  it  was  thought  proper  to  ascertain  whether  there  was  any 
water  in  the  bladder,  by  the  introduction  of  the  catheter :  and  none  was  found.  I 
was  then  called  (says  Sir  Henry),  and  another  inquiry  was  made,  some  few  hours 
afterwards,  by  one  of  the  most  experienced  surgeons  in  London,  whether  the  bladder 
contained  any  urine  or  not:  when  it  appeared  clearly  that  there  was  none.  The 
patient  sat  up  in  bed,  and  conversed  as  usual,  complaining  of  some  nausea;  but  of 
nothing  material  in  his  own  view :  and  I  remember  that  his  friends  expressed  their 
surprise  that  so  much  importance  should  be  attached  to  so  little  apparent  illness. 
The  patient's  pulse  was  somewhat  slower  than  usual;  and  sometimes  he  was  heavy 
and  oppressed. 

"  I  ventured  to  state  (continues  the  author)  that  if  we  should  not  succeed  in  making 
the  kidneys  act,  the  patient  would  soon  becor.ie  comatose,  and  would  probably  die  the 
following  night :  for  this  was  the  course  of  the  malady  in  every  other  instance  that 
1  naa  seen.  It  happened  so ;  he  died  in  thirty  hours  after  this,  in  a  state  of  stupe- 
faction " 

This  is  the  curious  and  important  point  in  the  history  of  such  cases.  If  no  urine 
l>e  separated  from  the  blood,  coma  soon  supervenes,  and  death.     It  is  beheved  that 


SUPPRESSION    OF   URINE.  867 

*hese  consequences  result  from  the  detention  of  urea  in  the  system.  Urea  is  a  mere 
excrement,  which,  in  health,  is  removed  from  the  blood  by  the  kidneys,  as  fast  as  u 
enters  that  fluid.  When  it  is  not  so  carried  off',  it  accumulates  in  the  blood,  circu- 
lates with  it  to  every  part  of  the  body,  and  acts  as  a  poison,  especially  upon  the 
brain.  This  is  one  of  several  cases,  showing  that  the  carrying  fluid  of  the  body  may 
become  the  vehicle  of  disease  and  death,  if  it  be  not  duly  purged  of  deleterious  mat- 
ters which  pertain  to  the  unceasing  processes  of  organic  life.  If  carbonic  acid  be 
not  extricated  by  the  lungs,  the  animal  functions  are  as  certainly  and  almost  as 
speedily  extinguished  by  that  gas,  as  the  flame  of  a  taper  might  be.  And  we  have 
recently  seen  that  when  the  outlet  from  the  liver  is  shut  up,  when  the  blood  is  not 
purified  from  the  excrementitious  bile,  the  powers  of  animal  life  are  weakened,  and 
sometimes  utterly  and  rapidly  destroyed. 

Suppression  of  urine,  for  a  considerable  time,  is  not,  however,  necessarily  and 
universally  fatal.  Patients  labouring  under  the  epidemic  cholera  would  secrete  not 
a  drop  of  water  for  some  days  ;  and  yet  recover.  It  was  remarkable  how  entirely 
free  such  patients  were  from  any  approach  towards  coma.  Was  the  urea  here 
drained  off' from  the  blood  in  the  enormous  and  unnatural  flux  from  the  stomach  and 
bowels  ?  I  think  it  probably  was  :  but  I  do  not  know  that  any  chemical  search  was 
ever  made  for  that  substance  in  the  fluids  so  effused.  There  are,  however,  sonrie 
very  singular  instances  on  record  of  persons  who  have  passed  days  and  even  weeks 
without  secreting  urine  ;  and  without  showing  any  other  indication  of  impaired 
health.  What  degree  of  credit  such  narratives  deserve  I  do  not  know  ;  but  assuming 
that  there  was  neither  fraud  nor  mistake,  it  may  be  suspected  that  either  the  natural 
secretion  was  compensated  by  some  vicarious  or  supplemental  discharge ;  or  that  a 
small  quantity  of  urine  was  actually  separated  by  the  kidneys.  "  If  any  water, 
however  small  the  quantity  (remarks  Sir  Henry  Halford),  had  been  made  in  these 
cases,  I  should  have  thought  it  possible  that  the  patient  might  have  recovered :  for  it 
has  often  surprised  me  to  observe  how  small  has  been  the  measure  of  that  excre- 
mentitious fluid  which  the  frame  has  sometimes  thrown  off',  and  yet  preserved  itself 
harmless.  But  the  cessation  of  the  excretion  altogether  is  universally  a  fatal  symp- 
tom in  my  experience,  being  followed  by  oppression  on  the  brain."  The  same  emi- 
nent physician  states  that  in  three  of  his  five  cases  there  was  observed  a  remarkably 
strong  urinous  smell,  in  the  perspiration,  for  twenty-four  hours  before  death.  This 
I  believe  is  of  common  occurrence  in  such  cases.  Other  patients  have  vomited,  or 
passed  by  the  bowels,  watery  matters  possessing  some  of  the  sensible  qualities  of 
urine :  and  a  urinous  fluid  is  said  to  have  been  found  in  the  ventricles  of  the  brain 
in  some  of  the  fatal  examples. 

I  have  spoken  of  suppression  of  urine  as  a  malady,  though  it  probably  is  never 
anything  more  than  a  symptom.  Yet  it  is  one  of  those  symptoms  which,  from  our 
uncertainty  respecting  their  origin  and  determining  cause,  we  are  obliged  to  treat, 
and  to  study,  as  if  they  were  substantive  diseases.  In  the  only  well-marked  instance 
that  I  have  seen  of  suppression  of  urine  coming  on  in  an  apparently  healthy  person, 
some  blood  had  appeared  in  the  urine  for  a  day  or  two  before  the  secretion  was 
totally  suspended  ;  and  the  kidneys  were  found  gorged  with  blood.  Extreme  con- 
gestion, or  inflammation,  of  the  substance  of  the  gland,  is  probably  at  the  bottom  of 
many  of  these  cases.  The  same  train  of  symptoms  supervene  not  unfrequently  upon 
organic  renal  disease.  They  happen,  too,  when  the  ureters  become  impervious 
from  disease,  or  from  impacted  gravel.  In  this  condition  urine  continues  to  be 
secreted,  for  a  time  at  least,  and  distends  the  ureter  behind  the  seat  of  the  obstruc- 
tion. The  apoplectic  state  which  ensues  may  arise  from  a  re-absorption  of  the 
fecreted  fluid  ;  or,  in  consequence  of  the  obstacle,  the  secretion  itself,  after  going  on 
to  a  certain  point,  may  stop,  and  then  the  case  becomes  a  case  of  suppression. 

Respecting  the  treatment  of  this  formidable  condition  I  can  say  but  little.  Cup 
ping  upon  the  loins,  venesection,  if  warranted  by  the  state  of  the  pulse,  the  hot  bath, 
sudorific  medicines,  purgatives,  and  large  warm  enemata,  seem  to  me  the  kind  of 
remedies  indicated.  To  endeavour  to  force  the  secretion  of  urine  by  strong  stimu' 
lating  diuretics,  would  strike  one,  a  priori,  as  being  hazardous.  Yet  this  practice 
has  its  advocates  ;  and  should  experience  declare  in  its  favour,  theoretic  objections 


868  DIABETES. 

ought  to  be  disregarded.  If  benefit  is  so  to  be  obtained,  probably  the  best  drug  for 
our  purpose  would  be  cantharides.  Dr.  EUiotson  refers  to  some  examples  of  its 
success  in  the  hands  of  Sir  Astley  Cooper ;  and  afterwards  of  another  practitioner 
who  took  the  hint  from  Sir  Astley.  He  suggests  that  as  the  tincture  of  cantharides 
is  a  very  uncertain  preparation,  the  remedy  should  be  given  in  the  solid  form,  a  grain 
at  a  time,  and  that  a  large  bhster  should  be  laid  upon  the  loins.  Beyond  these  hints 
I  am  unable  to  give  you  any  assistance  towards  the  management  of  this  obscure  but 
serious  complaint. 

The  opposite  condition  of  the  kidney,  in  respect  to  its  peculiar  function — that,  I 
mean,  in  which  its  secretion  is  largely  and  morbidly  augmented — is  scarcely  less 
fatal  than  the  total  suppression  we  have  just  been  considering;  but  it  is  not  so  rapidly 
fatal.  When  the  amount  of  urine  secreted  and  passed  is  permanently  too  great, 
when  it  is  constantly  running  off,  as  it  were,  from  the  system,  the  patient  is  com- 
monly said  to  have  diabetes:  from  5taf3aww,  to  pass  through. 

But  it  is  not  every  case  of  an  excessive  flow  of  urine  that  deserves  to  be  called 
diabetes.  Great  quantities  of  aqueous  urine  are  passed  by  hysterical  and  nervous 
patients.  We  all  make  more  water  in  cold  weather  than  in  warm  ;  the  functions  of 
the  skin  and  of  the  kidney  compensating  each  the  occasional  defect  of  the  other. 
Certain  drugs  and  articles  of  diet  are  also  well  known  to  cause  a  temporary  excess 
in  the  amount  of  urine  secreted. 

In  fact,  although  the  quantity  of  urine  voided  is  the  most  obvious  and  striking 
symptom  of  diabetes,  its  definite  and  characteristic  symptom  is  a  most  remarkable 
change  in  the  quality  of  that  liquid:  in  its  becoming  loaded  with  sugar.  You  will 
find,  indeed,  two  species  of  diabetes  mentioned  by  many  authors — the  diabetes  in- 
sipidus, and  the  diabetes  mellitus.  The  former  term  ought  in  my  opinion  to  be 
abolished.  If  it  refers  merely  to  an  unnatural  abundance  of  urine,  not  otherwise 
differing  in  its  composition  from  healthy  urine  than  in  containing  a  large  proportion 
of  water — by  calling  such  a  state  diabetes,  we  hnk  together  in  the  same  genus  two 
essentially  different  conditions.  In  true  diabetes  the  urine  is  never  without  sugar. 
The  quantity  may  indeed  be  small ;  and  it  may  not  be  sensible  to  that  coarse  test, 
the  taste :  but  modern  observers  almost  all  agree  in  rejecting  any  species  of  diabetes, 
in  which  the  urine  is  not  at  all  saccharine. 

The  sensible  qualities  of  diabetic  urine  differ  strikingly,  in  many  particulars,  from 
those  of  the  urine  of  health.  Its  chemical  quahty  differs  strikingly  too,  as  I  have 
already  told  you  ;  but  it  is  in  one  particular  only.  Fortunately,  no  extraordinary  skill 
is  required  to  recognize  the  morbid  secretion. 

Diabetic  urine  is  light-coloured,  and  transparent ;  of  a  pale  straw,  or  greenish  tint. 
Its  odour  is  peculiar.  According  to  Dr.  Prout  the  scent  somewhat  resembles  that 
of  sweet  hay,  or  that  of  milk ;  but  to  my  nose  it  is  more  like  the  faint  smell  of  certain 
apples,  or  rather  of  an  apple  chamber.  Its  taste  is,  more  or  less  decidedl)^  sweet. 
Notwithstanding  its  limpM  and  aqueous  appearance,  diabetic  urine  is  remarkably 
heavy. 

It  was  long  believed  that  the  quantity  of  urea  in  diabetic  urine  was  reduced  much 
below  the  natural  standard  ;  and  that  the  sugar  was  somehow  formed  at  the  expense 
of  the  urea.  Dr.  Prout,  in  his  earlier  researches,  always  detected  a  little,  and  but  a 
little,  of  this  peculiar  principle.  Later  observations  have  shown,  however,  that  the 
urea  is  not  so  scanty ;  nay,  that  it  is  generally  as  abundant  as  in  the  urine  of  health, 
and  sometimes  even  more  so.  The  presence  of  the  sugar  conceals  the  urea  ;  inter- 
feres with  the  action  of  the  ordinary  tests  of  that  substance.  By  certain  modes  of 
procedure,  which  I  need  not  stop  to  descrine,  the  urea  may  readily  be  discovered  : 
and  it  is  often  found,  I  say,  to  be  rather  excessive  than  deficient.  The  usual  saline 
matters  belonging  to  healthy  urine  are  present  also  in  that  of  diabetic  persons  ;  and 
m  the  same  relative  proportions;  but,  as  might  be  expected,  their  absolute  amount, 
m  a  givon  quantity  of  the  liquid,  is  very  much  diminished.  In  short,  the  only  essen- 
tial deviation  from  the  standard  chemical  constitution  of  the  urine  is,  that  it  holds  in 
solution  a  quantity  of  sugar.  This  explains  its  peculiar  odour,  its  sweetness,  and 
perhaps  its  excessive  quantity.     It  accounts  also  for  another  very  characteristic  pro- 


DIABETES.  869 

perly  of  diabetic  urine  ;  I  mean  its  high  specific  gravity.  In  general,  you  know,  the 
specific  gravity  of  the  urine  is  inversely  proportional  to  the  quantity  secreted  in  a 
given  time  ;  the  more  copious  and  dilute  it  is,  the  lighter  it  is.  But  in  diabetes,  so 
strong  is  the  saccharine  impregnation  that  the  specific  gravity  more  than  keeps  pace 
with  the  increased  quantity  of  the  liquid  secreted.  The  specific  gravity  of  diabetic 
urine  is  always  much  higher  than  that  of  healthy  urine. 

The  quantity  of  urine  secreted  and  voided  is  sometimes  enormous  :  far  more  than 
could  be  supphed  by  the  quantity  of  fluid  taken  as  a  drink,  although  that,  as  I  shall 
presently  explain,  is  excessive  too.  A  healthy  person  passes  from  one  to  three  or 
four  pints  of  urine  in  the  twenty-four  hours.  The  quantity,  as  you  well  know,  is 
liable  to  considerable  variation  :  perhaps  the  average  may  safely  be  laid  at  about  forty 
ounces.  But  patients  in  diabetes  will  void  40  pints  in  the  same  time.  I  have 
myself  seen  26 ;  13  or  14  are  not  uncommon ;  and  cases  are  recorded  by  writers  of 
credit  and  veracity,  in  which  70  pints  were  passed  daily.  Nay,  one  Italian  author 
declares  that  200  pints  have  been  discharged  in  that  time. 

The  saccharine  matter  thus  held  in  solution  may  be  obtained  in  its  solid  form,  by 
evaporating  the  urine.  I  have  seen  large  flat  cakes  of  beautifully  crystallized  diabetic 
sugar.  It  differs  somewhat  from  common  sugar,  the  produce  of  the  sugar  cane  ;  and 
approaches  more  nearly  to  the  sugar  of  grapes.  By  rapid  evaporation  of  the  water  a 
thick  syrup  is  procured  resembling  treacle ;  but  Dr.  Maclntyre,  who  has  presented 
to  our  hospital-museum  some  very  perfect  specimens  of  this  sugar,  prepared  by  Mr. 
Blandford,  informs  me  that  to  get  it  well  crystallized,  the  evaporation  in  a  steam  bath 
should  be  stopped  while  the  urine  is  still  of  thin  consistence.  It  may  be  quickly  re- 
duced to  one-half,  perhaps,  of  its  original  quantity.  Then  it  should  be  set  aside,  in 
shallow  plates  ;  and  in  the  course  of  ten  days  or  a  fortnight  the  sugar  will  be  depo- 
sited in  a  regularly  crystalline  form. 

The  sugar  is  sometimes  so  abundant,  that  it  undergoes  a  rude  crystallization  as  the 
urine  dries,  wherever  it  happens  to  fall.  A  girl  who  was  in  St.  Bartholomew's 
Hospital,  while  I  was  a  student  there,  observed  th^t  if  her  water  was  accidentally 
sprinkled  upon  her  black  stuff  shoes,  every  drop  left  a  white  powdery  spot  behind  it. 
So  also  an  aged  patient  under  Dr.  Maclntyre's  care  expressed  to  him  her  alarm  at 
finding  that  her  black  worsted  stockings  were  covered  with  a  white  dust,  from  the 
same  cause.  A  man  recently  under  my  charge  in  the  Hospital,  complained  that 
two  pair  of  his  black  cloth  trowsers  had  been  spoiled  in  a  similar  manner.  I  re- 
niember  hearing  from  a  diabetic  patient  in  the  Edinburgh  Infirmary,  that  his  atten- 
tion was  first  drawn  to  his  urine  by  the  number  of  flies  and  wasps  which  its  sweet- 
ness attracted  to  the  chamber-pot. 

This  daily  produce  of  sugar  from  the  laboratory  of  the  human  body,  is  surel}'  a 
very  singular  and  surprising  phenomenon.  Sugar  is  not  a  constituent  of  healthy 
urine.  i3r.  Prout  (who  is  more  consulted  on  this  subject  than  any  one  else,  and 
whose  experience  in  respect  to  it  is  commensurably  great)  says  that  he  has  never 
known  saccharine  matter  to  occur  in  the  urine  of  any  other  animal  than  man.  I 
once  had  a  coach-horse  which  I  supposed  might  have  diabetes.  He  was  a  greedy 
feeder,  and  drank  eagerly,  yet  he  grew  thinner  and  thinner ;  and  wherever  I  had 
occasion  to  stop,  there  he  invariably  began  to  stale :  so  that  I  became  thoroughly 
ashamed  of  his  leaking.  Dr.  Prout  was  good  enough  to  examine  his  urine  for  me. 
It  contained  no  sugar,  but  its  healthy  properties  were  much  changed :  it  had  less  than 
the  natural  quantity  of  hippuric  acid,  and  more  of  earthy  matters.  The  disease,  he 
tells  me,  is  known  at  the  Veterinary  College ;  whence  specimens  of  such  urine  havu 
been  sent  to  him  for  inspection  :  but  it  is  not  true  diabetes. 

The  unnaturally  high  specific  gravity  of  diabetic  urine  is  a  constant  quality;  and 
you  must  attend  to  this,  for  it  is  almost  always  a  faithful  index,  not  only  of  the  pre 
sence,  but  of  the  severity  of  the  disorder.  Dr.  Prout  places  the  specific  gravity  of 
healthy  urine  between  1015  and  1025,  that  of  distilled  water  being  represented  by 
1000.  Different  authors  vary  somewhat  in  their  estimate  of  the  natural  standard ; 
but  we  may  be  content  to  follow  Dr.  Prout.  He  says  that  the  specific  gravity  of 
diabetic  urine  has  been  stated  to  vary  from  1020  to  1050:  that  he  has  many  limes 

8x2 


870  DIABETES. 

seen  it  higher  than  this,  but  very  seldom  so  low.  In  fact  it  ranges  generally  between 
1030  and  1060 ;  and  the  average  may  be  taken  at  1040. 

So  much  with  reference  to  the  quantity  and  qualities  of  the  urine  discharged  in 
this  complaint.  It  is  attended,  however,  as  you  may  suppose,  with  other  and  im- 
portant symptoms. 

As  so  much  fluid  is  evacuated  from  the  body  through  this  channel,  it  might  be  ex- 
pected that  the  other  channels  for  the  excretion  of  liquid  matters  would  be  compara- 
tively dry:  and  so  they  are.  The  skin  is  arid,  harsh  and  unperspirable.  The 
patients  tell  you  that  they  never  sweat :  that  they  cannot  get  into  a  perspiration. 
This  is  a  very  general  symptom ;  yet  in  some  few  patients,  especially  as  the  fatal 
period  of  the  complaint  draws  near,  the  surface  readily  becomes  humid.  Again,  the 
bowels  are  mostly  costive,  and  the  feces  remarkably  solid  and  free  from  moisture. 
The  tongue  is  dry,  parched  and  sticky ;  sometimes  unnaturally  red  and  clean :  and 
the  waste  of  watery  particles  from  the  system  seems  to  be  felt  and  expressed  by  the 
inordinate  thirst  which  the  patients  suffer.  Their  drought  is  often  insatiable.  I  re- 
member one  girl  telling  me  that  when  she  was  debarred  from  an  excess  of  water  to 
drink,  she  would  get  up  if  she  heard  it  raining  in  the  night,  and  catch  some  of  the 
descending  drops  to  satisfy  the  tormenting  sensation  of  thirst.  And  another  patient, 
a  very  sensible  fellow,  informed  me  that,  believing  it  could  not  be  good  for  him  to 
drink  so  much,  and  feeling  no  confidence  in  his  own  resolution  to  refrain,  he  was  in 
the  habit  of  betaking  himself  in  the  summer  time  to  fields  and  dry  pastures,  where 
no  water  was  at  hand  to  quench  his  strong  desire  for  it.  The  appetite  for  food  is 
often,  but  not  always,  equally  keen  ;  and  the  patients,  especially  those  in  the  lower 
ranks  of  society,  are  apt  to  think,  while  they  wonder  at  their  weakness,  that  there 
cannot  be  much  the  matter  with  them,  since  they  continue  to  eat  and  drink  so  fa- 
mously. 

Again,  the  enormous  daily  drain  upon  the  system  may  be  expected  to  cause 
various  symptoms  and  sensations  which  may  all  be  referred  to  debility  "and  defective 
nutrition.  Dr.  Henry  published  a  table,  showing  the  quantity  of  solid  extract  in 
everj'  wine  pint  of  urine  of  different  specific  gravities  from  1020  to  1050.  Taking 
1040  as  the  average  specific  gravity,  and  ten  pints  as  the  average  quantity  of  the 
urine  discharged  daily,  the  patient  would  in  this  manner  lose,  every  twenty-four 
hours,  15  ounces  7  drachms  —  or  more  than  a  pound  and  a  quarter  —  of  solid  ma- 
terials. 

We  need  not  be  surprised,  therefore,  at  the  hunger,  the  wasting,  the  hectic  fever, 
the  feehng  of  emptiness  and  sinking  at  the  stomach,  the  debility,  the  chilly  state  of 
the  bod}',  and  especially  of  the  extremities,  the  aching  and  sense  of  weariness  in  the 
loins  and  legs,  the  aversion  to  exercise,  the  loss  of  virility;  all  of  which  symptoms 
are  generally  present.  I  may  add,  to  complete  the  picture,  some  others,  enumerated 
by  Dr.  Watt,  and  confirmed  by  Dr.  Prout,  and  consistent  with  my  own  experience 
of  the  disease.  They  are,  uneasiness  in  the  stomach  after  meals,  flatulence  and  acid 
eructations,  dimness  of  vision,  redness  of  the  whole  interior  of  the  mouth,  spongi- 
ness  of  the  gums,  looseness  of  the  teeth,  and  some  degree  of  irritation  and  inflam- 
matory redness  about  the  external  orifice  of  the  urethra:  these  last  are  symptoms 
noticed  in  persons  dying  of  inanition.  Again,  listlessness  and  depression  of 
spirits,  weakness  and  peevishness  of  temper :  "  the  once  vigorous  mind  becomes 
feeble,  oblivious,  and  vacillating  —  the  once  amiable  temper,  fretful,  suspicious,  and 
intolerant."  With  all  this  there  is  a  peculiar  faint  and  unpleasant  odour  of  the  breath 
and  person  ;  an  odour  which  Dr.  Prout  says  is  hay-like,  which  some  call  melleous, 
but  which  reminds  me,  as  I  said  before  respecting  the  urine,  of  the  smell  of  a  room 
in  which  apples  have  been  kept.  I  have  recognized  the  complaint,  upon  first  enter- 
ing the  sick-chamber,  by  this  pecuhar  scent. 

Diabetes  is  generally  a  chronic  disorder,  creeping  on  at  first  insidiously,  and 
spreading  itself,  under  judicious  management,  over  many  years.  Yet  it  is  some- 
times fairly  entitled  to  be  called  an  acute  disease ;  for  it  occasionally  breaks  out  sud- 
denly, is  attended  with  much  febrile  disturbance,  and  runs  a  short  course,  uncon- 
trolled by  any  treatment.  One  such  instance  I  have  seen.  Much  more  frequently 
Tl  proves  fatal  through  the  supervention  of  some  organic  mischief,  such  as  debility  is 


DIABETES.  871 

calculated  to  foster  and  develop.  It  often  becomes  associated  in  its  progress  with 
pulmonary  disease,  especially  with  tubercular  phthisis.  So  common  is  this,  that 
some  persons  have  thought  it  universal.  But  it  is  not  so.  I  have  myself  witnessed 
more  than  one  or  two  dissections  of  persons  dead  of  diabetes,  whose  lungs  did  not 
contain  a  single  tubercle.  Sometimes  the  disease  terminates  in  incurable  dropsy : 
and  sometimes  the  patient  is  cut  off  suddenly,  either  by  apoplexy,  or  by  some  pecu- 
liar affection  of  the  stomach. 

There  is  some  kind  of  connection  between  diabetes  and  certain  affections  of  the 
skin,  and  of  the  subjacent  reticular  membrane.  Dr.  Prout  remarks  that  it  usually 
follows  cutaneous  complaints,  but  accompanies  or  precedes  those  which  involve  the 
areolar  tissue.  Persons  have  been  known  to  lose  chronic  eruptions  upon  the  super- 
vention of  diabetes.  On  the  other  hand,  carbuncles  and  malignant  boils  are  frequently 
the  companions  of  that  disorder.  The  examination  of  the  dead  body  throws  little  or 
no  light  upon  the  pathology  of  diabetes.  We  naturally  look  with  interest  to  the 
kidneys.  But  we  find  nothing  there  to  explain  the  symptoms  noticed  during  life. 
What  I  have  usually  remarked  has  been  a  deep  purplish  red  colour  of  the  kidneys, 
which  were  veined  and  vascular,  but  not  otherwise  altered  in  texture.  Andral  and 
others  tell  us  that  the  kidneys  are  found  hypertrophied  in  diabetes.  But  hypertrophy, 
and  unnatural  vascularity,  are  circumstances  which  we  are  not  surprised  at  when  we 
reflect  upon  the  vastly  increased  quantity  of  vi-ork  which  the  glands  have  been  per- 
forming. W^e  must  regard  both  these  unnatural  conditions  rather  as  being  the  con- 
sequence, than  as  being  the  cause,  of  the  morbid  flow  of  urine.  In  one  instance, 
after  sudden  symptoms  of  gastritis,  which  followed  the  incautious  potation  of  strong 
ale,  I  found  the  mucous  membrane  of  the  stomach  distinctly  inflamed,  in  its  cardiac 
portion.  I  have  found  also  the  mesenteric  glands  diseased,  converted  almost  entirely 
into  bone.  But  neither  of  these  changes  is  constant.  They  were  purely  accidental 
in  those  particular  cases. 

What,  then,  is  the  origin  and  source  of  this  strange  complaint  ?  whereabouts  in 
the  body  is  the  sugar  formed  ?  is  it  made,  by  the  kidneys,  from  the  blood  1  or  is  it 
made,  from  the  food,  by  the  stomach ;  and  carried  into  the  blood  to  be  simply  cast 
out  through  the  urinary  channels  ?  or  is  it  elaborated  in  some  intermediate  stage  of 
what  Dr.  Prout  has  called  the  secondary  assimilation ;  which  includes  the  formative 
and  the  destructive  processes  that  take  place  in  the  body  subsequently  to  the  act  of 
sanguification  ?  These  questions,  which  are  full  of  interest,  have  been  much  de- 
bated ;  and  until  very  lately  pathology  was  unequal  to  their  solution.  It  was  natu- 
rally thought  that,  if  the  sugar  pre-existed  in  the  blood,  and  was  only  withdrawn 
from  it  by  the  kidneys,  it  would  be  discoverable  in  the  blood.  Yet  able  chemists 
sought  for  it  there  in  vain.  Hence  it  was  inferred,  that  by  some  new  combination 
of  its  elements,  saccharine  matter  was  actually  formed  in  the  kidneys.  The  chemistrv 
and  the  reasoning  were  both  faulty.  Sugar  has,  now,  been  detected  in  diabetic 
blood.  It  is  detected  with  some  difficulty,  partly  perhaps  because  its  presence  is 
masked  by  the  albumen  of  the  serum,  but  partly  because  its  quantity  is  small ;  and 
its  quantity  is  small  because  it  is  continually  decanted  out  of  the  blood,  as  fast  as  it 
enters,  and  with  it  a  profusion  of  water  also,  through  the  kidneys.  In  this  respect 
the  sugar  and  the  urea  are  alike.  They  are  both  excretions  which  the  blood  is  in 
haste  to  cast  forth.  It  would  seem  also  as  if  the  sugar  necessarily  carried  with  it  a 
large  quantity  of  aqueous  fluid  from  the  blood,  and  was  simply  diuretic.  When  the 
amount  of  sugar  eliminated  is  diminished,  as  by  certain  remedies  it  may  be,  the 
quantity  of  urine  diminishes  too. 

Traces  of  sugar  had,  I  believe,  been  found  in  the  blood  by  some  previous  in- 
quirers:  but  it  is  to  Mr.  M'Gregor,  of  Glasgow,  that  we  are  indebted  for  the  full 
exposition  of  this  interesting  fact.  His  researches,  published  last  year  (1837)  in 
the  Medical  Gazette,  have  thrown  a  new  and  strong  light  upon  the  patholog}'-  of 
diabetes. 

By  a  peculiar  process,  he  did,  I  say,  that  which  many  preceding  chemists  had 
failed  to  accomplish  ;  he  detected  sugar  in  the  serum  of  the  blood  of  diabetic  patients.. 
The  serum  had  a  milky  appearance,  he  says;  and  I  have  seen  that  myself:  il^ 
specific  gravity  was  above  the  healthy  standard.     Having  coagulated  the  serum  by 


872  DIABETES. 

heat,  he  carefully  dried  it ;  then  cut  the  dried  mass  into  very  small  pieces,  and  boiled 
then^  in  distilled  water;  and  lastly,  he  evaporated  the  decoction  to  a  certain  point. 
To  the  liquid  thus  concentrated  he  added  a  portion  of  yeast,  and  the  presence  of 
sugar  was  manifested  by  the  fermentation  which  ensued,  and  which  lasted  for  several 
hours.  Yeast,  I  should  tell  you,  is  a  most  delicate  test  of  sugar,  and  will  readily 
detect  half  a  grain  in  two  ounces  of  liquid. 

Mr.  M'Gregor  went  a  step  further  back.  He  obtained,  by  means  of  an  emetic, 
ihe  digested  food  from  the  stomachs  of  two  men  who  had  dined  two  or  three  hours 
before.  One  man  was  in  health ;  the  other  had  diabetes.  In  each  case  the  food  had 
been  of  the  ordinary  kind.  Applying,  after  due  preparation,  the  test  of  yeast,  he 
found  that  the  vomited  matters  fermented  strongly  ;  especially  those  from  the  diabetic 
patient. 

Then  he  varied  the  experiment.  Thinking  that  the  sugar,  in  these  cases,  might 
have  been  introduced  in  the  vegetable  portion  of  the  food,  he  adopted  precautions  to 
exclude  that  possible  source  of  fallacy.  He  administered  to  a  healthy  man,  and  to 
a  diabetic  man,  a  vomit  and  a  purge,  to  clear  out  the  alimentary  canal.  Next  he  fed 
them  upon  roast  beef  and  water,  and  nothing  else  for  three  days.  Then,  three  or 
four  hours  after  a  meal,  the  contents  of  their  stomachs  were  procured  by  the  operation 
of  the  sulphate  of  zinc,  as  an  emetic ;  and  treated  as  in  the  former  case.  What 
the  healthy  man  vomited  did  not  ferment  at  all.  What  came  from  the  diabetic  pa- 
tient fermented  "  pretty  briskly." 

The  fault,  then,  we  may  safely  conclude,  lies  in  the  digestive  organs.  Instead  of 
healthy  and  nutritive  chyle,  saccharine  matter  is  prepared  by  the  stomach,  and  enters 
the  circulation.  That  which  should  be  converted  into  muscle,  and  fat,  and  bone, 
and  nerve,  and  membrane,  is  hurried  ou^  of  the  system,  as  sugar,  with  the  urine. 
Thus  far  we  see  our  way  with  tolerable  clearness.  But  ivhy  the  stomach  should 
cease  to  perform  its  accustomed  chemistry  upon  the  food,  and  even  upon  sugar  itself 
as  an  article  of  food,  Ave  have  not  yet  learned.  That  single  important  step  is  still 
wanting  to  the  complete  solution  of  the  pathological  problem. 

I  may  mention  that  Mr.  M'Gregor  carried  his  inquiries  further  still,  and  met  with 
some  curious  results.  He  examined  the  saliva ;  the  feces ;  and  the  sweat.  He 
found  sugar  in  the  saliva.  He  could  find  none  in  the  sweat.  The  feces  of  one  pa- 
tient, allowed  to  dry  spontaneously,  became  covered,  after  the  lapse  of  some  time,  by 
distinct  crystals  of  sugar.  And  yeast  having  been  administered  to  two  patients,  in 
ounce  doses,  after  each  meal,  had  soon  to  be  discontinued,  because  the  patients,  to  use 
their  own  expressions,  felt  as  if  they  "were  on  the  eve  of  being  blown  up." 

We  know  but  little  about  the  causes  of  diabetes.  It  is  not  a  very  common  dis- 
order; and  in  those  who  become  afflicted  with  it,  there  probably  has  existed  a  pie- 
disposition  to  it.  Dr.  Prout  remarks  that  the  complaint  runs  sometimes  in  families, 
and  is  inherited.  I  had  under  mj  own  observation,  for  some  time,  three  children, 
two  brothers  and  their  sister,  all  affected  with  diabetes.  The  mother,  a  maternal 
uncle,  and  a  sister  of  a  friend  of  mine,  all  died  of  this  malady.  The  same  author 
mentions  among  the  predisposing  causes,  long-continued  intemperance,  and  especially 
the  immoderate  use  of  spirits,  severe  evacuations,  excessive  labour  joined  with  a  poor 
acescent  diet.  Distress  and  anxiety  of  mind  are  held  also,  and  justly  I  think,  to  be 
among  the  predisposing  causes.  It  occasionally  seems  to  be  produced,  at  once,  by 
the  operation  of  some  exciting  cause,  such  as  exposure  of  the  body  to  cold ;  or  the 
drinking  of  large  draughts  of  cold  fluid  while  the  person  w^as  hot  and  perspiring. 
Dr.  Bardsley  states  that,  in  twelve  instances  of  the  disease  which  had  fallen  under 
his  own  notice,  the  patients  attributed  their  ailment  to  one  or  the  other  of  these  two 
causes.  Now  these  are  common  causes  of  disease ;  and  that  a  predisposition  does 
exist  is  probable  from  the  fact,  that  where  the  exciting  cause  has  acted  on  several 
individuals  at  the  same  time,  one  alone  has  become  affected  with  diabetes.  There  is 
u  narrative  illustrating  this,  by  Sir  Henry  Marsh,  in  the  third  volume  of  the  Dublin 
HospiUd  Reports.  A  patient  of  his  traced  the  apparent  origin  of  his  diabetes  to  ex- 
posure to  wet,  cold,  and  privation,  at  sea,  while  in  imminent  danger  of  shipwreck. 
Another  of  the  crew  fell  ill  of  ague.  Others  escaped  entirely,  or  had  only  common 
colde 


DIABETES.  8^3 

If  the  account  which  I  have  been  obliged  to  give  you  concerning  the  intimate 
nature,  and  the  causes,  of  this  curious  malady,  should  appear  unsatisfactory,  so  also 
I  fear,  will  what  I  have  still  to  say  respecting  its  cure.  I  dare  not  affirm  that  diabetes, 
although  it  seems  a  merely  functional  disorder,  has  ever  been  cured.  Dr.  Prout  has 
known  some  kw  patients,  two  perhaps,  or  one,  recover.  Apparent  recoveries — nay, 
apparent  cures — are  not  very  uncommon.  And  this  it  is  of  great  importance  to 
know.  Remedies  are  not  useless  because  they  fall  short  of  their  full  scope.  It  is 
better  to  keep  a  man  on  the  edge  of  a  precipice,  if  you  cannot  pluck  him  away  from 
it,  than  to  let  him  fall  over.  And  many  diabetic  patients  are  kept  in  this  predica- 
ment of  dangerous  safety.  There  are  certain  remedies  that  exercise  a  strong  con- 
trolling influence  over  some  of  the  most  prominent  and  troublesome  of  the  symptoms; 
and  that  sometimes  even  restore  the  patient  to  a  state  which  he  mistakes  for  health ; 
and  which  a  medical  man,  unwarned  of  its  fallacious  character,  might  also  mistake. 
The  urine  may  recede  within  the  natural  limits.  There  may  remain  one  morbid 
circumstance  only,  and  that  of  a  nature  easily  overlooked  :  indeed  it  is  sure  to  escape 
observation  if  it  be  not  especially  searched  after.  I  allude  to  the  unnaturally  high 
specific  gravity  of  the  urine.  So  long  as  the  density  of  the  urine  continues  perma- 
nently and  decidedly  above  the  heakhy  standard,  there  is  no  real  security.  The 
smallest  disturbing  cause — exposure  to  cold,  an  intemperate  meal,  unusual  exertion 
and  fatigue,  sudden  or  strong  mental  emotion — may  bring  back  all  the  symptoms  in 
their  former  severity.  If  these  and  similar  hurtful  agencies  can  be  averted,  life  may 
sometimes  be  prolonged,  in  much  comfort,  for  many  years. 

There  are  three  objects  to  be  kept  in  view,  in  the  treatment  of  every  case  of 
diabetes. 

First,  to  restore  the  defective  power  of  the  digestive  apparatus : 

Secondly,  to  cut  off,  or  restrict  as  much  as  possible,  the  supply  of  saccharine  mat- 
ter from  without : 

Thirdly,  to  mitigate  or  remove  the  most  distressing  symptoms. 

If  we  could  achieve  the  first  of  these  objects,  the  other  two  would  fall  out  of  sight ; 
for  the  disease,  which  is  really  a  variety  of  dyspepsia,  would  be  cured.  But  hitherto 
all  the  resources  of  our  art  have,  in  this  respect,  been  baffled.  Our  main  hope  of 
uUimate  success  must  lie  in  the  regulation  of  the  ingesta;  whereby,  also,  the  second 
indication  is  to  be  fulfilled.  Some  of  the  food  is,  in  every  case,  carried  to  the  proper 
account,  or  the  patient  would  speedily  die.  If  we  can  succeed  in  directing  a  sufficient 
amount  of  healthy  nutriment  to  the  organic  tissues  of  the  body,  the  draining  away 
of  any  superfluous  sugar  will  be  borne  well  enough. 

About  the  beginning  of  the  present  century,  Dr.  Rollo  discovered  and  taught  that 
a  diet  composed  exclusively  of  animal  matters  had  a  signal  effect  in  reducing  the 
quantity  and  in  diminishing  the  sweetness  of  diabetic  urine.  Mr.  M'Gregor's  experi- 
ments tell  us  why  this  is.  Animal  food  furnishes  but  scantily  the  materials  for  the 
formation  of  sugar.  "The  saccharine  alimentary  principles  are  chiefly  derived 
(says  Dr.  Prout)  from  the  vegetable  kingdom,  and  indeed  constitute  what  may  be 
called,  by  way  of  distinction,  vegetable  aliments.''^  If,  then,  we  can  exclude  aliments 
of  this  kind,  and  confine  the  patient  to  animal  food  alone,  we  thus  cut  off"  the  supply 
of  the  materies  morbi ;  and  without  indeed  curing  the  disorder,  suspend  its  worst 
effects.  But  unluckily  very  few  persons  can  long  endure  this  mode  of  living.  So 
far  as  ihey  can  endure  it,  they  are  comparatively  safe.  We  are  obliged  to  relax,  in 
some  degree,  the  rigour  of  our  rule;  and  it  is  curious  to  observe  how  suddenly  and 
decidedly  the  saccharine  properties  and  the  quantity  of  the  urine  are  augmented, 
when,  by  stealth,  or  by  permission,  the  patient  adds  to  his  meal  the  smallest  portion 
of  vegetable  food — even  a  biscuit  or  two. 

We  must  therefore  contrive  to  vary  the  animal  diet  as  well  as  we  can ;  encourag- 
ing the  patient  by  a  free  license  to  choose  among  the  diffi?rent  kinds  of  meat,  game, 
poultry,  and  eggs,  in  their  diversified  modes  of  preparation,  and  admitting  into  his 
oill  of  fare  as  small  an  admixture  as  possible  of  vegetable  substances.  Green  gar- 
den-stuff, the  oleracea,  spinach,  cabbage,  celery,  and  the  like,  maybe  taken  with  less 
risk  of  increasing  the  saccharine  matters  in  the  system,  than  potatoes,  and  those  other 
articles  of  vegetable  diet  which  contain  a  notable  proportion  of  sugar,  gum,  or  starch 


S74  DIABETES. 

All  kinds  of  fruit  must  be  forbidden.  You  vill  seldom  be  able  to  debar  )'our  patients 
entirely  from  bread  :  none  should  be  allowed  but  such  as  is  well  fermented,  and 
somewhat  stale,  or  thoroughly  toasted  ;  and  even  that  as  sparingly  as  may  be. 

It  is  also  of  much  importance  to  admonish  the  patient,  whose  appetite  is  generally 
ravenous,  against  eating  too  large  a  quantity,  even  of  animal  food,  at  any  one  tune. 
Not  only  is  the  digestion  still  further  weakened  and  oppressed  by  an  intemperate 
meal,  but  the  patient's  life  may  be  put  in  peril  by  every  such  act  of  unwise  indul- 
gence.    Of  this  I  have  witnessed  one  example,  and  have  heard  of  several  more. 

The  quantity  of  drink  should  likewise  be  limited.  It  may  properly  enough  con- 
sist of  animal  broths  :  and  these  should  be  taken  tepid,,  for  they  are  then  more  likely 
to  be  taken  in  moderation.  The  patients  must,  however,  and  will,  have  something 
else,  to  slake  their  urgent  thirst.  I  have  found  (acting  upon  a  suggestion  of  the 
elder  Dr.  Latham)  that  distilled  water,  acidulated  with  phosphoric  acid,  appeases, 
more  than  most  things,  that  painful  sensation.  The  water  of  the  Bristol  Hot  Well, 
which  contains  carbonate  of  lime  in  solution,  is  praised  by  Dr.  Prout  for  the  same 
purpose. 

Dr.  Christison  gives  an  important  caution  in  respect  to  drinks ;  viz.,  that,  when 
the  thirst  has  already  been  much  indulged,  the  quantity  of  liquid  taken  must  not  be 
greatly  reduced  all  at  once.  Sudden  failure  of  the  vital  powers  has  not  unfrequently 
ensued  upon  abrupt  changes  of  that  kind. 

Very  numerous  are  the  remedies  which  have  been  tried,  and  which  have  been 
recommended,  for  this  disorder.  I  shall  notice  those  only  of  which  I  have  had  per- 
sonal, and  in  some  degree  favourable  experience. 

The  first  of  these  is  blood-letting,  which  has  been  strongly  advocated  by  Dr.  Watt, 
of  Glasgow,  and  by  Dr.  Satterley,  formerly  one  of  the  physicians  to  the  Middlesex 
Hospital.  It  is  not  a  remedy  which  would  naturally  occur  to  one's  mini  as  being 
likely  to  prove  of  service  in  such  cases ;  but  both  the  authors  I  have  mentioned 
speak  of  it  in  terms  of  high  commendation.  They  affirm  that,  under  small  and 
frequent  bleedings,  the  strength  increases ;  the  clamminess  of  the  mouth,  and  dry- 
ness of  the  skin,  diminish  ;  and  the  blood  by  degrees  assumes  the  buffy  coat.  I  have 
once  seen  the  method  of  frequent  blood-letting  fairly  put  to  the  test.  At  first,  the 
patient  did  seem  to  be  benefited  by  it ;  but  she  ultimately  died :  and  I  am  satisfied 
that  her  death  was  accelerated  by  one  bleeding  too  many,  or  by  too  large  an  abstrac- 
tion of  blood  at  one  time. 

This  measure  has  the  best  chance  of  being  useful,  when  the  malady  is  recent,  and 
attended  with  febrile  disturbance.  In  chronic  cases,  in  old  persons,  and  whenever 
the  debility  is  already  great,  venesection  can  seldom  be  requisite  or  proper  ;  although 
even  then,  as  Dr.  Prout  remarks,  it  may  be  borne  better  than  one  might  expect. 
Local  bleeding  is,  however,  of  much  service  in  relieving  local  uneasiness.  Leeches 
may  be  applied  to  the  epigastrium,  if  the  patient  has  tenderness  there,  or  complams 
of  a  sense  of  fullness  or  of  burning  in  the  stomach.  Cupping  to  the  loins,  if  they 
greatly  ache. 

Opium  is  a  treasure  to  us  in  this  disorder.  It  quiets  the  nervous  irritabihty  of  the 
patient,  allays  many  of  his  most  distressing  sensations,  and  restrains  in  a  remarkable 
manner  the  morbid  profluvium  from  the  kidneys.  But  you  must  not  suppose,  from 
observing  these  favourable  changes,  that  you  are  curing  the  disease  by  it.  It  appears 
to  control  the  diuretic  influence  of  the  sugar  in  the  blood  ;  but  it  does  not  banish  the 
sugar  itself.  And,  as  far  as  my  experience  goes.  Dr.  Prout  is  in  the  right  when  he 
stales  that  moderate  doses  of  opium  generally  suffice  to  check  the  excessive  dis- 
charge. Five  grains  of  Dover's  powder,  for  example,  three  times  a  day,  will  do  as 
much  good,  and  on  the  other  hand  be  productive  of  far  less  inconvenience  than  larger 
quantities  of  that  narcotic  substance.  The  sudorific  properties  of  this  compound 
are  thought  to  render  it  ehgible ;  although  it  has  seldom  any  apparent  efTect,  in  that 
way,  in  diabetes.  If  the  ipecacuanha  which  it  contains  should  disagree  with  the 
stomach,  an  equivalent  quantity  of  any  other  preparation  of  opium  may  be  substituted 
for  it. 

There  is  another  remedial  measure  which  has  also,  in  some  cases  at  least,  a  loosi 
beneficial  influence  on  the  condition  of  the  patient ;  I  mean  forced  perspiration^ 


DIABETES.  875 

perspiration  induced  by  the  hot-air  bath.  Of  this  I  have  seen  some  striking-  exam- 
ples. A  very  well-marked  case  of  diabetes  came  under  my  care  in  the  JMiddlesex 
Hospital  several  years  ago.  A  vapour,  or  hot-air  bath,  had  just  then  been  constructed 
in  the  hospital,  and  I  thought  it  a  good  opportunity  for  trying  whether  the  suo 
pended  functions  of  the  skin  might  not  be  restored,  and  the  extravagant  action  of  the 
kidneys  perhaps  corrected,  by  that  powerful  mode  of  exciting  perspiration.  I  should 
tell  you  that  other  plans  of  treatment  had  already  been  put  in  force,  with  but  partial 
advantage.  It  would  occupy  more  time  than  I  can  now  spare  to  enter  upon  the 
details  of  this  case  ;  but  I  will  read  to  you  the  man's  own  statement,  which  he  wrote 
down  before  he  left  the  hospital,  in  evidence  of  the  benefit  he  derived  from  the 
sudatorium. 

"The  urine"  (these  are  his  words)  "is  reduced  more  than  one-half,  and  does  rot 
contain  much  sweetness,  but  sometimes  tastes  salt,  with  a  mixture  of  bitter.  iViy 
stools,  which  were  dry,  and  like  balls  packed  together,  are  now  quite  natural.  The 
pains  in  my  limbs  are  entirely  removed.  My  spirits,  which  were  very  much  de- 
P'essed,  are  now  revived,  and  cheerful.  The  unpleasant  aching  of  my  kidneys,  of 
Afhich  I  spoke  little  lest  1  should  be  cupped  in  the  loins,  is  now  removed  ;  only  I  feel 
weak  there.  I  am  cured  of  the  pain  m  my  stomach,  and  the  circuitous  working  of 
the  wind  in  my  bowels,  which  formed  lumps  in  my  belly  as  it  passed,  resembling 
those  formed  by  the  cramp.  I  have  likewise  got  rid  of  the  palpitation  at  my  breast, 
which  was  accompanied  with  a  sort  of  dread.  My  breathing  is  much  improved  ; 
perspiration,  in  a  great  measure,  restored  ;  and  my  skin,  which  was  dry,  is  now  be- 
come moist.  I  sleep  well  at  night,  whereas  I  could  not  sleep  more  than  two  or  three 
hours  out  of  the  twenty-four.  My  thirst,  which  was  excessive,  has  ceased  to  be 
troublesome." 

This  man,  who,  m  the  statement  I  haVe  just  read,  has  so  graphically  described 
his  own  morbid  sensations,  and  the  relief  from  them  which  he  had  obtained,  left  the 
hospital  thinking  himself  well :  but,  the  specific  gravity  of  his  urine  remained  above 
1030. 

In  about  half  a  year  afterwards,  he  went  one  evening  to  Hyde  Park  to  see  some 
fire  works,  got  wet  feet,  and  began  to  cough.  The  diabetic  symptoms  returned 
more  severely  than  ever ;  and  he  soon  died.    I  found  his  lungs  stuffed  with  tubercles. 

In  furtherance  of  the  principle  upon  which  the  use  of  the  hot  bath  is  recom- 
mended, the  other  well-known  methods  of  promoting  the  natural  functions  of  the 
skin  should  be  followed;  friction,  and  more  especially  warm  clothing. 

Steel  is  sometimes  singularly  beneficial  in  repairing  the  strength,  and  enlivening 
the  spirits ;  as  indeed  it  is  well  known  to  be  in  other  forms  of  disease  attended  with 
a  copious  and  permanent  drain  upon  the  system,  and  with  a  diminution  of  red  blood. 
Of  course  it  may  be  combined  with  opium,  or  with  any  other  medicine  which  the 
circumstances  of  the  patient  may  render  needful. 

I  scarcely  need  say  that  the  bowels  require  attention.  Not  that  active  purgation  is 
advisable,  but  simply  their  regulation.  Castor  oil,  rhubarb,  aloes,  lenitive  electuary, 
are  more  appropriate  in  these  cases  than  the  purgative  salts,  w4iich  are  apt  to  be 
diuretic  also. 

There  is  one  other  drug  from  which  I  think  I  have  seen  the  happiest  effects. 
i  mean  the  creasoie.  I  first  became  acquainted  with  its  virtue,  from  prescribing  it, 
almost  accidentally,  until  a  consultation  could  be  arranged  with  Dr.  Prout,  for  a 
child,  eight  years  old,  in  whom  the  disease  was  well-marked,  and  who  had  been 
brought  to  London  f^om  the  country  for  advice.  She  had  been  rapidly  wasting  away 
for  ten  weeks,  was  extremely  feeble,  soon  tired,  very  thirsty,  especially  at  night,  and 
had  (what  was  also  new  to  her)  an  enormous  appetite.  She  was  passing  from  three 
pints  to  two  quarts  daily  of  pale  urine,  having  a  specific  gravity  greater  than  1040. 
I  desired  that  her  diet  should  be  as  exclusively  animal  as  she  could  bear,  and  that 
she  should  take  one  minim  of  creasote,  suspended  by  means  of  mucilage  in  an  ounce 
and  a  half  of  water,  three  times  a  day.  Curiously  enough,  the  child  liked  the  tarry 
flavour  of  the  medicine.  Upon  this  plan,  with  gentle  aperients  occasionally  to  regu- 
late her  bowels,  she  remained  for  upwards  of  a  twelvemonth.  Her  urine  soon  fell  in 
Quantity  within  the  limits  of  health,  and  in  density  to  about  1030.    She  regained  her 


876  CHRONIC   DIlrKii.dx'3. 

lost  flesh,  strength,  complexion,  and  spirits,  aad  p^rew  '"^ns'deraOly.  At  length  she 
suddenly  sank  under  an  obscure  affection  0/  the  chest.  a  brotner  of  this  iittle  girl 
has  lately  manifested  unequivocal  signs  ol  the  same  complaint ;  and  in  him  it  appears 
to  have  been  equally  checked  by  the  saiae  method  of  treatment.  I  have  detected 
sugar  in  the  urine  of  another  boy  belonging  to  the  same  family. 

There  were  two  points  in  this  young  lady's  case  which  deserve  a  passing  remark. 
As  her  urine  diminished  in  quantity  it  began  to  deposit  the  lithates.  This  Dr.  Prout 
considered  a  very  promising  earnest  of  a  return  to  a  better  diathesis :  and  I  find  that 
in  cases  which  have  crept  on  insidiously  from  the  first,  he  is  accustomed  to  date  the 
malady  from  the  time  when  lateriiious  sediments,  previously  common,  disappeared 
from  the  water. 

The  other  point  was,  that  calomel  always  sickened  this  child,  and  aggravated  all 
the  diabetic  symptoms.  This  is  consistent  with  Dr.  Front's  experience,  who  tells  us 
that  he  has  never  seen  mercury  do  good  in  diabetic  disease ;  but  on  the  contrary 
almost  invariably  do  mischief.  I  would  advise  you  to  read  his  judicious  observations 
upon  the  too  common  abuse  of  that  mineral. 

I  am  quite  aware  of  a  possible  fallacy  in  the  case  I  have  been  mentioning,  with 
respect  to  the  efficacy  of  the  creasote.  With  the  use  of  that  drug  was  associated  a 
stricter  adherence  to  a  purely  animal  diet ;  and  it  is  impossible  to  estimate  with  pre- 
cision the  separate  effects  of  these  two  remedial  measures.  I  am,  however,  disposed 
to  believe  that  the  creasote,  by  its  well-known  preservative  property,  checks  the  con- 
version of  the  food  into  sugar.  And  I  think  it  is  a  mistake  to  go  on  increasing  the 
dose.  To  most  stomachs  it  proves  irritating  and  hurtful  when  pushed  beyond  a  cer- 
tain small  amount.  Dr.  Maclntyre  tells  me  that  he  has  found  the  creasote  very 
useful  in  diabetes.  I  must,  however,  acknowledge  that,  in  common  with  others,  I 
have  sometimes  been  totally  disappointed  by  it. 

For  many  years  of  my  professional  life  I  had  not  met  with  an  instance  of  what 
has  been  called  diabetes  insipidus :  from  which  I  infer  the  rarity  of  that  disorder.  I 
shall  use  the  term  chronic  diuresis  to  express  this  affection. 

Very  recently  a  marked  instance  of  such  chronic  diuresis  has  presented  itself  in 
the  hospital.  A  boy,  eleven  years  old,  not  unhealthy  looking,  but  lean,  was 
admitted  there  under  my  care.  He  was  much  troubled  by  thirst ;  and  by  frequent 
micturition,  which,  even  in  the  night,  disturbed  him  many  times.  His  bowels  were 
costive,  he  had  a  capricious  appetite,  and  his  skin  was  dry.  He  voided  during  the 
twentj'-four  hours  several  pints,  seldom  less  than  nine  or  ten,  of  simply  dilute  urine, 
of  a  faintly  yellowish  hue,  and  having  the  specific  gravity  of  1002.  Sometimes, 
indeed,  it  was  found  to  be  scarcely  heavier  than  distilled  water.  In  other  respects 
he  appeared  tolerably  well.  It  was  supposed  that  he  had  been  affected  in  this 
way  for  about  twelve  months ;  his  desire  for  drink  having  been  the  first  symptom 
noticed. 

During  his  residence,  of  many  weeks,  in  the  hospital,  under  my  observation,  I 
made  trial  of  every  plan  and  drug  that  I  could  think  of,  for  repressing  the  unnatural 
flux  of  urine.  Nothing  did  him  any  good :  some  things,  I  fear,  by  disturbing  his 
stomach  and  bowels,  did  him  some  temporary  harm.  He  went  out  much  as  he 
camt  m. 

Although  I  can  tell  you  neither  upon  what  this  disorder  depends,  nor  how  it  may 
be  remedied,  I  mention  the  case  because  it  afforded  me  a  proof  that  liquid  may  be 
absorbed  into  the  body  from  the  atmosphere ;  either  by  the  external  skin,  or  by  the 
pulmonarj'  mucous  membrane,  or  by  both  these  surfaces.  Dr.  Prout,  to  whom  I 
showed  both  the  urine  and  the  patient,  advised  that,  for  a  time,  his  supply  of  drink 
should  be  limited.  Accordingly,  very  much  to  the  poor  boy's  sorrow,  he  was  put 
upon  a  daily  allowance  of  a  pint  and  a  half.  1  have  no  doubt  that  my  injunctions 
were  strictly  observed,  both  by  himself  and  by  the  nurses.  Nevertheless,  without 
losing  flesh  or  weight,  he  passed,  during  the  corresponding  twenty-four  hours,  ten 
pints  and  a  half  of  urine. 

T  got  evidence  of  the  same  fact  in  another  way  also ;  namely,  by  weighmg  the 


ALBUMINOUS    URINE.  877 

boy  at  short  intervals  :  although  the  experiment  was  not  repeated  so  often  as  I  wished 
it  had  been.     I  give  you  the  results  of  one  of  these  trials. 

Immediately  after  he  had  emptied  his  bladder  he  was  found  to  weigh  3  st.  8  lb. 
0  oz.  3  dr.  Three  hours  subsequently,  having  taken  nothing  in  the  interim,  he 
weighed  3  st.  9  lb.  0  oz.  2  dr.  Then  he  voided  16  oz.  of  urine :  after  which  his 
weight  was  again  3  st.  8  lb.  0  oz.  3  dr.  So  that  he  must  have  imbibed  about  a 
pound  of  liquid  in  that  brief  space  of  time.* 

In  this  instance  there  was  merely  an  excess  in  the  aqueous  ingredient  of  the  urine  ; 
the  solid  matters  were  apparently  there,  in  their  due  proportion  to  each  other,  but  in 
a  very  small  ratio  to  the  water. 

But  the  aqueous  ingredient  may  be  in  excess,  while  the  absolute  quantity  of  urea 
is  deficient.  On  the  other  hand,  with  an  excess  of  the  watery  material,  there  may 
be  an  excess  also  in  the  quantity  of  urea  it  contains. 

Dr.  Willis  has  distinguished  these  three  varieties  of  chronic  diuresis  by  the  terms 
hydruria,  anazoturia,  and  azoturia,  respectively.  Although  I  am  no  friend  to  the 
multiplication  of  technical  names,  I  must  tell  you  that  the  distinctions  expressed  by 
these  terms  are  real,  and  of  some  importance.  Anazoturia  we  shall  find  to  be  often 
symptomatic  of  a  peculiar  organic  disease  of  the  kidney,  which  I  hope  to  describe 
in  the  next  lecture. 

Azoturia,  which  is  accompanied  by  an  unnaturally  high  specific  gravity  of  the 
urine,  is  apt,  on  that  account  chiefly,  to  be  mistaken  for  diabetes.  As  recoveries 
from  it  are  not  uncommon,  it  may  be  suspected  that  some  of  the  boasted  cures  of 
diabetes  were  cures  of  this  less  serious  disorder.  In  the  one  case,  the  yeast  test 
detects  the  presence  of  sugar  in  the  superabundant  urine  ;  in  the  other  case  it  finds 
none. 


LECTURE  LXXVIII. 

Albuminous  Urine.  Means  of  detecting  the  Albumen.  What  it  imports.  Anato- 
mical  characters  of  Bright s  Kidney.  Symptoms  to  which  this  renal  disease 
gives  rise.     Nature  of  the  affection. 

Another  morbid  condition  of  the  urine,  imperatively  demanding  your  attention, 
is  that  in  which  it  is  habitually  impregnated  with  albumen.  This  albuminous  con- 
dition is  much  more  common,  and  in  general  not  less  serious,  than  the  saccharine 
condition  which  I  described  yesterday. 

There  is  no  albumen  in  healthy  urine.  Neither  can  we  recognize  its  presence, 
in  any  urine,  by  mere  inspection.  We  detect  it  by  certain  tests  :  and  I  will  tell  you, 
in  the  first  place,  what  these  are  ;  and  how  to  use  them. 

Albumen — of  which  we  have  so  familiar  an  example  in  the  "white"  of  eggs- 
begins  to  pass  from  the  fluid  to  the  solid  state  at  the  temperature  of  160°  Fahrenheit. 
When  diluted  it  may  require  for  its  complete  coagulation  the  heat  of  212°.  Hence 
one  simple  and  easy  test  of  its  presence.  We  discover  that  albumen  is  contained 
in  the  urine,  by  heating  that  fluid  to  the  boiling  point.  This  is  most  conveniently 
done  in  a  small  glass  tube,  by  the  flame  of  a  spirit  lamp.  It  is  seldom  that  any  pre- 
paration of  the  suspected  urine  is  requisite.  It  may,  perhaps,  be  hazy  in  conse- 
quence of  its  containing  mucus  ;  and  if  its  transparency  be  much  troubled,  it  will  be 
well  to  filter  the  fluid  before  testing  it.  When,  as  sometimes  happens,  albuminous 
urine  is  already  turbid  from  the  presence  of  the  lithates,  these  dissolve  as  the  heat 

*  This  boy  lived  more  than  two  years  afterwards,  and  continued  to  yield  an  excessive 
quantity  of  pale,  neutral  urine,  scarcely  heavier  than  distilled  water.  After  death,  scrofu- 
lous tubercles  were  found  in  his  brain  and  in  his  lungs.  His  kidneys  were  gorged  with 
venous  blood,  but  of  healthy  structure.  There  was  nothing  wrong,  apparently,  in  his  organ» 
of  digestion. 

3y 


878  bright's  kidney. 

IS  applied,  and  the  urine  first  beconties  clear ;  and  then,  as  the  temperature  rises,  the 
albuminous  opacity  begins  to  be  visible. 

The  phenomena  observable  in  the  heated  urine  vary  in  different  cases,  chiefly  by 
reason  of  the  variable  amount  of  albumen.  The  whole  is  sometimes  converted  into 
one  gelatinous  mass:  but  this  is  uncommon.  Usually  the  albumen  first  appears  in 
the  form  of  a  whitish  cloud,  of  which  the  constituent  particles  muhiply,  and  collect, 
in  proportion  as  the  quantity  is  considerable,  into  small  curdy  fragments  or  flakes. 
These  soon  subside  to  the  lower  part  of  the  tube,  leaving  the  supernatant  liquid 
clear.  The  amount  of  albumen  is  of  course  to  be  estimated  by  the  portion  of  the 
tube  that  it  occupies. 

Now  this  test,  by  heat,  is  not  conclusive,  nor  sufficient.  There  are  circumstances 
that  may  impede  or  prevent  its  effect  in  coagulating  albumen,  which,  nevertheless, 
is  present.  On  the  other  hand  it  may,  under  other  circumstances,  produce  a  falla- 
cious appearance  of  albumen  where  none  exists. 

Albuminous  urine  has  often  a  less  acid  reaction  with  litmus  paper  than  healthy 
urine.  The  reason  of  this  I  will  explain  presently.  When  recently  discharged  from 
the  bladder,  the  urine  may  be  neutral  or  even  alkaline ;  or  it  may  become  neutral  or 
alkaline,  by  spontaneous  decomposition  after  it  has  left  the  bladder.  In  any  case, 
the  urine,  thus  alkaline  or  neutral,  will  not  coagulate  when  heated,  even  thougn  it 
may  be  full  of  albumen.  Again,  although  there  may  be  no  albumen,  heat  may 
cause  a  flaky  precipitate,  consisting  of  the  earthy  phosphates. 

We  avoid,  or  remedy,  these  sources  of  fallacy,  by  testing  the  suspected  urine 
with  nitric  acid  also,  which  has  the  property  of  precipitating  the  albumen  in  a  flaky 
or  pulpy  form.  It  will  thus  detect  albumen  when  the  tested  urine  is  alkahne  ;  and 
by  restoring  its  acidity,  it  Avould  make  the  albumen  discoverable  by  the  test  of  heat. 
It  has  likewise  the  effect  of  redissolving  the  spurious  precipitates  which  may  be 
thrown  down  by  the  application  of  heat,  and  consequently  of  showing  that  they  are 
spurious. 

Nitric  acid  alone,  however,  is  not,  any  more  than  heat  alone,  an  unequivocal 
touchstone  of  the  presence  or  absence  of  albumen ;  for  it  may  occasion  a  flaky 
precipitate  of  lilhic  acid,  when  there  is  no  albumen.  But  this  defect  is  compen- 
sated by  the  complementary  criterion  of  heat ;  the  precipitate  being  redissolved 
by  raising  the  temperature  of  the  urine,  while  any  coagulated  albumen  remains 
insoluble. 

Dr.  Christison  states  that,  in  his  experience,  "sometimes  nitric  acid  added  in 
excess  did  not  separate  albumen  which  had  been  present  in  large  quantity" — a  fact 
which  he  thinks  "  is  probably  to  be  ascribed  to  the  albumen  itself  having  undergone 
more  or  less  decay,  along  with  the  other  principles  of  the  urine."  Hence  the  urine 
should,  if  possible,  be  examined  before  it  has  become  decomposed  by  lapst  of  time. 
If,  however,  you  employ  both  these  tests  with  different  portions  of  the  same  urine 
at  the  same  time,  and  with  the  same  portion  in  succession,  you  will  avoid  all  risk  of 
mistake. 

Other  tests  there  are,  frequently  spoken  of,  and  sometimes  recommended  ;  particu- 
larly the  ferrocyanate  of  potass,  corrosive  sublimate,  creasote,  and  oxalic  acid.  They 
are  unnecessary,  in  addition  to  heat  and  nitric  acid ;  and  they  are  liable  to  fallacies 
from  which  these  last,  when  combined,  are  free.  Unless  you  are  expert  chemists, 
you  had  better  avoid  them. 

Now  it  is  quite  certain  that  the  presence  of  albumen  in  the  urine  does  often  accom- 
pany and  bespeak  a  very  serious  organic  disease  of  the  kidney.  For  this  disease 
we  have  no  appropriate  name.  I  wish  we  had.  Some  call  it  granular  degeneration 
of  the  kidney,  but  the  epithet  granular  is  not  always  applicable.  It  is  most  fami- 
liarly known,  both  here  and  abroad,  as  Bright'' s  kidney  or  Bright'' s  disease ;  after 
the  eminent  physician  who,  in  1837,  first  described  it,  and  showed  its  great  patholo- 
gical importance.  These  are  odd-sounding  and  awkward  terms  ;  but  in  the  lark  of 
better  I  must  employ  them. 

It  is  very  difficult  to  describe,  in  words,  the  anatomical  characters  proper  to  this 
renaJ  disease  ;  for  they  are  neither  very  definite  nor  very  constant.    The  description 


bright's  kidney.  879 

that  I  am  about  to  attempt  will  be  made  more  intelligible  by  Dr.  Bright's  plates  and 
those  of  M.  Rayer,  which  are  both  before  you. 

The  morbid  appearances  presented  by  the  substance  of  the  kidney  are  such  as 
denote  some  change  in  its  intimate  structure.  Its  cortical  (or  secreting)  portion  is  the 
primary  and  chief  seat  of  this  degeneration ;  yet  what  is  called  its  medullary  (^'.  e., 
its  excreting)  part,  is  also  sometimes  implicated,  but  in  a  less  degree. 

These  morbid  appearances  relate  to  the  size,  figure,  and  consistence  of  the  kidney  ; 
to  the  colour  and  condition  of  its  surface,  and  of  its  interior.  With  respect  to  some 
of  these  points  there  is  much  variety  in  different  cases ;  and  studying  this  variety 
under  the  light  which  is  thrown  upon  it  by  the  clinical  history  of  the  disease,  we 
have  reason  to  believe  that  it  is  connected  with  different  stages  of  the  disorganizing 
process.  Thus  if  we  look  to  the  size  of  the  diseased  organs,  they  are  sometimes 
much  larger  than  natural,  sometimes  of  the  ordinary  magnitude,  sometimes  consider- 
ably smaller.  The  average  weight  of  the  adult  human  kidney  is  four  ounces.  M. 
Rayer  has  met  with  some,  in  this  disease,  weighing  twelve  ounces.  Both  the  incre- 
ment and  the  decrement  of  the  natural  bulk  belong  principally,  if  not  altogether,  to 
the  outer  secreting  portion  of  the  gland.  If  a  longitudinal  section  of  the  exaggerated 
kidney  be  made,  its  cortical  part  is  seen  to  be  unduly  broad  ;  and  the  same  part  is 
disproportion  ally  narrow  when  the  whole  organ  is  smaller  than  common.  For  this 
reason,  in  the  latter  case,  the  radiating  medullary  portions  approach  nearer  to  the 
surface  than  they  are  observed  to  do  in  a  healthy  kidney.  And  it  furthermore 
appears  that  the  enlargement  is  most  commonly  coincident  with  the  earher,  and  the 
contraction  or  shrinking  with  the  later  stages  of  the  renal  disease. 

The  consistence  of  the  diseased  gland  is  variable  also.  Sometimes,  and  for  the 
most  part  in  the  earlier  periods,  it  is  soft  and  flabby :  sometimes,  and  especially  m 
the  later  periods,  it  is  remarkably  compact  and  hard.  The  size  and  the  consistence 
of  the  kidney  are,  in  most  cases,  inversely  proportional  to  each  other. 

Again,  lhefor7n  of  the  kidney,  in  the  disease  in  question,  often  undergoes  some 
modification.  As  the  special  change  proceeds,  the  exterior  of  the  gland  shows  a 
tendency  to  become  indented  by  linear  depressions,  and  to  present  a  lobular  shape. 
This,  however,  is  by  no  means  a  constant  phenomenon,  even  in  the  most  advanced 
stage  of  the  malady. 

When  its  proper  investing  tunic  is  stripped  off — and  less  distinctly  through  the 
same  tunic,  before  its  separation — the  surface  of  the  kidney  appears  mottled,  mar- 
bled, or  stained  ;  of  a  yellowish-gray  colour  in  one  place,  and  of  a  dark  or  purple 
tint  in  another.  Occasionally  it  is  pale  throughout  its  whole  extent ;  more  commonly 
of  divers  hues,  and  variegated  with  httle  streaks,  which  are  portions  of  vessels  con- 
taining red  blood.  Sometimes  the  surface  is  curiously  speckled ;  often  uneven  as 
if  strewed  with  prominent  grains  ;  in  some  instances  quite  rough  and  scabrous.  These 
several  unnatural  appearances  are  usually  the  more  conspicuous,  in  proportion  as  the 
complaint  is  the  more  advanced. 

The  most  uniform,  however,  and  the  most  characteristic  of  the  morbid  appear- 
ances, are  those  presented  by  the  cut  surface  of  the  kidney,  when  it  has  been  divided 
into  two  symmetrical  portions  by  a  longitudinal  incision.  We  then  perceive  that  the 
cortical  substance  is  the  main  seat  of  the  morbid  alteration.  It  has  lost  in  a  greater 
or  less  degree,  its  proper  red  colour  and  uniform  aspect.  Sometimes  it  puts  on  a 
speckled  or  granular  appearance ;  but  this,  in  my  experience,  is  less  common  than  a 
pale,  nearly  homogeneous  surface,  somewhat  like  the  section  of  a  parsnip.  Its  na- 
tural strife  are  confused  or  obliterated.  The  incised  surface  gives  one  the  notion  of 
some  deposit,  whereby  the  original  texture  of  the  part  is  obscured.  The  blood- 
vessels seem,  many  or  most  of  them,  to  have  been  emptied  by  compression,  or  to  be 
blocked  up  by  yellowish  solid  matters  ;  while  the  healthier  pyramidal  masses  belong- 
ing to  the  medullary  portion  of  the  kidney  are  displaced,  and  pushed  aside,  or 
encroached  upon  by  the  same  yellowish  matter,  which  sometimes  interposes  itself 
between,  and  opens  out,  their  radiating  tubuli.  Together  with  these  changes  ol 
appearance  and  structure,  I  have  several  times  found  the  veins  that  emerge  from  the 
kidney  firmly  plugged  up  by  coagula  of  blood. 

In  some  rare  cases  the  kidney  is  studded,  both  on  its  surface  and  throughout  iu 


880  SYMPTOMS. 

interior,  with  numerous  small  cysts  or  cells,  contaming  a  thin  transparent  liquid. 
These  cysts  have  been  inaccurately  termed  hydatids.  It  is  not  at  all  uncommon  to 
meet  with  one  or  two  such  cysts  in  this  diseased  state  of  the  organ. 

It  has  been  made  a  question  whether  the  various  appearances  which  I  have  been 
attempting  to  describe,  and  which  sensibly  differ  in  degree  and  combination  in  dif- 
ferent cases,  are  characteristic  of  different  morbid  conditions,  or  merely  of  different 
stages  and  varieties  of  the  same  essential  change.  Our  knowledge  of  the  subject  is 
scarcely  sufficient  to  supply  a  positive  solution  of  this  question.  Excepting  perhaps 
the  cyst,  my  own  opinio?!  is,  that  they  are  all  accidental  forms  and  effects  of  one  and 
the  same  morbid  process.  At  the  same  time  I  ought  to  tell  you,  that  both  Dr.  Bright 
and  Dr.  Christison  appear  to  incline  to  the  opposite  conclusion. 

There  is  still  another  state  of  the  kidney,  very  different  to  the  eye  from  any  that 
I  have  yet  mentioned,  but  which  has  been  thought,  and  which  I  think,  to  be,  in 
some  cases  at  least,  the  first  stage  of  all  in  the  disorganizing  process.  This  state, 
which  I  referred  to  when  speaking  of  suppression  of  urine,  may  be  briefly  described 
in  two  words — sanguine  congestion.  The  whole  organ  is  gorged  with  blood,  which 
sometimes  drips  freely  from  it  when  it  is  cut  open.  The  kidney  is  in  general  large, 
somewhat  flabby,  of  a  deep  dark  red,  even  of  a  chocolate  or  purplish  colour,  nearly 
uniformly  diffused,  except  that  the  cut  surface  is  usually  diversified  by  still  darker 
tuft-like  spots,  which  have  been  ascertained  to  be  the  Malpighian  bodies  filled  with 
blood.  This  change  from  the  natural  appearance  of  the  kidney  is  evidently  of  a 
recent  kind ;  and  the  symptoms  that  have  been  observed  to  belong  to  it  are  these  :^ 
Fever  preceded  often  by  rigors ;  uneasiness  or  dull  pain  in  the  loins;  nausea  and 
vomiting ;  a  very  scanty  secretion  of  urine,  which  is  sometimes  tinged  with  blood, 
and  always  albuminous ;  occasionally  complete  suppression  of  urine.  To  these 
symptoms  there  is  presently  added,  in  most  cases,  sudden  and  general  anasarca — 
what  is  commonly  called  inflammatory,  active,  or  febrile  dropsy.  If  the  secretion 
of  urine  be  entirely  suspended,  death  soon  ensues  by  coma,  as  I  explained  to  you 
yesterday ;  but  if  not,  the  disorder  is  frequently  fatal  by  the  supervention  of  some 
acute  internal  inflammation  ;  pleurisy,  or  pericarditis,  or  pneumonia,  or  peritonitis. 
Many  persons  recover  completely  from  the  condition  expressed  by  this  combination 
of  pneumonia.  Many  seem  to  recover,  but  bear  about  with  them  the  germs  or 
beginnings  of  those  more  chronic  and  latent  changes  which  constitute  "  Bright's 
kidney." 

And  what  are  the  signs  which  indicate,  to  an  instructed  eye,  the  presence  of  those 
changes  ?  Some  of  them  are  precisely  the  same,  in  kind,  as  those  which  denote 
the  acuter  disorder ;  only  mitigated  in  degree,  and  of  slower  march  and  succession. 
The  patients  are  subject  to  obscure  lumbar  pains :  to  sickness  from  time  to  time, 
and  retching;  and  their  urine  is  apt  to  be  red,  brown,  or  dingy,  as  well  as  albumin- 
ous, from  the  intermixture  of  some  of  the  colouring  matter  of  the  blood.  They  are 
obnoxious  to  inflammations  of  the  serous  membranes  also;  and  more  particularly 
to  head  affections,  of  which  they  often  die ;  drowsiness,  convulsions,  apoplexy. 
And,  to  finish  the  resemblance,  many  of  them,  ay,  most  of  them,  become  at  length 
anasarcous.  Besides  these  symptoms  there  are  others  which  are  not  seen  in  the 
acute  malady  ;  because  it  is  acute.  Gradually  increasing  pallor  is  almost  constant ; 
disease  of  the  heart  is  common ;  and  the  skin,  in  general,  even  in  the  absence  of 
fever,  is  remarkably  dry  and  unperspiring.  The  patients  are  troubled  by  a  frequent 
want  to  make  water ;  by  flatulence  of  the  stomach  and  intestines ;  and  by  caprice 
of  the  bowels,  which  are  sometimes  obstinately  costive,  sometimes  prone  to  diar- 
rhoea. 

Now  it  is  worth  your  while  to  remark,  with  respect  to  this  category  of  symptoms, 
that  (the  state  of  the  urine  excepted)  they  have  no  special  prima  facie  reference  to 
renal  disease.  They  are  all  common  enough  in  various  other  complaints.  In  truth 
they  are  mere  secondary  consequences  of  Bright's  disease ;  and  in  so  far  as  they  are 
symptoms  of  it,  they  are  indirect  symptoms.  Before  Dr.  Bright,  no  one  perceived, 
in  such  symptoms,  any  indication  of  disease  of  the  kidney.  The  primary  and  fun- 
damental organic  malady  reveals  itself  by  no  direct  symptoms,  excepting  those  which 
are  furnished  by  the  urine. 


STAGES    OF   THE    DISEASE.  881 

Seeing,  then,  that  this  pecuhar  disease  ot  the  kidney  is  coupled  with  effects  so 
grave  and  perilous,  and  seeing  that  one  of  its  most  positive  and  distinctive  marks  is 
in  albuminous  state  of  the  urine,  two  questions  of  great  interest  at  once  present 
themselves. 

1.  Does  albuminous  urine  always  imply  the  presence  of  Bright's  disease  ? 

a,.  Is  Bright's  disease,  when  present,  always  accompanied  by  albuminous  urine! 

To  both  these  questions  the  answer  is — no. 

It  is  certain  that  some  articles  of  food  have  the  effect,  in  some  persons,  of  render- 
ing tne  urine  for  a  time  albuminous :  perhaps  it  would  be  more  correct  to  say  that 
certain  forms  of  indigestion  cause  this  change.  Albumen  has  also  been  detected  in 
the  urine  under  that  general  state  of  irritation  produced  occasionally  by  mercury,  or 
by  a  bUster  to  the  skin.  In  the  crisis  of  some  febrile  disorders,  and  in  some  cases 
of  pregnancy,  the  same  phenomenon  has  been  observed.  Whenever  blood,  pro- 
ceeding from  any  part  of  the  long  tract  of  mucous  membrane  which  lines  the  urinary 
organs,  mingles  with  the  urine,  that  fluid  of  necessity  contains  albumen,  and  coagu- 
lates if  tested  by  heat  or  by  nitric  acid. 

On  the  other  hand,  when  the  kidney  is  really  affected  in  the  way  already  described, 
the  admixture  of  albumen  with  the  urine  is  apt  to  disappear,  for  a  while,  even  sud- 
denly. I  have  known  it  vanish  for  several  hours,  immediately  after  the  effectual 
application  of  a  hot-air  bath  ;  and  after  profuse  purging  by  a  full  dose  of  elaterium. 
Sometimes  it  is  absent  for  a  longer  period. 

Another  important  question,  therefore,  now  arises.  Finding  albumen  in  the  urine, 
how  are  we  to  know  whether  it  does,  or  does  not,  indicate  the  presence  of  Bright's 
kidney  1 

We  may  judge,  in  part,  by  frequently  testing  the  urine,  and  noticing  whether  the 
albuminous  impregnation  be  transitory  or  persistent.  In  part  also  we  judge  by  the 
absolute  amount  of  the  albumen  in  a  given  measure  of  urine.  If  the  water  be  deeply 
charged  with  that  unnatural  ingredient,  the  presumption  is  strong  that  the  kidney 
disease  is  in  progress ;  and  when  that  disease  is  confirmed,  another  remarkable 
change  is  found  to  have  taken  place  in  the  urine.  Its  specific  gravity  is  very  low ; 
and  strikingly  in  contrast  with  that  of  diabetic  urine.  This  is  therefore  a  very  strong 
additional  diagnostic  circumstance. 

On  Dr.  Prout's  authority  we  have  assumed  the  specific  gravity  of  healthy  urine  to 
range  between  1015  and  1025.  Other  writers  make  it  higher.  But  the  urine  voided 
in  Bright's  disease  is  sometimes  as  low  as  1004 ;  and  its  mean  specific  gravity  does 
not  exceed  1013. 

I  need  scarcely  again  remind  you,  that  the  question  of  specific  gravity  must  always 
be  viewed  in  relation  to  the  absolute  quantity  of  urine  secreted.  The  specific  gravity 
depends,  of  course,  upon  the  proportion  of  the  solid  constituents  of  the  urine  contained 
in  a  given  quantity.  If  the  aqueous  portion  be  augmented,  the  effect  upon  the  abso- 
lute density  will  be  the  same  as  if  the  solid  contents  were  proportionally  diminished. 
But  when,  as  frequently  happens  in  certain  stages  of  this  renal  disease,  the  specific 
gravity  decreases  while  the  quantity  of  the  urine  decreases  also,  that  conjunction  of 
phenomena  becomes  especially  significant. 

The  density  of  the  urine  being  thus  unnaturally  low,  notwithstanding  the  addition 
of  the  new  substance  albumen,  it  follows,  as  a  matter  of  inference,  that  the  solid  con- 
stituents proper  to  healthy  urine  must  be  sensibly  diminished  :  and  they  are  found, 
in  fact,  to  be  so.  These  solid  ingredients  consist  mainly  of  urea,  and  of  certain  salts. 
The  aggregate  solid  contents  amount,  in  health,  to  sixty-seven  or  sixty-eight  parts  in 
every  1000.  In  Bright's  disease  the  amount  has  been  ascertained  to  be  diminished 
to  twelve  or  fourteen  parts,  and  even,  in  an  extreme  case,  to  less  than  this — to  about 
six  parts. 

The  urine  contains,  then,  albumen  :  and  it  is  deficient  in  urea.  These  two  facts 
suggested-,  naturally  enough,  to  M.  Solon,  and  to  others,  the  notion  that  ^he  albumen 
might  be  formed,  by  a  sort  of  conversion,  at  the  expense  of  the  urea;  since  these 
substances,  by  a  slight  alteration  in  the  ratio  of  their  elements,  pass  respectively  each 
into  the  other.  But  it  is  not  so.  Dr.  Christison  had  observed  many  years  ago,  thai 
when  the  urine  was  deprived  of  the  greater  part  of  its  urea,  the  quantity  of  al^'uraen 
'>(  3  V  3 


S82  bright's  kidney. 

contained  in  it  was  small ;  and,  on  the  other  hand,  in  cases  where  the  urea  was  con- 
siderable in  quantit}',  the  albumen  was  plentiful  also.  In  a  recent  work  on  this 
subject,  the  same  physician  states  that  the  whole  of  his  subsequent  experience  has 
been  in  conformity  with  this  observation. 

It  being  certain,  therefore,  that  the  albumen  is  not  vicarious  of  the  urea,  what 
(you  may  ask)  becomes  of  the  urea  ?  It  is  detained  in  the  blood ;  and  may  readily 
1)6  recognized  there  in  considerable  quantity  :  and  herein  lies,  as  I  conceive,  the  secret 
of  the  secondary  affections  which  belong  to  this  disorder,  and  of  its  great  fatality. 
The  body  is  poisoned  in  detail  by  the  retention  of  its  own  excrements.  The  blood 
not  being  dul}"^  purified  through  that  great  emunctory,  the  kidneys,  is  spoiled  for  its 
purpose  of  nutrition.  Besides  containing  urea,  it  undergoes  other  and  more  mani- 
fest changes.  Its  proportion  of  fibrin  varies;  and  it  gradually  becomes  poor  in 
colouring  matter  ;  the  serum  is  less  albuminous  also,  and  of  a  lower  specific  gravity, 
than  in  health.  The  quantity  of  albumen  in  heahhy  blood  averages  from  sixty-five 
to  sixty-nine  parts  in  1000.  In  this  malady  Dr.  Babington  has  found  it  reduced  to 
sixteen  parts.  The  average  specific  gravity  of  healthy  serum  is  1030 ;  but  in 
Bright's  disease  it  descends  to  1024,  1020,  and  even  to  1013.  Now  Dr.  Christison 
has  made  out  the  very  interesting  fact,  that  there  is  a  definite  inverse  ratio  between 
the  coagulabihty  of  the  urine,  and  the  density  of  the  serum.  The  more  albumen 
there  is  in  the  former  of  these  fluids,  the  less  is  there  in  the  latter,  and  the  lower 
is  its  specific  gravity.  So  that  the  deficiencies  of  the  one  fluid  balance  the  super- 
fluities of  the  other.  All  this  is  ver}^  diflt'rent  from  what  takes  place  in  diabetes,  in 
which  sugar  is  excreted  with  urine  that  is  otherwise  health}^ :  whereas,  in  Bright's 
disease,  urea,  which  ought  to  be  discharged,  remains  in  the  blood  ;  and  albumen, 
which  ought  not  to  be  separated,  is  taken  from  the  blood  and  carried  out  with  the 
urine. 

I  have  now  described  the  changes  presented  by  the  kidneys  in  this  disorder,  the 
symptoms  which  attend  it,  and  the  morbid  conditions  both  of  the  urine  and  of  the 
blood.  But  these  all  vary  and  fluctuate  at  different  periods  of  the  complaint.  I 
must  next,  therefore,  endeavour  to  state  what  has  been  ascertained  of  its  course  and 
progress. 

When  the  chronic  disorder  is  not  a  legacy  left  by  the  more  severe  and  acute  form 
of  disease  which  I  have  termed  febrile  dropsy,  it  is  apt  to  creep  on  very  insidiously, 
and  to  escape  our  notice  :  and  its  history  is  not  yet  fully  known.  It  will  be  enough 
if  I  distinguish  two  stages  of  the  malady — the  earl}^  and  the  advanced. 

In  the  early  stage  the  urine  is  generally  scanty.  Instead  of  about  40  ounces  in 
the  twenty-four  hours,  the  patient  voids  16,  12,  8,  or  even  so  little  as  2  or  3  ounces. 
Sometimes  the  secretion  is  nearly  or  quite  suppressed :  and  then  the  head  seldom 
fails  to  become  affected  in  the  way  already  described.  The  urine  has  also  an  un- 
natural appearance.  It  is  red,  or  dark,  obscurely  turbid,  like  muddy  beer.  It  froths 
more  than  usual:  and  if  you  blow  into  it  through  a  tube,  }^ou  raise  bubbles  similar 
to  those  which  may  be  formed  in  soapy  water.  Its  specific  gravity  is  somewhat, 
yet  not  greatly,  reduced  ;  about  1021,  perhaps  ;  it  is  seldom  at  this  period  so  low  as 
1016.     It  contains  an  abundance  of  albumen. 

At  the  same  early  period,  blood  drawn  from  the  arm  exhibits  the  bufl'y  coat.  The 
serunr.  is  much  diminished  in  density,  and  contains  a  considerable  quantity  of  urea. 
There  is  no  decrease  in  the  fibrin  ;  perhaps  it  is  a  little  augmented :  and  there  is  no 
great  change  in  the  amount  of  colouring  matter. 

In  the  more  advanced  stages  of  the  disease,  the  quantity  of  urine  is  frequently  not 
below  the  standard  of  health ;  and  it  sometimes  considerably  exceeds  that  standard, 
so  as  to  constitute  one  variety  of  chronic  diuresis  (anazotitria).,  which  some  call 
diabetes  insipidus.  It  is  usually  pale,  slightly  opaque,  and  of  a  very  low  specific 
gravity;  1014,  1010,  1007.  Once,  when  the  quantity  of  the  urine  was  7iot  in 
excess.  Dr.  Christison  found  the  specific  gravity  to  be  no  more  than  1004.  There 
is  a  corresponding  reduction  in  the  natural  solid  ingredients  of  the  urine.  Albumen, 
too,  is  present,  but  more  uncertainly  than  in  the  earlier  periods  :  fluctuations  in  this 
respect  are  more  common  than  before.  It  is  a  mistake  to  suppose  that  the  amount 
of  album2n  increases  as  the  disorder  advances.     The  contrary  rule  would  be  more 


SECONDARY   AFFECTIONS.  8^ 

near  the  truth.  Tn  general  the  albumen  is  plentiful  and  almost  constant  in  the  outset 
of  the  malady  ;  less  surely  present  as  it  proceeds ;  and  sometimes  entirely  absent 
in  its  latter  periods ;  and  it  is  of  importance  to  remark  that  the  alteration  in  tlie 
specific  gravity  follows  the  opposite  law.  The  declension  of  density,  so  far  from 
being  corrected,  augments  with  the  progress  of  the  disorder.  Hence  the  one  of 
these  morbid  phenomena  is  a  valuable  check  upon  the  other,  considered  as  an  index 
of  what  is  going  on  in  the  kidney. 

And  another  fact,  which  it  is  essential  for  you  to  know  and  to  remember,  is,  that, 
in  any  stage  of  the  disease,  the  supervention  of  febrile  disturbance,  from  local  inflam- 
nnation  or  whatever  other  cause,  tends  to  renew,  for  the  time,  those  qualities  of  the 
urine  which  belong, to  the  early  period. 

Meanwhile,  the  disease  advancing,  the  serum  of  the  blood  recovers  more  or  less 
Its  lost  specific  gravity,  in  proportion  to  the  decrease  of  albumen  in  the  urine.  The 
quantity  of  fibrin  seems,  in  some  cases,  to  diminish.  But  the  striking  and  most  cha- 
racteristic change  is  the  rapid  disappearance  of 'the  colouring  matter,  the  hematosin, 
as  it  is  called.  This  may  at  length  be  so  much  reduced,  as  to  form  less  than  a  third 
of  the  healthy  average.  If  venesection  be  occasionally  employed,  this  process  of 
depravation  is  accelerated;  but  it  takes  place  whether  blood  be  artificially  withdrawn 
from  the  system  or  not.  "  I  am  acquainted,"  says  Dr.  Christison,  "  with  no  natural 
disease,  at  least  of  a  chronic  nature,  which  so  closely  approaches  hemorrhage  in  its 
power  of  impoverishing  the  red  particles  of  the  blood.  Hence  the  peculiar  pallid 
or  dingy  hue  of  the  patient's  skin  ;  the  leucophlegmatic  and  even  waxy  aspect  which 
invariably  stamps  the  victims  of  this  complaint. 

These  characters,  then,  of  the  urine  and  of  the  blood,  when  rightly  compared  and 
interpreted,  reveal  not  only  the  existence  of  the  renal  disease,  but  also,  with  much 
probability,  the  stage  or  degree  that  it  has  reached. 

Let  us  next  review,  a  little  more  in  detail,  those  secondary  affections  which  I  have 
already  pointed  out  as  being  incidental  to  the  subjects  of  this  renal  malady.  They 
are  of  much  consequence  :  for  in  the  course  of  the  disease,  more  or  fewer  of  them 
are  almost  sure  to  occur ;  most  of  them  are  productive  of  very  serious  distress ;  and 
some  of  them  place  the  patient's  life  in  immediate  jeopardy,  and  often  bring  it  to  a 
premature  end.  Moreover,  it  is  by  these  secondary  affections  that  our  suspicion  of 
the  primary  disease  upon  which  they  depend  is,  in  general,  first  awakened :  and  it 
is  to  the  prevention  or  the  removal  of  these  same  secondary  affections  that  our  cura- 
tive endeavours  must  chiefly  be  directed. 

The  most  common,  and  practically  the  most  important,  of  them  all,  is  &>nasarca ; 
but  of  this,  although  I  mention  it  first,  I  shall  postpone,  for  a  while,  the  further  consi- 
deration. 

Another  very  common,  and  very  important  secondary  complication,  is  the  occur- 
rence of  what  we  compendiously  call  head-symptoms :  various  manifestations  of 
derangement  in  the  cerebral  functions;  headache,  drowsiness,  delirium,  epileptic 
seizures,  apoplexy.  So  frequently  indeed  is  the  death  of  the  patient  preceded  by 
coma,  with  or  without  convulsions,  that  Dr.  Christison  considers  this  to  be  the  "natu- 
ral termination  "  of  the  disease,  or  "  the  mode  in  which  it  proves  fatal  when  life  is 
not  cut  short  by  some  other  incidental  or  secondary  affection."  Of  seventy  fatal 
cases  observed  by  Dr.  Bright,  death  was  ushered  in  by  well-marked  cerebral  symp- 
toms in  thirty. 

I  have  already  told  you  the  circumstances  under  which  these  affections  of  the  brain 
usually  arise.  They  almost  always  follow  any  great  diminution,  or  the  entire  sus- 
pension, of  the  secretion  of  urine.  But  this  rule  is  not  so  strict  is  to  admit  of  no 
exception.  Occasionally,  but  I  believe  very  seldom,  the  urine,  in  this  disorder,  is 
reduced  to  a  very  small  amount,  while  the  head  remains  undisturbed.  Of  this  Dr 
Christison  has  recorded  a  remarkable  instance.  One  of  his  patients  voided  no  more 
than  two  ounces  of  light  urine  daily,  for  nine  days  before  his  death  ;  yet  he  continued 
sensible  to  the  very  last  minute  of  his  existence,  and  died  simply  of  inanition.  Some- 
times apoplectic  symptoms  occur,  and  carry  the  patient  off,  although  there  has  been 
no  extreme  or  material  reduction  in  the  quantity  of  urine. 

Now  when  death  has  thus  taken  place  in  the  way  of  coma,  and  the  case  had  been 


884  bright's  kidney. 

complicated  with  anasarca,  and  serous  liquid  is  found  accumulated  in  unnatural 
measure  in  the  cerebral  ventricles,  and  in  the  tissue  of  the  pia  mater,  it  seems  rea- 
sonable to  ascribe  the  coma  to  the  presence  and  the  pressure  of  that  liquid.  The 
dropsy  has  extended  to  the  brain.  And  this  view  of  the  matter  is  strengthened  by 
the  connection  which  may  sometimes  be  noticed  between  the  accession  of  coma  and 
the  visible  increase  of  the  dropsy  in  other  parts  of  the  bod3\  My  own  experience 
accords  entirely  with  that  of  Dr.  Christison  as  expressed  in  the  following  statement. 
"If  the  dropsical  fluid  be  allowed  greatly  to  accumulate,  drowsiness,  the  first  symp- 
tom of  the  affection  of  the  head,  very  soon  makes  its  appearance  in  the  generahty  of 
cases,  and  it  will  speedily  pass  to  fatal  coma  if  not  controlled,  but  the  removal  of  the 
dropsy  will  usually  remove  the  drowsiness." 

To  many  cases,  however,  this  explanation  will  not  apply,  there  being  no  morbid 
collection  of  water  within  the  skull,  nor  any  other  appreciable  change  there ;  nor, 
perhaps,  any  dropsy  elsewhere.  In  such  cases  we  refer  the  ultimate  symptoms,  the 
stupor  and  the  death,  to  the  poisonous  influence  of  the  urea  in  the  unpurified  blood 
upon  the  organs  of  animal  life.  Yet  this  explanation  also  has  its  difficulties.  Urea 
must  often  circulate  with  the  blood  without  affecting  the  brain.  Dr.  Christison 
states  tliat  he  has  repeatedly  known  the  daily  discharge  of  the  solids  of  the  urine  to 
be  reduced,  for  weeks  together,  to  one-fourth  of  the  natural  amount,  while,  moreover, 
analysis  of  the  blood  showed  that  it  was  loaded  with  urea,  without  the  appearance 
of  any  head-symptom.  Dr.  Bright  also  relates  a  case  to  the  same  purpose.  A  per- 
son labouring  under  this  disease  of  the  kidney  lived  for  four  or  five  years  under  his 
occasional  observation.  The  blooil  was  analyzed  in  the  earlier  stage,  and  found  to 
contain  a  large  quantity  of  urea ;  as  much  as  the  urine  itself  contained.  Yet  this 
patient  had  no  Jits  till  towards  the  close  of  his  life. 

I  have  sometimes  fancied  that  the  pale  and  watery  condition  to  which  the  blood  is 
at  last  reduced,  may  have  something  to  do  with  the  stupor  and  coma.  I  showed  you, 
some  time  ago,  when  speaking  of  spurious  hydrocephalus,  that  similar  symptoms  are 
apt  to  ensue,  in  conjunction  with  a  similar  defect  of  hematosin.  It  would  seem  that, 
under  such  circumstances,  the  functions  of  the  brain  are  exercised  irregularly,  lan- 
guidly, and  at  length,  not  at  all,  in  consequence  of  the  failing  supply  of  its  appro- 
priate stimulus  through  the  arteries. 

Another  striking  circumstance  observable  in  this  disease,  is  a  readiness  of  various 
organs  of  the  body  to  inflame,  and  particularly  of  the  serous  membranes.  According 
to  x\l.  Solon,  who  has  lately  published  a  thick  volume  on  Albumimme,  this  disposi- 
tion has  not  been  so  manifest  in  France ;  but  of  its  frequent  appearance  in  this 
country  I  can  add  my  own  testimony  to  that  of  Dr.  Bright,  of  Dr.  Christison,  and  of 
Dr.  Gregory.  Such  intercurrent  acute  inflammation  is  not  an  uncommon  cause  of 
the  patient's  death.  The  pleura  appears  to  be  much  more  often  affected  in  this 
manner  than  either  the  peritoneum  or  the  pericardium. 

It  follows  from  this  tendency  that  when  we  come  to  inspect  the  dead  body,  we 
seldom  find  the  kidney  to  be  the  only  part  in  which  structural  changes  are  plainly 
visible.     Most  commonly  evident  traces  of  disease  are  met  with  in  various  organs. 

Disorder  of  the  stomach  and  bowels  is,  certainly,  a  frequent  companion  of  the 
renal  malady:  nausea,  vomiting,  flatulent  distension,  diarrhoea. 

It  would  appear,  however,  that  these  incidental  and  secondary  complications  pre 
vail  with  irregular  frequency  in  different  places.  The}-  are  probably  determined,  in 
some  measure,  by  local  and  peculiar  agencies.  Thus  vomiting  and  diarrhoea  have 
been  more  familiar  to  the  Edinburgh  observers  than  in  London  to  Dr.  Bright,  or  in 
Paris  to  M.  Solon :  while  the  headaches  and  coma,  so  often  witnessed  by  the  British 
physicians,  have  been  comparatively  uncommon  in  France. 

Disease  of  the  heart,  if  not  a  secondary  consequence,  is  a  verj'^  frequent  accompa 
niment  of  Bright's  kidney.  It  is  probable  that  the  cardiac  disease,  and  the  renal 
disease,  have  sometimes  no  connection  in  respect  to  cause  and  effect,  but  are  both 
results  of  some  common  cause  ;  of  habitual  intemperance,  for  example. 

I  am,  however,  of  opinion  that  the  renal  malady  has  a  direct  tendency,  by  its  effect 
upon  the  blood,  to  generate  disease  of  the  heart.  It  induces  anaemia ;  and  anaemia, 
RS  I  shoAV?^  you  on  a  former  occasion,  implies  debility  of  the  muscular  texture  of  the 


NATURE    OF    THE    DISEASE.  885 

heart,  and  leads  to  dilatation  of  its  cavities  ;  and  the  weak  muscle,  becoming  irritable 
also,  grows  thicker  as  it  labours  more.  In  fact,  this  is  the  kind  of  cardiac  disease 
which,  more  than  any  other,  has  been  found  coincident  with  the  peculiar  change  in 
the  kidney.  Among  100  cases,  recorded  in  a  tabular  form  by  Dr,  Bright,  there  are 
27  in  which  no  affection  of  the  heart  could  be  detected.  In  52  instances  the  heart 
presented  the  characters  of  hypertrophy,  and  of  these  no  fewer  than  34  were  free 
from,  any  trace  of  valvular  disease.  Among  the  34  there  were  11  cases  of  disease 
affecting  the  aorta :  in  the  remaining  23  no  cause  for  the  existing  hypertrophy  and 
dilatation  could  be  found  in  the  heart  itself,  or  in  the  great  blood-vessels.  The  true 
cause  may  therefore  be  reasonably  supposed  to  have  been  the  renal  disease,  ope- 
rating upon  the  involuntary  muscle  through  the  quality  of  the  blood. 

Whether  the  renal  disease  be  ever  produced  by  the  cardiac,  is  more  questionable. 
In  the  acute  renal  affection,  when  it  proves  early  fatal,  the  kidney  is  always  found 
to  be  gorged  with  blood.  And  the  customary  intermixture  of  blood  with  the  urine 
warrants  the  belief  that  the  same  condition  was  present  in  the  patients  who  have 
recovered.  From  this  state  of  engorgement  springs,  apparently,  the  subsequent 
series  of  changes.  It  is  therefore  a  plausible  conjecture  that  whatever  tends  to  pro- 
duce congestion  of  the  kidney,  tends  also  to  aggravate,  and  may  even  cause,  the 
peculiar  changes  in  question.  I  need  not  now  tell  you  that  disease  of  the  heart  does 
frequently  occasion  congestion  of  the  venous  system,  and  gorge  the  viscera  with 
blood.  Under  this  influence  the  liver  often  enlarges.  On  the  other  hand,  disease 
of  the  heart,  even  such  as  gives  rise  to  venous  congestion  and  to  dropsy,  often  lasts 
long,  and  proves  ultimately  fatal,  without  the  occurrence  of  albuminous  urine,  and 
without  any  appreciable  change  of  structure  in  the  kidney. 

Pain  or  tenderness  of  the  loins,  is  sometimes,  and  sometimes  only,  an  accompani- 
ment of  the  renal  disease.  This  symptom  is  more  often  present  in  the  early  than  in 
the  later  stages  of  the  malady.  It  occurred  in  one-third  of  twenty-eight  cases 
narrated  by  M.  Solon.     Dr.  Gregory  noticed  it  in  the  half  of  his  patients. 

The  causes  of  the  disease  of  which  I  have  been  endeavouring  to  sketch  the  out- 
line, are  often  obscure.  Its  more  obvious  symptoms,  in  the  chronic  form  of  the 
malady,  have  been  observed,  in  very  many  instances,  to  begin  soon  after  the  ex- 
posure of  the  body  to  wet  and  cold  under  unfavourable  circumstances.  But  it  is  by 
no  means  certain — indeed  the  probabilities  preponderate  on  the  other  side — that,  in 
these  instances,  the  renal  disorder  had  not  previously  existed  in  a  latent  state. 

It  is  certain,  however,  that  the  acute  kidney  affection,  which  may  be  considered 
identical  with  febrile  dropsy,  does  often  ar.se  under  similar  circumstances  of  ex- 
posure, and  is  attended  with  a  marked  disturbance  of  the  functions  of  the  kidneys. 
And  Bright's  disease,  in  its  chronic  form,  has  been  noticed  as  occurring  in  persons 
who  had  previously  suffered,  and  had  apparently  recovered  from,  an  attack  of  febrile 
dropsy.  Are  we  not  warranted  in  believing  that  the  recovery  was  imperfect  in  such 
cases  ?  that  the  kidney  had  sustained  irretrievable  injury  ?  and  that  the  disease, 
although  from  the  treatment  employed,  or  by  lapse  of  time,  it  had  become  tranquil « 
or  latent,  was  ready  again  to  give  indications  of  its  existence  upon  any  repetition  of 
its  exciting  cause  ? 

Again,  it  is  matter  of  common  observation  that  intemperate  habits  have  often  pre- 
ceded the  development  of  this  disease.  Yet  we  may  conclude  that  intemperance  in 
drinking  is  rather  a  predisposing  than  an  essential  cause,  from  the  fact  that  the 
malady  is  not  unknown  among  children,  and  other  persons  whose  manner  of  life  has 
been  strictly  sober.  I  had  lately  an  example  of  this  in  a  young  girl,  fifteen  years 
old,  who  had  never  menstruated.  And  this  leads  me  to  remark  that  the  renal  disor- 
der has  been  known,  in  many  instances,  to  follow  a  sudden  check  or  suppression  of 
the  cataraenia.  It  has  sometimes  seemed  to  owe  its  origin  to  blows  received  upon 
the  loins. 

The  complaint  happens  at  all' ages:  less  often,  however,  in  extreme  youth  than 
afterwards.  Sabbatier  records  that  he  saw,  while  in  the  service  of  M,  Baudelocque, 
a  young  infant  affected  with  anasarca  and  albuminous  urine.  The  first  case  described 
by  M.  Solon  is  that  of  an  infant,  seventeen  months  old,  in  whom  similar  symp- 
toms appeared  shortly  after  exposfe  to  cold  and  wet.     In  1838  a  boy  between 


886  bright's  kidney. 

five  and  six  years  old,  anasarcous  and  passing  bloody  and  albuniinous  urine,  was  in 
the  Middlesex  Hospital,  under  the  charge  of  my  colleague,  Dr.  Wilson.  M.  Con- 
stant, in  the  Gazette  Medkah  for  1835,  citps  the  case  of  a  child  of  five  years  of  age  ; 
and  M.  Rayer  gives  two  plates,  representing  the  kidneys  of  two  children,  the  one 
five  and  the  other  six  years  old,  who  both  died  of  dropsy  with  albuminous  urine,  the 
sequel  of  scarlet  fever.  In  each  of  these  the  changes  described  bj'^  Dr.  Bright  were 
well  marked,  and  the  bulk  of  the  kidney  was  considerably  increased. 

The  malady  is,  however,  much  more  common  in  adults :  not,  in  all  probabihty, 
because  the  kidney  is  more  readily  susceptible  of  it  at  one  period  of  life  than  another, 
but  because,  as  life  advances,  the  circumstances  which  tend  to  produce  or  to  foster  it, 
become  of  more  frequent  operation  ;  intemperance,  exposure  to  great  vicissitudes  of 
temperature,  and  (perhaps)  disease  of  the  heart. 

It  occurs,  I  presume  for  the  same  reasons,  oftener  in  men  than  in  women. 

Dr.  Christison  suspects  that  Bright's  kidney  happens  chiefly  in  persons  of  scrofu- 
lous habit ;  and  he  found  it,  in  several  instances,  coincident  with  phthisis  pulmonalis. 
My  own  experience  would  not  have  led  me  to  that  opinion.  I  partake  of  M.  Solon's 
doubts,  whether  the  co-existence  of  pulmonary  consumption  and  of  this  renal  malady 
is  more  than  casual.  Dr.  Bright  tells  us  that  "  the  instances  in  which  phthisis,  or 
any  form  of  scrofulous  or  tubercular  disease,  has  been  connected  with  the  renal  affec- 
tion, have  been  decidedly  rare." 

What,  after  all,  is  the  true  character  and  essence  of  the  organic  metamorphosis 
which  constitutes  this  formidable  disorder,  Bright's  kidney  ?  All  that  has  been  as- 
certained of  its  early  stages,  of  its  course,  and  of  its  causes,  furnishes  to  my  mind  a 
strong  presumption  that  the  structural  change,  in  all  its  varieties  of  aspect,  may  be 
ultimately  traceable  to  an  undue  accumulation  and  stagnation  of  blood  in  the  blood- 
vessels of  the  kidney.  Those  curious  arterial  bunches,  the  Malpighian  bodies,  ap- 
pear especially  to  be  over-filled  and  obstructed.  Raj'-er  calls  the  complaint  albwni- 
noifs  nephrifis;  and  perhaps  the  congestion  (which  unquestionably  is  present  in 
what  I  consider  the  acute  form  of  the  malady)  may  sometimes  pass  into  chronic  in- 
flammation. We  do  not,  however,  find  that  it  ever  terminates  in  suppuration  :  yet 
suppuration  is  no  uncommon  event  of  true  inflammation  of  that  part,  excited  by  vio- 
lent injuries,  or  by  the  lodgment  of  calculi  within  it.  It  seems  to  me  more  probable 
that  the  mischief  done  to  the  kidney  is  owing  to  extreme  congestion,  and  its  usual 
consequences — the  oozing  forth  of  the  blood  in  substance,  or  of  some  of  its  constitu- 
ents, into  the  interstitial  textures,  as  well  as  into  the  excretory  tubes  of  the  kidney. 
The  appearance  of  these  ingredients  of  the  blood,  and  even  sometimes  of  blood  itself, 
in  the  urine ;  the  increased  size  of  the  gland  in  the  earlier  stages  ;  the  various  shades 
of  colour  which  its  surface  and  parts  of  its  interior  present,  as  the  colouring  matters 
of  the  effused  fluids  are  more  or  less  absorbed ;  the  impermeability  of  those  altered 
parts  by  artificial  injections  ;  the  ultimate  shrinking  and  hardness  of  the  organ,  as  the 
disorder  becomes  chronic,  and  absorption  proceeds ;  these  are  all  consistent  with  this 
theory.  It  is  plain  that  the  morbid  conditions  of  the  urine  depend,  in  part  at  least, 
upon  the  mechanical  transudation  of  certain  portions  of  the  blood,  which  pass  through 
the  kidney  unchanged,  as  through  an  inert  filter.  Mixed  with  the  urine  we  find 
serum,  with  its  albumen,  and  its  salts,  which  diminish  the  acidity  of  the  mixture,  or 
even  render  it  neutral ;  and  in  many  cases  we  find  more  or  less  of  the  colouring  mat- 
ter also  of  the  blood.  Those  portions  of  the  extravasated  fluid  which  have  no  outlet 
of  escape,  solidify,  and  thus  obliterate  the  natural  texture  of  the  part  they  have  in- 
vaded. The  obstruction  of  the  emergent  veins  of  the  kidney  by  firm  clots  of  blood 
is  in  harmony  with  the  same  supposition. 

When  the  kidney  is  thus  spoiled,  its  natural  function  is  imperfectly  or  but  partially 
performed.  The  change  which  it  should  effect  upon  the  blood  by  purifying  it  from 
urea,  fails  to  be  accomplished.  The  albuminous  impregnation,  and  the  other  altered 
qualities  of  urine  when  voided,  maybe  explained  either  by  supposing  that  the  secret- 
ing power  of  the  whole  gland  is  interfered  v/ith,  but  not  absolutely  suspended  ;  so 
that  the  urine  is  incomplet'ely  elaborated :  or,  by  supposing  that  portions  of  the  gland 
are  spoiled,  and  portions  remain  sound  and  effective ;  that  true  urine  is  formed  by 
the  healthier  portions,  and  mixes  with  the  constituents  of  the  blood  wKich  pass,  as 


ANASARCA.  887 

such,  througli  the  diseased  portions.  The  latter  of  these  hypotheses  :ys  most  in  ac- 
cordance with  the  fact,  that  in  the  advanced  stage  of  the  disorder  (when  we  may- 
conceive  the  spoiled  parts  to  have  become  mere  solid  unchanging  masses)  the  albu- 
men is  apt  to  disappear  from  the  urine  :  and  also  with  the  fact,  that  complete  recovery 
does,  sometimes,  appear  to  take  place  ;  in  which  cases  we  may  imagine  that,  although 
a  small  portion  of  the  substance  of  the  gland  has  undergone  irremediable  change, 
enough  of  it  remains  healthy  to  serve  the  wants  and  purposes  of  the  economy. 

I  have  yet  something  to  say  respecting  the  dropsy,  which  is  so  common  an  ac- 
companiment of  these  renal  changes  ;  but  I  must  d  ^fer  it  till  to-morrow. 


LECTURE  LXXIX. 

Anasarca;  its  consideration,  resumed.  Distinction  of  chronic  General  Dropsy 
into  cardiac  and  renal.  Characters  and  signs  of  each  of  these  varieties.  Treat- 
ment. 

We  were  yesterday  occupied  with  the  circumstances  of  that  remarkable  disease, 
which  has  never  received  a  good  distinctive  name,  but  which  is  sometimes  called 
Bright'' s  disease,  after  the  distinguished  living  physician  who  first  recognized  and 
described  it,  sometimes  yellow  degeneration  of  the  kidney,  sometimes  granular  dege- 
neration. I  endeavoured  to  represent  to  you  by  words  and  by  drawings,  thj  morbid 
appearances  that  are  most  commonly  noticed  in  the  several  stages  of  the  complaint : 
which  morbid  appearances  may,  one  and  all  of  them,  be  traced  (as  I  think)  to  con- 
gestion of  the  kidney ;  to  the  detention  of  blood  in  that  organ,  and  to  the  physical 
consequences  of  such  detention.  I  spoke  of  the  symptoms  which  appear  essential 
to  the  malady,  and  which  consist  in  certain  striking  changes  in  the  urine  and  in  the 
blood  of  the  patient.  I  mentioned  also  the  symptoms  which  are  incidental  to  the 
renal  disease.  But  of  one  of  those  incidental  symptoms,  or  secondary  consequences, 
I  postponed  the  full  consideration  till  to-day ;  I  mean  the  anasarca,  with  which,  most 
commonly,  yet  by  no  means  always  or  necessarily,  it  is  complicated. 

This  is,  for  several  reasons,  a  very  important  symptom.  It  is  usually  the  first 
thing  that  prompts  us  to  suspect,  and  to  inquire  after,  the  renal  malady.  It  was 
through  his  researches  into  the  relation  subsisting  between  chronic  dropsy  and  the 
conditions  of  the  urine,  that  Dr.  Bright  was  led  to  the  discovery  of  the  associated 
affection  of  the  kidney.  The  dropsical  accumulation  adds  greatly  to  the  patient's 
distress,  and  sometimes  constitutes  nearly  the  whole  of  it.  It  adds  proportionally  to 
his  danger.  Moreover,  it  is  that  consequence  of  the  renal  disorder  over  which  our 
curative  measures  have  the  most  control.  Indeed,  under  this  complication  we  have, 
practically,  to  consider  the  remedies  of  the  dropsy,  distinct  from  the  remedies  of  the 
renal  change. 

In  most  cases,  at  the  outset  at  least  of  the  dropsy,  the  skin  is  dry,  and  the  urine 
is  scanty :  and  the  anasarca  is  observed  to  increase,  or  to  decrease,  as  the  quantity  of 
urine  diminishes  or  augments.  The  aqueous  fluid,  Avhich  should  escape  from  the 
surface  and  through  the  kidneys,  collects  in  the  subcutaneous  areolar  tissue.  As  the 
disorder  advances,  the  tendency  to  effusion  of  serum  through  the  sides  of  the  blood- 
vessels is  probably  increased,  not  only  by  the  sluggish  movement  of  the  blood  in  the 
veins,  from  progressive  debility  of  the  heart,  but  also  by  the  cause  of  that  debility 
the  thin  and  watery  condition  of  the  blood  itself;  a  condition  which  I  yesterday 
pointed  out  to  you  as  one  of  the  most  uniform  and  striking  effects  of  the  primrry 
disease. 

And  here  I  again  take  up  the  subject  of  anasarca  and  gene  'al  dropsy.  You  will 
remember  that,  in  the  earlier  part  of  the  course,  I  entered  somewhat  fully  into  ihf 
general  pathology  of  dropsies.  At  the  same  time  I  promised  you  that  I  would  after- 
wards, and  when  you  were  better  prepared  to  understand  them,  endeavour  more  fully 


888  ANASARCA. 

to  explain  some  grand  distinctions  which  have  been  found  to  exist  between  different 
forms  of  general  dropsy.  Having  now,  at  last,  brought  before  you  all  the  ojganic 
changes  which  are  apt  to  give  rise  to  anasarca,  I  am  in  a  condition  to  redeem  that 
promise.  In  doing  so,  I  shall  probably  have  to  remind  you  of  some  things  which 
you  have  already  heard  from  me. 

^^nasnrca,  you  will  please  to  recollect,  signifies  the  filling  up  of  a  considerable 
part,  or  of  the  whole,  of  the  subcutaneous  areolar  tissue,  with  serous  or  watery  fluid  ; 
and  when  to  this  is  added  a  collection  of  liquid  in  the  large  serous  cavities  also,  we 
call  the  complaint  general  dropsy. 

It  is  obvious  that  this  condition  may  exist,  and  in  nature  it  does  exist,  in  various 
degrees :  from  slight  infiltration  of  the  areolar  tissue,  scarcely  noticeable  until,  after 
some  hours  passed  in  the  upright  posture,  it  accumulates  in  visible  oedema  about  the 
ankles — to  the  other  extreme,  in  which  the  integuments  are  everj'^where  stretched  to 
the  utmost,  even  to  bursting;  the  insteps  bulging  upwards;  the  legs  and  thighs 
enormously  enlarged,  cylindrical,  unshapely,  and  exhibiting  partial  vesications ;  the 
surface  of  the  trunk  of  the  body  capable  of  being  kneaded  and  moulded  hke  dough  ; 
the  skin  of  the  penis  distended,  and,  in  consequence  of  its  confinement  by  the  fras- 
num,  twisted  and  circumvolved  so  as  materially  to  impede  the  outward  passage  of 
the  urine ;  the  scrotum,  as  big  as  a  child's  head,  preventing  the  miserable  patient 
from  approximating  his  thighs,  and  from  lying  upon  either  side  ;  the  hands  swollen  ; 
the  face  and  neck  bloated.  With  all  this,  the  peritoneum  is  generally  full  of  hquid, 
and  at  length  the  pleurae ;  and  as  the  scene  is  about  to  close,  there  is  water  in  the 
ventricles  of  the  tirain,  and  an  anasarcous  pia  mater. 

Now,  from  whatever  cause  this  watery  condition  of  the  whole  body  may  arise,  the 
effects  resulting  yj-om  the  presence  of  the  water  are  the  same.  And  of  what  do 
patients  in  this  state  usually  complain  ?  Why,  of  shortness  of  breath,  and  palpitation 
of  the  heart ;  of  a  sense  of  impending  suffocation  if  they  intend  to  lie  down,  or 
actively  to  bestir  themselves ;  of  tightness  and  distress  across  the  epigastrium,  re- 
lieved somewhat  by  eructation,  augmented  by  food  and  drink  ;  of  weight  and  stiff- 
ness of  their  limbs  ;  and,  sometimes,  '^f  drowsiness. 

The  explanation  of  all  this  is  easy  and  obvious.  The  shortness  of  breath  may  be 
accounted  for  on  various  grounds :  by  oedema  of  the  lungs  themselves,  a  state  that  is 
revealed  to  us  through  auscultation ;  by  water  in  the  pleura ;  by  the  pressure  up- 
wards of  the  diaphragm,  which  embarrasses  still  more  the  labouring  heart  and  lungs  ; 
and  i\\\\  upward  pressure  is  increased  by  any  kind  of  distension  or  repletion  of  the 
stomach — diminished  when  the  stomach  is  collapsed,  and  the  upright  position  is 
maintained.  The  heaviness  and  want  of  pliability  of  the  unwieldy  Umbs  are,  hke 
the  rest  of  these  phenomena,  purely  mechanical.  All  parts  are  oppressed  by  the 
unnatural  load  of  water. 

But  we  must  look  beyond  the  dropsy,  and  inquire  whether  the  complaint  has  set 
in  suddenly,  and  simultaneously  with  febrile  disturbance,  invading  all  the  districts 
of  the  body  at  once,  and  quickly  reaching  its  present  degree  ;  or  whether  it  has  crept 
upon  the  patient  slowly  and  by  stealthy  steps :  whether  it  has  had  any  obvious  or 
probable  exciting  cause ;  or  whether  it  has  approached  insidiously,  we  know  not 
whence  or  a  hy :  whether  (in  a  word)  the  case  be  one  of  active  and  febrile  dropsy, 
or  of  chronic  and  passive. 

No'vV,  setting  aside,  for  the  present,  an)'-  more  particular  consideration  of  the  acute 
or  febrile  form  of  general  dropsy,  and  contemplating  those  forms  only  which  are 
chronic,  we  find  that  all,  or  nearly  all  of  them,  may  be  arranged  in  two  great  classes  ; 
those  Avhich  depend  upon  disease  or  debility  of  the  heart  forming  one  class,  those 
which  depend  upon  disease  of  the  kidney  constituting  the  other.  To  these  classes 
we  accordingly  apply  the  terms  cardiac  dropsy  and  renal  dropsy.  They  are  often 
combined  in  the  same  individual ;  but,  taking  the  pure  cases  of  each  form,  we  may 
proceed  to  inquire  into  their  peculiar  features,  how  they  may  be  distinguished,  and 
rthat  differences  of  treatment  they  may  require. 

And  first  of  cardiac  dropsj^ 

The  mode  in  which  disease  of  the  heart  may  occasion  general  dropsy  has  been 
sufficiently  explained  already.     We  infer  that  the  dropsy,  in  a  given  case,  has  this 


CARDIAC   DROPSY.  889 

origin,  if  we  find  that  thoracic  symptoms,  such  as  cough  and  dyspnoea,  preceded  the, 
dropsy :  or  if  we  perceive  direct  signs  of  cardiac  disease,  such  as  distended  jugular 
veins,  irregular  movements  of  the  heart,  unnatural  impulse,  altered  sounds;  or,  if 
we  trace  the  history  of  some  previous  acute  disease,  affecting  especially  the  left  side 
of  the  thorax:  or  if  we  learn  that  the  patient  has  formerly  suffered  acute  rheuma- 
tism :  or  if  the  patient's  age  is  so  much  advanced  as  to  make  it  probable  that  some 
of  those  organic  changes  in  the  heart  and  large  blood-vessels  are  in  progress,  which 
are  almost  natural  in  the  dechne  of  hfe.  And  our  inference  is  confirmed  if  there  be 
no  discoverable  indication  of  renal  disease. 

But  we  see  many  persons  who  labour  unequivocally  under  organic  disease  of  the 
heart,  yet  who  survive,  even  for  many  years,  without  becoming  dropsical.  The 
interesting  question  therefore  arises,  of  what  kind  of  heart-disease  is  dropsy  a  conse- 
quence and  symptom  ?  You  already  know  the  answer.  It  is  such  disease  as  offers 
a  certain  amount  of  permanent  obstruction  to  the  passage  of  the  venous  blood. 
Hence,  dropsy  is  especially  associated  with  dilatation  of  the  right  chambers  of  the 
heart.  It  would  not  be  correct  to  say  that  the  anasarca  is  dependent  on  such  dilata- 
tion, for  the  dilatation  itself  is  at  once  an  effect  and  a  sign  of  impeded  transmission 
of  blood  from  the  right  side  of  the  organ.  Nor  is  such  dilatation  a  necessary  attend- 
ant on  the  general  accumulation  of  water.  The  impediment  may  be  sufficient  to 
gorge  the  right  cavities,  while  it  is  yet  too  slight  in  amount,  or  too  recent  in  dura- 
tion, to  have  dilated  them. 

What,  then,  are  the  physical  conditions  which  oppose  to  the  blood  in  the  veins 
such  an  impediment  as  we  are  now  considering?  The  two  great  vital  organs  con- 
tained within  the  thorax,  the  heart,  namely,  and  the  lungs,  form  different  parts  of 
one  common  mechanism,  the  object  of  which  is  to  supply  every  tissue  of  the  body 
with  blood  that  has  recently  been  purified  by  exposure  to  the  air ;  and  these  organs, 
thus  closely  related  in  their  functions,  are  moreover  so  reciprocally  dependent,  that 
structural  disease  occurring  in  the  one,  tends  to  produce  disease,  sooner  or  later,  in 
the  other  also. 

And  I  wish  you  again  to  observe  the  order  and  direction  in  which  disease  is, 
almost  always,  propagated  from  one  part  of  this  apparatus  to  another.  It  is  a  back- 
ward direction — opposite,  I  mean,  to  the  course  of  the  blood.  There  are,  strictly 
speaking,  two  hearts,  which  he  side  by  side  in  respect  to  their  anatomical  position, 
but  which,  reference  being  made  to  their  vascular  inter-communication,  are  really 
separated  from  each  other  by  the  lungs.  The  great  veins  precede,  and  the  great 
arteries  follow,  this  chain  of  connected  organs.  Disease  occurring  in  any  one  part 
of  the  chain  becomes  a  cause  of  consecutive  disease  in  the  part  immediately  behind 
it.  And  this  law  obtains,  as  I  have  shown  you  before,  in  regard  to  the  several 
chambers  of  the  heart,  considered  as  a  single  organ. 

Thus,  structural  disease  situated  at  the  aortic  outlet  of  the  heart,  and  of  such  a 
kind  as  to  hinder  the  exit  of  the  blood  from  the  left  ventricle,  gives  rise  to  permanent 
changes  in  that  ventricle  ;  to  hypertrophy  with,  or  less  commonly  without,  dilatation. 
The  hypertrophy  is  strictly  a  compensating  and  conservative  change  ;  and  when  it 
is  exactly  proportioned  to,  and  keeps  pace  with,  the  impediment  which  has  given  it 
birth,  so  as  precisely  to  balance  and  countervail  it,  no  delay  takes  place  in  the 
stream  of  arterial  blood,  and  the  injury  is,  as  yet,  confined  to  the  left  ventricle.  That 
chamber  is  remodeled,  and  adapted  to  its  purpose  by  the  vis  medicatrix  naturae; 
and  no  other  evil  manifests  itself  than,  perhaps,  some  shght  encroachment  and 
pressure  upon  the  neighbouring  parts,  in  consequence  of  the  augmented  volume  of 
the  heart. 

So  long  as  the  mitral  valve  remains  healthy  and  effective,  it  offers  a  barrier  of  pro- 
tection against  the  extension  of  the  disease  in  the  direction  which  is  retrograde  to  the 
course  of  the  blood.  But  at  length,  in  most  instances,  the  stress  becomes  sensible 
further  back.  The  left  auricle  and  the  pulmonary  veins  become  choked  and  dis- 
tended ;  the  blood  is  detained  in  the  lungs.  Then  commences  dyspnoea :  at  first 
occasional  only,  whenever  the  heart  is  tasked  with  the  conveyance  of  a  greater  quan- 
tity of  blood  in  a  given  time  than  usual,  as  in  brisk  movements  of  the  body,  or  sud- 
den emotions  of  the  mind ;  or  when  it  is  oppressed  by  circumstances  that  diminisQ 

3z 


890  ANASARCA. 

:he  capacity  of  the  chest ;  by  a  full  meal,  therefore,  by  flatulent  disten^'ou  of  the 
Biomach  and  intestines,  by  the  recumbent  posture.  Afterwards  the  shortness  of 
breath  becomes  more  or  less  constant  and  distressing. 

Now  this  loaded  and  embarrassed  state  of  the  lungs,  even  when  it  is  permanent 
and  has  reached  a  considerable  degree,  may  exist  without  materially  interfering  with 
the  functions  of  the  right  or  venous  heart :  for  the  pulmonary  plethora  may  be 
reheved  by  increased  secretion  from  the  bronchial  mucous  membrane.  Dyspncsa, 
even  when  it  has  become  habitual,  may  piecede  for  some  time  any  appearance  of 
dropsy. 

At  last,  however,  the  effects  of  the  original  evil  augmenting  and  extending,  the 
right  ventricle  also  becomes  unable  duly  to  propel  its  contents  into  the  pulmonary 
vessels;  it  continues  morbidly  full,  is  first  distended  occasionally,  then  permanently, 
and  dt  length  really  dilated ;  and  with  that  dilatation  we  have  a  turgid  venous  sys- 
tem, of  which  we  see  a  part  in  the  prominent  veins  of  the  neck. 

In  this  way  then  may  be  explained  a  series  of  symptoms  which  you  will  often 
witness,  and  be  consulted  about,  in  persons  who  are  growing  old.  You  will  find 
irregularity  of  the  pulse;  preternatural  impulse  perhaps  of  the  heart;  occasional 
snortness  of  breath  ;  large  crepitation,  habitually  audible  in  the  lower  portions  of  the 
lungs ;  more  or  less  expectoration,  sometimes  tinged,  sometimes  even  loaded,  with 
biood.  Eventually  the  ankles  begin  to  swell ;  and  the  patient  (if  his  life  is  not  cut 
short  earlier  in  some  other  way)  becomes  by  degrees  decidedly  and  universally 
dropsical. 

Many  of  the  direct  signs  of  diseased  heart  may  exist,  therefore,  w^hile  there  is  no 
anasarca :  intermissions  and  irregularity  in  its  movements,  palpitation,  the  impulse 
proper  to  hypertrophj'.  But  when  dropsy  has  supervened,  we  may  expect  also  the 
signs  which  denote  dilatation  of  the  right  chambers.  The  heart  is  heard  and  felt  to 
beat  beyond  the  prcecordial  limits  ;  the  pulsations  become  feeble  and  unequal,  if  they 
were  not  so  before ;  the  patient  is  liable  to  fluttering  palpitations,  to  extreme  and 
panting  dyspnoea  on  the  shghtest  exertion,  even  on  taking  food  into  the  stomach,  or 
adopting  the  recumbent  posture ;  his  skin  assumes  a  dusky  hue,  and  his  lips  and 
extremities  are  apt  to  be  livid. 

In  these  cases  the  anasarca  first  becomes  manifest  about  the  ankles.  During  the 
earlier  stages  the  oedema  disappears  in  the  night,  and  returns  towards  the  next  even- 
'iig.  It  is  sometimes  confined,  for  a  long  while,  to  the  legs  ;  but  ultimately  it  creeps 
up  towards  the  trunk  of  the  body  ;  the  loins  and  flanks  become  doughy,  the  scrotum 
fills,  and  water  collects  in  the  serous  bags  of  the  abdomen  and  thorax.  In  extreme 
cases  the  dropsy  is  universal,  pervading  the  areolar  tissue  of  the  head  and  face  and 
upper  limbs. 

As  the  accumulation  of  serous  liquid  is  commonly  gradual,  the  reticular  tissue, 
partly  perhaps  through  maceration,  but  chiefly  from  continued  pressure  and  stretch- 
ing, loses  its  elasticity ;  and  the  cedema  is  soft,  and  pits  readily. 

Sometimes,  the  fluid  continuing  to  increase,  the  cuticle  is  raised  by  it,  and  large 
vesications  take  place  on  the  limbs  ;  or  some  part  of  the  areolar  tissue  sloughs,  and 
a  breach  of  surface  is  made,  and  the  fluid  drains  off  by  this  vent  in  great  abundance, 
to  the  signal  relief  of  the  patient.  This  beneficial  accident  furnishes  us  with  a 
valuable  practical  hint. 

Such,  then,  is  the  consummation  of  disease  commencing  in  the  left  heart,  and 
working  its  gradual  way,  through  the  lungs  to  the  right  heart.  But  the  obstacle  may 
originate  at  a  less  distant  link  in  the  chain.  The  circulation  may  be  checked,  first  of 
all,  in  the  intermediate  lungs :  and  it  may  be  worth  our  while  to  consider,  for  a  moment, 
the  relations  which  subsist  between  general  dropsy  and  certain  pulmonary  diseases. 

Whenever,  in  pneumonia,  a  large  portion  of  one  or  of  both  lungs  becomes  impei- 
vious  to  air  and  to  blood — or  when  pleurisy  fills  one  side  of  the  thorax  with  liquid, 
which,  by  its  pressure,  shuts  out  both  air  and  blood  at  once  from  one-half  of  the  respi- 
ratory apparatus — the  egress  of  the  blood  from  the  right  heart,  and,  therefore,  from 
the  venous  system,  must  be  checked.  We  might  expect  that  dropsical  effusion  would 
be  the  result  of  these  changes ;  and  in  truth  it  does  sometimes  occur.  That  it  does 
not  happen  more  frequently  is  to  be  attributed,  I  believe,  to  the  free  evacuations,  and 


RENAL   DROPSY.  891 

the  strict  abstinence,  which  are  early  put  in  force  in  those  complaints,  and  which 
rel'eve  the  venous  plethora  before  it  produces  eflusion. 

So,  again,  luncrs  that  are  hollowed  out  in  large  cavities  or  rendered  solid  over  a 
wide  space  by  numerous  tubercles,  are  manifestly  incapable  of  admittingr  inio  their 
vessels  from  the  right  ventricle  the  ordinary  quantity  of  venous  blood.  In  these 
cases,  however,  the  whole  mass  of  blood  is  diminished,  and  kept  within  the  limit 
which  does  not  imply  distension  of  the  veins,  by  the  constant  agency  of  various 
causes  ;  by  the  imperfect  nutrition  consequent  upon  abdominal  disease  ;  by  the  some- 
times copious  expectoration ;  by  the  wasting  diarrhosa ;  by  the  profuse  nocturnal 
sweats.  Accordingly  anasarca  is  an  unusual  symptom  in  pulmonary  phthisis,  or 
shows  itself  in  the  latter  periods  only  of  the  disease,  in  the  form  of  oedema  of  the 
legs :  and  its  occurrence  then  is  mainly  owing  to  the  debihty  which  affects,  in  com- 
mon with  the  other  muscular  parts  of  the  body,  the  moving  organ  of  the  blood. 

The  pulmonary  disease  which  more  commonly  and  certainly  than  any  other, 
though  often  very  slowly,  leads  to  dropsy,  is  emphysema  of  the  lungs.  I  showed 
you,  some  time  ago,  that  in  this  morbid  condition  many  of  the  smaller  blood-vessels 
of  the  lung  become  gradually  obliterated ;  and  when  the  disease  is  extensive  and 
advanced,  large  portions  of  the  organ  are  visibly  white  and  bloodless.  Meanwhile, 
the  nutrition  of  the  body  is  not  impaired  ;  the  same  quantity  of  blood  continues  to  be 
returned  towards  the  heart,  but  it  finds  not  a  ready  entrance  into  the  pulmonary 
blood-vessels,  when  delivered  from  the  right  ventricle.  A  certain  amount  of  accu- 
mulation becomes  habitual  in  that  chamber,  and  in  the  great  veins  ;  and  at  length 
the  capillary  vessels  feel  the  mechanical  congestion,  and  more  or  less  anasarca  ensues. 

So  much  for  dropsy  that  is  purely  cardiac.  Let  us  next  consider  the  circumstances 
from  which,  during  the  lifetime  of  the  patient,  we  draw  the  conclusion  that  the 
dropsy  he  exhibits  is  of  renal  origin. 

There  is  nothinsf,  that  I  know  of,  very  peculiar  or  distinctive  in  the  characters  of 
the  anasarca  itself.  When  the  renal  complaint  sets  in  suddenly,  and  with  acute 
symptoms,  dropsy  usually  supervenes  soon.  So  also,  during  its  more  chronic  pro- 
gress, anasarca  is  apt  to  show  itself,  or  to  increase,  whenever  local  inflammation,  or 
febrile  disturbance,  happens  to  arise.  The  more  rapid  and  copious  the  effusion,  the 
less  do  the  dropsical  parts  pit  upon  being  pressed.  It  may  be  said  also  of  this  renal 
form  of  dropsy,  that  accumulation  in  the  larger  serous  cavities  is  not,  in  general,  a 
prominent  feature. 

If  we  find,  upon  due  scrutiny,  no  material  or  adequate  embarrassment  of  the 
respiratory  functions,  no  deviations  from  the  natural  sounds  of  the  heart,  no  derange- 
ment of  its  regular  movements,  no  alteration  in  the  force  of  its  pulsations,  or  in  the 
space  over  which  they  can  be  felt  and  heard,  no  distension  of  the  large  veins  of  the 
neck — then  we  have  reason  for  suspecting  that  the  anasarca  is  connected  with  some 
vice  of  the  kidney. 

But  we  cannot  infer  from  the  presence  of  heart-symptoms,  that  the  kidney  is  free 
from  disease. 

Our  judgment  is  guided,  or  assisted,  in  some  degree,  by  the  complexion  of  the 
patient.  When  general  dropsy  depends  upon  disease  of  the  heart,  the  cheeks  and 
lips  are  occasionally  florid,  often  purplish  or  hvid,  frequently  dusky  and  loaded. 
Sometimes  (as  in  chlorotic  women,  where  the  heart  may  be  temporarily  distended 
without  any  positive  organic  disease,  and  the  blood  is  thin  and  poor)  the  face  and 
mucous  membranes  are  pale :  but  in  the  renal  variety  of  dropsy  there  is  a  very  cha- 
racteristic hue  ;  an  evident  lack  of  red  blood,  indeed,  in  the  capillaries,  but  withal  an 
unhealthy  dingy  sallowness,  significant,  to  a  practised  eye,  of  some  deep-seated  al- 
teration of  structure. 

Our  suspicion  that  the  kidney  is  the  organ  primarily  in  fault  is  strengthened,  if 
we  trace  certain  accidents  in  the  history  of  our  patient.  An  attack,  for  example,  of 
illness,  attended  perhaps,  with  temporary  swelUng  of  the  body  and  disturbance  of 
the  urinary  functions  (acute  dropsy,  in  short),  soon  after  some  exposure,  under  un 
favourable  circumstances,  to  the  influence  of  cold  ;  either  applied  to  the  external 
surface,  or  to  the  stomach  by  a  draught  of  cold  drink.  For,  as  I  told  you  yesterday, 
there  is  reason  to  believe  that  in  acute  dropsy  is  often  laid  the  foundation  of  thos« 


892  ANASARCA. 

peculiar  changes  in  the  kidney  which,  since  they  xere  first  pointed  out  by  Dr.  Bright, 
Lave  been  chiefly  studied  in  their  connection  with  chronic  dropsy.  That  as  rheu- 
matic carditis  may  occur,  and  become  latent  as  to  its  effects  for  some  time,  and  j'et 
implant  the  germs  of  future  cardiac  dropsy,  so  the  stress  or  strain  which  befalls  the 
kidney  in  cases  of  febrile  anasarca,  may  set  on  foot  a  morbid  process  that  long  works 
silently  and  unobserved,  but  at  last  declares  its  operation  by  symptoms ;  the  repro- 
duction of  the  dropsy  in  a  more  chronic  form  being  the  most  significant  symptom  of 
all.  The  acute  attack  may  have  been  forgotten  ;  there  may  have  been  no  obvious 
(though  there  may  have  been  ill-understood)  indications  of  the  renal  affection ;  and 
its  existence  has  been,  therefore,  unsuspected. 

The  discovery  of  intemperate  habits  would  also  be  of  importance  in  aid  of  our  di- 
agnosis, if  these  same  habits  had  not  a  like  influence  in  causing  disease  of  other  organs 
as  well  as  of  the  kidney,  and  especially  of  the  heart.  There  may,  however,  be  no 
such  episodes  as  these  in  the  patient's  history.  The  dropsy  may  have  come  on  im- 
mediately after  some  exposure,  or  obviously  injurious  influence,  yet  not  with  acute 
symptoms,  and  in  a  temperate  subject :  in  which  case  it  is  probable  that  the  renal 
disease  had  pre-existed  in  a  latent  state.  Or  the  anasarca  may  have  stolen  on  by 
degrees,  without  any  apparent  cause. 

But  the  most  conclusive  evidence  of  the  renal  disease  is  to  be  found  in  the  condi- 
tions of  the  urine :  which  were  fully  explained  to  you  in  yesterday's  lecture.  I  shall 
therefore  only  add  four  rules  upon  the  subject,  which  have  been  laid  down  by  Dr. 
Christison,  and  generally  acquiesced  in  by  Dr.  Prout.  These  rules  assert  that  or- 
ganic disease,  or  granular  degeneration,  or  granular  disorganization  of  the  kidney — 
all  which  phrases  we  may  condense  into  the  compendious  expression  "Bright's  kid- 
ney"— is  present : 

1.  In  most  cases  of  febrile  dropsy,  including  those  which  are  consequent  upon 
scarlet  fever.     To  this  proposition  I  have  already  given  my  full  assent. 

2.  In  all  cases  of  anasarca,  wherein  the  cedematous  parts  are  elastic,  and  do  not 
pit  upon  pressure.  I  am  not  so  sure  of  this  rule.  I  believe  that  the  firmness  of  the 
cedematous  parts  has  relation  rather  to  the  rapidity  with  which  the  effusion  has  taken 
place,  than  to  the  local  origin  of  the  dropsy.  In  proportion  as  the  accumulation  in 
the  areolar  tissue  has  been  chronic  and  gradual,  does  the  swelling  receive  and  retain 
indentation  from  external  pressure. 

3.  In  most,  or  all  cases  of  dropsy  attended  with  diuresis,  provided  the  urine  be 
not  saccharine.  Such  cases.  Dr.  Christison  truly  remarks,  are  far  from  being  un- 
common. Of  course  the  diuresis  here  spoken  of  is  such  as  occurs  independently  of 
diuretic  remedies. 

4.  In  all  dropsies  associated  with  urine  of  a  very  low  specific  gravity  (say  below 
1010),  and  not  exceeding  the  natural  standard  of  quantity,  whether  it  be  albuminous 
or  not.     To  the  last  two  rules  there  are  probably  very  few  exceptions. 

The  dropsy  which  is  dependent  upon  "  Bright's  disease"  yields,  not  unfrequently, 
to  treatment ;  but  it  is  prone  to  recur.  Of  the  renal  disease  itself  the  prognosis  is, 
no  doubt,  very  unpromising.  Yet  I  do  not  think  so  despairingly  of  these  cases  as  I 
once  thought ;  and  as  many  think.  I  have  known  a  few  instances  of  what  seemed 
complete  recovery  after  well-marked  symptoms  of  the  disorder.  Certainly  success 
enough  has  followed  careful  treatment  to  encourage  us  to  use  all  diligence  in  prose- 
cuting such  remedial  measures  as  are  already  known,  and  in  devising  new  ones. 

I  have  been  speaking  of  dropsies  that  are  purely  cardiac,  and  of  dropsies  that  are 
purely  renal.  But  I  have  already  told  you  that  disease  of  the  heart  and  disease  of 
the  kidney,  frequently  go  together;  and  I  have  endeavoured  to  estimate  their  relation, 
in  such  cases,  to  each  other.  When  both  organs  are  structurally  affected,  the  dis- 
position to  dropsical  accumulation  must  evidently  be  augmented.  What  share  they 
have,  respectively,  in  producing  the  dropsy,  it  would  be  very  difficult,  and  practically 
;t  is  not  very  important,  to  determine. 

In  chronic  general  dropsy  of  a  purely  cardiac  origin,  the  kidneys,  being  sound, 
offer  the  most  convenient  and  eligible  channel  for  carrying  off  the  superfluous  water. 
Diuretic  medicines,  therefore,  rank  among  the  most  important  of  our  curative  expe- 
dients.    AVhen  they  fail  to  act,  or  prove  insufficient  for  the  purpose  sought,  we  next 


RENAL   DROPSY.  893 

have  recourse,  the  state  of  the  bowels  permitting,  to  drastic  or  hydragogue  purga- 
tives. 

Diuretics  are  notoriously  of  most  uncertain  operations;  sometimes  completely 
answering  our  wishes,  oftener  perhaps  disappointing  them  altogether.  When  the 
urine  is  strongly  acid,  and  deposits,  on  coohng,  a  sediment  like  brick-dust,  it  may  be 
well  to  try,  at  first,  the  alkaline  diuretics,  and  particularly  the  salts  of  potass.  Nitre 
added  to  the  common  saline  draught ;  or  a  combination  of  the  acetate  and  bicarbon- 
ate of  potass ;  or  the  bitartrate  in  small  doses ;  or  the  iodide  of  potassium :  or  the 
liquor  potassse.  In  my  own  experience  the  tincture  of  squills  also  has  seemed  to 
correct  this  superacid  and  turbid  condition  of  the  urine,  while  it  increased  its  quantity. 

The  benzoate  of  ammonia  is  another  salt  which  I  have  found  to  operate  very 
powerfully,  in  several  instances,  as  a  diuretic. 

Digitalis  sometimes  promotes,  in  a  remarkable  degree,  the  flow  of  urine  ;  and  this, 
in  my  judgment,  is  its  most  useful  and  manageable  property.  Small  quantities  of 
the  tincture,  or  of  the  infusion,  may  be  added  to  other  formulae.  Or  the  powdered 
leaves  may  be  combined  in  pills.  But  one  of  the  best  modes  of  exhibitino-  dio-itahs 
for  this  purpose  is  to  give  larger  doses  of  the  infusion,  half  an  ounce,  for  example,  in 
some  cordial  water,  at  intervals  of  four  or  six  hours,  till  three  doses  have  been  taken 
in  succession  ;  and  then  to  pause  and  note  its  effects ;  and  to  repeat  the  three  doses, 
or  not,  accordingly. 

The  spirit  of  nitrous  aether,  and  the  compound  spirit  of  juniper,  have  both  of  them 
well-marked  diuretic  properties,  and  may,  with  propriety,  be  added  to  most  of  the 
liquid  formulae  for  augmenting  the  discharge  of  urine.  And,  as  vehicles  for  more 
active,  or  more  concentrated  ingredients,  those  vegetable  infusions  or  decoctions  should 
be  chosen  which  are  reputed  to  possess  similar  virtues ;  such  as  the  decoction  of 
broom-tops,  or  of  juniper-berries,  or  of  winter  green,  or  the  infusion  of  buchu. 

Squills,  turpentine,  the  tincture  of  cantharides,  are  drugs  of  a  more  stimulant  nature, 
more  peculiarly  adapted  to  cases  in  which  there  is  no  febrile  disturbance,  and  the 
kidneys  are  obstinately  inactive. 

Sometimes  a  combination  or  farrago  of  diuretic  substances  proves  more  efficacious 
than  larger  doses  of  any  of  the  ingredients  administered  singly :  and  the  operation 
of  some  of  these  combinations  is  undoubtedly  quickened  and  exalted,  in  many  in- 
stances, by  the  addition  of  mercury.  A  fluid  drachm  of  the  officinal  solution  of  the 
bichloride  in  each  dose  of  a  mixture ;  or  small  quantities  of  calomel  or  of  blue  pill 
when  the  medicines  are  given  in  a  solid  form.  A  very  useful  pill  of  this  kind,  much 
recommended  by  the  late  Dr.  Baillie,  consists  of  three  or  four  grains  of  the  pilula 
hydrargyri,  mixed  up  with  one  grain  of  the  dried  powder  of  squills,  and  half  a  grain 
of  the  dried  leaves  of  digitalis;  to  be  given  twice  or  thrice  a  day.  Dr.  Baillie  states 
that  squills  and  digitalis  are  much  less  effectual  by  themselves,  than  when  combined 
with  mercury. 

Tn  choosing  purgative  drugs  to  aid  the  effect  of  diuretics  in  carrying  off  the  drop- 
sical fluid,  or  to  take  their  place  when  these  fail  to  act,  we  select  those  which  produce 
copious  and  watery  discharges  from  the  bowels.  A  combination  of  jalap  and  cream 
of  tartar  has  been  long  and  deservedly  esteemed  for  its  excellent  operation  in  this 
way.  Gamboge  is  also  a  good  cathartic.  It  may  be  given  two  or  three  times  daily, 
in  grain  or  two-grain  doses,  with  a  drachm  of  cream  of  tartar,  suspended  in  two 
ounces  of  peppermint  water.  Or  half  an  ounce  of  cream  of  tartar,  mixed  in  six 
ounces  of  peppermint  water,  may  be  administered  in  one  dose  every  morning. 
Croton  oil,  and  elaterium,  are  still  more  powerful  evacuants  of  serous  liquid  from 
the  intestines.  One  or  two  drops  of  the  former,  or  from  a  quarter  of  a  grain  to  a 
grain  of  the  latter,  will  be  about  a  proper  dose.  It  is  astonishing  how  much  relief 
to  the  feelings  of  the  patient,  and  how  great  a  diminution  of  the  dropsical  symptoms, 
are  sometimes  obtained  by  these  active  cathartics.  Patients  will  earnestly  beg  for  a 
repetition  of  them,  even  when  their  operation  is  attended,  for  the  time,  with  consi- 
deraOie  pain  or  sickness,  and  much  general  distress. 

In  addition  to  these  measures  for  the  removal  of  the  collected  water,  auention  must 
be  paid  to  the  actual  condition  of  the  heart.  If  the  dropsy  has  been  the  result  of 
anaemia,  or  of  cachexy  of  the  system,  you  must  endeavour  to  strengthen  your  patient, 

3z2 


804  ANASARCA. 

nnd  to  repair  his  impoverished  blood,  by  nutritious  food  and  tonic  medicine,  and 
especially  by  the  administration  of  steel.  I  told  you  formerly  that  preparations  of 
iron  have  an  exceedingly  good  effect,  oftentimes,  even  in  cases  of  organic  disease 
of  the  heart,  consisting  in  dilatation  and  tenuity,  and  consequently  weakness  of  its 
muscular  parietes. 

On  the  other  hand,  if  there  be  violent  palpitations  of  the  heart,  with  a  strong 
heaving  impulse,  you  may  appease  the  excessive  action,  and  afford  sensible  comfort 
to  the  patient,  by  applying  leeches,  from  time  to  time,  to  the  prsecordia. 

Of  the  renal  variety  of  chronic  general  dropsy,  whether  pure  or  mixed,  the  treat- 
ment is  less  accurately  ascertained.  The  uncertainty  which  has  perplexed  men's 
minds  respecting  the  nature  of  the  renal  disorder,  has  extended,  in  some  measure,  to 
their  choice  of  remedies  for  it. 

Whenever  (in  renal  dropsy)  acute  symptoms  and  febrile  disturbance  occur,  much 
relief  may  be  expected  from  the  abstraction  of  blood.  When  drawn  from  a  vein,  it 
usually  shows  the  huffy  coat.  The  existence  at  the  same  time  of  pain  in  the  loins, 
would" indicate  the  propriety  of  applying  cupping  glasses  to  that  part.  Nevertheless, 
the  impoverishing  effect  of  the  disease  itself  upon  the  blood,  and  the  probable  de- 
pendence of  some  of  the  more  distressful  and  alarming  symptoms  upon  the  thin 
serous  condition  of  the  circulating  fluid,  as  well  as  the  increased  facility  with  which 
the  dilute  blood  may  transude  outwards — these  are  circumstances  which  should  in- 
duce every  cautious  practitioner  to  have  recourse  to  this  heroic  remedy  only  when 
it  is  clearly  demanded. 

One  definite  object,  in  the  renal  as  well  as  in  the  cardiac  variety,  is  to  remove  the 
dropsical  fluid,  from  which  the  danger  and  the  suffering  often  chiefly  proceed.  But 
it  is  a  more  nice  question,  when  the  kidney  is  involved  in  the  disease,  how  this  is  to 
be  accomplished.  Can  we,  with  the  same  safety  as  in  cardiac  cases,  employ  diuretics  ? 
It  has  been  thought  that  we  cannot.  As  the  primary  morbid  state  of  the  kidney  is 
certainly  often,  and  probably  always,  a  state  of  congestion,  it  has  been  feared  that 
direct  diuretics,  such  as  are  calculated  to  cause,  keep  up,  or  augment  congestion  of 
the  kidney,  or  to  stimulate  and  irritate  that  organ,  would  be  likely  to  accelerate  the 
disorganizing  process  of  which  it  is  already  the  seat. 

Now,  although  these  views  are  theoretical,  and  their  justness  has  not  yet  been 
established  by  positive  proof,  you  had  better,  when  yoM  can,  observe  the  caution 
which  they  suggest.  You  had  better  endeavour  to  empty  the  distended  cavities, 
and  to  relieve  the  loaded  areolar  tissue,  through  the  bowels,  or  through  the  skin. 
Sometimes,  however,  —  more  often  indeed  than  in  cardiac  dropsy  —  we  have  the 
untoward  complication  of  irritable  bowels,  or  habitual  diarrhcea ;  and  then  drastic 
cathartics  are  inadmissible.  But  when  this  complication  is  not  present,  they  are 
eminently  useful. 

Much  benefit  is  sometimes  derived  from  measures  that  act  powerfully  or  steadily 
upon  the  cutaneous  transpiration ;  and  especially  from  warm,  or  hot-air,  baths.  The 
hot-air  bath  is,  in  many  rpspects,  preferable  to  the  common  warm-water  bath,  and 
even  to  the  vapour  bath.  Upon  the  principle  of  heterogeneous  attraction,  the  escape 
of  the  liquid  from  the  surface  of  the  body  is  more  promoted  by  a  dry  heat  than  by 
water  artificially  raised  to  a  high  temperature,  and  even  than  by  an  atmosphere  made 
moist,  as  well  as  hot,  by  vapour.  The  risk,  moreover,  of  exposure  to  cold,  and  the 
inconvenience  and  hazard  of  fatigues,  are  much  less :  for  the  hot  air  can  be  brought, 
with  but  little  trouble  or  expense,  to  the  patient  as  he  lies  in  bed.  I  have  often 
applied  the  sudatorium  to  patients  labouring  under  renal  dropsy,  and  they  have  ob- 
tained much  relief  from  it :  but  the  relief  is  seldom  of  itself  sufficient,  or  of  more 
than  temporary  duration.  Still  it  is  an  expedient  that  should  never  be  neglected; 
and  in  pursuance  of  the  same  indication,  diaphoretic  medicines  should  at  the  same 
lime  be  diligently  exhibited.  Dr.  Osborne  states  that  when  the  renal  disease  has 
been  uncomplicated  with  other  organic  mischief,  he  has  always  found  the  dropsy  to 
disappear  upon  the  re-estabhshment  of  the  functions  of  the  skin. 

These  measures  failing — as  fail  they  often  will ;  and  diarrhoea  forbidding  the  use 
of  drastic  purgatives  ;  or  drastic  purgatives  and  diaphoretics  together  proving  insuf- 


TREATMENT  895 

ficient ;  we  miisf,  even  in  renal  dropsy,  choose  the  least  of  two  evils ;  or  rather  we 
must  incur  the  risk  of  one  possible  and  contingent  evil,  for  the  chance  of  obtaining 
what,  if  obtained,  is  a  certain  and  positive  benefit ;  we  must  endeavour  to  remove 
the  dropsical  accumulation  by  means  oi  diuretics,  whether  these  accelerate  the  pro- 
gress of  the  disease  in  the  kidney  or  not. 

Such  diuretics,  therefore,  are,  in  the  first  instance,  to  be  selected,  as  seem  the  least 
likely  to  stimulate  the  kidneys  injuriously.  The  bitartrate  of  potass  has  been  found 
one  of  the  most  certain  and  useful.  Digitalis  also  is  esteemed  safer,  and  therefore 
more  proper  for  this  purpose,  than  many  others :  and  the  simultaneous  exhibition 
of  these  two  has,  perhaps,  the  surest  effect  of  all. 

When  diuretic  medicines  act  as  we  intend  them  to  do,  and  increase  the  quantity 
of  urine,  they  are  commonly  of  great  service  by  reducing  the  dropsical  swelhng. 
But  they  are  apt  to  be  very  capricious  and  disappointing.  In  some  unhappy  caseL 
of  renal  dropsy  I  have  tried  every  known  form  and  combination  of  diuretics  without 
augmenting  the  secretion  from  the  kidneys.  And  sometimes,  although  a  plentiful 
discharge  of  urine  takes  place,  no  impression  is  made  upon  the  anasarca. 

It  is  yet  an  unsettled  question  whether  mercury  be  advisable,  or  even  admissible, 
in  these  cases.  The  current  of  medical  opinion  sets  against  it ;  perhaps  too  strongly. 
It  has  been  observed  that  salivation  is  apt  to  be  produced  by  a  small  quantity  of  this 
drug;  and  to  be  unusually  troublesome  and  severe,  without  bringing  any  commen- 
surate advantage.  I  mentioned  to  you  formerly  Dr.  Farre's  opinion,  that  mercury 
has  the  property  of  rapidly  destroying  red  blood :  if  so,  it  must  be  regarded  rather 
as  an  ally,  than  as  an  antagonist,  of  this  malady.  On  the  other  hand,  some  patients 
have  appeared  to  recover  altogether,  after  passing  through  a  furious  salivation.  One 
of  the  reputed  virtues  of  the  mineral  is  that  it  promotes  interstitial  absorption — a  pro- 
perty which  the  changes  apparent  in  the  kidney  in  renal  dropsy  would  seem  to  render 
valuable. 

When  internal  remedies  prove  inefTectual,  and  outward  applications  to  procure 
sweating  miss  their  aim,  we  turn  to  those  mechanical  expedients  which  (in  either 
variety  of  general  dropsy)  often  afford  ease,  and  prolong  life,  and  may  even  some- 
times, perhaps,  achieve  a  cure. 

I  have  told  you  that  the  tense  and  stretched  integuments  occasionally  give  way ; 
the  areolar  tissue  sloughs,  and  from  the  breach  thus  made  water  wells  copiously 
forth,  and  great  relief  ensues.  Sometimes,  though  very  rarely,  the  whole  of  the 
accumulated  liquid  has  so  escaped,  and  the  dropsy  has  not  reappeared.  The  sore 
has  healed,  and  the  natural  cure  has  been  complete. 

This  spontaneous  mode  of  draining  away  the  liquid  has  been  imitated  by  art.  For 
the  unwieldy  legs  become  painful  as  well  as  cumbrous;  the  integuments  threaten 
to  inflame,  or  to  mortify  ;  and  if  we  can  diminish  the  tension  by  removing  a  portion 
of  the  included  fluid,  we  avert  or  lessen  this  danger.  The  penis  and  scrotum  also 
in  the  male,  and  the  labia  pudendi  in  the  female,  become,  in  many  cases,  enormously 
swollen,  and  hinder  the  exit  of  the  urine,  which  is  therefore  spilled  upon  the  tumid 
parts,  rendering  them  erythematous  and  raw,  to  the  grievous  aggravation  of  the 
patient's  sufferings. 

Now,  seeing  that  vesications  sometimes  form  upon  the  dropsical  limbs,  and  give 
vent,  in  some  degree,  to  the  fluid,  practitioners  have  been  induced  to  follow  that  indi- 
cation by  exciting  artificial  blisters.  But  they  are  highly  dangerous  ;  leading  often 
to  gangrene  of  the  surface  thus  inflamed.  Within  my  recollection  it  was  the  custom 
to  make  incisions,  with  a  lancet,  in  the  oedematous  legs.  These  gashes  seldom 
healed  again ;  but  degenerated  into  sloughing  sores ;  and  not  unfrequently  they 
hastened  the  dissolution  of  the  patient. 

A  vast  improvement  upon  these  expedients  is  the  modern  practice  of  acupunc- 
ture, which  consists  in  perforating  the  integuments  here  and  there  with  a  fine 
needle. 

It  is  surprising  how  much  fluid  may  be  let  out  in  this  way ;  and  how  much  relief 
may  be  bestowed  by  this  trilling  operation.  The  liquid  trickles  rapidly  forth ;  and 
I  have  known  it  soak  through  the  patient's  bed,  and  form  a  pool  on  the  floor  of  the 
room.     In  one  instance,  a  physician  being  the  patient,  the  limpid  fluid  which  ihu* 


896  ANASARCA. 

oozed  from  a  puncture  in  the  thigh  was  caught,  and  collected  in  a  glass,  by  means 
of  a  little  gutter  of  oiled  silk.  It  was  found  that  ninety  minims,  or  a  fluid  drachm 
and  a  half,  escaped  in  a  minute ;  which  is  at  the  rate  of  eleven  ounces  and  a  quarter 
in  an  hour:  and  this  drain  went  on  for  upwards  of  four  hours. 

The  surface  on  which  punctures  of  this  kind  have  been  made,  sometimes  becomes 
red ;  erysipelas  supervenes,  which  it  is  difficult  to  arrest,  and  the  patient  sinks.  In 
some  of  these  cases  the  same  event  would  probably  have  occurred,  even  although 
no  punctures  had  been  ,made,  from  mere  tension  of  the  integuments,  and  the  pro- 
gress of  the  disease.  When  such  appearances  present  themselves,  the  affected  hmb 
should  be  kept  in  the  horizontal  position ;  and  strips  of  hnen,  wetted  with  a  solution 
of  goulard,  should  be  applied  to  the  inflamed  surface. 

Under  the  old  system  of  incisions  it  was  found  (and  reason  would  teach  us  to 
expect  this)  that  there  was  more  hazard  of  sloughing  when  they  were  made  on  the 
legs,  than  on  the  thighs.  The  risk  is  much  less  when  needles  are  used.  But  even 
these  punctures  are  not  to  be  made  without  attending  to  certain  precautions.  They 
should  not  be  too  near  each  other :  an  inch  and  a  half,  at  least,  should  intervene  be- 
tween them.  Neither  should  they  be  too  numerous,  nor  too  deep.  The  depth  must 
depend  upon  the  circumstances  of  the  case ;  and  especially  upon  the  place  where 
the  puncture  is  to  be  made.  The  needle  must  not  be  pushed  so  deep  as  to  penetrate 
or  wound  any  fascia ;  for  the  danger  of  subsequent  inflammation  would  thereby  be 
increased. 

The  peritoneum  may,  at  the  same  time,  require  to  be  emptied  in  the  same 
mechanical  way,  by  help  of  a  trocar.  I  am  always  loth  to  recommend  tapping,  until 
the  symptoms  actually  call  for  it,  and  until  all  other  means  of  dispersing  the  water 
have  been  tried  in  vain.  But  the  circumstances  that  warrant  or  demand  the  per- 
formance of  the  operation,  the  dangers  that  attend  it,  and  the  means  of  obviating 
these  dangers,  were  fully  pointed  out  Avhen  we  were  on  the  subject  of  ascites. 

By  whatever  means  we  may  succeed  in  getting  rid  of  the  dropsy,  there  will  still 
remain  (except  in  the  comparatively  few  cases  that  are  unconnected  with  organic 
disease,  and  depend  simply  upon  debility  and  aniemia)  the  necessity  for  guarding 
against  the  re-accumulation  of  the  water,  by  remedial  measures  addressed  to  the 
fauky  organs.  You  may  sometimes  keep  the  disease  of  these  organs  in  check,  even 
when  you  cannot  cure  it. 

In  cardiac  dropsies,  besides  the  medicines  already  specified,  andeviating  tem- 
perance and  regularity  of  life  must  be  enjoined ;  and  the  patient  should  carefully, 
and  always,  avoid  all  active  motion  or  exertion  of  the  body,  and  all  strong  emotion 
of  the  mind  ;  whatever,  in  short,  might  tend  to  hurry  the  circulation.  You  will 
scarcely  be  able  to  enforce  this  prudence,  without  plainly  showing  the  patient  the 
risk  he  will  incur  by  its  neglect. 

In  the  renal  variety  of  the  disorder,  in  addition  to  the  appropriate  remedies  alreadj'' 
enumerated,  particular  attention  must  be  paid  to  the  avoidance  of  all  exposure  to  cold 
and  vicissitudes  of  the  weather,  and  to  keeping  the  surface  of  the  body  warm.  Such 
patients  should  be  constantly  clothed  in  flannel  from  head  to  foot.  To  those  who  are 
able  to  choose  their  place  of  abode,  I  should  strongly  recommend  resort  to  a  warm 
climate.  Some  benefit  may  also  be  hoped  for  from  counter-irritation  —  blisters  or 
issues  to  the  loins. 

The  diet  in  the  chronic  forms  of  the  disease  should  be  nutritiv^e  but  unstimulating. 
M.  Solon  suggests  that  if,  in  the  renal  cases,  urea  be  detected  in  the  blood,  the 
patient  should  be  restrained  from  too  animalized  a  diet.  Dr.  Budd  has  had  the 
Bame  thought,  and  has  put  to  the  test,  I  believe  in  the  Hospital-ship  Dreadnought, 
tlie  utility  of  withholding  all  articles  of  food  that  contain  azote.  I  have  found  this 
restriction  entirely  useless  in  one  painful  case,  in  which  it  was  fairly  enforced.  la 
fact,  tne  principle  of  such  restriction  appears  to  be  wrong :  the  urea  is  furnished  to 
the  blood,  not  in  the  primary  assimilative  process,  but  in  that  which  is  secondary 
and  destructive. 

One  more  point,  and  I  have  done.  Much  unnecessary  penance  used  to  be  imposed 
upon  dropsical  persons,  by  stinting  their  allowance  of  drink.     It  was  natural  to  sup- 


CHYLOUS    URINE. 

pose  that  the  accumulation  would  increase  in  proportion  to  the  quantity  of  liquid 
swallowed.     But  experience  has  shown  this  opinion  to  be  erroneous,  and 

"  Crescit  indulgens  sibi  dirus  hydrops" 

has  ceased  to  be  more  than  a  poetical  doctrine.  The  patient  may  safely  be  allowed 
to  exercise  his  own  discretion  in  this  respect.  When  the  peritoneum  is  full,  distress 
is  apt  to  ensue  upon  the  distension  of  the  stomach  by  drinks ;  but  this  source  of  suf- 
fering is  soon  discovered  and  avoided.  The  sick  man  is  better  able  than  his  physi- 
cian to  judge  which  evil  is  the  greatest ;  the  torment  of  unslaked  thirst,  or  the  dis 
comfort  that  may  be  produced  by  its  immoderate  indulgence. 


LECTURE  LXXX. 


Chylous  Urine.  Hsematvria  ;  its  diagnosis,  general  and  particular ;  Local  dis- 
orders of  the  Urinary  Organs  on  which  it  depends ;  Treatment.  Abdominal 
Tumours. 

I  HOPE  I  have  convinced  you  that  the  morbid  conditions  of  the  urine  are  worth 
studying.  You  have  heard,  probably,  of  the  quacks  who  call  themselves  "water- 
doctors,"  and  who  pretend  that,  by  mere  inspection  of  the  urine  of  a  patient  living 
at  a  distance,  they  can  tell  what  is  the  matter  with  him,  and  how  he  may  be  cured. 
This  skill,  which  looks  like  conjuration,  the  scientific  physician  of  the  present  day 
does  really  possess.  Of  some  very  important  forms  of  constitutional  disorder,  and 
of  some  specific  local  maladies,  he  reads  the  sure  evidence  in  the  sensible  and 
chemical  qualities  of  the  secretion  from  the  kidneys.  And  I  do  not  hesitate  to  say, 
that  a  rightly  instructed  person  might  form  a  more  accurate  opinion  respecting  a  sick 
man  fifty  miles  ofT,  and  prescribe  for  him  more  judiciously,  upon  being  furnished 
with  a  vial  of  his  urine,  than  some  practitioners  whom  I  have  known  could  do,  if 
they  had  the  patient  bodily  before  them.  You  may  learn  much  (and  so,  no  doubt, 
you  ought)  by  prying  into  the  arcana  of  the  night-chair :  but  you  may  learn  more,- 
I  am  persuaded,  by  the  habitual  perusal  of  the  chamber-pot. 

1  have  not  yet  quite  done  with  the  subject. 

Sometimes  urine  is  voided  whi/^h  appears  to  contain  chyle.  It  looks  white  and 
milky,  and  stiffens  as  it  cools  into  a  tremulous  jelly,  like  blanc  mange,  and  takes  the 
shape  of  the  vessel  into  which  it  was  passed.  The  coagulum  gradually  separates 
again  into  two  portions  :  one  of  which  is  liquid  and  whitish,  and  when  left  at  rest  for 
a  few  hours,  throws  up  to  the  surface  a  sort  of  creamy  matter,  containing  (as  cream 
does)  a  butyraceous  or  oily  principle  :  the  other  is  a  delicate  fibrinous  mass,  of  flesh- 
like appearance,  having  a  red  tinge  from  the  presence  of  some  of  the  colouring 
matter  of  the  blood.  This  is  the  character  of  the  urine  passed  a  few  hours  after  a 
full  meal.  When  the  patient  has  long  been  fasting,  the  urine  is  simply  opalescent, 
and  the  coagulum,  small  and  partial. 

Dr.  Prout  attributes  this  curious  deviation  from  the  natural  qualities  of  the  urine 
to  a  double  fault ;  first,  in  the  organs  of  assimilation  ;  secondly,  in  the  functions  of 
the  kidney.  The  chyle,  from  some  derangement  of  the  assimilative  process,  is  not 
raised  to  the  blood  standard ;  and  being  unfit  for  its  purpose,  is  ejected  through  the 
kidneys ;  and  these  organs,  instead  of  converting  it,  as  usual,  into  the  lithate  of  am 
monia,  suffer  it  to  pass  through  them  unchanged. 

Of  this  rare  disorder  I  have  not  met  with  an  instance.  Dr.  Prout  has  seen  more 
or  less  of  thirteen  cases.  Five  of  the  patients  were  males,  eight  females.  Two  of 
the  males,  and  one  of  the  females,  were  below  the  age  of  puberty.  Seven  of  the 
cases  occurred  in  natives  of  the  East  or  West  Indies,  or  in  persons  who  had  lived 
for  many  years  in  hot  climates.  Mr.  Thomas  informs  me,  that  during  a  residence 
of  ten  v^ars  in  Barbadoes,  he  saw  at  least  a  dozen  well-marked  exaiaples  of  chyloiu 
".57 


898  HiEMATURIA. 

urine  in  negroes.  It  would  seem,  therefore,  that  a  tropical  climate  predisposes  cer- 
tain individuals  to  this  affection.  In  one  case,  drinking  cold  water  while  the  body 
was  warm  seemed  to  have  been  the  exciting  cause  ;  and  exposure  to  cold  was  thought 
to  have  had  something  to  do  with  the  attacks  in  other  cases. 

The  general  health  suffers  less  than  you  might  suppose.  Two  of  the  females, 
while  labouring  under  the  complaint,  became  pregnant,  and  brought  forth  healthy 
children ;  and  one  of  the  two  lived  nearly  twenty  years,  with  the  disorder  upon  hei 
all  the  time. 

In  the  slighter  cases  there  is  usually  some  degree  of  feverishness,  some  uneasi- 
ness in  the  back  and  loins,  some  thirst,  a  dry  skin,  and  torpid  bowels.  When  the 
malady  is  more  severe,  the  symptoms  approach  to  those  of  diabetes ;  the  thirst  is 
more  urgent,  the  appetite  unnaturally  craving ;  and  there  is  some  degree  of  emacia- 
tion and  debility.  In  this  severer  variety  the  urine  is  apt  to  coagulate  before  it  leaves 
the  bladder;  and  the  patient  experiences  difficulty  in  passing  it,  the  urethra  being 
blocked  up  by  the  clots.  Dr.  Prout  states  that  he  has  known  this  to  constitute  the 
most  troublesome  symptom  of  the  disease.  In  one  of  the  fatal  cases  the  body 
was  examined,  and  the  kidneys  found  perfectly  healthy.  Occasionally  the  com- 
plaint ceases  of  its  own  accord,  even  for  years,  and  then  recurs,  without  any 
apparent  cause.  We  may  conclude  from  these  circumstances  that  it  is  n  purely  func- 
tional disorder. 

With  respect  to  treatment,  little  can  be  said.  Dr.  Prout  has  found  several  things 
of  temporary  service,  in  the  chronic  state  of  the  affection.  The  mineral  acids  ;  astrin- 
gents, such  as  alum,  and  the  acetate  of  lead  ;  opium ;  counter-irritation.  But  the 
suspended  symptoms  have  always  soon  returned. 

Lastly,  the  urine  may  contain  blood:  and  I  proceed  to  consider  some  of  the  phe- 
nomena that  occur  in  connection  with  hxmaiurla  ^  under  which  term  1  would  com 
prebend  every  kind  of  bleeding  from  the  urinary  organs. 

Blood  alters,  of  course,  the  colour  of  the  urine  with  which  it  is  mixed ;  giving  it, 
in  some  instances,  a  bright  red  tinge,  and  causing  it,  in  others,  to  assume  a  dark  hue  ; 
to  become  brown,  like  coffee,  or  even  to  approach  to  blackness.  Hence  we  are  some- 
times too  ready  to  conclude  that  urine  of  a  distinctly  red  colour,  or  so  very  dark  as 
to  appear  almost  black,  derives  its  peculiar  tint  from  blood  that  has  somehow  mingled 
with  it. 

But.  in  truth,  urine  may  be  perfectly  red,  or  nearly  black,  and  yet  be  quite  free 
from  blood.  There  are  certain  substances  which,  when  taken  as  food,  invariably 
impart  a  red  colour  to  the  urine.  One  of  these  is  the  prick Ijr  pear,  or  Indian  fig  as 
it  is  sometimes  called,  the  cactus  opimtla  of  botanists.  When  the  Spaniards  first 
took  possession  of  America,  many  of  them  were  alarmed  by  observing  that  they 
passed  what  they  supposed  to  be  bloody  urine :  bat  it  was  soon  discovered  that  the 
red  colour  of  the  secretion  was  owing  to  the  liberal  use  they  made  of  that  fruit.  Dr. 
Hennen,  in  his  book  on  MilUary  Surgery,  quotes  a  precisely  similar  example  from 
Elliot's  Journal  of  his  Travels  for  determining  the  boundary  of  the  United  States. 
He  says  that  "his  people  ate  very  plentifully  of  this  substance  at  an  island  of  the 
iMississippi  (Kayo-ani),  and  were  not  a  little  surprised  the  next  morning  at  finding 
their  urine  appear  as  if  it  had  been  highly  tinged  with  cochineal.  No  inconve- 
nience resulted  from  it.  It  would  seem  (he  continues)  that  the  juice  of  this  plant 
rnay  be  analyzed  into  a  crimson  dye  by  other  processes  besides  that  of  the  cochineal 
insect." 

Another  vegetable  substance  with  which,  in  this  country,  we  are  more  familiar, 
and  which  will  produce  the  same  effect,  is  beet-root.  Desault  relates  the  case  of  a 
person  who  noticed  that  he  every  morning  voided  urine  of  a  deep  red  colour;  exactly- 
such  as  would  result  from  adding  fresh  blood  to  that  hquid,  except  that  no  deposit 
rook  place  The  man  became  frightened  at  this,  and  consulted  M.  Roux,  who,  after 
i>ome  examination,  began  to  suspect  that  the  water  owed  its  red  appearance  to  some 
other  cause  than  the  admixture  of  blood.  It  turned  out  that  his  patient  was  in  the 
habit  of  supping  every  night  upon  the  red  beet-root ;  and  as  soon  as,  by  M.  Roux's 
advice,  he  relinquished  this  article  of  diet,  he  was  freed  at  once  from  his  supposed 
bloody  urine,  and  froru  his  fears. 


I 


HEMATURIA.  W9 

A  similar  tinge  is  said  to  be  given  to  the  urine  by  the  use  of  madder  as  food,  by 
some  species  of  strawberries,  and  by  drinks  made  of  sorrel.  Logwood,  which  we 
sometimes  use  in  medicine,  has  the  same  effect. 

It  is  right  that  you  should  know  these  facts :  for  by  swallowing  large  quantities  of 
such  substances,  and  by  complaining  of  sensations  which  they  do  not  really  feel, 
impostors  may  endeavour,  without  any  difficulty,  or  pain,  or  danger  to  themselves,  to 
deceive  others  into  a  belief  that  they  are  suffering  under  some  serious  and  disquali- 
fying disease,  and  are  proper  objects  of  charity.  Moreover,  a  knowledge  of  the 
effects  of  these  vegetable  matters  may  sometimes  enable  you,  as  in  the  case  men- 
tioned by  Desault,  to  remove  unfounded  anxiety  and  alarm  from  the  minds  of  per- 
sons who  are  innocently  and  unconsciously  giving  themselves  red  urine. 

The  natural  tint  of  the  urme  inclines  towards  redness,  independently  of  any 
admixture  of  blood,  in  many  instances  of  fever,  and  of  acute  inflammation.  Occa- 
sionally urine  of  a  pink  colour  is  passed  by  persons  who  are  subject  to  obstinate 
dyspepsia  connected  with  organic  disease.  This  pink  tint  is  most  apparent  when 
the  water  is  contained  in  an  opaque,  shallow,  white  vessel. 

Again,  urine  of  so  deep  a  colour  as  to  be  called,  in  common  parlance,  black,  may 
or  may  not  owe  that  hue  to  the  presence  of  blood.  When  blood  is  the  cause  of  the 
unnatural  colour,  the  blackness  must  be  ascribed  to  the  chemical  action  of  some  free 
acid  upon  the  blood  :  as  I  showed  you  formerly  to  be  the  case  with  blood  that  is 
vomited  in  hcematemesis. 

1  also  pointed  out  to  you  some  little  while  since,  that  the  urine,  in  jaundice,  some- 
times, seems  to  be  black,  when  it  is  collected  in  large  quantity,  and  in  a  deep  vessel. 
This  colour  is  merely  a  concentration  of  yellowness,  as  appears  at  once  by  diluting 
the  urine  with  water.  It  then  assumes  a  bright  yellow  colour.  The  aspect  of  the 
skin  in  icterus  will  always  secure  you  against  mistaking  or  overlooking  this  cause 
of  black  urine. 

There  has  been  observed,  also,  though  very  rarely,  a  form  of  black  urine,  de- 
pending upon  the  presence  in  that  £2cretion  of  a  peculiar  principle  to  which  Dr. 
Marcet  gave  the  name  of  melanic  acid.  The  only  specimen  of  really  black  urine 
that  I  ever  saw,  was  shown  to  me  by  Dr.  Prout ;  who  knew  nothing,  however,  of 
the  circumstances  under  which  it  was  voided.  It  appeared  to  me  to  be  full  of  coal- 
dust. 

With  these  two  exceptions,  almost  all  urine  that  is  of  a  very  dark  or  blackish  colour 
owes  that  quality  to  the  circumstance  of  its  containing  blood,  which  has  been  more  or 
less  altered,  by  various  causes,  from  its  original  appearance. 

When  blood  is  present  in  any  considerable  quantity,  a  portion  of  it  subsides  to  the 
bottom  of  the  vessel,  and  may  be  recognized  without  any  difficulty.  And  even 
wh6n  there  is  not  enough  blood  to  give  a  marked  and  characteristic  deposit,  a  very 
small  admixture  of  it  will  be  found  to  disturb  the  natural  transparency  of  the  urine, 
rendering  it  of  a  smoke-brown  or  dull  cherry  colour;  whereas  the  reddish  or  pink 
urrne  which  contains  no  blood  is  clear  and  untroubled  ;  and  if,  on  cooling,  it  throws 
down  a  sediment,  that  sediment  may  be  redissolved  by  heating  the  urine  —  a  result 
which  does  not  take  place  when  a  portion  of  blood  has  been  deposited.  Another 
rough  test  is,  that  a  mixture  of  urine  and  blood  tinges  a  piece  of  white  linen  dipped 
into  it,  of  a  red  colour.  A  better  criterion  is  afforded  by  gradually  raising  the  sus- 
pected urine  to  the  boiling  temperature.  If  it  contains  blood,  a  grayish-brown  floe- 
culent  precipitate,  consisting  of  coagulated  albumen  tinged  with  the  colouring  matter 
of  the  blood,  will  form,  and  gradually  subside,  and  leave  the  supernatant  liquid  clear, 
and  with  its  natural  tint.  But  if  you  use  the  microscope,  that  will  furnish  you  with 
the  best  evidence  upon  this  point.  If  there  be  blood  in  the  urine,  there  will  be  blood- 
corpuscles,  turgid  or  collapsed,  diffused  through  the  urine,  or  collected  at  the  bottom 
of  the  vessel :  and  whatever  modifications  they  may  present,  they  may  always,  Dr 
Bird  says,  be  identified  by  "their  non-granular  surface,  uniform  size,  and  yellow 
colour  under  the  microscope." 

We  have  by  no  means  accomplished  the  diagnosis  when  we  have  merely  ascer- 
tained that  there  is  blood  in  the  urine ;  and  that  the  case  is  a  case  of  haematuna. 
The  question  remains,  of  what  is  such  haematuria  a  sign.     The  blood  emerges  from 


900  HiEMATURIA. 

the  urethra,  but  it  may  have  been  poured  out  at  any  point  of  a  long  and  somewhat 
complex  tract  of  mucous  membrane.  It  may  have  proceeded  from  one  or  both  of 
the  kidneys  ;  from  each  or  either  ureter ;  from  the  bladder ;  from  the  prostate  gland, 
or  from  the  urethra. 

Hsematuria  strictly  idiopathic  must  be  very  rare.  Cullen  remarks  that  neither  he 
nor  any  of  his  friends  had  ever  met  with  an  instance  of  it.  I  shall  mention  presently 
the  only  example  of  hemorrhage  from  the  urinary  organs,  apparently  idiopathic,  that 
has  fallen  under  my  own  notice. 

Blood  is  excreted  with  the  urine  in  that  acute  affection  of  the  kidney  which  I  have 
already  spoken  of  as  lying  at  the  root  of  most,  if  not  all  cases  of  febrile  dropsy.  The 
albuminous  urine  proper  to  the  chronic  form  of  Bright's  disease  sometimes  contains 
the  colouring  matter  as  well  as  the  serum  of  the  blood.  Hsematuria  is  occasionally, 
I  beheve,  vicarious  of  some  other  hemorrhage,  and  especially  of  bleeding  from  the 
hemorrhoidal  vessels  :  so  that  it  is  always  right,  in  obscure  cases,  to  inquire  w^hether 
the  patient  has  been  habitually  subject  to  hemorrhage  from  the  rectum  ;  and  if  so, 
whether  that  hemorrhage  is  suspended.  These  cases  have  even  been  called  hsemor- 
rhoides  vesicx. 

Hcematuria  occurs  also,  independently  of  any  strictly  local  complaint,  in  the  course 
of  certain  disorders  which  affect  the  system  at  large ;  especially  in  scurvy  and  pur- 
pura hemorrhagica.  Bloody  urine  is  sometimes  a  symptom,  and  one  of  the  most 
fatal  augury,  in  typhus  fever,  small-pox,  measles,  and  the  plague. 

But  setting  aside  these  more  general  forms  of  hsematuria,  let  us  inquire  what  local 
affections  of  the  urinary  organs  themselves  may  give  rise  to  hemorrhage ;  and  how, 
under  different  circumstances,  we  are  to  interpret  this  symptom. 

One  very  common  source  of  hemorrhage  from  the  urinary  passages,  is  the  presence 
within  them  of  calculous  matter.  The  pressure  occasioned  by  the  aggregation  of 
the  earthy  mass,  when  it  is  formed  in  the  kidney,  or  by  its  accidental  change  of  posi- 
ion,  lacerates,  or  lays  open  by  ulceration,  some  of  the  smaller  vessels  with  which 
.t  is  in  contact.  And  in  those  cases  in  which  a  calculus  descends  into  the  bladder, 
and  is  ultimately  voided,  it  may,  in  succession,  give  rise  to  hemorrhage,  first  from 
the  kidney  from  which  it  is  separated  ;  secondly,  from  the  narrow  tube  of  the  ureter 
through  which  it  is  forced ;  thirdly,  from  the  bladder,  which  it  enters,  and  wounds, 
or  irritates ;  and  fourthly,  from  the  urethra  in  the  last  stage  of  its  progress  out  of  the 
body. 

There  will  be  the  same  liability  to  hsematuria,  if  the  concretion,  instead  of  coming 
down  from  the  kidney,  is  formed  originally  in  the  bladder.  The  appearance  of  blood 
in  the  urine  suggests,  therefore,  in  many  cases,  the  fearful  suspicion,  that  there  is,  or 
is  likely  to  be,  a  stone  in  the  bladder.  Dr.  Heberden,  in  his  Commentaries,  says, 
"  urine  made  of  a  deep  coffee  colour,  or  manifestly  mixed  with  a  large  quantity  of 
blood,  has  within  my  experience  been  very  rarely  the  effect  of  any  thing  but  a  stone 
in  the  urinary  passages.  I  therefore  suppose  a  strong  probability  of  this  cause,  when- 
ever I  see  this  appearance." 

Again,  blood  may  proceed  from  the  kidne}',  or  from  the  bladder,  in  consequence 
of  malignant  fungous  growths,  to  which  those  parts  are  liable :  a  disease  which, 
though  more  surely  fatal  than  the  stone,  is  scarcely,  to  the  unhappy  subject  of  it,  so 
appaUing. 

Hemorrhage  may  take  place  from  the  surface  of  the  bladder  from  chronic  disease, 
not  cancerous,  of  that  membrane.  Mr.  Howship  has  recorded  an  instance  of  this 
kind  which  occurred  in  Mr.  Heaviside's  practice.  An  old  East  Indian,  who  had 
long  been  subject  to  nephritic  complaints,  was  suddenly  seized  with  what  was 
ihought  to  be  retention  of  urine.  A  catheter  was  passed,  but  as  no  water  flowed,  it 
was  supposed  that  it  had  not  entered  the  bladder,  in  the  situation  of  which  there 
was  a  manifest  tumour.  The  patient  died  the  next  day ;  and  the  bladder  was  found 
distended  by  a  very  large  coagulum  of  blood  which  had  come  from  the  diseased  mu- 
cous membrane.  There  was  no  trace  of  hemorrhage  in  the  kidneys,  nor  in  the 
ureters. 

I  hold  in  my  hand  a  preparation  showing  disease  of  the  prostate  gland,  which  had 
been  accompanied  by  hsematuria. 


HEMATURIA.  901 

Now  we  judge  of  the  exact  seat  of  the  hemorrhage,  and  of  its  cause,  partly  by  the 
nature  and  appearance  of  the  effused  blood,  and  partly  by  the  symptoms  that  precede 
or  accompany  the  bleeding. 

Dr.  Prout  states  that  "  when  blood  is  derived  from  the  kidney,  it  is  in  general 
equally  diffused  throughout  the  whole  urine :  on  the  contrary,  when  derived  from 
the  bladder,  the  blood  for  the  most  part  comes  away  in  greater  or  less  quantity  at  the 
termination  of  the  discharge,  the  urine  having  previously  flowed  off  nearly  pure." 

There  are  also  certain  modifications  of  the  sensible  qualities  of  the  excreted  blood, 
by  means  of  which  the  same  distinguished  physician  thinks  he  can  pronounce,  with 
considerable  confidence,  that  the  hemorrhage  is  owing  to  malignant  disease.  "The 
red  particles  of  the  blood  (he  says)  discharged  in  the  earlier  stages  of  fungoid  dis- 
ease, have  often  a  remarkable  appearance,  and  appear  to  the  eye  larger  than  natural; 
so  that  after  they  have  subsided  to  the  bottom  of  the  urine,  they  at  first  sight  some- 
what resemble  grains  of  lithic  acid  gravel,  and,  like  that  substance,  when  the  vessel 
is  inchned,  may  be  distinctly  seen  to  roll  along  the  bottom.  From  this  peculiar  ap- 
pearance of  the  red  particles  of  the  blood,  the  presence  of  malignant  disease  may  be 
often  suspected  before  the  symptoms  assume  a  decided  character."  .In  a  more  ad- 
vanced stage  of  the  disease,  there  is  often  a  dark-coloured  offensive  bloody  sanies  in 
the  urine,  and  more  or  less  of  mechanical  impediment  in  passing  it.  I  should  con- 
ceive that  the  microscope  might  aid  the  diagnosis  of  such  cases. 

There  is  one  phenomenon  which,  whenever  it  occurs,  is  very  characteristic  of 
hemorrhage  from  the  kidney,  or  the  commencement  of  the  ureter.  I  mean  the  ex- 
pulsion, with  the  urine,  of  slender  cylindrical  pieces  of  fibrin,  which  have  evidently 
been  moulded  in  the  ureter,  and  subsequently  washed  down  into  the  bladder  by  the 
descending  urine.  These  little  coagula  are  commonly  of  a  whitish  colour,  the  red 
particles  of  the  blood  having  been  removed ;  and  they  look  like  slim  maggots,  or 
small  worms.  They  denote,  with  much  certainty,  that  the  hemorrhage  which  they 
accompany  is  renal. 

Such,  then,  are  some  of  the  points  of  diagnosis  furnished  by  the  qualities  of  the 
excreted  fluid  itself. 

The  bleeding  may  be  presumed  to  come  from  the  kidney,  or  from  the  upper  part 
of  the  ureter,  when  it  is  accompanied  or  preceded  by  a  sensation  of  heat,  or  of 
weight,  or  by  some  degree  of  pain,  in  the  situation  of  the  kidney  ;  especially  if  these 
uneasy  feelings  are  confined  to  one  side  of  the  body.  This  presumption  will  of 
course  be  strengthened  if  calcuh  have  been  known  to  descend  from  the  kidney  ;  and 
converted  into  certainty  if  the  patient  suffers,  together  with  the  hasmaturia,  a  fit  of 
the  gravel ;  and  if  there  be  no  symptom  of  stone,  or  of  disease,  in  the  bladder. 

On  the  other  hand,  when  no  symptoms  referable  to  the  kil^ney  or  the  ureter  are 
present,  while  there  are  signs  of  stone,  or  of  disease  of  the  bladder,  or  of  a  diseased 
prostate- — a  mixture  of  mucus  with  the  blood ;  occasional  retention,  or  a  sudden  stop 
in  the  stream  of  urine  ;  pain  referred  to  the  glans  penis  immediately  after  the 
bladder  is  emptied — then  we  conclude  that  the  blood  proceeds  originally  from  thai 
receptacle. 

When  pure  blood  comes  away,  either  guttatim,  or  in  a  stream,  unmixed  with  urine, 
and  neither  preceded  nor  accompanied  by  any  desire  to  make  water,  it  is  probable 
that  the  itrefhra  is  the  locus  of  the  hemorrhage. 

Bleeding  from  the  surface  of  the  urethra  doubtless  niay,  and  commonly  does,  pro- 
ceed from  some  mechanical  injury  done  to  that  channel:  as  in  the  passage  outwards 
of  a  fragment  of  stone,  or  inwards  of  a  surgical  instrument.  But  it  is  probable  that 
blood  is  sometimes  exhaled  from  the  same  membrane  in  considerable  quantity,  under 
circumstances  which  favour  or  produce  a  strong  determination  of  blood  to  the  genual 
organs.  A  young  man  came  to  the  Middlesex  Hospital  with  hemorrhage  from 
the  urethra,  and  said  that  he  had  lost  a  considerable  quantity  of  blood  in  this  way, 
within  a  few  hours.  The  hemorrhage  appeared  to  have  been  the  consequence  of 
excessive  indulgence  in  sexual  intercourse.  His  own  account  of  the  matter  was 
that  he  had  passed  the  night  with  a  female,  in  whom  the  monthly  period  had  jusi 
returned  ;  and  he  ignorantly  fancied  that  the  hemorrhage  from  his  own  person  wti3 
the  result  of  a  sort  of  contagion.     However,  the  bleeding  was  permanently  arrestee! 

4a 


902  HEMATURIA. 

by  the  introduction  of  a  bougie,  which  was  allowed  to  remain  for  a  short  time  in 
the  urethra.  This  was  the  solitarj^  instance  to  which  I  alhided  just  now,  of  (perhaps) 
idiopathic  hemorrhage,  occurring  within  my  own  knowledge.  When  the  hemor 
rhage  comes  originally  from  the  urethra,  the  blood  may  regurgitate  into  the  bladder, 
and  coagulate  there ;  and  mislead  an  observer  into  the  belief  that  the  hemorrhage 
was  vesical. 

It  appears,  then,  that,  in  many  instances,  certain  local  symptoms  are  associated  with 
hcematuria,  and  point  distinctlj^  to  the  part  of  the  urinary  apparatus  whence  the  blood 
proceeds. 

But  many  cases  are  very  obscure.  Blood  sometimes  appears,  mixed  in  greater  or 
less  quantity  with  the  urine,  when  there  is  no  pain,  nor  any  other  sign  which  would 
lead  us  to  fix  upon  one  part  rather  than  another  as  the  source  of  the  hemorrhage. 
Now  I  believe  that  hasmaturia,  bearing  this  indeterminate  character,  will  generally 
turn  out  to  be  rcnuJ,  and  to  depend  upon  earthy  concretions  in  the  kidney.  It  is 
true  that  the  hemorrhage  which  results  from  cancerous  disorganization,  whether  of 
the  kidneys  or  of  the  bladder,  may  also  be  painless.  But  cancerous  disease  of 
these  organs  (unless  it  extends  from  parts  in  the  neighbourhood,  as  from  the  rectum, 
or  from  the  uterus,  to  the  bladder)  is  very  rare ;  and  when  it  does  occur,  the  nature 
of  the  case  ma]'  usually  be  ascertained  from  those  peculiar  qualities  of  the  effused 
blood  which  I  have  mentioned  as  being  characteristic  of  malignant  growths. 

A  calculus  can  seldom  remain  long  in  tjie  bladder,  at  any  rate  will  seldom  cause 
bloody  urine,  without  giving  some  other  notice  of  its  presence  there  :  but  concretions 
form  in  the  kidney,  sometimes  in  great  numbers,  and  reach  a  considerable  size,  and 
remain  there  long,  without  furnishing  any  signal  from  which  we  might  suspect  their 
existence  ;  except  (perhaps)  the  occurrence  of  hcematuria.  We  know  this,  because 
calculi  are  frequently  met  with  in  the  kidneys  of  persons  Avho  had  never  suffered 
anA'  pain  or  obvious  derangement  of  the  urinary  organs  during  life  ;  and  because,  in 
other  persons,  in  whom  such  calculi  pass  down  from  the  kidney  towards  the  bladder, 
the  first  notice  of  their  existence  is  often  given  by  the  acute  suffering  they  inflict 
during  their  transit  through  the  narrow  ureter. 

Yet  though  calculi  may  lodge  in  the  infundibula,  or  in  the  pelvis  of  the  kidney, 
without  manifesting  their  presence  by  exciting  pain,  it  is  very  conceivable  that,  by 
progressive  enlargement,  they  may  lay  open,  or  by  accidental  change  of  position 
they  may  wound,  some  of  the  smaller  blood-vessels  of  the  part,  and  so  give  rise  to 
painless  hfematuria.  It  will  strengthen  the  presumption  that  such  is  the  source  of 
the  bleeding,  if  it  has  succeeded  (as  hemorrhage  from  the  urinary  passages  often 
does  succeed)  to  a  fall ;  a  shock,  or  jar  of  the  body  ;  or  jolting  on  horseback  or  in  a 
carriage.  Similar  movements  may  occasion  bloody  urine  when  there  is  stone  in  the 
bladder;  but  then  the  irritation  will  he  felt  in  that  sensible  part;  the  hfematuria  will 
not  be  painless ;  the  bleeding  will  not  be  the  only  symptom. 

It  is,  then,  I  say,  my  belief  that  very  many  of  the  obscure  cases  of  hfematuria  may 
be  referred  to  renal  calcuU :  and  if  this  view  of  the  subject  be  correct,  it  will  render 
it  probable  that  the  alleged  instances  of.  idiopathic  hemorrhage  from  the  kidneys 
oucfht  thereby  to  be  reduced  in  number. 

The  expulsion  of  the  blood  in  hcematuria,  whether  it  be  painful  or  not,  is  sometimes 
attended  with  severe  rigors.  I  mentioned  before,  that,  in  some  persons,  almost  any 
irritation  of  the  urethra,  the  passing  a  bougie,  for  example,  will  bring  on  a  shivering 
fit.  I  had  some  time  ago  a  patient  under  my  care  in  the  hospital,  who  had  hsema- 
turia  of  an  obscure  kind,  and  the  discharge  of  blood  was  always  marked  by  a  smart 
rigor.  Dr.  Prout  speaks  of  an  instance  of  obstinate  hsematuria  in  which  a  shaking 
fit  constantly  preceded  hemorrhage.  Dr.  EUiotson,  too,  in  one  of  his  lectures,  gives 
•^n  account  of  a  case  of  intermittent  hasmaturia.  The  patient  was  under  his  care 
m  St.  Thomas's  Hospital,  and  had  formerly  had  the  Walcheren  fever.  He  was 
admitted  for  ague,  and  every  time  that  the  cold  stage  of  his  attack  came  on,  he  voided 
a  quantity  of  pure  blood  from  the  urethra.  He  was  cured,  by  quina,  both  of  his  ague 
and  of  his  hemorrhage. 

If  we  may  trust  to  the  records  of  physic,  instances  of  periodic  hsematuria  are  not 
oncommor. 


HEMATURIA.  003 

One  circumstance  yet  remains,  worth  noticing,  in  respect  to  htematuria ;  and  it 
depends  upon  tlie  hemorrhage  itself  rather  than  upon  the  disease  of  which  the  bleed- 
ing is  a  sign.  I  allude  to  the  coagulation  of  the  effused  blood  in  the  bladder,  how- 
ever it  may  have  got  there.  This  circumstance  is  sometimes  the  source  of  much 
inconvenience,  and  suffering,  and  even  of  danger,  to  the  patient.  It  may  cause  reten- 
tion of  the  urine  and  all  its  evil  consequences  ;  and  a  still  worse  event  is,  that  the 
coagulum  sometimes  supplies  a  nucleus,  around  which  calculous  matter  is  deposited, 
and  thus  lays  the  foundation  of  that  horrible  malady,  "  the  stone." 

You  will  perceive,  from  what  I  have  said,  that  the  /rca/??te/i/ of  hcematuria  resolves 
itself,  in  most  cases,  into  the  treatment  of  the  disorder,  or  bodily  condition  with  which 
the  hemorrhage  is  associated,  and  of  which  it  is  merely  a  symptom. 

Sometimes,  however,  the  bleeding  itself  is  so  profuse,  or  so  long-continued,  as  to 
require  direct  efforts  on  our  part  towards  its  restraint. 

"  When  (says  Dr.  Prout)  the  bladder  becomes  distended  with  blood,  and  complete 
retention  of  urine  in  consequence  takes  place,  recourse  must  be  had  to  a  large-eyed 
catheter,  and  an  exhausting  syringe,  by  the  aid  of  which,  and  the  occasional  injection 
of  cold  water,  the  coagula  may  be  broken  down  and  removed.  If  the  hemorrhage 
be  so  profuse  that  the  bladder  becomes  again  distended  with  blood  in  a  very  short 
time,  the  injection  of  cold  water  into  the  rectum  or  bladder  is  sometimes  of  great  use; 
and  should  these  means  fail,  from  twenty  to  forty  grains  of  alum  may  be  dissolved  in 
each  pint  of  water  injected  into  the  bladder;  a  remedy  that  seldom  fails  to  check  the 
bleeding,  even  when  the  cause  is  malignant  disease.  I  have  never  known  any 
unpleasant  consequences  follow  the  use  of  this  expedient,  and  have  seen  it  imme- 
diately arrest  the  most  formidable  hemorrhage,  when  all  other  means  had  failed ; 
and  when  the  bladder  had  repeatedly  become  distended  with  blood,  almost  imme- 
diately after  its  removal." 

Among  remedies  given  by  the  mouth,  the  same  physician  thinks  highly  of  the 
acetate  of  lead.  I  have  mentioned  before,  in  these  lectures,  a  nostrum  called,  after 
the  name  of  its  inventor,  Rnspini's  styptic.  This  has  often  been  known  to  put  a 
stop  to  hemorrhage  which  had  resisted  other  remedies.  I  will  read  you  one  example 
of  this  from  Sir  Benjamin  Brodie's  published  lectures.  Speaking  of  hfematuria, 
dependent  upon  disease  of  the  prostate  gland,  he  says :  "  Those  medicines  which 
operate  as  styptics  when  taken  internally,  and  which  are  useful  in  cases  of  hemor- 
rhage from  the  lungs,  are  also  useful  in  hemorrhage  from  the  prostate.  I  had  a 
patient  with  very  diseased  prostate.  A  frightful  hemorrhage  took  place.  The  usual 
methods  of  treatment  were  adopted,  but  were  of  no  avail.  The  skin  became  pale, 
the  pulse  became  weak,  and  the  patient  was  exhausted ;  yet  the  bleeding  continued. 
Large  quantities  of  blood  were  drawn  off  with  the  catheter :  nevertheless  the  bladder 
continued  to  become  more  and  more  distended  with  blood,  and  was  felt  prominent  in 
the  belly  as  high  as  the  navel.  All  other  remedies  having  failed,  I  gave  the  patient 
a  dose  of  the  nostrum  known  by  the  name  of  Ruspini's  styptic,  and  repeated  the  dose 
two  or  three  times  in  the  course  of  the  next  twelve  hours.  In  about  half-an-hour 
after  the  iirst  dose  was  taken  the  hemorrhage  ceased  ;  and  it  never  returned.  The 
patient  lived  a  year  and  a  half  afterwards,  and  there  was  no  reason  to  beheve  that 
any  ultimate  harm  arose  from  the  bleeding." 

For  a  long  while  this  nostrum  seems  to  have  baffled  analysis.  The  late  Dr. 
Maton  told  me  that  Dr.  Wollaston  had  examined  it,  and  had  arrived  at  the  negative 
conclusion,  that  it  contained  no  metallic  substance.  Dr.  A.  T.  Thomson  has  since 
announced  that  it  mainly  consists  of  a  solution  of  gallic  acid  in  alcohol  diluted  with 
rose-water. 

There  is  no  substance  more  highly  spoken  of  as  a  remedy  for  internal  hemorrhage^ 
by  foreigners,  and  especially  by  the  French,  than  the  extract  of  Rhatany  root,  the 
Krameria  of  our  Pharmacopffiia.  A  female  was  sent  to  me  by  my  colleague,  Mr. 
Arnolt,  complaining  that  for  some  weeks  she  had  been  passing  bloody  urine.  She 
had  gone  through  the  ordinary  routine  of  treatment  without  benefit.  There  were  no 
symptoms  present  which  threw  any  light  on  the  precise  source  or  cause  of  the 
hemorrhage.  I  recommended  a  trial  of  the  rhatany,  and  she  began  to  take  a  scrupi*:' 
of  the  extract,  mixed  with  water,  three  times  a  day.     As  in  Sir  Benjamin  Brodie's 


904  ABDOMINAL    TUMOURS. 

case,  the  hfematuria  ceased  after  the  first  dose,  and  it  did  not  return  for  many  months. 
I  mention  this  instance  the  rather,  because  the  gallic  acid  enters  into  the  composition 
of  this  vegetable  extract  also. 

Now  the  gallic  acid  is  one  of  those  substances  which,  when  introduced  from  the 
digestive  organs  into  the  blood,  passes  through  the  round  of  the  circulation  unchanged, 
and  reappears  in  the  urine.  We  may  conceive,  therefore,  that  it  stays  internal  hemor- 
rhage by  exciting  its  astringent  property  upon  the  ultimate  capillary  blood-vessels  in 
its  passage  through  them.  It  certainly  is  applied,  in  solution,  after  its  elimination 
from  the  blood,  to  the  urinary  passages  :  and  thus,  in  hsematuria,  it  may  be  presumed 
to  produce  its  styptic  effect  upon  the  bleeding  surface. 

To  the  same  principle  are  owing,  I  believe,  the  astringent  and  styptic  virtues  of 
the  uva  ursi,  bistort,  tormentil,  the  pomegranate,  kino,  catechu,  and  the  several  pre- 
parations of  gall  nuts.  I  am  sorry  that  I  have  not  had  much  opportunity  of  trying 
ihe  gallic  acid  itself,  in  its  separate  state ;  for  I  have  neard  of  several  instances  of  its 
successful  employment  in  cases  of  internal  hemorrhage.  If,  as  I  beheve,  it  really 
has  this  power,  it  is  very  desirable  that  it  should  be  prescribed  in  a  more  definite  and 
precise  manner  than  is  afforded  by  its  natural  combinations  with  so  many  different 
vegetable  matters. 

I  am  unwilling  to  take  leave  of  the  cavity  of  the  abdomen,  without  saying  a  few 
words  (very  iew  they  must  be)  respecting  the  various  kinds  of  tumour  to  which  it 
is  obnoxious.  It  may  seem  strange  that  the  diagnosis  of  abdominal  tumours,  which 
manifest  themselves  to  the  touch,  and  to  the  sight,  should  be  so  difficult  and  puzzling 
as  it  often  is.  I  mentioned  some  reasons  for  this  before :  the  loose  and  shifting  man- 
ner in  which  some  of  the  viscera  of  the  belly  are  packed  and  fastened  ;  their  fiabilitj'- 
to  enlarge  beyond  their  natural  limits ;  their  accidental  dislocations  under  disease.  It 
would  be  vain  to  attempt  even  a  sketch  of  the  infinite  variety  of  these  deviations 
from  the  healthy  state.  Every  case  of  abdominal  tumour  forms  a  separate  object  of 
study,  and  must  be  judged  of  by  its  proper  circumstances.  All  that  I  can  profess  to 
do,  is  to  offer  you  some  rough  hints  on  this  interesting  subject. 

Some  kinds  of  tumour  result  from  morbid  growths;  such  are  all  the  varieties  of 
cancer:  some  from  the  presence  and  multiphcation  of  parasites ;  of  which  we  have 
examples  in  collections  of  hydatids :  some  are  produced  by  the  distension  of  hollow 
organs  ;  as  when  concretions,  or  fecal  matters,  or  gases,  lodge  in  the  intestines  ;  or 
when  urine  accumulates  and  is  pent  up  in  the  bladder:  some  consist  in  the  mere 
enlargement  of  parts. 

Let  us  enumerate  the  principal  of  these ;  that  you  may  know  what  chiefly  to 
expect. 

1.  There  are,  I  say,  tumours  from  lodgments  in  the  bowels  _:  and  these  are  more 
hopeful  than  most  kinds  of  abdominal  tumours.  Sometimes  the  stomach,  or  some 
part  of  the  intestinal  canal,  is  distended  in  consequence  of  a  mechanical  impediment 
to  the  course  of  its  contents  :  and  this  impediment  may  be  invincible. 

2.  Ovarian  tumours  are  very  common.  Of  these  I  spoke  at  some  length  in  a 
former  lecture. 

3.  The  liver  is  very  liable  to  enlargement :  either  from  simple  congestion  of 
blood;  or  from  the  interstitial  deposit  of  adipose  matter;  or  from  the  intrusion  of 
malignant  growths  ;  or  from  colonies  of  hydatids. 

4.  So  also  the  spleen  swells,  from  fullness  of  blood,  or  from  specific  deposits  in  us 
substance. 

5.  The  kidneys  sometimes  attain  a  <zait  size  ;  being  occupied  by  malignant  disease, 
')r  swollen  by  pus  that  finds  no  vent. 

(5.  Enlargements  of  the  mesenteric  glands ;  cancerous  degeneration  of  the  peri- 
toneum, especially  where  it  forms  the  omentvm  ;  tumours  connected  with  the  uterus  ; 
nneurisms  of  the  aorta;  vast  distension  of  the  gall-bladder;  constitute  other  species 
of  abdominal  swelling,  which  I  simply  mention  without  further  comment. 

Now  oui  judgment  of  the  character  of  a  given  tumour  is  naturally  influenced  by 
'ts  place.  In  the  right  hypochondrium,  we  suspect  the  fiver;  in  the  left,  the  spleen  ; 
n  ihti  epigastric  region,  the  stomach ;  in  the  hypogastric,  the  womb,  or  the  bladder", 


ABDOMINAL   TUMOURS.  905 

;n  either  flank,  an  ovary,  or  perhaps  a  kidney ;  in  the  track  of  the  colon,  we  guess 
at  fecal  collections. 

But  sometimes  the  situation  of  the  tumour  fits  more  than  one,  or  than  two,  sup- 
positions. Between  the  ribs  and  the  ilium  on  the  right  side  we  may  have  an 
enlarged  ovary,  a  tumid  kidney,  a  distended  ceecum.  A  prominence  in  the  epigas- 
trium may  be  due  to  cancer  of  the  stomach,  to  an  infarcted  transverse  colon,  to  a 
ventral  aneurism.  Above  the  pubes,  the  distended  bladder,  or  the  enlarged  uterus, 
may  equally  project.  The  sigmoid  flexure  of  the  colon  loaded  with  feces,  the  left 
kidney  exaggerated  by  disease,  a  bulky  ovary,  may  either  of  them  occupy  the  same 
sinistral  space. 

Moreover,  the  colon  deviates  strangely,  and  not  seldom,  from  its  natural  course  and 
position  :  and  the  magnified  viscera  may  invade,  by  their  displacement,  or  by  their 
h'regular  expansion,  the  regions  that  are  proper  to  other  organs. 

Our  conjectures  are  assisted  by  the  associated  symptoms,  and  by  observation  of 
the  regular  performance,  or  of  the  disturbance,  of  particular  functions.  Yet  here, 
also,  we  meet  with  continual  sources  of  fallacy.  Pressure  from  a  tumour  without 
may,  as  well  as  infarction  wilhin,  impede  the  passage  of  alimentary  matters  through 
the  bowels,  of  urine  through  the  ureters ;  and  cause,  in  the  one  case,  flatulence  and 
tormina,  in  the  other,  retention  or  suppression  of  urine.  Growths  foreign  to  the  liver 
may,  nevertheless,  press  upon  its  excretory  ducts,  and  occasion  jaundice.  And  so  of 
other  parts  and  functions.  I  mean,  that  the  functions  prominently  deranged  are  not 
always  the  functions  of  the  part  occupied  by  the  tumour,  but  of  organs  which  are 
secondarily  and  accidentally  subjected  to  its  disturbing  influence.  Your  sagacity 
will  be  abundantly  tried  in  balancing  the  evidence  of  different  symptoms  in  these 
obscure,  yet  palpable,  forms  of  disease  :  and  after  all  you  will  often  doubt ;  and  often, 
when  you  do  not  doubt,  you  will  mistake. 

Enlargement  of  the  fiver  may  usually  be  distinguished  from  other  tumours  of  the 
right  hypochondrium,  by  y9ercws.sio?i.  Try  from  the  clavicle  downwards.  At  first, 
you  get  a  hollow  sound.  Then,  a  little  below  the  nipple  perhaps,  (for  the  spot  varies 
much  in  different  subjects,)  the  sound  begins  to  grow  dull.  If  this  dullness  be  trace- 
able, without  change  or  interruption,  to  the  tumour,  the  inference  is  strong  that  the 
tumour  is  hepatic.  Any  other  tumour  there  situate  leaves,  most  commonly,  when 
the  patient  is  recumbent,  a  palpable  sulcus  above  it :  or  a  space  in  which  the  sound, 
upon  percussion,  is  different  from  that  which  is  yielded  by  the  fiver. 

Percussion  helps  us  to  discriminate  an  ovarian  from  a  renal  tumour.  When  the 
swelling  is  large,  the  intestines  lie  behind  the  one,  in  front  of  the  other :  and  the 
sound  is  affected  accordingly. 

Tumours  that  are  readily  movable,  are  generally  intestinal,  omental,  or  ovarian. 

A  pulsating  tumour  is  not  necessarily  an  aneurism.  The  healthy  artery  will  fift 
almost  any  sort  of  hard  swelling  that  happens  to  lie  directly  over  it. 

The  occurrence  of  hsematemesis  or  melgena  would  corroborate  your  belief  that  a 
tumour  in  the  right  hypochondrium  was  hepatic — in  the  left,  was  splenic. 

Even  when  you  are  satisfied  as  to  the  organ  affected,  there  comes  another  ques- 
tion, scarcely,  in  some  cases,  less  difficult  than  the  first — What  is  the  nature  of  the 
tumour? 

Suppose,  for  the  sake  of  illustration,  that  your  inquiry  relates  to  the  liver.  If  the 
tumour  be  large,  smooth,  roundish,  of  slow  growth,  and  the  general  health  be  not 
materially  deranged,  it  is  most  likely  an  hydatid  tumour.  If,  along  the  edge  and 
upon  the  surface  of  the  augmented  liver,  you  can  feel  large  inequalities  and  projec- 
tions, and  if  the  complexion  and  general  state  of  the  patient  are  expressive  of  failing 
health,  the  enlargement  is,  in  all  probability,  cancerous :  and  if  there  be  other  traces 
of  carcinoma  in  the  system,  this  conclusion  becomes  almost  certain.  Small  hard 
irregularities  betoken  the  hobnail  liver;  which  is,  sooner  or  later,  accompanied  by 
ascites.  When,  without  pain  or  jaundice,  the  liver  of  a  phthisical  patient  trans- 
gresses  its  natural  boundaries,  it  is,  presumably,  a  fatty  liver. 

By  applying  a  similar  method  of  investigation  to  other  ventral  enlargements,  you 
may  frequently  hit  the  right  scent,  and  trace  the  mischief  to  its  true  source.  T* 
treat  the  subject  in  detail  would  require  a  volume.     I  may  refer  you  to  a  series  o*" 

4a3 


906  ACUTE    RHEUMATISM. 

papers  by  Dr.  Bright,  in  the  Giiy^s  Hospilal  Reports ;  where  you  will  find  a  host 
of  examples,  and  much  valuable  informalion,  concerning  the  most  common  and  the 
most  important  kinds  of  "abdominal  tumours  and  intumescence." 


LECTURE  LXXXI. 

Acute  Rheumatism;  Symptoms;  Varieties;  Treatment.     Chronic  Rheumatism ; 

Phenomena  :  Plan  qjf  Cure. 
Gout:  Description  of  a  Paroxysm;  Progress  of  the  Disease ;  General  state  of 

the  Health  in  Gouty  Persons ;  Causes  of  the  Disease;  Diagnosis  between  Gout 

and  Rheum,atism. 

I  PROCEED,  this  afternoon,  to  the  consideration  of  that  very  common,  very  painful, 
attd  sometimes  very  perilous  disease,  rheumatism.  There  are  two  species  of  it,  the 
acute  and  the  chronic.  They  graduate,  however,  insensibly  into  each  other;  and 
the  chronic  is  often  a  sequel  of  the  acute  form.  Yet  this  is  not  necessarily  so. 
Chronic  rheumatism  occurs  in  persons  who  have  had  no  preceding  attack  of  the 
disorder  in  its  acute  stage  or  degree. 

Rheumatism  implies  inflammation:  but  as  I  mentioned  in  an  early  part  of  the 
course,  it  is  inflammation  of  a  peculiar  or  specific  kind.  In  the  first  place,  it  is  in- 
flammation of  a  particular  tissue — \he  fibrous  tissue:  and  it  may,  therefore,  manifest 
itself  wherever  that  tissue  is  employed  in  the  fabric  of  the  body.  No  doubt  the  in- 
flammation does  involve  other  tissues  also :  but  it  is  ahvaj^s,  probably,  by  extending 
to  them  through  what  has  been  called  contiguous  sympathy.  Thus  we  have  the 
synovial  membrane  of  a  joint  inflamed  in  many  cases,  the  inflammatory  action  having 
spread  from  the  fibrous  textures  around  the  joint :  or,  as  1  formerly  pointed  out  to 
you  more  in  detail,  the  serous  surface  of  the  pericardium,  and  the  serous  surface  (or 
what  is  analagous  to  a  serous  surface)  of  the  inside  of  the  heart,  and  especially  that 
part  of  it  which  is  carried  over  the  valves — each  and  all  of  these  serous  membranes 
are  extremely  liable  to  be  affected  with  inflammation  in  the  acute  form  of  rheumatism: 
but  in  all  of  them  it  is  probable  that  the  fibrous  tissue  was  the  first  to  suffer.  The 
pericardium  is,  as  you  know,  a  fibro-serous  membrane  ;  and  fibrous  tissue  is  inter- 
posed between  the  folds  of  the  serous  membrane,  in  the  cardiac  valves. 

Rheumatism,  therefore,  is  essentially  inflammation  of  the  fibrous  tissue  :  and  it 
most  commonly  seizes  upon  the  fibrous  parts  that  lie  round  the /a?'0"e/' Join/s  ;  the 
ligaments  and  the  tendons :  and  in  this  respect  you  may  almost  consider  the  perpe- 
tually moving  heart  as  one  of  the  large  joints.  Yet  this  inflammation,  when  confined 
to  the  fibrous  tissues,  is  not  common  inflammation.  At  any  rate,  it  does  not  reckon 
among  its  events  (as  common  inflammation  does)  either  suppuration  or  gangrene.  If 
suppuration  sometimes  occurs  (and  it  certainly  occurs  very  rarely)  it  is  because  the 
rheumatismal  inflammation  has  extended  to  contiguous  textures,  and  then  has  run 
the  ordinary  course  of  inflammation.  Inflammation  of  the  areolar  tissues  around  a 
joint  may  thus  inflame  and  suppurate.  The  inflammation  of  the  synovial  membrane 
nuty  be  of  sufficient  intensity  to  give  rise  to  the  formation  of  pus.  When,  however, 
the  inflammation  extends  to  the  serous  tissues  within  and  around  the  heart,  the  pro- 
ducts of  the  inflammaliorv  are  jus  the  same  as  when  inflammation  of  the  same  tex- 
ture, of  the  common  kind,  is  any  how  produced. 

Acute  rheumatism,  then,  consists  in  redness,  heat,  pain,  and  swelling  (that  is  to 
say,  in  inflammation)  of  the  parts  lying  around,  or  entering  into  the  composition  of, 
one  or  more  of  the  larger  joirus  of  the  bodj'-  :  general!}"  of  several  at  the  same  time, 
or  in  succession  ;  with  a  disposition  to  shift  from  one  joint  to  another,  or  to  certain 
internal  organs,  and  especially  to  the  membranes  of  the  heart;  and  with  fever. 

This  tendency  to  shift  its  place — to  what  is  usually  called  metastasis — is  a  very 
remarkable  feature  of  the  disease.     The  inflammation  will  appear  in  one  joint  sud- 


ACUTE    RHEUMATISM.  907 

denly,  and  as  suddenly  subside  in  another  which  it  previously  occupied  ;  and  then, 
perhaps,  it  will  jump  back  again  to  its  old  quarters.  In  many  instances,  however, 
it  invades  fresh  joints  without  wholly 'ceasing,  and  sometimes  even  without  diminish 
ing  at  all,  in  those  formerly  affected.  It  may  visit  in  this  way  every  large  joint  in 
the  bod}',  and  even  seize  upon  some  of  the  smaller  ones ;  or  it  may  possess  nearly 
all  of  them  at  once.  It  is  most  commonly  seen  to  affect  the  ankles  and  knees,  the 
knuckles,  wrists  and  elbows.  It  is  often  seated  in  the  shoulders,  also,  and  in  the 
hips.  The  joints  of  the  fingers  frequently  suffer ;  and  I  have  seen  one  instance  in 
which  the  joints  of  the  jaws  were  manifestly  implicated  in  the  rheumatic  inflamma- 
tion. But  by  far  the  most  serious  and  dangerous  leap  which  the  diseased  action  is 
apt  to  take,  is  to  the  membranes  of  the  heart. 

But  I  pointed  out  to  you,  in  a  former  lecture,  the  symptoms  of  rheumatic  car- 
ditis, its  consequences,  the  various  ways  in  which  it  connects  itself  with  the  joint 
affection,  and  the  treatment  by  which  we  are  to  attempt  to  moderate  it.  I  dismiss, 
therefore,  this,  the  most  momentous  complication  of  acute  rheumatism,  from  the  pre- 
sent discussion,  and  shall  confine  myself  solely  to  the  disease  as  it  manifests  itself 
externally. 

The  shifting  and  migratory  inflammation  of  the  textures  lying  round  or  composing 
the  larger  joints,  is  attended  with  high  inflammatory  fever;  with  a  remarkably  full, 
bounding  pulse  ;  with  flushed  cheeks;  headache;  profuse,  drenching,  sour-smelling 
perspirations,  which  distress  and  weaken  the  patient,  but  bring  no  relief  to  his  pain; 
with  a  white-coloured,  dirtyish,  thick  fur  on  the  tongue,  which  is  red,  however,  at  its 
tip  and  edges ;  with  turbid  and  acid  urine.  But  this  severe  and  inflammatory  fever 
(si/nocha,  CuWen  calls  it)  has  no  tendency  to  degenerate  into  a  typhoid  form ;  and 
that  is  a  striking  feature  in  the  complaint.  Neither  is  the  intellect  affected,  except 
when  carditis  takes  place  ;  and  then,  as  I  stated  formerly,  violent  delirium  is  apt  to 
ensue,  misleading  the  practitioner,  drawing  his  attention  away  from  the  chest,  where 
fatal  changes  are  in  progress,  and  fixing  it  upon  the  head,  where  no  inflammation  at 
all  exists,  but  which  is  disturbed  through  sympathy  with  the  cardiac  disorder. 
With  this  exception,  we  do  not  find  patients  in  acute  rheumatism  delirious.  Through- 
out all  this  febrile  disturbance,  there  is  no  coma,  no  marked  trouble  of  the  stomach 
or  of  the  bowels,  no  vomiting,  no  diarrhoea,  no  petechise,  no  aphtha;,  no  sordes  about 
the  mouth,  all  which  are  of  ordinary  occurrence  in  the  course  of  common  continued 
fevers. 

The  joints  are  exquisitely  tender,  as  well  as  painful.  The  fibrous  tissues,  which 
are  endowed  with  but  little  sensibility  in  their  sound  and  healthy  state,  become 
acutely  painful  when  occupied  by  inflammation.  The  pain  is  increased  by  pressure, 
and  therefore  by  whatever  implies  pressure ;  by  movements  of  the  joints,  conse- 
quently. The  patients  are  reduced  to  perfect  helplessness  by  the  pain.  Their  com- 
mon phrase  is,  that  they  have  entirely  lost  the  use  of  their  limbs ;  and  this  is  true 
enough  in  fact,  but  not  true  in  the  medical  sense  of  those  words.  They  have  not 
lost.  \\\e  power  oi  moving  them;  there  is  wo  palsy ;  but  iYiey  dare  not  inovQ  them, 
because  the  effort  gives  them  so  much  torment. 

Pain  in  the  affected  joints  is  more  constant  than  swelling,  and  swelling  more  con- 
stant than  redness.  The  swelling  diflers  also,  in  different  cases,  in  rather  a  remark- 
able manner.  In  fact,  two  varieties  have  been  made  of  acute  rheumatism.  The 
distinction  was  first  drawn  by  Dr.  Chambers,  at  St.  George's  Hospital,  and  after- 
(\'ards  made  public  by  Dr.  Francis  Hawkins,  in  his  Gulstonian  lectures.  The  vari- 
eties are  spoken  of  under  the  names  oi  fibrous  or  diffused  rheumatism,  and  synovial 
rheumatism.     I  will  briefly  state  their  distinctive  characters. 

In  the  one,  then,  the  inflammation  commences  in  the  immediate  neighbourhood 
of  one  of  the  larger  joints :  not  in  the  joint,  but  near  it.  It  attacks  the  tendons, 
fasciae,  ligaments,  and  possibly  also  the  muscles.  There  is  not  at  first  much  redness, 
or  swelling ;  but  after  the  pain  has  been  of  some  duration,  there  is  a  puffiness  around 
the  parts  affected,  caused  apparently  by  turgescence  of  the  blood-vessels,  and  at 
length  ?light  pitting,  or  oedema,  may  supervene,  from  effusion  into  the  surroimding 
areolar  tissue;  and  what  redness  is  present  is  disposed  in  streaks,  foUow'ng  the 
course  of  the  tendons. 


908  ACUTE    RHEUMATISM. 

On  the  other  hand,  in  the  synovial  variety,  which  shows  itself  more  frequently 
and  more  plainly  in  the  knee  than  anywhere  else,  the  pain  which  marks  the  onset 
of  the  complaint  does  not  last  long  before  some  degree  of  swelling  is  perceptible, 
together,  in  most  instances,  with  slight  redness  of  the  skin;  and  this  swelling  is  not 
due  so  much  to  turgescence  of  the  blood-vessels,  or  to  oedema  of  the  areolar  tissue, 
as  to  fluid  poured  into  the  cavity  of  the  joint.  And  the  form  and  character  of  the 
swelling  indicate  that  it  is  the  result  of  the  fullness  and  distension  of  the  synovial 
membrane.  It  is  tight  and  elastic,  and  protrudes,  as  it  were,  through  the  spaces  that 
intervene  between  the  tendons  and  ligaments  by  which  it  is  in  other  parts  bound 
down  and  restrained  ;  and  JItccf nation  is  often  distinctly  perceptible  in  the  superficial 
joints,  when  both  hands  are  apphed  to  them. 

These  are  the  local  differences  between  the  two  forms  of  the  disease.  And  there 
are  differences  equally  well-marked  between  the  constitutional  symptoms  that  attend 
them. 

It  is  in  that  form  which  xar  ihx^iv  is  called  fibrous  rheumatism,  that  the  inflam- 
matory fever  runs  so  high ;  that  the  tongue  is  so  thickly  furred  ;  that  the  round,  full, 
bounding  pulse  occurs  ;  that  the  profuse,  spontaneous,  acid  perspirations  break  out. 
which  exhaust  the  patient's  strength  without  alleviating  his  sufferings  ;  that  the  urine 
is  high-coloured,  and  deposits  a  copious  sediment  like  brick-dust. 

In  the  synovial  form,  the  fever  is  either  less  intense  from  the  beginning,  or  soon 
moderates  after  the  joints  begin  to  swell;  the  tongue  is  less  foul;  the  patient  sweats 
much  less.  It  is  to  this  form  that  the  term  rheumatic  gout  is  often  applied.  And 
growing  experience  has  led  me  to  beheve,  that  in  this  popular  appellation  the  real 
nature  of  the  complaint  is  most  truly  expressed.  Gout  and  rheumatism  are  very 
similar  in  kind  ;  and  what  has  been  called  synovial  rheumatism,  while  it  forms  a 
connecting  link  between  the  two,  and  partakes  of  the  characters  of  both,  is  more 
nearly  allied  to  gout  than  it  is  to  rheumatism. 

Conformably  with  this  belief,  it  has  been  noticed  that  the  tendency  of  the  inflam- 
mation to  settle  upon  the  cardiac  membranes  is  much  greater  in  the  fibrous  than,  in 
the  synovial  disease.     This  is  a  most  important  difllerence. 

I  know  of  no  other  exciting  cause  of  acute  rheumatism  than  exposure  to  cold,  and 
especially  cold  combined  with,  moisture.  And  this  is  the  reason  why  the  disease  i' 
very  common  among  the  poorer  classes  of  society,  who  are  more  in  the  way  of  thai 
cause,  and  cannot  guard  against  it  so  effectually  as  their  wealthier  brethren ;  among 
whom  it  is  comparatively  rare. 

Acute  rheumatism  is  principally  a  disease  of  youth,  prevailing  most,  I  believe, 
from  the  age  of  puberty  to  that  of  thirty-five  or  forty.  I  have  repeatedly,  however, 
seen  it  in  children  ;  sometimes  as  early  as  the  third  or  fourth  year ;  and  I  slated  to 
you  some  time  ago,  that  the  chance  of  the  joint  affection  being  complicated  with 
rheumatic  carditis  is  the  greater  in  proportion  as  the  patient  is  the  younger.  With, 
perhaps,  one  exception,  I  never  knew  the  disease  occur  in  an  unequivocal  form  before 
puberty,  without  its  being  attended  with  inflammation  of  the  fining  or  investing 
membranes  of  the  heart. 

I  have  already  told  you  what  I  believe  to  be  the  proper  plan  of  treatment  to  pursue 
when  rheumatic  carditis  is  present:  in  that  case,  the  affection  of  the  limbs  is  of 
secondary  consequence.  But  what  are  we  to  do  when  there  is  no  complication  of 
the  joint  disease  ;  no  invasion  of  any  of  the  viscera  ? 

Why,  if  you  seek  for  instruction  upon  this  matter  in  books,  or  even  among  prac- 
tic^l  men,  you  will  meet  with  a  very  perplexing  diversity  of  opinion.  Apart  from 
the  cardiac  afl^eclion,  acute  rheumatism  has  no  danger  about  it ;  and  the  articular 
inflammation  usually  terminates,  sooner  or  later,  in  recovery,  whether  the  heart  be 
implicated  or  not.  And  most  persons  who  have  been  for  any  considerable  time  in 
practice  have  their  own  favourite  method  of  conducting  the  disorder  to  its  termina- 
tion. While  many  employ  free  blood-letUng,  and  other  active  antiphlogisiic  reme- 
dies, some,  on  the  contrary,  even  in  the  present  day,  put  their  trust  in  bark.  Some 
give  large  doses  of  calomel  in  the  outset  of  the  disease,  such  as  half  a  scruple  or  a 
scruple,  with  or  without  a  grain  or  two  of  opium  ;  and  they  repeat  the  dose  daily 
or  oftener,  till  the  urgent  symptoms  give  way ;  and  in  this  manner  I  have  seen  the 


ACUTE   RHEUMATISM.  909 

disease  apparently  cut  short.  But  I  have  also  known  many  instances  in  which  the 
disease  was  painful,  and  protracted,  and  obstinate,  although  this  practice  was  adopted 
early,  and  fairly  prosecuted.  Some  physicians,  again,  give  smaller  and  more  fre- 
quent doses  of  calomel  and  opium ;  and  some  think  opium  alone  to  be  as  useful  as 
this  combination.  Others  depend  mainly  upon  colchicum  ;  others,  upon  large  and 
repeated  doses  of  conium ;  and  some  attempt  the  cure  of  acute  rheumatism  by 
sweating  the  patient  by  means  of  guaiacum,  and  similar  stimulant  medicines,  and  a 
profusion  of  bed-clothes. 

Now  you  may  be  sure — when  men's  opinions,  concerning  the  treatment  of  a  dis- 
ease which  is  of  common  occurrence  and  easy  recognition,  are  thus  unsettled  and 
diverse — you  may  be  sure,  first,  that  no  specific  for  that  disease  has  yet  been  disco- 
vered ;  and  secondly,  that  the  disease  is  not  very  obedient,  or  not  steadily  obedient  to 
any  remedial  plan.  When  I  first  began  to  practise,  I  pleased  myself,  now  and  then, 
with  the  belief  that  I  had  ascertained  the  best  cure  for  acute  rheumatism  :  so  rapidly 
and  decidedly  did  the  disorder  recede  and  cease  upon  the  administration  of  such  or 
such  a  remedy.  But,  on  the  next  trial  of  it  perhaps,  my  expectations  have  been 
miserably  disappointed.  This  marked  improvement  has  happened  under  the  use  of 
colchicum,  of  conium,  of  calomel  with  opium,  of  alkahes.  I  did  not,  in  the  prosperous 
cases,  mistake  spontaneous  recovery  for  cure.  The  change  was  too  great  and  imme- 
diate, and  the  instances  of  success  were  too  numerous,  to  admit  of  that  explanation. 
Whether  it  be  (as  I  suspect)  that  shghter  diagnostic  marks  have  been  overlooked, 
and  that  sometimes  goiit  has  in  reality  been  cured  under  the  semblance  of  rheuma- 
tism— whether  bodily  idiosyncrasies  have  withstood  the  influence  of  remedies  —  or 
whether  atmospheric  agencies  have  kept  up  the  disorder  in  spite  of  proper  treatment 
— I  cannot  tell :  certain  it  is  that  we  are  occasionally  baffled,  and  the  patient  con- 
tinues to  suffer,  notwithstanding  the  diligent  enforcement  of  all  the  approved  reme- 
dies and  plans  of  treatment,  one  after  the  other.  I  am  far,  however,  from  thinking 
that  remedies  are  useless  :  and  I  do  by  no  means  assent  to  the  dictum  of  the  first  Dr. 
Warren,  who,  when  asked  what  was  good  for  acute  rheumatism,  answered  "  six 
weeks." 

In  the  fibrous  or  genuine  form,  with  the  bounding  pulse,  the  flushed  face,  the  high 
inflammatory  fever,  you  may  bleed  your  patients  from  the  arm  ;  especially  if  they 
are  young  and  robust.  They  will  bear  to  lose  a  large  quantity  of  blood  without, 
fainting;  and  you  will  always  find  the  blood  drawn  to  be  remarkably  buffed  and 
cupped.  The  pain  and  inflammation  are  'ocal ;  but  the  case  is  not  adapted  to  local 
remedies.  W^e  may,  by  leeches,  or  cupping,  or  cold  applications,  be  able  perhaps 
to  subdue  the  inflammation  in  a  knee  or  an  elbow :  but  from  the  migratory  character 
of  the  disorder,  we  incur  the  risk,  by  such  topical  measures,  of  giving  the  inflamma- 
tion a  new  and  a  more  serious  location. 

Venesection  will,  almost  always,  afford  a  marked  degree  of  relief  to  the  sufferings 
of  the  patient :  but  the  relief  will  seldom  be  complete  or  permanent :  and  we  may 
sometimes  with  propriety  repeat  the  bleeding.  In  very  few  instances,  however,  can 
we  hope  to  extinguish  the  disease  by  blood-letting.  And  this  is  one  of  the  cases  in 
which  you  must  not  take  the  state  of  the  blood  already  drawn  as  a  criterion  of  the 
propriety  of  abstracting  more.  The  blood  will  remain  ready  to  show  the  buffy  coat 
long  after  the  use  of  the  lancet  has  ceased  to  be  available  or  safe. 

The  advantages  of  blood-letting  in  this  complaint  are,  first,  the  partial  relief  which 
it  bestows.  It  is  seldom  that  the  pain  is  not  sensibly  mitigated,  and  the  fever  calmed, 
provided  the  bleeding  has  been  carried  to  a  proper  extent,  sufficiently  soon.  Secondly, 
free  and  early  venesection  may  sometimes  perchance  (but  not  often)  cut  short  the 
attack.  This,  however,  is  a  favourable  effect  which  you  must  not  reckon  upon,  and 
which  I  would  not  advise  you  to  aim  at.  But,  in  the  third  place,  blood-letting  may 
be  serviceable,  by  preparing  the  body  for  other  remedies :  for  calomel,  opium,  pur- 
gatives, colchicum. 

Yet,  looking  to  my  own  practice  in  acute  rheumatism,  I  find  that  although  I  am. 
in  the  almost  daily  habit  of  treating  it — for  it  is  a  disorder  from  which  our  wards  are 
never  perhaps  entirely  free — I  rarely  prescribe  phlebotomy.  Many  of  the  patients 
come  under  our  care  at  an  advanced  period  of  the  disease ;  when  the  time  for  bleed  • 


910  ACUTE    RHEUMAVISM. 

\ng  with  an)'  prospect  of  benefit  has  gone  by.  Some  have  been  bled  before  their 
admission.  Others,  in  whom  the  rheumatic  diathesis  has  become  inveterate,  are 
sufiering  recurrences  of  the  malady:  and  neither  does  the  recurrent  disease  require, 
nor  would  the  system  bear,  active  and  repeated  depletion.  In  many  instances,  again, 
the  constitution  has  been  battered  and  broken  by  a  London  life  :  while  in  others  there 
is  no  great  intensity  of  febrile  disturbance  from  the  first.  So  that  the  cases  in  which 
I  am  tempted  to  employ  the  lancet  are  really  few  and  far  between.  At  the  same 
time  I  can  well  believe  —  what  I  have  often  heard  —  that  in  the  country,  in  young 
persons  of  unimpaired  vigour,  in  the  first  attacks  of  the  disorder,  and  when  the  iti- 
flammatory  symptoms  run  high,  venesection  may  be  of  much  service  in  mitigating^ 
the  sufferings  of  the  patient,  and  in  facilitating  his  cure. 

I  believe  few  persons  now  adopt  the  plan  of  forced  perspiration  for  the  cure  of 
acute  rheumatism.  Formerly  it  was  the  fashion  to  give  powerful  sudorifics  :  Dover's 
powder,  or  antimony,  in  large  doses  ;  and  the  patient  was  "  accinctus  ad  sudorem  ;" 
covered  up  in  bed  between  thick  blankets,  with  a  hot  bottle  or  brick  at  his  feet.  But 
in  the  severe,  unequivocal  fibrous  form  of  rheumatism  the  perspiration  is  profuse 
without  any  artificial  means  being  used  to  excite  it,  and  it  is  not  accompanied  by  the 
smallest  alleviation  of  the  pain:  nay  sometimes  the  patients  will  teU  you  that  they 
are  worse,  in  that  respect,  while  the  sweating  continues. 

The  preparations  of  colchicum  have  sometimes,  whether  venesection  has  been  pre- 
mised or  not,  an  almost  magical  effect  in  quelhng  the  disease.  Frequently,  when 
most  successful,  (though  that  is  by  no  means  a  necessary  condition  of  their  success.) 
they  exercise  some  marked  influence  upon  the  stomach  and  bow^els.  Colchicum  is 
very  apt  to  occasion  deadly  nausea  and  vomiting,  griping,  and  diarrhoea,  and  when 
these  consequences  ensue  from  its  use,  the  inflammation  of  the  joints  often  subsides 
entirely.  At  any  rate,  if  the  rheumatism  does  not  give  way  when  the  stomach  and 
bowels  become  thus  affected,  you  may  be  certain  that  to  push  the  colchicam  further 
would  be  useless. 

Our  wishes,  however,  and  our  expectations,  from  colchicum,  are  often  doomed  to 
be  defeated.  I  believe  that  in  proportion  as  the  synovial  symptoms  predominate,  or 
mix  themselves  distinctly  with  the  fibrous — in  proportion  as  the  disease  approaches 
in  its  characters  to  gout — you  may  expect  to  be  successful  with  colchicum.  Large 
doses  are  not  requisite.  Twenty  minims  of  the  wine  or  of  the  tincture  may  be  given 
every  six  hours,  until  some  result  is  obtained.  Or  a  grain  of  the  inspissated  juice,  or 
of  the  acetous  extract  of  colchicum,  every  four  hours.  Under  this  treatment  the  dis- 
ease sometimes  vanishes  within  three  or  four  days ;  the  medicine  producing  sickness 
and  purging,  and  the  rheumatism,  or  the  rheumatic  gout,  rapidly  declining.  Occa- 
sionally the  same  favourable  event  takes  place,  although  there  has  been  no  disturb- 
ance in  the  stomach  or  bowels. 

There  are  some  cases  which  yield  readily  to  calomel  and  opium  :  and  in  the  fibrous 
disease  I  think  that  calomel  and  opium  are  the  remedies  to  which,  after  sufficient 
bleeding,  you  will  do  well  to  trust.  For  it  is  under  this  character  that  the  extension 
of  the  disease  to  the  membranes  of  the  heart  is  so  liable  to  happen  :  and  if  anything 
can  protect  the  patient  against  this  fearful  complication  of  a  malady  w'hich,  previously 
attended  by  no  danger,  becomes  by  this  addition  almost  necessarily  fatal — or  if  any- 
thing can  arrest  the  carditis  before  it  leaves  indelible  mischief  imprinted  on  the  heari 
— it  is  (in  my  opinion)  mercury. 

Dr.  Hope  has  lately  (1837)  published  an  account  of  a  particular  mode  of  using 
calomel  and  opium  in  this  disease,  which  mode  he  learned  from  Dr.  Chambers,  and 
which  is  followed,  more  or  less  closely,  I  fancy,  by  many  other  physicians.  It  is 
said  to  be  so  successful  that  even  the  details  of  it  ought  to  be  known.  The  plan  is 
described  as  foUow^s  : — After  a  full  venesection,  or  even  two,  in  the  robust,  but  with- 
out any  bleeding  in  the  feeble  and  delicate,  eight  or  ten  grains  of  calomel,  with  a 
grain  and  a  half  of  opium,  according  to  the  age  of  the  patient  and  the  severity  of  the 
case,  are  administered  every  night ;  and  followed  every  morning  by  a  strong  black 
dose,  sufficient  to  ensure  four  or  five  stools  at  least.  With  this  treatment  is  combined 
ihrice  a  day,  a  saline  draught  containing  from  fifteen  to  twenty  minims  of  the 
vinum  colchici,  and  five  gmins  of  Dover's  powder.     When  the  pain  and  swelling 


ACUTE   RHEUMATISM.  911 

are  greatly  abated,  if  not  almost  gone  (which  Dr.  Hope  affirms  to  happen  often 
within  two  da_y3,  and  almost  always  within  four),  the  calomel  is  omitted  ;  or  it  is 
omitted  sooner  if  the  gums  become  at  all  tender.  The  opium,  however,  is  con- 
tinued to  the  amount  of  a  grain  or  a  grain  and  a  half  at  bed-time  ;  and  in  severe 
cases  a  grain  also  at  noon  is  added ;  and  the  colchicum,  and  the  black  dose,  are 
still  given  as  at  first.  Dr.  Hope  considers  it  a  case  of  exception  if  the  patient  be 
not  well  in  a  week. 

The  following  are  stated  by  Dr.  Hope  as  being  the  great  advantages  of  this  plan 
of  procedure: — 1.  That  the  patient  is  generally  sound,  well  and  fit  for  work,  in  a 
week  or  ten  days  after  the  pains  have  ceased.  2.  That  the  gums  are  rarely  affected, 
especially  if  you  previously  ascertain  that  the  patient  has  not  a  morbid  susceptibility 
of  mercury.  3.  That  it  is  rare  to  see  inflammation  of  the  heart  if  the  treatment  is 
early  begun  ;  not  oftener,  he  thinks,  than  in  one  of  a  dozen  cases.  4.  If  the  slightest 
symptom  of  endo-  or  peri-cardilis  does  supervene,  a  few  extra  doses  of  calomel  and 
opium,  given  every  four  or  six  hours,  will  generally  affect  the  constitution  in  twenty 
or  thirty  hours,  which,  with  two  or  three  cuppings  or  leechings  on  the  region  of  the 
heart,  almost  always  place  the  patient  in  a  state  of  safety. 

Now,  believing  that  some  such  plan  as  this,  made  up  of  blood-letting  in  some  cases, 
purging,  calomel  and  opium,  and  colchicum,  is  as  good  as  can  be  pursued ;  and  in- 
deed that,  with  individual  modifications,  it  is  very  much  pursued,  especially  in  Lon- 
don at  present;  still  I  cannot  help  feeling  great  doubt — doubt  which  I  would  will- 
ingly not  entertain — about  all  the  advantages  just  enumerated.  Too  often  we  do 
not  see  the  patient  till  there  is  such  disease  of  the  heart  present  as  is  manifest  to  the 
ear ;  and  then,  as  T  stated  in  a  former  lecture,  perfect  recovery  and  repair  seem 
scarcely  within  the  scope  of  possibility.  Too  often,  when  the  patient  is  seen  early, 
the  sj'stem  refuses  to  admit  of  the  specific  protection  of  the  full  mercurial  action. 
There  is  a  practical  objection  also  to  the  exaction  of  four  or  five  motions  from  the 
bowels  of  these  rheumatic  patients  every  day ;  I  mean  the  inconvenience,  the  increase 
of  pain,  and  the  fresh  exposure  to  cold,  occasioned  by  frequently  going  to  stool ;  and 
this  is  a  disadvantage  likely  to  be  particularly  felt  in  hospitals. 

Bark  used  to  be  highly  thought  of  for  the  cure  of  acute  rheumatism  ;  but  it  is  only 
Deneficial,  or  safe,  during  the  convalescence.  Where  the  system  has  been  much 
reduced  or  broken  by  the  complaint,  or  by  the  disciphne  the  patient  has  undergone, 
1  think  that  the  decoction  of  cinchona  is  of  service  in  fortifying  the  body  against  the 
renewed  agency  of  those  causes  on  which  the  original  attack  depended. 

Cases  frequently  occur  which  are  neither  absolutely  acute,  nor  absolutely  chronic. 
The  inflammation,  without  being  intense  in  any  one  joint,  lingers  in  many;  and  the 
fever,  though  not  entirely  absent,  is  moderate.  The  joints  are  hot  and  painful,  and 
the  skin  is  dry,  and  there  is  some  thirst.  To  this  intermediate  character  the  term 
subacute  is  sometimes  applied  ;  and  it  will  serve  our  purpose  of  distinction. 

In  this  form  of  the  disease,  as  well  as  in  the  more  active  form,  the  urine  is  almost 
always  loaded  with  lateritious  matters,  and  strongly  acid.  Looking  upon  this  as  an 
indication  of  treatment,  I  have  prescribed  alkalies,  and  with  much  success :  the 
liquor  potassfe,  for  instance,  to  the  amount  of  a  drachm  daily,  for  several  days  to- 
gether ;  keeping  the  bowels  free  by  laxative  medicine.  Under  this  plan,  more  surely 
in  my  experience  than  under  any  other,  the  urine  clears,  the  pain  abates,  and  the 
joints  are  liberated.  Nitre  has  been  praised  of  late  as  being  eminently  successful 
against  rheumatism:  I  have  not  had  much  opportunity  of  trying  it,  but  I  should 
think  it  likely  to  do  good  in  these  subacute  cases. 

There  are  two  kinds  of  chronic  rheumatism :  one  attended  with  local  heat  and 
swelling,  although  the  constitution  at  large  sympathizes  very  little  or  not  at  all  wuh 
the  topical  inflammation  ;  the  other  characterized  rather  by  coldness  and  stiffiiess  ot 
the  painful  joints.  In  the  former  of  these  the  pains  are  increased  by  pressure,  anr' 
by  movements  of  the  limbs,  and  by  external  warmth  ;  the  warmth  of  a  bed,  for  ex 
ample ;  and  there  may  be  even  some  slight  degree  of  pyrexia  at  night.  In  truth 
this  form  of  chronic  rheumatism  claims  a  near  relationship  with  the  acute,  rn^o  which 
ii  sometimes  passes,  and  o/"  which  it  is  frequently  the  sequel.    It  accordingly  requirei* 


912  CHRONIC    RHEUMATISM. 

antiphlogistic  remedies,  only  less  vigorously  applied.  It  is  important  for  you  to  know 
that,  in  these  cases,  you  may,  with  less  hesitation,  less  fear  I  mean  of  driving  the  in- 
flammation to  some  more  vital  part,  apply  leeches,  and  cold  washes,  to  the  painful 
joints.  Otherwise,  the  principle  of  treatment  remains  unchanged.  The  complaint 
is,  however,  often  obstinate,  and  lingering,  and  prone  to  recur.  It  frequently  involves 
and  cripples  the  smaller  joints,  especially  those  of  the  knuckles  and  fingers  ;  render- 
ing them  knobby,  and  distorting  their  form  and  position.  The  fingers  take  a  per- 
manently oblique  direction,  slanting  outwards  towards  the  ulna  :  and  Dr.  William 
Budd  has  drawn  attention  to  the  curious  fact  that  the  corresponding  joints  of  the  two 
sides  of  the  body  are  always  affected  exactly  in  the  same  manner.  To  use  a  para- 
doxical expression,  the  deformity  is  symmetrical.  One  crooked  joint  is  just  the  copy 
of  its  fellow.     Surely  this  indicates  the  constitutional  origin  of  the  disorder. 

In  the  other  form  of  chronic  rheumatism,  what  some  call  passive,  the  remedies 
that  answer  best  are  of  a  different  kind.  The  pain  is  alleviated  by  friction  of  the 
joint,  and  the  patients  are  most  comfortable  when  they  are  warm  in  bed,  and  espe- 
cially when  moderate  perspiration  is  present.  They  are  singularly  benefited  also 
by  summer  weather.  Persons  who  are  much  troubled  by  this  wearing  complaint, 
and  who  can  afford  to  live  where  they  please,  would  do  well  to  take  up  their  resi- 
aence  in  a  warm  climate.  Wherever  they  may  be,  such  patients  should  be  protected 
ao-ainst  atmospheric  vicissitudes  by  warm  clothing :  they  should  be  cased  in  flannel 
from  the  neck  downwards.  Warm  bathing  is  of  great  service  ;  and  especially  baths 
of  salt  water,  of  a  temperature  not  less  than  100°,  that  they  may  act  as  a  stimulus  to 
the  cutaneous  circulation  ;  warm  douches  ;  the  vapour  bath  ;  or  the  hot-air  bath,  of 
which,  as  I  said  before,  the  patient  may  receive  the  benefit  lying  in  bed.  And  to 
warm  clothing,  and  warm  bathing,  may  be  added  friction,  with  some  stimulating  lini 
ment,  and  what  is  called  shampooing.  It  is  in  these  cases  that  stimulating  internal 
medicines  are  often  of  use.  Turpentine  ;  some  of  the  animal  oils,  the  cod-liver  oil, 
for  instance ;  guaiacum.  Opiates,  too,  are  frequently  remedial  of  the  pain :  and 
there  can  be  no  better  form  for  their  administration  than  that  presented  to  us  in  the 
celebrated  Dover's  powders  ;  the  pidvis  ipecacuanhsc  compositixs  of  the  Pharmaco- 
pceia. 

There  is  a  remedy  which  has  recently  come  into  extensive  use,  for  the  relief  of 
chronic  rheumatism;  I  mean  the  iodide  of  potassium.  It  is  most  certain  of  acting 
beneficially  when  that  fibrous  part,  the  periostetnn,  is  principally  aflxjcted.  Its  vir- 
tues in  the  case  of  venereal  nodes  (/.  e.,  in  venereal  inflammation  of  the  periosteuiaj, 
were  first  distinctly  pointed  out  by  Dr.  Williams,  of  St.  Thomas's  Hospital.  I  believe 
it  is  equally  effectual  upon  whatever  cause  chronic  inflammation  of  the  same  part, 
with  nodes  and  thickenings,  may  depend. 

Some  of  you  probably  saw  a  woman  who  was  lately  my  patient  in  the  hospital, 
and  who  had  been  worn  down  to  a  skeleton  by  the  pain  she  had  endured  from 
chronic  periostitis  giving  rise  to  nodes,  which  did  not  appear  to  be  traceable  to 
syphilis.  She  had  been  in  the  habit  of  lulling  the  pain  by  large  opiates  at  night, 
and  begged  to  have  them  after  her  admission.  I  gave  only  the  iodide  in  the  ordinary 
dose  (five  grains  thrice  daily),  and  she  slept  without  opium ;  and  in  a  week  or  two 
lost  her  nodes,  and  was  perfectly  well. 

Cfosely  allied  to  acute  rheumatism,  and  yet  distinct  from  it,  is  the  singular  dis- 
ease which  in  this  country  is  popularly  called  the  spoilt:  which  CuUen,  in  the  first 
.nstacice,  was  disposed  to  term  arthritis;  but  as  arthritis  would  imply  inflammation 
of  all  or  any  of  the  joints,  he  afterwards  adopted  the  ancient  name  of  podagra  (foot- 
pain). 

The  same  author  has  given,  in  his  First  Lines,  an  excellent  account  of  the  phe- 
nomena which  constitute  a  paroxysm  of  gout.  It  is  copied  from  Sydenham,  who 
drew  from  nature :  for  he  had  himself  suffered  frequent  and  severe  visitations  of  the 
disease  during  a  period  of  thirty-four  years. 

llie  attack  begins,  most  commonly,  an  hour  or  two  after  midnight.  The  patient, 
who  had  gone  to  bed  and  to  sleep  in  his  usual  health,  and  without  suspecting  wtiat 
was  about  to  happen,  is  awakened  by  a  pain  in  one  of  his  feet,  mostly  in  the  first 


GOUT. 

joint  or  ball  of  the  great  toe  ;  but  sometimes  in  other  parts  of  the  foot — the  heel,  the 
instep,  the  ankle.  With  the  coming  on  of  this  pain  there  is  generally  more  or  less 
of  a  cold  shivering,  which  gradually  ceases  as  the  pain  gets  worse,  and  is  succeeded 
by  heat.  The  pain  grows  more  and  more  violent  and  intolerable  ;  and  is  spoken  of 
by  those  who  suffer  it,  as  amounting  to  torture.  It  is  a  grinding,  crushing,  wrench- 
ing pain  ;  or  a  burning  sensation  as  if  a  hot  iron  were  pressed  into  the  joint.  Some 
humorous  Frenchman  described  it  in  this  way.  "  Place  (said  he)  your  joint  in  a 
vice,  and  screw  the  vice  up  until  you  can  endure  it  no  longer.  That  may  represent 
rheumatism.  Then  give  the  instrument  another  twist,  and  you  will  obtain  a  notion 
of  the  gout."  The  pain  is  attended  with  great  restlessness  and  misery,  and  exquisite 
tenderness.  The  patient  cannot  bear  the  weight  of  the  bed-clothes  upon  the  affected 
limb ;  nor  the  jar  of  a  heavy  foot-fall  in  his  chamber.  In  a  vain  search  after  comfort 
he  is  perpetually  shifting  his  foot  from  place  to  place,  and  from  posture  to  posture. 
At  length,  about  the  ensuing  midnight,  the  pain  remits ;  sometimes  gradually,  some 
times  so  suddenly  that  the  patient  attributes  the  relief  to  his  having  at  last  found  an 
easy  position.  He  falls  asleep  in  a  gentle  perspiration,  and  when  he  wakes  the  next 
morning  he  finds  the  part,  which  had  been  so  painful,  to  be  red,  swelled,  tense  and 
shining,  surrounded  by  more  or  less  cedema,  and  by  turgid  veins.  The  same  series 
of  symptoms  recur,  in  a  mitigated  degree,  for  some  days  and  nights;  and  then  the 
disease  often  goes  entirely  off,  not  to  return  till  after  a  long  interval. 

As  the  oedema  subsides,  and  the  redness  fades,  the  cuticle  of  the  part  that  has 
been  inflamed  peels  off;  and  this  process  of  desquamation  is  generally  attended  with 
troublesome  itching. 

Such  is  a  picture  of  an  attack  of  gout,  occurring  in  an  adult  subject,  for  the  first 
time,  and  in  its  most  regular  and  genuine  form. 

Attacks  of  this  kind  are  preceded,  in  most  instances,  by  some  marked  disorder  of 
the  functions  of  the  stomach  ;  diminished  appetite,  flatulence,  heartburn,  nausea  per- 
haps. And  during  the  paroxysm  the  urine  is  very  high-coloured,  and  acid,  and 
turbid  ;  depositing  a  copious  pink,  or  brick-dust  sediment.  The  stools,  also,  are  un- 
natural ;  pale,  or  of  a  dark  green,  and  very  offensive.  After  the  fit,  when  the  com- 
plaint has  ceased  entirely,  it  generally  (says  CuUen)  "leaves  the  person  in  very 
perfect  health ;  enjoying  greater  ease  and  alacrity  in  the  functions  of  both  body  and 
mind,  than  he  had  for  a  long  time  before  experienced." 

But  the  disorder,  which  has  thus  departed,  is  very  apt — nay,  un-less  extreme  care 
be  taken  to  prevent  it,  and  even  in  spite  of  all  care,  it  is  almost  sure — to  return.  At 
first,  perhaps,  it  recurs  not  oftener  than  once  in  every  three  or  four  years ;  but  after 
some  time  the  intervals  are  shorter,  and  the  attacks  become  annual,  happening  about 
the  same  time  of  the  year  :  afierwards  they  come  twice  every  year ;  and  at  length 
they  return  several  times  during  the  course  of  the  autumn,  winter,  and  spring.  And 
as  the  fits  are  more  frequent,  so  also  are  they  more  protracted,  till,  in  the  advanced 
state  of  the  disease,  the  patient  is  hardly  ever  free  from  it,  except  perhaps  for  two  or 
three  months  in  summer.  I  do  not  mean  that  all  this  occurs  invariably  in  all  cases 
ahke  ;  but  this  is  a  sketch  of  the  general  course  of  the  complaint. 

There  are  other  phenomena  also  to  be  noticed  as  time  advances,  and  as  the  dis- 
ease is  repeated.  At  first,  I  say,  it  commonly  appears  in  one  foot  only;  afterwards 
every  fit  includes  both  feet,  the  one  after  the  other :  and  as  the  disease  continues  to 
recur,  it  not  only  attacks  both  feet  in  succession,  but  after  having  ceased  in  the  foot 
whicli  was  secondly  visited,  it  will  return  again  into  the  foot  first  affected,  and  per- 
haps a  second  time  also  into  the  other.  It  passes,  too,  into  other  joints,  both  of  the 
upper  and  lower  extremities,  large  as  well  as  small;  so  that  there  is  scarcely  a  joint 
that  may  not,  at  one  time  or  another,  be  seized  upon.  But  as  the  disease  proceeds, 
and  the  fits  get  to  be  more  numerous,  the  pains  are  commonly  less  violent  than  they 
Avere  at  first;  the  patient  is,  however,  more  affected  with  sickness,  and  suffers  more 
in  his  general  health. 

Again,  after  the  earlier  attacks,  the  joints  usually  recover  entirely  their  former 
strength  and  pliancy ;  but  when  the  disorder  has  returned  again  and  again,  they 
are  not  so  readily  nor  so  completely  restored  to  their  previous  condition,  but  re* 
58  4  b 


914  GOUT. 

main  weak  and  stiff,  and  sometimes  they  lose  at  length  their  capacity  of  motion 
altogether. 

Also,  in  many  gouty  persons,  but  not  in  all,  after  the  disease  has  frequently  re- 
curred, what  are  called  chalk-stones  form;  concretions  that  look  exactly  like  c'haitf 
take  place  around  and  outside  the  joint,  filling  up  the  areolar  tissue,  and  lyinfr,  in 
general,  immediately  beneath  the  skin.  The  material  of  these  curious  concretions 
is  deposited  at  first  in  a  half  fluid  state,  and  resembles  soft  mortar ;  but  the  more 
watery  ingredients  being  afterwards  absorbed,  it  becomes  dry  and  hard.  Of  course 
when  this  stuff  is  deposited  in  any  quantity  on  the  outside  of  a  joint,  it  must  limit  in 
a  great  measure,  or  entirely  prevent,  the  motion  of  that  joint.  And  sometimes  matter 
of  the  same  kind  is  efiljsed  into  the  joint  itself;  as  I  have  once  seen  in  a  gouty  pa- 
tient who  died  in  the  Middlesex  Hospital. 

Gout  is  a  disease  that  was  well  known,  and  well  observed,  by  the  ancients.  In 
its  genuine  form  it  could  neither  be  overlooked  nor  mistaken.  Many  very  interest- 
ing facts  relative  to  this  painful  disorder  have  accordingly  been  ascertained :  and  I 
proceed  to  notice  the  chief  of  these ;  but  must  do  so  with  as  much  brevity  as  I  can. 

First,  then,  gout  is  an  hereditary  disease.  I  do  not  mean  to  say  that  the  disposi- 
tion to  it  is  always  a  transmitted  disposition ;  but  that  the  complaint  is  much  more 
likely  to  occur  in  persons  in  whose  pedigree  it  can  be  traced,  than  it  is  in  othei 
persons.  It  may,  I  beheve,  be  generated  by  certain  habits  of  life;  and,  on  the  othei 
hand,  in  spite  of  an  inherited  predisposition,  ti?e  disease  may  be  staved  off  and 
averted.  Let  the  son  of  a  rich  and  gouty  nobleman  change  places  with  the  son  of  a 
farm-servant,  and  earn  his  temperate  meal  by  the  daily  sweat  of  his  brow,  and  the 
chance  of  his  being  visited  with  gout  will  be  very  small.  Granting  this,  we  see 
reason,  independent  of  the  general  analogy  of  hereditary  disorders,  why  the  gout 
may  be  expected  sometimes  to  leap  over  a  generation,  just  as  family  likenesses  are 
known  to  intermit ;  while  yet  the  disposition  may  descend  to  the  children  of  those 
who,  in  their  own  persons,  have  never  sufl"ered  the  disease.  Among  522  gouty 
persons,  concerning  whom  Sir  Charles  Scudamore  had  collected  information,  332 
could  trace  their  disease  to  the  father,  mother,  grandfather,  grandmother,  uncle,  or 
aunt.  In  the  remaining  190  the  disease  was  not  known  to  have  existed  in  either 
upward  branch  of  the  family-tree. 

2.  There  is  a  pattern  of  body  which  is  believed  to  be  favourable  to  the  acquisition 
of  gout.  "  It  attacks  (says  Cullen)  especially  men  of  robust  and  large  bodies,  men 
of  large  heads,  of  full  and  corpulent  habits,  and  men  whose  skins  are  covered  with  a 
thicker  rete  mucosimi,  which  gives  a  coarser  surface." 

3.  Whether,  in  a  given  individual,  there  be  an  inherited  tendency  to  the  disorder 
or  not,  its  access  is  promoted  in  a  remarkable  manner  by  a  full  and  luxurious  mode 
of  Hfe,  and  b}''  sedentary  or  inactive  habits. 

4.  It  is  observed  of  gouty  persons,  that  they  are  usually  subject  to  nephritic  com- 
plaints also,  to  fits  of  the  gravel,  to  renal  and  vesical  calculi.  These  disorders  of  the 
urinary  organs  commonly  begin  to  manifest  themselves  after  the  gout  has  plagued 
the  patient  for  some  time.  They  do  not  coincide  with  the  paroxysms  of  gout,  but 
the  two  happen  alternately:  or  (vv'hat  is  equally  e.^pressive  of  the  connection  between 
the  two  forms  of  disease)  the  children  of  gouty  and  nephritic  parents  inherit  often 
the  one  or  the  other  of  these  maladies  ;  but  "  whichever  may  have  been  the  principal 
disease  of  the  parent,  some  of  the  children  have  the  one,  and  some  the  other.  In 
some  of  them  the  nephritic  affection  occurs  alone,  without  any  gout;  and  this  fre- 
quently happens  in  the  female  ofl^spring  of  gouty  ancestors." 

The  urinary  concretions  to  which  gouty  people  are  so  subject,  and  the  morbid 
states  of  their  urine  generally,  belong  to  the  lithic  diathesis.  Dr.  Prout  holds  that 
"the  lithic  acid,  developed  principally  during  the  mal-assimilation  of  the  albuminous 
textures,  may  be  considered  as  the  characteristic  feature  in  gout."  And  the  chemical 
composition  of  the  chalk-stones  which  sometimes  accompany  gout,  is  in  accordance 
with  this  statement ;  and  illustrates  strongly  the  connection  between  gout  and  gravel 
The  so-called  chalk-stones  consists  mainly  of  lithic  acid  combined  with  soda ;  of  the 
'ithaie  or  superlithate  of  soda.  Sometimes  this  very  hthate  of  soda,  perfectly  white,  \t 
deposited  in  large  quantities  in  the  urine.     Dr,  Prout  says  that  he  has  seen  it  co- 


GOUT.  915 

piously  secreted  of  the  consistence  of  mortar,  so  as  to  block  up  the  urethra  in  its  pas- 
sage outwards.  Now  this  is  just  the  stuff  which  is  deposited  around,  and  sometimes 
within,  the  joints,  and  which  hardens  as  it  collects.  I  may  mention  here  again  that 
many  persons  have  the  gout  long,  and  severely,  without  having  any  of  these  concre- 
tions. They  are  incidental  to  the  more  chronic  forms  of  the  disorder,  in  which  the 
pain  and  the  fever,  though  of  long  duration  and  frequent  recurrence,  are  slight  in 
degree.  The  cuticle  at  length  gives  way,  and  the  earthy  matter  lies  bare.  A 
namesake  of  mine,  Mr.  Henry  Watson,  describes,  in  the  first  volume  of  the  Medical 
Communications,  the  case  of  a  Mr.  Middleton,  who  was  accustomed,  when  playing- 
at  cards,  to  chalk  or  score  the  game  upon  the  table  with  his  gouty  knuckles. 

5.  Gout  attacks  especially  the  male  sex.  Some  few  women,  however,  suffer  iU 
in  its  regular  and  decided  form  ;  and  generally  these  women  are  robust  and  plethoric. 
Cullen  noticed  its  occurrence  in  "several  females  whose  menstrual  evacuations  were 
more  abundant  than  usual,"  But  the  disease  chiefly  happens  in  women  after  the 
catamenia  have  ceased  to  appear.  Heberden  knew  a  female  who  had  numerous 
sores  from  chalk-stones. 

6.  Cullen  observes  that  the  gout  does  not  usually  come  on  till  after  the  age  of  five 
and  thirty.  Heberden,  who  in  his  long  and  extensive  practice  among  the  higher 
classes  of  society  in  this  town  saw  as  much  of  this  disease  as  any  physician  ever 
did,  says  that  he  never  met  with  a  case  which  he  could  decidedly  pronounce  to  be 
gout,  before  the  age  of  puberty.  Sir  Charles  Scudamore  has  collected  a  statistical 
account  of  515  examples  of  gout,  in  which  the  period  of  the  first  assault  had  been 
noted.  Of  these,  142  began  between  the  ages  of  20  and  30 ;  194  between  30  and 
40;  118  between  40  and  50.  The  greater  number,  you  will  observe,  was  between 
30  and  40. 

However,  I  believe  that  where  the  inherited  disposition  is  strong,  and  the  habits 
of  hving  are  such  as  to  foster  that  disposition,  gout  may  show  itself,  occasionally, 
even  prior  to  the  age  of  puberty :  but  this  is,  certainly,  the  exception  to  a  very 
general  rule. 

7.  Gouty  persons  are  subject  to  various  ailments,  which  spring  from  the  same 
fountain  as  the  well-marked  paroxysm  :  derangements  in  the  functions  of  the  digestive 
organs,  of  the  heart  and  lungs,  of  the  brain  and  nerves. 

The  most  familiar  of  these  ailments  is  indigestion,  with  its  various  circumstances 
of  impaired  appetite,  sickness,  vomiting,  flatulency,  heartburn,  acid  eructations,  gas- 
trodynia.  Pains  and  cramps  occur  in  several  parts  of  the  trunk,  and  shoot  thence 
into  the  upper  extremities,  and  are  relieved  by  the  extrication  of  wind  from  the 
stotnach.  The  bowels  are  irregular  ;  colicky  diarrhoea  being  sometimes  the  prevail- 
ing fault,  but  more  commonly  costiveness.  With  all  this  the  patient  is  apt  to  be  ex- 
cessively dejected  and  hypochondriacal,  morbidly  attentive  to  every  bodily  feehng, 
disposed  to  exaggerate  his  sufferings,  and  apprehensive  of  the  worst  event. 

When  the  viscera  of  the  thorax  are  affected,  the  patient  has  palpitations,  fits  of 
dyspnoea,  faintings,  or  even  pangs  like  those  of  angina. 

In  the  head  occur  pain,  giddiness,  transient  affections  of  the  vision  and  of  the 
hearing,  threaienings  of  palsy  and  apoplexy. 

All  these,  you  may  say,  are  feelings  and  ailments  to  which  any  and  all  persons 
are  liable.  True :  but  the  remarkable  peculiarity  which  connects  them,  in  some 
men,  with  gout  is  this;  —  that  they  often  all  clear  away  and  disappear  upon  the 
breaking  out  of  a  paroxj'-sm  of  that  disease  in  the  foot. 

Hence  such  symptoms  are  regarded  as  indicating  one  variety  of  irregular  gout. 
Cullen,  led  by  a  questionable  theory,  classes  them  under  the  head  of  atonic  gout. 
Sometimes  the  patient  so  affected  is  said  to  have  lurking  gout ;  or  masked  gout. 

In  another  variety  of  irregular  gout,  the  complaint  commences,  in  the  ordinary 
way,  in  a  joint ;  but  the  pain  and  inflammation  do  not  reach  the  ordinary  degree  of 
intensity,  or  at  any  rate  do  not  continue  for  the  usual  time  and  then  recede  gradually 
in  the  accustomed  manner,  but  they  disappear  abruptly  and  entirely,  while  symp- 
toms of  severe  and  alarming  disorder  arise,  as  suddenly,  in  some  internal  part.  Tills 
Culli^n  names  retrocedent  gout.  It  affords  an  example,  as  I  conceive,  of  true  metas 
tasis.     The  internal  part  most  commonly  attacked  is  the  stomach.     It  becomes 


916  GOUT. 

affected  with  a  peculiar  feeling  of  anxiety  and  distress ;  with  sickness,  vomiting,  or 
violent  pain,  which  the  patient  calls  spasm,  and  which,  probably,  is  of  a  spasmodic 
character.  More  rarely  the  retrocession  is  to  the  heart,  when  syncope  or  urgent 
dyspncea  ensues ;  or  to  the  head,  when  it  may  terminate  in  a  stroke  of  apoplexy,  or 
a  paralysis. 

In  a  few  cases  the  disorder,  thus  alighting  on  some  other  part  than  a  joint,  is 
plainly  inflammatory.  The  most  common  example  of  this  is  gouty  inflammation  of 
the  urethra,  with  scalding  and  a  puriform  discharge ;  simulating  very  exactly  an 
attack  of.  gonorrhoea.  So  also  there  is  a  gouty  form  of  ophthalmia,  or  gout  in  the 
eye ;  gout  in  the  testicle ;  and  a  year  or  two  ago  an  eminent  physician  of  my  ac- 
quaintance suffered  a  violent  and  dangerous  attack  of  what  was  considered  to  be  gout 
in  the  throat.  Dr.  Cullen  speaks  of  these  inflanunatory  affections  under  the  title  of 
misplaced  gout :  but  they  may  well  enough  be  ranked  under  one  of  the  preceding 
heads  of  masked,  or  retrocedent  gout. 

The  disposition  to  gout  may  be  engendered,  and  when  inherited  will  infallibly  be 
strengthened  and  developed,  as  I  have  told  you  already,  by  certain  habits  of  life  :  by 
sensual  indulgences,  and  (but  in  a  less  degree,  I  believe)  by  want  of  bodily  exercise. 
Of  this  we  have  the  strongest  negative  evidence  in  the  remarkable  immunity  from 
the  disease  enjoyed  by  the  working  poor  in  our  rural  districts.  One  never  hears  of 
the  gout  among  agricultural  labourers.  Sir  Gilbert  Blanc  states  that,  during  ten 
years  in  which  he  was  physician  to  St.  Thomas's  Hospital,  although  in  his  private 
practice  he  reckoned  130  patients  who  had  gout,  being  about  one  in  twenty-six  of 
the  whole  number,  he  had  not  a  single  case  of  it  among  3406  patients  in  the  hospital. 
This  I  think  strange,  for  in  the  London  hospitals  it  is  not  very  uncommon  for  us  tc 
meet  with  gout ;  but  then  it  is  in  persons  who  have  lived  fully  and  inactively :  in  the 
servants  of  wealthy  families  for  instance,  butlers,  coachmen,  porters — men  who  often 
live  more  luxuriously,  and  more  idly  a  great  deal,  than  their  masters.  And  among 
the  rich,  those  who  are  most  subject  to  gout  are  notoriously  those  who  indulge  most 
in  what  are  called  the  pleasures  of  the  table ;  who  eat  largely  of  animal  food,  and 
drink  much  wine,  especially  if  they  are  indolent  withal.  Such  men  generate  far 
themselves  the  lilhic  acid  diathesis  ;  and  if  the  gouty  tendency  happens  to  have  been 
born  with  them,  they  incur  the  disease,  under  these  habits,  with  more  or  less  readi- 
ness, according  to  the  degree  of  that  innate  disposition.  Strong  exercise  certainly 
remedies,  in  some  measure,  the  evil  effects  of  this  mode  of  life,  by  promoting  the 
excretions  of  the  body  :  but  gout  used  to  be  exceedingly  common  in  the  old-fashioned 
fox-hunter,  who  "rode  hard,"  while  he  also  "  hved  hard."  Mere  sedentary  habits 
do  not  produce  gout,  as  we  learn  from  the  comparative  exemption  of  females,  and  of 
the  poor,  who,  following  sedentary  employments,  are  yet  compelled  by  their  poverty, 
which  is  so  far  a  blessing  to  them,  to  be  temperate.  Men  who  eat  much  meat  gene- 
rally indulge  themselves  in  drinking  also :  the  two  causes  go  together,  and  it  is 
difficult  to  estimate  their  separate  influence.  Butchers,  who  live  fully  upon  animal 
diet,  are  said  to  be  rarely  affected  with  gout,  but  then  they  necessarily  take  a  great 
deal  of  exercise.  It  appears  that  the  use  of  wine,  and  of  malt  liquors,  fosters  the 
disposition  to  gout  much  more  than  the  abuse  of  distilled  spirits.  The  paucity  of 
gouty  patients  among  the  lower  classes  in  this  gin-drinking  town  suffices  to  show 
this.  I  have  been  told  that  gout  is  very  little  known  in  Glasgow,  where  the  com- 
mercial men  live  richly,  and  lead  sedentary  lives,  but  do  not  drink  much  wine,  their 
favourite  beverage  being  rum-punch,  of  which  they  are  not  at  all  sparing.  Dr.  Wil- 
liam Budd  says  that  the  disease  is  common  among  the  "  ballasters"  o-n  the  Thames ; 
that,  although  they  are  not  a  numerous  body,  many  are  admitted  with  gout  every 
year  into  the  JJreadnought.  Now  these  men  being  much  exposed  to  inclemencies 
of  weather,  and  using  great  bodily  exertion,  which  is  attended  with  profuse  sweating 
and  much  exhaustion,  think  themselves  warranted  in  drinking  (besides  spirits)  two 
or  three  gallons  of  porter  daily.  This  shows  the  effect  of  malt  liquor  in  producing 
the  gouty  habit  of  body. 

On  the  otiier  hand,  the  inbred  gouty  tendency  may  be  so  strong,  as  to  be  scarcely 
Kept  in  check  by  the  most  abstemious  regimen. 


GOUT.  917 

A  fit  uf  the  gout  may  be  brought  on  by  various  circumstances :  in  other  words, 
the  possio.e  exciting  causes  of  gout  are  many.  A  paroxysm  has  been  frequently 
known  lo  follow  immediately  upon  an  unusually  severe  debauch.  Strong  mental 
emotion  has  sometimes  the  same  consequence,  especially  emotion  of  a  depressing 
kind.  Excessive  fatigue — more  particularly  fatigue  produced  by  too  much  walking 
exercise  on  any  one  day — is  another  exciting  cause.  And  this  is  unlucky,  for  it  often 
discourages  a  patient  from  again  making  use  of  a  proper  and  even  a  necessary  amount 
o\  exercise  of  that  kind.  Another  exciting  cause  which  frequently  operates  is  exr- 
ternal  injury.  The  first  attack  of  gout  often  fixes  upon  the  seat  of  an  old  hurt :  and 
a  very  slight  recent  injury  is  sometimes  enough  to  determine  a  paroxysm — a  trifling 
bruise  or  sprain,  the  pressure  of  a  tight  shoe ;  nay,  Dr.  Heberden  tells  us  that  he 
verily  beheves  he  has  seen  an  attack  of  gout  brought  on  by  the  bite  of  a  flea ;  show- 
ing how  easily  the  disease  may  be  excited,  when  there  is  a  strong  predisposition  to 
it.  This  it  is  which  makes  us  so  often  doubt  the  accuracy  of  gouty  persons,  when 
they  tell  us  that  they  are  lame  from  a  sprain. 

Dr.  Cullen  enumerates  sundry  debilitating  circumstances,  which,  as  such,  appear 
to  operate  in  calhng  into  action  the  gouty  disposition.  And  there  can  be  no  doubt 
that  a  state  of  weakness  does  often  favour  the  eruption  of  the  malady.  A  friend  of 
my  own  had  lately  a  most  serious  attack  of  contin  jed  fever,  in  the  course  of  which 
he  became  hemiplegic,  and  his  fife  was  despaired  of.  Soon  after  the  fever  had  left 
him,  and  while  he  was  yet  extremely  feeble,  he  had  three  attacks  of  gout  in  quick 
succession. 

Pains  have  been  taken  by  several  writers,  especially  by  Heberden,  to  lay  down 
the  distinguishing  characters  between  gout  and  rheumatism.  A  first  assault  of  gout 
can  scarcely  be  confounded  with  an  attack  of  acute  rheumatism.  The  hmitation  of 
the  inflammatory  redness  to  one  foot,  and  the  restless  distress  of  the  gouty  patient, 
contrasts  strongly  with  the  helpless  and  motionless  condition  of  the  rheumatic,  who 
is  pinioned,  so  to  speak,  in  many  limbs.  There  may  be  more  room  for  doubt  and 
mistake  in  the  advanced  state  of  gout,  when  m.any  joints  have  at  length  become 
involved  ;  but  even  then  you  may  generally  decide  by  inquiring  into  the  history  of 
the  patient,  and  learning  the  circumstances  of  his  early  attacks. 

The  main  points  of  distinction  may  be  broadly  and  generally  stated  thus. 

In  gout  the  small  joints  are  first  and  chiefly  affected,  especially  the  joint  of  the 
great  toe  :  in  rheumatism,  the  large.  The  redness  of  the  gouty  inflammation  is  more 
bright  and. vivid  than  that  of  the  rheumatic  ;  and  the  fluctuations  between  agony  and 
ease  are  greater  and  more  frequent.  Gout  usually  affects  one  joint  only  at  a  time  : 
rheumatism  often  many  at  once.  The  inflammation  in  gout  is  attended  with  more 
oedema  than  in  rheumatism ;  and  is  followed,  in  the  majority  of  instances,  by  de- 
squamation and  itching,  phenomena  which  we  do  not  notice  at  the  close  of  rheumatic 
inflammation.  Gout  is  not  attended  with  those  drenching  acid  sweats  which  are  so 
characteristic  of  acute  fibrous  rheumatism.  The  gout  is  decidedly  hereditary  :  rheu- 
matism, if  hereditary  at  all,  is  much  less  distinctly  so.  The  gout  occurs  rarely  or 
never,  whereas  rheumatism  is  not  very  uncommon,  before  the  age  of  puberty.  In 
gout,  though  many  functions  suffer,  there  is  no  tendency  to  carditis  :  in  rheumatism, 
with  far  less  general  disturbance,  that  tendency  is  very  marked.  Gout  is  the  punish- 
ment (some  have  thought  it  the  privilege)  of  the  rich,  of  persons  who  live  fully, 
luxuriously,  and  idly :  rheumatism  is  most  frequently  the  appanage  of  the  poor,  and 
of  those  who  toil. 


LECTURE  LXXXII. 


Pathology  of  Goid.    Prognosis.    Prejudices  respecting  the  disease.     Treatment 
during  the  paroxysms  ;  during  the  intervals.     Cutaneous  Diseases. 

1  YESTERDAY  described  the  phenotnena  of  gout,  from  its  primary  outbreak  to  \\.s 
crippling  consummation.     I  told  you  what  observation  has  collected  concerning  its 

4b3 


918  GOUT. 

# 

causes;  and  I  pointed  out  the  circumstances  which  distinguish  it  from  rheumatism. 
Let  us  look  a  httle  closer  into  the  essence  of  this  curious  m!\]ad3\ 

The  pathology  of  gout  has  been  the  theme  of  endless  controversj'.  Humoralists 
and  solidists  contend  alike  for  the  triumph  of  including  the  disease  within  the  palo 
of  their  respective  theories.  The  very  name,  gout,  derived  through  the  French 
goutle  from  the  Latin  gutta,  expresses  summarily  the  doctrine  of  those  who  imposed 
It:  and  we  trace  the  same,  or  a  similar  idea,  in  the  appellation  of  the  kindred  dis- 
order, rheiimaimm. 

"  The  opinion  (says  Cullen)  which  has  generally  prevailed,  is,  that  gout  depends 
upon  a  certain  morbific  matter,  always  present  in  the  body ;  and  that  this  matter,  by 
certain  causes  thrown  upon  the  joints  or  other  parts,  produces  the  several  phenomena 
of  the  disease." 

You  will  find  this  doctrine  at  the  bottom  of  all  Sydenham's  speculations  on  the 
subject.  But  Cullen  doubted  it,  and  even  endeavoured,  in  an  elaborate  argument 
which  you  may  read  in  his  First  Lines,  to  disprove  it.  He  held  gout  to  be  an 
afiection  of  the  nervous  system.  I  shall  not  trouble  you  by  detailing  his  argument, 
for  I  consider  it  an  utter  failure.  I  am  satisfied  that  the  ancient  doctrine,  which 
asserts  the  humoral  origin  of  the  disease,  is  the  true  one.  "Morbific  matter"  (it 
may  well  be  called  a  poison)  is  generated,  or  detained,  under  certain  circumstances, 
within  the  bod}',  and  silently  collects  in  the  blood ;  until,  after  obscure  threats,  per- 
haps, and  prelusive  mutterings,  it  explodes  in  the  foot ;  and  then  the  bodily  economy, 
like  the  atmosphere  after  a  thunder-storm,  is,  for  a  while,  unusually  pure  and  tran- 
quil. To  some  such  conclusion  as  this  the  result  of  all  modern  research  seems 
clearly  and  unfailingly  to  tend.  Dr.  Holland,  for  example,  in  his  thoughtful  and 
thought-exciting  volume,  recently  published,  expresses  his  belief  in  "  a  materies 
morbi,  which,  whatever  its  nature,  is  capable  of  accumulation  in  the  S5'stem,  of 
change  of  place  within  the  body,  and  of  removal  from  it."  In  this,  and  fn  several 
other  propositions  relative  to  gout,  enunciated  in  distinct  terms  by  this  learned  writer, 
I  fully  concur.  Some  speculations  still  more  lately  put  forth  by  Dr.  William  Budd, 
in  a  communication  to  the  Medical  and  Chirurgical  Society,  throw  a  strong  light 
upon  this  perplexed  subject ;  and  bring  the  phenomena,  not  only  of  gout,  but  also 
of  many  other  important  complaints,  within  the  operation  of  one  general,  compre- 
hensive, and  intelligible  law.  I  shall  take  leave  to  refer,  in  a  very  cursory  manner, 
to  some  of  Dr.  Budd's  positions. 

I  need  not  remind  you  of  the  various  ways  in  which  extraneous  matters  find  en 
trance  into  the  blood.  Poisons,  under  their  proper  shape  and  name  ;  medicines 
which  misapplied  become  poisons ;  our  natural  food  and  drink,  which  the  folly  of 
man  converts  into  poison ;  the  products  or  dregs  of  the  secondary  assimilative  pro 
cess ;  these  are  common  sources  of  impurities,  more  or  less  hurtful,  which  mix  and 
circulate  with  the  vital  fluid.  Some  of  these  extraneous  matters  escape  harmlessly 
by  one  or  more  of  the  waste-pipes  and  emunctories  of  the  body.  Some  are  entan- 
gled in  its  solids  :  but  not  indiscriminately  ;  for  different  substances  have  their  special 
or  their  favourite  resting-places.  All  this  is  well  known  to  persons  conversant  with 
toxicological  researches. 

Now,  this  doctrine  of  the  elective  affinity  between  certain  tissues  or  parts  of  the 
body,  and  certain  morbific  principles  conveyed  to  them  by  the  blood,  is  applied  by 
Dr.  Budd  to  elucidate  the  very  curious  fact  of  the  symmetrical  local  manifestations 
of  many  disord<?rs ;  which  disorders  ars  themselves  so  far  general  that  they  derive 
their  origin  from  the  circulating  fluids.  This  symmetiy  he  finds  the  most  exact  in 
chronic  constitutional  complaints,  wherein  the  local  morbid  changes  are  effected  in  a 
mahner  which  approximates  closely  to  the  processes  of  heahhy  nutrition.  He  shows 
good  reason  for  believing  (what,  if  the  whole  theory  be  true,  we  should  expect)  that 
the  same  symmetrical  phenomena  are  mo^tfied  by  the  amount  of  the  poison  collected 
in  the  system.  If  there  be  a  certain  quantity  only,  it  may  settle  in  some  favourite 
or  congenial  spot,  on  one  side  of  the  body.  If  there  be  more  than  enough  to  satu- 
rate that  part,  it  goes  next  to  the  corresponding  spot  upon  the  opposite  side  ;  or,  per- 
haps, to  an  analogous  part  of  the  other  limb  of  the  same  side.  If  there  be  more  stilJ 
of  the  poisonous  material,  it  flies  to,  and  occupies,  other  parts  also.     He  further 


^^  GOUT.  019 

shows  that  the  elective^Ktiity  is  more  exclusive,  and  the  bond  of  union  stronger,  in 
respect  to  some  m.orbid  principles,  than  to  others  :  and  in  proportion  as  the  affinity 
is  weak,  so  is  the  local  manifestation  of  the  disease  apt  to  shift,  by  metastasis,  from 
place  to  place.  When  the  matter  which  has  thus  entered,  or  combined  with,  a  cer- 
tain tissue  or  organ,  is  any  how  loosened  and  released  from  that  union,  or  repelled 
from  the  part,  it  is  again  set  afloat  in  the  blood,  to  "  break  out"  elsewhere  ;  to  tease 
various  organs,  perhaps,  or  to  derange  the  whole  economy.  The  alternation  so  often 
to  be  noticed  between  certain  cutaneous  eruptions  and  internal  disorders  of  function, 
is  a  striking  and  famihar  example  of  this.  The  eruption  affords  presumptive  evi- 
dence of  the  detention  of  some  peculiar  morbid  principle  in  that  part ;  and  the 
internal  affection  which  succeeds  the  disappearance  of  the  eruption,  denotes  that  the 
morbid  principle  has  re-entered  the  blood.  Some  of  these  peccant  or  poisonous 
matters  fix  permanently  in  the  affected  spot  or  spots ;  and  some  of  them  may  even 
be  recovered  in  substance  from  the  dead  tissue  by  chemical  means ;  the  poison  of 
lead,  for  example,  from  the  symmetrically  palsied  muscles.  Others  appear  to  be 
expended  gradually  in  the  part,  and  so  eliminated  from  the  system.  Dr.  Budd 
observes,  that  the  regular  arrangement  of  these  local  tokens,  whether  they  be  out- 
ward or  internal,  is  disturbed  by  the  presence  of  fever.  Probably  the  febrile  tumult 
may  itself  be  owing  to  the  quantity  of  the  noxious  matter  in  circulation  within  the 
body.  He  states,  also,  that,  cxteris  paribus,  this  morbific  matter  is  most  apt  to 
pounce,  in  the  first  instance,  upon  parts  which  have  been  previously  hurt,  or  which 
are  mechanically  irritated  at  the  time.  For  which  reason  a  part  that  has  once  been 
affected  by  it  is  more  likely  than  other  parts  to  suffer  again. 

Now,  see  how  thoroughly  the  ascertained  phenomena  of  gout  accord  with  this 
theory.  Certain  habits  of  fife  produce  fullness,  and  richness,  and  impurity  of  blood  ; 
the  same  habits  which  breed  the  lithic  acid  diathesis.  We  may  even  conjecture  this 
acid,  or  some  of  its  compounds,  to  be  the  actual  materies  morbi.  Lithates  are 
poured  forth  with  the  urine,  and  sometimes  deposited  in  vast  masses  around  and 
within  the  gouty  joints.  At  first,  after  obscurer  intimations  of  the  presence  of  the 
poison  in  the  system,  it  thunders  in  the  foot ;  and  there,  perhaps,  is  all  discharged 
and  spent.  The  chemist,  Berthollet,  found  that  the  skin  of  a  part  affected  with 
gouty  inflammation  communicated  instantly  to  litmus  paper  a  deep  red  colour :  a 
large  quantity  of  acid  was  evidently  passing  off  by  exhalation  from  the  inflamed 
surface.  If  the  poison  be  too  copious  to  find  sufficient  vent  in  one  joint,  it  attacks 
another,  or  more  than  one.  "duandoque  etiam  primis  morbi  diebus,  cum  materia 
peccans  adeo  exuberat  ut  ei  capiendse  pes  unus  impar  sit,  utrosque  sirnul  pari  vehe- 
mentiii  fatigat :  sed  ut  plurimum  pedes  successive,  uti  diximus,  adgreditur."  These 
are  Sydenham's  words.  A  chain  of  repeated  paroxysms  at  length  purifies  the  blood  : 
"  Donee  tandem  materia  peccante  prorsus  absumta,  ^ger  pristinam  obtinuerit  sani- 
tatem."  The  descent  of  the  disorder  upon  a  particular  joint  is  often  determined  by 
a  recent  blow  or  sprain,  or  by  the  chronic  weakness  consequent  upon  an  ancient 
hurt.  If  the  inflammation,  after  thus  settling,  be  repelled  from  the  foot,  the  poison, 
being  driven  again  into  the  blood,  may  light  upon  some  vital  organ,  and  place  the 
patient's  life  in  immediate  jeopardy.  The  late  Dr.  Parry,  of  Bath,  had  at  one  time 
under  his  care  two  patients  who- had  attempted  to  cut  short  or  to  ease  a  paroxysm 
of  gout  by  plunging  the  affected  foot  into  cold  water.  This  gave  instant  relief  to  the 
pain,  and  in  both  instances  the  inflammation  presently  abated ;  but  in  both  also, 
hemiplegia  occurred  a  few  hours  afterwards. 

If  these  views  respecting  the  pathology  of  gout  be  true,  it  can  scarcely  be  doubted 
that  they  are  applicable,  mutatis  niutcuidis,  to  the  cognate  disorder — acute  rheuma- 
tism. Dr.  Prout,  indeed,  considers  the  lactic  acid,  developed  chiefly  during  the 
secondary  mal-assimilalion  of  the  gelatinous  tissues  of  the  body,  to  have  the  same 
relation  to  rheumatism  which  the  lithic  acid,  derived  from  the  mal-assimilaticm  of  the 
albuminous  textures,  has  to  gout. 

The  prognosis  of  gout  may  be  gathered,  without  much  further  suggestion  on  my 
part,  from  what  has  already  been  said.  The  inflammation  which  befalls  the  joints 
has  no  worse  event  than  the  thickening,  or,  perhaps,  the  chalk-like  deposit,  which  it 
produces ;  so  that  gout  in  the  extremities  is  not  a  mortal  disease.     But  as  it  Is  not 


920  GOUT. 

always  confined  to  the  extremities,  the  life  of  a  gouty  person  is  justly  held  to  be 
insecure.  "La  goutte  articulaire  (says  some  French  author)  est  celle  dont  on  est 
malade  ;  et  la  goutte  interne  est  celle  dont  on  meurt."  You  will  find  that  all  insur- 
ance companies  exact,  cseleris  paribus,  a  larger  premium  from  those  who  have  had 
the  gout.  When  it  proves  fatal,  it  is  by  translation  of  the  disease,  or  rather  of  the 
gouty  virus,  to  some  vital  part;  to  the  stomach,  the  heart,  the  lungs,  the  brain. 

As  the  early  visits  of  gout  are  generally  followed  by  a  striking  change  for  the 
better  in  the  health  and  feehngs  of  the  patient,  it  is  not  to  be  wondered  at  that  the 
disease,  in  its  genuine  and  decided  form,  should  have  sometimes  been  wished  for, 
and  even  courted.  It  is  commonly  thought  that  a  fit  of  the  gout  clears  the  system 
of  all  other  disorders.  It  does,  indeed,  clear  it,  for  the  time,  of  those  disorders  which 
resulted  from  the  poison  of  gout.  But  this  fact  has  led  to  great  practical  mistakes. 
First,  to  the  error  of  looking  on  inertly,  and  doing  nothing  to  remedy  the  ailments 
which  are  supposed  (often  very  wrongly)  to  depend  upon  lurking  gout,  and  to  require 
a  fit  of  the  gout  for  their  cure ;  and,  secondly,  to  the  more  dangerous  experiment  of 
endeavouring  to  force  on  such  a  fit  by  excess  and  intemperance.  Men  forget,  or  do 
not  know,  that  the  enemy  thus  reinforced,  instead  of  evacuating  the  fortress  by  its 
oulports,  may  retreat  triumphant  into  the  citadel.  To  drop  metaphor,  such  a  course 
of  living  may,  indeed,  determine  an  attack  of  the  disease  in  the  extremities,  but  in- 
volves the  fearful  peril  of  some  fatal  internal  seizure.  Besides,  the  benefits  expected 
from  external  gout  belong  to  its  earlier  returns  alone.  The  more  numerous  the  fits, 
the  faster  does  the  general  health  break,  and  the  more  stubbornly  do  the  associated 
symptoms  cling  to  the  patient :  and  many  persons  linger  on,  martyrs  (as  they  say) 
to  the  disease,  long  after  they  have  ceased  to  be  fit  for  any  of  the  business  of  life,  or 
capable  of  any  of  its  pleasures.  Nevertheless,  as  Heberden  observes,  "  people  are 
neither  ashamed  nor  afraid  of  it ;  but  solace  themselves  with  the  hope  that  they  shall 
one  day  have  the  gout;  or,  if  they  have  already  sufl^ered  it,  impute  all  their  other 
ails,  not  to  having  had  too  much  of  that  disease,  but  to  wanting  more.  The  gout, 
far  from  being  blamed  as  the  cause,  is  looked  up  to  as  the  expected  deliverer  from 
these  evils." 

And  this  mistaken  ambition  is  heightened,  no  doubt,  by  the  notion,  still  more  ab- 
surd and  ridiculous,  yet  very  generally  prevalent,  that  it  is  a  creditable  thing  to  have 
the  gout:  a  notion  which  evidently  originated  in  the  fiict  of  its  being  peculiarly  inci- 
dental to  the  wealthy  and  the  great,  to  men  of  cultivated  minds,  and  intellectual  dis- 
tinction. Nothing  can  show  more  strongly  the  power  of  fashion  than  this  desire  to 
be  thought  to  possess,  not  only  the  tone  and  manners  of  the  higher  orders  of  society, 
not  their  follies  merely  and  pleasant  vices,  but  their  very  pains  and  aches,  their 
bodily  imperfections  and  infirmities.  All  this  is  more  than  sufficiently  ludicrous  and 
lamentable  :  but  so  it  is.  Even  the  philosophic  Sydenham  consoles  himself,  under 
the  sufferings  of  the  gout,  with  the  reflection  that  it  destroys  more  rich  men  than 
poor — more  wise  men  than  fools.  "At  vero  (quod  mihi  aliisque  licet,  tam  fortunaB 
quam  ingenii  dotibus  mediocriter  instructis,  hoc  morbo  laborantibus  solatio  esse 
possit)  ita  vixerunt  atque  ita  tandem  mortem  obierunt  magni  Reges,  Dynastae,  exer- 
cituum  classiumque,  Duces,  Philosophi,  aliique  his  similes  baud  pauci.  Verbo  dicam, 
articularis  hicce  morbus  (quod  vix  de  quovis  alio  adfirmaveris)  divites  plures  interemit 
quam  pauperes,  plures  sapientes  quam  fatuos." 

The  treatment  of  a  gouty  patient  naturally  divides  itself  into  that  which  is  proper 
during  the  paroxysm,  and  that  which  is  proper  during  the  intervals  between  the 
paroxysms. 

It  was  maintained  by  the  great  physician,  whose  words  I  have  just  been  quoting, 
that  all  artificial  evacuations  during  a  fit  of  the  gout  are  useless  or  hurtful.  He, 
therefore,  discountenanced  blood-letting,  purging,  and  the  use  of  diaphoretic  medi- 
cines. It  was  nature's  prerogative,  he  said,  to  exterminate  the  peccant  matter  in  her 
own  way  ;  namely,  by  depositing  it  in  the  joints,  whence  it  might  be  dispersed  by 
insensible  transpiraiion.  Evacuant  remedies  had  no  other  effect  than  that  of  recall- 
ing into  the  blood  this  peccant  matter,  which  nature  had  already  thrust  forth  to  the 
ext'-emities  of  the  body  ;  whereby  it  happened  that  the  virus,  which  should  have 
been  eliminated  through  the  joints,  fell  upon  some  of  the  viscera  ;  and  so  the  patient, 


GOUT.  921 

who  was  in  no  clanger  before,  became  in  peril  of  his  life.  I  mention  all  this  to  shcv 
you  how  entirely  identical  was  Sydenham's  theory  of  the  gout  with  that  which  is 
now  rapidly  regaining  its  lost  ground  in  this  country,  and  which  I  firmly  believe  to 
be  the  true  one.  After  his  time,  and  upon  his  authority,  the  treatment  of  gout  lapsed 
into  an  inert  expectancy.  Even  Cullen  came  to  the  conclusion  that  the  best  thing  to 
be  done  is  to  commit  the  sick  man  to  "  patience  and  flannel  alone."  Here  and  there, 
indeed,  an  advocate  of  more  active  measures  sprang  up.  Dr.  Rush  thought  that 
venesection  was  always  safe,  and  generally  serviceable :  and  some  persons,  following 
the  bad  example  of  the  illustrious  Harvey,  were  for  extinguishing  the  inflammation 
by  immersing  the  affected  joint  in  cold  water.  Heberden,  however,  had  clearer  and 
juster  views  upon  the  subject.  He  perceived  that  one  reason  why  physicians  did 
nothing  to  check  the  paroxysm  was,  that  they  did  not  know  what  would  check  it. 
He  agreed  with  Cullen  in  thinking  "  that  no  medicine  for  curing  the  gout  had  yet 
been  found ;"  but  he  did  not  partake  of  his  belief  in  "the  impossibility  of  a  cure  by 
medicines." 

"  The  itch  (he  observes)  is  supposed  to  be  wholesome  in  some  countries,  where  it 
is  endemical ;  and  an  ague  has  been  considered  as  a  minister  of  health,  whose  pre- 
sence and  stay  ought  by  all  means  to  be  courted.  These  opinions  are  now  pretty 
generally  exploded  in  England ;  and  I  hope  the  time  will  come  when  a  specific  for 
the  gout,  as  certain  as  those  which  have  been  discovered  for  these  two  disorders,  will 
ascertain  the  equal  safety  and  advantage  of  immediately  stopping  its  career,  and  pre- 
venting its  return." 

That  time  has  come :  for  the  colchicum,  judiciously  employed,  may  fairly  be 
accounted  a  specific  for  the  gouty  paroxysm.  And  it  is  remarkable  how  long  this 
truth  has  been  seen,  though  not  distinctly  or  steadily.  The  hermodactyl  of  the 
ancients  is  the  modern  colchicum,  and  was  in  high  estimation  among  them  for  its 
efficacy  in  the  same  forms  of  disease  as  are  benefited  by  the  colchicum  now.  It 
bore,  with  some,  the  name  of  anima  articulorum,  the  soul  of  the  joints,  because  (as 
Gluincy  states)  it  prevented  "  the  lodgment  of  such  gritty  matter  as  occasions  the  gout 
and  arthritic  complaints."  And  I  think  there  can  be  no  doubt  that  the  active  prin- 
ciple of  the  quack  medicine  so  much  in  vogue  for  the  cure  of  gout  some  years  ago— 
I  mean  the  eau  medicinale — was  either  the  same  with  that  of  the  meadow-saffi-on,  or 
derived  from  the  same  family  of  plants  which  DecandoUe  has  associated  together 
under  the  title  "  Colchicaceas." 

This  drug  has  certainly  the  property  of  easing,  in  an  almost  magical  manner,  the 
pain  of  gout.  How  it  operates  is  not  so  clear.  It  is  apt  to  produce  nausea,  faintness, 
and  diarrhoea ;  but  its  curative  influence  is  not  conditional  upon  the  occurrence  of 
these  symptoms.  Sometimes  the  rapid  disappearance  of  the  gouty  inflammation  is 
its  only  perceptible  eflect.  The  patient  may  be  in  helpless  agony,  with  a  tumefied 
red  joint,  to-day ;  and  walking  about,  quite  well,  to-morrow.  The  colchicum  is, 
therefore,  plainly  an  anodyne.  It  also  sensibly  modifies  the  condition  of  the  urine, 
rendering  it  less  acid,  and  even  alkahne ;  and  increasing  its  quantity.  These  effects 
are  consequent,  I  presume,  upon  changes  in  the  blood  wrought  by  this  substance, 
which  thus,  and  there,  proves  somehow  an  antidote  to  the  poison  of  gout. 

There  are,  as  you  are  aware,  various  preparations  of  colchicum  in  use :  the  wine 
of  the  bulb :  the  wine  of  the  seeds ;  the  vinegar  of  colchicum  ;  the  acetous  extract, 
made  by  evaporating  that  vinegar;  the  inspissated  juice  of  the  plant  itself.  These 
are  all  of  them  active  and  valuable  medicines ;  and  I  should  pretend  to  more  know- 
ledge than  I  possess,  if  I  undertook  to  tefl  you  which  of  them  is  the  best. 

The  mode  of  adnninistering  the  remedy,  in  a  regular  fit  of  the  gout,  is  simple 
enough.  For  example,  you  may  give  forty  or  sixty  minims  of  the  viniim  colchici, 
in  a  saline  draught,  at  bed-time  ;  and  half  a  drachm  more,  in  a  warm  black  dose,  the 
next  morning;  and  you  may  repeat  this  sequence  if  the  gout  continues.  Some  per- 
sons give  twenty  minims  every  six  hours,  with  a  drachm  of  Epsom  salts,  and  a 
drachm  of  syrup  of  poppies  in  the  draught,  till  the  symptoms  yield  ;  but  I  prefer  the 
other  plan.  In  this  way  the  pain  is  usually  calmed,  and  the  swelling  reduced  in  a 
few  days  ;  or  even,  as  if  by  a  charm,  in  a  few  hours. 

B<'   vou  must  not  be  satisfied  with  thus  quelling  the  pain  and  inflammation.     A 


922  GOUT. 

strong  prejudice  at  one  time  existed,  and  still  exists  among  some  practitioners,  against 
the  colchicum.  It  was  said  tliat  it  Jiad  indeed  the  power  of  cutting  short  the  paroxysms, 
but  that  it  cut  short  the  patient's  life  also :  that  they  who  trusted  to  it  for  getting  rid 
of  the  gout,  very  seldom  lived  more  than  two  or  three  years  afterwards.  How  far 
this  was  true  I  cannot  tell :  but  even  admitting  it  to  be  true,  it  was  not,  I  conceive, 
so  much  the  fault  of  the  medicine  as  of  the  patient,  or  of  the  medical  man  who  did 
not  properly  admonish  the  patient.  Men  were  very  glad  to  get  rid  of  their  gout  on 
such  easy  terms ;  and  they  will  sometimes  say  to  us  now :  "  I  have,  as  you  see,  got 
the  gout.  This  is  Monday.  I  must  be  in  the  House  of  Commons,  or  attend  such 
and  such  a  meeting,  or  be  at  the  head  of  my  regiment,  on  Wednesday  :  and  I  expect 
that  you  will  enable  me  to  do  so."  Or  even  sometimes  the  reason  may  be  that  they 
are  engaged  to  some  good  dinner  two  or  three  days  afterwards.  Now  if  patients  are 
content,  or  are  suffered  to  be  content,  with  expelling  the  gout  from  their  toe,  without 
observing  abstinence  more  than  a  day  or  two,  and  without  any  depletion  or  further 
medication  at  the  time,  we  can  easily  perceive  the  probability  of  their  being  soon 
attacked  by  some  formidable  internal  complaint.  I  apprehend  that  the  proper  way 
to  eradicate  the  lurking  residue  of  the  mischief  is  to  continue  to  give  small  doses  of 
the  colchicum ;  five  minims  of  the  wine,  for  instance,  two  or  three  times  a  day,  for  a 
while.  Moreover,  purgatives  must  be  employed,  if  that  remedy  does  not  prove 
aperient.  Not  violent  purgatives,  however,  which,  by  weakening  the  patient,  seem 
to  strengthen  the  power  of  the  gouty  virus.  With  mild  cathartics,  moderate  doses 
of  mercury  will  generally  be  advisable,  to  correct  the  subsisting  disorder  of  the 
hepatic  functions ;  and  the  patient  must  adopt  and  pursue  abstinent,  or  at  any  rate 
strictly  temperate  habits,  in  respect  to  meat  and  wine. 

And  as  I  think  that  the  dregs,  if  I  may  so  speak,  left  behind  it  by  a  gouty 
paroxysm,  may  be  dispersed  by  the  continued  use  of  what,  in  the  usual  acceptation 
of  that  word,  I  may  call  alttrative  doses  of  colchicum  (doses,  that  is,  which  produce 
the  desired  purpose  gradually,  and  by  insensible  operation),  so  I  think  it  probable 
that  many  a  fit  of  the  gout  might  be  averted,  if  the  remedy  were  given  in  the  same 
way  upon  the  first  occurrence  of  the  ordinary  premonitory  troubles.  Many  of  those 
troubles  never  appear  to  reach  the  crisis  of  a  fit.  There  are  headaches,  attacks  of 
asthma,  derangements  of  the  digestive  organs,  which,  occurring  in  a  gouty  person, 
are  presumed  to  be  fainter  intimations  of  the  presence  of  the  gouty  poison  in  the 
blood :  and  if  such  symptoms  yield  (as  unquestionably  they  often  do)  to  colchicum, 
the  presumption  draws  near  to  proof.  Dr.  Holland  has  well  remarked  that  the 
meadow-safTron,  by  its  curative  effects,  may  bring  sundry  maladies,  hitherto  thought 
anomalous,  under  the  same  law  of  morbid  gouty  action  ;  just  as  the  Peruvian  bark 
has  reduced  many  complaints,  that  were  previously  vague  in  their  nature,  within  the 
same  category  of  aguish  distempers.  The  same  author  conjectures  that  as  hypo- 
chondriasis is  certainly  often  symptomatic  of  the  gouty  poison  in  the  male,  so  may 
sometimes  the  kindred  disease,  hysteria,  be  in  the  female. 

Strange  stories  are  recorded — strange,  but  I  believe  true — of  instantaneous  cures 
of  the  gout  by  strong  mental  emotion  ;  by  sudden  terror,  by  violent  wrath.  Dr.  Rush 
relates  an  instance  of  this.  An  old  man  who  for  several  years  had  suffered  an 
annual  attack  of  gout,  was  lying  in  one  of  these  paroxysms,  when  his  son,  by  some 
■iccident,  drove  the  shaft  of  a  wagon  through  the  window  of  his  room,  with  vast 
iioise,  and  a  great  smashing  and  destruction  of  glass.  The  old  man  leaped  out  of 
bed,  forgetting  his  crutches ;  and  his  wife,  on  entering  the  apartment,  was  surprised 
to  see  him  walking  up  and  down,  and  exclaiming  angrily  against  the  author  of  the 
mischief.  The  late  Professor  Gregory,  of  Edinburgh,  was  in  the  habit  of  mention- 
ing another  example  to  the  same  effect,  authenticated  to  him  by  a  naval  surgeon. 
It  occurred  to  the  person  of  an  officer  who  was  fieed  from  an  attack  of  the  gout,  when 
at  sea,  b\'  an  alarm  of  fire.  Whether  this  influence  of  certain  states  of  ihe  mind  be 
rightly  alleged  or  not,  it  is  clear  that  we  can  never  hope  to  make  any  practical  use 
of  such  a  remedy.  Indeed,  a  fit  of  the  gout  has  been  sometimes  brought  on  by  a 
mental  shock. 

The  treatment  of  a  gouty  patient  in  the  interval  between  his  attacks  of  gout, 
whether  regular  or  irregular,  must  be  chiefly  regimenal.     The  instances  are  not  few 


GOUT.  923 

of  men  of  good  sense,  and  masterb  of  themselves,  who,  being  warned  by  on''  visita- 
tion of  the  gout,  have  thenceforward  resolutely  abstained  from  rich  living,  and  from 
wine  and  strong  drinks  of  all  kinds,  and  who  have  been  rewarded  for  their  prudence 
and  self-denial  by  complete  immunity  from  any  return  of  the  disease  ;  or  upon  whom, 
at  any  rate,  its  future  assaults  have  been  iew  and  feeble.  On  the  other  hand,  manj' 
who  are  liable  to  gout  are  taught  by  sharp  experience  that  a  single  debauch,  a  casual 
glass  or  two  of  champagne,  even  an  unusual  indulgence  in  the  use  of  animal  food, 
may  suffice  to  bring  their  enemy  suddenly  upon  them.  I  am  sure  it  is  worth  any 
young  man's  while,  who  has  had  the  gout,  to  become  a  teetotaller.  But  the  case  is 
different  with  the  old,  and  with  those  whose  health  has  been  broken  by  the  inveterate 
disease.  They  must  be  allowed  a  certain  quantity  of  their  accustomed  good  cheer, 
or  they  become  an  easier  prey  to  the  disease.  In  such  cases  you  must  trim,  as  well 
as  you  can,  between  opposite  dangers ;  between  the  Scylla  of  excess,  and  the  Cha- 
rybdis  of  debility. 

It  is  the  same  with  respect  to  exercise.  The  young  ai/d  the  hearty  can  scarcely 
take  too  much :  the  old  and  the  dilapidated,  by  one  act  of  over-exertion,  may  incur 
the  penalty  of  an  attack.  Although  I  can  do  little  more  than  point  out  general  prin- 
ciples for  your  guidance,  I  may  remark,  in  reference  to  exercise,  that  it  should 
never  be  violent,  lest  it  excite  a  paroxysm  by  straining  any  part,  or  by  causing  great 
fatigue  :  that  it  should  be  habitual,  daily — not  used  by  fits  and  starts,  and  interrupted 
by  long  periods  of  indolence  or  inaction  :  and  that  it  should  be  active  muscular  ex- 
ercise, as  distinguished  from  passive  exercise  or  gestation.  No  mode  of  exercise  is  so 
good  as  that  of  walking;  and  with  this  may  be  agreeably  and  beneficially  conjoined 
riding  on  horseback. 

Early  and  regular  hours  are  also  of  much  importance  ;  and  the  avoidance  of  severe 
mental  application.  Sydenham  relates  that  one  of  the  most  atrocious  attacks  of  gout 
he  ever  underwent  was  induced  by  intense  thought  and  study,  in  the  composition  of 
his  medical  works. 

The  regimen  which  I  have  been  recommending  may  require  some  power  of  self- 
control  ;  yet  in  reality  it  implies  no  severity  of  inortification.  It  is  perfectly  compa- 
tible with  life's  best  enjoyments  ;  but  to  be  effectual  it  must  be  adopted  early,  as  soon 
as  the  disease  threatens  :  and  steadily  persevered  in.  Gouty  persons,  however,  do 
not  like  these  restraints.  They  are  ready  to  believe  that  an  attack  of  gout  will  do 
them  good  ;  or  if  they  are  disabused  of  that  error,  they  are  desirous  that  some  medi- 
cine may  be  found  which  will  avert  the  disease,  without  their  being  obliged  to  forego 
their  accustomed  indulgences.  "To  gratify  this  desire  (says  Cullen)  physicians 
have  proposed,  and  to  take  advantage  of  it  empirics  have  feigned,  many  remedies." 
One  of  these  was  the  famous  Portland  powder,  of  which  Heberden  remarks  :  "  Unum 
est  ex  multis  quae  vocantur  remedis  specifices,  quorum  ortum,  et  splendorum,  et  oc- 
casum  vidi."  It  consisted  chiefly  of  bitters  and  aromatics,  and  had  descended,  with 
some  slight  variations  in  its  composition,  from  the  times  of  Galen.  Another  pre- 
ventive has  recently  been  praised  by  Dr.  Graves,  of  Dublin,  as  being  highly  ser- 
viceable, although  (what  is  a  suspicious  circumstance)  it  had,  like  the  Portland  pow- 
der, fallen  out  of  fashion.  These  are  its  ingredients : — Two  ounces  of  orange  peel, 
an  ounce  of  powdered  rhubarb,  and  two  ounces  of  the  pidvis  aloes  cum  canelld  of 
the  Dublin  Pharmacopceia,  steeped  for  a  week  in  a  quart  of  brandy.  A  tablespoon- 
ful  of  the  strained  infusion  is  to  be  taken,  mixed  with  two  or  three  spoonfuls  of 
water,  night  and  morning.  Sir  Henry  Halford  recommends  what  I  think  a  betttr 
form  of  prophylactic  remedy;  viz.,  a  few  grains  of  rhubarb,  with  double  the  quantity 
of  magnesia,  every  day  :  or  some  light  bitter  infusion,  with  tincture  of  rhubarb,  and 
about  fifteen  grains  of  the  bicarbonate  of  potass. 

Now  what  has  been  observed  respecting  preventive  remedies  of  this  kind  is,  not  so 
much  that  they  are  inefficacious,  as  that,  when  exclusively  trusted  to,  they  are  unsafe 
I  believe  that  they  are  often  useful  by  improving  the  digestive  process ;  but  they  are 
dangerous  substitutes  for  a  course  of  temperance  and  exercise. 

When  gout  attacks  the  stomach,  either  by  retrocession  or  primarily,  it  often  proves 
rapidly  fatal.  The  gastric  affection  is  not,  in  general,  inflammatory  ;  so  we  judge,  at 
least,  from  the  jiivantia.     The  attack,  which  consists  of  violent  pain,  and  a  sense  of 


i/24  CUTANEOUS    DISEASES. 

weight  or  of  constriction  in  the  epigastrium,  with  sickness,  vomiting,  and  a  disposi- 
tion to  faint,  is  often  reheved  by  the  employment  of  stimulants.  But  such  remedies 
would  be  likely  to  aggravate  inflammation.  It  will  always  be  Avell  when  symptoms 
like  these  occur,  to  inquire  whether  any  indigestible  food  has  been  lately  taken  ;  for 
s:oid  (so  called)  in  the  stomach  has  sometimes  turned  out,  under  the  test  of  an  emetic, 
to  have  been  nothing  more  than  pork  in  the  stomach.  In  the  true  gouty  seizure, 
antacids  will  frequently  remove  the  pain ;  magnesia,  in  full  doses,  with  rhubarb.  If 
this  does  not  succeed,  opium  may  be  resorted  to;  and  if  it  should  be  vomited,  opiate 
enemata  may  be  injected.  Dr.  Heberden  thought  that  opium,  and  hot  spices,  were 
more  efficacious  and  less  inconvenient,  in  these  cases,  than  wine  and  spirits;  but 
when  they  fail,  a  glass  of  brandy  will  often  allay  the  pain  completely.  The  mus- 
tard poultice,  or  the  turpentine  stupe,  applied  over  the  epigastrium,  has  been  follow- 
ed by  strikingly  good  effects.  And  it  is  in  these  emergencies,  contingent  upon 
retrocedent  or  misplaced  gout,  that  we  are  justified  in  the  endeavour  to  induce  gout 
in  the  extremities ;  not,  however,  by  internal  stimuli,  bat  by  enveloping  the  feet  in 
a  mustard  poultice,  and  so  enticing  or  provoking  the  foe  to  quit  his  hold  of  the  inte- 
rior, and  to  appear  at  the  outposts.  And  this  expedient  should  be  practised,  what- 
ever may  be  the  internal  organ  upon  which  the  gouty  disorder  has  settled. 

Sometimes,  but  much  less  commonly,  actual  gastritis  does  seem  to  ensue  ;  and 
therefore  all  these  cases  are  anxious  and  alarming  cases,  I  do  not  know  how  the 
inflammatory  afl^ection  can  be  discriminated  from  the  non-inflammatory,  unless  it  be 
by  the  occurrence  of  tenderness  with  the  pain,  and  of  fever.  You  must  treat  such 
cases  as  you  would  treat  an  ordinary  case  of  gastritis,  taking  no  further  heed  of  the 
gout,  except  by  the  application  of  stimulating  cataplasms  to  the  feet. 

This  concludes  what  I  proposed  to  say  respecting  gout  and  rheumatism ;  diseases 
of  which  the  local  seat  is  not  exactly  external,  nor  yet  do  they  belong  strictly  to  the 
interior  of  the  body,  except  in  their  accidental  complications.  They  form  a  link  of 
connection  between  the  internal  and  external  disorders  which  fall  to  the  care  of  the 
physician;  and  I  proceed,  in  the  next  and  last  place,  to  speak  of  those  complaints 
which  either  concern  the  integuments  alone,  or  which,  at  any  rate,  are  attended  with 
some  notable  affection  of  the  skin. 

Under  the  general  head  of  cutaneous  diseases,  are  included  maladies  of  very  dif- 
ferent kinds,  and  of  verj^  different  degrees  of  importance.  Some  are  attended  with 
fever,  and  run  a  definite  course,  and  are  often  dangerous  to  life.  Others  are  chronic, 
irregular  in  their  progress,  troublesome  perhaps,  and  obstinate,  and  disfiguring,  yet 
implying  no  peril  to  the  existence  of  the  patient.  Some  again  are  contagious,  while 
many  are  not  so.  But  before  I  enter  upon  any  further  account  of  these  diseases,  I 
wish  to  make  you  acquainted  with  the  names  by  which  the  various  morbid  appear- 
ances presented  by  the  skin  have  been  known,  since  the  time  of  Dr.  Willan. 

That  author — whose  works  have  been  augmented  by  Dr.  Bateman,  so  that  ptr 
haps  I  ought  to  say  those  authors — divides  cutaneous  diseases  into  eight  orders,  dis- 
tinguished from  each' other  solely  by  the  appearances  upon  the  skin.  I  shall  omit 
the  last  of  these  orders,  the  order  of  macidse,  such  as  freckles,  and  congenital  spots 
and  discolorations,  because  in  fact  these  are  not  diseases  at  all. 

The  first,  then,  of  the  appearances  described  by  Dr.  Willan  are  papidx;  pimples. 
These  are  little  elevations  of  the  cuticle,  of  a  red  colour,  and  solid  ;  not  containing, 
I  mean,  any  fluid.  They  are  of  uncertain  duration,  and  often  terminate  in  scurf. 
They  are  supposed  to  denote  inflammation  of  the  papillse  of  the  skin.  If  you  wish 
for  an  example  of  a  papular  eruption,  look  at  that  of  small-pox,  at  its  very  earliest 
outbreak. 

The  second  are  squampe;  scales.  These  are  small,  hard,  thickened,  opaque, 
whitish  patches  of  unhealthy  cuticle.  The  subjacent  surface  is  red.  They  are  well 
seen  in  lepra  and  psoriasis,  and  are  very  common  in  syphilitic  eruptions. 

The  third  aie  exunlhemata;  rashes.  They  consist  of  superficial  red  patches  on 
ihe  skin,  variously  figured  and  irregularly  diffused,  and  of  all  sizes.  We  have  exam- 
ples of  them  in  some  of  the  most  important  febrile  cutaneous  diseases  ;  scarlet  fever, 
measles,  and  others. 


EXANTHEMATA.  925 

It  is  a  pity  '.hat  some  other  technical  denomination  was  not  chosen  to  express  these 
'^shes  ;  for  the  term  exanthemata  has  long  been  familiar  to  the  profession  as  the  title 
of  an  order  of  diseases  in  Cullen's  Nosology. 

The  fourth  are  bulls;;  blebs,  miniature  blisters.  Large  portions  of  cuticle  are 
detached  from  the  subjacent  skin,  by  the  interposition  of  a  thin  transparent  liquid  ; 
with  inflammation  beneath  them.  Such  occur  in  erysipelas  sometimes,  and  in 
pemphigus. 

The  fifth  are  pustulas;  pustules.  Circumscribed  elevations  of  the  cuticle,  con- 
taining pus,  and  having  red  inflamed  bases.  We  have  instances  of  these  in  common 
boils,  and  in  the  eruption  of  small-pox  when  at  its  height  and  maturity. 

The  sixth  are  vesiculas;  vesicles.  Small  elevations  of  the  cuticle,  covering  a 
fluid  which  is  generally  clear  and  colourless  at  first,  but  becomes  afterwards  whitish 
and  opaque,  or  pearly.  These  are  exemplified  in  the  eruption  of  cow-pox,  and  in 
the  chicken-pox.  You  will  observe  that  these  vesiculae  differ  very  little,  except  in 
size,  from  the  bullae,  or  blebs.     They  often  terminate  in  small  scabs. 

The  seventh  are  tuberculse;  tubercles.  This  also  is  an  unlucky  appellation,  since 
the  word  tubercle  is  almost  appropriated,  in  the  present  day,  to  the  scrofulous  depo- 
sits which  infest  the  lungs,  and  other  parts  of  the  body,  in  pulmonary  phthisis. 
However,  these  cutaneous  tubercles  are  small,  hard,  superficial  tumours,  circum- 
scribed and  permanent;  or,  if  they  suppurate  at  all,  the  suppuration  in  them  is  par- 
tial. Sometimes  they  slowly  ulcerate  at  the  summit.  The  imperfectly  suppurating 
pustules  of  the  modified  small-pox,  and  certain  red  spots  which  are  apt  to  haunt  the 
face,  particularly  of  young  persons,  furnish  examples. 

Now,  it  is  very  convenient,  for  the  purpose  of  distinguishing  different  diseases, 
and  of  describing  them,  to  know  these  outward  marks  when  you  see  them,  and  to 
use  these  names.  But  they  form  a  very  unfit  basis  for  the  classification  of  diseases. 
Maladies  may  usefully  be  classed  according  to  their  causes  ;  according  to  their  inti- 
Tiate  nature ;  according  to  the  general  plan  of  treatment  they  may  require.  But 
the  superficial  markings  of  disease  have  no  definite  relation  to  any  of  these  heads. 
Besides,  a  complaint  which  is  papular  to-day,  may  be  vesicular  to-morrow,  and  pus- 
tular next  Saturday.  Yet  the  classification  most  commonly  followed  in  this  country, 
and  in  France,  is  that  of  Willan  and  Bateman.  Here  we  find  collected  under  one 
and  the  same  division,  maladies  which  nature  has  stamped  with  broad  and  obvious 
marks  of  distinction :  the  febrile  with  the  non-febrile ;  contagious  complaints  with 
those  which  have  not  that  property;  ailments  that  are  local  and  trivial,  with  diseases 
of  grave  import,  and  deeply  rooted  in  the  system  at  large.  And,  on  the  other  hand, 
distempers  which  nature  has  plainly  brought  together,  and  connected  by  striking 
analogies  and  resemblances,  this  methodical  arrangement  puts  widely  asunder.  I 
point  out,  without  professing  to  remedy,  these  imperfections.  I  cannot  even  under- 
take to  give  you  any  full  or  systematic  account  of  the  many  disorders  comprised  in 
this  classification.  There  is,  however,  one  group  so  remarkable,  so  important,  and 
so  highly  interesting,  that  I  shall  consider  it  as  much  in  detail  as  I  can.  I  allude  to 
the  group  which  CuUen  comprehends  under  the  title  exanthemata.  With  this 
exception,  the  advancing  year  warns  me  that  I  must  contract  what  I  have  to  say 
respecting  diseases  of  the  skin  within  very  narrow  limits 


LECTURE  LXXXIII. 

Exanthemata.  They  are  contagious ;  sometimes  epidemic.  Period  of  the  Erup- 
tion ;  Period  of  Incubation.  Theory  of  Contagious  Febrile  Diseases.  Conti- 
nued Fever. 

Of  the  numerous  complaints  which  are  ranked  among  the  diseases  of  the  skm, 
some,  I  observed  in  my  last  lecture,  are  attended  with  fever,  and  some  ar«  not 

4c 


926  EXANTHEMATA. 

Among  the  former  there  is  a  highly  interesting  group,  distinguished  by  other  and 
more  important  characters  than  the  mere  presence  of  fever,  or  pecuUar  marks  upon 
the  skin  ;  characters  that  enabled  Cullen  to  collect  these  diseases  into  a  separate 
order,  to  which  he  gave  the  name  of  exanthemata.  This  is  his  description  of  them  : 
"  Morbi  contagiosi,  semel  tantum  in  decursu  vitas  aliquem  afficientes  ;  cum  febre  inci- 
pientes  ;  definito  tempore  apparent  phlogoses,  Scepe  plures,  exiguas,  per  cutem  spar- 
see."  Contagious  diseases  ;  attacking  a  person  once  only  in  his  life  ;  beginning  with 
fever.  At  a  definite  period  small  eruptions  appear,  often  numerous,  scattered  over 
the  skin.  These,  you  will  allow,  are  \exy  remarkable  characters.  They  are  not 
all  strictly  and  universally  true,  perhaps,  of  all  the  forms  of  disease  which  I  propose 
to  bring  now  under  your  notice ;  but  they  apply  with  more  or  less  exactness  to  con- 
tinued fever,  to  the  plague,  to  small-pox,  chicken-pox,  measles,  scarlet  fever,  and 
erysipelas. 

Hooping-cough,  and  the  mumps,  might  be  placed  in  the  same  catalogue,  although 
there  is  no  specific  eruption  on  the  skin  in  them:  but  I  have  already  spoken  of  these 
two  disorders. 

Before  I  take  up  the  consideration  of  any  one  of  these  diseases  in  particular,  I  shall 
premise  a  brief  survey  of  certain  circumstances  that  are  more  or  less  common  to  them 
all.  This  preliminary  examination  of  the  exanthemata  as  a  class,  will  give  you,  I 
trust,  clearer  ideas  respecting  them  :  at  any  rate  it  will  enable  me  to  dispense  with 
much  needless  repetition  afterwards,  and  so  to  save  both  your  time  and  my  own ;  a 
matter  of  some  consequence  at  this  advanced  period  of  the  session. 

In  the  first  place,  then,  the  diseases  comprehended  in  this  group  are  contagious 
diseases.  You  will  hear  persons  disputing  about  the  term  contagion  ;  but  such  dis- 
putes can  only  arise  from  the  want  of  a  distinct  definition  of  the  sense  in  which  it 
is  employed.  I  understand  a  disorder  to  be  contagious,  when  it  is  in  any  way  com- 
municable from  one  person  to  another.  Some  would  restrict  the  word  contagion  to 
the  cases,  in  which  there  must  be  absolute  contact  of  the  healthy  body  with  the 
sick  bod}',  or  with  its  visible  offscourings.  When  the  disease  can  be  conveyed 
through  the  medium  of  the  atmosphere,  or  by  means  of  other  intermediate  substances 
called  fomites,  they  would  call  it  infectious.  And  there  is  no  objection  to  such  a 
distinction,  provided  it  is  understood  b}''  the  reader,  or  hearer,  as  well  as  by  the  writer 
or  speaker.  But  since  in  all  cases  the  disease  is  conveyed  to  the  person  of  the  reci- 
pient by  particles  of  matter  proceeding  from  the  person  of  the  sick,  and  since  it 
seems  very  unimportant  whether  those  particles  are  in  a  solid  or  in  a  gaseous  form, 
whether  they  are  imparted  by  direct  contact  of  the  two  human  bodies,  or  by  being 
wafted  through  the  air,  or  carried  upon  articles  of  clothing,  I  shall  include  both  and 
all  these  modes  of  communication  under  the  single  term,  contagion.  This,  in  fact, 
is  what  is  done  in  common  discourse  :  all  disorders  that  are  "  catching,"  I  shall  take 
leave  to  consider  contagious. 

In  this  sense  I  believe  that  all  the  diseases  just  now  enumerated  are  contagious  ; 
some,  no  doubt,  much  more  strongly  and  distinctly  than  others.  Some  of  them, 
indeed,  are  undeniably  contagious.  For  example,  we  are  privy  to,  and  sometimes 
willing  agents  in,  the  communication  of  small-pox  from  one  individual  to  another. 
There  are  others  concerning  the  contagious  nature  of  Avhich  medical  opinion  is  less 
settled  and  unanimous.  Many  persons  deny  that  continued  fever  is  communicable 
from  person  to  person.  The  evidence  from  which  I  conclude  that  it  is  so,  I  will  lay 
before  you  when  I  have  described  that  disorder.  Even  they  who  admit  that  it  is 
contagious,  are  of  opinion,  many  of  them,  that  it  sometimes  breaks  out  spontaneously, 
without  the  intervention  of  any  specific  virus.  No  one  questions,  I  fancy,  the  con- 
tagious properties  of  measles  ;  or  of  scarlet  fever.  Whether  the  plague,  and  whether 
erysipelas,  be  always  or  ever  so  produced,  has  been  thought  more  doubtful.  There 
is  everj^  reason  for  believing  that  the  small-pox,  at  least,  has  now  no  other  source  than 
contagion.  How  it  first  arose,  it  may  be  difficuh  to  conjecture  ;  but  it  is  never  known 
to  originate  spontaneously  now-a-days. 

Small-pox  may  in  truth  be  regarded  as  the  rtopo^styiua,  or  type,  of  this  group  of 
diseases.  I  shall,  therefore,  take  by  anticipation,  some  well-ascertained  facts  in  its 
history,  for  the  sake  of  illustrating  the  general  subject.     It  is  a  malady  which  could 


1 


EXANTHEMATA.  927 

scarcely  be  mistaken  for  any  other ;  and  of  which  the  horrible  aspect  and  fatal 
tendency  are  so  strongly  marked,  that  its  appearance  has  always  been  watched 
with  affright  by  mankind  in  general,  and  with  intense  interest  by  the  philosophic 
physician. 

In  the  acme  of  this  disease,  when  it  is  severe,  the  whole  surface  of  the  body  is 
covered  with  innumerable  httle  pustules.  A  minute  portion  of  the  matter  contained 
in  any  one  of  these  pustules,  just  so  much  as  may  suffice  to  moisten  the  point  of  a 
lancet,  is  inserted,  we  will  suppose,  beneath  the  cuticle  of  a  healthy  man,  who  has 
not  been  near  the  sick  man.  What  follows  this  engrafting?  Nothing,  apparently 
for  several  days  :  but  then  febrile  symptoms  burst  forth :  and  by  and  by  a  crop  of 
papulas  appear  sprinkled  over  the  skin  :  and  these  gradually  ripen  into  pustules  pre- 
cisely resembling  that  from  which  the  engrafted  drop  was  taken. 

The  very  same  phenomena  ensue,  if  a  healthy  man  enters  the  chamber  of  a  small- 
pox patient,  and  breathes,  for  a  certain  time,  an  atmosphere  tainted  with  the  'jmana 
tions  from  his  body. 

The  points  to  be  noticed  here  are — 1,  the  manifest  introduction  of  the  virus  into 
the  sj^stem :  2,  its  dormancy  for  a  while,  in  other  words,  the  occurrence  of  a  period 
of  incubation :  3,  the  breaking  out,  at  length,  of  a  disease  identical  in  its  symptoms 
and  in  its  character  with  that  of  the  first  patient :  and  4  (most  surprising  of  all),  the 
enormous  increase  and  multiplication  of  the  poisonous  matter. 

I  say  the  history  of  small-pox  leads  to  the  settled  behef  that  this  disorder,  of  which 
few  persons  are  not  readily  susceptible,  never  occurs,  except  from  contagion.  It 
was  quite  unknown  in  Europe  till  the  beginning  of  the  eighth  century.  No  men- 
tion of  any  such  malady  is  to  be  found  in  the  Greek  or  Roman  authors  of  antiquity. 
Now  whatever  may  have  been  the  deficiencies  of  the  ancient  physicians,  they  were 
excellent  observers,  and  capital  describers  of  disease  :  and  it  is  impossible  that  a 
disorder  so  diffusive,  and  marked  by  characters  so  definite  and  conspicuous,  should 
have  escaped  their  notice,  or  have  been  obscurely  portrayed  (if  known)  in  their 
writings. 

On  the  other  hand,  Mr.  Moore,  in  his  learned  and  interesting  History  of  Small' 
pox,  has  shown  that  it  prevailed  in  China  and  Hindostan  from  a  very  early  period  • 
even  more  than  1000  years  before  the  time  of  our  Saviour.  That  it  did  not  sooner 
extend  westward  into  Persia,  and  thence  into  Greece,  may  be  attributed  partly  to  the 
horror  which  the  complaint  everywhere  inspired,  and  the  attempts  that  were  conse- 
quently made  to  check  its  progress  by  prohibiting  all  communication  with  the  sick 
partly  to  the  limited  intercourse  which  then  took  place  among  the  eastern  nations., 
but  principally  to  the  peculiar  situation  of  the  regions  through  which  the  infection 
was  diffused  ;  separated  as  they  were  from  the  rest  of  the  world  by  immense  deserts 
and  by  the  ocean. 

The  disease  is  said  to  have  broken  out  in  jlrabia  at  the  siege  of  Mecca,  in  the 
year  in  which  Mahomet  was  born  ;  i.  e.,  in  the  sixth  century.  It  was  widely  pro- 
pagated by  his  wars,  and  by  those  of  the  Arabs  afterwards  ;  and,  as  I  said  before, 
it  is  generally  believed  to  have  first  found  entrance  into  Europe  at  the  time  of  the 
overthrow  of  the  Gothic  monarchy  in  Spain  by  the  Moors  ;  when  to  avenge  the  well- 
known  outrage  upon  his  daughter,  "  Count  Julian  called  the  invaders."  Whensoever 
and  wheresoever  it  came,  it  spread  with  fearful  rapidity  and  havoc. 

What  I  wish  you  to  remark  is  this  :  that  while  almost  all  men  are  prone  to  take 
the  disorder,  large  portions  of  the  world  have  remained  for  centuries  entirely  exempt 
from  it,  until  at  length  it  was  imported  ;  and  that  then  it  infallibly  diffused  and  esta- 
blished itself  in  those  parts. 

Of  the  more  modern  history  of  the  disease  our  knowledge  is  more  precise  and 
sure.     It  tends  uniformly  to  the  same  conclusion. 

There  was  no  small-pox  in  the  New  World  before  its  discovery  by  Columbus  in 
1492.  In  1517  the  disease  was  imported  into  St.  Domingo.  Three  years  later,  in 
one  of  the  Spanish  expeditions  from  Cuba  to  Mexico,  a  negro  covered  with  the  pus- 
tules of  small-pox  was  landed  on  the  Mexican  coast.  From  him  the  disease  spread 
with  such  desolation,  that  within  a  very  short  time,  according  to  Robertson,  three 
millions  and  a  half  of  people  were  destroyed  in  that  kingdom  alone.     Small-pox  wiw 


928  EXANTHEMATA. 

introduced  into  Iceland  in  1707,  when  16,000  persons  were  carried  off  by  its  ravages  ; 
more  than  a  fourth  part  of  the  whole  population  of  the  island.  It  reached  Green- 
land still  later,  appearing  there  for  the  first  time  in  1733,  and  spreading  so  fatally  a.', 
almost  to  depopulate  the  country. 

Evidence  to  the  same  effect  is  furnished  by  the  results  of  vaccination  in  somr 
countries.  In  Mr.  Cross's  History  of  a  Variolous  Epidemic  which  occurred  at 
Norwich  in  1819,  it  is  stated,  upon  good  authority,  that  vaccination  was  adopted  ir 
Denmark,  and  made  compulsory,  in  1800.  After  the  year  1808,  small-pox  no  longer 
existed,  and  was  a  thing  totally  unknown.  Whereas  during  the  twelve  years  pre 
ceding  the  introduction  of  the  preventive  disease,  5,500  persons  died  of  the  small- 
pox in  Copenhagen  alone.  Statements  corroborative  of  this  account  have  been  made 
to  me  in  the  present  year  (1838)  by  Dr.  Blick,  an  intelligent  Danish  physician,  who 
was  on  a  visit  to  London. 

Now  it  is  a  very  instructive  fact  respecting  this  disease,  thus  rankly  contagious, 
and  arising  from  no  other  source  than  contagion,  that  when  it  is  epidemic  in  any 
places,  many  instances  of  it  occur  which  we  can  by  no  means  trace  to  contagion. 
Dr.  Gregory  tells  us  that  of  the  numerous  cases  received  into  the  Small-pox  Hospital 
(to  which  he  has  long  been  phj'-sician)  not  one  in  twenty  is  capable  of  being  referred 
to  any  known  source  of  infection  ;  the  disease  being  ascribed  by  the  patient  to  cold, 
fatigue,  change  of  air,  or  some  other  innocent  circumstance.  A  prisoner  shut  up  in 
solitary  confinement  in  the  Penitentiary  at  Milbank  was  seized  with  small-pox. 
Surely  this  should  warn  us  against  inferring  of  analogous  disorders  (of  continued 
fevers,  for  example)  that  they  are  necessarily  not  contagious,  because  we  often  fail 
to  discover  any  way  in  which  the  poison  could  have  been  appHed.  If  small-pox  be 
produced  by  contagion  alone,  and  yet  the  mode  in  which  the  contagious  matter  has 
been  communicated  eludes  sometimes  our  closest  scrutiny,  then  we  must  conclude 
that  the  same  thing  may  happen  in  o//ier  contagious  diseases,  of  which  the  contagious 
property  may  not  he  so  strong  or  so  obvious.  Nay,  the  argument  from  analogy  will 
lead  us  a  step  further.  If  once  a  disorder  of  this  kind  is  decidedly  proved  to  be 
sometimes  the  effect  of  contagion  (and  this  I  think  I  shall  be  able  to  prove  to  you  of 
continued  fever) — we  cannot  help  entertaining  a  doubt  whether  the  disorder  in  ques- 
tion really  ever  has  any  other  cause.  It  is  chiefly  with  a  view  to  the  light  which 
ihey  throw  upon  the  obscurer  subject  of  continued  fever,  that  I  am  thus  anticipating 
some  points  in  the  history  of  the  contagious  nature  of  small-pox. 

Again,  it  is  noticed  of  small-pox — and  it  is  the  same  with  the  other  diseases  in 
this  group — that  the  human  body  is  not  always  equally  susceptible  of  its  contagious 
influence.  Some  individuals  are  more  readily  affected  by  it  than  others:  and  the 
same  individual  more  so  at  one  time  than  at  another.  There  are  even  some  who 
seem  to  be  incapable  of  taking  the  small-pox — ^just  as  some,  who  are  quite  as  much 
perhaps  in  the  way  of  it  as  their  neighbours,  never  become  infected  with  the  great- 
pox.  Of  215  persons  who  had  not  been  vaccinated,  nor  had  the  small-pox,  and  who 
were  living  at  Norwich  in  the  same  houses  with  persons  ill  of  that  disease,  fifteen 
did  not  become  affected  with  it ;  and  of  these  fifteen  it  was  ascertained  that  ten  had 
escaped  under  similar  circumstances  of  exposure  before.  I  mentioned,  on  a  former 
occasion,  the  fact  that  a  certain  dog,  in  Paris,  could  not  be  made  to  take  the  conta- 
ion  of  rabies. 
It  is  not  at  all  uncommon  for  persons  to  resist  the  influence  of  contagion  at  one 
period,  and  to  yield  to  it  at  another,  even  when  the  exposure  has  appeared  to  be 
less  complete.  Mr.  Cross  gives  a  striking  example  of  this.  A  man,  who  believed 
that  he  had  had  the  small-pox,  lived  for  twelve  years  as  a  nurse  in  an  estabhshment 
for  the  reception  of  persons  inoculated  with  that  disorder.  At  the  end  of  that  time 
he  caught  the  small-pox,  which  proved  fatal  to  him.  Now  this  might  have  been, 
and  probabl}'  was,  as  the  man  supposed,  a  second  attack.  The  late  Mr.  Lockley 
told  me  an  instance  still  more  remarkable,  as  being  free  from  that  ambiguity.  Nearly 
the  first  patient  he  ever  attended,  if  not  the  very  first,  was  an  old  woman,  who  for 
years  had  been  in  the  habit  of  going  from  village  to  village  as  a  nurse ;  and  of  nurs- 
ing a  great  number  of  persons  labouring  under  small-pox,  which  she  had  never  had, 
flnd  agamsf  which  she  (naturally  enough)  believed  herself  proof.     At  length  she 


EXANTHEMATA.  929 

was  taken  ill,  and  died  of  small-pox,  under  Mr.  Lockley's  observation,  at  the  age  of 
sighty-four. 

In  many  cases  we  can  assign  no  reason  for  these  variations  and  differences.  Age 
seems  to  have  something  to  do  with  them.  Infants  are  but  little  susceptible  of  the 
operation  of  contagions.  Debility,  howsoever  produced,  certainly  augments  the  dis- 
position to  be  affected  by  this,  as  by  other  causes  of  disease.  The  dose  and  strength 
of  the  poison  must  also  be  taken  into  account.  As  some  men  can  drink  a  much 
larger  quantity  of  wine  (which  is  an  alcoholic  poison)  than  others,  without  being  in- 
toxicated, and  are  differently  influenced  by  the  same  quantity  at  different  times,  so  is 
it  also  with  the  animal  poisons  we  are  now  considering ;  so  is  it,  as  I  showed  you 
before,  with  the  mineral  poison  of  mercury. 

This  fluctuating  power  to  resist  contagion  is  most  conspicuous,  perhaps,  when 
viewed  in  reference  to  scarlet  fever.  After  the  very  earliest  periods  of  life,  children 
catch  infectious  disorders  of  all  kinds  readily  enough  ;  more  readily  than  in  mature 
age.  The  poison  of  scarlet  fever  operates  with  less  certainty  upon  aduhs  than  the 
poisons  of  small-pox,  or  of  measles.  Some  medical  men  escape  scarlet  fever  alto- 
gether, although  brought  much  into  contact  with  it  by  their  vocation.  I  do  not  know 
that  I  ever  had  scarlet  fever. 

Another  fact,  well  worthy  of  notice,  is,  that  small-pox,  which  is  so  rankly  conta- 
gious, and  which  has  at  present  no  other  source  besides  contagion,  has  its  alternate 
periods  of  slumber  and  of  activity.  This  metropolis,  and  most  of  our  large  towns,  are 
never  entirely  free  from  it.  Scattered  cases  occur  here  and  there  ;  and  when  thus 
thinly  disseminated,  the  disease  is  said  to  be  sporadic.  But  there  are  seasons  in 
which  it  spreads  rapidly  and  extensively,  and  assumes  the  form  of  an  epidemic  dis- 
temper. We  are  now  living  (1838)  in  the  midst  of  one  of  these  epidemics  of  small- 
pox. The  same  is  equally  true  of  the  other  complaints  included  in  this  group. 
Sometimes  they  are  confined  to  single  families ;  sometimes  they  pervade  a  whole 
district. 

Hence  you  can  never  infer  that  any  febrile  disorder  is  not  contagious,  merely  be- 
cause it  prevails  epidemically.  Many  epidemic  diseases  are  not  contagious.  But 
the  two  properties  may  and  do  meet  in  the  same  malady.  They  are  not  to  be  set  in 
opposition  to  each  other,  or  regarded  as  incompatible  properties,  as  they  have  been 
by  some  ingenious  writers. 

With  respect  to  these  epidemic  visitations  of  the  exanthemata,  certam  general  facts 
have  been  ascertained,  very  useful  and  necessary  to  be  known. 

1.  The  strength  of  the  contagion,  and  the  severity  and  fatality  of  the  disease,  vary 
at  different  periods  of  an  epidemic.  In  general  the  contagion  is  the  most  active,  and 
the  disorder  the  most  fierce,  at  the  outset  of  the  epidemic.  By  degrees  its  violence 
slackens,  and  it  ceases  to  spread.  This  is  partly  to  be  explained  by  the  circumstance 
that  the  number  of  persons  who  are  susceptible  of  the  disease,  and  who  have  not  yet 
been  attacked,  are  fewer  and  fewer  as  the  epidemic  proceeds.  The  fire  iangfuishes 
for  lack  of  fuel.  But  this  does  not  seem  to  be  all.  The  disease  dies  out  before  it 
has  affected  all  those  who  are  capable  of  receiving  it.  We  might,  I  think,  expect, 
prior  to  experience,  that  the  earlier  cases  would  usually  be  the  severer:  for  the 
weak,  who  are  less  liable  to  struggle  with  the  complaint,  and  those  who,  by  pecu- 
liarity of  constitution,  are  most  susceptible  of  the  morbific  influence,  are  likely  to  be 
the  first  to  suffer. 

2.  There  are  great  varieties  also  in  the  general  character  of  the  symptoms  that 
occur  in  different  epidemics  of  the  same  disorder.  At  one  time,  or  in  one  place,  in- 
flammatory symptoms  run  high ;  in  another  place,  or  at  another  time,  there  is  an 
early  tendency  to  debihty  and  sinking.  One  epidemic  is  more  malign  than  another. 
And  the  practice  varies  accordingly  ;  so  that  these  are  facts  of  the  greatest  importance 
The  prevailing  character  of  the  malady  is  attributed  to  what  is  called  the  epidemic 
constitution  of  the  season.  And  when  we  have  made  out,  by  observation,  what  this 
epidemic  constitution  is,  we  have  obtained  a  clue  to  the  proper  management  of  thu 
disorder.  Thus  continued  fever,  as  it  has  appeared  in  London  during  the  last  twelve 
years,  has  required  and  borne  far  less  depletion  than  it  did  for  the  preceding  twelve 
years  or  more. 

59  4c2 


930  EXANTHEMATA. 

You  may  learn  from  this  how  dangerous  it  is  to  apply  indiscriminately  in  one 
epidemic  the  remedies  that  may  have  been  found  useful  in  another :  and  also  how 
foolish  and  unfair  it  is  to  censure  the  practice  employed  and  recommended  by  others, 
merely  because  it  differs  from  that  which  we,  in  other  epidemic  visitations  of  the 
same  disorder,  have  considered  fitting  and  beneficial. 

These  differences  in  the  pre  valency  of  the  disease,  and  in  the  character  of  its 
SA'mptoms,  are  not  to  be  explained  by  any  variation  in  the  exciting  cause,  which  is  a 
definite  animal  poison ;  nor  can  they  be  reasonably  ascribed  to  any  appreciable 
quality  or  agency  of  the  weather  at  the  time.  They  must  depend  upon  changes 
that  have  been  slowly  wrought  upon  the  human  body  :  and  those  changes,  consti- 
tuting an  acquired  predisposition,  are  probably  due  to  previous  conditions  of  the 
atmosphere,  which  have  exercised  a  long  and  gradual  influence  upon  all  the  indivi- 
duals of  a  community. 

After  stating,  in  the  first  clause  of  his  definition,  that  the  exanthemata  are  conta- 
gious diseases,  Cullen  announces,  in  the  next  place,  the  very  curious  fact,  that  they 
occur  but  once  in  a  person's  life.  "  Semel  tantum  in  decursu  vitas  aliquem  affi- 
cientes."  In  this  they  offer  a  remarkable  contrast  to  inflammations,  which,  having 
happened  once,  are,  for  that  very  reason,  more  apt  to  happen  again. 

You  will  take  care  to  observe,  that  it  is  not  the  mere  circumstance  of  the  disease 
being  contagions  that  makes  the  difference.  Those  disorders  which  shield  the  sys- 
tem against  their  own  future  recurrence  are,  all  of  them  probably,  contagious ;  but 
the  converse  does  not  hold.  It  is  not  true  that  all  contagious  disorders  protect  the 
constitution  from  their  own  return.  Syphihs,  purulent  ophthalmia,  the  itch :  these 
not  only  do  not  secure  a  patient  from  a  repetition  of  the  disease,  but  perhaps  they 
even  render  him  more  liable  to  it  in  future. 

K*either  is  the  proposition  absolutely  and  invariably  true  of  any  disease.  Like 
most  general  rules,  it  admits  of  occasional  exceptions.  There  is  not  one  of  the  group 
enumerated  in  the  beginning  of  this  lecture,  which  has  not  been  known  to  occur 
more  than  once  in  the  same  person.  Small-pox  has,  in  many  instances,  affected  the 
same  individual  twice ;  even  when  the  first  attack  had  been  so  severe  as  to  have 
engraved  deep  traces  of  its  visit  upon  the  skin.  There  are  a  few  instances  recorded 
of  its  third  recurrence.  It  was  believed,  at  one  time,  that  whenever  the  disease  was 
thus  repeated,  it  was  always,  in  the  first  instance,  severe,  which,  taken  in  conjunc- 
tion with  the  rep'^lition,  was  thought  to  indicate  a  strong  natural  susceptibihty  of  the 
disorder.  But  it  has  since  been  noticed  that  the  primary  visit  is  sometimes  unusu- 
ally mild :  and  this  fact  (so  powerful  is  the  love  of  theory)  has  led  to  the  supposition 
that  the  first  attack  was  not  sufficiently  intense  to  affect  the  whole  mass  of  blood,  and 
to  exhaust  the  inborn  susceptibility.  I  believe  that  the  two  attacks  have  always  been 
separated  by  a  considerable  interval  of  time.  I  have  myself  known  one  very  strik- 
ing instance,  about  which  there  could  be  no  mistake,  of  the  recurrence  of  measles  in 
several  children  of  the  same  parents.  This  proclivity  to  be  again  affected  by  the 
specific  poison  seems  to  run  in  families.  It  is  less  uncommon  for  scarlet  fever  to 
happen  a  second  time  in  the  same  individual.  No  contagious  disease  therefore  fur- 
nishes complete  future  protection  against  itself.  But  that  this  privilege  belongs,  as  a 
general  rule,  to  small-pox,  to  measles,  and  to  scarlet  fever,  there  can  be  no  doubt : 
and  the  validity  of  the  rule  is  applicable  in  the  order  in  which  I  have  here  mentioned 
them.  It  applies,  also,  though  less  uniformly,  to  the  other  exanthemata.  A  person 
who  has  suffered  a  well-marked  attack  of  continued  fever  is  far  less  hable  than  ano- 
ther, according  to  my  experience,  to  have  that  disease  again.  The  plague  is  said  to 
afford  a  temporary  safeguard  against  itself.  Very  few  persons  have  it  twice  in  the 
same  season.  During  one  epidemic  Dr.  Russell  found  that,  among  4,400  individuals 
who  underwent  the  disease,  only  twenty-eight  contracted  it  a  second  time.  The 
singular  property  we  are  considering  is  less  plainlj?-  visible  in  erysipelas  than  in  any 
other  malady  of  the  group. 

The  next  clause  in  CuUen's  definition  asserts  the  supervention  of  the  cutaneous 
inarks,  in  technical  language,  of  the  eruption,  at  fixed  times  [dejinito  tempore)  after 
the  commencement  of  the  general  fever.  It  is  clear,  therefore,  that  the  cutaneous 
'nflammation  cannot  be  the  cause  of  the  fever,  but  is  itself  an  effect  of  the  contagious 


EXANTHEMATA.  951 

poison.  Here  again  we  have  a  mark  of  distinction  between  febrile  exanthemata 
and  inflammatory  fevers,  or  what  CuUen  calls  the  phlegmasiae,  in  which  the  local 
inflammation  commonly  precedes  the  pyrexia. 

In  point  of  fact,  the  circumstance  to  which  I  have  just  referred  shows  the  impro- 
priety of  ranking  these  diseases  under  the  head  of  cutaneous  diseases.  They  would 
more  rightly  be  called  blood  diseases.  The  disseminated  cutaneous  inflammation  is 
A  curious  and  an  important  circumstance ;  and  it  is  the  symptom  which,  in  the  ma- 
jority of  cases,  is  most  distinctive  of  the  disorder :  but  it  is  not  an  essential  circum- 
stance. Thus,  although  there  often  is  a  manifest  eruption  (quite  independent  of 
common  petechias)  in  the  earlier  stage  of  continued  fever,  a  lenticular  mottling,  some- 
what like  that  of  measles,  yet  it  is  often  absent  altogether.  And  the  very  same 
tiling  happens  in  other  diseases  of  the  same  group — diseases  which  all  the  world 
considers  and  calls  cutaneous.  A  febrile  affection,  often  a  fatal  one,  but  attended 
with  no  rash,  proceeds  sometimes  from  the  contagion  of  scarlet  fever.  The  fever — 
or  rather  the  patient — is  not  scarlet.  The  worst  form  of  cynanche  maligna  is  of 
this  kind.  It  is  just  the  same  in  measles.  Authors  speak  of  morbilli  sine  morbillis  ; 
of  scarlatina  sine  scarlatina ;  and  even  of  variolas  sine  variolis.  Catarrhal  symp- 
toms certainly  occur  sometimes  in  weakly  children  who  have  been  fully  exposed  to 
the  contagion  of  measles ;  and  the  complaint  has  proved  fatal,  without  there  having 
been  any  eruption  at  all.  So  in  the  plague  :  certain  cases  occur  in  which  there  are 
no  buboes  nor  carbuncles,  yet  which  undoubtedly  originated  from  the  common  con- 
tagion of  the  prevaihng  epidemic. 

The  time  at  which  the  eruption  comes  out  differs  in  the  different  diseases  ;  and 
even  in  the  same  disease,  it  is  subject  to  occasional  variation.  The  rule  with  re- 
spect to  small-pox  is,  that  the  spots  begin  to  be  visible  on  the  third  day ;  that  on 
which  the  sickness  and  fever  commenced  being  reckoned  the  first.  As  far  as  I 
have  observed,  this  rule  is  a  very  constant  one.  It  has  been  noticed,  however,  that 
when  the  disease  is  confluent,  and  therefore  severe,  it  occasionally  shows  itself  in 
eruption  on  the  second  day  ;  and  when  quite  distinct  and  mild,  sometimes  not  till 
the  fourth. 

The  regular  period  for  the  outbreak  of  the  cutaneous  affection  in  measles  is  the 
fourth  day  :  it  scarcely  ever  begins  sooner;  but  it  is  often  later — on  the  fifth  or  the 
sixth  day,  or  even  later  than  that. 

Cullen  assigns  the  fourth  day  for  the  ordinary  appearance  of  the  rash  in  scarlet 
fever  also.  But  in  this  he  is  decidedly  wrong.  Sometimes  it  is,  I  believe,  percepti- 
ble on  the  first  day ;  but  its  most  general  period  is  the  second  day.  In  severe  and 
unfavourable  cases  it  may  be  postponed  till  the  fourth  day,  or  longer. 

The  eruption,  which  is  tolerably  constant  in  some  varieties  of  continued  fever, 
observes  less  regularity  in  the  time  of  its  arrival. 

The  period  which  intervenes  between  the  reception  of  the  poison,  and  the  super- 
vention of  distinct  symptoms — the  period  during  which  the  virus,  though  doubtless 
at  work,  seems  to  lie  dormant  in  the  system — the  period  (in  one  word)  of  incubation, 
differs  also  in  the  different  diseases  of  this  group,  and  varies  even  in  different  cases 
of  the  same  disease.  Although  no  marked  changes  occur  during  this  period,  I  be- 
lieve that  some  slight  deviation  from  the  usual  condition  and  feeHngs  of  the  patient 
might  often  be  observed,  if  they  were  expected  and  looked  for. 

The  period  of  incubation  in  continued  fever  is  very  uncertain.  In  a  paper  upon 
this  curious  subject,  published  in  the  ninth  volume  of  the  Medical  Gazette,  Dr. 
Gregory  states  it  as  his  opinion,  derived  from  much  inquiry,  that  ten  days  is  the 
average  period.  Dr.  Haygarth  reckoned  the  minimum  period  at  seven  ;  the  maxi 
mum  at  seventy-two  days.  Sir  William  Burnett,  in  his  Account  of  a  Contagious 
Fever  at  Chatham,  gives  the  history  of  a  party  of  men  belonging  to  the  St.  George, 
lying  at  Spithead,  who  were  sent,  on  the  3d  of  January,  1811,  to  assist  in  navigating 
the  Dolphin  troop-ship ;  the  crew  of  which  were  affected  with  typhus  fever.  On 
the  10th  (seven  days  after  exposure)  fourteen  of  these  men  were  sent  to  the  Hos- 
pital-ship from  the  St.  George,  ill  with  the  fever ;  and  many  subsequently,  up  to 
the  21st  of  January  (the  eighteenth  from  exposure),  after  which  period  no  cases 
occurred 


932  CONTAGION. 

The  period  of  dormancy  is  more  definite,  yet  still  liable  to  some  variation,  in  most 
of  the  other  exanthemata.  "At  the  Small-pox  Hospital,"  says  Dr.  Gregory,  "  abun- 
dant evidence  has  been  afforded  that  the  period  of  incubation  is  usually  about  twelve 
days."  It  is  a  remarkable  fact  that, "  when  the  small-pox  is  received  into  the  system 
by  inoculation,  seven  days  only  elapse  between  the  insertion  of  the  virus  and  the 
estabhshment  of  the  fever." 

Dr.  Bateman  puts  the  period  of  incubation  in  measles  at  "  from  ten  to  fifteen 
days."  I  have  known  several  instances  in  which  the  date  of  a  single  short  exposure 
was  exactly  ascertained,  and  in  which  the  disease  commenced  precisely  a  fortnight 
afterwards.  In  scarlet  fever,  the  average  period  is  shorter ;  not  more  than  from  four 
to  six  days.  In  the  plague  it  is,  I  beheve,  more  variable  ;  but  generally  not  exceed- 
ing a  few  days.  Dr.  Russell  tells  us  that,  among  those  inhabitants  of  Aleppo  who 
shut  themselves  up  after  having  been  in  the  way  of  the  contagion,  no  instance 
occurred  of  the  appearance  of  the  malady  later  than  the  ninth  or  tenth  day. 

To  say  that  a  febrile  disorder  is  contagious,  is  the  same  thing  as  to  say  that  it  is 
produced  by  an  animal  poison.  Now,  there  are  many  poisons,  very  deadly  poisons 
too,  which  cause  diseases  that  are  not  communicable  from  person  to  person.  That 
particular  poison,  the  malaria,  is  of  this  kind. 

Of  the  inorganic  poisons,  some  are  taken  into  the  blood,  and  emerge  again  from 
the  body,  unaltered,  with  one  or  more  of  the  ordinary  secretions ;  chiefly  with  the 
urine.  They  may  induce  changes  in  the  body  as  they  pass ;  and  if  these  changes 
be  salutary,  the  substances  so  inducing  them  become  medicaments.  If  the  changes 
be  destructive  or  injurious,  they  are  strictly  poisons. 

Other  of  the  inorganic  poisonous  substances  do  not  find  so  ready  an  exit  from  the 
body.  They  enter  into  permanent  chemical  union  with  the  constituent  tissues  of 
particular  organs.  In  this  way,  to  use  the  words  of  Liebig,  they  deprive  the  organs 
of  the  principal  property  which  appertains  to  their  vital  condition,  viz.,  that  of  suf 
fering  and  of  effecting  transformations.  If  the  organs  of  which  the  functions  are 
thus  destroyed  be  vital  organs,  these  poisons  are  fatal. 

But  the  animal  poisons,  those  at  least  with  which  we  are  now  concerned,  act  in  a 
totally  different  manner.  They  effect  changes  in  the  blood,  whereby  they  are  them- 
selves abundantly  multiplied  or  reproduced;  and  the  eruptive  disease  that  ensues 
seems  to  be  the  mode  provided  by  nature  for  the  escape  or  the  expulsion  of  this 
newly-formed  morbid  matter  from  the  system.  This  is  the  old-fashioned  humoral 
pathology,  founded  on  bold,  unproven  speculation ;  and  it  is  most  curious  to  see 
these  very  doctrines,  which  had  sunk  into  universal  discredit  and  contempt,  now 
again  assuming  their  places,  as  scientific  truths,  upon  the  secure  basis  of  organic 
chemistry.  A  wonderful  specimen  this  of  the  sagacity  of  the  older  physicians — of 
the  despised  wisdom  of  our  forefathers. 

The  ancients  attributed  various  disorders  to  a  fermentation  of  the  animal  fluids. 
The  cause  of  fever,  according  to  Hippocrates,  was  some  morbid  matter  in  the  blood. 
This  matter,  by  a  process  of  concoction,  was  brought,  in  a  certain  number  of  days, 
into  a  state  in  which  it  was  ready  for  expulsion  from  the  body.  It  was  then  thrown 
off  by  hemorrhage,  by  sweat,  by  alvine  discharges  ;  or  deposited  upon  the  surface 
in  the  form  of  abscess,  or  cutaneous  eruption :  and  these  eruptions  or  evacuations 
constituted  the  crisis  of  each  fever. 

The  doctrine  thus  enunciated  by  the  father  of  physic  is  very  nearly  the  same  with 
that  which  Liebig  is  teaching  in  the  nineteenth  century.  This  distinguished  chemist 
ascribes  the  pfienomena  which  succeed  the  introduction  of  certain  animal  poisons  into 
the  blood,  to  a  process  exactly  resembling  fermentation.  Let  me  try,  in  a  few  sen- 
tences, to  expound  to  you  his  views  on  this  deeply  interesting  subject. 

You  know  that  the  brewer  excites  the  fermentation  of  his  siveelwort  by  adding  to 
it  a  small  quantity  oi  yeast.  Wort  is  an  infusion  of  malt,  and  contains  sugar  and 
gluten,  with  other  vegetable  matters,  in  solution.  Yeast  is  putrefying  gluten  ;  and 
its  component  particles  are,  therefore,  in  a  state  of  intestine  motion  or  transposition. 
When  placed  in  contact  with  sugar  in  solution,  it  has  the  property  of  communicating 
a  similar  intestine  motion  to  the  elements  of  the  sugar,  whereby  they  arrange  them- 


THEORY    OF    CONTAGIOUS    FEVERS.  933 

selves  into  new  and  simpler  forms  ;  namely,  into  alcohol  and  caroonic  acid.  If  there 
were  no  gluten  in  the  wort,  this  would  be  the  whole  of  the  process  ;  during  which 
the  added  yeast  disappears. 

But  the  decomposition  ov  fermentation  of  the  sugar  reacts  upon  the  gluten  in  the 
wort,  and  converts  it  gradually  into  yeast,  which,  minghng  with  the  liberated  car- 
bonic acid,  rises  and  floats  upon  the  surface  of  the  fermenting  liquid.  So  that,  when 
the  process  is  completed,  there  has  been  produced  thirty  times  as  much  yeast  as  was 
originally  added  to  the  wort. 

Now,  this  is  but  a  type  of  what  happens  in  other  fluids  under  analogous  circum- 
stances ;  and  it  may  be  laid  down  as  an  abstract  proposition  in  Liebig's,  or  rather  his 
translator's  words,  that  "  a  substance  in  the  act  of  decomposition,  added  to  a  mixed 
fluid  in  which  its  constituents  are  contained,  can  reproduce  itself  in  that  fluid,  exactly 
in  the  same  manner  as  new  yeast  is  produced,  when  yeast  is  added  to  Hquids  con- 
taining gluten." 

Thus,  the  virus  of  small-pox  (which  virus  is  formed  out  of  the  blood)  causes  such 
a  change  in  the  blood  as  gives  rise  to  the  reproduction  of  the  poison  from  the  con- 
stituents of  that  fluid ;  and  whilst  this  process  is  going  on,  the  natural  working  of 
the  animal  economy  is  disturbed — the  person  is  ill.  The  transformation  is  not 
arrested  until  all  the  particles  of  the  blood  which  are  susceptible  of  the  decomposi- 
tion have  undergone  the  metamorphosis. 

Liebig  shows  that  similar  processes  may  take  place  in  mixed  fluids  (and  therefore 
in  the  blood),  without  the  regeneration  of  the  added  substance  ;  just  as  the  ferment- 
ation of  a  solution  of  sugar  is  effected  by  the  addition  of  yeast,  without  any  repro- 
duction of  the  yeast,  if  there  be  no  gluten  in  the  saccharine  solution.  In  such 
cases,  the  disease  which  accompanies  or  results  from  the  transformations  that  occur 
in  the  blood,  is  not  contagious  ;  the  poison  is  not  renewed.  It  is  thus,  apparently, 
that  certain  miasms  produce  disorders  which  are  not  communicable  from  person  to 
person. 

In  order  that  a  specific  animal  poison  should  effect  its  O'vn  reproduction  in  the 
blood,  and  excite  that  commotion  in  the  system  which  results  from  the  formation  and 
expulsion  of  the  new  virus,  it  is  requisite  that  a  certain  ingredient  (analogous  to  the 
gluten  in  the  brewer's  sweetwort)  should  be  present  in  the  blood  ;  and  this  ingre- 
dient must  have  a  definite  relation  to  the  given  poison. 

If  this  ingredient  be  indispensably  necessary  to  life,  the  poison  which  transforms 
and  destroys  it,  is  inevitably  a  fatal  poison.  May  not  this  be  the  modus  operandi 
of  the  poison  of  hydrophobia  ? 

Again,  if  this  ingredient  be  wanting,  no  reproduction  of  the  poison  takes  place ; 
nor,  of  course,  any  of  those  symptoms  which  are  consequent  upon  such  reproduc- 
tion. The  poisonous  qualities  of  the  animal  substance  are  not  developed.  It  ceases 
to  be  a  poison. 

And  this  ingredient,  if  naturally  present,  is  exhausted  and  destroyed,  for  a  while 
at  least,  by  the  operation  of  the  poison.  Hence,  for  a  while  at  least,  the  same  dis- 
ease cannot  be  again  produced  by  the  agency  of  that  poison. 

Supposing  the  ingredient  to  be  one  which  is  not  essential  to  the  composition  of  the 
blood,  and  to  have  been  thus  destroyed  or  exhausted,  it  may  never  be  replaced.  Or 
it  may  be  replaced  only  after  a  long  interval.  In  some  persons  it  may  never  exist 
at  all,  or  it  may  exist  at  certain  periods  only  of  their  lives.  It  may  even  be  acquired 
by  unnatural  or  peculiar  modes  of  living. 

All  this  is  not  only  very  possible,  but  probable.  A  certain  number  of  peculiar 
substances  do  certainly  exist  in  the  blood  of  some  men  which  are  absent  from  the 
blood  of  others.  In  childhood  and  in  youth,  the  blood  of  the  same  individual  con- 
tains variable  quantities  of  substances  which  are  not  to  be  found  in  it  at  other  periods 
of  life. 

This  theory  of  Liebig's  ofl^ers,  then,  a  reasonable  explanation,  the  only  explanation, 
indeed,  that  1  have  ever  met  with — of  the  curious  facts,  that  certain  contagious  dis- 
orders furnish  a  protection,  temporary  or  permanent,  against  their  own  return  ;  that 
thej'  have  a  tolerably  definite  period  of  incubation,  and  run,  for  the  most  part,  a  de- 
terminate course  ;  that  some  persons  are  less  susceptible  than  others  of  the  influtuca 


934  THEORY    OF    CONTAGIOUS    FEVERS. 

of  these  animal  poisons,  or  not  susceptible  at  all ;  and  that  the  same  individual  may 
be  capable  of  taking  a  contagious  disease  at  one  time,  and  not  at  another. 

Moreover,  the  light  supplied  by  this  theory  gives  distinctness  to  our  conceptuns 
respecting  certain  deviations  from  the  regular  course  and  type  of  these  diseases ; 
which  deviations  are  not  uncommon. 

Thus  the  symptoms  which  precede  and  usher  in  the  eruption  are  sometimes  slow, 
halting,  and  irregular  in  their  progress  ;  appear,  and  then  recede,  and  reappear,  so 
that  we  are  in  doubt  what  is  about  to  happen,  until  at  length  the  disease  declares 
itself  in  its  decided  and  authentic  form. 

We  may  suppose  this  to  depend  upon  some  tardiness  or  interruption  of  the  pro- 
cess, whereby  the  virus  is  (to  use  the  ancient  term)  concocted. 

Again,  the  series  or  combination  of  sj'mptoms  that  marks  the  specific  disease  is 
sometimes,  as  I  stated  before,  incomplete.  We  have  the  eruption  of  measles  without 
the  catarrhal  symptoms  ;  the  sore  throat  without  the  rash  of  scarlet  fever.  And  expe- 
rience has  found  that,M'here  the  malady  is  thus  imperfectly  developed,  the  protection 
it  confers  against  its  own  recurrence  is  also  incomplete.  To  explain  this  double 
failure  we  may  reasonably  infer  a  corresponding  defect  in  the  series  of  changes  which 
the  poison  tends  to  produce  in  the  mass  of  the  blood. 

Glandular  enlargements  and  chronic  abscesses  are  frequent  sequelae  of  these  ex- 
anthematous  disorders.  They  may  be  considered  to  represent  the  dregs  of  the  repro- 
duced virus,  which  has  been  imperfectly  eUminated  from  the  system  by  the  usual 
channels. 

Such  is  a  brief  exposition  of  Liebig's  ingenious  theory.  Do  you  ask  whether  I 
adopt  it,  with  implicit  credence  in  its  truth  ?  I  answer,  "  By  no  means."  Respect- 
ing points  so  curious,  it  is  scarcely  possible  to  refrain  from  speculation  altogether. 
These  views  come  recommended  by  the  authority  of  a  consummate  chemist.  They 
furnish  a  plausible  explanation  of  the  main  facts  of  the  case  :  namely,  that  the  disease 
is  produced  by  an  animal  poison ;  that  the  specific  virus  increases  prodigiously  in 
quantity  within  the  body  during  the  progress  of  the  disease;  and  that  the  suscepti 
bihty  of  its  influence  in  that  individual,  is  thereby  somehow  exhausted.  I  entertain, 
the  theory,  therefore,  until  a  better  one  is  propounded.  It  has  this  incidental  merit, 
that  it  involves  no  risk  of  practical  error. 

The  subtle  contaminating  effluvia  which  proceed  from  the  bodies  of  the  sick  enter 
the  blood  of  those  who  catch  the  disorder,  chiefly,  I  imagine,  by  being  inhaled  into 
their  lungs  in  breathing.  The  poison  may,  perhaps,  be  capable  of  being  spontane- 
ously absorbed  through  the  skin :  and  upon  this  supposition  oil  has  been  smeared 
over  the  surface  with  the  view  of  shutting  out  the  contagion  of  the  plague.  The 
virus  may  gain  direct  entrance  into  the  blood  ;  we  know  that  it  sometimes  does  so, 
for  we  ourselves  insert  it,  in  inoculation  of  the  small-pox.  Dr.  Francis  Home  im- 
parted measles  by  engrafting  some  blood  of  a  person  ill  of  that  complaint ;  and  sub- 
sequent attempts  to  excite  the  disease  in  that  way  have  been  equally  successful. 
Some  rash  and  unfortunate  trials  have  proved  that  the  plague  is  communicable  by 
inoculation  with  matter  from  the  buboes. 

Endeavours  have  been  made  to  estimate  the  distance  to  which  the  influence  of 
different  contagious  emanations  extends.  The  effluvia  in  small-pox,  measles,  and 
scarlet  fever,  are  the  most  active ;  operate,  I  mean,  at  the  greatest  distance.  la 
continued  fever  they  have  a  less  range ;  and  in  the  plague  the  diameter  of  the  infec- 
tious circle  is  probably  very  small.  Some  have  even  supposed  that  the  plague  is 
communicable  only  by  actual  contact;  but  the  opposite  opinion  seems  the  more 
likely,  namely,  that  you  may  touch  plague  patients  with  impunity  (as  Bonaparte  is 
known  to  have  done  on  a  memorable  occasion)  if  you  avoid  inhaling  their  breath,  or 
the  effluvia  proceeding  from  their  bodies. 

The  most  important  practical  result  of  the  experiments  made  by  Dr.  Haygarth  and 
others,  for  determining  the  absolute  distances  to  which  the  power  of  the  contagion 
extends  in  different  disorders,  was,  that  where  ventilation  is  complete,  in  other  words, 
where  the  gaseous  poison  is  freely  diluted  with  atmospheric  air,  the  sphere  of  its 
operation  is  very  limited. 


I 


( 


CONTINUED    FEVER.  935 

It  is  an  interesting  subject  of  inquiry,  worth  glancing  at  for  a  moment,  how  far  the 
power  of  different  contagions  is  modified  by  differences  of  temperature.  Small-pox 
is  readily  propagated  either  in  hot  or  in  cold  regions  ;  in  Mexico  near  the  equator,  in 
Greenland  towards  the  pole.  The  plague  does  not  spread  when  the  temperature  is 
below  60°  or  above  90*^  Fahrenheit.  The  vaccine  matter  loses  its  property  of  pro- 
ducing the  cow-pox  if  it  be  exposed  for  a  certain  time  to  extreme  cold,  or  to  a  heat 
of  95°.  Typhus  fever,  measles,  and  scarlet  fever,  are  said  to  be  of  extremely  rare 
occurrence  in  the  intertropical  regions.  Dr.  Henry  has  turned  these  facts  to  useful 
account  by  proposing  to  decompose  and  destroy  certain  contagions  lurking  in  fomites, 
by  the  operation  of  artificial  heat. 

Having  thus  pointed  out  many  circumstances  of  interest,  which  are  common  to 
all,  or  nearly  all,  the  diseases  grouped  together  under  the  title  of  exanthemata,  I  may 
now  proceed  to  a  more  particular  account  of  those  diseases  in  succession.  And  I 
shall  begin  with  continued  fever ;  because,  although  it  does  not  afford  the  best- 
marked  example  of  the  collection  of  symptoms  that  compose  CuUen's  definition  of 
the  order,  yet  a  right  understanding  of  the  practical  points  concerned  in  the  manage- 
ment of  this  febrile  disease  will  assist  us  materially  towards  a  just  conception  of  the 
modifications  of  treatment  that  may  be  required  by  the  rest. 

We  hear  continuallj'-,  both  in  and  out  of  the  profession,  d,ifl"erent  species  of  fever 
spoken  of.  By  the  public,  typhus  fever,  brain  fever,  bilious,  putrid,  low,  nervous. 
And  systematic  writers  are  to  the  full  as  particular :  mucous  fever,  ataxic,  adynamic, 
gastro-enteric,  and  so  forth.  Now,  admitting  that  fever  shows  itself  under  various 
forms,  I  am  persuaded  that  the  effect  upon  the  mind  of  all  this  subdivision  is  bad 
and  hurtful.  It  encourages  a  disposition,  already  too  prevalent,  to  prescribe  for  a 
disease  according  to  its  name.  There  is  no  fine  of  genuine  distinction  between 
continued  fevers  that  can  be  rehed  on.  They  run  insensibly  into  each  other,  even 
the  most  dissimilar  of  them ;  and  are  traceable  often  to  the  same  contagion.  I 
shall  in  the  first  place,  therefore,  attempt  to  describe  this  disease  of  continued  fever 
as  it  occurs  in  its  most  ordinary  and  simple  form ;  and  then  point  out  its  principal 
varieties. 

Continued  fever  does  not  always  commence  in  the  same  way.  It  often  happens, 
that  for  several  days  before  the  disease  assumes  its  distinct  and  proper  aspect,  and 
before  the  patient  is  rendered  unable  to  pursue  his  usual  occupations,  he  is  affected 
with  certain  morbid  symptoms,  which  may  be  considered  premonitory  of  the  fever ; 
so  that  it  is  sometimes  difficult  to  mark  the  precise  beginning  of  the  disease.  These 
prehminary  symptoms  result  apparently  from  an  altered  condition  of  the  nervous 
system.  The  poison  in  the  blood  disturbs  the  functions  of  animal  life  before  it 
causes  any  palpable  derangement  in  the  mechanism  of  the  circulation.  The  expres- 
sion of  the  patient's  countenance  alters ;  he  becomes  pale,  languid,  and  abstracted. 
Those  about  him  observe  that  he  is  looking  very  ill.  He  is  feeble,  and  easily  tired; 
reluctant  to  make  any  exertion  of  mind  or  body  ;  listless,  and  apprehensive  often  of 
some  impending  evil.  He  loses  his  appetite  ;  his  tongue  becomes  white  and  inclined 
to  tremble ;  the  bowels  are  irregular,  often  confined,  sometimes  affected  with  diar- 
rhcEa ;  his  senses  lose  their  natural  delicacy.  He  has  uneasiness  or  wandering  pains 
in  various  pariS  of  the  body  ;  and  occasionally  there  is  some  giddiness :  drowsiness, 
perhaps,  during  the  day,  and  unsound  and  unrefreshing  sleep  at  night.  To  collect 
all  this  into  one  expressive  word,  the  patient  evidently  droops. 

In  other  cases  these  preliminary  movements  are  altogether  wanting.  Chome 
gives  the  following  comparative  account,  deduced  from  the  exact  observation  of  1 12 
patients  in  this  particular.  In  73  of  these  cases  the  invasion  of  the  disease  was  sud- 
den, without  any  warning,  in  the  midst  of  apparent  good  health.  In  39  there  were 
prelusive  circumstances. 

The  regular  onset  of  the  fever  is,  very  frequently  indeed,  marked  by  a  shivering 
fit.  Another  common  phenomenon  at  the  period  of  the  invasion  is  severe  headache: 
pain  or  aching  across  the  forehead.  According  to  Chomel,  the  headache  is  usually 
first  experienced  by  the  patient  when  he  gets  up  in  the  morning.  But  this  certainly 
is  not  a  constant  symptom.     There  is  sometimes  a  sense  of  heaviness  and  vertigo 


936  CONTINUED    FEVER. 

rather  than  headache.  Another  symptom  which  sometimes,  but  not  so  often,  sets  in 
with  the  fever,  is  diarrhoea;  and  this  is  an  important  circumbtance  when  it  does 
occur.  It  is  attended,  perhaps,  with  pain  or  uneasiness  in  the  abdomen.  You  will 
also  perceive,  even  when  there  have  been  no  premonitory  circumstances,  that  symp- 
toms arise,  even  thus  early,  which  belong  to  the  nervous  system,  and  denote  some 
disturbance  and  alteration  in  the  functions  of  sensation,  thought,  and  voluntary  mo- 
tion. They  are  comprised  under  the  general  phrase,  '■'■febrile  oppression"  and  they 
are  different  from  what  we  notice  when  pyrexia  supervenes  upon  inflammation. 
You  will  obtain  a  clearer  notion  of  what  this  term,  febrile  oppression,  means,  by 
watching  at  the  bedside  of  one  patient  in  this  disease,  than  by  any  description  T  can 
give  you.  There  is  great  inaptitude  for  exertion  of  the  power  of  thought,  or  of  mo- 
tion. The  expression  of  the  face  is  dull  and  heavy,  absent,  puzzled.  The  patient 
presents  very  much  the  appearance  of  a  person  made  stupid  by  drink ;  and  he  stag- 
gers a  little  if  he  attempts  to  walk.  The  muscular  power  is  sensibly  enfeebled: 
sometimes  the  patient  will  struggle  against  this  ;  but  in  a  few  hours,  or  in  a  day  or 
two  at  furthest,  he  takes  to  his  bed. 

These  are  the  symptoms  which  mark  the  outset  of  the  disease  we  are  about  to 
consider.  They  occur  sometimes  in  other  disorders  of  the  class  in  which  I  have 
placed  continued  fever.  In  the  plague,  for  example.  The  patients  appear  hke  people 
who  are  drunk.  Now  these  symptoms  result,  no  doubt,  from  changes  which  are 
going  on  in  the  blood,  and  which  make  an  earl}'  and  a  strong  impression  upon  the 
nervous  system.  And  there  is  another  circumstance  which,  when  it  is  observable, 
denotes  a  depressed  state  of  the  nervous  power.  Practitioners  sometimes  are  in 
doubt  whether  the  case  may  not  be  one  of  some  visceral  inflammation :  or,  perhaps, 
knowing  it  to  be  continued  fever,  they  still  think  it  expedient  to  bleed  the  patient. 
Now  faintness  or  actual  syncope  is  much  more  easily  produced  by  the  abstraction 
of  blood,  in  continued  fever,  than  it  is  in  inflammation:  and  this  fact  may  occasion- 
ally be  the  means  of  distinguishing  between  incipient  continued  fever,  attended,  for 
instance,  with  catarrhal  sj'^mptoms,  and  pure  incipient  pneumonia. 

In  order  the  more  clearly  to  describe  the  course  of  continued  fever,  I  shall  divide 
it,  as  others  have  done,  into  periods ;  weekly  periods.  Not  that  there  is  any  such 
period  of  seven  days  allotted  to  particular  symptoms  ;  but  that  in  the  simplest  forms 
of  the  disease,  when  it  runs  its  course  most  evenly  and  favourably,  and  therefore,  we 
may  suppose,  the  most  regularly  also,  there  is  a  succession  of  different  sets  of  symp- 
toms, which  occupy  each  about  that  space  of  time ;  nearly  enough  to  allow  of  my 
taking  it,  I  say,  as  a  help  to  the  better  describing  the  disease. 

Many  of  the  symptoms  which  occur  during  the  first  stage  of  the  disorder — during 
the  first  week,  we  will  say  —  are  such  as  belong  to  the  sanguiferous  system.  The 
pulse  becomes  more  frequent  than  in  health,  there  is  increased  heat  of  skin,  and 
thirst ;  headache,  and  throbbing  of  the  temples.  The  pulse  varies  considerably  in 
different  cases.  Generally,  I  say,  its  frequency  augments ;  but  sometimes  it  is  even 
slower  than  natural.  The  acceleration  of  the  pulse  is  greatest  [cxteris  paribus)  in 
those  constitutions  which  are  the  most  irritable.  In  young  persons,  in  females,  and 
in  weak  or  delicate  males,  it  will  often  rise,  soon,  to  120:  while  in  stronger  adults, 
it  does  not  so  early  attain  its  maximum  of  frequency,  and  perhaps  does  not  exceed 
100  throughout  the  whole  course  of  the  disease.  Should  the  pulse  in  any  instance 
reach  130  or  140,  the  disease  is  severe  :  and  the  majority  of  such  patients  die.  The 
absolute  frequency  of  the  pulse  is  not,  however,  of  so  much  importance  in  this  dis- 
order, as  its  steadiness.  If  it  shifts  from  one  number  to  another,  that  affords  a  worse 
prognostic  even  than  its  being  very  frequent ;  provided  it  keeps  at  the  same  standard. 
The  skin,  during  this  period,  is  generally  hot  and  dry,  and  it  feels  to  a  b3'stander 
very  hot  and  pungent.  The  actual  heat,  however,  is  not  so  great  as  the  sensation 
given  to  the  hand  might  persuade  us  it  was.  Dr.  Bateman  found  that,  in  a  m.-ijority 
of  the  ciises  treated  by  him,  the  heat,  as  ascertained  bj^  the  thermometer,  was  about 
t00°  ;  and  he  never  observed  it  higher  than  104°.  The  thirst  is  usually  troublesome 
for  the  first  few  days.  The  tongue  becomes  clammy  or  dry ;  sometimes  it  is  clean 
ana  smooth  ;  more  often  furred ;  its  edges  and  tip  will,  perhaps,  be  red,  then  a  white 
lur  will  begin,  which  euher  covers  the  central  part  of  the  tongue,  or  is  divided  by  a 


SYMPTOMS.  937 

straight  brown  streak  which  occupies  its  middle  portion.  This  brown  streak  is  often 
the  first  step  to  dryness  and  blackness  of  the  tongue. 

During  the  same  period  a  careful  examination  of  the  abdomen  will  detect  indica- 
tions of  diseased  action  there.  Sometimes  diarrhoea  is  an  early  symptom  ;  generally 
it  is  postponed,  I  think,  to  the  next  period  ;  or  to  the  latter  part  of  the  first.  When 
it  does  occur,  the  stools  are,  for  the  most  part,  loose  and  frequent;  and  either  of  a 
dark  colour,  and  fetid,  or  of  a  yellow-ochre  appearance,  like  pea-soup  somewhat. 
If  you  make  pressure  upon  the  abdomen,  you  will  find  it  unnaturally  hard  and  re- 
sisting, as  though  its  walls  were  made  of  pasteboard ;  slightly  tympanitic,  as  you 
learn  by  making  percussion.  Frequently,  uneasiness  is  manifested  when  pressure 
is  made  on  the  belly,  particularly  over  the  csecal  region ;  and  Chomel  remarks  that 
another  symptom,  not  commonly  met  with  in  other  diseases,  is  usually  noticeable  in 
the  first  stage  of  this,  viz.,  a  little  gurgling  movement,  evidently  from  the  intermix- 
ture of  liquid  and  gas  within  the  bowel,  which  movement  becomes  audible,  or  pal- 
pable to  the  hand,  upon  pressing  the  same  region.  This  symptom  is  still  more 
common  in  the  more  advanced  stages  of  the  disorder. 

There  is  evidence,  frequently,  of  a  slight  affection  in  the  membrane  lining  the 
air-passages,  from  nearly  the  first :  some  notable  quickness  of  respiration,  and  some 
diffused  rhonchus  and  sibilus,  audible  through  the  stethoscope.  ^ 

And  among  all  the  indications  of  increased  action  in  the  circulating  system,  the 
symptoms  that  relate  to  the  nervous  centres  remain  perceptible.  The  aspect  of  the 
patient  is  peculiar :  the  features  are  fixed  and  inexpressive ;  or  expressive  merely 
of  apathy  and  indifference.  If  he  is  spoken  to  briskly,  he  responds  ;  and  although 
his  sensibility  seems  blunted,  his  answers  are,  as  yet,  rational,  and  to  the  purpose. 
Delirium  does  not  come  on,  in  general,  till  towards  the  end  of  the  first  week.  The 
muscular  power  is  greatly  depressed.  The  patient  lies  on  his  back,  motionless ;  he 
sleeps  but  little,  waking  often ;  and  the  short  snatches  of  repose  which  he  seems  to 
get,  are  disturbed,  apparently,  by  uneasy  dreams :  and  he  fancies,  and  says  perhaps, 
that  he  does  not  sleep  at  all.  Sometimes,  even  during  the  first  stage  of  the  disorder, 
when  the  bowels  are  relaxed,  the  prostration  of  strength  is  so  great,  or  the  tendency 
to  stupor  and  indifference  is  so  marked,  that  the  stools  are  passed  under  him  as  he 
hes  in  bed,  without  any  apparent  endeavour  on  the  part  of  the  patient  to  prevent  it ; 
and  without  any  notice  of  his  wants  being  made  to  his  nurse.  The  urine,  during 
the  same  stage,  is  scanty,  and  high-coloured,  and  ill-smelling  often.  Towards  the 
very  end  of  the  first  weekly  period,  the  eruption  which  is  peculiar  to  continued  fever 
sometimes  begins  to  show  itself:  but  this  is  commonly  postponed  to  the  next  stage ; 
and  I  shall  describe  it  in  connection  with  the  other  symptoms  that  are  apt  to  occur 
in  the  second  week  of  the  disorder. 

It  is  seldom,  except  in  very  mahgnant  forms  of  continued  fever,  that  death  takes 
place  during  its  primary  stages.  Of  forty-two  cases  treated  by  Chomel,  one  alone 
was  fatal  in  that  period. 


LECTURE  LXXXIV. 

Continued  fever,  continued.     Phenomena  of  the  second  week ;  Delirium,  an  Erup 
tion,  Diarrhcea:  of  the  third  week;  Recovery,  or  death  in  the  way  of  Coma, 
of  Jipnoea,  of  Jlsthenia.     Symptoms  that  usher  in  those  anodes  of  death  ;  morbid 
changes  found  after  them. 

In  the  last  lecture  I  commenced  the  consideration  of  that  important  disease,  which 
IS  best  known,  in  this  country,  under  the  name  of  continued  fever.  I  told  you  my 
opinion  that  there  is  but  one  species,  although  there  are  many  varieties,  of  continued 
fever.  Sometimes  this  disease  is  preceded  by  symptoms  of  a  shghter  disturbance 
of  the  system ;  and  sometimes  it  sets  in  suddenly,  in  the  midst  of  apparent  health 

4d 


938  CONTINUED    FEVER. 

Whatever  premonitory  symptoms  may  take  place,  they  indicate  some  alteration  in 
the  functions  of  the  nervous  system,  upon  tvhich  many  pathologists  have  supposed 
that  the  first  and  most  direct  impression  is  made,  by  the  exciting  cause  of  the  fever. 
But  the  exciting  cause,  in  most  cases,  probably  in  all,  is  a  specific  poison  received 
into  the  blood :  and  all  analogy  is  in  favour  of  the  belief  that  the  primary  change  is 
wrought  upon  the  blood  itself.  The  whole  mass  of  the  blood  is  gradually  vitiated ; 
and  the  first  evidence  of  the  circulation  of  this  altered  fluid,  is  depression  of  the 
powers  and  functions  of  animal  hfe.  Among  the  earlier  symptoms  of  the  declared 
disease,  shivering,  headache,  and  occasionally  diarrhcea,  take  the  lead. 

For  the  convenience  of  description  I  divided  the  course  of  the  disorder  into  three 
weekly  stages :  not  that  it  necessarily  runs  its  course  in  three  weeks,  but  because 
the  sets  of  symptoms  which  succeed  each  other  while  the  disease  is  in  progress, 
occupy,  in  the  cases  which  seem  to  proceed  the  most  regularly,  about  the  space  of 
seven  days  each. 

Now  the  symptoms  present  during  the  first  week  are  expressive  of  disorder  both 
of  the  sanguiferous  and  of  the  nervous  system.  The  patient  is  hot,  flushed  perhaps, 
and  thirsty,  and  he  has  a  frequent  and  hard  pulse.  Besides  this  he  manifests  in- 
difference and  stupor  ;  his  senses  are  blunted ;  his  intelligence  is  diminished.  His 
muscular  strength  is  reduced  in  a  remarkable  manner ;  so  that  he  cannot  sit  up  ;  in 
many  cases  he  cannot  even  lie  on  his  side,  or  turn  himself  about  well  in  bed,  but 
remains  in  the  supine  position :  and  if  he  be  purged  by  medicine,  or  spontaneously, 
the  stools  are  apt  to  pass  from  him  into  the  bed,  without  his  knowing  it,  or  without 
his  taking  any  cave  to  prevent  it.  This,  however,  is  more  common,  and  more 
marked,  in  the  second  period  or  week ;  the  phenomena  of  which  I  next  go  on  to 
sketch. 

In  the  first  place,  in  mild  cases,  and  in  some  epidemics,  the  patients  begin  to 
improve  soon  after  the  first  week.  Dr.  Welsh,  in  his  account  of  fever  as  it  occurred 
some  years  since  in  the  Q,ueensbury-House  Establishment  in  Edinburgh,  says  that 
of  743  patients,  373  (that  is  fully  one-half)  had  passed  the  worst,  or  had  begun  to 
get  belter,  by  the  ninth  day ;  and  several  of  the  physicians  who  witnessed  the  fever 
that  prevailed  in  Ireland  in  the  earlier  part  of  the  present  century,  concur  in  declaring 
that,  in  a  vast  majority  of  cases,  the  disease  had  "  taken  the  turn,"  and  the  patient 
began  to  mend,  by  that  time.  But  the  epidemics,  in  these  cases,  were  undoubtedly 
mild.  In  general  no  change  for  the  better  takes  place  at  the  end  of  the  first  seven 
or  eight  days ;  but  what  are  called  the  typhoid  symptoms  develop  themselves  more 
distinctly. 

The  changes  that  occur  are  usually  the  following :  —  The  pulse  becomes  more 
frequent,  weaker,  and  more  compressible.  The  tongue  grows  drier  and  browner. 
More  sordes,  and  of  a  darker  colour,  accumulate  on  the  teeth  and  lips :  and  it  is  in 
this  period  that  delirium  is  most  apt  to  ensue ;  and  that  certain  eruptions  are  most 
often  observed.  But  the  symptoms  that  relate  to  the  nervous  system  are  often  still 
the  most  prominent.  The  patient  generally  loses  his  headache.  His  voluntary 
movements,  however,  become  very  much  weakened,  and  are  sometimes  exercised 
irregularly.  The  posture  which  the  patient  in  this  stage  almost  always  assumes  is, 
I  say,  indicative  of  this  weakness ;  he  lies  on  his  back,  and  he  sinks  down  in  the 
bed,  slips  towards  the  foot  of  the  bed.  He  is  unable  to  make  or  bear  that  degree  of 
voluntary  exertion  which  would  be  necessary  to  place  him  upon  his  side.  Hence 
we  hail  it  as  a  good  omen  —  because  it  is  an  indication  that  the  patient  still  retains 
some  strength — if  we  find  him  on  his  side,  or  even  on  his  back  with  his  knees  drawn 
up.  Other  proofs  of  muscular  debility,  approaching  to  palsy,  are  apt  to  present 
themselves.  The  voice  becomes  feeble ;  the  patient  can  scarcely  utter  an  audible 
fcound.  Perhaps  he  is  unable  to  swallow.  This  is  a  very  bad  symptom,  though  it 
is  one  that  has  been  recovered  from.  Sometimes  it  seems  that  the  power  of  degluti- 
tion is  not  lost,  but  the  sick  man  is  too  listless  to  try  to  swallow ;  or  the  dry  and 
parched  stale  of  his  tongue  and  throat  renders  it  difficult  and  painful  for  him  to 
attempt  to  do  so.  The  patient  is  apt  to  lie  with  his  mouth  open :  and  breathing 
thus  through  the  mouth  tends  to  dry  the  tongue.  Hence  it  is  well  to  desire  the  sick 
per  on  to  swallow  a  mouthful  or  two  of  water,  and  so  to  moisten  his  tongue,  before 


SYMPTOMS.  939 

you  decide  upon  the  state  of  that  organ,  or  upon  his  facility  of  deglutition.  Often, 
m  bad  cases  especially,  there  are  little  convulsive  startings  of  the  tendons,  {siibsultiis 
tendinum  is  the  technical  name  of  the  symptom,)  and  other  irregular  and  involuntary 
actions  of  the  muscles :  tremulous  movements,  especially  of  the  tongue  and  of  the 
hands  ;  and  sometimes  the  patient  is  unable  to  put  out  his  tongue  at  all.  There  are 
two  symptoms  which  present  themselves  in  the  majority  of  instances  in  the  second 
vi^eek  of  the  fever,  and  which  deserve  your  particular  attention:  I  mean  delirium, 
and  the  eruption  which  belongs  to  the  disease. 

The  delirium  is  peculiar.  The  patient  wanders,  at  first,  in  the  night  only  ;  and 
the  deliriurti  commonly  appears  on  his  awaking  from  disturbed  sleep.  Sometimes 
ne  is  desirous  of  getting  up,  and  talks  incessantly  and  earnestly  in  a  loud  voice,  and 
can  only  be  kept  in  bed  by  the  imposition  of  some  restraint.  Usually,  however,  his 
rambling  is  of  a  tranquil  kind,  and  without  agitation.  His  nrind  seems  elsewhere : 
he  is  inattentive  to  all  that  passes  around  him ;  but  he  lies  still,  muttering  disjointed 
words  or  sentences,  like  a  man  talking  in  his  dreams.  From  this  state  of  typho' 
mania  the  patient  may  sometimes  be  roused  by  loud  speaking  addressed  to  him,  or 
by  the  sight  of  a  strange  face  ;  so  that,  though  incoherent  and  dehrious  just  before, 
he  may  become  collected  when  his  medical  attendant  enters  the  room.  But  he 
presently  relapses.  During  the  delirious  state  there  is  a  great  deficiency  of  sensa- 
tion, and  insensibihty  to  impressions.  The  patient  is  deaf.  This  deafness  you  may 
hear  spoken  of  as  being  a  good  omen,  or  favourable  sign  ;  but  it  is  so  only  by  com- 
parison :  it  indicates  a  condition  of  brain  less  perilous  than  its  opposite,  in  which  the 
sense  of  hearing  is  morbidly  acute.  Imperfection  or  loss  of  vision  is  much  rarer, 
and  much  more  dangerous,  than  deafness ;  yet  the  eye  is  generally  dull — unlike  the 
brilliant  eye  of  acute  phrenilis ;  it  corresponds  with  the  expression  of  the  counte- 
nance, which  is  perplexed  rather  than  wild.  Sometimes,  however,  as  the  disease 
advances,  black  spots,  like  flies  on  the  wing,  muscse  voUtantes,  appear  before  the 
patient's  eyes :  in  consequence,  it  is  presumed,  of  partial  insensibility  of  the  retina. 
The  patient  attempts  to  grasp  or  catch  these  in  the  air,  or  to  pick  them  from  the  bed 
clothes.  This  is  Q.a\\eA./loccifatio.  After  these  symptoms  recovery  is  not  common. 
The  mouth  and  tongue  are  dry  ;  yet  the  patient  no  longer  complains  of  thirst.  The 
taste,  the  smell,  the  sense  of  touch,  are  all  impaired  ;  even  external  inflammation  may 
take  place,  especially  about  the  hips  and  sacrum,  and  go  on  to  gangrene,  without  any 
complaint  of  pain  from  the  patient.  He  seems  altogether  careless  about  the  issue  of 
his  disorder.  If,  at  this  period  of  the  fever,  you  ask  him  how  he  does,  he  will  pro- 
bably declare  that  he  is  quite  well.  I  hive  already  alluded  to  the  involuntary 
passage  of  the  feces  :  this  may  depend,  in  }>art,  especially  in  the  advanced  stage  of 
the  disorder,  upon  debility  or  paralysis  of  the  sphincter  muscles.  The  urine  also 
dribbles  away  frequently:  and  these  are  points  which  must  always  be  looked  after; 
first,  for  the  sake  of  keeping  the  patient  as  clean  and  dry  as  possible,  the  irritation  of 
the  urine  and  fecal  matters  tending  to  produce  sloughing  ulceration;  and,  secondly, 
with  the  view  of  preventing  the  bladder  from  becoming  unduly  distended.  Reten- 
tion of  urine,  and  all  its  bad  consequences,  may  otherwise  occur.  It  is  a  good  general 
rule,  therefore,  to  examine  the  hypogastric  region  every  day  with  the  hand  ;  and  also 
to  ask  to  see  the  urine,  not  for  any  purposes  of  prognosis,  but  to  ascertain  that  it  is 
regularly  discharged.  ^  -■ 

It  is  also,  I  repeat,  in  this  stage  of  the  disorder  that  the  rash  or  eruption,  which  so 
often  accompanies  it,  very  frequently  shows  itself.  Sometimes  it  is  noticed  earlier. 
It  consists  of  small  rosy  blotches,  of  a  roundish  or  lenticular  shape ;  scarcely  raised, 
if  raised  at  all,  above  the  general  surface  of  the  skin  on  which  they  appear.  Ohomel 
states  that  they  vanish  under  pressure ;  but  it  is  not  so.  I  have  again  and  again  ob- 
served that  they  diminish  or  become  fainter  under  the  pressure  of  the  finger ;  but 
they  are  not  effaced  even  for  an  instant.  They  are  sometimes  few ;  sometimes  so 
numerous  as  to  dapple  the  whole  surface  of  the  abdomen,  or  of  the  thorax,  or  of  both. 
Upon  the  limbs  they  are  less  common,  and  less  closely  set.  I  believe  that  they  often 
besprinkle  the  back,  although  they  are  seldom  looked  for  there.  They  vary  in 
intensity  of  colour,  and,  therefore,  in  distinctness.     The  whiter  the  skin,  the  mofH 


940  CONTINUED   FEVER. 

obvious  do  the  spots  become.     In  brunettes  they  may  easily  escape  notice.     In  this 
form  of  disease  the  entire  skin  is  often  unnaturally  duskjr,  • 

The  eruption  does  not  come  out  all  at  once  :  nor  is  its  duration  always  the  same. 
Sometimes  it  disappears  entirely  after  two  or  three  days.  Sometimes,  on  the  other 
liand,  it  lasts  a  fortnight,  or  more.  In  the  latter  case  it  is  probable  that  successive 
crops  of  the  spots  continue  to  arise. 

The  rash  now  described  stamps  continued  fever  with  one  of  the  most  striking 
characters  of  the  exanlhematous  group  of  febrile  diseases :  but  it  certainly  is  less 
constant  than  the  cutaneous  phenomena  of  small-pox,  measles,  or  scarlet  fever.  It 
occurs  much  more  regularly  in  some  epidemics  than  in  others.  Fever  is  very  rife  in 
St.  Giles's,  and  in  other  crowded  parts  of  this  town,  just  now  (1838).  Our  wards  at 
the  Middlesex  are  full  of  it;  and  scarcely  a  case  presents  itself  without  these  spots. 
We  speak  of  it  familiarly  as  the  spotted  fever ;  or,  (from  the  resemblance  which  the 
rash  bears  to  that  of  measles,  hereafter  to  be  described)  as  the  rubeoloid  fever. 

You  cannot  well  confound  this  mottled  rash  with  petechise,  which  are  little  specks, 
or  dark  circular  spots,  resulting  from  a  minute  extravasation  of  blood  beneath  the 
cuticle.  The  specific  rash  and  these  petechiae  are,  however,  sometimes  mingled 
together. 

It  may  not  be  superfluous  to  caution  you  against  mistaking  Jlea-hites,  which  are 
common  to  nearly  all  our  hospital  patients,  for  this  specific  eruption,  which  is  pecu- 
liar to  the  fever  patients.  The  round  red  stain,  with  a  dark  point  for  its  centre, 
sufficiently  distinguishes  the  mark  of  the  insect  from  the  rose-coloured  blotches  of 
the  disease- 
There  is  another  eruption  described  by  the  French  as  occurring  in  this  disease 
without  being  peculiar  to  it.  In  this  country  it  is  now  very  rare  ;  but  it  used,  whea 
the  hot  plan  of  treatment  was  in  vogue,  to  be  very  common  indeed  here,  in  various 
febrile  complaints  ;  and  it  was,  and  is,  occasioned  by  profuse  sweating.  Sudariiina, 
the  vesicles  composing  the  eruption  are  called.  They  are  small,  hemispherical, 
transparent  elevations  of  the  cuticle,  containing  a  clear  watery  fluid.  The  vesicles 
are  frdm  a  quarter  of  a  line  to  half  a  Hne  in  diameter ;  they  have  no  red  bases ;  and 
they  are  so  perfectly  pellucid,  that  when  you  look  upon  them  in  a  direction  perpen- 
dicular to  the  skin  on  which  they  stand,  they  may  readily  elude  observation.  Viewed 
sideways,  they  present  bright  surfaces,  and  look  like  so  many  drops  of  w^ater,  and 
you  may  feel  with  your  hand  that  they  roughen  that  part  affected  with  them.  These 
sudamina  are  mostly  met  with  on  the  thorax,  along  the  sides  of  the  neck,  and  about 
the  axillee.  By  degrees,  the  limpid  fluid  disappears,  and  they  shrivel  up  ;  the  cuticle 
becomes  wrinkled,  and  dries  into  a  whitish  powder. 

Diurrhcca  is  another  marked  symptom  observed  in  many  cases  of  continued  fever, 
though  not  in  all,  at  this  period  of  the  disease.  When  the  stools  are  involuntary, 
when  they  are  passed  in  bed  without  notice  on  the  part  of  the  patient,  they  add  ma- 
terially to  his  danger,  by  the  irritation  and  the  sores,  which  are  liable  to  result  from 
their  contact  with  the  skin.  There  is  seldom  much  pain  of  the  abdomen  complained 
of  by  the  patient ;  but  if  you  make  pressure,  especially  about  the  situation  of  the 
cscum,  you  may  often  remark  that  he  winces,  or  that  a  transient  expression  of  suf- 
fering passes  across  his  features.  The  character  of  the  evacuation  remains  the  same, 
and  is  almost  distinctive  of  the  disease  :  thin,  yellowish,  ochrey,  like  pea-soup. 
When  in  fever,  such  stools  persist  day  after  day,  and  several  of  them  every  day, 
you  may  safely  infer  that  there  is  ulceration  of  the  bowels,  although  there  should  be 
no  pain  complained  of,  even  when  the  abdomen  is  pressed. 

And  the  same  conclusion  will  become  still  more  certain  when  hemorrhage  from 
the  bowels  occurs,  as  it  is  apt  to  do,  in  this  stage  of  the  fever.  It  often  takes  place 
unexpectedly,  sometimes  in  considerable  quantities,  and  rapidly  exhausts  the  patient: 
or  it  recurs  at  intervals  to  a  smaller  amount,  wasting  his  strength  as  efl^ectually, 
thougn  more  slowly.  The  bleeding  is  probably  owing,  in  general,  to  the  division  or 
opening  of  some  of  the  mesenteric  veins,  by  the  ulcerating  process  which  I  shall 
more  fully  describe  by  and  by.  This  is  not,  however,  a  necessary  consequence  of 
the  ulceration ;  for  the  vessels  are  usually  obliterated  previously  to  their  erosion. 
Boraetimes  blood  may  be  thus  poured  into  the  bowel  without  being  voided.    Andral 


SYMPTOMS.  941 

relates  a  case  in  which  a  raan  died  suddenly,  and  unexpectedly,  at  an  advanced 
period  of  continued  fever.  Large  clots  of  black  blood  filled  the  lower  two-thirds  of 
the  small  intestines,  which  were  crowded  with  patches  of  ulceration.  No  part  of 
the  blood  had  passed  the  valve  of  the  csecum. 

Hemorrhage  from  the  bowels  occurs  also  in  continued  fever  sometimes  in  another 
way ;  in  connection  with  other  putrid  symptoms,  as  they  are  not  unaptly  called : 
petechicB,  purple  spots,  bruise-like  blotches,  and  extreme  depression  of  the  vital 
powers.  In  these  cases  the  hemorrhage  is  strictly  of  the  passive  kind,  and  it  is  a 
symptom  of  the  worst  omen.  Like  those  effusions  of  blood  from  the  same  parts  that 
happen  in  scurvy  and  purpura,  it  depends  upon  a  morbid  condition  of  the  blood. 
This  is  no  matter  of  speculation,  for  by  this  time  the  sensible  qualities  of  the  blood 
are  manifestly  changed :  its  natural  tendency  to  coagulate  when  withdrawn  from  the 
body  is  diminished,  the  crassamentum  is  large  and  loose,  and  fills  the  cup,  and  some- 
times is  rather  an  incoherent  sediment  than  a  clot.  When  these  putrid  symptoms 
are  strongly  marked,  a  pecuhar  fetor  is  exhaled  by  the  patient's  body ;  his  tongue 
becomes  dry,  black,  and  fissured ;  his  teeth  are  covered  with  dark  sordes  ;  sloughs 
form  from  the  mere  pressure  of  the  bed  on  which  he  lies ;  in  extreme  cases  the  toes 
have  mortified ;  and  Dr.  Roupell  relates  one  terrible  instance  in  which  both  legs  rot- 
ted away  to  the  bones,  which  it  became  necessary  to  saw  through :  yet  this  patient 
recovered. 

Death  may  take  place  in  this,  the  second  period  of  continued  fever.  Of  forty-two 
patients  who  died  under  his  care,  Chomel  counted  nine  in  which  the  fatal  event 
occurred  between  the  eighth  and  the  fifteenth  days. 

The  phenomena  belonging  to  the  third  period  of  the  fever  vary  considerably 
according  as  the  disease  is  about  to  terminate  in  death,  or  in  recovery.  Among 
Chomel's  forty-two  fatal  cases,  I  have  already  mentioned  that  one  death  took  place 
in  the  first  week,  and  nine  in  the  second ;  the  remaining  thirty-two  all  occurred  in 
the  third  period.  And  the  tendency  of  the  fever  to  terminate  during  this  period  is 
equally  well-marked  in  the  cases  which  recovered.  Of  twenty-four  such  patients 
one  alone  began  to  be  convalescent  in  the  first  week  ;  and  of  those  whose  symptoms 
were  at  all  serious,  not  one  showed  marks  of  convalescence  before  the  end  of  the 
second. 

When  the  disorder  is  about  to  end  favourably,  the  more  formidable  of  the  symp- 
toms diminish  and  abate.  The  patient  begins  again  to  attend  to  questions  that  are 
put  to  him ;  the  air  of  stupor  which  had  hung  over  his  countenance  clears  away ; 
he  once  more  shows  an  interest  in  what  is  going  on  around  him ;  the  temperature 
of  his  skin  becomes  more  natural,  the  tongue  moist  and  cleaner  at  its  edges,  and  the 
frequency  of  the  pulse  is  Jess.  The  evacuations  from  the  bowels  are  less  numerous, 
more  consistent,  and  more  healthy ;  and  the  patient  is  aware  when  the  necessity  for 
passing  them  arrives,  and  he  gives  notice,  or  asks  for  assistance.  Generally,  at  the 
same  time  with  these  tokens  of  improvement,  the  emaciation  which  has  taken  place 
becomes  remarkably  conspicuous ;  perhaps  it  is  the  more  observable  on  account  of 
the  patient's  resuming  a  more  natural  expression  of  countenance. 

In  many  instances,  the  amendment  is  so  gradual  that  we  can  scarcely  say  when 
it  begins.  In  other  cases  the  favourable  crisis  is  preceded  by  an  aggravation  of 
most  of  the  former  symptoms,  and  a  marked  increase  of  the  general  distress.  This 
is  a  very  curious  circumstance ;  and  it  did  not  escape  the  notice  of  our  great  dra- 
matist. 

Before  the  curing  of  a  strong  disease, 
Even  in  the  instant  of  repair  and  health, 
The  fit  is  strongest.     Evils  that  take  leave, 
In  their  departure  most  of  all  show  evil. 

Certain  evacuations  are  also  sometimes  observed  to  accompany  or  to  be  connected 
with  the  favourable  change ;  and  the  most  common  of  those  is  the  evacuation  of 
sweating. 

On  the  other  hand,  when  the  disease  is  about  to  terminate  in  death,  that  event  may 
take  place  in  different  ways  ;  in  either  of  those  modes,  in  short,  which  I  took  some 
pains  to  distinguish  in  the  earlier  part  of  this  course  of  lectures.     I  told  you  then  thai 

4d3 


942  CONTINUED   FEVER. 

I  had  been  taught  the  importance  of  studying  the  tendency  to  this  or  that  mode  of 
dying,  in  reference  especially  to  fever,  by  Dr.  Alison.  My  own  experience  has 
since  sufficiently  approved  to  me  the  wisdom  of  his  teaching.  CuUen  inculcates  the 
necessity  of  "obviating  the  tendency  to  death."  To  do  so,  we  must  ascertain  the 
direction  of  that  tendenx:y.  We  do  not  so  much  cure  these  exanthematous  maladies, 
as  keep  our  patients  alive  while  they  recover.  If  we  would  prevent  their  dying  we 
must  know  in  what  manner  they  are  in  danger  of  dying. 

The  most  common  mode  of  death  in  continued  fever  is  certainly  that  of  coma. 
The  organic  life  survives  the  animal  life.  The  muttering,  half-conscious,  dream-like 
stupor,  from  which  the  patient  may  be  roused  for  a  while,  becomes,  by  degrees, 
more  profound,  and  death  begins  in  the  head.  This  mode  of  death,  occurring  in  the 
second  or  third  week  of  the  fever,  is  associated,  frequently,  with  the  symptoms  of 
putrescency  already  described.  But  as  the  stupor  deepens,  the  pulse  generally 
grows  weak,  and  the  extremities  become  cold.  So  that  death  does  not  come  purely 
in  the  way  of  coma ;  but  we  have  a  compound  of  coma  and  asthenia,  in  which  the 
coma  takes  the  lead. 

Now  coma  may  result  from  at  least  two  different  kinds  of  cause.  One  cause  is 
pressure,  which  is  mechanical.  Another,  which  is  probably  chemical,  is  the  circu- 
lation of  some  noxious  or  narcotic  substance  (such  as  opium)  in  the  blood.  And 
there  are,  doubtless,  many  physical  conditions  of  the  nervous  mass  itself  which  are 
capable  of  arresting  the  cerebral  functions,  and  producing  coma.  To  which  kind  of 
cause  are  we  to  ascribe  the  stupor  that  supervenes  during  the  progress  of  fever  ? 
That  is  an  interesting,  and  in  reference  to  practice,  an  important,  question. 

Physicians  have  diligently  attempted  its  solution,  by  examining  the  dead  brain. 
I  cannot  tell  you  how  often  I  have  looked,  and  looked  in  vain,  for  some  palpable  dis- 
organization, or  some  effusion  implying  pressure.  All  who  are  familiar  with  the 
dead-house  of  a  hospital  are  aware  that  this  fruitless  search  for  some  physical  expla- 
nation of  the  comatose  state,  after  death  by  fever,  is  of  very  common  occurrence. 

Chomel — one  of  the  latest,  and  a  very  able  and  accurate  French  writer  on  fever — 
gives  the  following  statement  in  respect  to  38  fatal  cases,  in  which  the  brain  was 
carefully  and  minutely  inspected  by  him.  In  15  of  the  38,  no  morbid  appearance 
at  all  was  perceptible :  in  13  there  was  some  serous  fluid,  from  a  teaspoonful  to  a 
tablespoonful,  in  the  ventricles  :  in  7  there  was  what  he  calls  (edema  of  the  meninges, 
effusion,  that  is,  in  the  meshes  of  the  pia  mater :  in  6  general  but  slight  diminution 
of  consistence :  in  2  some  alteration  of  density  :  in  5  a  speckled  appearance  of  the 
cerebral  substance.  Now  to  what  conclusion  do  these  facts  lead  us  ?  Why,  in  the 
first  place,  to  the  conclusion  that  those  pathologists  are  in  error  who  maintain  (as  Dr. 
Clutterbuck  does,  for  whose  experience  and  talents  I  entertain  a  sincere  respect,) 
that  the  essence  of  continued  fever  is  inflammation  of  the  brain.  Not  only  do  we 
fail  to  discover,  in  many  instances,  any  traces  of  inflammation,  upon  inspecting  the 
dead  brain,  but  we  find  that,  during  the  life  of  the  patient,  measures  which  would  be 
likely  to  aggravate  any  inflammatory  mischief — strong  stimulants,  for  example,  wine 
or  brandy, — do  actually  and  obviously,  in  cases  innumerable,  relieve  the  comatose 
symptoms,  and  benefit  the  patient.  The  inference  seems  unavoidable,  that  the  coma, 
in  such  cases,  has  some  other  cause  than  that  mechanical  pressure  which  arises 
sometimes  from  the  effusion  of  fluid  upon  the  surface  of  the  brain,  or  within  its  ven 
tricles ;  and  that  other  cause  is  supplied  by  the  poisoned  blood.  Here  again  we 
may  adopt  the  pathology  of  Shakspeare  : — 

The  life  of  all  his  blood 
Is  touched  corruptibly :  and  his  pure  brain 
(Which  some  suppose  the  soul's  frail  dwelling-house) 
Doth  by  the  idle  comments  that  it  makes 
Foretel  the  ending  of  mortality. 

In  some  malign  epidemics  the  nervous  system  is  overwhelmed  at  once,  in  the  very 
outset,  by  the  force  of  the  poison.  The  patient  becomes  stupid  or  bewildered  ;  his 
surface  is  cold,  clammy,  purplish,  and  his  pulse  feeble :  the  coma  rapidly  augments, 
and  deatn  may  ensue  within  twenty-four  hours.  We  sometimes  see  this  fearful 
train  of  symptoms  in  small-pox ;  and  still  more  often  and  more  strikingly  in  the 


I 


MORBID   APPEARANCES.  943 

worst  forms  of  scarlet  fever.  I  believe  that  in  these  cases,  there  is  no  deviation,  cog- 
nizable by  our  senses,  from  the  healthy  texture  and  appearance  of  the  parts  within 
the  skull. 

Nevertheless,  there  maybe,  and  there  often  is,  in  these  fevers,  actual  inflammation 
of  the  brain  or  its  membranes  :  but  this  is  an  incidental  complication.  We  conjec- 
ture that,  in  addition  to  the  influence  of  the  poison  upon  the  nervous  system,  there 
may  be  a  low  degree  of  inflammation  going  on  within  the  head,  when  we  find  it 
externally  hot,  when  the  patient  has  flushed  cheeks,  and  a  vascular  eye,  and  com- 
plains of  dull  headache.  And  there  are  some  instances  in  which  we  recognize  more 
distinctly  the  outward  signs  of  encephalitis — severe  pain  in  the  head,  high  and  fierce 
delirium,  intolerance  of  light  and  of  sound,  with  much  heat  of  skin,  and  a  hard  pulse. 
When  coma  succeeds  such  symptoms  as  these,  we  naturally  ascribe  it,  in  part  at 
least,  to  the  effects  of  the  inflammation :  and  rightly,  for  we  find  traces  of  inflamma- 
tion after  death ;  serous  effusion  beneath  the  arachnoid  and  in  the  cerebral  ventri- 
cles ;  shreds  of  coagulable  lymph ;  and  more  rarely  suppuration.  T  suspect  that 
genuine  encephalitis,  which  is,  of  course,  attended  Avith  pyrexia,  is  sometimes  mis- 
taken for  continued  fever  with  intercurrent  inflammation  of  the  brain.  Great  atten- 
tion, and  some  skill  and  judgment,  are  required  for  discriminating  those  cases  of  fever 
in  which  such  inflammation  occurs,  and  for  directing  the  appropriate  treatment. 

The  death  in  fever  by  apncea  is  certainly  much  rarer  than  that  by  coma :  yet  it 
is  not  very  unfrequent.  It  often  mingles  itself  with  the  death  by  coma.  From  the 
earhest  period  of  the  fever  we  may,  in  most  cases,  notice  some  increased  quickness 
of  respiration,  which  is  not  entirely  owing  to  the  mere  fever,  or  to  acceleration  of  the 
circulation  ;  for  the  ear,  when  applied  to  the  parietes  of  the  chest,  discovers  rhon- 
chus,  and  sibilus,  at  least.  Frequently  there  is  considerable  dyspnoea  for  some 
hours,  or  for  a  day  or  two,  before  death  :  and  this  may  be  apparent  only,  in  conse- 
quence of  the  stupor ;  or  it  may  be  real,  and  proceeding  from  a  low  degree  of  pneu- 
monia, which,  by  interfering  with  the  due  arteriahzation  of  the  blood,  may  aggravate, 
or  even  give  rise  to  the  coma :  and  such  pneumonia  is  apt  to  be  masked  by  the 
fever;  declaring  itself  by  none  of  the  ordinary  symptoms  of  cough,  rust-coloured 
sputa,  or  pain  in  the  thorax.  The  inflammation,  thus  latent,  is  discoverable,  how- 
ever, by  the  sense  of  hearing. 

Now  what  does  dissection  teach  us  with  respect  to  the  condition  of  the  lungs  after 
death  from  continued  fever  1  Why,  the  most  common  unnatural  appearance  met 
with  in  the  pulmonary  substance  is  engorgement :  a  state  similar  to  that  which  oc- 
curs in  the  first  stage  of  pneumonia.  But  here  the  engorgement  is  probably  in  a 
great  measure  mechanical,  and  takes  place  during  the  last  few  days  of  the  patient's 
life.  As  the  vital  powers  diminish,  the  laws  which  govern  the  physical  world  re- 
sume their  empire.  The  fluids,  and  the  blood  especially,  accumulate  in  the  most 
depending  parts  of  the  viscera ;  and  the  lower  and  posterior  portions  of  the  lungs  in 
particular  become  loaded.  But  besides  this,  it  is  not  unusual  to  find  large  portions  of 
the  lungs  in  a  state  of  hepatization,  and  even  infiltrated  with  pus :  and  the  bronchial 
tubes  clogged  up  by  viscid  and  frothy  mucus. 

The  mode  of  death  by  asthenia  or  syncope  is  not  very  common  as  existing  by 
itself;  but  it  is  often  combined  with  one  or  both  of  the  two  other  modes.  In  some 
cases  of  fever,  however,  death  does  appear  to  take  place  from  mere  debility  of  the 
heart;  there  having  been  no  pulmonary  embarrassment,  and  the  head  having  remained 
clear.  Death,  in  such  cases,  is  preceded  by  those  symptoms  of  debiHty  which  have 
been  already  described.  The  pulse  becomes  small  and  weak,  and  hke  a  thread  ;  the 
patient  lies  on  his  back,  and  sinks  down  in  the  bed  ;  the  features  sharpen  ;  the  eyes 
are  hollow  and  dim,  as  though  glazed ;  the  sphincter  muscles  fail  to  contract ;  the 
extremities  grow  cold  ;  cold  sweats  appear  on  different  parts  of  the  body :  and  at  length 
the  heart  ceases  to  beat  and  the  patient  to  exist. 

Death  occurring  in  this  manner  does  not  occur  early.  It  happens  at  an  advanced 
period  of  the  disease.  It  is  noticed  sometimes  in  persons  who  have  been  largely 
bled,  or  too  actively  depleted  at  the  commencement  of  the  fever:  and  in  those  who 
have  suffered  a  good  deal  from  diarrhoea.  In  short,  as  the  two  previous  modes  of 
ieath  are  connected,  often,  with  morbid  conditions  of  the  head  and  chest  respectively, 


944  CONTINUED   FEVER. 

so  death  in  fever  occurring  purely  or  chiefly  by  asthenia,  connects  itself  with  morbid 
conditions  existing  within  the  belly. 

And  we  trace  the  vestiges  of  disease  much  oftener  in  the  abdomen  than  either  in 
the  brain  or  in  the  thorax ;  and  the  mischief  which  we  there  discover  is  more  con- 
stant and  definite  than  elsewhere.  It  is  proper,  therefore,  to  inquire  somewhat  more 
closely  into  the  morbid  appearances  observed  in  the  abdomens  of  those  who  die  of 
continued  fever. 

I  need  scarcely  remind  you  that  the  intestinal  canal  is  largely  furnished,  on  its 
inner  surface,  with  glands,  or  follicles,  which  consist  of  little  more  than  crypts,  and 
of  which  the  precise  office  has  not  yet,  I  think,  been  accurately  determined.  Some 
of  these  glands  are  sprinkled  (one  may  almost  say  at  random)  over  the  whole  tract 
of  mucous  surface.  These  are  accordingly  called  solitary  ghtnds.  Till  I  was  better 
instructed  by  Professor  Todd,  I  used  to  speak  of  them  as  being  the  glands  of  Brunner  ; 
whereas  the  glands  discovered  and  described  bj^  that  anatomist  are  limited  to  the 
duodenum.  Other  glands  or  folhcles  are  collected  into  groups,  and  are  named  glan- 
didx  agminatse,  or  often  the  glands  of  Peyer,  who  has  given  a  capital  description 
of  them.  Now  the  arrangement  of  these  glands  of  Peyer  is  peculiar  :  and,  in  refer- 
ence to  the  morbid  anatomy  of  continued  fever,  very  necessary  to  be  known.  They 
are  met  with  in  the  ileum  alone :  they  are,  mostly,  oblong  in  form :  and  they  occupy 
that  part  of  the  bowel  which  is  opposite  its  mesmeric  attachment.  They  are  largest, 
and  most  numerous,  and  consequently  most  thickly  set,  in  the  lower  end  of  the  ileum, 
which,  in  some  instances,  is  almost  entirely  covered  with  them ;  they  are  found  also 
upon  the  ileo-csecal  valve  ;  but  beyond  that  they  do  not  go  in  that  direction.  Ascend- 
ing from  the  cascum  towards  the  jejunum,  these  groups  or  patches  become  smaller, 
shorter,  more  circular,  and  less  numerous  ;  they  are  separated  by  longer  and  longer 
intervals,  till  at  last  they  cease  to  be  visible  at  all.  Where  there  are  valvuke  conni- 
ventes,  there  the  situation  of  these  patches  is  very  obvious  ;  for  the  valvulae  conni- 
ventes  are  interrupted,  and  never  run  across  them.  This  fact  has  sometimes  led  to 
curious  mistakes.  I  have  seen  in  the  museum  of  the  College  of  Surgeons  a  prepa- 
ration put  up  by  Mr.  John  Hunter  (but  not  labeled,  I  presume,  by  him),  professing 
to  be  an  example  of  the  destruction  of  portions  of  the  valvulte  conniventes  by  ulcera- 
tion. It  is  nothing  more  than  one  of  these  natural  patches,  rather  more  plainly  de- 
veloped than  usual. 

These  glands,  in  their  healthy  state,  are  much  more  conspicuous  in  some  bodies 
than  in  others.  Yoii  may  see,  if  you  look  at  them  attentively,  that  they  are  made 
up  of  a  congeries  of  mucous  folhcles,  of  which  the  orifices  are  obsourely  apparent. 
Now  the  main  alterations  met  with  in  the  abdomen  after  death,  in  continued  fever, 
are  alterations  of  these  very  glands  :  of  the  solitary  glands,  to  wit ;  and  still  more  con- 
stantly and  remarkably  of  the  agminate  glands. 

The  changes  which  these  glands  undergo  are  of  the  following  kind.  In  the  first 
place  they  become  enlarged,  and  more  perceptible  than  they  are  in  the  natural  state. 
They  then  present  a  grayish  transparent  surface,  dotted  over  with  black  points ; 
which  black  points  mark,  I  conceive,  the  excretory  mouths  of  the  several  follicles. 
Then,  as  the  inflammation,  for  such  it  is,  advances,  the  patch  becomes  reddish  per- 
haps ;  and  the  follicles  burst  or  ulcerate,  or  slough  away  :  not  altogether,  but  partially 
and  by  piecemeal ;  so  that  an  irregular  ragged  ulcer  is  generally  left,  having  thicken- 
ed edges.  Sometimes,  however,  the  follicles  disappear  without  there  being  much 
redness  or  thickening:  the  mucous  membrane  immediately  adjacent,  and  even  the 
'•emaining  part  of  the  patch  of  folhcles,  being  pale,  and  level.  Sometimes  the  patch 
pufls  up  into  a  sort  of  fungous  swelling,  in  which  all  trace  of  the  follicular  structure 
Is  lost.  The  colour  of  the  ulcerated  surface  is  various,  as  well  as  its  form  and  ap- 
pearance. Sometimes  it  is  pale  and  grey ;  sometimes  red  ;  oftentimes  yellow,  as  if 
the  exposed  cellular  and  other  tissues  were  stained  by  the  ochrey  fluid  which  had 
been  poured  from  the  bowels  during  hfe.  What  I  have  hitherto  stated  relates  to 
Peyer's  glands ;  but  the  sohtary  glands  participate,  usually,  in  the  change.  They 
become,  in  the  first  place,  large  and  hard,  and  present  a  whitish-coloured  projection 
from  the  surface,  which,  by  a  mistaken  analogy,  has  sometimes  been  called  a  pustule. 


MORBID   APPEARANCES.  945 

At  length  a  loss  of  substance  takes  place  in  these  also ;  beginning  at  their  summit, 
and  producing  a  small,  but  sometimes  a  deep  ulcer. 

And  of  these  changes  it  is  further  to  be  observed,  that  they  are  more  common, 
more  numerous,  more  extensive,  more  advanced,  in  proportion  as  we  approach  the 
caecum.  It  is  natural  that  we  should  meet  with  more  ulcers  near  the  cascal  valve, 
because  there  are  more  glands  there;  but  undoubtedly  the  ulcers  are  (in  general) 
further  advanced  there  than  higher  up  in  the  bowel. 

Going  along  with  this  ulceration  of  the  mucous  glands  of  the  intestines,  and  above 
all  of  the  aggregate  glands  of  the  ileum,  you  will  frequently  find  inflammation  (j,  e., 
redness,  hardness,  and  swelling)  of  the  corresponding  mesenteric  glands.  This  would 
seem  to  be  a  consequence  of  the  inflammation  and  ulceration  of  the  mucous  glands. 
The  inflammation  of  the  mesenteric  gland  is,  I  conceive,  secondary ;  and  bears  the 
same  relation  to  the  ulcers  seen  in  the  bowel,  as  a  bubo  in  the  groin  bears  to  a  chancre 
on  the  glans  penis. 

These  alterations  are  extremely  interesting,  because  they  aflx)rd  a  plausible  ex- 
planation of  many  of  the  symptoms  of  continued  fever.  They  account  for  the 
diarrhoea ;  they  account  for  one  form  of  occasional  hemorrhage  from  the  bowels ; 
they  account  for  the  uneasiness  of  pain  which  is  experienced  when  the  abdomen  is 
pressed,  and  teach  us  why  that  uneasiness  is  greatest  in  the  situation  of  the  caecum. 
Nay,  we  can  even  understand  why,  although  these  ulcerations  exist,  there  may  be 
no  pain  occasioned  by  them.  This  may  be  partly  owing  to  the  general  insensibility 
to  impressions  and  sensations  of  all  kinds,  produced  by  the  stupor;  but  partly,  also, 
it  probably  depends  upon  the  depth  to  which  the  ulceration  goes.  The  mucous 
tissues  are  possessed  of  but  little  sensibility  even  under  inflammation  ;  but  if  the 
muscular  and  peritoneal  coats  become  involved  in  the  inflammatory  process,  then 
pain  begins  to  be  felt.  I  remember,  a  few  years  ago,  attending  a  young  lady  ill  of 
fever,  with  a  very  well-informed  practitioner,  but  one  of  the  old  school,  for  he  had  not 
turned  his  attention  much  to  the  state  of  the  intestines  in  that  disease.  One  day  we 
learned  that  our  patient  had  had  hemorrhage  ;  from  the  uterus  her  friends  supposed; 
but  when  I  saw  the  discharge,  I  was  certain,  by  its  appearance,  and  by  its  odour, 
though  it  was  not  mixed  with  any  feces,  that  it  had  come  from  the  bowels ;  and  I 
stated  my  conviction  that  there  was  ulceration  in  the  lower  portion  of  the  ileum.  But 
she  had  no  pain  in  the  abdomen.  You  might  press  any  part  of  it  without  exciting 
the  smallest  uneasiness.  So,  distrustful  of  my  opinion,  they  called  in  an  eminent 
accoucheur,  who  also  pressed  and  examined  the  belly :  but  neither  could  he  detect 
any  tenderness  or  undue  sensibility.  He  next  examined  the  uterus  per  vaginam  ; 
but  could  discover  nothing  wrong  there.  Some  few  nights  afterwards  the  general 
practitioner  was  called  out  of  his  bed  to  this  patient.  He  was  told  that  the  hemor- 
rhage (or  flooding  as  they  called  it,  for  they  persisted  in  believing  that  it  was  uterine,) 
had  returned  ;  and  before  he  arrived  at  the  house  the  patient  was  dead.  We  next 
day  opened  the  body  together.  The  uterus  was  perfectly  natural ;  there  was  no 
vestige  of  discharge  or  bleeding  in  the  vagina;  but  the  ileum,  for  about  a  foot  above 
its  entrance  into  the  caecum,  was  in  a  state  of  superficial  but  ragged  ulceration,  and 
universally  red  and  smeared  with  blood.  I  mention  this  as  a  strong  fact  in  illustra- 
tion of  the  possibility  of  there  being  much  disorganization  of  the  inner  surface  of 
the  intestines,  without  any  pain  to  reveal  it. 

Now  the  alterations  I  have  last  been  sketching — the  thickening,  redness,  tumefac- 
tion, and  ulceration  or  sloughing  of  the  glands  of  Peyer,  and  also  of  the  solitar}'- 
glands — are  so  common  in  fever,  particularly  in  some  epidemics,  that  many  patholo- 
gists are  of  opinion  that  fever  is  essentially  inflammation  of  these  glands,  and  nothino- 
else.  But  this,  I  am  sure,  is  an  error.  In  the  first  place,  if  this  doctrine  were  true, 
it  would  almost  follow  of  necessity  that  the  severity  of  the  case,  and  the  intensity  of 
the  symptoms,  should  be  in  proportion  to  the  number,  depth,  and  extent  of  the 
ulcerations.  But  this  is  far  from  being  so.  In  cases  in  which  the  symptoms  have 
:)een  of  the  worst  kind,  there  have  been  found  very  ievf  ulcerations,  and  those  small 
and  apparently  insignificant.  On  the  other  hand,  when  the  complaint  has  run  a 
moderate  course,  but  at  length  has  terminated  fatally,  it  is  not  uncommon  to  discovei 
a  frightful  amount  of  disorganization  in  the  ileum. 
60 


9-16  CONTINUED    FEVER. 

But  what  is  more  conclusive  is,  that  the  occurrence  of  this  inflammatory  condition 
of  the  mucous  follicles  of  the  intestines  is  not  constant,  in  continued  fever.  If  one 
well-marked  instance  of  the  disease  should  occur,  without  any  trace  of  a  morbid 
action  having  been  going  on  in  the  mucous  follicles,  that  instance  would,  of  course, 
suffice  to  overturn  the  theory.  But  scores  of  such  cases  have  occurred.  I  have  seen 
many  such  myself;  and  other  persons  have  seen  more.  Since  attention  has  been 
drawn  to  the  subject,  the  patches  of  glands,  and  the  whole  tract  of  mucous  mem- 
brane, from  the  stomach  to  the  rectum,  have  been  diligently  explored :  and  the  result 
seems  to  be  that,  at  certain  times  and  places  (in  other  words,  in  certain  epidemics) 
the  ulceration  of  the  inner  surface  of  the  intestines  is  far  less  common  than  at  others. 
It  was  comparatively  rare  in  an  epidemic  of  which  I  witnessed  some  part  in  Edin- 
burgh. Then  I  came  to  London  ;  and  for  several  years  I  never  saw  a  body  opened 
after  death  by  continued  fever,  without  finding  ulcers  in  the  bowels.  More  recently, 
however,  and  especially  during  the  present  epidemic  (1S38),  I  have  looked  for  them, 
carefully,  in  many  cases  that  have  proved  fatal  in  the  Middlesex  Hospital,  and  have 
discovered  neither  ulceration  nor  any  other  apparent  change  in  the  folhcles  of  the 
intestines.  Still,  in  my  own  experience,  such  ulcers  have  been  vastly  more  often 
present  than  absent.  Chomel,  during  five  years'  investigation  of  this  matter  in  the 
Hotel  Dieu,  never  met  with  an  exception  to  the  general  rule  of  their  occurrence  ;  or 
of  some  degree  or  form  of  that  kind  of  alteration  in  the  mucous  glands,  of  which  the 
ulcer  is  the  last  stage. 

We  must  conclude,  upon  the  whole,  that  although  an  inflammatory  state  of  the 
solitary  and  aggregate  glands,  which  strew  the  surface  of  the  mucous  membrane  of 
the  alimentary  canal,  is  not  the  essence  of  fever,  yet  that  it  is  a  very  frequent  com- 
panion of  continued  fever. 

But  when  it  does  occur,  is  this  state  of  things  always,  or  necessarily  fatal  ?  By 
no  means.  It  may  be  fatal,  in  more  ways  than  one.  It  may  lead  to  death,  by  ex- 
hausting diarrhnea,  in  the  way  of  slow  asthenia ;  it  may  kill  by  laying  open  a  large 
mesenteric  blood-vessel,  and  so  producing  copious  hemorrhage  and  mortal  syncope  ; 
it  may,  and  often  does,  destroy  the  patient,  by  perforation  of  the  bowel;  the  ulcer 
penetrates  the  mucous  and  muscular  coats,  and  reaches  the  peritoneum :  and  some- 
times that  membrane  gives  way,  and  sometimes  it  does  not.  The  consequence  of  iis 
rupture  or  perforation  —  the  escape,  I  mean,  of  the  contents  of  the  bowel,  and  the 
supervention  of  intense  and  uncontrollable  peritonitis — I  need  not  again  dwell  upon. 
But  the  ulcers  may,  and  doubtless  often  do,  heal :  and  the  scars  which  they  leave 
behind  them  are  frequently  to  be  seen.  The  ulcerated  surface  seems  to  clothe  itself 
afresh,  by  degrees,  with  a  new  mucous  membrane ;  which  is  thin,  however,  and 
adherent  to  the  subjacent  tissues,  and  does  not  sHde  over  them  when  pressed  between 
the  finger  and  thumb,  as  the  healthy  portions  of  the  coats  of  the  bowel  will  do  upon 
each  other.  And  in  the  place  of  the  cicatrix  there  is  usually  to  be  seen  a  manifest 
puckering,  and  a  number  of  little  wrinkles  or  lines,  radiating  from  a  common  centre. 

The  spleen — I  may  observe,  before  I  conclude  this  lecture — is  more  frequendy 
found  altered  in  texture  after  death  by  continued  fever,  than  any  other  part  except 
the  glands  of  which  I  was  last  speaking.  It  is  usually  enlarged,  of  a  dark  colour, 
and  "of  soft,  and  sometimes  almost  rotten,  consistence. 

To-morrow  I  shall  endeavour  to  point  out  some  of  the  most  important  varieties 
that  have  been  found  to  occur  in  this  disease  of  continued  fever. 


LECTURE  LXXXV. 

Varieties  of  Continued  Fever.     Its  Causes.     Exciting  and  Predisposing.    Pro- 
phylaxis. 

Having  traced,  in  the  last  lecture,  as  clear  an  oudine  as  I  could,  of  the  ordinary 
course  and  the  diflerent  terminations  of  continued  fever,  I  wish  to  touch,  briefly,  to- 
day on  some  of  its  principal  varieties ;  and  then  to  inquire  into  its  causes. 


CONTINUED   FEVER.  947 

Although  fever  is,  as  I  have  stated,  a  specific  disease,  it  assumes  divers  forms  ; 
atid  so  dissimilar  are  some  of  its  phases  that  they  might  seem  to  belong  to  totally 
different  maladies.  These  variations  relate  not  only  to  individual  cases,  but  to  whole 
epidemics.  In  some  places  and  seasons,  the  inflammatory  type  predominates,  marked 
by  excitement  of  the  sanguiferous  system ;  in  others,  depression  of  the  nervous 
system,  characteristic  of  the  typhoid  type,  is  the  prominent  feature  of  the  disease. 
Most  generally  of  all,  the  disorder  commences  with  inflammatory  fever,  and  ends 
with  typhoid  symptoms.  The  distinctions  drawn  by  Cullen,  now  well  nigh  obsolete, 
were  founded  in  nature.  To  the  inflammatory  form  he  gives  the  name  of  synocha, 
which  he  thus  defines:  "Calor  plurimum  auctus  ;  pulsus  frequens,  vahdus,  et  durus; 
urina  rubra  ;  sensorii  functiones  parum  turbatse."  With  this  he  contrasts  his  typhus. 
"Calor  parum  auctus;  pulsus  parvus,  debilis,  plerumque  frequens;  urina  parum 
mutata ;  sensorii  functiones  plurimum  turbatEe ;  vires  multum  imminutte."  These 
forms  I  would  have  you  bear  in  mind  :  not  that  you  are  likely  to  meet  with  many 
instances  of  pure  synocha,  nor  of  pure  typhus,  but  because  they  furnish  standards 
of  comparison,  towards  which,  in  opposite  directions,  the  fevers  of  different  epide- 
mics approach.  The  most  usual  variety  of  continued  fever  is  represented  by  the 
synochus  of  the  same  author,  which  is  a  compound  of  the  two  others.  "Febris  ex 
synocha  et  typho  composita :  initio  synocha,  progressu  et  versus  finem  typhus." 
The  unsoundness  of  many  of  Cullen's  theories,  and  the  conceit  of  later  and  far  in- 
ferior writers,  have  thrown  his  First  Lines  into  undeserved  neglect ;  but  his  clear, 
succinct,  and  faithful  pictures  of  disease,  will  not  easily  be  surpassed,  and  are  worthy 
of  your  attentive  study. 

The  difference  is  very  striking  between  the  kind  of  fever  that  I  witnessed  in  Lon- 
don for  ten  years  before  the  arrival  of  the  spasmodic  cholera  in  this  country,  and  the 
kind  of  fever  that  has  since  prevailed,  and  is  now  (1838)  so  rife  around  us.  During 
the  first  of  these  periods,  the  antiphlogistic  regimen  was  indispensable  in  the  outset 
of  the  disease;  in  most  instances,  bleeding,  either  general  or  topical,  was  required, 
and  well  borne ;  there  was  no  eruption  to  be  seen  upon  the  skin ;  the  glands  of 
Peyer,  according  to  my  own  experience  of  the  fatal  cases,  were  almost  invariably 
affected ;  and  the  mortality  was  very  moderate.  This  was  an  inflammatory  phase. 
The  present  epidemic  offers  a  marked  contrast  in  all  these  points.  A  large  per 
centage  of  those  who  contract  the  fever  die ;  after  death  we  seldom  detect  any  dis- 
ease of  the  agminate  glands  of  the  intestine ;  the  peculiar  rash  scarcely  ever  fails  to 
show  itself;  we  are  taught  b}''  experience  to  refrain  as  much  as  possible  from  blood- 
letting ;  and  almost  from  the  beginning,  or  quite,  we  find  it  necessary  to  sustain  our 
patients  by  a  liberal  allowance  of  strong  animal  broths.  The  typhoid  is  now  the 
prevailing  type.  You  might,  I  say,  almost  suppose  that  I  have  been  speaking  of 
two  distinct  maladies.  But,  during  each  of  the  periods  in  question,  some  scattered 
cases  have  occurred,  bearing  most  of  the  characters  proper  to  the  other  period. 
Moreover,  all  acute  diseases  have  assumed,  wnthin  the  last  ten  years,  in  this  town  at 
least,  an  unusually  asthenic  character.  So  that  the  differences  observed  in  the  aspect 
and  phenomena  of  continued  fever,  depend  more,  I  conceive,  upon  an  acquired  dis- 
position of  the  human  body,  produced  by  some  obscure  general  influence,  and  there- 
fore affecting  the  entire  London  community,  than  upon  any  change  in  the  essential 
nature  of  the  disease,  or  in  the  virus  which  (as  I  beheve)  occasions  it. 

The  inverse  relation  between  the  rash  and  the  intestinal  ulceration  is  remarkable. 
When  the  one  is  prevalent,  the  other  is  rare.  It  would  seem,  in  conformity  with 
Dr.  William  Budd's  views,  that  the  specific  poison  displays  its  elective  affinities  by 
settling  sometimes  upon  the  mucous  glands,  sometimes  upon  the  cutaneous  tissues, 
and  sometimes  by  sharing  itself,  though  unequally,  between  the  two. 

I  have  incidentally  alluded  to  the  duration  of  the  fever.  In  this  particular,  also, 
there  is  much  variety;  a  fact  which  is  apparent  even  to  the  vulgar,  and  expressed 
in  their  ordinary  discourse.  They  talk  of  the  one-and-twenty  day  fever,  and  of  the 
fourteen-day  fever,  according  as  the  disorder  "takes  the  turn"  in  three  weeks  or  in 
a  fortnight.  It  appears  from  the  report  made  some  years  ago  to  the  government 
upon  the  state  of  fever  in  Ireland,  that  the  fever  there  generally  began  to  depart  on 
the  fifth  day ;  wherefore  it  was  called,  in  that  part  of  the  kingdom,  the  five-day  fever 


948  ^CONTINUED   FEVER. 

Of  the  fever  patients  whom  I  saw  in  the  Edinburgh  Infirmary,  almost  all  were  fairly 
convalescent,  or  dead,  before  the  end  of  the  third  week.  In  this  place,  the  disease 
runs  out  longer;  lasting  three,  four,  or  five  weeks.  I  observed  also,  in  Edinburgh, 
that  many  of  those  who  recovered  had  a  tedious  convalescence,  in  consequence  of 
very  troublesome  sloughs  and  ulcers  which  formed  upon  the  sacrum  and  hips.  In 
London,  these  bed-sores  are  comparatively  uncommon. 

The  symptoms  attending  the  fever  seem  to  vary  also,  cseteris  paribus,  according 
to  the  season  of  the  year,  and  the  situation  of  the  patient :  whether,  I  mean,  he  be 
surrounded  with  pure  and  cool  air,  or  with  a  foul  and  hot  atmosphere.  In  the  colder 
months  there  is  greater  risk  of  inflammatory  complications,  and  especially  of  pectoral 
affections  :  in  the  autumn  we  look  more  for  diarrhoea,  or  for  dysenteric  complaints, 
engrafting  themselves  on  the  disorder.  Where  the  air  is  close  and  foul,  the  symp- 
toms show  a  much  greater  tendency  to  the  typhoid  type,  and  the  deaths  are  more 
numerous,  than  where  it  is  pure. 

It  is  of  great  importance  to  hold  correct  notions  as  to  the  exciting  cause  of  conti- 
nued fever;  respecting  which  there  has  been,  and  there  still  is,  a  perplexing  contra- 
riety of  opinion  among  medical  men.  You  are  aware,  from  what  has  already  been 
stated,  that  I  consider  the  disorder  to  originate  in  an  animal  poison,  and  to  be  conta- 
gious ;  communicable,  I  mean,  from  one  who  is  labouring  under  the  complaint,  to 
another  who  is  not. 

When  the  same  disease  attacks  many  persons  in  the  same  house  or  neighbour- 
hood, at  about  the  same  time,  the  popular  suspicion  soon  arises  that  the  disease  is 
catching.  Yet  you  know  that  disorders  may  be  widely  prevalent  without  being 
contagious.  Agues,  for  example,  engendered  by  malaria ;  ordinary  catarrhs  and 
sore  throats,  produced  by  vicissitudes  of  the  weather.  When  an  epidemic  malady 
affects  large  masses  of  the  people  suddenly  and  at  once,  it  is  presumably  not  conta- 
gious ;  at  any  rate,  it  must  have  some  other  source  besides  contagion.  When,  on 
the  contrary,  it  begins  in  a  certain  spot,  and  gradually  spreads  thence  as  from  a  centre, 
the  presumption  is  in  favour  of  its  propagation  from  person  to  person.  In  investi- 
gating this  subject,  if  we  trace  the  fever  among  persons  who  have  had  intercourse 
with  the  sick,  and  more  frequently  in  proportion  as  that  intercourse  has  been  close 
and  continued;  and  if  we  find  that  other  persons,  living  in  the  same  place,  and 
under  precisely  the  same  circumstances,  except  that  they  have  had  no  known  com- 
munication with  the  sick,  escape  the  fever ;  we  have  in  these  facts  convincing  evi- 
dence that  the  disease  has  been  spread  by  such  intercourse  ;  in  one  word,  that  it  is 
contagious. 

Have  we,  then,  facts  of  this  kind  ?     We  have,  in  the  amplest  abundance. 

We  find,  even  in  hospitals,  where  cleanliness  and  ventilation  are  prized  and  en- 
forced, that  fever  attacks  many  of  the  persons  who  come  most  often  and  most  inti- 
mately in  contact  with  those  already  ill  of  that  disease :  chiefly  the  nurses,  next  the 
clinical  assistants  and  the  most  assiduous  of  the  students,  and  the  medical  officers; 
rarely  the  other  patients,  even  in  the  same  ward.  The  separation  of  a  few  feet,  if 
due  regard  be  had  to  ventilation,  is  sufficient  to  render  the  poison  inoperative,  by 
diluting  and  diffusing  it  in  the  surrounding  purer  atmosphere.  Three  of  our  nurses 
in  the  Middlesex  Hospital  have  fallen  ill  of  fever  during  the  epidemic  now  prevail- 
ing, and  two  of  the  three  have  died.  I  am  now  attending  a  pupil  of  the  Charing 
Cross  Hospital,  who  is  persuaded  that  he  caught  the  fever  while  watching  some  bad 
cases  of  it  there.  It  is  only  when  our  wards  are  unusually  full  of  fever  patients 
that  these  disasters  occur;  but  they  happen  very  often,  indeed,  constituting  the  rule 
rather  than  the  exception,  wherever  many  fever  patients  are  collected  together:  as 
in  hospitals  which  are  exclusively  appropriated  to  their  reception,  or  in  the  fevei 
loards  of  certain  general  hospitals.  In  such  places,  the  effluvia  which  proceed  from 
the  bodies  of  the  sick  are,  in  spite  of  all  care,  the  most  abundant  and  the  most  con- 
centrated. 

Dr.  Welch,  whose  book  I  have  referred  to  before,  has  the  following  statement  in 
point :  "  In  this  hospital  (that  is,  Queensbury  House  in  Edinburgh,  which  was  opened 
for  the  sole  use  of  fever  patients  during  the  prevalence  of  a  severe  epidemic  in  that 


EXCITING    CAUSE.  949 

City,  in  the  years  1817,  '18  and  '19),  since  it  was  opened  (which  was  the  year  before 
the  time  when  Dr.  Welch  was  writing),  my  friends,  Messrs.  Stephenson  and  Chris- 
tison,  the  matron,  two  apothecaries  in  succession,  the  shop-boy,  washerwoman,  and 
thirty-eight  nurses,  have  been  infected  ;  and  four  of  the  nurses  have  died.  With  the 
exception  of  but  two  or  three  nurses,  who  have  been  but  a  short  time  in  the  hospital, 
I  am  now  the  only  person  who  has  not  caught  the  disease,  either  here  or  at  the 
infirmary,  within  the  last  eight  or  ten  months." 

I  may  quote  a  passage  from  Dr.  Alison,  in  illustration  of  the  same  thing.  He  is 
speaking  of  a  more  recent  epidemic,  which  occurred  in  Edinburgh  in  1827  and  1828. 
He  says:  "During  this  epidemic,  as  well  as  that  of  1817-19,  many  of  the  clerks 
and  nurses  employed  in  the  Royal  Infirmary  have  taken  fever.  Since  November 
last,  six  of  the  clerks  employed  in  the  clinical  wards  only,  four  of  those  employed 
in  the  ordinary  wards,  and  twenty-five  nurses  or  servants,  have  taken  fever.  All 
these  persons  had  necessarily  frequent  and  close  intercourse  with  the  fever  patients 
in  the  house,  having  been  employed  more  or  less  constantly  in  the  fever  wards, 
excepting  only  four  of  the  servants.  Of  these  four,  two  had  been  employed  in  the 
laundry  where  the  linen  from  the  fever  wards  was  washed ;  one  was  a  porter  em- 
ployed at  the  gate,  who  would  of  course  have  communication  with  the  fever  patients 
at  their  entrance  or  dismissal,  as  well  as  with  their  relations  coming  to  visit  them ; 
and  one  was  a  nurse  employed  in  the  servants'  ward,  but  who  was  in  the  habit  of 
visiting  the  fever  wards."  Now,  mark  the  contrast.  He  adds  that,  "in  this  very 
place  and  season,  those  of  its  inhabitants  who  have  not  had  intercourse  with  fevet 
patients  have  almost  uniformly  escaped  the  disease.  Of  the  inhabitants  of  the 
ground-Jloor  of  the  house  (including  patients  in  the  lock-ward),  none  but  those 
already  mentioned  as  having  washed  the  linen  from  the  fever  wards,  and  the  barber 
who  shaved  the  heads  of  the  fever  patients,  have  taken  the  disease.  Yet  in  the 
case  of  malaria"  (to  which  I  must  apprise  you  that  many  medical  men  of  great 
authority  ascribe  the  occurrence  of  continued  fever,)  "  it  is  the  ground-floor  of  the 
house  that  is  generally  found  the  most  dangerous.  No  one  of  the  nurses,  whose 
duty  has  confined  them  to  the  medical  or  surgical  wards  where  no  fever  patients 
were  admitted,  has  taken  fever,  with  the  single  exception  of  the  woman  in  the  serv- 
ants' ward  above  mentioned.  And  of  the  numerous  patients  in  these  ordinary 
wards,  the  only  one  who  has  taken  the  fever,  within  my  knowledge,  during  the  pre- 
sent year,  was  a  patient  in  the  men's  general  chnical  ward,  who  lay  in  the  bed  next 
the  door  that  communicates  with  the  clinical  fever  ward.  If  there  be  malaria  in 
this  house,  therefore,  it  would  seem  to  restrict  \i?,e{{  in  point  of  space,  as  at  Queens- 
bury  House  in  point  of  time,  to  the  immediate  vicinity  of  fever  patients."  To  under- 
stand this  last  remark,  you  should  know  that,  in  ordinary  years,  the  inmates  of 
Glueensbury  House  escaped  fever. 

We  have  similar  testimony  nearer  home  ;  in  this  metropolis.  "Every  physician 
connected  with  the  London  Fever  House,  with  one  exception  (writes  Dr.  Tweedie), 
has  been  attacked  with  fever ;  and  three  out  of  eight  have  died  of  it.  Also  the  re;u- 
dent  medical  officers,  matrons,  porters,  laundresses,  domestic  servants  not  connected 
with  the  wards,  and  every  female  who  has  performed  the  duties  of  nurse,  have,  one 
and  all,  invariably  been  the  subjects  of  fever.  And  to  show  that  the  disease  is  capable 
of  being  engendered  by  fomites,  or  clothes,  the  laundresses,  whose  duty  it  is  to  wash 
the  patients'  clothes,  are  so  invariably  attacked  with  fever,  that  few  women  will  un- 
dertake the  loathsome  and  disgusting  office." 

Now,  it  is  in  vain  to  attempt  to  escape  from  this  kind  of  evidence,  by  saying  thai 
the  situation  of  the  Fever  Hospital  is  infested  with  some  local  miasm ;  for  the  in- 
mates of  the  Small-pox  Hospital,  which  is  immediately  adjacent  to  it,  are  not  affected 
in  this  way  with  continued  fever,  but  remarkably  exempt  from  it,  as  Dr.  Gregory 
testifies. 

Evidence  of  a  somewhat  different  kind,  but  leading  to  the  same  conclusion,  is 
to  be  found  in  the  fact,  that  when  persons,  having  the  fever  upon  them,  are  trans- 
ferred to  some  distant  spot  that  was  previously  free  from  fever,  they  frequently 
form  centres  from  which  the  disease  begins,  thenceforward,  to  spread.     It  is  im 

4£ 


950  CONTINUED    FEVER. 

parted,  i-n  this  way,  even  in  the  country,  from  family  to  family,  and  from  village  to 
village. 

I  was  summoned  home  from  Edinburgh  on  account  of  my  mother's  serious  illness 
with  continued  fever.  She  was  living  in  a  village  where  there  was  little  or  no  fever 
prevailing.  While  she  was  recovering  my  sister  took  the  disease,  and  had  it  se- 
verelj'.  It  had  evidently  been  introduced  into  the  house  by  a  man-servant,  whose 
family  lived  in  a  neighbouring  villag-e.  This  family  had  the  disease  raging  in  their 
house,  and  he  was  in  the  habit  of  going  thither  occasionally,  and  always  of  sending 
his  linen  to  be  washed  there.  He  first,  in  our  house,  had  the  disorder,  then  two  of 
the  maid-servants,  and  next  my  mother. 

The  cook  of  Trinity  College,  Cambridge,  living  in  a  street  called  the  Petty  Cury, 
had  a  daughter  in  London  who  fell  ill  with  continued  fever,  and  who  insisted  upon 
going  home.  At  that  time  there  probably  was  no  case  of  fever  in  Cambridge : 
certainly  none  in  the  Petty  Cury,  as  Dr.  Haviland  (who  gave  me  the  account)  satis- 
fied himself  by  inquiry.  The  girl  was  very  ill  indeed,  after  she  reached  her  father's 
house ;  but  she  ultimately  recovered.  Every  inhabitant  of  that  house,  except  an 
old,  seasoned  nurse,  became  affected  with  the  fever ;  and  three  or  four  of  them  died. 
But  no  fever  existed  in  the  other  houses  of  the  same  street.  When  one  of  the  sick 
persons  was  convalescent,  it  was  thought  her  recovery  might  be  accelerated  if  she 
were  put  into  a  lodging  at  Trumpington,  a  small  village  two  or  three  miles  from 
Cambridge,  in  which  there  certainly  was  then  no  fever.  Here  she  and  the  old 
nurse  were  waited  on  by  a  servant  belonging  to  the  Trumpington  House.  That 
servant  soon  sickened  of  the  fever,  and  was  sent  to  Addenbrook's  Hospital,  where 
she  died. 

Take  one  more  instance  to  the  same  effect,  related  by  Dr.  Alison.  "  Some  years 
ago,  at  a  time  when  there  was  no  great  number  of  fever  cases  in  Edinburgh,  I  met 
with  a  case  in  the  son  of  a  shoemaker,  who  was  lying  in  a  room  in  which  his  father 
and  two  apprentices  were  at  work.  I  could  not  prevail  upon  the  father  to  remove 
his  son  to  the  hospital,  although  I  stated  the  danger  of  the  apprentices  being  affected. 
AVithin  two  or  three  weeks  after,  I  found  that  the  two  apprentices  were  lying  ill  of 
fever  in  their  own  houses :  one  of  them  two  hundred  yards,  the  other  half  a  mile 
distant  from  the  workshop,  and  Avidely  distant  from  each  other.  These  young  men 
likewise  lay  at  home  during  the  fever;  and  each  of  their  cases  was  speedily  followed 
by  a  succession  of  others  in  the  inhabitants  of  the  rooms  which  they  occupied,  and 
of  those  immediatel}-  adjoining,  who  had  never  been  at  the  workshop.  In  one  of 
these  houses  seven,  and  in  the  other  twelve,  were  thus  affected.  Now,  on  the  sup- 
position of  the  fever  being  contagious,  all  this  was  to  be  expected,  and  all  corresponded 
to  the  predictions  which  were  hazarded  on  that  belief.  But  on  the  supposition  of 
such  succession  of  fever  cases  depending  on  miasmata,  there  must  have  been  at 
least  two,  more  probably  three,  separate  and  accidentally  concurring  miasmata  to 
explain  the  phenomena  here  observed  ;  one  at  the  workshop,  and  one  at  each  of  the 
houses  of  the  apprentices  :  and  there  must  have  been  this  extraordinary  coincidence, 
that  at  each  of  these  last  the  malaria  sprung  up  just  at  a  time  when  a  patient  was 
lying  ill  there  of  fever,  which  he  had  apparently  contracted  elsewhere.  Further, 
the  three  houses  in  which  these  successions  of  fever  cases  were  observed,  are  in 
situations  very  different  from  one  another;  and  all  of  them  have  been,  to  my  know- 
ledge, perfectly  free  from  fever  for  years  together,  both  before  and  since  that  time, 
notwithstanding  that  fever  has  been  much  more  generally  prevalent,  and  that  they 
have  been  inhabited  by  successive  families.  What  probability  is  there  (continues 
Dr.  Alison)  that  three  separate  miasmata  should  have  arisen  in  these  three  houses, 
just  at  the  time  when  their  presence  was  required  in  each  to  produce  an  effect 
which  had  been  foretold  as  the  consequence  of  another  cause  undeniably  operating 
i)n  all?' 

If  we  contrast  facts  such  as  I  have  been  advancing,  with  other  cases,  in  which  all 
die  circumstances  appear  to  have  been  precisely  the  same,  except  the  presence  of  the 
alleged  cause  of  the  disease — making  our  observations  always  upon  as  large  a  scale 
us  possible — we  approach,  as  nearly  as  the  subject  will  admit  of,  to  a  demonstrative 
l^roof  that  continued  fever  spreads  by  contagion. 


EXCITING    CAUSE.  951 

The  reports  which  were  made  by  the  accredited  physicians,  to  a  committee  of  the 
House  of  Commons,  respecting  epidemic  fever  in  Ireland,  contain  abundant  and 
valuable  evidence  on  this  point  also.  Dr.  Chejme  states  that  the  farmers  and  house- 
holders in  some  parts  of  Wicklow,  who  would  not  harbour  or  admit  into  their  houses 
strolling  persons,  nor  go  to  wakes  or  funerals,  remained  free  from  the  disease.  In 
Ballytore  a  committee  was  formed  of  persons  who  took  pains  to  instruct  the  inha- 
bitants as  to  the  precautions  to  be  observed  against  infection  :  such  as  refusing  admis- 
sion to  wandering  beggars,  absenting  themselves  from  wakes  and  other  assemblies ; 
and  even,  under  certain  circumstances,  from  places  of  worship.  These  precaotrons 
were  so  effectual  that  not  a  case  of  fever  occurred.  Four  villages  in  the  neighbour- 
hood of  Lismore  are  stated  by  Dr.  Barker  to  have  been  preserved  from  the  fever, 
chiefly  by  the  exertions  of  some  Roman  Catholic  clergymen,  who  persuaded  the 
inhabitants  to  avoid  all  communication  with  Lismore,  and  with  another  town  in  its 
vicinity,  where  the  fever  was  rife. 

Tt  was  observed  also  that  bodies  of  persons  collected  together,  and  fenced  about  by 
barriers  which  precluded  intercourse  betAveen  them  and  places  infected  with  the 
fever,  remained  exempt  from  it ;  children  in  charity  schools,  soldiers  in  barracks, 
and  even  prisoners  in  the  jails.  In  the  same  parliamentary  report  you  may  see  a 
letter  from  Dr.  M'Donald,  who  had  established  a  fever  hospital  at  Belfast,  which 
hospital  alone,  at  one  period,  contained  190  cases  of  typhus.  Very  near  the  hospital 
was  a  school,  containing  700  or  800  young  persons  ;  a  poorhouse  with  800  inmates  ; 
and  a  barrack  with  1000  soldiers.  These  places  were  never  more  free  from  fever 
than  at  that  time. 

Facts  to  the  same  purpose  abound  in  the  medical  reports  of  the  army  and  navy. 
Those  of  the  navy  are  especially  valuable  and  instructive  in  this  matter,  because  the 
whole  of  the  circumstances  in  which  the  patients  are  placed  come  under  the  certain 
and  immediate  cognizance  of  the  medical  officers  superintending  them.  I  cannot  go 
into  particulars  here,  but  must  content  myself  v.'ith  referring  you  to  the  writings  of 
Dr.  Lind,  Sir  Gilbert  Blane,  and  Dr.  Trotter.  You  will  there  find  that  ships  which 
had,  for  a  great  length  of  time,  been  quite  free  from  fever,  have  had  that  disease 
spread  rapidly  from  one  individual,  recently  imported,  so  as  to  affect  almost  all  the 
crew.  This  was  often  the  case  when  raw  recruits  were  drafted  from  the  receiving 
ships.  It  appears,  from  reports  made  to  Dr.  Trotter  by  different  naval  surgeons, 
and  published  in  his  Mcdidna  Naiitica,  that  the  fever  was  conveyed  to  a  great 
number  of  vessels  forming  the  Channel  Fleet,  from  the  receiving  ship  called  the 
Cambridge. 

It  is,  moreover,  found,  that  when  persons  ill  of  fever  are  taken  away  from  their 
own  close  crowded  houses,  and  when  means  of  purification  are  employed,  the  fever 
ceases  to  spread  in  those  houses.  This  well-ascertained  fact  it  is  which  gives  to 
fever  hospitals  their  greatest,  nay,  almost  their  only  value.  They  would  otherwise, 
as  we  have  already  seen,  be  detrimental  or  dangerous  to  all  concerned  with  them,  by 
concentrating  the  poison  that  produces  the  fever;  without  equivalent  benefit.  As  it 
is,  they  cause,  indeed,  a  certain  amount  of  disease  and  of  death ;  but  by  affording 
opportunities  for  cleaning  an  infected  neighbourhood  of  the  seeds  of  the  fever,  and 
by  so  preventing  its  diffusion  among  a  large  and  healthy  community,  they  save  many 
more  lives  than  they  sacrifice. 

You  may  be  surprised  that  I  should  appear  to  labour  this  point ;  and  should  take 
so  much  pains  to  prove  what  may  seem  to  you,  as  I  confess  it  seems  to  me,  to  be  an 
undeniable  proposition.  But  I  do  so  because  many  have  denied,  and  do  still  deny 
it ;  and  plausible  reasons  are  given,  by  men  of  name  and  character,  for  discarding 
altogether  the  notion  of  continued  fever  being  propagated  by  contagion.  Some  even, 
who  have  begun  by  expressing  their  belief  that  the  disorder  was  contagious,  have 
ended  by  becoming  strong,  ay,  violent  anti-contagionists.  The  late  Dr.  Armstrong 
was  one  of  these ;  and  there  are  living  men,  of  high  and  deserved  repute,  both  in 
this  country  and  abroad,  who  hold  what  I  cannot  help  thinking  erroneous — and  if 
erroneous,  then  manifestly  dangerous — opinions  on  the  subject.  Chomel  informs  us. 
that  not  one  in  a  hundred  of  the  profession  in  Paris  believes  that  typhoid  fever  is  a 
communicable  disease.     Upon  a  subject  so  important  it  is  right  that  vou  should  bo 


952  CONTINUED   FEVER. 

furnished  with  data  for  forming  a  correct  and  settled  judgment.  But  I  scarcely  ex- 
pect that  the  facts  I  have  now  brought  forward  will  carry  the  same  conviction  to  you 
all ;  for  I  agree  with  Dr.  Christison  in  believing  that  the  discrepancy  which  exists 
upon  this,  as  upon  some  other  controverted  questions,  depends,  in  part,  upon  the  dif- 
ferent constitution  of  men's  minds,  and  their  peculiar  habits  of  thought.  Most  of  the 
anti-contagionists  whom  I  have  known  have  belonged  to  that  party  in  this  country 
which  advocates  what  are  called  liberal  opinions  in  pohtics  and  in  religion.  If  this 
should  prove  to  be  generally  true,  it  must  be  regarded  as  a  curious  psychological 
fact. 

I  have  laid  before  you  some  of  the  positive  evidence  which  goes  to  prove  the  con- 
tagiousness of  continued  fever.  You  may  naturally  ask,  and  it  is  but  fair  that  I 
should  tell  you,  what  are  the  arguments  on  the  other  side  of  the  question. 

First,  then,  it  is  asserted  that  continued  fever  cannot  be  contagious,  because  some, 
nay  many  persons,  who  JiCive  intercourse  with  the  sick,  do  not  contract  the  disease. 

But  the  force  of  this  reasoning  is  completely  broken  by  the  well-known  fact  that, 
in  respect  to  diseases  which  are  on  all  hands  acknowledged  to  be  contagious,  and 
which  are  even  propagable  by  inoculation,  small-pox  for  example,  the  same  kind  of 
exemption  notoriously  happens.  Some  of  those  who  so  escape  may  have  had  the 
fever  before ;  and  have  thereby  become  less  capable  of  being  re-infected  by  the 
poison.  I  believe  it  to  be  uncommon  for  a  person  to  have  genuine  continued  fever 
for  a  second  time,  unless  he  is  exposed  to  the  contagious  matter  in  a  very  concen- 
trated state,  or  for  a  long  time  together.  Some  may,  by  original  peculiarity  of  con- 
stitution, be  proof  against  its  power;  but  probably  in  most  cases,  the  immunity  arises 
from  the  circumstance  that  the  person  has  been  fortunate  enough,  or  careful  enough, 
to  escape  imbibing  an  effective  dose  of  the  poison.  You  may  breathe,  for  a  good 
while,  without  much  hazard,  an  atmosphere  but  faintly  imbued  with  the  contagious 
effluvia ;  and  you  may,  though  with  somewhat  more  of  hazard,  breathe,  for  a  short 
time,  air  which  is  strongly  tainted  by  them,  and  yet  go  free. 

Allowance  must  also  be  made,  in  some  cases,  for  the  effect  of  habit  in  fortifying 
the  system  against  contagion.  Persons  who  are  much  and  often  exposed  to  these 
effluvia,  are  thereby  seasoned,  in  some  degree,  to  the  noxious  atmosphere :  just  as 
drunkards  and  opium  eaters  become  at  length  impassive  under  such  a  dose  of  their 
customary  stimulus  as  would  intoxicate  or  stupefy  a  novice.  Upon  this  principle  has 
been  explained  the  comparative  immunity  from  contagious  diseases,  (under  like  cir- 
cumstances of  exposure,)  of  medical  practitioners,  and  nurses  ;  of  the  keepers  of  filthy 
lodging-houses,  while  the  new-coming  inmates  suffer ;  and  even  of  prisoners,  who, 
without  having  had  the  disease  themselves,  may  nevertheless  carry  forth  and  com- 
municate the  infection :  as  is  said  to  have  happened  at  the  celebrated  "  black  as- 
sizes" in  Oxford ;  and  again  at  the  Old  Bailey  in  the  year  1750. 

This  argument,  that  the  fever  cannot  be  contagious  because  many  of  those  who 
come  near  the  sick  are  not  affected  with  it,  has  been  happily  ridiculed  by  comparing 
an  epidemic  to  a  battle.  A  man  might  say,  "  I  was  in  the  battle  of  Waterloo,  and 
saw  many  men  around  me  fall  down,  and  die,  and  it  was  said  that  they  were  struck 
down  by  musket  balls  ;  but  I  know  better  than  that,  for  I  was  there  all  the  time,  and 
so  were  many  of  my  friends,  and  we  never  were  hit  by  any  musket  balls.  Musket 
balls,  therefore,  could  not  have  been  the  cause  of  the  deaths  we  witnessed."  And 
if,  like  contagion,  they  were  not  palpable  to  the  senses,  such  a  person  might  go  on  to 
affirm  that  no  proof  existed  of  there  being  any  such  things  as  musket  balls. 

It  must  not  be  forgotten  that  this  same  argument,  whatever  may  be  its  validity,  is 
equally' potent  against  any  other  general  cause:  against  local  miasms;  against  an 
undefined  something  in  the  air. 

Again,  the  disorder  does  not  spread,  say  they,  in  the  houses  of  the  rich.  But  why 
should  it  not  do  so,  if  it  proceeds  from  any  cause  which  strict  attention  to  cleanliness 
and  ventilation  does  not  disarm  ?  The  fact,  when  rightly  considered,  is  a  strong  cir- 
'.•umstance  in  favour  of  the  theory  of  contagion. 

But  then  the  disorder  often  occurs  when  we  can  trace  no  contagion  :  and  the  full 
answer  to  this  argument  is  to  be  found  in  the  fact  that  the  same  difficulty  applies  to 
diseases  which  are  not  only  confessedly  contagious,  but  which  are  believed  to  have, 


ALLEGED   CAUSE.  953 

now,  no  other  source  than  contagion ;  even,  as  I  showed  you  before,  to  small-pox 
All  that  the  argument  can  amount  to,  is  a  presumption  that  the  distemper  may 
sometimes  originate  independently  of  contagion.  A  person  may  be  exposed  to  the 
agency  of  the  contagious  matter  quite  unconsciously,  by  coming  into  contact  with 
fomites,  or  by  approaching  another  person  who  is  just  convalescent  from  the  disease. 
A  nobleman  died  here,  in  the  prime  of  life,  last  year,  of  scarlet  fever.  The  story 
goes  that  he  had  just  come  to  town,  and  was  dining  out,  and  by  his  side  sat  a  young 
lady  who  had  just  recovered  from  that  complaint ;  and  that  from  her  he  unwittingly  re- 
ceived it.  Tn  such  a  place  as  this  there  are  a  thousand  unsuspected  ways  in  which 
contagion  may  be  disseminated.  It  may  lurk  in  a  hackney  coach  ;  you  may  catch 
the  complaint  from  your  neighbour  in  an  omnibus,  or  at  the  theatre,  or  at  church ; 
your  linen  may  be  impregnated  with  the  subtle  poison  in  the  house  of  your  laundress  ; 
or  your  coat  may  convey  it  from  the  workshop  of  your  tailor.  So  that,  when  con- 
tinued fever  occurs,  it  is  very  difficult  indeed  to  be  sure  that  it  has  not  arisen  from 
contagion  ;  and  it  becomes  a  very  interesting  question  whether  the  disease  ever  pro- 
ceeds from  any  other  cause.  It  is,  however,  of  primary  importance  to  determine 
whether  it  be,  or  be  not,  communicable.  By  our  belief  in  this  matter  the  lives  of 
our  neighbours  and  clients  may  be  saved,  or  lost.  Even  if  we  doubt  about  the  con- 
tagiousness of  the  disease,  we  are  bound  to  act  as  if  we  had  no  doubt  upon  the  sub- 
ject ;  and  I  would  admonish  you  (although  that  is  a  lower  and  poorer  motive)  that 
your  own  reputation  and  success  may  be  endangered  by  mistakes  in  this  very  thing. 
I  have  been  told  of  one  instance  which  may  serve  as  a  warning.  A  lady  came  from 
the  country  to  London,  to  see  a  sister,  who  was  ill  of  fever.  She  asked  the  medical 
attendant  if  there  was  any  danger  of  infection.  He  happened  to  be  a  staunch  non- 
contagionist ;  and  he  said  "  no  danger  whatever."  Upon  the  faith  of  that  assurance, 
the  lady  resolved  to  sit  up  with,  and  to  nurse  her  sister ;  but  she  fell  sick  herself  of 
the  disease,  and  died.  I  believe  this  did  not  shake  the  medical  man's  opinion.  He 
attributed  the  mischance  to  some  local  miasm.  But  he  could  not  persuade  the  lady's 
friends  of  this.  They  maintained  that  her  death  lay  at  his  door ;  and  whether 
they  were  right  or  wrong,  the  affair  was  so  much  talked  of,  and  was  so  injurious  to 
him,  that  he  was  obliged  to  leave  that  part  of  the  town,  and  to  seek  for  practice  else- 
where. 

Many  sporadic  cases  occur  of  febrile  disorder,  which  do  not  belong  to  the  category 
of  continned  fevers,  and  yet  are  liable  to  be  confounded  with  them.  All  the  phleg- 
masice  are  attended  with  pyrexia,  and  the  local  inflammation  may  be  slight,  or  very 
obscurely  marked,  and  easily  overlooked ;  but  the  febrile  symptoms  are  much  the 
same  as  those  which  constitute  the  more  inJJammatory  forms  of  continued  fever.  In 
hke  manner  severe  bodil}''  injuries,  compound  fractures,  for  example,  sometimes  give 
rise  to  constitutional  symptoms  precisely  resembling  the  most  prominent  phenomena 
of  its  typhoid  forms.  Excluding  all  such  spurious  resemblances  of  the  genuine  dis- 
ease, I  confess  my  own  opinion  to  be,  that  continued  fever,  hke  small-pox  and 
measles,  originates,  in  all  cases,  from  a  specific  poison.  With  respect  to  all  these 
disorders,  I  conceive  that,  in  every  large  community,  there  is  constantly  kept  up  a 
sufficient  stock  of  contagious  matter,  to  act  as  a  sort  of  leaven,  whenever  circum- 
stances favourable  to  the  development  of  the  disease,  as  an  epidemic  may  chance  to 
arise. 

Continued  fever  has  been  ascribed,  by  those  who  deny  its  origin  in  contagion,  to 
certain  other  causes  ;  some  of  which  demand  attention,  not  merely  on  account  of  the 
interest  that  belongs  to  the  whole  inquiry,  but  also  because  they  really  are  important 
agents  in  the  extension  of  the  disease. 

First,  then,  it  was,  and  is,  a  common  belief,  that  continued  fever  may  be  generated 
by  the  effluvia  constantly  proceeding  from  the  human  body,  even  when  healthy,  if 
these  effluvia  be  accumulated  and  condensed  by  the  crowding  tofjether  of  many  per- 
sons m  close,  dirty,  and  ill-ventilated  places.  It  is  unquestionable  that,  when  once 
introduced,  the  disease  spreads,  under  such  circumstances,  with  fearful  rapidity  ;  but 
the  point  at  issue  is  whether  it  be  ever  so  caused  de  novo.  I  must  refer  you,  for  good 
evidence  that  it  is  not  so  engendered,  to  Dr.  Bancroft's  book  on  the  yellow  fever. 
He  shows  that  typhus  fever  does  not  spring  up  in  places  where  it  could  scarcely  fail 

4e^ 


954  CONTINUED   FEVER. 

to  appear  if  that  theory  were  true.  He  instances  the  natives  of  the  arctic  regions, 
who,  in  order  to  shelter  themselves  against  the  extreme  cold  of  their  chmate,  live 
during  the  greater  pan  of  the  j^ear  in  close  subterraneous  dwellings,  from  which  the 
fresh  air  is  studiously  excluded,  and  of  which  the  atmosphere  becomes  so  offensively 
foul  as  to  be  scarcely  supportable  by  a  stranger:  yet  continued  fever  is  not  known 
among  them.  A  similar  exemption  from  that  disease  is  observed  within  the  tropics, 
in  the  African  slave  ships,  where  "  the  poor  wretches  are  crowded  together  below 
the  deck,  as  close  as  they  can  possibly  lie,  in  a  sultry  climate,  barred  down  with  iron 
to  prevent  insurrection."  Although  many  of  them  die  from  suffocation,  and  from 
fluxes,  5'et  Dr.  Trotter,  who  was  himself,  at  one  time,  surgeon  to  a  slave  ship,  de- 
clares that  "contagious  fevers  are  not  their  diseases."  Dr.  Bancroft  quotes  also  a 
narrative  of  the  sufferings  of  193  Europeans,  w'ho,  during  the  time  of  the  French 
Revolution,  were  "deported"  to  Cayenne,  in  the  Decade  frigate.  They  were 
crowded,  and  even  squeezed  together,  in  so  small  a  space,  and  for  so  long  a  time, 
that  the  sentinels,  who  were  placed  at  the  hatchways  to  guard  them,  and  who  were 
thus  exposed  to  the  hot  and  fetid  air  which  came  from  their  hole  of  confinement,  de- 
manded that  their  period  of  offensive  duty  might  be  shortened.  Yet  none  of  these 
miserable  persons  perished,  nor  did  fever,  properly  so  called,  arise  among  them. 
Neither  did  that  distemper  present  itself  in  any  of  the  survivors  of  the  Black  Hole  at 
Calcutta ;  the  frightful  account  of  which,  by  one  of  those  survivors,  Mr.  Howell,  is 
abstracted  in  an  appendix  to  Dr.  Bancroft's  work. 

Fever  used  to  infest  our  English  jails  ;  but  that  it  was  always  imported,  and  never 
engendered  there  by  filth  and  defective  ventilation,  and  by  the  accumulation  of 
human  effluvia,  may  be  concluded  from  the  fact  that  the  benevolent  Howard,  when 
he  visited  the  prisons  on  the  continent,  found,  to  his  great  surprise,  that  they  were 
free  from  fever,  although  they  were  no  less  close,  crowded,  and  impure  than  our 
own.  He  brings  the  result  of  his  observations  and  inquiries  concerning  the  cause  of 
the  jail-fever,  to  this  pointed  conclusion  : — "  If  it  were  asked,"  says  he,  "  what  is  the 
cause  of  the  jail-fever,  it  would  in  general  be  readily  replied,  the  want  of  fresh  air 
and  cleanhness ;  but  as  I  have  found  in  some  prisons  abroad,  cells  and  dungeons  as 
offensive  and  dirty  as  any  I  have  observed  in  this  country,  where,  however,  this  dis- 
temper was  unknown,  I  am  obliged  to  look  out  for  some  additional  cause  for  its  pro- 
duction"— which  additional  cause  can  be  no  other  than  the  contagious  poison  ema- 
nating from  the  bodies  of  those  who  have  the  fever.  It  is  true  that  fever  is  most 
frequently  met  with,  and  most  rapidly  propagated,  where  men  are  crowded  together 
in  jails,  or  in  close  and  ill-ventilaied  places ;  but  this  affords  no  reason  for  supposing 
that  it  is  ever  generated  there,  any  more  (to  use  a  homely  illustration  of  Dr.  Ban- 
croft's) than  the  general  prevalence  of  lice  and  other  parasitic  vermin  in  such  places, 
proves  that  these  vermin  are  generatedhy  fihh,  by  pent-up  human  effluvia,  and  vv'ant 
of  ventilation,  instead  of  being  merely  fostered  thereby. 

Again,  continued  fever  has  been  attributed  with  great  confidence,  to  a  vitiated 
state  of  the  air,  from  the  putrefaction  of  dead  animal  and  vegetable  substances.  Dr. 
Bancroft  deals  with  and  demolishes  this  error  also  :  showing  that  neither  the  putrid 
atmosphere  of  dissecting-rooms  (respecting  which  you  must  have  some  personal  ex- 
perience), nor  the  noisome  effluvia  from  full  and  ill  conducted  burial-grounds,  nor 
those  to  which  tallow-chandlers,  soap-boilers,  glue  and  cat-gut  makers,  and  the 
melters  of  whale  blubber  are  exposed,  nor  the  foul  air  of  sewers  and  privies,  have 
ever  been  known  to  produce  anything  like  continued  fever.  In  some  parts  of  Essex, 
near  the  coast,  where  the  farmers  are  in  the  habit  of  manuring  their  fields  with  shoals 
of  sprats,  I  have  seen  large  tracts  covered  with  these  fish  in  a  state  of  putrefaction. 
The  stench  they  occasion  is  horrible ;  but  no  disease  results.  Dr.  Chisholm,  in  a 
paper  to  which  I  can  only  refer,  but  which  I  would  recommend  you  to  look  at,  in  the 
sixth  volume  of  the  Edinburgh  Medical  and  SurgicalJournal,  brings  forward  other, 
and  very  satisfactory,  instances,  to  the  same  purpose :  from  a  bone  manufactory,  near 
Briton,  in  Gloucestershire;  from  an  establishment  (now  relinquished)  on  the  banks  of 
the  Avon,  for  converting  the  flesh  of  dead  animals  into  adipocire  ;  from  manufactories 
for  refining  sugar,  where  the  blood  of  slaughtered  animals  is  kept  for  that  use  by 
butchers ;  from  the  leather-dressing  business  ;  —  all  tending,  I  say,  to  the  conclusion, 


ALLEGED    CAUSE.  955 

that  air,  contaminated  by  ihe  decomposition  of  animal  substances,  is  not  necessarily 
noxious  to  life  ;  still  less  productive  of  that  specific  disease  which  we  are  now  con- 
sidering. The  old  belief,  therefore,  was  unfounded,  that  the  exhalation  from  the 
dead  and  putrefying  bodies  of  men  and  horses,  lying  unburied  on  the  field  of  battle, 
is  capable  of  producing  a  pestilence.  Many  instances  to  the  contrary  are  on  record: 
one,  of  an  early  date,  is  thus  stated  by  Biemerbroek: — "Anno  1G42,  in  agro  Julia- 
censi  maxima  strages  facta  est,  et  ad  minimum  8000  militum  occisi  fuerunt,  praster 
majorem  adhuc  famulorum,  rusticorum,aurigarum,  puerorum  et  mulierum  numerum, 
atque  equorum  copiam  innumerabikm ;  corpora  inhuraata  sub  dio  computruerunt, 
nulla  tamen  pestis  insecuta  est." 

It  has  been  said  that  fever  is  produced  by  some  unknown  condition  of  the  air,  im- 
perceptible by  our  senses,  but  distinct  from  contagion.  I  believe  this  is  a  very 
popular  notion ;  but  it  is  perfectly  gratuitous  and  untenable,  and  inconsistent  with 
observed  facts.  You  may  have  fever  raging  in  certain  parts  of  a  town,  and  yet  the 
parts  in  the  immediate  vicinity  of  these  be  quite  exempt  from  it.  Now  this  could 
hardly  be,  if  there  were  some  general  property  diffused  through  the  atmosphere 
capable  of  engendering  continued  fever ;  and,  as  I  stated  before,  this  notion  is  severely 
pressed  by  one  of  the  arguments  which  the  non-contagionists  themselves  are  fond 
of  employing  If  the  disease  depend  upon  contagion,  some  persons  in  the  commu- 
nity may  come  less  near  the  sick,  or  imbibe  a  less  dose  of  the  contagious  poison, 
than  others,  and  so  escape :  but  if  the  cause  of  fever  were  spread  abroad  throughout 
the  whole  atmosphere,  all  must  be  exposed  to  its  influence,  and  fevv,  we  may  sup- 
pose, could  avoid  suffering  from  its  operation. 

Exposure  to  cold  is  another  cause  to  which  fever  has  been  sometimes  attributed. 
But  this  is  an  agency  so  widely  prevalent  that  if  it  alone  could  excite  fever,  that 
complaint  Avould  be  far  more  general  than  it  really  is,  and  we  should  be  able  to  trace 
it  oftener  and  more  distinctly  than  we  can,  to  the  alleged  cause.  That,  by  its  debili- 
tating effect,  cold  will  predispose  the  body  to  be  affected  by  the  contagion  of  fever, 
I  well  believe :  and  the  same  remark  is  appUcable  to  another  cause  that  has  been 
assigned  ;  namely,  deficiency  of  nourishment.  Dr.  Alison,  in  his  admirable  essay 
On  the  Management  of  the  Poor  in  Scotland,  has  clearly  proved  that  the  preva- 
lence of  contagious  fever  amongst  the  lower  orders  is  always  in  direct  proportion  to 
their  state  of  physical  destitution.  The  association  of  pestilence  with  famine  is  pro- 
verbial. But  we  do  not  find  that  continued  fever  is  ever  created  by  the  mere  want 
of  nutriment.  In  persons  who  have  sought  to  starve  themselves  to  death — among 
sailors  who  have  of  necessity  been  kept  upon  very  short  allowances  of  food — in  cases 
of  insulation  by  snow  storms,  or  by  the  accidental  closure  of  a  mine — we  find,  indeed, 
that  disease  is  produced  by  the  privation  of  nourishment ;  but  it  is  not  continued 
fever.  The  condition  into  which  the  sufferers  are  brought  is  more  like  scurvy.  So 
that  although  a  want  of  sufficient  aliment  may  be,  and  doubtless  is,  a  powerful  aux- 
iliary in  prornoting  the  effect  of  the  contagious  poison,  there  is  no  ground  for  sup- 
posing that  it  ever  primarily  or  solely  occasions  fever. 

In  fact,  all  the  circumstances  which  I  have  now  been  considering  act  as  predis- 
posing causes.  They  render  the  human  body  an  easier  prey  to  the  real  exciting 
cause,  which  is  a  specific  animal  poison.  You  will  remark  that  they  are  all  debili- 
tating circumstances ;  and  where  several  of  them  co-exist,  their  joint  influence  ir 
subduing  the  system,  and  bringing  it  into  subjection  to  the  contagion,  is  very  great. 
For  the  same  reason,  depression  of  spirits,  however  produced,  has  a  strong  predis- 
posing effect ;  as  strong,  perhaps,  as  any  other  single  cause.  Of  this  I  have  seen, 
if  I  mistake  not,  some  remarkable  examples.  Upon  this  principle  we  may  explain 
the  fact,  that  continued  fever  is  especially  apt  to  attack  those  of  the  lower  classes 
who  have  recently  come  to  reside  in  the  metropolis ;  who  are  often  living  anxiously, 
and  with  persons  to  whom  they  were  not  previously  known.  We  have  had  nume- 
rous opportunities,  in  the  hospital,  of  noticing  this  curious  circumstance ;  and  it  is 
mentioned  by  almost  all  the  French  writers  on  fever.  To  the  same  principle  also 
we  must  attribute  the  tendency  to  fall  down  in  fever,  observed  in  young  soldiers  and 
sailors.  You  will  find  statements  to  that  effect  in  Dr.  Trotter's  works,  and  in  those 
of  Dr.  Lind  and  of  Sir  Gilbert  Blane.     When  fever  appears  in  a  ship,  the  raw 


956  CONTINUED   FEVER. 

sailors  are  always  the  soonest  attacked  by  it :  and  it  is  the  same  with  the  recruits  in 
the  land  service.  In  a  defeated,  dispirited,  or  retreating  army,  its  ravages  are  often 
frightful.  Here  we  have,  combined,  fatigue,  a  deficiency  of  wholesome  food,  and 
mental  depression. 

However  paradoxical  the  assertion  may  seem,  a  predisposing  cause  may  even  be 
applied,  and  operate,  after  the  exposure  to  the  exciting  cause — and  so  render  the 
latter  effective  when  it  might  not,  otherwise,  have  been  so.  Dr.  Russell  observed 
the  plague  sometimes  to  "  hang  ambiguously"  about  persons  for  several  days.  In 
this  state,  an  overheated  bath,  or  a  sudden  impression  of  fear,  especially  fear  of  the 
disease,  has  roused  the  lurking  poison  into  activity.  It  is  a  suggestion  of  Dr.  Hen- 
ry's, that  atmospheric  variations  may  call  into  action  contagious  poisons  already 
admitted  into  the  system,  but  not  yet  manifested  by  the  usual  phenomena ;  and, 
operating  thus  over  a  wide  space,  and  upon  numbers  at  once,  may  occasion  those 
sudden  and  violent  outbursts  of  epidemic  disease,  of  which  numerous  examples  are 
on  record. 

You  must,  I  think,  perceive  the  importance  of  distinguishing  between  the  one 
exciting  cause  and  the  many  predisposing  causes  of  fever.  The  latter  are  generally 
beyond  our  control.  We  cannot  hope  to  remedy  extensive  destitution  ;  nor  to  sepa- 
rate it  effectually  from  its  concomitants  of  filth,  and  despondency  of  mind.  But  we 
may,  by  timely  diligence,  root  out  the  specific  contagion,  or  confine  it  within  narrow 
bounds.  When  the  sick  can  be  at  once  removed  from  their  crowded  homes  to  a 
fever  hospital,  and  their  impure  apartments  ventilated,  cleansed,  and  whitewashed, 
the  disease  may  often  be  kept  in  check,  if  not  entirely  stopped  ;  and  the  yet  healthy 
persons  of  the  infected  district  be  preserved  from  its  grasp.  For,  as  I  stated  before, 
there  is  reason  to  believe  that  the  poison,  unless  pent  up,  does  not  remain  active  at 
any  great  distance  from  the  person  from  whom  it  proceeds ;  not  even  many  yards, 
or  feet.  It  is  very  rare,  I  apprehend,  to  meet  with  instances  of  the  disease  being 
communicated  in  the  open  air.  It  is  almost  always  caught,  if  at  all,  in  the  interior 
of  houses.  It  is  extremely  uncommon  for  it  to  extend  from  one  bed  to  anothe"  in 
our  general  hospitals,  where  great  attention  is  paid  to  cleanliness  and  ventilation. 
The  noxious  qualities  of  the  poison  are  diminished,  and  at  length  destroyed,  by  its 
dilution  with  common  air,  just  as  those  of  other  gaseous  poisons  are  :  and  hence,  in 
private  houses,  in  the  better  ranks  of  society,  where  the  rooms  are  spacious  and  airy, 
and  proper  precautions  are  taken,  the  disease  hardly  ever  spreads. 

What  are  those  proper  precautions  ?  They  are  simple,  and  may  be  stated  in  a 
very  few  words. 

Where  choice  can  be  made,  a  large  apartment  should  be  selected  for  the  sick  per- 
son. Unless  the  weather  be  very  hot,  there  should  be  a  fire  in  the  room,  for  it  acts 
as  a  ventilator.  The  air  of  the  chamber  should  be  kept  fresh  by  having  a  window 
or  door  (according  to  the  weather)  always  open  :  or  both  window  and  door.  Bed 
and  window  curtains,  carpets,  and  all  superfluous  articles  of  furniture,  should  be 
removed.  Great  diligence  should  be  used  in  keeping  the  patient  clean,  by  the 
requisite  ablutions,  and  by  frequently  changing  his  sheets  and  his  bod}^  linen  ;  and 
these  should  be  immersed  at  once  in  water;  and  all  discharges  from  the  sick  per 
son's  body  should  be  instantly  carried  out  of  the  room. 

All  unnecessary  intercourse  with  the  patient,  by  his  family  and  friends,  should, 
for  his  sake  as  well  as  theirs,  be  forbidden.  As  life  advances,  the  susceptibility  of 
the  disease  appears  to  diminish  :  for  which  reason  the  nurses  and  personal  attendants 
of  the  patient  should  not  be  very  young :  and  all  who  do  approach  the  sick  bed 
should  take  care  to  avoid,  as  much  as  possible,  inhaling  the  patient's  breath,  or  the 
emanations  which  proceed  from  his  person.  Friends  who  visit  the  apartment  at 
intervals  only,  should  never  enter  it  fasting. 

And  you  may,  if  you  please,  employ  the  chloride  of  lime  as  a  disinfecting  agent, 
in  aid  of  the  simple  measures  I  have  just  recommended ;  but  by  no  means  instead 
of  them.  People  hang  a  big  of  camphor  round  their  necks,  and  think  themselves 
safe  against  infection.  The  mental  confidence  which  that  expedient  is  calculated  to 
inspire,  may  perhaps  afford  some  degree  of  protection  ;  but  camphor  has,  in  reality, 
no  prophylactic  virtue ;  and  all  these  artificial  scents  are  objectionable,  inasmuch 


TREATMENT.  957 

as  they  tend  to  conceal  offensive  odours  which  might  otherwise  reveal  the  actual 
danger. 

I  shall  speak  of  the  treatment  of  continued  fever  when  we  next  meet. 


LECTURE  LXXXVI. 

Continued  Fever,  concluded.  Treatment.  Small-pox.  Its  essential  symptoms. 
Distinction  into  discrete  and  confluent.  Periods  and  modes  in  which  it  proves 
fatal. 

The  treatment  of  continued  fever  has  been,  at  all  times,  a  stumbling  block  to  young 
practitioners  ;  and  a  subject  of  dispute  even  among  physicians  who  have  built  it  upon 
their  own  experience.  Before  I  attempt  to  trace  out  any  plan,  or  to  lay  down  any 
principles  for  your  guidance,  it  may  be  useful  to  inquire  how  it  happens  that  the 
practice  in  this  disease  has  been  so  fluctuating  and  unsettled. 

In  the  first  place,  then,  it  is  very  difficult  to  estimate  the  value  and  efficacy  of  any 
particular  plan  of  treatment,  and  still  more  of  any  particular  remedial  substances,  in 
this  disease.  Continued  fever,  like  other  disorders  which  run  a  definite  course,  and 
have  no  direct  or  necessary  operation  in  spoiling  the  structure  of  vital  organs,  has  a 
strong  natural  tendency  to  terminate  in  health.  We  see  this  tendency  when  the 
disease  is  left  entirely  to  itself,  and  it  equally  exists  when  remedies  are  employed  to 
regulate  its  course,  or  to  abbreviate  its  duration.  No  one  can  doubt,  who  has  had 
much  experience  in  fever,  that  this  tendency  is  sometimes  thwarted  by  the  nimia 
cura  medici;  and  that  patients  get  well  in  spite  of  the  well-meant  but  mischievous 
interference  of  the  doctor.  This  tendency  to  recovery  is  a  constant  source,  therefore, 
of  fallacy  in  our  observations  upon  the  behaviour  of  this  disease  under  different  plans 
of  treatment ;  and  upon  the  effects  and  utility  of  remedies.  It  leads  us,  loo  oftenv 
into  the  danger  of  ascribing  to  drugs  what  is  really  due  to  the  workings  of  nature : 
of  confounding  antecedents  and  sequences  with  causes  and  effects ;  of  counting  re- 
coveries as  cures.  And  this  danger  is  increased  by  the  circumstance  that  continued 
fever,  although  it  observes  a  certain  definite  course,  is  nevertheless  liable,  even  when 
left  altogether  to  itself,  to  sudden  and  remarkable  changes  in  the  symptoms,  some- 
times for  the  worse,  and  sometimes  for  the  better  ,'  and  often  we  cannot  perceive  any 
obvious  reason  for  these  fluctuations.  But  if  this  happen  when  no  medicine  is  given, 
so  also  will  it  happen  when  the  disease  is  submitted  to  treatment;  and  it  requires 
more  than  a  Uttle  care  and  discretion  to  avoid  attributing  the  changes  which  so  occur 
to  the  remedy  which  was  last  employed.  For  example,  the  abatement  or  cessation  of 
headache,  after  a  few  days  have  elapsed,  is  a  natural  phenomenon :  whereas  an 
inexperienced  or  a  careless  person  might  easily  persuade  himself  that  it  had  yielded 
to  his  method  of  treatment,  and  that  it  was  a  favourable  omen :  neither  of  which 
conclusions  would,  however,  be  warranted  by  the  circumstance  upon  which  it  was 
founded. 

There  is  yet  another  source  of  difficulty  connected  with  this  subject.  I  have 
shown  you  that  not  only  individual  cases  of  fever,  but  different  epidemics,  vary 
much  in  their  character ;  so  that  a  plan  of  treatment  which  was  well  suited  to 
one  epidemic,  may  be  improper  and  even  hurtful  if  indiscriminately  applied  in 
another. 

These  considerations  may  serve  in  some  measure  to  teach  us  how  it  has  happened 
that  so  many  different,  and  sometimes  opposite  remedies  and  modes  of  treatment 
have  been  recommended  by  different  practitioners  for  the  cure  of  this  disorder.  The 
tendency  to  a  termination  in  health  was  very  plainly  visible  in  the  epidemic  fever  in 
Ireland,  to  which  I  have  more  than  once  referred.  The  mortality  among  the  patients 
who  were  placed  in  sheds  upon  straw,  with  very  little  medical  care,  and  even  with 
out  any  great  personal  attention  from  others,  was  very  small  indeed.  No  one  can 
form  even  an  approximate  judgment  of  this  tendency,  who  has  not  seen  the  disease 


958  CONTINUED    FEVER. 

under  several  varieties  of  practice.  Doubtless  one  rule  which  we  derive  from  a 
clear  perception  of  the  same  tendencj''  is,  that  we  should  not  interfere  unnecessarily. 
Aoxftf  rtfpt  to.  vovsr^uata.  hvo,  (says  Hippocrates)  a^iXsew,  rj  fxri  j57Mrf(£iv,  There  are  two 
things  to  be  considered  in  the  treatment  of  diseases :  first,  that  we  do  the  patient 
good ;  secondly,  that  at  least  we  do  him  no  harm.  In  all  these  exanthemata,  he 
must  be  reckoned  the  safest  and  the  best  practitioner  who  knows  when  to  abstain 
from  acting,  as  well  as  when  to  act ;  in  other  words,  who  has  learned  when,  and  to 
what  extent,  the  case  may  be  left  to  the  salutary  processes  of  nature. 

However,  there  is  an  opposite  error  to  that  of  mischievous  activity.  The  tendency 
to  recover  which  manifests  itself  under  different  modes  of  treatment,  and  even  in 
spite  of  opposite  modes,  has  induced,  in  some  minds,  a  degree  of  scepticism  as  to  the 
utility  of  any  remedies,  that  may  easily  be  carried  too  far.  It  does  not  follow,  be- 
cause the  majority  of  patients  under  continued  fever  would  at  length  emerge  into 
health,  although  no  remedial  measures  were  employed,  that  the  disease  ought  there- 
fore to  be  abandoned  to  what  Cullen  calls  the  vis  medicatrix  naturae.  It  is  not  quite 
correct  to  say,  with  the  older  pathologists,  that  the  whole  disorder  is  merely  an  effort 
oi  nature  to  throw  off  something  noxious  to  the  system,  and  therefore  is  not  to  be 
interfered  with.  The  true  view  of  the  matter  I  apprehend  to  be  that  which  a  toxi- 
cologist  might  take.  The  disease  is  produced  by  a  poison  of  which  the  injurious 
impression  upon  the  animal  economy  at  length  ceases,  or  passes  off,  of  itself;  in  the 
same  manner,  only  more  slowly,  as  the  influence  of  a  dose  of  opium  will  spontane- 
ously pass  away.  But  during  the  natural  course  of  the  fever,  as  in  many  other  cases 
of  poisoning,  morbid  processes  are  apt  to  be  set  up,  which,  if  suffered  to  proceed 
unchecked,  would  inflict  irreparable  injury  upon  important  organs,  and  which  are 
fairly  within  the  scope  of  remedial  management.  Our  object  must  be,  when  the 
fever  is  once  established,  to  conduct  it  to  a  favourable  close  ;  to  "obviate  the  tend- 
ency to  death."  Upon  this  point  I  agree  most  entirely  with  Pitcairn,  who,  being 
asked  what  he  thought  of  a  certain  treatise  on  fevers,  declared,  "  I  do  not  like  feve. 
curers.  You  may  guide  a  fever  ;  you  cannot  cure  it.  What  would  you  think  of  a 
pilot  who  attempted  to  quell  a  storm  ?  either  position  is  equally  absurd.  In  the  storm 
you  steer  the  ship  as  well  as  you  can  ;  and  in  a  fever  j^ou  can  only  employ  patience 
and  judicious  measures  to  meet  the  difficulties  of  the  case." 

When  some  immediate  change  ensues  in  the  symptoms  or  in  the  feelings  of  the 
patient  upon  the  administration  of  remedies  that  are  generally  followed  by  sensible 
effects,  we  are  warranted  in  ascribing  the  change  to  those  remedies.  But  even  here 
comes  in  the  fallacy  already  noticed,  arising  from  the  sudden  and  spontaneous  changes 
that  are  apt  to  occur  in  fever :  and  this  fallacy  is  to  be  got  over  only  by  multiplying 
our  observations. 

After  all,  the  best  guide  that  j'-ou  can  have  in  determining  upon  the  general 
principle  of  treatment  in  a  given  epidemic,  or  even  in  an  individual  case,  is  that 
which  Dr.  Alison  has  so  ably  enforced  in  his  lectures  and  in  his  writings  upon 
this  subject.  I  mean  the  observed  tendency  to  this  or  that  mode  of  dying.  The 
manner  and  circumstances  of  the  deaths  are  of  more  practical  importance  than  of 
the  recoveries. 

After  briefly  passing  in  review  some  of  the  principal  remedies  that  have  been  em- 
ployed and  recommended  for  this  disease,  I  propose  to  sketch  the  plan  which  I  am 
myself  in  the  habit  of  pursuing  in  the  management  of  fever  patients. 

It  was  once  a  favourite  practice  with  physicians  to  attempt  to  cut  short  the  fever 
at  its  outset:  and  the  two  expedients  which  were  chiefly  relied  upon  for  that  purpose 
were  emetics,  and  the  cold  ciffusion.  They  have  both  of  them,  in  this  country,  gone 
very  much  out  of  fashion.  In  truth,  neither  reason  nor  experience  encourages  us  to 
look  for  such  a  result  from  such  measures.  If  fever  depend  (as  I  believe  it  does) 
upon  a  poison  in  the  blood,  it  is  not  to  be  dislodged  by  the  act  of  vomiting,  nor  washed 
out  by  the  forcible  descent  of  cold  water  upon  the  skin :  and  in  the  few  instances 
in  which  the  one  or  the  other  of  these  remedies  may  have  seemed  to  arrest  a  fever, 
or  to  check  its  progress,  that  effect  has  always  occurred  at  the  very  commencement 
»f  the  complaint :  so  that  we  cannot  be  sure  (and  the  probability  lies  the  other  way) 
that  these  were  really  cases  of  fever  at  all,  or  that  they  would  not  have  ceased  even  ii 


TREATMENT.  959 

nothing  had  been  done  for  them.  Perhaps  emetics  may,  in  the  present  day,  be  too 
much  neglected.  1  have  no  notion  of  their  stopping  the  fever;  but  when  given 
early,  especially  if  gastric  disturbance  is  a  prominent  symptom,  they  are  sometimes 
followed  by  a  marked  abatement  of  many  morbid  sensations.  "  It  is  astonishing," 
says  the  observant  Sydenham,  "  how  it  happens,  that  a  vomit,  which  does  not  pro- 
duce either  a  large  or  a  morbid  discharge  from  the  stomach,  should  so  materially  re- 
heve  the  nausea,  restlessness,  anxiety,  and  furred  tongue  of  the  patient." 

The  cold  affusion  is  not  more  effectual  in  cutting  fever  short  than  the  treatment  by 
emetics;  and  it  has  these  great  disadvantages,  that  it  fatigues  and  alarms  the  patient: 
and  when  the  vital  powers  are  naturally  feeble,  or  are  much  depressed  by  the  disease, 
the  very  shock  of  the  affusion  may  be  attended  with  injurious  consequences. 

A  modification  of  this  expedient  is,  however,  often  of  great  use  in  abating  the 
morbid  heat,  and  soothing  the  uneasy  feelings  of  the  patient.  I  mean  the  practice 
of  cold  or  tepid  sponging  of  the  surface.  This  is  one  of  the  remedies  which,  when 
the  symptoms  appear  to  indicate  it,  deserves  to  be  tried  ;  and  the  propriety  of  con- 
tinuing or  of  discontinuing  it  may  be  determined  by  a  very  simple  test;  namely,  the 
feehngs  and  wishes  of  the  patient  himself  respecting  it.  It  is  most  adapted  to  the 
more  inflammatory,  and  least  adapted  to  the  more  typhoid  types  of  the  malady. 

Great  controversies  have  been  maintained  in  regard  to  the  effect  of  blood-letting 
in  fever.  They  who  hold  that  the  fever  consists  in  a  general  disturbance  of  the  sys- 
tem, growing  out  of  some  local  inflammation,  and  they  especially  who  believe  that 
continued  fever  is  nothing  else  than  inflammatioa  of  the  brain  and  its  membranes, 
would  naturally  seek  to  cure  it  by  the  remedies  of  inflammation.  But  although  local 
inflammation,  and  even  inflammation  of  the  brain,  is  very  apt  to  spring  up  in  the 
course  of  continued  fever,  there  is  no  reason  for  thinking  that  inflammation  anywhere 
is  essential  to  the  fever ;  but  very  much  reason  for  the  opposite  opinion.  The  active 
use  of  blood-letting  has  been  in  favour  and  out  of  favour,  with  the  medical  world, 
again  and  again  :  and  this  very  circumstance  would  of  itself  make  us  doubt  the  pro- 
priety of  its  indiscriminate  adoption. 

The  late  Dr.  Armstrong  gave  a  strong  and  unfortunate  impulse  to  the  practice  of 
free  blood-letting  in  continued  fever,  by  the  publication  of  his  well-known  and  inge- 
nious treatise  on  the  disease.  I  have  no  doubt  that  great  mischief  was  done  by  that 
work.  I  may  say  so  without  scruple,  since  Dr.  Armstrong  is  gone,  and  neither  his 
feelings,  nor  his  success,  can  be  hurt  by  the  expression  of  such  an  opinion :  and  I 
do  so  the  rather,  because  it  is  well  known  here  that  Dr.  Armstrong  saw  reason,  as 
his  experience  increased,  to  qualify  those  views  respecting  the  nature  and  manage- 
ment of  fever,  which  his  earlier  observation  of  it  in  the  country  had  led  him  to  form. 
This  change  in  his  sentiments  was  probably  justified  and  produced  by  a  change  in 
the  character  of  the  fevers  that  he  witnessed ;  but  it  does  not  appear  in  his  book. 
You  have  heard  me  state  already  that  whereas  the  fevers  which  occurred  in  London 
for  some  time  previously  to  the  year  1831  or  1832,  not  only  bore,  but  required  the 
abstraction  of  blood,  in  some  way  or  another, — since  that  period,  and  especially  since 
the  epidemic  cholera  visited  us,  i-t  has  been  necessary  to  abstain,  whenever  we  could 
with  safety,  from  taking  blood  at  all ;  and  still  more  necessary,  even  if  we  take  away 
blood  with  one  hand,  to  uphold  the  patient  with  the  other:  while,  in  the  former  pe- 
riod, wine  and  stimulants  of  all  kinds  seemed  generally  superfluous,  if  not  pernicious. 

Dr.  Williams,  of  St.  Thomas's  Hospital,  has  shown  very  clearly,  I  think,  in  his 
recent  publication  on  "  Morbid  Poisons,"  that  the  evidence  against  the  eflicacy  and 
the  safety  of  bleeding  in  continued  fever — of  bleeding  largely,  I  mean,  from  the  arm — 
far  outweighs  that  in  its  favour :  and  I  venture  to  advise  you,  as  the  result  of  all  that 
I  have  seen  of  the  disease  in  London  and  elsewhere,  not  to  draw  blood  from  a  vein, 
even  early,  merely  because  the  disease  is  or  appears  to  be  fever  ;  not  to  order  vene- 
section unless  there  be  some  other  manifest  reason  for  it — i.  e.,  unless  the  febrile 
symptoms  run  unusually  high,  or  unless  some  local  inflammation  is  unequivocally 
present :  and,  when  you  do  bleed,  do  not  take  a  drop  of  blood  more  than  seems  ab- 
solutely necessary  to  answer  the  desired  end.  Bleed  your  patient,  therefore,  if  at  all, 
m  the  upright  posture. 

Purgatives. — What  are  we  to  say  in  general  with  respect  to  them  ?     This,  I 


960  CONTINUED    FEVER. 

believe — that  the  intestines  should  be  cleared  by  an  active  aperient  in  the  outset: 
and  that  laxatives  should  be  continued  if  the  bowels  do  not  act  every  day  without 
them.  When  the  typhoid  type  is  strongly  marked,  and  when  the  symptoms  indicate 
ulceration  of  the  intestinal  glands,  purgatives  are  not  to  be  pressed. 

Much  contrariety  of  opinion  has  prevailed  also  among  practitioners,  and  does  pre- 
vail, about  the  administration  of  mercury  in  this  disorder.  Without  attempting  to 
strike  the  balance  between  these  conflicting  judgments,  it  is  my  business  and  duty 
to  state  my  own  belief,  to  tell  you  what  is  the  result  of  my  own  observation,  upon 
this  and  other  disputed  points.  I  must  repeat,  then,  that  my  practice  has  altered, 
in  several  particulars,  within  the  last  iew  years.  In  the  fevers  which  I  treated,  or 
saw  others  treat,  in  London,  prior  to  the  breaking  out  of  the  present  epidemic,  mer- 
cury, in  one  shape  or  another,  was  ahnost  constantly  prescribed :  and  a  great  num- 
ber of  the  patients  were  brought,  sooner  or  later,  under  the  specific  operation  of  that 
mineral :  and  in  these  patients  (with  one  exception  only,  where  the  mercury  appeared 
to  do  neither  good  nor  harm)  a  decided  improvement  was  almost  immediately  appa- 
rent upon  the  supervention  of  soreness  of  the  mouth  ;  and  all  such  patients  ultimately 
recovered.  I  am  aware,  however,  and  I  wish  you  to  be  aware,  of  an  alleged  source 
of  fallacy  in  this  matter.  The  gums  in  that  variety  of  fever  to  which  I  am  at  present 
referring,  did  not  readily  take  on  the  mercurial  action  ;  and  it  might  be  (though  such 
is  not  my  own  impression),  it  might  be  that  the  affection  of  the  mouth  by  mercury 
was  attributable  to  the  mildness  or  to  the  cessation  of  the  disease,  rather  than  the 
cessation  of  the  disease  to  the  effects  of  the  mercury  upon  the  system:  that  the  im- 
provement was  the  cause,  and  not  the  consequence,  of  the  mercurial  action. 

In  the  form  of  fever  that  is  ??o?<j  epidemic  (1838),  I  do  not  think  mercury  so  proper. 
Last  year  the  spotted  fever  broke  out  in  a  patient  of  mine  while  he  was  in  the  hos- 
pital, and  while  his  gums  were  sore.  I  found,  upon  inquiry  at  that  time,  that  of 
twelve  fever  patients  who  had  been  recently  treated  in  the  hospital,  by  my  colleagues 
and  myself,  with  mercurials  in  greater  or  less  quantity,  four  had  died,  in  all  of  whom 
the  gums  were  affected  :  whereas,  of  sixteen  others,  who  took  no  mercury,  three  only 
died  ;  and  cjf  these  three,  one  was  pulseless  at  her  admission,  from  uterine  hemorrhage, 
and  the  other  two  were  so  feeble  and  exhausted  that  they  were  scarcely  able  to  swal- 
low. I  should  give  mercury  very  cautiously,  therefore,  if  at  all,  in  this  typhoid 
variety  of  the  fever. 

Besides  a  strict  enforcement  of  the  antiphlogistic  regimen,  my  own  mode  of  treat- 
ing continued  fever  is  somewhat  of  this  kind.  I  am  always  desirous  that  the  patient's 
hair  should  be  cut  off.  The  mere  removal  of  it  is  often  attended  with  benefit :  the 
headache  and  confusion  of  thought  are  relieved,  and  the  patient  is  calmed.  We  can 
then  also,  with  much  greater  convenience  and  effect,  apply  cold  washes  to  the  head. 
Patients  sometimes  demur  to  this  shaving  of  their  heads  :  but  they  generally  consent 
if  you  explain  to  them  that  their  hair  will  at  length  fall  off,  in  consequence  of  the 
fever ;  and  that  the  head,  if  on  that  account  only,  had  better  be  shaved  at  once. 
The  head  and  shoulders  should  be  somewhat  raised,  and  thin  strips  of  hnen,  kept 
constantly  wet  with  some  cold  lotion,  should  be  continually  applied  upon  the  forehead 
and  scalp.  It  should  be  the  business  of  one  person  to  attend  to  this.  You  would  be 
surprised  at  the  rapidity  with  which  the  cloths  sometimes  dry. 

Now,  with  regard  to  this  remedial  measure,  you  need  not  have  any  difficulty.  It 
will  do  good,  and  should  be  steadily  employed,  so  long  as  it  is  grateful  to  the  feel- 
ings of  the  patient ;  and  it  ivill,  generally,  be  pleasant  and  agreeable  to  him,  so 
long  as  the  head  remains  morbidly  hot.  If  the  temperature  of  the  scalp  be  not 
above  the  natural  standard,  and  especially  if  the  cold  application  make  him  shivery 
or  uneasy,  and  give  him  annoyance  instead  of  comfort,  then  it  must  be  at  once 
discontinued. 

If  the  patient  suffered  intense  headache,  and  his  face  were  flushed,  and  the  heat 
of  the  surface  great,  and  he  weore  wildly  delirious,  and  his  pulse  were  full  and  hard, 
I  might  perhaps  deem  it  right  to  take  blood  from  his  arm,  while  he  sat  up.  But, 
even  under  these  circumstances,  I  should  generally  think  it  better  to  apply  leeches 
to  his  temples,  or  behind  his  ears,  or  to  remove  a  few  ounces  of  blood  from  his  neck 
by  means  of  cupping-glasses,  and,  at  the  same  time,  to  ply  assiduously  the  cold  lotion 


TREATMENT.  96T 

If  the  bowels  have  not  been  already  purged  by  nature  or  art,  it  is  right  to  give 
three  or  four  grains  of  calomel  at  once,  and  to  follow  this  up  by  a  black  dose.  After 
that,  I  was  formerly  in  the  habit  of  prescribing,  in  the  early  periods  of  the  fever, 
unless  the  bowels  were  irritable,  a  pill  composed  of  two  grains  of  calomel  with  two 
grains  of  James's  powder,  every  six  hours ;  washing  it  down  with  a  common  saline 
draught.  In  hospital  practice,  I  frequently  omitted  the  sahne  draught ;  allowing  the 
patient  to  drink  toast  and  water,  or  barley  water,  as  often  as  he  wished.  If  there 
was  diarrhoea,  or  early  prostration,  I  gave,  instead  of  the  combinatfon  just  mentioned, 
five  grains  of  the  hydrargyrum  cum  cretd.  At  the  same  time,  I  carefully  investi- 
gated the  state  of  the  abdomen  ;  and  if  I  found  tenderness  at  the  epigastrium,  or  in 
the  coecal  region,  in  both  of  which  situations  tenderness  was  common,  I  applied,  over 
the  tender  spot,  from  six  to  ten  leeches,  and  covered  the  leech-bites  with  a  light  poul- 
tice. If  the  diarrhoea  ran  on  profusely,  I  added  to  the  hydrargyrum  cum  creta  a 
certain  quantity  of  Dover's  powder,  or  of  the  extract  of  poppy. 

In  those  forms  of  fever  (whereof  the  prevailing  epidemic  affords  you  a  well- 
defined  specimen)  in  which  there  is  a  strong  and  early  tendency  to  typhoid  symp- 
toms, a  signal  loss  of  strength,  a  confused  and  dusky  countenance,  a  mottled  state 
of  the  skin,  simulating  the  eruption  of  measles,  a  dark  dry  brown  tongue,  a  feeble 
pulse — in  these  forms  I  begin  very  early  to  give  the  patient  a  full  allowance  of  beef 
tea;  and  if  the  typhoid  and  nervous  symptoms  become  more  pronounced,  I 
add  ammonia,  Hoffman's  sether,  and,  what  is  better  still,  wine ;  and  I  omit  the 
mercury. 

Under  this  kind  of  management  the  patients  will  often  go  on,  in  a  doubtful  state, 
for  some  days,  and  at  length  begin  to  recover.  Many  of  them,  especially  in  the 
more  typhoid  varieties,  sleep  heavily,  as  the  disorder  passes  slowly  off. 

There  is  one  point  in  the  treatment  of  fever,  of  exceeding  importance,  and  of 
some  nicety:  I  mean  the  use  of  opiates.  If  they  are  given  inopportunely,  they  are 
apt  to  puzzle  and  perplex  the  case.  You  do  not  know  how  much  of  the  disposition 
to  coma  is  owing  to  the  disease,  and  how  much  is  the  consequence  of  the  remedy. 
Again,  you  may  easily  augment  the  natural  tendency  to  coma,  and  lull  your  patient 
into  a  fatal  stupor.  But,  when  judiciously  administered,  opium  will  often  save  a 
patient  who  would  inevitably  sink  without  it. 

It  is  in  that  form  of  fever  which  the  French  call  the  fievre  ataxique, — when  the 
patient  is  affected  with  delirium,  restlessness,  wakefulness,  and  spasm,  and  the  dis- 
turbance of  the  nervous  system  outruns  the  disturbance  of  the  sanguiferous  system, 
— that  opium  is  so  beneficial.  The  condition  of  the  patient  resembles  that  of  a  person 
in  delirium  tremens.  It  is  said  that  these  symptoms  occur  most  commonly  amang 
patients  in  those  ranks  of  life  that  are  above  the  lowest  rank;  and  it  probably  is  so: 
but  they  are  apt  to  take  place  in  any  patients,  high  or  low,  rich  or  poor,  who  have 
had  the  mind  over-wrought,  and  the  nervous  system  unstrung,  whether  by  dissipa- 
tion and  intemperance,  or  by  anxiety  of  any  kind.  Sydenham  was  quite  aware  ol 
the  existence  of  this  particular  set  of  symptoms,  and  of  the  remedy  for  them.  Of 
all  these  symptoms,  sleeplessness  is  the  most  urgent.  Dr.  Grattan  and  Dr.  Latham 
have  both  written  in  praise  of  the  same  opiate  treatment,  under  such  circumstances, 
as  was  recommended  by  Sydenham.  Dr.  Grattan  observes,  with  great  truth,  that 
two  or  three  nights,  spent  in  restless  delirium,  are  followed  by  the  worst  conse- 
quences ;  and  that  patients  who  pass  three  nights  in  succession  in  that  way,  almost 
invariably  die.  If  the  symptoms  be  well  marked,  the  best  mode  of  proceeding  is  to 
give  a  tolerably  full  dose  of  opium  in  the  evening;  one-third  of  a  grain  of  acetate 
of  morphia  is  a  common  prescription  with  me.  The  amendment  of  the  patient,  on 
the  following  day,  is  often  very  striking.  Unless  the  same  symptoms  recur,  it  is 
better,  I  think,  not  to  repeat  the  anodyne.  But,  as  Dr.  Latham  cautions  us,  "there 
are  cases,  where  the  indications  for  the  employment  of  opium  are  doubtful.  Wild 
delirium,  and  long  wakefulness,  and  a  circulation  weak  and  fluttering,  seem  to  call  for 
a  considerable  dose  of  opium.  Yet,  withal,  there  is  a  certain  jerk  in  the  pulse,  so 
that  we  cannot  help  suspecting  that  the  blood-vessels  have  something  to  do  with  the 
sensorial  excitement.  Under  such  circumstances,  I  have  certainly  seen  (says  he) 
twenty  minims  of  laudanum  produce  tranquil  sleep,  from  whi-ch  the  patient  has 
01  4f 


962  CONTLXUED    FEVER. 

awoke  quite  a  new  man.  But  I  have  also  seen  the  same  quantity  produce  a  fataL 
coma,  from  which  he  has  never  been  roused.  Now,  (continues  Dr.  Latham,)  since 
it  is  a  fearful  thing  to  strike  a  heavy  blow  in  the  dark,  where  the  akernative  is  of 
such  magnitude,  it  is  the  safest  and  the  best  method  to  administer  a  small  dose,  at 
intervals  of  an  hour  or  two  :  so  as  to  stop  short  of  actual  mischief  at  the  first  glimpse 
of  its  approach,  or  to  be  led,  by  a  plain  earnest  of  benefit,  to  push  the  remedy  to  its 
full  and  consummate  effect.  Many  doses  may  be  required  for  this  purpose  ;  but  we 
shall  see,  after  the  first  or  second,  whether  to  go  on  or  to  desist." 

When,  as  is  sometimes  the  case,  the  stress  of  the  disorder  falls  upon  the  thorax, 
and  there  is  much  dyspnoea,  with  the  sounds  that  denote  inflammation  of  the  bron- 
chial membrane,  or  of  the  pulmonary  substance,  leeches  or  cupping-glasses  may  be 
applied  to  the  chest;  and,  in  milder  cases,  a  blister,  or  a  mustard  cataplasm. 

These  remedies — cold  to  the  shaven  head  ;  the  local  abstraction  of  blood  wherever 
there  happens  to  arise  evidence  of  local  inflammation ;  an  active  purge  at  first,  and 
mild  aperients  afterAvards,  if  the  bowels  are  confined  or  sluggish;  moderate  astrin- 
gents, if  there  is  much  or  urgent  diarrhosa,  a  few  grains  of  Dover's  powder,  for  ex- 
ample, or  of  the  extract  of  catechu  ;  opium  in  a  more  efficient  dose,  when  the  nervous 
symptoms  are  prominent,  particularly  sleepless  delirium  and  restlessness  ;  in  certain 
cases  small  and  repeated  doses  of  some  preparation  of  mercury  ;  and  in  certain  cases, 
earlij  support  by  animal  broths,  and  even  by  wine — these  remedies,  adapted  to  the 
particular  circumstances  of  individual  patients,  form  the  staple  of  the  treatment  of 
continued  fever,  according  to  the  best  of  my  judgment  and  experience. 

After  what  has  been  said,  I  need  scarcely  again  admonish  you  to  study  carefully, 
not  merely  the  symptoms  of  any  particular  case  to  which  you  may  be  called,  but  the 
general  character  of  the  fevers  that  are  at  the  same  time  prevalent,  and  the  manner 
of  dying  in  the  fatal  cases.  If  you  find  that  they  who  die,  die  chiefly  in  the  way 
of  asthenia,  that  will  be  a  strong  reason  for  caution  in  respect  to  the  removal  of  blood, 
and  for  the  early  employment  of  beef-tea,  and  other  means  of  support.  In  the  form 
of  fever  which  has  of  late  years  been  common  in  the  most  crowded  and  unhealthy 
parts  of  London,  I  am  sure  that  the  risk  of  beginning  this  sustaining  treatment  a  little 
too  early  is  much  less  than  the  risk  of  commencing  it  a  little  too  late.  If  plenty  of 
beef-tea  does  not  suffice,  you  must  give  the  patient  wine,  and  that  sometimes  to  a 
considerable  amount,  or  even  brandy  ;  the  egg-flip  of  the  Pharmacopoeia  for  instance, 
the  mistura  vini  gallici.  The  object  is  to  keep  him  alive,  to  keep  the  heart  in  mo- 
tion, until  the  depressing  influence  of  the  exciting  cause  of  the  disease  shall  have 
passed  by.  If  the  wine  should  flush  or  excite  him,  or  render  the  pulse  hard,  it  must 
be  diminished  in  quantity,  given  less  frequently,  or  omitted  altogether.  If  there  be 
indications  of  local  inflammation — pain  (for  example)  in  the  caecal  region,  increased 
by  pressure  —  leeches  may  be  used,  and  wine  given  at  the  same  time.  There  is 
nothing  inconsistent  in  such  mixed  practice.  We  seek  to  remove  the  local  inflam- 
mation by  unloading  the  capillary  blood-vessels  of  the  part,  while  we  uphold  the 
general  powers  of  the  constitution  which  are  ready  to  sink.  The  great  art  of  getting 
a  lever  patient  through  a  bad  attack,  is  to  have  him  judiciously  and  perpetually 
watched,  by  night  and  by  day.  The  remedy  that  is  proper  one  hour  may  do  harm 
if  pushed  during  the  next.  And  there  is  another  reason,  which  I  may  mention  en 
paasunt,  why  the  sick  person  should  never  be  left  alone,  even  for  a  moment.  I  have 
heard  of  moie  than  one  or  two  instai.ces,  of  patients,  in  the  delirium  which  attends 
the  disease,  getting  out  of  bed,  and  out  at  the  window,  during  the  temporary  absence 
of  their  nurse,  and  perishing  from  the  fall. 

If  the  patient  relishes  and  wishes  for  the  beef-tea,  or  the  wine,  that  is  no  small 
vvarranl  of  the  propriety  and  usefulness  of  its  administration. 

A  word  or  two  more  may  be  proper,  even  in  this  cursory  sketch,  respecting  cer- 
;ain  incidental  points  of  practice  that  are  apt  to  arise. 

Often,  when  there  is  no  longer  any  detectible  uneasiness  produced  by  pressing 
tne  oelly,  the  diarrhoea  will  persist,  and  meteorismiis  will  come  on  ;  a  tympanitic 
dis^tension  of  the  intestines  with  gas.  When  this  happens,  especially  in  the  latter 
periods  of  the  fever,  a  large  blister,  laid  over  the  abdomen,  has  often  very  happy 
t'lfects,  both  upon  the  diarrhoea  and  the  meteorismus.     The  diarrhoea,  whea  very 


CONTINUED   FEVER.  963 

urgent  and  obstinate,  nnay  often  be  checked  by  opiate  entmata.  In  some  cases  I 
have  recently  found  catechu  of  great  use,  in  these  long-drawing  forms  of  diarrhosa 
during  fever. 

Again,  if  the  patient  sinks  into  profound  coma,  a  blister  should  be  applied  to  the 
shaven  scalp.  The  sick  man.  will  sometimes  awake  from  deep  stupor  while  the 
blister  is  still  rising. 

It  is  always  a  matter  of  importance,  as  I  stated  before,  to  inquire  carefully,  every 
day,  into  the  condition  of  the  bladder  of  these  fever  patients.  In  the  state  of  stupor 
and  indifference  in  which  they  often  lie,  they  appear  not  to  be  sensible  to  the  want 
of  passing  the  urine,  which  collects  in  the  bladder,  and  distends  it  enormously ;  not 
only  increasing  the  present  hazard  of  the  patient,  but  laying  the  foundation,  some- 
times, of  future  disease  of  the  kidneys,  in  case  he  recovers  from  the  fever.  You  must 
not  take  the  assurances  of  the  nurses  upon  this  point.  They  will  often  tell  you  that 
the  patient  has  made  plenty  of  water,  when  in  fact  the  urine  has  been  dribbling  away 
from  him,  overflowing,  while  the  bladder  is  stretched  to  the  utmost.  Feel,  therefore, 
with  your  hand,  and  percuss  the  hypogastric  region,  as  well  as  that  of  the  caecum, 
at  every  visit. 

It  is  requisite,  too,  that  the  under  surface  of  the  patient's  body  should  not  only  be 
kept  scrupulously  dry  and  clean,  but  be  looked  at  every  day,  or  twice  a  day.  If  the 
projecting  points,  the  hip  bones,  the  sacrum,  the  shoulders,  the  elbows,  should  become 
red,  that  is  a  sign  that  they  are  likely  to  slough  or  ulcerate.  This  evil  consequence 
of  continued  pressure  upon  parts  of  which  the  vital  power  and  healthy  tone  are  lower- 
ed, may  often  be  prevented  by  washing  the  erythematous  spots  with  brandy.  Should 
the  skin  be  already  broken,  the  place  may  be  covered  with  soap-plaster.  An  adjust- 
ment of  pillows  and  of  posture  —  or  the  water-bed  —  may  sometimes  supersede  the 
necessity  of  these  local  expedients. 

When  ulceration  of  the  mucous  follicles  perforates  the  bowel,  that  catastrophe  does 
not  cdways  so  distinctly  declare  itself  in  fever,  as  in  other  cases.  I  have  seen  such 
perforation,  and  its  resulting, peritonitis,  when  no  complaint  of  pain  had  been  made 
by  the  patient,  so  great  was  his  insensibihty.  In  general,  however,  the  accident  is 
denoted  by  symptoms  which  cannot  be  mistaken.  When  it  does  occur,  there  is  but 
little  chance  of  the  patient's  recovery ;  and  that  little  will  be  best  husbanded  by  the 
adoption  of  the  plan  of  treatment  which  I  formerly  laid  down  :  opiates,  to  check  the 
peristaltic  movements  of  the  intestine  ;  and  a  rigid  adherence,  for  some  days,  to  the 
horizontal  posture. 

I  have  seen  a  few  instances,  in  which  an  oedematous  swelling  of  one  leg  and  thiffh 
has  occurred  in  the  advanced  stage  of  fever,  hke  that  which  is  incidental  to  parturient 
women,  and  depending  upon  the  same  cause  —  inflammation  and  obstruction  of  the 
great  vein  that  returns  the  blood  from  the  limb  towards  the  heart.  I  believe  that 
the  inflammation  extends  itself,  in  such  cases,  from  some  of  the  smaller  veins  of  the 
mesentery,  and  is  excited  in  them  by  the  intestinal  ulceration.  Fomentation  of  the 
affected  limb  comprises  all  the  remedial  treatment  which  this  accident  requires  or 
admits  of. 

The  management  of  the  patient  during  convalescence  is  scarcely  of  less  import- 
ance than  during  the  progress  of  the  fever.  The  chief  danger  is,  that  his  desire  to 
be  allowed  to  get  up,  and  his  wish  to  eat  animal  food,  shoulcf  be  too  soon  indulged. 
The  latter  of  these  errors  is  more  frequently  the  cause  of  a  relapse  than  any  other 
circumstance ;  and  relapses  are  often  more  perilous  and  difficult  to  remedy  than  the 
original  malady.  You  must  be  prepared,  therefore,  to  withstand  the  solicitations  of 
the  patient  and  of  his  friends,  who  think  that  if  strength  be  wantino-,  strono-  drinks, 
and  plenty  of  meat,  are  the  things  to  impart  it.  Until  the  tongue  is  quite  clean  and 
moist,  and  of  its  natural  colour,  and  the  pulse  has  lost  all  its  hardness,  and  the  skin 
its  excess  of  heat,  the  patient  must  be  kept  to  broth,  jellies,  puddings,  and  prepara- 
tions of  the  well-known  farinaceous  articles  of  food.  Then  he  may  begin  with  some 
boiled  white  fish,  and  so  gradually  eat  his  way,  through  chicken,  and  a  mutton-chop, 
to  his  ordinary  diet  again. 

Such,  I  say,  is  the  general  plan  of  treatment  which  some  observation  of  this  dis- 
order has  persuaded  me  is  the  best.    Summarily  expressed,  it  consists  in  the  exercisio 


964  BILIOUS   REMITTENT   FEVER. 

of  incessant  vigilance,  and  the  adoption  of  the  proper  remedy  at  the  proper  moment. 
It  lies  between  a  timid  or  scepticaJ  abandonment  of  all  known  resources,  and  a  med- 
dlesome rashness  in  applying  them.  The  flame  of  life  may  be  suffered  to  expire 
for  want  of  timely  succour,  by  the  practitioner  who  folds  his  arms,  and  looks  on ; 
as  it  may  be  rudely  extinguished  by  a  restless  or  routine  interference  which  has 
no  definite  or  intelligible  purpose.  Boerhaave,  in  the  preface  to  his  Aphorisms, 
professes  that  he  knows  of  nothing  which  can  be  fitly  termed  a  remedy,  "quin 
solo  tempestivo  usu  tale  fiat."  In  fevers  the  wisdom  of  this  maxim  is  eminently 
conspicuous.  The  rational  objects  of  treatment  are,  to  mitigate  the  urgency  of 
symptoms  that  cannot  be  wholly  subdued ;  to  redress  (so  far  as  art  may  redress) 
those  dangerous  complications  which  are  incidental,  but  not  essential,  to  the  dis- 
ease ;  and  to  aid  the  conservative  efforts  of  nature,  when  these  manifestly  languish 
and  fail. 

Dr.  Williams  holds  that  enemata  of  warm  water  and  syrup  of  poppies  will  do  all 
that  can  be  done  beneficially.  For  some  time  he  lost  only  one  patient  out  of  sixty- 
three  thus  treated.  This  was  a  most  encouraging  result.  But  then,  when  the  fever 
changed  its  type,  as  it  did  about  the  period  of  the  arrival  of  the  epidemic  cholera, 
he  lost  one  in  every  four  or  five  ;  a  very  large  mortality.  These  facts  illustrate,  in  a 
strong  manner,  the  necessity,  which  I  have  so  often  endeavoured  to  inculcate,  of 
taking  into  the  account,  when  we  would  estimate  the  value  of  a  particular  remedy 
or  plan,  the  difference  which  obtains  in  different  epidemics,  whether  bad,-good,  or  no 
treatment  at  all  be  adopted.  A  far  surer  method  is  to  compare  (if  you  would  expe- 
riment at  all)  two  or  more  different  modes  of  practice  in  different  cases  of  the  same 
epidemic.  Thus  Dr.  Latham,  finding  during  one  season  that  his  wards  were  full  of 
fever,  while  yet  its  type  was  so  mild  that  scarcely  any  died,  thought  this  a  favour- 
able opportunity  for  trying  whether  mercury  had  any  beneficial  operation  upon  the 
disease.  Accordingly  he  treated  half  his  cases  with  small  doses  of  the  hydrargyrum 
cum  creld  ;  and  the  other  half  with  the  liquor  aminonix  ucetatis,  and  so  forth,  and 
no  mercury ;  and  he  found  that  the  patients  in  the  first  of  these  classes  were,  on  the 
average,  convalescent  sooner  than  those  in  the  last.  Chomel  fancies,  from  some  trials, 
that  the  chlorate  of  soda  is  a  useful  remedy,  in  addition  to  the  general  plan  of  man- 
agement ;  but  further  experience  seems  wanting  to  settle  this  question. 

[Although  the  present  note  may  be  considered  somewhat  out  of  place,  considering  the 
class  of  diseases  with  which  Dr.  Watson  has  associated  Continued  Fever,  )'et  as  circumstances 
prevented  us  from  introducing  an  account  of  Bilious  Remittent  Fever,  after  the  author's  lec- 
ture on  Intermittents,  while  that  portion  of  the  work  was  passing  through  the  press,  we  knovr 
of  no  place  where  it  can  now  be  introduced  with  more  propriety  than  the  present :  the  dis- 
ease holding  a  kind  "of  middle  rank,  as  to  external  character,  between  intermittent  and 
continued  fevers,"  it  matters  little  in  connection  with  which  it  is  studied. 

Bilious  Remittent  Fetek.  —  With  the  exception  of  the  intermittent,  the  most  common 
form  of  fever  prevalent  in  the  middle,  southern,  and  south-western  sections  of  tlie  United 
States,  is  the  remittent,  or,  as  it  is  generally  denominated,  from  the  evidences  of  more  or 
less  derangement  of  the  hepatic  function  by  which  it  is  attended,  the  bilious  remittent,  or, 
simply,  bilious  fever.  It  constitutes  the  summer  and  autumnal  endemic  of  many  of  our  states, 
and  even  in  those  which  are  exempted  from  its  annual  occurrence,  it  occasionally  prevails, 
during  seaso»s  of  unusual  heat  and  dryness,  sporadically,  or  as  a  severe  and  widely-spread 
e-pidemic.  It  is  this  form  of  disease  to  the  attack  of  which  individuals,  from  the  cold  and 
temperate  sections  of  our  union,  are  so  peculiarly  liable  on  removing  to  those  localities 
where  it  is  endemic,  or  on  visiting  them  during  the  summer  and  autumn.  The  bilious  remit- 
tent fever  is  not  peculiar  to  the  United  States;  it  prevails  extensively  in  the  southern  portions 
of  France  and  Italy,  and  other  parts  of  the  south  of  Europe,  in  Africa,  and  in  the  East  and 
West  Indies:  it  is  in  fact  the  endemic  of  the  paludal  districts  of  all  hot  climates.  A  high 
degree  of  atmospherical  temperature  has  a  very  marked  influence  in  the  production  of  this 
form  of  fever;  either  by  eliminating  an  aeriform  morbific  matter,  or  by  predisposing  the  sys- 
tem to  the  action  of  the  morbific  causes  by  which  it  is  constantly  surrounded.  Its  prevalence, 
us  well  as  violence,  is  almost  invariably  in  direct  proportion  to  the  heat  nf  the  season,  white, 
in  many  of  the  more  northern  states,  where  the  disease  is  not  one  of  ordinary  occurrence, 
during  a  summer  of  extreme  heat,  it  will  prevail,  often  to  a  considerable  extent  —  and 
marked,  occasionally,  by  symptoms  of  extreme  violence ;  it  being  limited,  however,  almost 
exclusively  to  tho3e  situations,  noted  in  other  seasons  for  their  insalubrity,  or  in  which  the 


BILIOUS    REMITTENT    FEVER.  965 

causes  of  disease  are  ready  to  be  developed  upon  the  occurrence  of  any  unusual  degiee  of 
atmosplierical  heat. 

Notwithstanding  the  bilious  remittent  fever  can  scarcely  ever  be  mistaken  by  the  least 
experienced  jiractitioner,  it  exhibits,  nevertheless,  considerable  diversity  in  many  of  its  phe- 
nomena in  ditTerent  seasons  and  localities,  and  often  in  diflerent  individuals.  While,  in 
many  cases,  the  remissions  are  well-marked,  approaching  in  some  to  a  complete  intermission, 
in  others  the  remissions  are  so  slight  that  the  fever  has  almost  a  continued  form.  There  are 
always,  however,  certain  prominent  symptoms,  invariably  present,  an  attention  to  which 
will  lead  at  once  to  an  accurate  diagnosis : — Th'ese  are,  gastric  irritability,  a  sense  of  oppres 
sion  and  distress  at  the  epigastrium,  pain  of  the  head,  back,  and  limbs,  and  the  great  pros- 
tration of  strength  early  exhibited  by  the  patient. 

Bilious  remittent  fever  is  closely  allied  in  its  nature,  the  localities  in  which  it  chiefly  pre- 
vails, and  in  many  of  its  phenomena,  to  intermittent  fever,  of  which  by  many  it  is  considered 
as  a  mere  modification.  It  is  presumed,  and  with  much  plausibility,  that  "  a  more  intense 
operation  of  the  same  morbific  cause  required  for  the  production  of  intermittent  fever  engen- 
ders remittent,"  and  that  "the  more  violent  the  latter,  the  more  remote  is  its  character  from 
that  of  intermittent ;  or,  in  other  words,  the  less  perceptible  the  remissions."  That  a  more 
pow^erful  action  of  the  morbific  cause  is  demanded  for  the  production  of  remittent  fever,  is 
supposed  to  be  indicated  "by  the  circumstance,  that  when  periodic  fevers  are  prevailing  in 
certain  countries,  the  jiermanent  residents  are  often  observed  to  have  the  disease  in  the  form 
of  ague  only,  and  the  mortality  among  them  is  small;  but  strangers,  unhabituated  to  the  cli- 
mate and  its  diseases,  suSer  from  remittents,  with  a  proportionably  greater  loss  of  life.  la 
more  sickly  seasons  remittents  will  be  the  prevailing  form  among  both  classes  of  persons, 
but  strangers  are  more  violently  afiected,  and  the  mortality  among  them  is  greater.  Its 
affinity  to  intermittent  is  shown,  too,  by  the  tendency  which  it  has  to  pass  into  that  form, 
and.  inversely,  by  the  proclivity  of  ague  to  assume  the  remittent  type."  (Brown;  Cydopcedia 
of  Prad.  Med.) 

There  is  a  very  striking  analogy  between  the  milder  and  more  ordinary  form  of  the  bilious 
remittent  fever,  in  its  course  and  progress,  and  the  periods  of  a  double  tertian  ague.  Although 
the  exacerbations  occur  daily,  yet  there  is  almost  always  a  very  manifest  aggravation  of  all 
the  symptons  on  the  odd  or  alternate  days.  When  the  disease  assumes,  as  it  does  occasion- 
ally, a  quotidian  type,  the  exacerbations  generally  occur  several  hours  earlier  than  those  of 
the  double  tertian  form  —  the  former  happening  usually  about  nine  or  ten  o'clock,  and  the 
latter  not  until  towards  noon,  or  an  hour  or  two  later. 

The  milder  and  more  simple  form  of  bilious  remittent  fever  is  generally  preceded,  for 
some  days,  by  listlessness,  languor,  a  bitter  taste  in  the  mouth,  nausea,  aversion  from  food, 
an  indescribable  uneasiness  and  sense  of  fulness  about  the  epigastrium,  sometimes  costive- 
ness,  and,  very  generally,  more  or  less  pain  and  heaviness  over  the  eyes.  The  attack  is 
usually  ushered  in  by  a  slight  chill,  or  merely  by  a  sense  of  coldness,  particularly  about  the 
back,  which,  after  one  or  more  hours,  and  often  sooner,  is  followed  by  increased  heat  of  the 
whole  surface — the  skin  becoming,  at  the  same  time,  dry  and  constricted,  the  face  flashed 
and  turgid,  the  eyes  red  and  suffused,  the  respiration  hurried  and  uneven,  the  pulse  quick 
and  frequent,  but  rarely  tense;  there  is  great  prostration  of  strength,  with  considerable  rest- 
lessness and  watchfulness.  The  patients  complain  of  pain  and  a  sense  of  fullness,  weight, 
and  tension  of  the  head,  pain  of  the  back  and  of  the  extremities,  particularly  of  the  calves 
of  the  legs ; — and  of  a  sense  of  weight  or  oppression,  and  often  of  pain  at  the  epigastrium, 
which  part  generally  exhibits  more  or  less  tenderness  upon  pressure,  even  when  no  pain  is 
complained  of.  The  stomach  is  more  or  less  irritable  —  some  cases  being  attended  with 
distressing  nausea,  while  in  others,  everything  swallowed  is  instantly  rejected.  Spontaneous 
vomiting  is  a  not  unfrequent  symptom  —  it  is  often  present  from  the  commencement  of  the 
attack,  but  more  generally  it  does  not  commence  until  the  second  or  third  day,  or  even  later; 
the  matter  vomited  is  of  a  bitter  taste,  and  of  a  yellow,  greenish,  or  bright-green  colour. 
The  tongue  is  usually  moist,  red  at  the  sides  and  edges,  and  coated  on  its  upper  surface  with 
a  whitish,  light-brown,  or  yellowish  fur,  which  often  acquires  considerable  thickness.  There 
are  usually  considerable  thirst,  a  costive  state  of  the  bowels,  and  a  diminished  amount  and 
increased  coloration  of  the  urine ;  and,  after  the  disease  has  continued  for  some  days,  the 
skin  acquires  a  yellow  tinge,  which  is  sometimes  very  dec'ded,  and  extends  to  the  adnata  of 
the  eyes.  The  exacerbation  lasts  from  eight  to  twelve  hours,  when  a  gradual  abatement  of 
all  the  prominent  symptoms  takes  place,  and  often  a  slight  moisture  breaks  out  upon  the  sur 
face,  and  the  patient  falls  into  a  refreshing  sleep ;  more  generally,  however,  the  skin  conti 
nues  dry  after  the  heat  has  declined,  and  the  patient  during  the  remission  continues  restless, 
uneasy,  and  disinclined  to  sleep.  The  duration  of  the  remission  varies  with  the  violence  of 
the  attack ;  gradually,  however,  the  heat  of  tlie  surface  increases,  and  an  exacerbation  ot  the 
fever  follows,  marked  by  the  same  degree  of  intensity  as  the  former,  or  even  by  increased 
violence. 

All  the  preceding  symptoms,  in  an  aggravated  degree,  with  long-continued  exacerbation^ 
And  less  distinct  remissions,  naark  what  has  been  termed  the  highly  inflammatory  form  of 

4f2 


966  BILIOUS    REMITTENT    FEVER. 

the  disease.  lAiring  die  exacerbation  the  skin  is  intensely  hot,  the  eyes  are  suffused,  of  a 
muddy,  yellowish  hue,  and  often  dull  and  languid;  there  are  intense  pain,  and  a  sense 
of  insupportable  weight  and  tension  of  the  head  ;  aversion  from  light  and  sound  is  ordina- 
rily present,  and  occasionally  delirium  ;  there  are  great  thirst,  and  a  feeling,  often  almost 
insupportable,  of  oppression  at  the  chest ;  the  respiration  being  quick  and  laborious,  fre- 
quently irregular ;  the  pains  in  the  baclc  and  extremities  are  often  of  great  severity ;  the 
pulse  is  quick,  frequent,  and  more  or  less  tense ;  occasionally  it  exhibits  some  degree  of  irre- 
gularity ;  the  nausea  and  vomiting  are  generally  peculiarly  distressing — the  matter  discharged 
being  a  thick  ropy  fluid,  of  a  yellow,  darkish-brown,  or  green  colour;  the  bowels  are  costive, 
or  if  open,  discharge,  with  tenesmus  and  griping,  a  thin  watery  fluid:  when  evacuations  are 
procured  by  appropriate  means,  they  are  large  in  quantity,  dark,  slimy,  tenacious,  and  offen- 
sive. There  is  always  an  intolerable  sense  of  oppression  or  constriction  at  the  epigastrium, 
accompanied  by  a  degree  of  tenderness  which  renders  the  slightest  amount  of  pressure 
insupportable  —  or  a  severe  pain  and  burning,  attended  in  many  cases  with  great  nausea, 
and  frequent  ineffectual  efforts  to  vomit,  are  experienced.  There  is  great  restlessness,  with 
jactitation,  and  continued  watchfulness.  In  the  course  of  the  disease,  the  skin  acquires, 
most  generally,  a  brownish,  bronzed,  or  more  frequently,  a  deep  yellow  tinge,  which  is  par- 
ticularly marked  upon  the  face  and  breast.  A  symptom  mentioned  by  Rush,  as  generally 
present  in  cases  of  bilious  remittent  —  namely,  a  screatus,  or  constant  hawking  and  spitting 
of  a  small  quantity  of  tough,  glairy  matter — we  have  repeatedly  noticed. 

The  succeeding  exacerbations  are  marked  by  an  increased  violence  of  all  the  predominant 
symptoms  of  the  disease,  and  unless  the  intensity  of  the  fever  is  relieved  by  an  appropriate 
course  of  treatment,  the  powers  of  life  gradually  sink;  the  surface,  at  length,  becomes  cool, 
and  covered,  generally  or  partially,  with  a  cold  clammy  sweat;  the  pulse  becomes  small  and 
weak;  the  tongue  covered  with  a  dark,  thick  coating,  and  occasionally  dry  and  chapped; 
the  respiration  short,  quick,  and  difficult;  the  abdomea  sometimes  swollen  and  tympanitic; 
stupor  or  coma  often  ensues ;  not  unfrequently,  repeated,  and  at  length  involuntary,  dis- 
charges take  place  from  the  bowels,  of  a  dark,  offensive  matter,  and  finally  death  ensues. 

In  the  milder  forms  of  the  disease,  or  when  it  has  been  from  the  commencement  of  the 
attack  subjected  to  an  appropriate  treatment,  instead  of  an  increased  violence  in  the  pheno- 
mena of  each  succeeding  paroxysm,  there  is  less  decided  heat  of  the  surface,  the  pulse 
becomes  slower  and  less  frequent,  there  is  less  gastric  distress,  less  pain  and  tenderness  of 
the  epigastrium;  less  pain  of  the  head  and  back;  the  exacerbation  is  of  shorter  duration, 
and  as  it  declines,  the  skin  becomes  softer  and  more  moist,  the  tongue  less  coated,  the  coun- 
tenance more  cheerful,  and  the  patient  obtain.s  often  several  hours  of  quiet  and  refreshing 
sleep  ;  the  remissions  are  more  distinct,  and  of  longer  continuance,  until  finally  a  complete 
intermission  occurs,  followed  by  a  state  of  convalescence — which  is  usually  protracted. 

There  generally  takes  place  in  the  milder  and  uncomplicated  forms  of  bilious  remittent,  a 
distinct  exacerbation,  followed  by  an  evident  remission,  once  in  every  twenty-four  hours: 
but  in  the  more  violent  and  decidedly  inflaminatory  form,  the  remissions,  as  we  have  already 
remarked,  are  so  short  and  slight  as  almost  to  pass  unnoticed,  and  hence  the  inflammatory 
bilious  fever  is  described  by  many  writers  as  a  continued  fever. 

The  duration  of  the  disease  varies  with  its  degree  of  violence  and  its  simple  or  compli- 
cated character — it  may  terminate  in  a  few  days  or  run  on  for  several  weeks — but  its  usual 
duration  is  froin  nine  to  fifteen  days.  It  is  not  uncommon.  Dr.  Dickson,  of  South  Carolina, 
reiTiarks,  especially  among  the  most  perfectly  acclimated  adult  natives  resident  in  malarious 
localities,  and  strangers  long  familiarized  to  them,  to  find  bilious  remittent  fever  of  very  pro- 
tracted duration  ;  "  the  patient  sinking,  after  the  tenth  or  twelfth  day,  into  a  low  form,  resem- 
bling the  less  severe  grades  of  typhus,  and  hence  obtaining  among  us  the  designation  of  the 
typhoid  stage  of  bilious  fever.  Here  the  well-marked  lines  which  separate  the  period  of 
exacerbation  and  remission,  are  almost  effaced  ;  the  characteristic  periodicity  almost  obli- 
terated ;  the  fever  degenerates  nearly  into  the  continued  type,  and  the  patient,  in  the  lan- 
guage of  the  older  practitioners,  '  M'ades  through'  the  attack  with  no  definitely  regular 
changes  observable  from  time  to  time,  until,  by  the  success  or  failure  of  our  efforts  in  his 
behalf,  he  recovers  or  is  lost.  The  pulse  is  small  and  chorded,  the  tongue  throws  off  its  fur, 
and  is  smooth,  red,  and  dry,  or  smeared  over,  like  the  teeth  and  lips,  with  foul  sordes;  the 
stomach  loses  its  irritability,  and  the  vomitings  cease;  the  stools  are  dark  or  even  black; 
meteorism  occasionally  shows  itself;  there  is  muttering  delirium  or  disposition  to  heavy  stu- 
por and  coma;  the  countenance  is  dull  and  inexpressive;  muscular  languor  and  great  debi- 
lity ensue,  with  nervous  tremors  on  motion,  and  perpetual  subsultus  tendinum."  Dr.  DicV 
son  has  known  cases  of  this  kind  protracted,  in  three  instances,  to  thirty,  thirty-five,  and  fifty 
((ays,  though  the  average,  he  observes,  would  scarcely  reach  beyond  fifteen  or  twenty. 

A  carefal  analysis  of  the  phenomena  of  bilious  remittent  fever  shows,  very  conclusively, 
iliat  the  organs  chiefly  affected  are  the  liver  and  stomach,  and  the  results  of  post-mortem 
examinations  confirm  the  accuracy  of  this  deduction.  In  many  cases,  it  is  true,  the  symp- 
toms during  life,  and  the  lesions  detected  after  death,  indicate  more  or  less  affection  of  the 
jungs  or  brain ;  but  this  latter  is  to  be  viewed  as  an  accidental  complication,  and  not  essea 


BILIOUS    REMITTENT    FEVER.  967 

tial  to  the  disease.  Busing  our  conclusions  upon  the  investigations  of  Dr.  Stewardson, 
(American  Journ.  Med.  Scien.,  April,  1841,  and  April,  1842,)  which  are  confirmed  by  the  sub- 
sequent observations  of  Dr.  Svvett,  (i6i(/,  Jan.,  1S4.5,)  and  correspond  in  many  particulars 
with  those  of  Mr.  Twining  (^Diseases  of  Bengal,  chap,  v.),  a  morbid  condition  of  the  liver 
would  appear  to  be  invariably  present  in  remittent  fever — to  be  indeed  diagnostic  of  the 
disease  ;  it  is  nevertheless  very  certain  that  few  cases  of  bilious  fever,  of  any  intensity,  occur 
without  being  attended  also  by  indubitable  symptoms  of  gastro-enteric  disease — the  evidences 
of  which  are  very  generally  detected  in  those  who  die  of  the  fever.  In  many  cases  the 
indications  of  hepatic  disease  predominate,  wliile  in  others  those  of  gastric  adection  are 
most  prominent;  in  general,  however,  both  are  sufficiently  well  marked  in  the  same  case. 
It  has  been  proposed  to  distinguish  the  fever,  according  as  the  phenoiTiena  of  hepatic  or 
gastro-enteritic  disorder  predominates,  by  the  terms  hepatic  and  gastric.  Hepatic  remittents 
being  characterized  by  intense  febrile  heat;  violent  pain  of  the  head;  fullness  and  tension 
of  the  right  hypochondrium,  with  pain  and  pulsation  of  this  part  and  of  the  epigastrium  ; 
excessive  irritability  of  the  stomach ;  frequent  and  forcible  vomiting,  the  ejections  being 
without  any  trace  of  bile;  a  clean  state  of  the  tongue  in  the  early  stages;  a  decidedly  yel- 
hiw  colour  of  the  skin  and  adnata  of  the  eye  ;  great  torpor  of  the  bowels,  until  towards  the 
decline  of  the  disease,  when  a  copious  discharge  takes  place  from  the  bowels  of  a  dark  or 
pitch-like  tenacious  matter,  which  may  be  considered  as  in  some  degree  critical. 

Gastric  remittents  are  distinguished  by  a  bitter  taste  in  the  mouth;  great  thirst,  with 
a  craving  for  cool  and  acidulated  drinks;  frequent  vomiting  of  a  green  or  dark-brown  fluid; 
total  loss  of  appetite,  and  generally  disgust  for  every  kind  of  food;  a  feeling  of  great  weight 
and  anxiety  at  the  pra'cordia ;  pain  and  tenderness,  chiefly  at  the  epigastrium ;  intense  pain 
of  the  loins  and  knees,  and  soreness  of  the  calves  of  the  legs ;  severe  and  constant  pain  of 
the  forehead  ;  the  tongue  coated  in  the  centre  with  a  thick  layer  of  yellowish  mucus,  and 
red  at  the  sides  pnd  tip;  the  remissions  distinctly  marked  ;  bowels  costive,  or  when  dis- 
charges from  them  take  place,  these  are  thin  and  watery,  and  often  attended  with  griping 
and  tenesmus :  in  the  course  of  protracted  cases  the  stools  not  unfrequently  consist  of  a  red- 
dish fluid  resembling  the  washings  of  meat.  In  the  progress  of  the  disease,  the  tongue 
becomes  dry,  cracked,  and  covered  with  a  dark-brown  or  blackish  crust ;  upon  the  separation 
of  which  the  tongue  presents  a  smooth,  shining,  and  red  surface.  In  the  advanced  stage, 
there  is  often  retention  of  urine,  difl3culty  of  swallowing  fluids,  meteorism  of  the  abdo- 
men, &.C. 

Although  we  frequently  meet  with  cases  in  which  the  predominance  of  hepatic  or  of  gas- 
tric disorder,  but  especially  of  the  first,  is  thus  strongly  marked  ;  nevertheless,  in  the  gene- 
ral run  of  cases,  there  is  a  complete  blending  of  the  two  sets  of  phenomena. 

There  is  one  form  of  bilious  intermittent  stiU  to  be  described,  with  which  "  the  experience 
of  the  last  ten  years"'  has  made  the  practitioner  of  the  southern  and  south-western  portions 
of  the  United  States,  "unhappily,  too  well  acquainted,  under  the  denomination  o( congestive 
fever.  In  certain  localities,  indeed,  remarks  Dr.  Dickson,  the  ancient  inflammatory  features 
of  malarious  endemics  seem  to  have  disappeared,  and  to  have  become  supplanted  by  the 
more  hideous  and  pestilential  modification  thus  entitled." 

The  form  of  the  disease  to  which  we  allude  is  marked  by  a  diminished  temperature  and 
decreased  sensibility  of  the  whole  surface  of  the  body  —  the  skin  being,  at  the  same  time, 
soft,  contracted,  and  often  clammy,  or  wet  with  a  copious  perspiration  ;  when  a  partial  reac- 
tion takes  place,  the  heat  is  never  considerable,  and  it  is  often  confined  to  particular  parts  of 
tl)e  surface.  There  are  considerable  and  universal  lassitude  and  debility ;  the  head  is  con- 
fused and  affected  with  vertigo,  and  sometimes  with  a  deep-seated  pain  or  a  sensation  of 
oppressive  weight  or  tension  ;  the  eyes  are  heavy,  suffused  and  dull ;  the  countenance  is 
haggard,  and  the  face  j)ale,  and  of  a  dingy,  muddy  appearance;  the  pulse  is  small,  frequent, 
and  indolent,  or  struggling,  compressible  and  variable ;  the  tone  of  the  voice  is  often 
changed,  the  articulation  slow  and  drawling,  or  imperfect  and  stammering.  The  respiration 
is  anxious  and  laborious,  with  frequent  sighing.  The  tongue  exhibits,  at  first,  but  little 
change,  but  soon  becomes  dark-brown  or  black,  especially  in  those  cases  in  which  the  earlier 
stages  of  the  disease  have  been  marked  by  some  degree  of  excitement.  The  stomach 
is  occasionally  irritable  ;  the  epigastrium  and  right  hypochondrium  are  tender  upon  pressure, 
and  more  or  less  tinnid  ;  the  bowels  are  torpid,  and  when  stools  are  procured,  they  are  dark- 
coloured  and  ofiensive,  and  often  attended  with  tormina  and  tenesmus.  The  mind  is  gene- 
rally dull,  indifferent,  or  confused,  from  the  commencement  of  the  attack,  and,  in  the  progress 
of  the  disease,  sinks  into  a  state  of  more  or  less  complete  stupor,  or  of  low  muttering  deli- 
rium. The  remissions  of  the  fever  in  the  congestive  form  are  not  well  marked,  or  rather, 
there  is  an  entire  absence  of  the  febrile  exacerbations  and  remissions,  the  phenomena  of  the 
disease  presenting  but  little  other  change  than  a  rapid  or  a  gradual  augmentation  in  intensity 
In  fatal  cases,  death,  which  may  take  place  between  the  fifth  and  fifteenth  days,  or  even 
later,  is  often  preceded  by  hiccup,  subsultus  tendinum,  involuntary  stools,  hemorrhage  fiom 
the  stomach  or  bowels,  petechice.  &c. 

The  congestive  form  of  bilious  remittent   fever  may  attack  suddenly,  when  it  is  apt  '«■ 


968  BILIOUS    REMITTENT    FEVER. 

assume  a  peculiarly  malignant  form,  and  to  terminate  rapidly  in  death  ;  in  many  cases,  how 
ever,  it  is  preceded  by  the  same  symptoms  as  the  milder  and  more  open  forms  of  tlie  dis- 
ease. In  the  more  violent  attacks  of  congestive  fever,  "the  system  seems,"  to  use  the  words 
of  Dr.  Dickson,  "  to  sink  at  once  prostrate  before  the  invasion  or  exacerbation,  which  can 
scarcely,  at  times,  be  called  febrile.  Reaction,  to  use  our  technical  phrase,  does  not  take 
place,  or  very  feebly,  if  at  all.  The  skin  is  cold,  and  covered  with  a  clammy  sweat,  as  in 
rhe  collapse  of  cholera;  the  pulse  is  weak  and  fluttering;  the  stomach  is  very  irritable,  with 
frequent  and  painful,  but  usually  inelfectual,  eiforts  to  vomit ;  the  countenance  is  shrunken 
and  pale  or  livid;  there  is  often  low  muttering  delirium,  with  shivering  and  fainting.  In 
some  cases,  no  complaint  is  made,  a  lethargic  insensibility  seeming  to  oppress  the  patient; 
in  others,  the  most  extreme  anguish  is  endured  by  the  miserable  sufferer,  who  in  his  agony 
often  utters  groans  or  loud  cries.  The  vital  powers  are  speedily  and  irrecoverably  exhausted 
by  the  recurrence  of  a  few  such  exacerbations,  although  the  remissions  in  this  class  of  cases 
are  usually  well  defined,  and  full  of  transient  relief  and  hope.  The  third,  fourth,  or  fifth 
return  of  the  train  of  symptoms  delineated,  for  the  most  part,  puts  an  end  to  the  distressing 
scene." 

The  phenomena  of  congestive  fever  are  evidently  the  result  of  defective  innervation,  and 
an  impeded  action  of  the  heart  and  lungs;  the  blood,  imperfectly  decarbonized,  accumulates 
in  the  interior  organs,  and  thus  presents  the  full  and  regular  exercise  of  their  functions.  The 
impression  of  the  morbific  causes  by  which  the  disease  is  produced  is,  in  all  probability, 
made  primarily  upon  the  nervous  centre,  and  by  depressing  the  energy  of  its  action,  gives 
rise  to  all  the  other  phenomena  which  characterize  this  form  of  fever. 

The  propriety  of  denominating  these  cases  of  congestive  disease  bilious  remittent  fever, 
when  they  frequently  run  their  course  without  exhibiting  the  slightest  indication  of  febrile 
reaction,  has  been  doubted  by  some.  They  are,  however,  produced  by  the  same  causes  as 
the  bilious  fever,  and,  when  the  congestion  is  early  reduced,  the  case  often  assumes  all  the 
characteristics,  and  runs  the  same  course  as  in  the  ordinary  form  of  bilious  fever,  showing 
that  the  phenomena  of  the  latter  were  merely  masked  or  suspended  by  the  congestive  state 
of  the  principal  vital  organ. 

The  convalescence  from  an  attack  of  all  the  forms  of  bilious  remittent  fever  is  always 
protracted,  and  relapses,  from  slight  irregularities  of  diet  or  too  early  exposure,  are  not  unfre- 
quent.  After  severe  attacks,  the  hair  often  falls  entirely  off,  and  is  only  slowly  and  imper- 
fectly renewed,  or  the  patient  remains  permanently  bald.  The  functions  of  the  stomach  and 
alimentary  canal,  generally,  are  imperfectly  performed  for  a  long  period  after  recovery,  and 
require  the  utmost  circumspection  on  the  part  of  the  patient  to  insure  their  complete  restora- 
tion. Jaundice  is  a  very  frequent  consequence  of  bilious  "remittents.  This,  Dr.  Dickson 
states,  "was  noticed  generally  in  the  summer  "and  autumn  of  1824  ;  very  few  patients  reco- 
vering from  the  fever  in  that  year  without  becoming  icteric.  Nor  is  it  rare  to  meet  with 
hepatic  enlargement  and  induration,  attended  by  a  long  succession  of  saflerings  from  visceral 
obstructions  and  mechanical  impediments  to  the  performance  of  the  abdominal  functions, 
and  to  the  transmission  of  the  abdominal  circulation.  Hence  ascites  and  anasarca,  and  hence 
diarrhoea  and  dysenteries  called  hepatic,  and  occasionally  melcena  and  true  intestinal  hemor- 
rhage. The  spleen  suffers  from  remittents  of  malarious  origin,  as  from  their  kindred  iiiter- 
mittents,  though  not  by  any  means  so  uniformly,  sometimes  undergoing  a  permanent  and 
inconvenient  increase  of  size  or  hypertrophy."' 

With  the  pathological  anatomy  of  remittent  fever  we  are  but  imperfectly  acquainted  ;  very 
few  facts  in  relation  to  it  have  been  recorded,  and  of  these  few  many  are  loosely  and  imper- 
fectly detailed,  while  those  upon  the  accuracy  of  which  reliance  can  be  placed,  are  derived 
from  too  limited  a  series  of  observations  to  allow  of  any  positive  general  conclusions  being 
based  upon  them.  That,  however,  the  stomach  and  liver  are  the  organs  in  which  indications 
of  disease  are  the  most  luiiformly  detected,  all  the  facts  in  our  possession  very  clearly  prove, 
although  the  exact  nature  of  the  morbid  lesion  is  not  very  clearly  made  out.  "The  closest 
attention  to  clinical  observations,"  remarks  Mr.  Twining  (Diseases  of  Bengal,  chap,  v.),  "as  well 
as  the  result  of  post-mortem  examinations,  convince  me,  that  remittent  fevers  in  Bengal  art 
invariably  connected  with  loral  congestions,  which  often  run  rapidly  into  inflammations,  attended 
with  much  interstitial  effusion.  The  seat  of  these  local  affections  is  foimd  principally  ir  the 
stomach,  intestines,  cellular  structure  about  the  duodenum,  and  at  the  root  of  the  mesocolon, 
more  especially  where  it  passes  across  the  spine.  The  principal  disease  is  also  often  found 
in  the  spleen,  liver,  brain,  or  lungs."  Dr.  Gerhard,  of  Philadelphia,  maintains,  as  the  result 
of  his  observations,  that  the  anatomical  character  of  the  more  severe  forms  of  intermittent 
fever  is  to  be  detected  in  the  spleen,  liver,  and  stomach  ;  the  bilious  and  remittent  fevers 
being  "  ])robably  referable  to  the  same  class  as  the  malignant  remittents."  These  conclusions 
are  confirmed  by  the  observations  made  by  Dr.  Stewardson,  in  the  Pennsylvania  Hospital ; 
by  those  of  Dr.  bwett,  made  in  the  New  York  Hospital ;  and  by  the  results  of  dissections  in 
single  cases,  as  reported  by  Dr.  Howard  and  others.  Dr.  Boyd  describes  the  indications  of 
disease,  after  death,  in  the  bilious  fever  of  Minorca,  as  occurring  in  the  brain,  lungs,  liver, 
and  stomach ;  the  liver,  he  states,  was  in  most  instances  enlarged,  often  inflamed,  with  jt« 


BILIOUS   REMITTENT   FEVER.  969 

inferior  margin  livid  ;  the  gall-bladder  distended  with  viscid  bile.  The  stomach  and  intes- 
tines were  often  inflamed ;  the  villous  coat  being  of  a  dark  colour. 

The  appearances  in  the  stomach  are  variously  described ;  but  in  general,  they  are  stated 
to  be  injection,  M'ith  increased  redness  of  the  mucous  membrane — sometimes  thickening  and 
occasionally  softening  of  that  membrane.  In  many  instances,  the  same  appearances  are 
described  as  being  present  in  the  duodenum.  The  glands  of  Brunner,  in  this  intestine,  were, 
according  to  Dr.  Stewardson,  "  develof)ed  in  a  remarkable  manner,"  in  the  cases  examined 
by  him  ;  a  similar  development  did  not,  however,  occur  in  the  fatal  cases  which  fell  under 
the  notice  of  Dr.  Swett. 

In  all  the  dissections  made  by  Drs.  Stewardson  and  Swett,  and  the  one  reported  by  Dr. 
Howard,  the  liver  was  found  to  be  flabby,  of  a  bronze  colour,  the  two  substances  composing 
the  organ  being  blended  together  in  such  a  manner  as  to  be  scarcely  distinguishable.  The 
spleen  was  much  enlarged  and  softened.  The  peculiar  condition  of  the  liver,  just  described, 
Dr.  Stewardson  considers  to  constitute  "  the  essential  anatomical  character''  of  remittent 
fever:  he  thinks  it  highly  probable  that  the  same  alteration  of  the  liver  will  be  found 
to  exist  in  intermittents  which  prove  fatal  in  their  early  stage ;  these  and  intermittents  being, 
in  his  opinion,  essentially  the  same  disease. 

Drs.  Gerhard,  Stewardson,  Swett,  and  Howard,  never  detected  in  any  case,  after  death  from 
remittent  fever,  the  glands  of  Peyer,  and  the  other  intestinal  follicles,  in  a  diseased  condition  ; 
and  although  we  believe  that  these  parts  will  generally  be  found  in  a  perfectly  healthy  state, 
nevertheless,  it  is  certain  that  cases  do  occur,  particularly  of  the  more  protracted  forms  of 
the  disease,  in  which  the  evidences  of  follicular  inflammation  of  some  portion  of  the  small 
intestines,  terminating  occasionally  in  ulceration,  especially  of  the  glands  of  Peyer  at  the 
lower  end  of  the  ileum,  are  present  after  death.  Such  cases  are  referred  to  by  Dr.  Geddings, 
of  Charleston,  Drs.  Stevens  and  Vache,  of  New  York,  Dr.  Harrison,  of  Cincinnati,  as  quoted 
by  Dr.  Dunglison,  (^Practice  of  Med.,  2d  ed.,  vol.  ii.,  p.  450.)  A  diseased  condition  of  the  glands 
of  Peyer  is  stated  to  have  been  present  also,  in  all  the  cases  examined  by  Dr.  Richardson  in 
the  New  York  Hospital,  in  1840,  (^Dr.  Swett,  American,  Tourn.  Med.  Sciences,  January,  1845  ;)  and 
the  same  lesion  was  noticed  by  Dr.  Mc William  in  the  African  remittent  fever. 

The  indications  of  congestion  and  of  inflammation  so  frequently  met  with  in  the  brain 
and  lungs,  point  out,  it  is  true,  the  tendency  there  exists  in  remittent  fever  to  disease  of  those 
organs,  but  tliey  are  not  invariably  present,  nor  are  they  essential  to  the  disease. 

In  cases  of  congestive  intermittents,  the  anatomical  lesions  are  the  same  as  those  de- 
scribed above,  excepting,  that  when  death  takes  place  previously  to  the  occurrence  of 
complete  reaction,  there  is  very  generally  extensive  hyperemia  of  tlie  brain,  lungs,  liver,  and 
spleen. 

The  diagnosis  in  bilious  remittent  fever  will  depend,  in  a  great  measure,  upon  the  charac- 
ter which  the  disease  presents  in  different  localities  and  in  different  years,  as  well  as  upon 
the  constitution  and  other  circumstances  connected  with  the  individuals  attacked  by  it.  In 
the  milder  forms  of  the  disease,  with  distinct  exacerbations  and  remissions,  and  no  marked 
tendency  to  disease  of  the  more  important  organs,  particularly  when  they  occur  in  persons 
of  temperate  habits,  and  of  constitutions  neither  broken  down  on  the  one  hand  by  previous 
disease,  fatigue,  or  the  depressing  passions,  &,c.,  nor  on  the  other,  marked  by  undue  plethora, 
or  a  tendency  to  congestive  or  inflammatory  affections  of  tlie  central  organs  ;  by  a  judicious 
treatment,  early  commenced  with,  a  favourable  result  may  very  generally  be  obtained. 
Even  the  more  strongly  marked  inflammatory  form  of  the  fever  seldom  terminates  fatally 
when  vigorously  treated  from  its  onset.  The  congestive  or  malignant  form  of  the  disease  is 
one  in  which  the  prognosis  is  much  more  unfavourable ;  in  epidemics  of  congestive  bilious 
fever  the  mortality  is  often  truly  appalling.  Remittent  fever,  generally  speaking,  attacks 
with  less  severity,  and  is  more  readily  controlled  in  those  acclimatized,  as  it  is  termed,  to  the 
districts  of  country  in  which  it  occurs  as  an  epidemic  —  that  is,  persons  who,  having  passed 
through  the  disease,  continue  to  reside  in  those  districts.  A  stranger,  recently  arrived,  par- 
ticularly if  a  high  liver,  or  of  intemperate  habits,  or  whose  occupation  subjects  him  to 
exposure  and  fatigue,  is  not  only  more  liable  to  be  attacked  than  the  former  class  of  indivi- 
duals, but  in  such  a  one  the  disease  will  usually  be  marked  by  greater  severity,  and  be  more 
liable  to  terminate  fatally.  The  favourable  symptoms,  in  individual  cases,  are,  the  mildness 
and  comparative  shortness  of  the  exacerbation,  the  completeness  and  long  duration  of  the 
remission,  particularly  when  this  is  accompanied  by  a  free  and  diffused  perspiration,  and 
the  patient  falls  into  a  quiet  and  refreshing  sleep;  the  postponement  of  the  succeeding  exa- 
cerbations beyond  their  anticipated  periods;  the  diminution  or  removal  of  the  tendency  to 
disease  of  particular  organs;  the  occurrence  of  more  regular  and  healthy  discharges  from 
the  bowels;  the  tongue  becoming  cleaner  and  the  pulse  slower  and  less  frequent,  &c. 

The  bilious  remittent  fever,  as  we  have  already  remarked,  is  a  disease  of  hot  climates  ana 
of  the  season  of  greatest  heat;  thus,  while  it  constitutes  the  summer  endemic  of  the  south- 
ern portion  of  our  Union,  it  seldom  occurs  in  the  middle  and  northern  states,  excepting 
during  those  summers  that  are  marked  by  an  unusual  elevation  of  temperature;  and  here,  as 
well   as  in   the   places  where   it  prevails   endemically,  it  ceases  as  the  winter  approaches. 


J70  BILIOUS    REMITTENT    FEVER. 

Whether  the  fever  can  be  produced  by  exposure  alone  to  a  high  degree  of  atmospherical 
temperature,  is  a  question  that  has  been  frequently  raised ;  and  while  many  maintain  the 
affirmative,  others  as  positively  assume  the  negative.  It  is  very  certain,  however,  that  the 
long-continued  action  of  excessive  heat  upon  the  body,  by  predisposing  it  to  the  action 
of  other  morbific  agents,  will,  in  this  manner,  often  bring  on  an  attack  of  bilious  fever,  inde- 
pendently of  malarious  influences.  Thus,  nothing  is  more  common  than  for  the  disease  to 
immediately  occur  in  those  who,  after  exposure  to  the  midday  sun,  or  many  hours  of  severe 
labour  in  intensely  hot  weather,  allow  their  bodies  to  become  chilled  by  sleeping  on  the 
ground  in  the  open  air  after  night;  by  neglecting  to  change  their  clothing  when  they  become 
wet  by  a  shower  of  rain  or  other  cause;  or,  while  the  perspiration  is  running  in  streams  from 
every  pore,  by  throwing  oii"  a  portion  of  their  clothing,  and  sitting  or  lying  in  a  draught  of 
air,  j)articulaily  after  sundown.  But  while  many  of  die  sporadic  cases  are  produced  in  this 
manner,  and  the  same  species  of  imprudence  is  a  common  exciting  cause  of  the  fever,  wlien 
it  prevails  as  an  endemic  or  eiDidemic,  a  large  number  of  incontestable  facts  would  seem  to 
prove  that  its  more  common  cause  is  a  poison  produced  by  the  action  of  high  degrees  of  solar 
heat  upon  such  portions  of  the  earth's  surface  as  are  ordinarily  covered  or  soaked  with  water, 
when  these  are  accidentally  laid  bare,  or  rendered  dry  by  long-continued  heat  and  drought. 
The  presence  of  substances,  whether  vegetable  or  animal,  liable  to  decomposition,  is  to  be 
included  among  the  causes  capable  of  generating  bilious  fever  in  liot  climates,  and  in  the 
more  temperate  climates  during  summers  of  unusual  heat.  In  our  larger  cities  the  disease 
always  prevails  most  extensively,  and  in  its  more  malignant  forms,  in  the  most  confined  and 
filthy  districts,  to  which  it  is  often  entirely  confined  ;  or,  when  it  makes  its  appearance  in 
other  parts  of  them,  it  can  generally  be  traced  to  the  presence  of  some  local  cause  of  infec- 
tion. In  Philadelphia,  where  bilious  remittent  fever  was  formerly  a  common  disease  of  the 
summer  and  early  autumnal  months,  it  is  now  of  rare  occurrence,  excepting  in  its  mildest 
form;  and  this  disappearance  of  the  disease  from  our  city  is  to  be  ascribed  more  to  tlie  better 
construction  and  cleanliness  of  our  docks,  and  the  greater  attention  which  is  paid  to  the 
paving,  draining,  and  sewerage  of  our  streets;  to  the  filling  up  of  the  numerous  ponds 
which  formerly  existed  in  and  about  the  city,  and  to  the  preventing  any  mass  of  putrefiable 
materials  from  being  stored  in  the  city  proper  and  surrounding  districts,  than  to  any  very 
decided  diminution  in  the  temperature  of  our  summers. 

In  the  treatment  of  bilious  remittent  fever,  the  first  and  most  important  question  that  pre- 
sents itself  is,  the  propriety  of  direct  depletion  by  the  lancet.  This  must  be  determined 
solely  by  the  character  of  the  symptoms  and  condition  of  the  patient  in  each  case.  In  the 
more  decidedly  inflammatory  cases,  when  the  exacerbation  is  well-marked  and  prolonged — 
when  it  is  attended  by  a  hot  skin,  flushed  and  turgid  face,  severe  pain  of  the  head  and  back, 
great  oppression  about  the  prascordia,  and  a  firm  or  chord ed  pulse — and  when  the  intermis- 
sions are  short  and  imperfect — more  particularly  in  cases  occurring  in  young,  robust,  and 
plethoric  habits,  and  who  have  but  lately  arrived  from  a  colder  climate,  there  can  be  no  doubt 
of  the  importance  of  blood-letting.  In  such  cases  a  vein  in  the  arm  should  be  opened  at  the 
early  period  of  the  attack,  and  a  sufficient  amount  of  blood  drawn  off  at  once  to  reduce  the 
violence  of  the  exacerbation:  one  sufficient  bleeding  at  the  onset  of  the  disease  is  far  more 
efficacious  and  better  adapted  to  prevent  local  determination  than  the  repeated  detraction  of 
small  quantities  of  blood  during  its  course.  A  repetition  of  the  bleeding  will  seldom  be  de- 
manded when  the  first  operation  has  been  carried  to  a  sufficient  extent ;  should,  however, 
the  succeeding  exacerbation  be  marked  by  any  degree  of  violence,  we  should  not  hesitate 
again  to  resort  to  the  lancet;  but  the  loss  of  a  less  amount  of  blood  will  be  required  to 
reduce  the  excitement  than  in  tlie  first  instance.  If  direct  depletion  by  the  lancet  has  been 
neglected  in  the  early  stage  of  the  disease,  it  will  seldom  be  admissible  subsequently — or, 
should  symptoms  seem  to  demand  it,  it  should  be  employed  with  the  utmost  caution,  and 
only  to  a  moderate  extent. 

That  numerous  cases  of  bilious  fever  occur  in  which  venesection  is  altogether  unneces- 
sary, is  unquestionably  true  ;  in  those,  however,  that  are  marked  in  their  early  stage  by  3 
high  degree  of  arterial  excitement,  and  a  tendency  to  local  hypera;mia  or  inflammation,  the 
remedy  cannot  be  dispensed  with  without  danger  to  the  patient.  When  timely  employed, 
we  have  repeatedly  been  surprised  at  the  \ery  great  and  prompt  relief  produced  by  it — the 
violence  of  the  exacerbations  becoming  reduced,  the  intermissions  more  complete,  the  skin 
cooler  and  more  relaxed — the  pain  of  the  head  relieved — the  bowels  readily  acted  upon; 
and  a  state  of  calmness,  often  of  refreshing  sleep,  will  often  succeed  to  the  previous  rest- 
lessness and  distress. 

Local  blood-letting  is  a  remedy  more  generally  demanded  in  bilious  remittent  fever  than 
bieeding  from  the  arm.  In  all  cases  attended  with  intense  pain  of  the  head,  throbbing  of 
the  temples  or  delirium — or  with  pain  or  decided  tenderness  of  the  epigastrium  and  right 
hypochondrium,  or  with  pain,  and  a  sense  of  tightness  or  oppression  about  the  thorax — in 
oonjunction  with  general  bleeding,  or  where  this  has  not  been  judged  necessary,  the  appli- 
cation of  leeches  or  cups  in  the  neighbourhood  of  the  local  suffering,  in  numbers  propor- 
tionate to  its  intensity  and  to  the  age  and  condition  of  the  patient,  will  invariably  be  followed 


BILIOUS    REMITTENT    FEVER.  971 

by  decided  and,  geneially,  permanent  relief.  The  very  great  suffering  which  many  patients 
experience  from  pain  in  the  back  and  loins,  we  have,  in  repeated  instances,  known  to  be 
completely  relieved  by  cups  applied  along  the  spine. 

In  regard  to  the  propriety  of  cathartics  in  the  treatment  of  bilious  remittent  fever,  there  is 
a  much  greater  unanimity  of  opinion  than  in  relation  to  blood-letting.  There  are  few,  if  any 
cases,  in  wliich  their  operation  will  not  be  found  beneficial,  by  removing  from  the  intestines 
the  vitiated  secretions  with  which  they  are  often  filled — procuring  regular  stools,  and  by 
assisting  to  reduce  the  congestion  of  the  portal  system,  and  thus  restoring  the  healthy  func- 
tions of  the  liver  and  digestive  organs  generally. 

It  is  not,  however,  every  purgative  from  which  good  effects  are  to  be  anticipated  in  bi- 
lious fever.  Under  the  free  employment  of  certain  cathartics  the  patient  will  often  be  found 
gradually  to  become  more  and  more  debilitated,  and  finally  to  sink  into  a  state  of  stupor, 
with  suffused  eyes,  weak,  fluttering  pulse,  and  other  symptoms  of  extreme  exhaustion  ;  in 
such  cases  it  will  be  found  that  the  discharges  from  the  bowels  consist  of  a  thin,  serous 
fluid  ;  whereas,  under  the  employment  of  such  purgatives  as  produce  consistent,  viscid,  and 
dark-coloured  stools,  the  indications  of  improvement  in  the  symptoms  of  the  disease  are  often 
prompt  and  striking.  Calomel  is  probably  one  of  our  best  cathartics  in  this  disease.  It  may 
be  given  either  alone,  in  a  full  dose,  and  followed  by  occasional  doses  of  castor  oil — senna 
tea — calcined  magnesia — or  laxative  enemata  ;  or  the  calomel  may  be  combined  with  rhu- 
barb, or  jalap  ;  or,  what  is  frequently  a  more  effectual  plan,  a  full  dose  of  the  calomel  ad- 
ministered at  first,  and  then,  every  three  or  four  hours,  according  to  the  effects  produced, 
moderate  doses  of  the  blue  mass  and  rhubarb,  with  the  addition  of  a  small  portion  of 
ipecacuanha.  By  these  means  we  shall  generally  succeed  in  freeing  the  bowels  of  the 
dark-coloured,  viscid  matter  with  which  they  are  often  loaded,  and  procuring  more  regular 
and  healthy  stools — after  which,  an  occasional  dose  of  the  milder  laxatives  will  alone  be 
required. 

In  all  -Cases  of  bilious  remittent  fever  attended  with  a  hot  and  dry  skin,  the  application 
of  cold  to  the  surface,  either  by  sponging  it  with  cold  water  or  cold  water  and  vinegar,  or  by 
the  application  of  cold  water  in  the  form  of  affusion,  will  have  the  effect,  while  it  reduces  the 
morbidly  increased  temperature,  of  relaxing  the  skin,  and  promoting  perspiration,  and  in  this 
manner  of  shortening  the  exacerbations  and  inducing  a  complete  intermission  ;  even  the  ex- 
posure of  the  body  to  a  current  of  cool  air — by  throwingoff  the  clothing  and  opening  the  doors 
and  windows  of  the  patient's  chamber,  will  in  most  cases  be  productive  of  the  most  beneficial 
effects.  The  mere  immersion  of  the  hands  and  arms  in  cold  water,  by  carrying  off  a  portion 
of  the  morbid  heat  and  allaying  thirst  and  restlessness,  will  be  found  grateful  to  the  patient, 
who  not  unfrequently  will  fall  immediately  afterwards  into  a  refreshing  sleep:  whenever, 
however,  the  exacerbation  is  attended  by  intense  heat  of  the  surface  and  other  symptoms  of 
violent  excitement,  it  is  from  the  application  of  cold  water  to  the  surface  by  affusion  or  spong- 
ing that  the  most  prompt  and  permanent  advantage  is  to  be  obtained.  Dr.  Dickson  ranks 
it  among  the  most  efficient  of  our  febrifuge  measures — far  above  the  lancet,  both  in  the 
extent  of  its  adaptation,  and  in  its  degree  of  specific  utility.  All  that  we  can  hope  or  anticipate 
from  blood-letting  may  be  obtained,  in  the  majority  of  cases,  from  the  use  of  the  cold  bath, 
while  the  latter  possesses  this  striking  and  obvious  advantage,  that  we  can  repeat  it  as  often 
as  the  symptoms  are  renewed  that  require  its  employment.  The  local  determination  which  it 
controls  most  promptly,  he  very  correctly  remarks,  is  that  to  the  brain,  shown  by  headache, 
flushed  face,  red  eye,  delirium,  &c.,  with  a  full,  hard,  bounding  pulse.  In  such  cases,  the 
patient  being  seated  in  a  convenient  receptacle,  a  large  stream  of  cold  water  should  bo 
poured  over  his  head  and  naked  body  froin  some  elevation,  and  continued  until  he  becomes 
pale,  or  his  pulse  loses  its  fullness,  or  his  skin  becomes  corrugated  and  he  begins  to  shiver; 
he  should  then  be  dried  and  placed  in  bed,  with  just  so  much  covering  as  he  feels  to  be 
comfortable,  the  chamber  being,  at  the  same  time,  fully  and  freely  ventilated;  or  without 
removing  the  patient  from  the  bed,  he  may  be  su])portetl  in  a  leaning  posture  over  its  edge, 
and  the  cold  water  poured  from  a  pitcher  over  the  vertex. 

The  application  of  cold  water  to  the  surface  is  proper  only  when  the  temperature  of  the 
latter  is  considerably  and  permanently  increased  over  the  whole  body,  and  at  the  same  time 
the  surface  is  perfectly  dry — when  the  skin  is  cool  or  covered  with  moisture,  the  use  of  the 
cold  water  is  inadmissible  ;  it  is  also  of  doubtful  propriety  when  there  exists  a  decided  tend- 
ency to  hyperemia  or  inflammation  of  the  lungs,  or  in  cases  attended  with  diarrhoea.  Its 
repetition  is  forbidden  when  it  has  occasioned  a  protracted  chill  or  rigor  ;  or  the  patient 
continues  to  feel  cold  or  uncomfortable  after  its  use. 

Tiie  testimony  of  Dr.  Dickson  in  relation  to  the  curative  powers  of  cold  water  applied  to 
the  surface  in  the  bilious  remittent  fevers  of  the  south  is  strong  and  pointed,  and  is  fully 
borne  out  by  the  experience  of  physicians  of  other  portions  of  the  United  States  and  of 
Europe,  who  have  extensively  employed  it  in  the  disease  under  consideration.  Equally 
important  with  the  external  employment  of  cold  water  is  its  use  internally: — allowing  the 
patient  to  drink  freely  of  cold,  or  even  iced  water    or  iced  lemonade,  is  not  only  highly 


972  BILIOUS    REMITTENT    FEVER. 

grateful  to  liim,  Lut  it  tends  to  diminish  the  morbid  excitement,  relax  the  skin,  and  promote 
a  free  and  uniform  diaphoresis. 

Diaphoi-f^tics,  particularly  a  combination  of  tartar  emetic,  nitre,  and  calomel,  have  been 
recommended  and  highly  extolled  by  many  practitioners,  in  the  inflammatory  forms  of 
bilious  fever.  We  have  occasionally  employed  the  combination  just  mentioned,  but  have 
never  seen  any  decidedly  beneficial  effects  produced  by  it,  while  the  emetic  tartar,  in  how- 
ever minute  doses  administered,  we  have  found,  very  generally,  to  augment  the  irritability 
of  the  stomach,  and  increase  in  this  manner  the  distress  of  the  patient.  The  neutral  mixture, 
.spirits  of  mindererus  with  the  sweet  spirits  of  nitre,  or  a  weak  solution  of  nitre  in  water,  we 
have  occasionally  employed,  but  we  must  frankly  confess,  that  we  are  not  aware  of  any 
benefit  resulting  in  a  single  case  from  the  administration  of  either. 

Upon  the  propriety  of  blisters  in  bilious  remittent  fever,  there  exists  not  a  little  dispute, 
their  use  being  entirely  condemned  by  some  practitioners,  while  others  rank  them  among 
our  most  valuable  remedies.  In  the  more  inflammatory  forms  of  the  disease,  until  the 
violence  of  the  exacerbation  has  been  reduced  by  the  remedies  already  detailed,  from  the 
application  of  blisters  more  injury  than  good  will  unquestionably  result;  but  as  soon  as  the 
exacerbations  have  become  less  intense,  and  the  remissions  more  marked,  in  all  cases  where 
considerable  gastric  distress  remains,  or  any  considerable  affection  of  the  head  or  lungs, 
from  blisters  over  the  epigastrium  and  right  hypochondrium,  to  the  nape  of  the  neck,  along 
the  spine,  or  to  the  chest,  very  considerable  and  j^rompt  relief  will  always  be  obtained. 

In  many  cases  of  bilious  fever  there  is  so  great  a  degree  of  irritability  of  the  stomach, 
that  not  only  is  everything  taken  into  it  rejected  as  soon  as  it  is  swallowed,  but  the  patient 
is  tormented  with  almost  constant  vomiting  or  frequent  ineffectual  efforts  to  vomit.  This 
distressing  symptom  will,  very  often,  be  completely  removed  by  the  abstraction  of  blood 
from  the  arm,  whenever  this  is  admissible,  or  by  cups  or  leeches  over  the  epigastrium,  or 
by  a  large  blister  applied  to  the  latter  part.  Relief  will  also  be  obtained  from  small  portions 
of  ice  held  in  the  mouth,  from  the  effervescing  draught,  the  artificial  mineral  water  of  the 
shops,  taken  perfectly  cold,  or  from  iced  lemonade  or  toast  water.  Minute  doses  of  calomel, 
say  a  third  to  half  of  a  grain,  suspended  in  some  simple  mucilage,  and  repeated  at  short  inter- 
vals, wiil,  very  generally,  promptly  relieve  the  gastric  irritability  and  suspend  the  vomiting. 
In  cases  where  every  other  remedy  has  failed  in  relieving  the  irritable  state  of  the  stomach, 
we  have  repeatedly  seen  it  promptly  removed  by  a  grain  of  the  acetate  of  lead,  given  every 
hour  or  two,  dissolved  in  a  small  quantity  of  water. 

By  a  few  practitioners,  a  mercurial  course  is  recommended  in  all  the  more  violent  forms 
of  bilious  remittent  fever.  Calomel  is  directed  to  be  given  first,  in  large  doses,  as  a  purga- 
tive, and  subsequently,  in  small  doses,  continued  until  its  specific  effects  are  obtained  ;  our 
own  experience  is  not,  however,  in  favour  of  this  practice.  In  the  inflammatory  form  of  the 
disease,  a  mercurial  impression  is  calculated  rather  to  protract  than  to  diminish  the  suffering 
and  danger  of  the  patients,  while  the  milder  forms  of  the  fever  may  be  readily  controlled 
without  it.  Cases,  however,  occasionally  occur  in  which  an  alterative  course  of  mercury 
will  be  found,  we  are  convinced,  highly  advantageous.  We  have  repeatedly  observed,  that 
after  the  violence  of  the  exacerbations  has  been  reduced,  the  patients  will  continue  to  be 
affected  by  a  low  form  of  fever,  marked  by  a  dry  skin,  a  small  irritated  pulse,  a  dry  dark- 
brown  tongue,  frequent  watery  discharges  from  the  bowels,  restless  nights,  and  a  total  want 
of  appetite,  and  have  found  this  condition  of  things  to  be  speedily  removed  by  a  cautious 
mercurial  course,  carried  to  the  extent  of  producing  a  slight  tenderness  of  the  gums.  In 
these  cases  small  doses  of  calomel,  or,  wirat  is  preferable,  the  blue  mass,  combined  with  a 
portion  of  opium  and  ipecacuanha,  may  be  given  every  three  hours  until  the  desired  effect 
results.  A  form  of  the  disease,  somewhat  similar  to  the  one  just  referred  to,  is  described 
by  Eberle  as  occurring  "when,  either  from  the  imprudent  employment  oiirritatmg  purges, 
or  from  other  causes,  the  mucous  membrane  of  the  intestinal  canal  is  brought  into  a  state  of 
high  irritation  or  subacute  inflammation.  The  disease  then  generally  loses  its  remittent 
form,  and  often  assumes  a  low  typhoid  character,  with  almost  constant  delirium,  a  tender 
and  tympanitic  state  of  the  abdomen ;  a  dry,  dark-brown,  or  black  crust  on  the  tongue,  with 
clean  red  edges;  watery  and  reddish  stools;  great  prostration;  and  a  very  dry  and  hot  skiru 
Cases  of  this  kind  frequently  run  on  for  several  weeks,  and  the  convalescence  is  always  very 
gradual  and  tedious."  The  treatment  directed  by  Dr.  Eberle  is  leeches  to  the  abdomen,  fol- 
lowed by  a  large  emollient  poultice;  small  doses  of  calomel  and  opium — one-sixth  of  a  grain 
of  the  former  to  a  quarter  of  a  grain  of  the  latter — every  two  or  three  hours.  The  bowels  to 
be  kept  open  by  laxative  enemata,  and  the  patient  directed  to  partake  freely  of  some  bland 
mucilaginous  fluid — such  as  barley  water,  very  thin  oatmeal  gruel,  or  a  solution  of  gum  aca- 
cia in  water;  no  other  article  of  food  being  allowed.  "In  such  cases,''  he  remarks,  "I  have 
thought  that  considerable  benefit  was  derived  from  epispastics  on  the  legs  just  above  the 
ankles;  this  measure  is  particularly  useful  when  the  extremities  are  cool,  while  the  skin  of 
the  body  is  hot  —  a  circumstance  which  is  not  uncommon  in  instances  of  this  kind.  An 
emulsion  of  balsam  copaiba  may  aito  be  frequently  employed  with  unequivocal  advantage. 
I  havb  so  often  seen  the  most  decided  benefit  derived  from  this  article,  in  cases  attended 


BILIOUS    REMITTENT   FEVER.  973 

with  great  irritation  or  sv\bacute  inflammation  of  the  bowels,  that  I  should  consider  myself 
neglecting  an  important  curative  means,  were  I  to  omit  prescribing  it  in  diseases  of  this  cha- 
racter." "Although  very  considerable  prostration  often  occurs  in  such  cases,  stimulants  or 
tonics  are  by  no  means  admissible." 

Throughout  the  entire  course  of  bilious  remittent  fever,  little  desire  for  food  will  be 
expressed  by  the  patient,  nor  should  any  be  allowed  until  after  the  disease  is  fully  subdued  ; 
and  then  only  barley  or  rice  water,  thin  gruel  or  panada,  in  very  moderate  quantities.  To 
allay  the  thirst,  which  is  always  present  and  frequently  very  urgent,  the  cold  drinks,  already 
pointed  out,  will  be  the  most  suitable.  Perfectly  cold  toast  water,  slightly  acidulated  with 
lemon  or  orange  juice,  tamarinds,  or  currant  or  plum  jelly,  forms  generally  a  very  palatable 
beverage,  of  which  the  patient  may  partake  at  short  intervals.  Small  quantities  of  cold 
acidulated  fluids,  slowly  swallowed,  it  is  to  be  recollected,  are  far  more  efficacious  in  allay- 
ing thirst  than  large  draughts  hastily  swallowed.  Frequently  sponging  die  patient's  mouth  with 
cold  water,  cleaning  his  tongue  with  a  slice  of  orange,  or  allowing  him  to  suck  the  juice  of 
the  latter,  will  aid  very  materially  in  abating  his  sense  of  thirst,  and  is  always  refreshing 
to  him. 

The  chamber  of  the  patient  should  be  kept  perfectly  clean  and  cool,  and  while  a  free  ven- 
tilation is  kept  up,  it  should  be  guarded  from  any  glare  of  light.  His  body  shouhl  be  slightly 
covered  with  bed-clothes,  which,  together  with  his  linen,  should  be  frequently  changed.  At 
all  times  the  patient  should  be  kept  perfectly  quiet,  and  the  most  perfect  calmness  and  quiet- 
ness should  be  maintained  within  and  around  his  apartment. 

In  our  enumeration  of  the  symptoms  of  bilious  fever,  it  was  stated  that  great  restlessness 
and  wakefulness  were  very  commonly  present.  So  long  as  the  period  of  increased  excite- 
ment lasts,  or  there  is  any  tendency  to  disease  of  the  brain,  the  only  means  by  which  the 
restlessness  of  the  patient  is  to  be  subdued  and  sleep  procured,  are  the  general  remedies  that 
have  been  already  enumerated  ;  but  after  the  morbid  excitement,  and  whatever  cerebral 
affection  that  may  exist,  have  been  reduced,  a  state  of  restlessness  and  an  inability  to  sleep 
often  still  continue  from  mere  nervous  irritability,  when  the  exhibition  of  an  opiate  in  the 
form  of  Dover's  powder,  about  bed-time,  will  very  generally  be  found  advantageous :  by 
some  practitioners,  the  extract  of  hyosciamus,  combined  with  ipecacuanha,  is  preferred  to 
any  preparation  of  opium  ;  while  others,  again,  recommend  the  tincture  of  opium,  combined 
widi  a  vegetable  acid,  as  tinct.  opii  3ss.,  acid,  citric,  gr.  v.  to  viij.,  aq.  puree  gij.,  M. ;  of 
which  a  tablespoonful,  or  half  an  ounce,  is  a  dose,  to  be  repeated,  if  necessary,  after  a  short 
interval. 

We  have  now  presented  a  general  outline  of  the  treatment  of  bilious  remittent  fever,  in 
its  mild  and  inflammatory  forms.  It  is  hardly  necessary  for  us  to  repeat,  that  the  extent  to 
which  each  remedy  is  to  be  carried,  and  the  propriety  of  its  repetition  and  continuance,  as 
well  as  the  period  and  particular  circumstances  of  the  disease  to  which  it  is  adapted,  must 
be  determined  by  the  application  of  the  general  principles  of  pathology  and  therapeutics  to 
each  case  we  are  called  upon  to  treat;  and  although  this  will  demand  a  degree  of  judgment 
in  the  practitioner,  which  he  can  only  acquire  by  habits  of  close  attention  and  nice  discri- 
mination, and  a  somewhat  extended  field  for  observation,  it  is  the  only  course  from  which 
success  can  be  anticipated  in  the  treatment  of  a  disease,  which,  like  the  one  under  considera- 
tion, varies  so  much  in  its  character  in  dilFerent  seasons  and  localities,  and  even  in  diflerent 
individuals  attacked  at  the  same  place  and  during  the  same  period. 

When  the  disease,  notwithstanding  our  best  directed  eflbrts,  runs  on  to  that  stage  when  its 
symptoms  resemble  those  of  the  last  stage  of  typhus  fever,  nothing  is  left  us  but  to  endea- 
vour to  sustain  the  patient's  strength,  and  to  remove  or  relieve  any  urgent  cause  of  distress  or 
danger.  He  should  be  allowed  such  nourishing  food  as  is  easy  of  digestion,  as  beaf  tea, 
sago,  arrow-root,  and  the  like,  with  wine-whey,  wine,  pure  or  diluted,  porter,  milk-punch,  or 
brandy,  in  quantities  adapted  to  the  emergency  of  the  symptoms  and  the  effects  produced. 
Sinapisms  or  blisters  may  at  the  same  time  be  applied  to  the  inside  of  the  thighs  or  calves 
of  the  legs,  and  to  the  epigastrium.  If  diarrhoea  be  present,  this  we  should  attempt  to  abate 
or  suspend  by  opiate  and  astringent  injections.  The  singultus,  which  is  often  present  to 
a  very  distressing  degree,  may  be  frequently  allayed  by  the  camphor  julep ;  and  the  meteor- 
ism  of  the  abdomen  may  often  be  considerably  relieved  by  the  spirits  of  turpentine,  thirty 
drops  of  which  may  be  given  every  two  or  three  hours  ;  this  latter  is  said  indeed  to  be  among 
the  safest  and  most  useful  remedies  at  this  stage  of  the  disease ;  it  will  often  be  found  to  pro- 
duce a  beneficial  impression  upon  the  diseased  mucous  membrane  of  the  alimentary  canal, 
to  suspend  the  frequent  griping  stools,  and  to  correct  the  morbid  character  of  the  discharges. 
In  the  sinking  stage  of  bilious  remittent  fever,  the  effects  of  ammonia,  with  a  strong  decoc- 
tion of  serpentaria  or  valerian,  or  combined  with  the  aromatic  confection,  have  been  repre- 
sented as  peculiarly  beneficial ;  but,  unfortunately,  when  the  disease  has  arrived  at  this  stage, 
every  remedy  will  too  often  be  found  unavailing,  and  our  best  directed  efforts  to  save  the  life 
of  the  patient  ineffectual. 

A  question  has  been  agitated  both  as  to  the  propriety  of  and  proper  period  for  the  adnii 
nistration  of  cinchona  or  quinia  in  remittent  fever.    Without  attempting  to  detail  the  varion* 

4g 


974  BILIOUS    REMITTENT    FEVER. 

and  opposite  opinions  that  have  been  advanced  upon  this  subject,  we  shall  merely  remark, 
thai  in  the  simple  and  inflammatory  forms  of  bilious  remittent  fever,  it  would  be  reasonably 
inferred  from  the  character  of  the  disease,  that  the  bark  or  quinia  is  not  a  remedy  adapted 
to  contrpl  the  symptoms  of  its  earlier  stages,  and  the  correctness  of  this  inference  has  been 
very  fully  established  by  the  result  of  experience.  So  soon,  however,  as  a  complete  inter- 
mission has  been  obtained,  and  no  indications  of  visceral  hyperaemia  or  inflammation  are 
present,  a  cautious  administration  of  the  cold  infusion  of  the  cinchona,  combined  with  ser- 
pentaria  or  some  agreeable  aromatic,  will  be  found,  in  general,  to  cut  short  the  remaining 
symptoms  of  tlie  disease  and  accelerate  the  period  of  convalescence.  The  quinine  may  be 
given  in  solution  with  the  addition  of  a  few  drops  of  the  elixir  of  vitriol,  and  to  the  extent 
of  from  three  to  five  grains,  repeated  at  such  intervals  as  the  circumstances  of  the  case  )Ray 
demand.  The  more  violent  the  form  of  disease  has  been,  the  more  important  is  the 
administration  of  the  quinine,  so  soon  as  a  complete  remission  has  been  obtained,  and  the 
larger  should  be  the  dose  of  the  remedy. 

During  the  period  of  convalescence,  the  patient  should  be  guarded  from  the  effects  of  any 
sudden  transitions  of  temperature,  and  from  incurring  the  least  degree  of  fatigue  by  sitting 
up  too  soon  or  for  too  long  a  period  ;  and  while  his  mind  should  be  occupied  and  amused,  at 
proper  times  of  the  day,  by  the  conversation  of  his  friends,  or  some  light  occupation,  fatigue 
from  this  source  must  also  be  avoided.  His  bowels  are  to  be  kept  regularly  open,  which 
may  generally  be  done  by  allowing  him  to  partake,  in  moderation,  of  any  of  the  perfectly 
ripe  subacid  fruits  of  the  season ;  if  they,  however,  should  become  closed,  some  mild  laxa- 
tive should  be  occasionally  administered.  In  regard  to  diet  much  caution  is  to  be  observed. 
The  patient  should  be  confined  at  first  to  moderate  quantities  of  the  more  agreeable  farina-' 
ceous  articles ;  and  if  his  strength  has  been  greatly  prostrated,  a  glass  or  two  of  sound  wine 
will  not  be  improper.  As  his  digestive  powers  improve,  he  may  be  allowed  plain  beef  oi 
chicken  broth,  oysters  slightly  cooked,  parboiled  eggs,  and  finally,  the  lighter  and  more  rea- 
dily digested  meats,  jolainly  but  nicely  cooked.  The  appetite  often  remains,  for  a  long  time, 
weak  and  capricious — and  frequently,  some  agreeable  bitter  infusion,  as  Colombo,  quassia,  or 
the  wild  cherry  tree  bark,  will  be  proper,  to  augment  the  tone  of  the  stomach.  In  all  cases, 
the  food  of  the  patient  should  be  presented  to  him  in  small  quantities,  and  served  with  great 
neatness ;  large  masses  of  food,  slovenly  prepared  and  served,  will  in  general  disgust,  and 
thus  destroy  what  little  appetite  may  exist.  In  regard  to  exercise  and  exposure  to  the  open 
air,  the  convalescent  should  undertake  them,  only  so  soon  as  he  has  acquired  some  degree  of 
strength,  when  a  trip  to  some  agreeably  situated  watering-place  will  often  restore  him  to  per- 
fect health,  more  quickly  than  can  be  effected  during  his  continuance  at  home,  where  his 
mind  is  too  early  directed  with  anxious  care  to  the  concerns  of  his  family  and  of  his  pro- 
fession. 

In  the  congestive  form  of  bilious  fever,  the  indications  of  cure  are,  to  rouse  the  nervous 
energies  of  the  system,  to  relieve  as  quickly  as  possible  the  central  organs  from  their  state 
of  hypersemia,  and  to  restore  to  the  capillaries  of  the  surface  their  healthy  action.  Among 
the  most  important  of  the  remedies  calculated  to  effect  these  objects,  is  the  external  appli- 
cation of  heat  to  the  surface  of  the  body  in  the  form  of  the  warm  or  hot  bath,  the  vapour 
bath,  or  in  a  dry  form  by  bags  of  heated  bran,  salt  or  sand,  bottles  of  hot  water,  &c.  We 
shall  often  succeed  in  rousing  the  patient  by  immersing  the  whole  of  his  body,  as  early  as 
possible  after  he  is  attacked,  in  water,  of  a  temperature  proportioned  to  the  urgency  of  his 
Bymptoms ;  that  is,  of  a  greater  or  less  degree  of  heat,  within  proper  limits,  according  as 
the  temperature  of  the  skin,  the  state  of  the  pulse,  and  the  general  strength  is  more  or  less 
depressed,  and  the  greater  or  less  degree  of  torpor  of  the  nervous  system  ;  at  the  same  time 
applying  brisk  friction  with  a  soft  brush  or  a  flannel  cloth,  to  the  whole  surface,  and  particu- 
larly to  the  epigastric  and  abdominal  regions.  On  coming  out  of  the  bath  the  patient  is  to 
be  rubbed  dry  with  heated  flannels,  put  into  a  well-aired  bed  between  blankets,  and  supplied 
with  some  mild  diaphoretic  drink,  as  the  infusion  of  serpentaria,  of  tepid  warmth.  A 
full  dose  of  the  Dover's  powder,  or  a  combination  of  opium,  camphor  and  ipecacuanha, 
one  grain  each,  with  ten  of  nitre,  given  at  this  period,  will  often  be  found  particularly 
beneficial. 

Next  in  efficacy  to  the  warm  bath,  we  may  rank  external  stimulants ;  sinapisms  should, 
therefore,  be  early  applied  to  the  extremities  and  over  the  epigastrium,  while  frictions,  with 
some  stimulating  liniment,  are  made  along  the  spine.  By  some  practitioners  internal  stimu- 
lants have  been  strongly  recommended,  as  a  means  of  rousing  the  central  organs  from  their 
r>tate  of  torpor,  and  bringing  on  a  general  and  moderate  reaction:  it  is  probable  that  in  certain 
cases,  where  the  state  of  congestion  is  very  considerable,  and  it  is  not  promptly  and  perma- 
nently relieved  by  the  remedies  already  recited,  some  mild  stimulant,  as  the  ammonia,  or 
turpentine,  or  wine-whey,  may  prove  advantageous,  if  cautiously  administered  and  its  effects 
carefully  watched  ;  as  a  general  rule,  however,  the  free  use  of  stimulants,  particularly  of  the 
more  active  ciass,  is  calculated  to  produce  injury  rather  than  good. 

An  active  cathartic,  as  the  combii  ation  of  calomel  or  blue  mass  with  aloes  and  extract  of 
colocvnth,  followed  in  a  few  hours  1  y  the  compound  infusion  of  senna,  will  very  generally 


SMALL-POX.  975 

cause  a  copious  discharge  from  the  bowels,  of  a  dark-coloured,  tenacious  matter,  and  by  thus 
assisting  to  unload  the  j^ortal  system,  will  often  produce  a  marked  improvement  in  the  general 
symptoms  of  the  disease.  In  the  treatment  of  congestive  bilious  fever,  the  abstraction  of 
blood  from  the  arm,  in  the  first  period  of  the  attack,  or  subsequent  to  the  use  of  the  warm 
bath  and  frictions  to  the  surface,  has  been  recommended  by  many  practitioners  as  an  imporant 
remetly — one  indeed  from  which  more  prompt  and  certain  relief  is  to  be  obtained  than  from 
any  other  that  we  can  employ.  The  evidence  in  its  favour  is  certainly  very  strong;  and  we 
believe  that  there  are  many  cases  in  which  prompt  reaction  maybe  produced,  and  the  danger 
of  permanent  local  disease  prevented  by  its  employment.  The  greatest  judgment  and 
caution,  however,  are  demanded  in  the  use  of  the  lancet  in  all  cases  of  congestive  disease; 
the  effect  produced  upon  the  pulse  must  be  carefully  watched,  and  the  flow  of  blood  instantly 
stopped  if  any  disposition  to  sinking  is  detected.  To  determine  beforehand  the  amount  of 
blood  that  it  will  be  projier  to  take  away  is  impossible — the  effects  produced — the  relief 
obtained,  are  the  only  guide.  Even,  however,  when  during  the  flow  of  blood  the  pulse 
becomes  more  free  and  developed,  but  a  moderate  quantity  should  be  taken  away  at  once — 
should  we  have  to  repeat  the  operation  after  a  short  interval.  Occasionally  but  a  drop  or 
two  of  blood  will  escape  from  the  vein  when  it  is  first  opened,  but,  after  a  short  time,  the 
circulation  becoming  more  free,  the  blood  flows  in  a  full  stream,  with  decided  relief  to  the 
patient.  It  is  only,  however,  in  the  early  stage  of  the  highly  congestive  forms  of  bilious  fever 
that  venesection  is  admissible,  and  even  in  these  the  flow  of  blood  should  be  instantly 
arrested  if  the  pulse  is  found  to  sink,  or  even  to  remain  oppressed  and  undeveloped  after  a 
small  quantity  has  been  lost. 

When  prominent  symptoms  of  hyperemia  of  the  brain,  lungs,  or  other  important  viscera 
present  themselves,  the  application  of  cups  to  the  head,  chest,  or  in  the  neighbourhood  of  the 
aifected  organ,  will  often  be  found  decidedly  advantageous. 

As  soon  as  reaction  takes  place,  the  use  of  quinia  should  be  commenced  with,  in  large 
doses,  repeated  at  short  intervals.  Of  the  curative  jiowers  of  the  quinia  in  this  form  of  fever 
we  have  the  fullest  and  most  unquestionable  testimony.  Many  of  the  physicians  of  the 
southern  and  western  portions  of  the  United  States  place  their  chief  reliance,  in  congestive 
remittent  fever,  upon  the  sulphate  of  quinia  prescribed  in  enormous  doses — twenty,  thirty 
and  even  fifty  grains,  repeated  at  short  intervals  until  a  solution  of  the  disease  is  obtained; 
but  although  we  are  convinced  of  the  propriety  of  large  and  frequent  doses,  those  a^Uuded  to 
are  certainly  excessive  and  uncalled  for. 

The  period  of  convalescence  from  the  congestive  form  of  bilious  fever  will  require  the 
same  management  as  that  from  the  more  open  and  inflammatory  forms. 

In  the  highly  malignant  remittent,  occasionally  met  with,  in  which  the  vital  forces,  crushed 
at  once  by  the  overwhelming  intensity  of  the  morbid  cause,  fail  apparently  to  exhibit  any 
resistance  or  reaction ;  they  must  be  sustained,  to  use  the  words  of  Dr.  Dickson,  {Essays  on 
Pathol,  and  Therapeut.,  vol.  i.,  p.  319,)  by  every  means  within  our  power,  while  we  have 
immediate  recourse  to  the  most  impressive  revulsives.  The  hot  bath,  sinapisms,  vesications, 
must  be  quickly  and  assiduously  applied,  while  we  stimulate,  by  the  freest  use  of  internal 
remedies — carefully  selecting  such  as  are  best  adapted  to  the  circumstances  presented.  If, 
as  is  often  the  case,  the  patient  suffers  severely  from  pain  in  the  chest  or  abdomen,  large 
doses  of  opium  or  morphine  must  be  administered,  while  Ave  keep  up  his  sinking  strength 
by  brandy,  ammonia  or  ether.  In  the  superintendence  of  such  cases  we  should  rather  incur 
tlie  risk  of  over-stimulating  transiently,  than  fall  below  the  requisite  point  of  excitement  in 
our  use  of  stimulants.  Dr.  Dickson  is  fully  persuaded,  that  he  has  seen  more  than  one  patient 
die  from  the  timidity  of  his  physician  in  this  respect;  •who,  keeping  at  a  cautious  distance 
behind  the  disease,  would  not  venture  on  the  exhibition  of  any  excitant  adapted  to  the  feeble 
excitability,  until  the  vital  energies  upon  which  alone  stimulants  can  act,  had  become  worn 
out  and  exhausted.  If  the  stomach  will  bear  it,  it  will  be  proper  to  administer,  also,  some 
of  the  preparations  of  cinchona.  The  sulphate  of  quinia  in  full  doses  will  be  often  retained 
and  do  good.  "-Alternate,  combine,  and  recombine  your  stimulants,  the  effects  of  which  may 
perhaps  be  aided  by  warm  and  nutritious  fluids,  wine-whey,»arrow-root  with  wine,  wine 
alone  or  spiced,  brandy  with  milk  or  in  mucilage.  These  energetic  measures  will  usually 
be  found  effective  within  a  very  short  period — improving  the  pulse,  and  arousing  the  general 
powers  of  the  system.  Yet  you  must  not  permit  yourselves  to  be  disheartened  into  inaction 
by  their  apparent  inefiicacy  or  slowness  of  impression.  Persevere,  not  only  while  there  is  a 
reasonable  hope,  but  even  after  all  hope  seems  extinguished  ;  and  you  will  feel  yourselves 
amply  repaid  by  the  gratification,  which  will  not  perhaps  be  denied  you,  of  saving  more  than 
one  fellow-creature  from  the  destruction  which  seems  inevitably  to  await  him." — C] 

I  pass,  without  pausing,  from  the  consideration  of  continued  fever,  to  that  of  small' 
pox  or  variola :  a  disease,  fortunately,  less  common  in  this  country  than  it  used  to 
De,  yet  still  sufficiently  frequent  and  formidable  to  require  that  we  should  acquami 
ourselves  with  the  phenomena  it  is  accustomed  to  present;  and  very  prevalent  hero 


9T6  SMALL-POX. 

as  it  happens,  at  present  (1838).     I  have  already  mentioned,  by  anticipation,  severa 
points  in  its  history. 

This  frightful  disease  sets  in  with  smart  febrile  symptoms  :  rigors,  followed  by 
heat  nnd  dryness  of  skin,  a  hard  and  frequent  pulse,  pain  in  the  epigastrium,  with 
nausea  and  vomiting,  and  headache.  Sometimes  wild  delirium,  sometimes  convul- 
sions, mark  its  outset.  Then,  to  use  the  words  of  Cullen's  definition,  "  tertio  die 
incipit,  et  quinto  finitur,  eruptio  papularum  phleginonodearum,  qua3  spatio  octo  dierum, 
in  suppurationem  et  in  cruslas  demumabeunt,  ssepe  cicatrices  depressas,  sive  foveolas, 
in  cute  relinquentes." 

When  small-pox  is  fully  formed,  it  cannot  be  mistaken  for  any  other  complaint : 
but  it  is  of  some  importance  to  recognize  it  at  its  very  commencement,  for  the  force 
of  the  impending  disorder  may  sometimes  be  lessened  by  judicious  measures  adopted 
at  that  early  stage.  The  symptoms,  however,  that  mark  the  outset  of  all  febrile 
diseases  are  necessarily  very  much  the  same.  If  the  pyrexia  set  in  when  small-pox 
is  prevalent  in  the  neighbourhood,  if  the  person  in  whom  it  occurs  be  an  "  unpro- 
tected" person  {i.  e.,  one  who  has  neither  been  inoculated  nor  vaccinated  previously), 
and  especially  if  he  be  known  to  have  been  exposed,  within  from  nine  or  ten  days 
to  a  fortnight,  to  the  contagion  of  variola,  we  may  well  suspect  that  the  disease  will 
turn  out  to  be  small-pox,  and  act  upon  that  suspicion. 

Nevertheless  there  are  some  symptoms  which,  being  common  in  the  commence- 
ment of  variola,  and  not  common  at  the  beginning  of  continued  fever,  or  of  the  other 
exanthemata,  may  assist  the  early  diagnosis.  Vomiting  is  one  of  these  ;  pain  of  the 
back  another.  When  these  symptoms  are  violent,  they  usually  usher  in  a  severe 
form  of  the  disease.  The  same  may  be  inferred  from  a  continuance  of  the  nausea 
and  vomiting,  after  the  coming  out  of  the  eruption  ;  which  is  very  unusual. 
Heberden  noticed  that  acute  pain  in  the  loins  was  almost  always  followed  by  a 
severe  disorder  ;  that  pain  higher  up,  between  the  shoulders,  was  of  better  augury ; 
and  that  it  was  to  be  reckoned  in  all  cases  a  good  sign,  if  there  was  no  pain  of  the 
back  at  all.  Early  delirium,  stupor,  or  convulsions,  announce  severity  in  the  subse- 
quent course  of  the  malady.  Yet  not  always,  especially  in  children.  W^ithin  the 
last  month  I  was  asked  to  see  a  child  which  had  been  suddenly  attacked  with  con- 
vulsions, followed  by  coma.  In  due  time  the  eruption  of  variola  appeared,  and  the 
aisease  ran  a  mild  course,  with  little  aid  from  medicine,  although  the  child  was 
previously  unprotected. 

The  peculiar  eruption  almost  always  begins  to  show  itself  on  the  third  day  of  the 
fever.  The  earlier  it  comes,  the  severer  generally  does  the  disorder  prove.  In 
judging  of  the  date  of  the  eruption,  you  must  bear  in  mind  that  parents  and  servants 
are  apt  to  state  its  accession  to  have  been  later  than  it  was  in  reality :  for  the  spots 
are  at  first  so  minute  that  they  often  escape  observation.  They  also  frequently  begin 
Jio  come  out  in  the  night ;  and  the  morning  of  the  second  day  of  the  eruption  is  called 
the  first  day. 

The  eruption  comes  out  first  on  the  face,  then  on  the  neck  and  Avrists  and  on  the 
trunk  of  the  body,  and  lastly  on  the  lower  extremities.  Such  is  the  rule  ;  so  that 
(as  is  specified  in  the  definition)  it  does  not  cease  to  come  out  till  the  fifth  day  :  and 
it  keeps  a-head,  in  that  order,  throughout  the  disease.  There  are,  indeed,  some 
exceptions  to  this  rule.  Occasionally  the  spots  appear  first  upon  the  extremities,  but 
this  is  very  rare.  In  some  instances  straggling  papulse  continue  to  spring  up  after 
the  main  crop  is  fairly  completed ;  but  these  stragglers  seldom  arrive  at  the  same 
size  with  the  others. 

The  pimples,  or  papulae,  ripen  gradually  into  pustules,  the  suppuration  being 
complete  by  their  eighth  day  ;  and  on  that  day  the  pustules  generally  begin  to  break, 
and  crusts  or  scabs  to  form.  In  four  or  five  days  more,  the  scabs  are  falling  off. 
There  are  some  variations  in  all  this,  also.  In  children,  the  crusts  are  sometimes 
visible  on  the  seventh  day  ;  and  in  adults,  when  the  disease  is  severe,  they  sometimes 
do  not  begin  to  form  till  the  ninth  day.  In  all  cases,  some  of  the  pustules  are  hable 
to  be  prematurely  broken,  by  accident,  or  by  the  patient's  scratching  ;  and  these  will 
crust  over  earlier  than  they  otherwise  would  have  done.     So  that,  in  fijcing  the  period 


SMALL-POX.  977 

of  incrustation,  you  are  to  regard  those  pustules  or^ly  of  which  the  ;ialural  progress 
has  not  been  interfered  with. 

All  that  I  have  hitherto  been  saying,  applies,  with  more  or  less  exactness,  to  the 
disease  in  all  its  varieties.  But  its  severity  differs  oicceedingly,  as  I  have  already 
hinted,  in  different  cases.  Its  severity,  in  truth,  is  almost  always  in  direct  relation  to 
the  quantity  of  the  eruption.  The  number  of  pustules  indicates,  in  the  first  place, 
the  quantity  of  the  variolous  poison  which  has  been  reproduced  in  the  blood.  In 
the  second  place,  it  is  also  a  direct  measure  of  the  extent  to  which  the  skin  suffers 
inflammation.  Sometimes  there  are  not  more  than  half  a  dozen  pustules ;  some- 
times there  are  many  thousands.  If  all  these  were  collected  into  one,  it  would  be 
an  enormous  phlegmon.  For  both  these  reasons,  the  system  sufiijrs  commotion,  dis- 
tress and  peril,  in  proportion  to  the  quantity  of  the  eruption. 

When  the  pustules  are  very  many,  they  run  together ;  when  they  are  ^ew,  they 
are  separate  from  each  other.  And  this  affords  a  broad  line  of  distinction,  which 
can  neither  be  overlooked  nor  mistaken,  between  the  variola  discreta,  and  the  variola 
confiuens.  In  the  one,  the  pustules  are  distinct,  and  of  a  regularly  circumscribed 
circular  form.  In  the  other  they  coalesce,  and  their  common  outline  becomes 
irregular.  Now,  the  discrete  form  of  the  disease  is  scarcely  ever  dangerous  ;  the 
confluent  form  is  never  free  from  danger.  The  distinction,  therefore,  is  of  the  great- 
est importance  and  interest.  For  its  full  estimation,  each  form  must  be  considered 
separately. 

In  the  discrete  variety,  in  which  the  disorder  may  be  presumed  to  run  its  most 
natural  course,  the  eruption  is  at  first,  according  to  the  phraseology  of  Willan,  papu- 
lar. The  pimples  gradually  increase  in  magnitude ;  but  it  is  not  till  the  third  day 
of  their  appearance  that  they  begin  to  contain  a  little  fluid  on  their  summits. 

For  two  days  after  this  they  increase  in  breadth  only,  and  a  depression  is  observ- 
able in  the  centre  of  many  of  them.  The  cuticle  is  bound  down  there  somehow, 
for  a  time,  to  the  cutis  vera.  It  is  the  eighth  day  of  the  disease,  or  ihejifth  day  of 
the  eruption,  before  the  pustules  become  perfectly  turgid  and  hemispheroidal.  During 
the  time  in  which  they  are  thus  filling  up,  the  face  swells  ;  often  to  so  great  a  degree 
that  the  eyelids  are  closed,  and  the  natural  aspect  is  completely  changed  or  concealed. 
The  skin  between  the  pustules  on  the  face  assumes  a  damask-red  colour.  About  the 
eighth  day  of  the  eruption,  a  dark  spot  makes  its  appearance  on  the  top  of  each 
turgid  pustule,  and  at  that  spot  the  cuticle  breaks,  a  portion  of  the  matter  oozes  out, 
and  the  pustule  dries  into  a  scab.  When  this  crust  at  length  falls  off^  it  leaves  be- 
hind it  either  a  purplish  red  stain,  which  is  still  very  characteristic  of  the  disease, 
and  which  very  slowly  fades  ;  or  a  depressed  scar,  which  is  indelible.  In  the  latter 
case,  the  patient,  or  more  properly  his  skin,  is  said  to  be  pitted  with  the  small-pox, 
or  pock-marked.  The  swelling  of  the  face  begins  gradually  to  diminish  after  the 
eruption  has  become  thoroughly  pustular. 

This  is  the  course  which  the  eruption  pursues  on  the  face,  where  the  pustules, 
even  in  the  discrete  form  of  the  disease,  are  usually  thicker  set  than  on  any  other 
part  of  the  surface.  And  it  pursues  the  same  course,  only  two  or  three  days  later, 
upon  the  extremities,  where  it  also  begins  later.  The  feet  and  hands  swell  just  as 
the  face  swelled,  but  they  begin  to  tumefy  as  the  features  begin  to  subside.  Some 
of  the  pustules,  especially  on  the  extremities,  do  not  burst  at  all,  but  shrivel  up. 

In  this,  the  distinct  variety  of  the  disorder,  the  fever  generally  ceases  entirely  upon 
the  coming  out  of  the  eruption ;  the  headache,  the  pain  of  the  back,  the  vomiting, 
the  restlessness,  abate  and  disappear ;  the  pulse  resumes  its  natural  force  and  fre- 
quency, and  the  skin  its  natural  temperature.  About  the  seventh  or  eighth  day  of 
the  eruption  there  is  commonly,  for  a  day  or  two,  a  recurrence  of  fever.  This  is 
called  the  fever  of  maturation. 

You  are  to  observe  that  we  judge  of  the  eruption  as  it  appears  on  the  yace.  Th«^ 
disease  is  of  the  confluent  kind,  when  the  pustules  are  confluent  there,  whether  thej 
be  so  or  not  upon  the  trunk  and  extremities.  Sometimes  they  are  neither  strictlv 
confluent  nor  strictly  separate,  but  stand  just  thick  enough  to  touch  each  other,  with- 
out absolutely  coalescing;  every  pustule  preserving  its  circular  outline.  In  thai 
case,  the  disease  is  said  to  be  of  the  cohering  form.  When  the  pustules  are  conflu- 
«3  4g3 


978  SWALL-POX. 

ent  over  the  whole  bodj',  their  number  is  often  prodigiously  great,  and  their  progress 
is  less  regular  than  in  the  discrete  and  milder  variety  of  the  complaint. 

In  the  first  place,  the  eruptive  fever  itself  is  usually  more  violent  and  tumultuous 
m  the  confluent  disease  ;  the  disturbance  of  the  sensorial  functions  is  more  common 
and  more  decided,  the  sickness  more  distressing,  the  pain  of  the  back  and  loins  more 
severe.  The  eruption  comes  out  earlier,  and  more  confusedly ;  the  pimples  being 
at  first  very  minute,  and  crowded  together  in  patches,  and  not  seldom  accompanied 
by  a  rash  like  that  of  scarlet  fever,  or  er}'sipelas :  whereby  the  diagnosis,  in  so  far 
as  it  depends  upon  the  appearance  of  the  skin,  is  rendered  for  a  while  uncertain.  I 
have  at  present  in  the  Middlesex  Hospital  a  patient  in  whom  the  papulae  of  small- 
pox were,  at  the  outset,  so  intermingled  with  the  appearances  and  sensations  of  urti- 
caria, that  I  doubted,  for  twenty-four  hours,  what  the  true  character  of  the  eruption 
might  be.  It  is  sometimes  like  that  of  measles;  but  the  similarity  and  the  uncer- 
tainty are  soon  at  an  end,  for  the  pimples  soon  begin  to  exhibit  a  fluid  on  their  sum- 
raits.  They  do  not,  however,  as  they  advance  and  pass  into  pustules,  fill  up  so 
completely  as  in  the  distinct  form ;  they  are  flatter,  less  plump,  more  irregularly 
depressed,  and  even  of  a  different  colour  ;  being  at  first  whitish,  and  then  of  a  brow'n 
tint,  and  seldom  of  the  yellow  purulent  hue  which  is  seen  in  the  variola  discreta. 
Sometimes  they  are  even  bluish,  or  purple.  In  the  confluent  form  there  is  commonly 
some  abatement  of  the  febrile  distress  upon  the  coming  out  of  the  eruption ;  but  the 
remission  is  much  less  marked  than  in  the  discrete.  About  the  fifth  or  sixth  day, 
fresh  rigors  are  apt  to  occur,  marking  the  fever  of  maturation.  Most  of  these  points 
of  distinction  between  the  two  varieties  of  the  disease  are  well  marked  in  Cu lien's 
definitions.  The  distinct  form  he  defines  thus:  "  Variola  (discreta)  pustulis  paucis, 
discretis,  circumscriptione  circularibus,  turgidis  ;  febre,  eruptione  facta,  protinus  ces- 
sante."  And  of  the  confluent  kind  his  definition  is,  "Variola  (confluens)  pustulia 
numerosis,  confluentibus,  circumscriptione  irregularibus,  flaccidis,  parum  elevatis; 
febre  post  eruptionem  perstante." 

But  the  most  important  difference  between  the  two  forms  is  in  what  is  called  the 
secondary  fever,  which  sets  in  about  the  eleventh  day  of  the  disease,  or  the  eighth 
of  the  eruption,  just  when  the  maturation  of  the  pustules  is  complete,  and  they  begin 
to  desiccate.  This  secondary  fever  is  slightly  marked  in  the  distinct  small-pox,  and 
very  intense  and  perilous  in  most  instances  of  the  confluent.  It  is  at  this  period  of 
the  disorder,  that  death,  in  the  fatal  cases,  oftenest  occurs.  Of  168  such  cases, 
recorded  by  Dr.  Gregorj',  the  deaths  happened  in  tw^enty-seven  (nearly  one-sixth  of 
the  whole)  upon  the  eighth  day  of  the  eruption.  That,  therefore,  is  the  most  perilous 
day,  as  the  second  is  the  most  perilous  iceek.  Thirty-two  died  in  the  first  week, 
ninety-nine  in  the  second,  twenty-one  in  the  third.  The  early  occurrence  of  death 
denotes  a  peculiar  inalignancy  in  the  disease.  The  nervous  system  appears  to  be 
overwhelmed  by  the  force  of  the  poison.  During  the  second  week  the  disorder 
proves  fatal  chiefly  in  the  way  of  apnoea ;  from  some  affection  of  the  respiratory 
passages.  After  that  period  the  characters  of  asthenia  commonly  predominate.  The 
patient  sinks  under  some  casual  complication,  or  the  powers  of  life  are  gradually 
worn  out  by  so  much  irritation  of  the  surface,  and  so  large  an  amount  of  suppuration. 

So  much  for  the  ordinary  course  of  small-pox,  and  of  the  symptoms  that  are  essen- 
tial to  that  disease.  There  are,  however,  other  concomitant  circumstances,  with 
which  you  ought  to  be  acquainted:  and  these  I  will  endeavour  to  specify  at  our 
next  assembling. 


LECTURE  LXXXVII. 

iSinall-pox,  continued.    Inoculation.    Vaccination.    Their  comparative  advantages 

Treatment  of  Small-pox. 

In  the  last  lecture  I  brought  before  you,  in  a  rapid  sketch,  the  ordinary  course, 
hod  th.e  essential  symptoms  of  small-pox ;  both  in  its  distinct  and  in  its  confluent 


SMALL-POX.  ,  979 

form.  I  have  yet  to  mention  some  other  circumstances  that  are  very  frequently  to 
be  noticed  in  connection  with  that  disease. 

Both  kinds  are  accompanied  by  sore  throat ;  the  tonsils  and  fauces  are  tumid  and 
red :  and  with  this  sore  throat  there  is  associated,  about  the  period  when  the  face 
swells,  sometimes  in  the  discrete  variety,  and  almost  always  in  the  confluent,  more 
or  less  salivation,  which  lasts  for  several  days.  At  first  the  discharge  is  thin  and 
plentiful ;  but,  towards  the  period  of  maturation,  it  often  becomes  viscid  and  ropy, 
and  is  with  difficulty  got  rid  of  by  the  patient.  This  salivation  is  of  some  importance 
as  a  prognostic  symptom.  If  it  cease  abruptly,  and  especially  if  at  the  same  time 
the  swelling  of  the  face  suddenly  and  prematurely  subside,  the  peril  is  great.  Besides 
this,  Sydenham  regarded  the  ptyalism  as  a  diagnostic  circumstance  ;  as  a  mark  which 
identified  with  true  small-pox  a  fever  called  by  him  the  variolous  fever,  the  variolas 
sine  variolis  of  De  Haen  and  others.  "  The  resemblance  (says  he)  which  this  fever 
bore,  in  its  symptoms,  to  small-pox,  induced  me  to  give  it  the  title  of  variolous  fever, 
which  seemed  indeed  so  much  the  more  appropriate,  as  the  fever  raged  at  the  same 
time  with  small-pox,  and  got  well  under  the  same  treatment.  The  two  diseases 
belonged  evidently  to  one  family,  and  there  was  no  difference  between  them,  saving 
that  in  small-pox  the  morbific  matter  was  directed  towards  the  skin,  in  the  shape  of 
an  eruption  ;  while  in  the  variolous  fever  this  matter  was  expelled  from  the  system 
by  the  salivary  glands."  Notwithstanding  this  statement,  it  is  difficult  to  believe 
that  any  such  disorder  as  variolse  sine  variolis  ever  proceeds  from  the  contagion  of 
small-pox. 

This  affection  of  the  salivary  glands  does  not  so  often  occur  in  children ;  but  diar- 
rhoea appears  sometimes  to  take  its  place. 

The  soreness  of  the  fauces. often  depends,  in  great  measure,  upon  pustules  there 
situate.  You  may  see  that  the  tongue,  the  roof  of  the  mouth,  the  inside  of  the 
cheeks,  the  uvula,  and  the  velum  palati,  are  thickly  studded  with  them.  It  is 
affirmed  by  some  writers  that  the  pustules  of  small-pox  occur  in  various  internal 
parts  of  the  body,  and  especially  upon  the  mucous  membrane  of  the  intestinal  canal. 
I  believe  this  to  be  a  mistake.  The  enlarged  solitary  follicles  often  put  on  very 
much  the  appearance  of  pustules.  Cotunnius,  who  has  written  a  good  book,  De 
sedilms  variolariim,  asserts  that  pustules  appear  only  upon  the  skin,  and  upon  those 
parts  of  the  mucous  membranes  which  are  freely  exposed  to  the  air.  In  one  soli- 
tary instance  he  met  with  them  in  the  trachea  so  low  as  its  third  ring.  He  fancied 
that  previous  desiccation  of  the  part  was  necessary  to  their  formation.  He  says  that 
none  appear  on  the  cornea,  while  it  is  kept  moist.  He  denies  that  they  are  seen  in 
the  interior  of  the  body,  or  upon  the  fostus  in  utero :  but  in  this  last  point  he  is  cer- 
tainly wrong  :  and  this  is  a  strong  objection  to  his  theory.  The  most  striking  facts 
which  he  alleges  in  support  of  his  opinion  of  the  necessary  presence  of  air — besides 
the  fact  of  the  eruption  being  more  copious  on  parts  usually  exposed  to  the  atmo- 
sphere, as  the  face  and  hands — are,  that  pustules  do  not  form  on  the  inner  surface 
of  the  eyelids,  except  in  cases  of  ect r opium ;  that  they  appear  on  hemorrhoidal 
tumours  only  when  these  project  beyond  the  margin  of  the  anus ;  and  that  that  por- 
tion alone  of  the  glans  penis  is  ever  affected  by  them  which  is  uncovered  by  the 
prepuce. 

Dr.  Gregory,  however,  states  that  true  variolous  pustules  do  not  form  upon  the 
conjunctival  membrane:  and  that  the  blindness  of  one  or  both  eyes  which  is  so  com- 
mon a  result  of  small-pox,  especially  in  children,  is  produced  by  an  intense  kind  of 
ophthalmia,  which  sets  in  at  the  period  of  the  secondary  fever,  and  rapidly  involves 
and  spoils  the  transparent  tissues  of  the  organ. 

During  the  period  of  maturation,  a  peculiar  greasy,  disagreeable  odour,  quite  sui 
generis,  proceeds  from  the  body  of  the  patient.  If  taken  into  the  sick  chamber  blind- 
folded, one  might  name  the  disease  at  once  by  this  smell.  About  the  same  time  also 
many  patients  are  tormented  by  itching  of  the  surface ;  so  that  they  are  provoked  to 
scratch  oft' the  heads  of  the  pustules  :  and  by  so  doing  they  often  ensure  the  formation 
of  pits.  In  many  cases  of  confluent  small-pox  this  itching  appears  to  constitute  the 
chief  part  of  the  patient's  suffering. 

There  are  various  troublesome  complications  to  which,  in  severe  cases  of  the  con 


980  SMALL-POX. 

fluent  form,  the  patients  are  liable  during  the  secondary  fever;  erysipelatous  inflam- 
mation involving  the  subcwtaneous  areolar  tissue  in  various  parts  of  the  body,  and 
leading  to  the  formation  of  abscesses;  glandular  swellings  in  the  groins  and  axilla;, 
going  on  sometimes  to  suppuration;  sloughing  sores  on  the  hips  and  sacrum; 
phlebitis ;  and  in  two  or  three  instances  I  have  seen  the  large  joints,  after  death,  full 
of  matter.  One  of  the  most  serious  symptoms,  at  this  period  of  the  disease,  is 
dyspnoea.  The  air-passages,  and  especially  the  larynx,  become  clogged  by  viscid 
mucus,  the  arterialization  of  the  blood  is  interfered  with,  and  the  patient  is  in  danger 
of  suffocation.  Occasionally  life  is  suddenly  extinguished  by  oedema  of  the  glottis, 
supervening  upon  that  affection  of  the  fauces  which  I  mentioned  just  noAV. 

In  one  most  fearful  phase  of  this  always  formidable  disorder,  symptoms  indicative 
of  what  is  called  the  putrid  diathesis  manifest  themselves — petechise,  vibices,  hemor- 
rhages from  various  parts  of  the  body.  The  pustules,  instead  of  being  plump  and 
yellow,  are  flat,  red,  purple,  or  blue  ;  that  is,  they  contain  blood,  or  a  sanious  ichor, 
in  the  place  of  pus,  constituting  the  variolse  nigrx  of  Sydenham,  the  bloody  small- 
pox of  Mead.  I  believe  that  these  appearances  augur  in  all  cases  a  fatal  result. 
Hemorrhage  from  the  uterus  is  not  uncommon ;  and  in  pregnant  women  abortion, 
and  then,  most  commonly,  death.  Heberden  says  that  he  examined,  in  many  in- 
stances, the  fcstuses  so  parted  with,  but  never  could  perceive  upon  them  any  traces 
of  small-pox.  His  experience,  therefore,  agreed  with  that  of  Cotunnius ;  and  we 
may  conclude  that  infection  of  the  foetus  in  utero  is  very  rare.  Yet,  unquestionably, 
it  sometimes  happens ;  and  the  circumstances  under  which  it  has  been  noticed  are 
various  and  interesting.  In  one  instance,  related  by  Mr.  Flinders,  the  disorder  was 
eight  or  ten  days  later  in  the  foetus  than  in  the  mother.  A  woman,  near  her  full 
time,  took  small-pox.  The  pustules  were  mature  about  the  10th  or  11th  of  June, 
On  the  18th  she  gave  birth  to  a  full-grown  boy,  upon  whose  face  and  body  there 
were  many  pustules,  discrete,  and  nearly  ripe.  The  child  died  the  same  iiight.  It 
is  a  very  curious  fact  that  the  foetus  has  caught  the  disorder,  doubtless  through  the 
medium  of  the  mother,  although  she,  having  had  it  previously,  was  unaffected  by  the 
contagion.  Dr.  Mead  relates  that  "a  certain  woman,  who  had  formerly  had  the 
small-pox,  and  was  now  near  her  reckoning,  attended  her  husband  in  this  distemper. 
She  went  her  full  time,  and  was  dehvered  of  a  dead  child.  It  may  be  needless  to 
add,  that  she  did  not  catch  it  on  this  occasion ;  but  the  dead  body  of  the  infant  was  a 
horrid  sight,  being  covered  all  over  with  pustules."  In  the  first  volume  of  the 
Medico-Chirurgical  Transactions,  Dr.  Jenner  gives  an  account  of  an  infant  which, 
upon  the  fifth  day  of  its  age,  became  indisposed,  and  on  the  seventh  exhibited  the 
eruption  of  small-pox ;  so  that  the  contagion  must  have  been  communicated  to  it 
while  yet  in  the  womb.  A  few  days  before  her  confinement  the  mother  of  this  child 
had  seen,  in  the  street,  a  person  covered  with  small-pox  pustules,  the  smell  and  sight 
of  whose  body  had  sensibly  affected  her.  I  see  no  reason,  therefore,  for  doubting 
that  the  unborn  being  may  pass  safely  through  the  disease  while  in  the  womb,  and 
derive  from  that  attack  the  customary  immunity  for  the  future.  My  namesake.  Sir 
William  Watson,  describes  in  the  Philosophical  Transactions,  an  instance  in  which 
the  scars  left  by  the  pustules  were  visible  upon  an  infant  at  its  birth.  The  child  was 
afterwards  inoculated  without  taking  the  disease.  Its  mother,  who  had  formerly  had 
it,  nursed,  when  far  advanced  in  pregnancy,  a  servant  ill  of  small-pox.  Dr.  Pearson 
met  with  a  similar  example.  Mary  Spooner  was  inoculated  by  him  in  her  sixth 
month  of  utero-gestation,  and  had  the  disease  severely.  Her  child  was  twice  inocu- 
lated with  small-pox  matter,  but  without  effect. 

Like  all  these  contagious  exanthemata,  small-pox  has  its  periods  of  dormancy  and 
of  activity.  Every  now  and  then,  at  irregular  intervals  —  and,  as  it  would  seem  to 
our  ignorance  of  the  cause,  capriciously  —  it  overspreads  a  district  or  country  as  an 
epidemic.  At  this  moment  (1838)  it  is  more  prevalent  in  London,  and  in  many 
parts  of  England,  than  it  has  been  known  to  be  for  many  years  past.  W'hen  epi- 
demic, it  is  also,  in  general,  more  than  ordinarily  severe  ;  although  different  epidemics 
vary  much  in  that  respect. 

There  is  no  contagion  so  strong  and  sure  as  that  of  small-pox :  none  that  operates 
at  so  great  a  distance.     Dr.  Haygarth  states,  "that  during  his  long  attention  to  this 


SMALL-POX.  981 

subject,  not  a  single  instance  had  occurred  to  prove  that  persons  liable  to  the  small- 
pox could  associate  in  the  same  chamber  with  a  patient  in  the  distemper,  without  re- 
ceiving the  infection."  It  is  readily  communicable  in  every  way  ;  by  inoculation,  by 
breathing  a  contaminated  atmosphere,  by  the  contact  or  vicinity  of  fomites.  Naj^  it 
may  be  caught  from  the  dead  body.  Mr.  Ctesar  Hawkins  has  recorded  an  interesting 
example  of  this.  The  body  of  a  man  who  died  of  small-pox,  was  brought  into  his 
dissecting  room  in  Windmill  street;  and  four  students  took  the  disease  from  that 
source.     Of  these,  one  only  had  touched  the  body. 

There  is  one  appearance  which  I  think  curious,  although,  perhaps,  it  has  not  any 
great  practical  interest ;  and  which  I  omitted  to  notice  in  the  last  lecture,  when  de- 
scribing the  course  of  the  eruption.  Without  going  minutely  into  the  anatomy  of 
the  pustules,  you  may  distinctly  see,  if  you  closely  examine  them  when  they  are 
about  five  or  six  days  old  —  you  may  see,  at  least,  in  many  of  them  —  two  colours, 
viz.,  a  central  whitish  disc  of  lymph,  set  in,  or  surrounded  by,  a  circle  of  yellower 
puriform  matter.  In  truth,  there  is,  in  the  centre,  a  vesicle,  which  is  distinct  from  the 
pus.  You  may  puncture  the  vesicle,  and  empty  it  of  its  contents,  without  letting  out 
any  of  the  pus ;  or  you  may  puncture  the  part  containing  the  pus,  and  let  thai  out, 
without  evacuating  the  contents  of  the  vesicle.  The  vesicles  have  even,  by  careful 
dissection,  been  taken  out  entire ;  and  they  are  said  to  consist  of  several  little  cells. 
It  is  most  probable  that  the  lymph  contained  in  this  separate  vesicle  is  the  purest 
part  of  the  variolous  poison. 

Before  I  say  anything  of  the  measures  to  be  adopted  during  the  progress  of  small- 
pox, I  have  to  bring  under  your  notice  two  expedients  of  still  greater  interest  and 
importance ;  the  one  of  them  contemplating  a  mitigation  of  the  disorder,  the  other  its 
total  prevention.  You  anticipate  that  I  am  about  to  speak  of  inoculated  smali-pox  in 
the  first  instance,  and  of  the  vaccine  disease  in  the  second. 

I  have  many  times  stated,  and  all  the  world  knows,  that  small-pox  maybe  imparted 
to  a  healthy  person  by  inserting  beneath  his  cuticle  a  minute  quantity  of  the  matter 
taken  from  a  variolous  pustule.  This,  perhaps,  is  not  very  surprising;  but  it  is  sur- 
prising that  the  disease,  so  received,  should  be  much  milder  than  if  it  had  been  con- 
tracted in  what  is  called  "  the  natural  way,"  by  breathing  an  atmosphere  charged 
with  the  contagious  poison.  Why  it  should  be  so  it  is  difficult  to  conjecture.  The 
fact  is  sometimes  expressed  by  saying  that  the  disease  is  milder  when  the  virus  is 
admitted  through  the  cutaneous,  than  when  through  the  mucous  tissues.  But  I  am 
not  at  all  sure  that  the  hypothesis  involved  in  this  proposition  is  true.  No  attempts 
have  been  made,  that  I  know  of,  to  introduce  the  poison  artificially  through  a  wound 
in  any  mucous  surface.  I  should  rather  guess  that  the  small  quantity  of  the  poison 
conveyed  by  inoculation  into  the  blood  may  make  the  difTerence.  But  whatever  the 
explanation,  the  fact  is  unquestionable,  and  obviously  of  the  highest  importance.  By 
what  accident  it  was  first  learned  (for  it  evidently  could  not  have  been  reasoned  out) 
we  do  not  know.  The  Chinese  claim  to  have  been  in  the  habit,  for  many  centuries, 
of  sowing  the  disorder,  by  putting  some  of  the  crusts  into  the  nostrils.  But  this  is  a 
different  thing  from  inoculation,  the  surface  being  entire,  and  the  effluvia  from  the 
crusts  being  drawn  into  the  lungs  by  the  act  of  inspiration.  It  is  said  that  a  true 
engrafting  of  the  virus  has  been  in  use  by  the  Brahmins  in  India,  time  out  of  mind. 
It  certainly  was  practised  in  Turkey  at  the  very  beginning  of  the  last  century,  and 
perhaps  somewhat  earlier.  In  1713,  Dr.  Emanuel  Timoni,  an  Oxford  graduate,' 
who  had  settled  at  Constantinople,  wrote  to  Dr.  Woodward,  in  London,  giving  him 
an  account  of  the  new  process,  and  testifying  to  its  success.  This  account  was  com- 
municated to  the  Royal  Society,  and  published  in  its  Transactions  the  following  year. 
In  1715,  Mr.  Kennedy,  an  English  surgeon  who  had  travelled  in  Turkey,  gave 
similar  information  to  the  English  public  in  his  Essay  on  External  Remedies.  And 
in  the  Philosop/iical  Transactions  for  1716  you  may  see  a  notice  of  the  same  pro- 
cess, as  described  by  M.Pylarini,  the  Venetian  consul  at  Smyrna.  But  these  stare- 
ments  were  neglected,  or  had  no  practical  result.  We  owe  the  actual  introduction 
of  the  practice  of  inoculation  into  Great  Britain  to  the  good  sense  and  courage  of  an 
English  lady,  whose  lively  epistles  have  taken  their  permanent  place  in  our  country's 
literature.     Lady  Mary  Worlley  Montagu,  the  wife  of  our  ambassador  at  the  OttO' 


982  SMALL-POX. 

man  Court,  writes  thus,  from  Adrianople,  in  the  year  1718:  "The  small-pox,  so  fatai 
and  so  general  amongst  us,  is  here  entirely  harmless  by  the  invention  oi  engraftino;, 
which  is  the  term  they  give  it.  Every  year  thousands  undergo  the  operation  ;  and 
the  French  ambassador  sayc,  pleasantly,  that  the}'  take  the  small-pox  here  by  way  of 
diversion,  as  they  take  the  waters  in  other  countries.  There  is  no  example  of  any 
one  who  has  died  in  it ;  and  3'ou  may  believe  I  am  well  satisfied  of  the  safety  of  this 
experiment,  since  I  intend  to  try  it  on  my  dear  little  son.  I  am  patriot  enough  to 
take  pains  to  bring  this  useful  invention  into  fashion  in  England."  In  fact,  she  re- 
commended it  by  her  own  example.  The  first  person  inoculated  with  small-pox  in 
England  was  her  daughter.  Then  a  child  of  a  physician.  Dr.  Keith,  who  had  visited 
Miss  Wortley ;  afterwards  some  condemned  felons,  who  were  pardoned  on  condition 
of  their  submitting  to  the  experiment ;  and  at  length  some  of  the  royal  family.  But 
the  practice  was  not  thoroughly  established,  nor  properly  appreciated,  by  the  English 
public,  until  the  middle  of  that  century. 

Its  efficacy  in  mitigating  the  severity  and  danger  of  the  disease,  in  saving  life  and 
preventing  deformity,  was  signally  great.  The  mortality  in  the  natural  small-pox 
was  estimated  at  one  in  five.  But  Baron  Dimsdale,  a  great  inoculator,  declared  that 
not  one  in  fifteen  hundred  died  of  the  engrafted  disease.  Two  brothers,  named 
Sutton,  who  had  introduced,  or  rather  revived,  a  very  improved  method  of  treating 
the  disorder,  professed  to  have  inoculated  20,000  persons  without  fairly  losing  one. 
But  these,  doubtless,  were  exaggerated  statements.  Among  5964  individuals,  inocu- 
lated at  the  Small-pox  Hospital  in  1797,  1798,  and  1799,  there  were  nine  deaths; 
»,  e.,  one  in  six  hundred  and  sixty-two.  We  may  take  Dr.  Gregory's  estimate  of 
one  death  in  five  hundred  cases,  as  being  probably  within  the  mark. 

In  the  inoculated  disease  the  period  of  incubation  is  comparatively  short;  the  pus- 
tules are  seldom  numerous,  and  still  more  seldom  confluent;  and  the  secondary  fever 
is  generally  slight  or  awanting, 

I  may  mention  here,  also,  that  the  eruption  is  not  unfrequently  preceded  by  a  rash, 
something  like  that  of  scarlet  fever,  and  called  by  Willan  the  roseola  variolosa. 
It  fades  in  the  course  of  a  day  or  two,  and  then  the  small-pox  pustules  are  seen 
emerging  just  in  the  same  state  that  they  would  have  been  in,  at  the  same  period,  if 
no  such  rash  had  appeared.  The  efflorescence  happens  oftener  in  the  inoculated 
than  in  the  casual  disease.  In  the  former  it  is  looked  upon  as  rather  a  favourable 
sign  ;  in  the  latter,  especially  if  the  rash  be  of  a  dark  red  colour,  it  is  considered  un- 
favourable, and  as  the  herald  of  a  severe  confluent  disorder, 

A  far  superior  expedient  has  since  been  discovered,  in  the  practice  of  vaccination, 
which  has  rendered  the  inoculation  of  small-pox  not  merely  unnecessary,  but,  in 
most  cases,  perfectly  unjustifiable.  Yet  circumstances  do  sometimes  arise,  even  now, 
in  which  it  may  be  allowable  and  right  to  engraft  the  matter  of  small-pox ;  as  when 
an  unprotected  person  is  unavoidably  exposed,  or  has  recently  been  exposed,  to  the 
contagion  of  that  disease,  and  there  is  no  vaccine  matter  at  hand.  The  advantage 
of  inoculating  in  such  a  case  is,  that  the  inoculated  or  milder  form  gets  the  start  of 
the  natural  and  severer;  the  fever  commencing  sooner  than  it  would  otherwise  do. 
To  show  you  the  value  of  the  practice  in  such  cases,  and  the  degree  of  protection 
which  it  aflbrds  to  individuals  whom  we  cannot  vaccinate,  I  may  mention  a  fact 
which  Professor  Gregory,  of  Edinburgh,  was  in  the  habit  of  relating,  and  which 
"vas  told  him  by  a  naval  surgeon.  The  small-pox  was  introduced  among  the  crew 
«)f  a  man-of-war,  in  a  tropical  climate,  where  no  vaccine  matter  was  to  be  procured. 
The  men  were  almost  all  unprotected.  Sixteen  of  them  took  the  disease  in  the 
natural  way;  and  of  these,  nine,  or  more  than  one-half,  died.  Of  303  who  were 
inoculated,  under  the  disadvantages  of  a  hot  climate,  and  no  preparation,  not  one 
perished. 

That  a  disorder  communicated  to  the  human  animal  from  one  of  the  brutes  should 
protect  the  former  aaainst  the  contagion  of  small-pox,  is  one  of  the  most  interesting 
^acls  in  the  Avhole  history  of  medicine.  How  glimpses  of  a  truth  so  remarkable 
were  first  revealed  to  the  casual  observation  of  certain  peasants,  and  how  the  result 
of  this  chance  observation  was  gradually  "  matured  into  a  rational  and  scientific  form 
bv  a  mind  deeply  imbued  with  the  best  principles  of  sound  philosophy,"  I  have  not 


VACCINATION.  983 

leisure  to  tell  you  in  detail.  And  it  is  the  less  necessary  that  I  should  do  so,  as  you 
may  find  the  whole  subject  thoroughly  naiTattd  and  discussed  by  Dr.  Baron,  in  his 
interesting  biography  of  Edward  Jenner. 

Dr.  Jenner  found  among  the  great  dairy  farms  in  Gloucestershire  a  popular  belief 
that  no  person  who  had  had  the  cow-pox  (an  eruptive  vesicular  complaint  communi- 
cated from  the  udder  of  the  cow  to  the  hands  of  the  milkers)  could  "  take  the  small- 
pox." Satisfied,  by  inoculating  with  small-pox  matter  several  individuals  who  had 
had  the  vaccine  eruption,  that  this  was  not  an  unfounded  notion,  he  at  length  con- 
ceived the  great  and  happy  idea  of  propagating  the  cow-pox  from  one  human  being 
to  another,  and  so  preventing,  in  all  cases,  the  perilous  distemper  of  small-pox,  which 
he  hoped  might  thus  be  finally  expelled  from  the  earth. 

By  degrees.  Dr.  Jenner  ascertained  that  some  persons,  who  had  had  sore  hands 
from  milking,  were  not  thereby  rendered  proof  against  the  contagion  of  small-pox; 
but  this  difBculty  was  soon  cleared  up  by  the  discovery  that  the  teats  of  cows  were 
liable  to  different  kinds  of  eruption,  and  he  learned,  by  close  observation,  which  of 
these  was  the  peculiar  eruption  that  produced  in  the  human  frame  the  protecting 
disorder. 

Dr.  Jenner  set  himself  to  trace,  if  possible,  the  origin  of  the  disease  of  the  cow. 
First,  he  found  that  it  was  peculiar  to  certain  dairies;  then,  that  in  those  dairies  men 
were  employed  in  milking.  Following  up  this  clue,  he  further  made  out  that  those 
men  had  also  the  charge  of  the  farm-horses.  Next,  he  learned  that  the  teats  of  the 
cows  generally  began  to  exhibit  the  specific  eruption  at  that  time  of  the  year  when 
a  complaint  called  "  the  grease"  chiefly  prevailed  among  the  horses.  Hence  he 
concluded,  that  the  malady  was  conveyed  "to  the  cows  by  the  hands  of  the  men  who 
had  been  dressing  the  heels  of  horses  affected  with  the  grease.  Subsequent  inquiries 
have,  however,  shown  that  this  conclusion  was  not  strictly  correct. 

Another  difficulty  which  lay  in  Dr.  Jenner's  way,  and  which  his  patience  and 
sagacity  surmounted,  was  this.  He  found  that  some  who  were  casually  infected  from 
the  true  complaint  in  the  cow  were  not  protected.  This  depended,  as  he  afterwards 
ascertained,  upon  the  period  of  the  disease  in  the  cow,  at  which  the  virus  was  com- 
municated to  the  milker.  The  thick  matter  proceeding  from  the  vesicle  late  in  its 
progress  produced  indeed  a  severer  local  sore  than  the  thinner  matter  of  its  earlier 
state,  but  it  did  not  confer  the  desired  protection.  The  same  thing  is  observed  in 
respect  to  small-pox.  If  the  matter  used  for  inoculating  be  taken  from  a  fully 
matured  pustule,  it  does  not  so  surely  excite  the  disease  as  when  taken  from  a  more 
crude  one. 

The  next  important  step  in  this  most  interesting  investigation  was  to  determine 
whether  the  vaccine  disease  could  be  transmitted,  by  engrafting  from  one  human 
being  to  another,  and  whether,  if  so  transmitted,  it  retained  its  protecting  power. 
The  14th  of  May,  1796,  was  the  birth-day  of  vaccination.  On  that  day,  "  matter 
was  taken  from  the  hand  of  Sarah  Nelmes,  who  had  been  infected  by  her  master's 
cows,  and  inserted  by  two  superficial  incisions  into  the  arms  of  James  Phipps,  a 
healthy  boy  of  about  eight  years  old.  He  went  through  the  disease  apparently 
in  a  regular  and  satisfactory  manner;  but  the  most  agitating  part  of  the  trial  still 
remained  to  be  performed.  It  was  needful  to  ascertain  whether  he  was  secure  from 
the  contagion  of  small-pox.  This  point,  so  full  of  anxiety  to  Dr.  Jenner,  was 
fairly  put  to  issue  on  the  1st  of  the  following  July.  Variolous  matter,  immediately 
taken  from  a  pustule,  was  carefully  inserted  by  several  incisions  —  but  no  disease 
followed." 

It  is  scarcely  necessary  for  me  to  notice  the  objections  which  were  made  to  the 
practice  of  vaccination.  Some  of  them  were  merely  foolish — as,  that  it  was  unna- 
tural and  impious  to  engraft  the  diseases  of  a  brute  upon  a  Christian.  Others  were 
untrue — as,  that  it  introduced  into  the  system  new  disorders,  distinct  from  the  cow- 
pox.  It  triumphed  over  all  these  cavils  ;  and  in  six  years  from  its  first  promulgation 
the  discovery  was  known  in  every  region  of  the  world. 

It  was  soon  found,  however,  that  some,  who  had  apparently  had  the  cow-pox  by 
inoculation,  were  nevertheless  not  incapable  of  taking  the  small-pox ;  and  that  these 
failures  were,  many  of  them  at  least,  attributable  to  the  mistakes  that  were  made  in 


984  VACCINATION. 

the  time  or  manner  of  performing  the  operation.  It  became  necessary,  therefore,  to 
ascertain  precisely  the  conditions  requisite  for  the  production  of  the  genuine  disease. 
And  these  conditions  have  been  successfully  investigated  by  Dr.  Jennerand  by  sub- 
sequent surveyors. 

You  will  learn  to  recognize  the  true  vaccine  vesicle  only  by  repeatedly  examining 
it  for  yourselves.  Yet  a  brief  description  of  its  characters  and  progressive  changes 
may  be  useful  to  you. 

On  the  second  or  third  day  after  the  insertion  of  the  vaccine  matter  into  the  arm, 
the  punctures  look  red  and  inflamed,  and  on  the  fourth  or  fifth  day  the  vesicle  becomes 
perceptible  ;  a  pearl-coloured  elevation  of  the  cuticle  enclosing  a  minute  quantity  of 
a  thin  transparent  liquid.  It  gradually  increases  in  magnitude  till  the  eighth  day, 
when  it  should  measure  from  a  quarter  to  half  an  inch  across.  Like  the  pustule  of 
small-pox,  it  is  more  prominent  at  its  circumference  than  at  its  centre,  and  it  consists 
of  small  cells,  from  ten  to  fourteen  in  number.  By  puncturing  carefully  one  of  these 
cells,  a  drop  of  the  virus  may  be  let  out,  the  other  cells  remaining  full.  Up  to  the 
seventh,  or  eighth,  or  even  to  the  beginning  of  the  ninth  day,  the  inflammation  around 
the  vesicle  should  extend  to  only  a  very  small  distance  from  it.  After  this,  it  spreads, 
and  what  is  called  the  areola  is  formed ;  a  circular  red  border,  which  continues  to 
increase  during  the  ninth  and  tenth  daj^s,  and  begins  to  fade  on  the  eleventh,  passing 
through  shades  of  blue  as  it  dechnes,  and  leaving  a  degree  of  hardness  behind  for 
two  or  three  days  more.  By  this  time,  a  brown  or  mahogany-coloured  crust  has 
formed  over  the  vesicle,  of  a  nearly  circular  shape;  this  becomes  gradually  harder 
and  darker,  and  finally  detaches  itself  about  the  twentieth  day.  The  cicatrix  which 
it  leaves  should  be  somewhat  less  than  an  inch  broad,  circular,  slightly  depressed, 
marked  by  radiating  lines,  and  dotted  with  little  pits  which  seem  to  correspond  to 
the  cells  of  the  vesicle. 

About  the  eighth  day  there  is  usually  some  slight  febrile  excitement  manifested, 
which  soon  subsides.  This  is  analogous  to  the  secondary  fever  of  cimall-pox :  and 
it  appears  to  furnish  the  condition  of  the  desired  protection. 

Of  course  it  is  of  much  moment  to  determine  whether  the  cow-pox  has  run  its 
proper  course  or  not ;  and  it  is  not  always  easy  to  say  how  far  the  progress  of  the 
vesicle  may  deviate  from  that  which  has  just  been  described,  without  failing  of  its 
protecting  influence.  A  very  ingenious  teat  of  this,  free  from  all  ambiguit}%  has 
been  devised  by  Mr.  Bryce.  His  plan  is  this.  He  vaccinates  the  other  arm,  or 
some  other  part  of  the  body,  four  or  five  days  after  the  first  vaccination.  If  the  con- 
stitution has  been  properly  affected  by  the  first  operation,  the  inflammation  of  the 
second  vesicle  will  proceed  so  much  more  rapidly  than  usual,  that  it  will  be  at  its 
height,  and  will  decline  and  disappear  as  early  as  that  of  the  first:  only  the  vesicle 
and  its  areola  will  be  smaller.  In  fact,  from  the  time  of  the  formation  of  the  areola, 
the  second  vesicle  is  an  exact  miniature  of  the  first.  If  the  system  has  not  been  duly 
influenced  by  the  first  vesicle,  the  second  will  run  its  own  course,  increasing  up  to 
its  eighth  day,  and  so  on.  Should  this  be  the  case,  the  second  vesicle  should  be 
tested  by  a  third. 

We  find  the  germ  of  this  criterion  in  the  early  history  of  vaccination.  Dr.  Jenner 
vaccinated  the  children  of  his  friend  Mr.  Hicks,  the  first  gentleman  who  consented 
to  adopt  the  practice.  This  Mr.  Hicks  became  afterwards  an  expert  vaccinator  him- 
self, and  it  was  his  custom,  in  a  doubtful  case,  to  perform  a  second  vaccination  in  a 
few  days  after  the  first :  and  he  remarked  that  the  second  vesicle  made  "  immense 
strides  to  overtake  the  first." 

After  some  time  it  became  apparent  that  Dr.  Tenner's  estimate  of  the  protecting 
power  of  the  vaccine  disease  had  been  set  too  high.  He  had  hoped  and  believed, 
as  others  also  had,  that  the  cow-pox  would  in  all  cases  prove  a  perfect  and  permanent 
protection  against  the  small-pox ;  but  those  hopes  have  been  disappomted.  Doubt- 
less complete  protection  is  the  rule  ;  but — how  thoroughly  and  regularly  soever  the 
vaccine  malady  may  have  proceeded — it  is  most  certain  that  very  many  exceptions 
1.0  tins  rule  have  taken  place,  and  are  daily  taking  place  around  us. 

And  this  fact,  which  has  become  too  glaring  to  be  denied  or  explained  away,  has 
flepreciated  the  value  of  the  process  of  vaccination,  in  the  public  esteem,  far  moie 


SMALL-POX.  985 

than,  if  rightly  considered,  it  should  have  done.  For  it  is  a  remarkable  and  most 
important  truth  that  the  disease  which,  in  some  duly  vaccinated  persons,  follows  ex- 
posure to  the  contagion  of  small-pox,  is  much  milder  and  shorter  even  than  the 
inoculated,  and  a  forliori,  than  the  natural  smalt-pox.  The  disorder  thus  occurring 
is,  therefore,  denominated  the  varioloid  disease,  or  (more  conveniently,  in  my  opinion), 
the  modijied  small-pox. 

The  constitutional  symptoms  of  this  modified  disease  are,  in  general,  at  the  outset, 
and  for  several  days,  much  the  same  with  those  of  the  regular  small-pox.  The 
eruptive  fever  is  of  equal  length  and  intensity.  There  are  frequently  much  head- 
ache, and  sickness,  and  sometimes  even  delirium.  The  eruption  begins  about  the 
third  day ;  it  is  often  copious,  and  sometimes  confluent ;  and  in  the  confluent  cases 
the  eruptive  fever  does  not  entirely  subside  as  soon  as  the  crop  of  pimples  has  come 
out. 

It  is  in  its  subsequent  progress  that  the  complaint  is  modified :  in  respect  both  to 
the  appearances  presented  by  the  skin,  and  to  the  constitutional  symptoms. 

Three  distinct  kinds  of  eruption  have  been  observed — 

1.  The  eruption  sometimes  approaches  in  its  character  and  course  very  nearly  to 
that  of  the  ordinary  small-pox.  The  pustules  fill  up,  have  the  central  depression, 
and  ultimately  crust  over,  and  the  face  swells.  But  this  course  is  performed  in  a 
shorter  time  than  that  of  the  ordinary  disease,  and  the  pustules  are  usually  smaller. 
This  is  the  severest  and  the  least  common  form  of  the  modified  small-pox. 

2.  Sometimes  the  papulae  show  a  little  fluid  on  their  tops  only,  but  never  fairly 
suppurate  nor  break  ;  but  the  vesicles  dry  up,  and  hard  prominences,  with  livid  bases 
and  horny  summits,  remain. 

3.  There  are  other  cases  in  which  a  great  part  of  the  eruption  consists  of  red 
pimples,  which  soon  become  livid,  but  contain  from  first  to  last,  no  fluid  whatever. 

In  the  majority  of  instances  of  modified  small-pox,  all  these  forms  of  eruption  co- 
exist. Some  of  the  papulae  go  on  to  suppuration,  others  become  crowned  with  a 
horny  summit,  and  others  never  exhibit  any  fluid  at  all. 

Bnt  the  most  important  characteristic  of  the  modified  disease,  is  the  total  absence 
of  secondary  fever.  The  constitutional  disturbance  which,  for  the  first  week,  may 
have  been  as  severe  as  in  the  ordinary  small-pox,  generally  subsides  entirely  when 
the  eruption  has  reached  its  acme.  The  patient  is  convalescent  just  when,  in  the 
unchecked  and  regular  form  of  the  malady,  his  danger  is  beginning  to  be  most 
urgent. 

These  two  circumstances,  then — the  short  duration  of  the  eruption,  and  especially 
the  absence  of  secondary  fever — furnish  the  broad  distinctions  between  the  regular 
and  the  modified  small-pox :  and  almost  always,  when  vaccination  has  been  tho- 
roughly effected,  and  small-pox  occurs  afterwards,  it  occurs  in  this  modified  form  ; 
and  the  modified  form  of  small-pox  is  seldom  fatal,  though  some  instances  of  death 
resulting  from  it  have  certainly  happened. 

Several  questions  of  the  greatest  practical  moment  and  interest  here  present  them- 
selves: but  it  is  impossible  that  T  should  discuss  them.  I  will  state  some  of  them, 
however,  that  you  may  bear  them  in  mind  in  your  future  opportunities  of  observa- 
tion ;  especially  as  they  are  yet,  for  the  most  part,  undecided  questions ;  and  ques- 
tions which  can  be  answered  only  after  repeated  and  careful  observation. 

The  first  is,  whether  the  protecting  influence  of  cow-pox  upon  the  human  frame 
diminishes  by  lapse  of  time,  and  at  length  wears  out.  There  seems  reason  for  sus- 
pecting that  such  may,  sometimes  at  least,  be  the  case.  Certainly  in  many,  but  not 
in  all,  of  those  who  have  gone  through  the  vaccine  disease,  revaccination  at  a  distant 
period  reproduces,  in  a  greater  or  less  degree,  its  primary  effects.  A  friend  of  mine, 
who  was  vaccinated  in  179!),  has  a  son  nine  or  ten  years  old,  who  was  vaccinated  at 
the  age  of  three  weeks.  Both  of  them  have  lately  been  revaccinated.  Tht-  boy 
was  somewhat  afl^ected  by  the  renewal  of  the  operation  ;  the  father  not  at  all.  It  yet 
remains  to  be  determined  whether  all  those  who  are  susceptible  of  some  impression 
from  a  second  vaccination,  are  liable  to  be  affected  by  the  contagion  of  small-pox: 
and  whether  a  repetition  of  the  operation  of  engrafting  the  cow-pox  renews,  or  adds 
to,  their  security  against  small-pox.     At  any  rate,  the  practice  of  revaccination  is  p. 

4h 


986  SMALL-POX. 

safe  and  advisable  precaution.  Dr.  Gregory  says  of  it,  "  we  have  sufficient  facts 
before  us  to  state  with  confidence  that  it  need  never  be  recommended  prior  to  the 
tenth  year  of  life ;  and  that  the  age  best  fitted  for  it  is  from  the  period  of  puberty  to 
that  of  confirmed  manhood." 

But,  secondly,  is  there  any  ground  for  supposing  that  the  wished-for  protection 
ever  fails  to  be  conferred,  because  the  operation  is  performed  too  early  ?  It  has  been 
suspected  that  it  is  less  likely  to  produce  the  requisite,  or  an  enduring,  effect  upon 
the  constitution  when  it  is  done  while  the  child  is  at  the  breast.  But  most  children 
are  vaccinated  within  that  period.  We  know  that  this  is  a  time  when  they  are  but 
little  susceptible  of  contagious  disorders  in  general.  If  this  suspicion  be  well-founded, 
Dr.  Gregory's  first  proposition  requires  correction. 

A  third  question  is,  how  far  the  frequent  failure,  in  late  years,  of  complete  protec- 
tion can  be  ascribed  to  the  circumstance  that  the  vaccine  virus  has  been  repeatedly 
transmitted  from  one  human  being  to  another,  and  its  supply  thus  kept  up,  without 
any  fresh  recurrence  to  the  cow,  the  original  source  of  the  disorder.  Dr.  Jenner  was, 
himself,  not  without  apprehension  that  this  might  prove  a  cause  of  failure.  But  the 
analogy  of  other  animal  poisons  supplies  no  warrant  for  such  a  belief.  For  one  year 
I  had  a  seat,  as  the  Senior  Censor  of  the  College  of  Physicians,  at  the  National  Vac- 
cine Board,  and  I  then  had  opportunities  of  satisfying  myself  that  lymph  which  had 
been  transmitted  without  interruption  from  person  to  person  ever  since  the  time  of 
Jenner,  continued  to  generate  as  perfect  a  cow-pox  vesicle  as  at  first.  If,  as  Dr. 
Heim  asserts,  there  are  no  less  than  five  kinds  of  spurious  cow-pox^  all  communicable 
by  inoculation  from  the  teats  of  the  animal  to  the  human  body,  I  cannot  help  thinking 
that  recourse  should  not  be  had  rashi}'  or  needlessly  to  lymph  recently  obtained  from 
the  cow. 

In  the  fourth  place  there  are  yet  moot  points,  respecting  the  number  of  vesicles, 
and  the  degree  of  constitutional  disturbance,  which  are  requisite  to  ensure,  and  to 
prolong,  the  protective  power  of  vaccination.  The  constitutional  effect  will  bear 
some  proportion  to  the  number  of  vesicles  ;  and  of  these,  it  would  seem,  there  should 
be  several ;  and  one  or  two  of  them,  at  least,  should  be  suffered  to  pursue  their  entire 
course  untouched. 

With  regard  to  a  fifth  question,  the  most  important  of  all,  we  may  speak  very  de- 
cidedly ;  and  it  is  a  question  concerning  which  it  is  of  the  utmost  consequence  that 
medical  men  should  form,  and  disseminate  among  the  public,  correct  opinions :  1 
allude  to  the  comparative  merits  and  advantages  of  inoculation  with  smcdl-pox  and 
vaccination. 

The  advantages  of  the  practice  of  inoculation  to  the  individual,  supposing  him 
doomed  to  have  small-pox,  were  great  and  obvious ;  to  the  community  at  large  they 
were  very  doubtful.  It  gave  the  undoomed  individual,  for  certain,  an  ugly  disease, 
which  was  comparatively  free  from  danger,  in  exchange  for  the  chances,  on  the  one 
hand,  of  contracting  a  very  hazardous  form,  and  on  the  other,  of  escaping  altogether 
from  any  form,  of  variola.  We  need  not  inquire  which  is  the  most  eligible  branch 
of  this  alternative ;  we  know  which  was  by  most  men  actually  chosen.  But  the 
practice  of  inoculation,  by  carrying  the  virus  and  the  disease  into  every  village 
throucrhout  the  length  and  breadth  of  the  land,  filled  the  country  with  contagion; 
ensured  the  disease  to  all  who  were  subjected  to  the  operation;  and  diminished  to 
all  who  were  not,  the  chances  of  escaping  it.  No  doubt  the  distemper  was  produced 
artificially  in  many  more  persons  than  would  have  caught  it  naturally,  had  inoculation 
never  been  thought  of.  So  that  while  the  relative  mortality,  the  per  centage  of 
deaths  from  small-pox,  was  lessened  by  this  practice,  the  absolute  mortality  was 
fearfully  increased.  Such  at  least  is  the  judgment  expressed  by  most  who  have 
thought  and  written  on  the  subject.  Dr.  Heberden  compared  the  number  of  deaths 
ascribed  in  the  London  bills  of  mortality  to  small-pox  during  the  first  thirty  years  of 
the  last  century,  and  he  found  that  they  had  increased  from  7*4  per  cent,  to  9-5  per 
cent.  To  be  sure,  some  allowance  must  be  made  for  the  increase  in  the  whole 
population  of  London  during  that  interval ;  but  on  the  other  hand  we  must  take  into 
account  the  deaths  (not  noted  in  those  bills)  which  followed  the  inoculation  of  small- 
pox in  secluded  villages,  where  but  for  that  practice,  the  poison  might  seldom  have 


I 


SMALL-PCX.  987 

been  found.  It  is  right,  I  say,  that  this  matter  should  be  steadily  contemplated,  in 
all  its  lights,  and  in  all  its  shadows,  in  order  that  the  inestimable  blessing  conferred 
upon  mankind  by  the  researches  of  Dr.  Jenner  may  be  fairly  set  forth,  and  adequately 
appreciated.  The  vaccine  virus  produces  a  shght  disorder,  which  is  attended  with 
no  risk,  and  which  (unluckily  I  may  say)  is  not  communicable  except  by  direct  en- 
grafting. It  not  only  does  not  disseminate  a  dangerous  and  deadly  poison,  but  if 
rightly  used,  it  affords  the  means  of  eradicating  from  a  well-regulated  community, 
or  at  least  of  confining  within  narrower  limits,  the  most  loathsome  pestilence  which 
the  world  has  known.  Where  vaccination  is,  the  contagion  of  small-pox  need  never 
come.  In  Denmark,  as  I  told  you,  variola  had  at  one  time  disappeared  before  the 
defensive  influence  of  compelled  vaccination.  Chance,  and  a  careless  security,  en- 
gendered by  the  absence  of  the  pest,  have  led  to  its  re-introduction  there.  It  is  much 
to  be  regretted  that  the  boasted  liberty  of  this  countr}'"  renders  it  almost  impossible  to 
enforce  by  law  a  practice  which  would  be  so  conducive  to  the  public  weal.  Some 
good  might  be  done  by  enacting  that  no  person  should  be  eligible  to  even  any  paro- 
chial office  of  trust  or  profit  who  could  not  produce  a  certificate  that  he  had  been 
duly  vaccinated.  And  the  benefits  which  this  safeguard  confers  on  the  individual 
are  scarcely  inferior  to  those  which  it  is  calculated  to  bestow  upon  society.  It  un- 
fortunately does  not  give  complete  protection  against  small-pox  to  all,  but  it  gives 
complete  protection  to  many.  And  you  must  recollect  that  small-pox  itself  is  not  a 
universal  and  absolute  assurance  against  its  own  return.  But  the  cow-pox  relieves 
all  from  the  necessity,  imposed  by  inoculation,  of  coming  within  the  sphere  of  the 
variolous  contagion.  It  renders  many,  I  repeat,  impregnable  to  that  poison,  if  they 
do  chance  to  be  within  its  range ;  and  its  advantage  to  the  comparative  few  who 
suffer  the  double  misfortune  of  being  exposed  to  the  contagion  of  small-pox,  and  of 
being  affected  by  it,  is  this,  that  it  gives  safety,  though  not  exemption  ;  that  it  takes 
away  the  sting  and  peril  of  the  variolous  disease,  by  curtailing  it  of  the  secondary 
fever.  At  the  very  worst,  it  leaves  the  individual  liable,  by  a  twofold  ill  luck,  to 
contract  a  form  of  small-pox  less  dangerous  than  that  which  he  would  voluntarily 
accept  by  submitting  to  the  operation  of  inoculation,* 

It  is  difficult  to  adduce  exact  numerical  comparisons  in  illustration  of  this  reason 
ing ;  but  I  may  quote  two  short  series  of  facts  as  samples. 

During  an  epidemic  in  Scotland,  Dr.  John  Thomson  saw  from  June,  ISIS,  to  De- 
cember, 1819,  550  cases.  Of  these  205  had  previously  had  neither  small-pox  nor 
cow-pox,  and  50  of  them  died  ;  nearly  1  in  4.  Forty-one  took  the  small-pox  for  the 
second  time,  and  Dr.  Thomson  knew  of  30  other  such  cases,  making  71  in  all, 
whereof  3  died  ;  or  1  in  23.  Three  hundred  and  ten  had  been  previously  vaccinated, 
and  among  these  there  was  but  one  death. 

The  population  of  Marseilles  at  the  time  of  an  epidemic  there,  in  1S28,  was  esti- 
mated at  40,000;  that  is  to  say,  of  30,000  vaccinated,  2000  variolated,  and  8000 
unprotected.  Among  the  30,000  vaccinated,  about  2000  were  attacked  with  small- 
pox, and  20  perished;  1,  namely,  in  100.  Of  the  8000  unprotected,  4000  were 
attacked  ;  and  1000,  or  1  in  every  4,  died.  And  out  of  the  2000  variolated,  20  took 
the  disease  a  second  time,  and  4  died  ;  or  1  in  5. 

There  yet  remains  a  highly  interesting,  but  a  less  practical  question.  Dr.  Jenner, 
as  I  stated  before,  believed  that  he  had  traced  the  cow-pox  to  its  origin  in  the  heels 
of  the  horse  afflicted  with  the  grease.  It  has  since  been  made  out  that  the  disease 
which,  in  the  horse,  corresponds  with  and  produces  the  specific  malady  of  the  cow, 
is  a  vesicular  eruption,  having  no  necessary  connection  with  the  grease,  but  extend- 
ing sometimes  all  over  tlie  animal's  body.  Now  the  question  is,  whether  these  two 
disteinpers,  occurring  in  the  cow  and  in  the  horse,  are  identical  in  their  essence  and 
nature  with  the  small-pox  of  man.  If  so  (as  Dr.  Jenner  believed,  and  Dr.  Baron 
strongly  maintains),  a  part  of  the  mystery  attending  the  whole  subject  vanishes. 
The .  protection  furnished  by  the  cow-pox  resolves  itself  into  the  more  familiar  law, 


*[Tlie  accuracy  of  this  latter  statement  is  contravened  by  statistical  results,  derived  from 
-foment  epidemics  of  small-pox  in  this  country.  But  neither  the  tendency,  nor  the  foice  of 
ibie  main  argument,  is  much  affected  by  this  admission. —  C.] 


988  SMALL-POX. 

that  certain  diseases  engendered  by  animal  poisons,  happen  to  the  same  individual 
out  once,  and  shield  the  body  against  their  own  recurrence.  In  conformity  with 
this  theory,  Dr.  Baron  names  the  disorders  respectively,  variolee,  variolse  vaccinae, 
and  variolfe  equinfe. 

The  notion,  you  see,  is  this,  that  the  vaccine  disease  is  in  truth  small-pox,  rendered 
mild  by  passing  through  the  system  of  the  cow.  The  great  object  of  inoculating 
the  small-pox  is  to  produce  a  benignant  form  of  that  disease,  by  diminishing  the 
number  of  pustules.  The  cow-pox  diminishes  the  number  to  one;  and  while  it 
reduces  the  severity  of  the  disorder  to  a  minimum,  it  absolutely  takes  away  its 
j)ower  of  propagating  itself,  except  by  a  direct  engrafting  of  the  visible  virus.  The 
disease  is  not  sufficiently  intense  to  taint  the  air  with  poisonous  effluvia.  At  the 
same  time  it  affords  (but  less  surely  and  less  permanently)  the  customary  protec- 
tion. Such  is  the  theory,  which  is  intelligible  and  plausible,  and  supported  by  strong 
facts  and  persuasive  reasoning ;  for  all  which  I  must  needs  refer  you  to  Dr.  Baron's 
book. 

To  avoid  breaking  the  thread  which  connects  the  different  parts  of  the  main 
subject,  I  have  postponed  to  the  last  what  I  have  to  say  respecting  the  treatment  of 
small-pox.    ' 

This,  for  a  long  time,  was  conducted  upon  an  erroneous  principle,  and  eminently 
disastrous.  The  older  physicians  attempted  to  force  out,  through  the  skin,  the  mor- 
bid matter  existing  in  the  blood.  The  eruption  they  considered  to  be  the  natural 
and  only  cure:  and  adopting  the  vulgar  maxim,  that  "it  was  better  out  than  in," 
they  did  all  they  could  to  promote  a  copious  eruption,  by  a  hot  regimen,  by  covering 
the  patient  with  bed-clothes,  by  keeping  the  doors  and  windows  jealously  closed,  and 
excluding  every  breath  of  fresh  air,  and  sometimes  by  administering  wine  and  cor- 
dials. The  celebrated  John  of  Gaddesden,  the  author  of  that  curious  book,  the  Rosa 
Anglica,  improved  even  upon  this.  He  surrounded  the  half-suffocated  patient  with 
red  curtains,  red  walls,  red  furniture  of  all  kinds  :  everything  he  saw  was  to  be  red  ; 
for  in  that  colour  there  was,  he  pretended,  a  peculiar  virtue.  This  John  of  Gaddes- 
den, by  the  way,  was  a  very  sad  knave,  and  the  first  Englishman,  I  believe,  who  had 
the  luck  to  be  made  court  physician.  He  had  one  medicine  so  good  as  to  be  fit  for 
the  rich  only;  and  he  recommended  a  double  dose  for  the  wealthy.  "Duplum  sit, 
si  pro  divite."     He  flourished  in  the  fourteenth  century. 

Sydenham  was  the  first,  in  this  country,  to  employ  the  opposite  or  cool  regimen 
in  small-pox  ;  and  although  his  prejudiced  cotemporaries  refused  to  follow  his  exam- 
ple, and  adopt  his  practice,  he  confidently  predicted  its  final  triumph — "  obtinebit 
demum  me  vita  functo." 

But  it  was  subsequently  to  the  introduction  of  the  method  of  inoculation  that  the 
rooling  treatment  was  fairly  established,  by  the  Suttons — two  brothers,  one  of  whom, 
Robert,  lived  at  Bury  St.  Edmunds ;  the  other,  Daniel,  at  Ingateslone,  in  Essex. 

These  men,  wiser  in  their  generation  than  the  regular  physicians,  had  the  good 
sense  to  pursue  the  same  plan  of  general  management  which  had  been  so  prosperous 
in  the  East,  whence  the  practice  of  engrafting  was  originally  imported.  Daniel,  in 
particular,  became  famous  for  his  successful  inoculations  :  and  the  great  secret  of  his 
success  seems  to  have  consisted  in  his  making  one  puncture  only ;  exposing  his 
patients  much  and  often  to  a  cool  atmosphere  ;  supplying  them  freely  with  refrigerant 
drinks  ;  and  restricting  them  to  a  spare  diet.  Under  this  course,  Cullen,  who  adopted 
it  from  the  Suttons,  declares  that  ninety-nine  times  in  the  hundred,  inoculation  imparts 
a  distinct  small-pox,  and  very  generally  of  the  mildest  form. 

Now  the  same  principle  applies  to  the  casual  disease  when  we  have  reason  to 
suspect  that  it  is  impending,  or  to  have  the  opportunity  of  treating  it  at  its  commence- 
ment. The  object  is  to  prevent,  if  possible,  a  copious  eruption  ;  upon  which,  as  we 
have  seen,  the  severity  and  peril  of  the  disorder  entirely  depend.  It  has  been  thought 
that  venesection,  by  its  antiphlogistic  power,  and,  perhaps,  by  letting  out,  with  the 
blo^^G,  some  portion  of  the  regenerated  virus,  might  lessen  the  number  of  the  forth- 
coming pustules.  But  you  cannot  ensure  this  effect  by  blood-letting :  and  you  mUol 
bear  in  mind  that,  should  the  eruption  prove  confluent,  suppuration,  to  a  large  amount. 


SMALL-POX.  989 

is  inevitable,  and — like  that  of  an  extensive  bum — will  require  in  order  to  go  on 
favourably,  a  certain  degree  of  constitutional  vigour. 

You  may  abate  the  force  of  the  eruptive  fever,  and  keep  down,  it  is  believed,  the 
number  of  pustules,  by  saline  purgatives,  so  exhibited  as  to  produce  two  or  three 
loose  stools  every  day,  and  by  free  ventilation  of  the  surface  of  the  body.  The  skia 
may  even  be  sponged  with  tepid  water,  if  the  temperature  be  very  high. 

When  the  eruption  is  all  come  out,  if  the  pimples  on  the  face  be  very  few  and 
distinct,  the  danger  is  over,  and  there  is  no  more  to  be  done.  At  this  period  Cullen 
dissuades  the  further  use  of  purgatives,  as  being  sometimes  hurtful. 

But  if  the  pimples  on  the  face  be  many,  and  confluent,  the  patient  will  still  re- 
quire a  great  deal  of  attention.  Our  business  is  to  look  out  for,  and  to  meet,  unto- 
ward symptoms. 

About  the  eighth  or  ninth  day,  wakefulness,  and  restlessness,  and  sometimes  tre- 
mors, are  apt  to  come  on  ;  and  the  proper  remedies  for  this  set  of  symptoms,  in  small- 
pox as  well  f.s  in  continued  fever,  are  opiates.  In  variola,  when  given  in  full  doses 
at  bed-time,  their  good  effects  are  often  very  conspicuous  the  next  day. 

If  the  maturation  of  the  pustules  should  proceed  tardily,  if  they  should  not  fill  up 
properly,  nor  their  contents  become  purulent,  then  strong  broths  may  be  of  use,  or 
even  wine.  But  the  effects  of  these  must  be  carefully  watched,  and  their  amount 
adjusted  to  the  necessities  of  the  case. 

When  the  pustules  are  livid,  and  intermixed  with  petechia,  and  typhoid  symp- 
toms occur,  the  disorder  generally  proves  fatal.  In  such  cases  it  is  customary  to  pre' 
scribe  bark  and  acids,  in  addition  to  the  wine  and  opiates. 

The  proper  plan  of  managing  the  patient  during  the  continuance  of  the  secondary 
fever,  is  to  keep  his  bowels  moderately  open  by  gentle  laxatives,  or  by  enemata  ;  and 
to  give  opiates  once  or  twice  a  day.  These  are  the  more  necessary  on  account  of 
the  irritation  of  the  skin.  The  cooling  regimen  must  now  be  given  up  ;  and  the 
strength  must  be  supported  by  a  nourishing  diet.  Wine  and  cordials  are  indicated 
if  the  pulse  be  feeble ;  but  the  swelling  of  the  hands  and  wrists  often  makes  it  diffi- 
cult to  feel  the  pulse. 

Various  external  applications  have  been  tried,  with  the  view  of  relieving  the  into- 
lerable itching :  which  often  induces  the  patients  to  scratch  and  tear  their  faces,  and 
to  ensure  the  formation  of  scars.  Cold  cream  is  used  for  this  purpose  :  or  a  solution 
of  common  salt,  applied  lukewarm ;  or  a  liniment  composed  of  equal  parts  of  olive 
oil  and  lime-water.  This  may  be  smeared,  from  time  to  time,  over  the  itching  sur- 
face, by  means  of  a  soft  camel's  hair  pencil. 

The  dj'spncea  which  sometimes  comes  on  late  in  the  disease,  is  a  very  ugly 
symptom.  I  know  of  nothing  that  can  be  done  for  it  beyond  blistering  the  throat 
and  chest. 

[The  following  presents  a  very  fair  exposition  of  the  views  of  a  large  portion  of  the  phy- 
sicians of  the  Continent  of  Europe  in  relation  to  the  protective  powers  of  vaccination.  It 
is  the  substance  of  a  report  made  to  the  Academy  of  Sciences  of  France,  on  the  25th  of 
February,  1845,  by  the  Committee  on  Vaccination,  to  which  were  referred  the  various  essays 
sent  in  by  the  competitors  for  the  prize  proposed  by  the  Academy  for  the  most  satisfactory 
solution  of  the  following  questions: — • 

\.  Is  the  preservative  power  of  vaccination  absolute,  or  merely  temporary?  If  it  is  tem- 
porary only,  determine,  by  accurate  experiments  and  authentic  facts,  what  is  the  period  for 
which  the  vaccine  matter  exerts  its  protective  influence  against  small-pox?  2.  Has  vaccine 
matter,  taken  directly  from  the  cow,  a  more  certain  and  durable  protective  power  than  vac- 
cine matter  transmitted  a  greater  or  lesser  number  of  times  through  the  human  subject?  3. 
If  the  protective  power  of  vaccine  matter  becomes  enfeebled,  should  it  be  renewed ;  and  if 
so,  how?  4.  Is  it  necessary  to  vaccinate  the  same  individual  several  times,  and  if  so,  after 
how  many  years  should  the  vaccination  be  repeated  ?  The  portion  of  the  report  of  which 
the  following  is  an  abstract,  relates  to  the  first  two  questions  only. 

The  protecting  power  of  vaccination  being  definitely  established,  the  question  arises  —  is 
it  possible,  after  forty-five  years'  experience,  to  determine  the  limits  of  that  power  ?  Ths 
answer  to  this  question  is  extremely  difiicult,  as  it  embraces  inquiries  not  in  France  alone, 
but  throughout  the  whole  world  :  in  fact,  a  general  investigation  of  every  case  in  which  vac- 
cination had  been  formed  could  alone  supply  the  fundamental  elements  of  the  problem  to  be 
answered.     The  competitors  for  the  prize  have  particularly  examined  how  vaccinated  per 

4 II 2 


990  SMALL-POX. 

sons  are  circiiinstaneed  during  the  prevalence  of  epidemic  small-pox;  in  other  words,  what 
is  the  proportinn  of  vaccinated  persons  in  the  entire  nun:ber  of  those  attacked  with  small- 
pox. The  protective  power  of  vaccination  is,  by  this  mode  of  investigation,  reduced  to  a 
numerical  question.  An  attentive  examination  of  what  occurred  during  thirty  epidemics  of 
small-pox  in  France,  shows  two  important  facts: — First,  that  somewhat  more  than  one-third 
of  the  entire  number  of  persons  attacked  with  the  small-pox  had  been  vaccinated;  secondly, 
tliat  the  mortality  among  the  vaccinated  persons  was  very  small.  According  to  the  author  of 
one  of  the  memoirs,  more  than  one-third  of  those  attacked  in  the  epidemics  which  occurred  at 
Montbeillard  had  been  vaccinated,  but  there  was  no  corresponding  increase  in  the  amount 
of  mortality  amongst  the  vaccinated  patients ;  and  the  same  result  was  observed  in  the  epi- 
demic of  1828,  at  Marseilles.  The  same  results  follow,  also,  from  an  examination  of  the 
epidemics  that  have  occurred  in  England,  Sweden,  Denmark,  Italy,  IMalta,  Geneva,  &c. 

The  fact,  then,  being  established,  that  vaccinated  persons  can  become  affected  with  small- 
pox, and  the  proportion  so  attacked  during  epidemics  being  nearly  determined,  a  most  im- 
portant problem  remained  to  be  solved — viz.,  what  was  the  condition  of  the  vaccinated  per- 
sons affected  as  regarded  the  mere  fact  of  their  vaccination'?  The  authors  of  all  the  memoirs 
agree  in  stating  that  vaccinated  persons  were  not  afiected  indiscriminately  or  by  chance,  as 
it  were;  on  the  contrary,  the  small-pox  seems  to  make  a  kind  of  selection  from  amongst 
them.  With  some  exceptions,  the  small-pox  attacks  those  who  have  been  vaccinated  since 
a  long  period,  and  spares  those  who  are  recently  so.  An  examination  of  the  tables  published 
in  various  parts  of  Europe  proves  positively,  that  children  are  seldom  attacked  with  small- 
pox before  the  ninth  year  after  vaccination  ;  and  also  the  converse  fact,  namely,  that  it 
attacks  in  preference  persons  who  had  been  vaccinated  fifteen,  twenty,  thirty,  or  even  thirty- 
five  years  previously.  A  general  fact,  which  may  be  anticipated  from  the  history  of  erup- 
tive complaints  is,  that  after  the  age  of  thirty-five  years,  the  aptitude  of  vaccinated  person? 
to  contract  small-pox  becomes  so  slight  that  it  may  be  considered  as  having  vanished. 

An  investigation  of  the  facts  relative  to  the  occurrence  of  small-pox  in  vaccinated  person? 
leads  to  the  three  following  conclusions: — First.  Tile  protective  power  of  vaccination  is  abso- 
lute and  general  for  the  first  five  or  six  years,  and  even  to  the  eleventh  or  twelfth  year,  tc 
judge  from  the  experiments  on  re  vaccination.  Second.  After  the  foregoing  period,  a  part,  bu' 
a  part  only,  of  those  vaccinated  again  become  liable,  especially  under  the  influence  of  at 
epidemic,  to  contract  small-pox.  Third.  The  greater  number  of  those  vaccinated  proba- 
bly remain  completely  protected  from  small-pox  during  their  entire  life. 

Has  the  cow-pox,  taken  directly  from  the  cow,  a  more  certain  and  permanent  protective 
power  than  vaccine  matter  that  has  been  transmitted  more  or  less  frequently  through  the 
human  constitution?  The  experiments  contained  in  several  of  the  memoirs  confirm  the 
observations  made  by  the  Committee  on  Vaccination,  at  Paris.  The  greater  intensity  of  the 
new  vaccine  matter,  as  compared  with  that  long  in  use,  is  a  fact  definitely  established  by 
experience  in  England,  Germany,  Italy,  and  France.  But  is  this  greater  intensity  coupled 
with  a  greater  preservative  power  ?  or,  as  the  report  puts  the  question — Is  there  any  relation 
between  the  lesser  or  greater  intensity  of  the  local  phenomena  and  the  protective  power  of 
the  variolous  matter?  The  experiments  made  on  tliis  point  show  that  the  protective  power 
of  vaccine  matter  is  not  proportionate  to  the  intensity  of  the  local  symptoms,  but  that  vac- 
cination with  matter  taken  from  the  cow  is  more  certain  than  with  old  vaccine  matter.  Ad- 
mitting that  the  protective  power  of  vaccine  matter  diminishes  with  time,  should  it  be 
renewed,  and  if  so,  how? 

As  to  the  means  of  renewal,  the  first  mode  employed  was  the  transmission  of  the  vaccine 
matter  from  man  to  the  cow — an  experiment  frequently  performed  as  a  matter  of  curiosity, 
but  only  recently  sought  to  be  rendered  a  means  of  restoring  to  the  vaccine  matter  its  lost 
energy.  The  authors  of  several  of  the  memoirs  maintain  that  the  cow,  when  thus  vaccin- 
ated, restores  the  vaccine  matter  unaltered,  and  therefore  unregenerated  ;  but  the  commission 
of  the  Academy  thinks  this  conclusion  too  absolute :  in  fact,  it  has  been  established  by  the 
experiments  of  the  author  of  one  of  these  memoirs,  that  vaccine  matter  taken  from  man  is 
regenerated  during  its  transmission  through  the  cow.  The  same  fact  results  from  thousands 
of  experiments  made  in  Bavaria  under  the  direction  of  the  government.  Vaccine  matter 
tlius  regenerated  failed  in  less  than  one  case  in  a  hundred,  while  the  failures  of  the  old  vac- 
cine matter  were  nearly //tree  ^cr  cent.  Would  it  not  be  better  to  transmit  the  vaccine  matter 
through  several  cows  in  succession  than  through  one  only?  The  mode,  however,  which 
should  be  preferred  to  all  others — the  only  one  on  which  we  can  entirely  rely — is,  as  recom- 
mended by  Jenner,  to  obtain  vaccine  matter  from  its  original  source.  Several  circumstances 
seem  to  show  that  the  cow-pox  is  perhaps  of  less  frequent  occurrence  than  is  commonly  sup- 
posed, and  the  commission  suggests,  that  those  who  happen  to  meet  with  it  should  not  con- 
tent themselves,  as  has  been  done  hitherto,  with  transmitting  jt  to  man,  but  transmit  it  to 
other  cows,  and  thus  regenerate  the  infection. 

Is  it  necessary  to  vaccinate  the  same  person  several  times?  and  if  so,  after  the  lapse  of 
how  many  years  should  the  revaccination  be  performed  ?  On  this  head  the  report  first  referi 
to  the  fact  that  the  revaccinations,  performed  for  a  considerable  period  after  the  discovery  cf 


SMALL-POX.  991 

vaccination,  did  not  succeed,  except  in  some  rare  cases,  because  they  were  performed  too 
soon  alter  the  primary  vaccination.  But  when,  at  a  later  period,  experience  showed  tliat  the 
protective  power  of  vaccination  diminished  with  time,  the  practice  of  revaccination  was 
resumed,  &ad  then  succeeded  beyond  expectation.  la  some  parts  of  Germany,  especially, 
revaccination  has  been  practised  universally  in  the  army,  and  even  in  civil  life.  Physicians, 
also,  who  had  had  small-pox,  in  some  instances  revaccinated  themselves  with  success,  of 
which  Dr.  Heim  is  a  remarkable  example.  He  attended  on  his  brother  for  three  weeks, 
while  he  laboured  under  confluent  small-pox,  and  three  weeks  after  having  gone  through 
this  decisive  trial,  he  vaccinated  himself,  and  had  pusttiles  almost  of  the  ordinary  size.  M. 
Moreau,  the  celebrated  accoucheur,  who  had  small-pox  in  early  life,  revaccinated  himself 
three  times  with  success. 

A  document  published  by  the  Government  of  Wurtemberg,  which  showed  that  of  1677 
persons  affected  with  small-pox,  between  the  years  1831  and  1S3G,  1055  had  been  vaccinated, 
contributed  greatly  to  extend  the  practice  of  revaccination  in  Germany,  and  in  the  north  of 
Europe.  In  France,  the  statistics  of  epidemic  small-pox  show  that  the  number  of  vaccinated 
persons  attacked  with  small-pox  constitute  more  than  a  third  of  the  whole  number  of  patients 
affected.  It  is  impossible,  therefore,  to  doubt  the  propriety  of  practising  revaccination.  It  is 
during  epidemic  small-pox,  especially,  that  the  utility  of  revaccination  becomes  obvious.  Not 
only  have  individuals  been  thus  protected,  but  the  spread  of  the  epidemic  has  been  arrested. 
In  Prussia  revaccination  has  been  practised  in  the  army  since  1833,  and  the  small-pox  has 
been  almost  entirely  extirpated.  In  Wurtemberg,  but  one  case  of  variola  occurred  in  five 
years,  among  14,384  revaccinated  soldiers,  and  three  only  among  29,684  revaccinated  civil- 
ians. Epidemic  small-pox  has  not  appeared  in  France  since  1830,  the  period  when  revac- 
cination was  commenced.  The  authors  of  the  memoir  agree  that  during  epidemics  it  is 
prudent  to  revaccinate  after  about  the  eighth  or  ninth  year. 

The  answers  given  by  the  competitors  for  the  prize  to  the  questions  proposed  by  the 
A-cademy,  may  be  thus  summed  up  : — 

1st.  The  preservative  power  of  vaccination  is  absolute  for  the  majority,  and  temporary  for 
a  small  number ;  and  even  in  the  latter  it  is  absolute  until  adolescence. 

2d.  Small-pox  rarely  attacks  those  who  have  been  vaccinated  in  infancy  before  the  age  of 
ten  or  twelve ;  from  which  age,  however,  until  thirty  or  thirty-five,  they  are  particularly 
liable  to  small-pox. 

3d.  In  addition  to  its  protective  power,  vaccination  so  modifies  the  animal  economy,  that 
it  attenuates  the  symptoms  of  small-pox,  abridges  its  duration,  and  considerably  diminishes 
its  danger. 

4th.  Vaccine  matter  taken  directly  from  the  cow  causes  local  symptoms  of  greater  inten- 
sity; its  effects  are  also  more  certain  than  those  of  old  vaccine  matter,  but  after  being  trans- 
mitted for  a  few  weeks  through  the  human  subject,  the  local  intensity  disappears. 

5th.  The  preservative  power  of  vaccine  matter  does  not  seem  to  be  intimately  connected 
with  the  intensity  of  the  symptoms  of  vaccination ;  nevertheless,  it  is  prudent  to  regenerate 
vaccine  matter  as  frequently  as  possible,  to  preserve  its  protective  power. 

6th.  The  only  mode  of  regenerating  vaccine  matter  deserving  of  confidence  is  to  procure 
it  from  the  cow. 

7th.  Revaccination  is  the  only  known  method  of  distinguishing  those  vaccinated  persons 
that  remain  protected  from  those  that  do  not. 

8th.  The  success  of  revaccination  is  not  a  certain  proof  that  the  person  in  whom  it  suc- 
ceeds was  liable  to  contract  small-pox ;  it  merely  establishes  a  tolerably  strong  presumption 
that  they  were  more  or  less  liable  to  be  so. 

9th.  In  ordinary  periods,  revaccination  should  be  practised  after  fourteen  years,  but  sooner, 
as  already  remarked,  during  an  epidemic. 

See  also,  on  this  subject,  Condie  on  Diseases  of  Children,  p.  458,  et  seq. — C] 


LECTURE  LXXXVIII. 

Chicken-Pox.    Measles.     Scarlet  Fever. 

I  MUST  not  omit  a  short  notice  of  the  disorder  called  chicken-pox;  for  although  a 
very  unimportant  complaint,  it  has  given  rise  to  many  disputes.  Other  names  which 
it  has  borne  are  varicella,  crystalli,  variolse  pusillge. 

Connected  with  the  small-pox,  and  arising  from  the  same  contagion,  there  are 
several  forms  of  eruptive  disease.  I  mentioned  the  chief  of  them  in  the  last  lecture, 
as  varieties  of  modified  small-pox.     Now  these  mild  and  irregular  forms  of  variola. 


992  CHICKEN-POX.  ' 

both  parents  and  medical  men,  wishing,  I  suppose,  to  believe  nothing  in  disparage- 
ment of  the  protecting  power  of  vaccination,  are  very  apt  to  consider,  and  to  call, 
chicken-pox :  and  this  error  having  been  discovered,  some  persons  have  rushed  to, 
or  rather  revived,  the  opposite  opinion  —  equally  erroneous  in  my  judgment  —  that 
there  is  no  such  substantial  disorder  as  chicken-pox ;  but  that  all  the  eruptions  which 
have  passed  under  that  name  have  reall}^  been  forms  of  modified  small-pox.  Dr. 
John  Thomson,  of  Edinburgh,  is  one  of  the  stoutest  maintainers  of  this  doctrine.  No 
doubt  an  eruption  of  short  duration,  and  vesicular  through  the  greater  part  of  its  pro- 
gress, is  often  caused,  especiall}'  in  persons  who  have  been  vaccinated,  b)^  the  conta- 
gion of  small-pox:  but  a  similar  eruption  proceeds  also  from  another  distinct  contagion, 
that,  namely,  of  chicken-pox. 

The  best  description  of  the  true  chicken-pox  that  I  am  acquainted  with  has  been 
given  by  Dr.  Gregory.  The  disorder  is  almost  pecuhar  to  infants,  and  children  of 
tender  years.  Willan  has,  however,  described  one  unambiguous  example  of  it,  in  a 
gentleman  thirty  years  old  ;  and  another  genuine  instance  was  seen  by  Dr.  Gregory, 
at  the  Small-pox  Hospital,  in  the  person  of  an  adult  female.  The  eruption  is  pre- 
ceded by  little  or  no  premonitory  fever,  commencing  usually  on  the  shoulders,  neck, 
and  breast,  affecting  almost  always  the  scalp,  but  sparing  very  much  the  face — which, 
in  small-pox,  never  escapes. 

The  eruption  is  composed,  from  the  very  first,  of  perfectly  transparent  vesicles, 
surrounded  by  a  very  slight  degree  of  superficial  redness.  They  are  usually  numer- 
ous, but  distinct.  Dr.  Gregory  says  that  when  the  eruption  is  very  copious,  the 
body  has  the  appearance  of  having  been  exposed  to  a  momentary  shower  of  boiling 
water,  each  drop  of  which  had  occasioned  a  minute  blister.  Crops  of  vesicles  ap- 
pear in  succession  for  two  or  three  days ;  and  while  new  ones_are  forming,  the  first 
are  beginning  to  shrivel.  The  vesicles  that  remain  after  the  second  or  third  day 
become  slightly  opaque,  and  hke  pearls.  AVhen  irritated  by  friction,  they  some- 
times take  on  so  much  inflammation  as  to  be  converted  into  pustules.  The  scabs 
are  small  and  gummy,  dry  quickly,  and  crumble  off',  instead  of  being  detached  in 
one  r.)ass.  In  a  few  instances,  shallow  cicatrices  are  left  by  the  vesicles.  During 
the  short  progress  of  this  eruptive  disease  there  is  no  constitutional  disturbance  of 
any  consequence. 

It  has  been  ascertained  of  this  genuine  chicken-pox,  or  varicella  lymphatica,  that 
it  occurs  once  only  to  the  same  person ;  that  it  spreads  by  contagion ;  that  never- 
theless, it  is  not  communicable  by  inoculation — whereas  the  matter  of  modified  small- 
pox, when  engrafted,  produces  genuine  variola;  that  it  occurs  equally  among  those 
who  have,  and  those  who  have  not,  been  vaccinated  ;  that  its  course  is  not  afl^ected 
bv  antecedent  vaccination ;  and  that  the  vaccine  vesicle  and  disease  proceed  with 
perfect  regularity  after  the  occurrence  of  chicken-pox.  Now  this  never  happens 
after  small-pox. 

It  appears,  from  Mohl's  work  De  Varioloidihus  et  Varicellis,  that  from  the  year 
1809  to  182:3,  chicken-pox  was  annually  observed  at  Copenhagen  without  concomi- 
tant small-pox;  and  that  both  diseases  have  since  prevailed  at  intervals  epidemically, 
but  always  under  circumstances  which  satisfied  the  physicians  of  the  town  that  theii 
sources  were  distinct. 

It  must,  therefore,  I  think,  be  admitted,  tnat  there  is  a  separate  disease,  called 
chicken-pox,  which  springs  from  a  specific  poison;  produces  a  vesicular  eruption ; 
runs  a  definite  course  ;  has  no  tendenc5%  when  undisturbed,  to  suppuration  ;  occurs 
but  once ;  and  affords  no  protection  against  small-pox ;  while,  on  the  other  hand, 
small-pox  affords  no  protection  against  it. 

The  main  point  of  practical  importance  is,  however,  this ;  that  if  we  meet  with 
any  eruption  which  is  at  all  equivocal,  we  should  use  the  same  precautionary  mea- 
sures for  preventing  the  extension  of  the  disease  as  if  we  were  sure  that  it  was  modified 
small-pox.  But  this  salutary  rule  is  often,  I  say,  neglected  or  infringed,  to  the  darv- 
ger  and  detriment  of  those  unprotected  persons  who  happen  to  be  in  the  vicinity  of 
the  sick  child. 

The  treatment  required  in  chicken-pox  is  abundantly  simple ;  it  is  the  same,  in 


MEASLES.  993 

fact,  which  has  been  already  recommended  for  the  mildest  cases  of  the  discrete 
small-pox. 

Another  of  these  blood  diseases  is  the  measles;  called,  also,  by  nosologists,  rubeola., 
and  morbilli. 

Like  different  human  faces,  all  the  complaints  belonging  to  this  group  have  the 
same  set  of  features,  and  therefore  a  mutual  resemblance,  while  the  separate  linea- 
ments differ  so  much  in  their  character  and  relative  circumstances,  as  to  give  to  each 
disease  its  distinctive  aspect.  There  are  also  minor  shades  of  difference  between  in- 
dividual cases  of  the  same  specific  malady. 

Measles,  accordingly,  has  its  introductory  fever,  its  period  of  eruption,  its  peculiar 
kind  of  eruption,  its  course  by  stages.  It  is  communicable  from  person  to  person, 
and  it  generally  occurs  but  once  to  the  same  person.  On  some  of  these  points  1 
spoke  before. 

The  introductory  fever  is  sometimes  severe,  and  nearer  in  its  type  to  synocha 
than  to  typhus.  Like  all  fevers,  it  begins  with  lassitude,  and  shivering,  which  is 
soon  followed  by  heat  of  skin,  acceleration  of  the  pulse,  anorexia,  and  thirst.  But 
the  pecuharity  in  the  fever  which  precedes  the  eruption  of  measles  is,  that  it  is  very 
constantly  attended  with  an  imflammatory  condition  of  the  mucous  membranes ; 
especially  of  those  which  are  proper  to  the  air-passages.  The  eyes  become  vascular 
and  watery,  the  eyelids  heavy,  turgid,  and  red.  The  membrane  which  lines  the 
nasal  cavities,  the  fauces,  the  larynx,  trachea,  and  brcnchial  tubes,  is  affected.  Flence 
we  have,  generally,  as  symptoms,  much  sneezing,  as  Avell  as  lachrymation,  a  copious 
defluxion  from  the  nostrils,  soreness  of  the  throat,  and  an  obvious  redness  of  the  fauces, 
and  most  commonly  a  dry,  hoarse,  pecuhar  cough.  In  short,  the  symptoms  which 
usher  in  an  attack  of  measles  are  the  symptoms  of  coryza  and  catarrh.  In  some 
instances  there  is  diarrhoea  also,  indicating  a  simultaneous  affection  of  the  mucous 
membrane  of  the  intestines;  and  not  unfrequently  vomiting:  but  the  vomiting,  as  in 
small-pox,  ceases  upon  the  coming  out  of  the  eruption. 

The  regular  period  for  the  appearance  of  the  eruption  is  the  fourth  day  of  the 
disease;  seldom  earlier,  frequently  later :  sometimes  as  late  as  the  eighth  or  tenth 
day  from  the  commencement  of  the  catarrh.  The  eruption  itself  is  a  rash,  consisting, 
at  first,  of  minute  papulae,  which,  as  they  multiply,  coalesce  into  blotches  that  have, 
more  or  less,  a  horse-shoe  or  crescentic  shape,  and  leave  the  intermediate  portions 
of  skin  of  their  natural  colour.  It  is  two  or  three  days  in  coming  out,  beginning  on 
the  face,  neck,  and  arms,  then  reaching  the  trunk  of  the  body,  and  so  travelling 
down  to  the  lower  extremities.  In  this  course  it  resembles  the  eruption  of  small- 
pox. It  fades  in  the  same  order,  standing  out  three  days  at  least  on  the  face  before 
it  begins  to  decline ;  so  that  its  whole  duration  comprises  a  space  of  six  or  seven 
days.  It  becomes  browner  as  it  fades.  You  may  feel  that  it  is  slightly  elevated 
above  the  general  surface  of  the  skin,  especially  upon  the  face,  which  is  somewhat 
bloated  and  swollen.  The  parts  which  the  rash  has  recently  occupied  are  left  covered  ' 
with  a  dry,  small  scurf.  The  cuticle  does  not  peel  off  in  large  flakes,  as  I  shall  have 
to  tell  you  that  it  oftentimes  does  in  scarlet  fever,  but  a  great  part  of  it  crumbles 
away  in  a  fine  branny  powder.  Occasionally,  yet  very  seldom  I  beheve,  the  rash  is 
intermixed  with  a  few  small  and  short-lived  vesicles. 

This  termination  of  papulae  is  very  unlike  what  happens  in  variola  ;  and  connected 
with  the  eruption  there  are  two  other  important  particulars  in  which  the  measles 
differs  essentially  from  the  small-pox.  In  the  first  place,  the  fever  does  not  cease, 
nor  even  abate,  upon  the  emergence  of  the  eruption ;  but  sometimes  increases  in 
intensity.  And,  in  the  second  place,  the  disorder  is  not  more  severe,  nor  more  dan- 
gerous, because  the  eruption  is  plentiful,  or  early.  So  far  from  it,  indeed,  that  iu 
some  of  the  worst  and  most  perilous  cases  the  eruption  is  apt  to  be  partial,  and  to 
appear  late  and  irregularly. 

The  eruption  is  the  distinguishing  feature  of  measles ;  but  the  catarrhal  affection 

IS,  in  every  way,  the  most  important.     Indeed,  the  rash  may,  and  sometimes  does, 

happen  without  the  fever  and  the  catarrh ;  and  nosologists  recognise  a  variety  of  thi; 

disorder  under  the  title  of  rubeola  sine  catarrho.     But  it  is  observed  of  this  variety 

63 


994  MEASLES. 

that,  it  confers  no  protection  whatever  against  the  recurrence  of  the  malady  ;  in  truth, 
It  is  most  commonly  succeeded  in  a  few  days  b}''  an  attack  of  measles  in  its  regular 
and  complete  form. 

f  need  not  stop  to  repeat  what  I  told  you  in  a  former  lecture  about  the  other  gene- 
ral features  of  this  eruptive  complaint.  The  period  of  incubation  is  from  ten  days 
to  a  fortnight.  The  contagion  is  active  enough,  though  certainly  it  is  less  strong  and 
diffusive  than  that  of  small-pox.  When  once  introduced  into  a  family  or  school,  the 
disease  rapidly  spreads  to  those  individuals  who  have  not  already  had  it.  It  is  capa- 
ble, though  with  much  less  readiness  and  certainty  than  small-pox,  of  being  propa- 
gated by  inoculation  ;  but  as  the  disorder  is  not  rendered  milder  by  Being  so  intro- 
duced into  the  system,  this  process  has  no  utility  or  interest,  and  is  never  resorted  to. 
Occasionally,  rubeola  visits  the  same  individual  twice  ;  but  this  is  the  exception  to 
the  general  rule.  Perhaps,  in  some  reputed  instances  of  its  recurrence,  the  first 
accession  may  have  been  without  fever  and  catarrh,  and  therefore  an  ineffectual 
safeguard  for  the  future.  I  myself  know,  however,  two  large  families  in  which 
most  of  the  children  have  suffered  a  repetition  of  the  genuine  unmitigated  disease. 

The  measles  resembles  the  other  diseases  of  the  group  in  this  also,  that  at  times  it 
pervades  a  community  as  an  epidemic ;  at  times  occurs  here  and  there  only,  spora- 
dically. The  general  character  of  the  symptoms  varies  considerably  in  different 
epidemics.  Morton  and  Sydenham,  and  after  them  Sir  William  Watson,  have 
described  visitations  of  what  they  call  putrid  measles.  Sir  William  Watson  was 
physician  to  the  Foundling  Hospital,  and  he  witnessed  two  epidemics  of  this  putrid 
kind  among  the  children  in  that  institution.  He  states  that  the  eruption  appeared 
unusually  early,  so  early  as  the  second  day  of  the  disease;  and  that,  besides  cough 
and  d\'spnoea,  the  complaint  was  marked  by  extreme  debility,  and  attended  with 
dysenteric  diarrhcEa.  More  seemed  to  die  of  the  intestinal  affection,  than  of  the 
pectoral.  He  lost,  in  one  of  these  epidemics,  nineteen  out  of  one  hundred  and 
eighty-three  patients.  The  malignant  character  of  the  disorder  was  manifested  by 
the  frequent  occurrence  of  gangrene,  both  externally  and  internally.  In  this  more 
typhoid  variety  of  measles,  the  rash  is  often  irregularly  and  imperfectly  developed, 
and  of  a  livid  colour. 

Sydenham  found  that  measles  of  an  unusually  bad  kind  prevailed  in  London  in 
the  years  1G70  and  1G74  ;  the  very  same  years  in  Avhich  small-pox  was  also  remark- 
ably malignant  and  fatal.  This  illustrates  what  I  have  stated  before,  viz.,  that  the 
typhoid  tendencies  of  these  and  other  febrile  disorders  depend  less  upon  any  pecu- 
liar virulence  in  their  exciting  causes,  than  upon  some  change  previously  effected 
in  the  human  body  by  the  silent  and  gradual  influence  of  certain  predisposing 
causes. 

The  diagnosis  of  measles  is  seldom  difficult.  In  the  outset  of  the  fever,  you  may 
guess  what  is  coming  by  the  coryza,  catarrh,  and  hoarse  cough;  especially  if  the 
disease  be  about.  On  the  very  first  day  of  the  eruption,  the  small,  red,  and  hitherto 
separate  spots,  are  very  like  the  incipient  pimples  of  small-pox.  Do  not,  therefore, 
at  this  period,  express  too  confidently  your  opinion  respecting  the  nature  of  the  com- 
plaint. Parents  and  nurses  might  be  uncharitable  enough  to  attribute  your  mistake 
to  inexperience  or  ignorance.  The  progress  of  the  disease  will  soon  remove  all 
doubt.  The  eruption  of  small-pox  presently  exhibits  some  fluid,  while  that  of  mea- 
sles has  none — unless,  indeed  (what  is  uncommon),  a  k\v  miliary  vesicles  mix  them- 
selves with  it.  But  these  make  no  advance  in  twenty-four  hours.  Ordinarily,  the 
isolated  pimples  visible  upon  the  first  day  soon  augment  in  number,  and  collect  them- 
selves into  semicircular  groups ;  and  if  any  question  at  all  arises,  it  is  whether  the 
disease  be  measles  or  scarlet  fever.  I  shall  presently  describe  the  latter  disorder ; 
and  then  I  will  point  out  the  marks  of  distinction  between  the  'wo. 

The  prognosis  in  measles  is  governed  chiefly  by  the  mildness  or  the  severity  of 
the  pectoral  symptoms.  The  most  common  cause  of  death,  in  the  fatal  cases,  is 
inflammation  of  some  one  or  more  of  the  textures  that  compose  the  lungs.  And 
even  when  this  immediate  danger  has  passed  by,  the  disease  too  often  leaves  chronic 
pulmonarj'  mischief  behind  it.  In  scrofulous  children,  and  j^oung  persons,  it  fre- 
quently awakens  the  slumbering  germs  of  consumption.     And  when  that  specific 


MEASLES. 


ddS 


effect  is  not  produced,  it  is  apt,  in  adults,  to  inflict  upon  the  constitution  a  blow  which 
is  never  thoroughly  recovered  from ;  the  patient  becoming,  from  that  time  forwards^ 
delicate  and  valetudinary.  The  prognosis  is  always  unfavourable  when  the  eruption 
does  not  stand  out  well,  is  of  a  livid  colour,  and  accompanied  with  typhoid  symp- 
toms, or  with  a  disposition  to  gangrene. 

We  augur  favourably  of  the  case  when  the  thoracic  symptoms  are  not  severe ; 
when  the  fever  moderates  upon  the  coming  out  of  the  rash ;  and  when  the  rash  is 
steadily  persistent,  and  there  is  no  excessive  prostration  of  the  strength. 

Being  contagious,  and  occurring  for  the  most  part  but  once,  measles  is  principally 
seen  in  children  ;  although  no  period  of  hfe  is  exempt  from  its  attacks.  In  many 
children,  the  disorder  is  so  slight  as  to  require  little  more  than  judicious  domestic 
attentions.  The  free  application  of  cold  air  to  the  surface,  which  is  so  beneficial  in 
small-pox,  would  in  measles  be  unsafe,  on  account  of  the  pectoral  symptoms.  For 
this  reason,  the  patient  should  be  kept  in  bed ;  with  no  more  clothes,  however,  or 
warmth  of  the  apartment,  than  he  is  accustomed  to  in  health.  The  antiphlogistic 
regimen  must  be  adopted  ;  and,  if  the  bowels  are  not  quite  open  naturally,  gentle 
laxatives  should  be  given.  It  may  be  well,  also,  to  prescribe  some  diaphoretic  medi- 
cine ;  a  draught,  for  example,  containing  two  or  three  drachms  of  the  liquor  ammonise 
acelatis,  with  half  a  drachm  of  the  spiritics  xtheris  nitrici,  and  an  ounce  of  cam- 
phor julep,  to  be  taken  three  or  four  times  in  the  twenty-four  hours. 

The  most  important  part,  however,  of  the  treatment  relates  to  the  remedies  to  be 
employed  for  the  pulmonary  symptoms,  which,  in  the  outset,  depend  almost  always 
upon  bronchitis.  But  the  inflammation  is  apt,  in  severe  cases,  to  spread  insidiously 
from  the  mucous  to  the  other  tissues — the  bronchitis  becomes  pneumonia — and  we 
find,  after  death,  some  portions  of  the  lungs  hepatized  ;  usually  small  portions.  For 
the  most  part,  however,  it  is  extensive  inflammation  of  the  bronchial  mucous  mem- 
brane that  we  have  to  dread.  And  really  I  cannot  give  you  any  better  or  fuller 
directions  in  respect  to  the  management  of  these  inflammatory  affections,  than  I 
endeavoured  to  lay  down  when  I  was  speaking  of  bronchitis  and  pneumonia,  as 
they  occur  idiopathically.  You  will  judge  of  the  extent  and  severity  of  the  inflam- 
mation, partly  by  the  common  symptoms,  partly  by  the  help  of  your  ear ;  and  j^ou 
must  apportion  your  remedies  to  that  intensity,  so  judged  of.  You  will  take  blood 
from  the  arm,  or  from  the  chest,  apply  a  blister,  and  give  tartar  emetic.  And  it  is 
of  importance  that  whatever  kind  or  amount  of  depletion  is  adopted,  should  be 
resorted  to  early. 

When  the  rash  is  about  to  decline,  a  spontaneous  diarrhcea  often  sets  in,  and 
appears  to  have  a  beneficial  effect  in  abating  the  febrile  symptoms.  If  this  natural 
curative  process  should  fail  to  occur,  it  may  be  imitated  by  the  exhibition  of  gentle 
aperients. 

In  weakly  children  blisters  are  apt  to  cause  troublesome  sores  ;  and  in  some  epi- 
demics of  measles,  the  sores  thus  produced  show  a  disposition  to  become  gangrenous. 
When  any  such  tendency  is  noticed,  blisters  had  better  be  avoided  altogether.  At 
other  times,  the  inconvenience  to  be  apprehended  from  a  blister  may  be  prevented 
by  one  of  two  plans ;  either  by  interposing  a  piece  of  silver  paper  between  the 
blistering  plaster  and  the  skin ;  or  by  suffering  the  blister  to  remain  upon  the  part 
three  or  four  hours  only,  then  taking  it  off,  and  applying  a  pouUice.  The  cuticle 
will  rise  under  the  poultice,  and  the  sore  will  not,  in  general,  be  a  troublesome  one. 

If  the  eruption  disappear  prematurely,  it  may  sometimes  be  restored  by  putting 
the  patient  into  a  warm  bath.  And  if  he  be  at  the  same  time  in  a  low  state,  espe- 
cially if  typhoid  symptoms  threaten  or  show  themselves,  you  must  treat  the  case 
upon  that  indication,  just  as  you  would  in  continued  fever;  giving  wine  and  support, 
with  great  caution  and  watching  of  their  effects. 

It  is  of  considerable  importance  to  protect  the  patient  from  danger  after  the  disease 
has  subsided  ;  by  warm  clothing,  by  preventing  him  from  going  out  of  doors  too 
early,  or  being  in  any  way  exposed  to  cold.  Pneumonic  inflammation,  and  dysenteric 
purging,  are  frequent  consequences  of  the  want  of  prudence  in  this  respect. 

I  proceed,  in  the  next  place,  to  the  consideration  of  scarlet  fever. 


996  SCARLET   FEVER. 

This  also  is  a  contagious  febrile  disease,  attended  almost  always,  during  a  part  of 
its  course,  by  a  rash,  and  by  sore  throat.     It  seldom  comes  on  a  second  time. 

There  are  some  distinct  varieties  of  this  disorder,  concerning  which  it  is  necessary 
that  I  should  say  a  few  words. 

The  two  striking  and  important  features  of  the  disease  are  the  affection  of  the 
throat,  and  the  affection  of  the  skill.  They  may  both  be  well  marked  ;  or  only  one 
of  them  may  be  well-marked :  and  this  circumstance  has  led  nosologists  to  divide 
one  and  the  same  complaint  into  two  independent  maladies ;  to  which  Cullen  and 
others  have  assigned  the  respective  names  of  cynanche  maligna,  and  scarlatina. 
When,  in  an  earlier  part  of  the  course,  I  was  treating  of  the  diseases  of  the  throat,  I 
purposely  omitted  the  cynanche  maligna ;  because  that  is  only  another  name  for  a 
particular  form  of  scarlet  fever.  If  you  look  to  CuUen's  definitions  of  these  com- 
plaints, you  will  see  how  very  much  alike  they  are.  They  both  specify  inflamma- 
tion of  the  fauces,  a  cutaneous  rash,  and  fever.  But  in  the  definition  of  scarlatina, 
the  rash  is  dwelt  upon  and  described,  and  the  fever  is  called  synocha ;  while  in  that 
of  cynanche  maligna,  the  ulceration  of  the  throat  is  more  insisted  on,  and  the  fever 
is  said  to  be  typhoid.  The  truth  is,  that  these  two  kinds  of  disorder  both  spring 
from  the  same  contagious  poison.  The  malignant  sore  throat  may  be  caught  from  a 
patient  who  has  mild  scarlet  fever ;  and  mild  scarlet  fever  may,  in  like  manner,  be 
contracted  from  one  who  is  labouring  under  the  malignant  sore  throat.  The  two 
forms  graduate  insensibly,  in  different  cases,  towards  each  other ;  and  it  would  be 
impossible,  even  if  it  were  desirable,  to  draw  any  strict  line  of  separation  between 
them. 

For  convenience,  however,  of  description,  and  for  the  better  direction  of  the  treat 
ment,  authors  generally  make  three  varieties  of  scarlatina.  Scarlatina  simplex,  ir 
which  there  is  a  florid  rash,  and  httle  or  no  affection  of  the  throat ;  scarlatina  anginosa 
in  which  both  the  skin  and  the  throat  are  decidedly  implicated  ;  and  scarlatina  ma 
ligna,  in  which  the  stress  of  the  disease  falls  upon  the  throat.  The  epithet  maligna 
marks  truly  the  fearful  character  of  this  form  of  the  malady, 

I  need  scarcely  remind  you  of  a  sort  of  mystification  which  prevails  among  the 
public  about  this  complaint,  and  which  many  practitioners,  for  no  good  reason  that  I 
can  see,  seem  disposed  to  encourage.  Mistaking  the  Latin  and  scientific  name  of 
the  disorder  for  a  mere  diminutive,  you  will  hear  mammas  say,  "  Oh,  my  children 
have  not  got  the  scarlet  fever,  but  only  the  scarlatina.''''  I  always  disabuse  them  of 
this  absurd  error,  when  the  opportunity  of  doing  so  occurs.  It  can  produce  nothing 
but  confusion,  and  a  disregard  of  requisite  precautions. 

Like  measles,  and  for  the  same  reasons,  scarlet  fever,  though  persons  of  all  ages 
are  susceptible  of  it,  is  eminently  a  disease  of  children ;  but  it  is  much  more  to  be 
dreaded  than  the  measles. 

It  is  somewhat  strange  that  scarlet  fever  was  not  recognized,  in  this  country  at 
least,  as  a  distinct  disease,  till  about  two  centuries  ago.  In  all  probability  it  had  long 
existed,  and  had  been  always  confounded  with  measles,  Morton  speaks  of  it  under 
the  name  of  morbili  confluent es  ;  and  Hoffman  calls  it,  by  a  similar  mistake,  rubeola 
rossalia.  The  febris  scarlatina  described  by  Sydenham  must  have  been  of  a  very 
mild  kind;  for  he  does  not  mention  any  ulceration  of  the  throat.  Dr.  FothergiU, in 
1748,  was  the  first  to  describe,  as  a  new  and  separate  disorder,  that  perilous  form  of 
the  complaint  which  Cullen  designates  cynanche  maligna ;  and  it  was  long  called 
the  FothergiU  sore-throat.  The  identity  of  this  affection  with  genuine  scarlef  fever 
has  been  slowly  established  by  subsequent  observers.  The  characteristic  differences 
between  scarlet  fever  and  measles  were  first  fully  specified  by  Dr.  Withering. 

The  disease  begins,  as  the  exanthemata  in  general  begin,  and  as  continued  feverj 
which  I  have  grouped  with  them,  is  apt  to  begin,  with  shivering,  lassitude,  and  rapidly 
augmenting  debihty ;  headache,  frequently  severe,  sometimes  with  delirium,  occa- 
Bionally  with  nausea  and  vomiting.  Then,  generally,  on  the  second  day  (and  Cullen 
is  wrong  when  he  says  it  is  generally  on  the  fourth),  the  eruption  begins  to  come 
out.  In  some  of  the  worst  forms  of  the  disease,  it  may,  indeed,  be  deferred  till  the 
fourth  day. 

Although  scarlet  fever  and  measles  were  so  long  confounded  together,  the  differ- 


SCARLET    FEVER.  997 

ences  between  them  are  well  pronounced,  and,  when  once  pointed  out,  are  easily 
enough  recognized. 

Rubeola  is  distinguishable,  then,  from  scarlatina — 

1.  By  the  presence,  at  the  outset,  of  catarrhal  symptoms — by  the  sneezing,  the 
cough,  the  defluxion  from  the  eyes  and  nose,  which  precede  the  rash.  There  is, 
doubtless,  in  many  cases  of  scarlatina,  a  running  from  the  eyes  and  nose,  but  not  tiJl 
late  in  the  disease ;  at  any  rate  not  prior  to  the  eruption. 

2.  By  the  absence  of  severe  inflammation  and  ulceration  of  the  throat ;  symptoms 
which  always  accompany  severe  cases,  at  least,  of  scarlet  fever. 

3.  By  the  characters  of  the  eruption  itself.  The  rash  in  measles  is  more  elevated 
above  the  surface  than  in  scarlatina,  and  of  a  darker  colour.  In  measles  it  is  said  to 
present  somewhat  the  tint  of  a  raspberry,  and  in  scarlet  fever  to  be  that  of  a  boiled 
lobsters.  In  measles  the  papulae  are  collected  into  semilunar  clusters,  leaving  inter- 
stices between  them  of  healthy  skin.  The  redness  of  scarlatina  commences  in 
minute  points,  which  speedily  become  so  numerous  and  crowded,  that  the  surface 
appears  to  be  universally  red.  They  begin  on  the  face,  neck,  and  breast,  and  extend 
to  the  extremities,  pervading  at  last  every  part  of  the  skin.  The  scarlet  colour  is 
deeper,  in  general,  about  the  groins,  and  in  the  flexures  of  the  joints,  than  elsewhere. 
Lastly,  the  rash  of  measles,  in  its  most  regular  form,  appears  on  the  fourth  day  of 
the  disease ;  that  of  scarlet  fever  on  the  second. 

On  the  arms  and  legs  the  eruption  of  scarlatina  occasionally  difl^ers  somewhat 
from  that  which  is  visible  on  the  trunk ;  is  more  spotty,  more  papular,  and  the 
papulte  are  somewhat  prominent,  while  over  the  body  there  is  a  general  diffused 
blush. 

In  some  cases  of  scarlet  fever  (probably  in  some  epidemics,  for  I  observed  the 
phenomena  I  am  about  to  mention  in  four  or  five  cases  in  succession  which  were 
brought  into  the  Middlesex  Hospital  within  the  space  of  a  month  or  six  weeks), 
some  parts  of  the  red  surface  are  closely  studded  with  little  transparent  vesicles,  con- 
taining a  thin  colourless  liquid,  and  resembhng  what  I  described  to  you  before  as 
sudamina.  In  all  the  instances  in  which  I  have  seen  them,  these  minute  vesicles 
have  been  most  thickly  set  on  the  thorax,  and  on  the  front  and  sides  of  the  neck. 
The  liquid  is  soon  re-absorbed,  and  the  cuticle  under  which  it  had  been  enclosed 
shrivels  up,  turns  white,  and  comes  off"  in  a  thick  white  scurf:  so  that  the  part  from 
which  it  separates  looks  at  first  sight  as  if  it  had  been  powdered.  I  have  recently 
seen  two  cases  of  this  vesicular  form  of  scarlatina  in  private  practice.  I  show  you 
Rayer's  delineation  of  the  vesicles. 

The  eruption,  in  the  most  regular  and  favourable  cases,  stands  out  for  three  or  four 
days,  and  then  begins  to  fade  and  decline,  becoming  by  degrees  indistinct,  and  disap- 
pearing altogether,  in  the  majority  of  instances,  before  the  end  of  the  seventh  day. 
About  this  time  desquamation  of  the  cuticle  begins  to  take  place,  in  smaller  scurf  or 
scales  from  the  face  and  body,  in  large  flakes  frequently  from  the  extremities.  The 
scarf-skin  of  the  hands  and  of  the  feet  sometimes  separates  almost  entire.  A  glove 
or  a  slipper  of  cuticle  comes  away  at  once.  You  may  see  such  things  in  most 
museums. 

In  that  variety  of  the  disorder  which  we  call  scarlatina  maligna,  the  rash  is  apt  to 
come  out  late,  and  imperfectly,  and  sometimes  not  at  all;  and  instead  of  being  bright 
and  florid,  to  present  a  bluish  or  hvid  tint.  Sometimes  it  suddenly  recedes ;  and 
then,  perhaps,  appears  again :  and  occasionally  it  is  diversified  by  purple  spots. 

Willan  and  Bateman  have  given  the  name  oi  roseola  to  an  eruption  which  is  also 
attended  with  inflammation  of  the  throat,  and  between  which  and  scarlatina  it  is  cer- 
tainly difficult,  if  not  impossible,  at  first  to  discriminate.  The  roseola,  however,  is 
not  contagious,  and  has  more  of  a  chronic  character  than  scarlatina.  It  comes  and 
goes,  and  has  no  settled  or  definite  course.  Dr.  A.  T.  Thomson  lays  down  this  dis- 
tinction between  them  ;  but  I  do  not  know  that  we  can  trust  to  it : — "  In  scarlatina 
(he  says)  the  rash  first  attacks  the  face,  and  then  extends  to  the  trunk  of  the  body, 
passing  off' by  the  extremities  ;  whereas  in  roseola  the  extremities  ^xe  first  affected." 

The  appearances  of  the  tongue  in  scarlet  fever  are  also  peculiar  and  characteristic 
In  the  scarlatina  simplex,  and  anginosa,  it  is  often  covered,  at  the  outset,  with  a 

4i 


998  SCARLET    FEVER. 

thick,  white,  cream-like  fur,  through  which  are  seen  projecting  the  red  and  exagcre. 
rated  papillae ;  the  edges  of  the  tongue  being  likewise  of  a  bright  red  colour.  The 
red  points  gradually  multiplj^  and  the  white  fur  clears  away,  and  at  length  the 
whole  surface  of  the  tongue  becomes  preternaturally  red,  and  clean,  and  raw-looking: 
and  after  becoming  thus  clean,  as  well  as  red  and  rough,  and  like  a  strawberry,  it 
will  sometimes,  when  the  disease  goes  on  unpromisingly,  get  dry,  and  hard,  and 
brown — as  you  know  it  is  apt  to  be  in  certain  forms  and  stages  of  continued  fever. 

The  first  thing  of  which  the  feverish  patient  usually  complains  is  sore  throat,  with 
some  stiffness  of  the  neck :  and  if  you  inspect  the  fauces,  you  will  see,  without  in 
general  so  much  swelling  of  the  tonsils  as  occurs  in  common  quinsy,  a  diffused  red- 
ness, sometimes  of  a  dark  claret  colour,  including  a  large  part  of  the  palate.  In  a 
short  time  you  may  perceive  that  the  tonsils  and  vellum  are  covered  irregularly  with 
whitish  exudations,  or  gray  aphthous  crusts  :  or,  perhaps,  you  see  a  sloughy  kind  of 
ulceration  left  by  the  separation  of  these  crusts. 

The  progress  of  the  distemper,  and  its  degree  of  severity  and  of  danger,  differ  very 
greatly  in  different  cases.  Sometimes  the  deviation  from  the  feelings  and  condition 
of  health  is  so  very  slight  as  scarcely  to  deserve  the  name  of  a  disease ;  sometimes 
the  disorder  defies  all  treatment,  and  the  deadliest  forms  of  plague  are  not  more  fatal. 

In  these  mahgnant  and  terrible  cases,  the  eruption,  if  it  appear  at  all,  is  livid  and 
partial,  and  fades  early,  and  is  attended  with  a  feeble  pulse,  a  cold  skin,  aiid  typhoid 
depression.  Sometimes  the  patient  sinks  at  once,  and  irretrievably,  under  the  viru- 
lence of  the  poison,  and  life  is  extinguished  in  a  few  hours.  A  gentleman  called  one 
day  at  my  house,  and  not  finding  me  there,  followed  me  between  twelve  and  one 
o'clock  to  the  hospital.  He  wished  me  to  visit  his  wife,  four  or  five  miles  out  of 
town,  who  had  been  taken  ill  that  morning.  He  feared  that  she  was  about  to  have 
scarlet  fever,  but  he  was  not  much  alarmed  for  her  safety ;  for  when  he  found  that  1 
could  not  be  at  his  house  before  six,  he  said  that  that  hour  would  not  suit  the  gene- 
ral practitioner  in  attendance  upon  her,  and  he  begged  me  to  fix  some  time  for  seeing 
her  the  next  day.  I  did  so ;  but  the  same  afternoon  rapid  sinking  came  on,  and  the 
patient  was  dead  very  soon  after  the  hour  at  which  I  had  first  proposed  to  visit  her. 

In  other  cases  of  scarlatina  maligna,  the  typhoid  symptoms  rapidly  deepen  ;  and 
death,  in  children,  is  apt  to  occur  on  the  fifth  day  of  the  complaint ;  and  not  uncom- 
monly as  soon  as  the  third.  The  pulse  becomes  frequent  and  feeble;  the  tongue 
dry,  brown,  and  tremulous;  the  debility  extreme;  the  throat  is  ulcerated  and  gan- 
grenous ;  and  the  respiration  is  impeded  by  viscid  mucus  which  collects  about  the 
fauces.     Over  this  variety  of  the  disease,  medicine  has  comparatively  little  control. 

The  chance  of  recovery  is  much  greater  in  the  scarlatina  anginosa,  when  the 
eruption  is  florid,  and  stands  well  out.  But  even  in  this  form  of  the  disorder  there 
are  many  sources  of  danger,  and  various  ways  in  which  it  may  prove  fatal. 

In  the  first  place  many  of  the  patients  die,  apparently  from  inflammation  or  effu- 
sion within  the  head.  They  have  violent  headache,  with  furious  dcHrium,  which  is 
followed  by  coma,  and  death. 

And  secondly,  the  state  of  the  throat  is  full  of  peril.  As  the  disease  proceeds, 
although  the  rash  may  be  steadily  persistent,  the  throat  becomes  foul  and  sloughy, 
an  acrid  discharge  from  the  nostrils,  which  are  so  stufft'd  and  swollen  internally  that 
the  patient  can  scarcely  breathe  through  them,  runs  over  and  frets  the  upper  hp ; 
the  parotid  and  sub-maxillary  glands  swell,  sometimes  enormously;  and  fever  is 
lighted  up  afresh.  In  this  way  many  cases  prove  fatal  in  the  second  week  of  the 
disorder.  The  cervical  swelling  causes  constriction  of  the  fauces  and  stiflriess  of  the 
neck ;  and  sometimes,  doubtless  by  interfering  with  the  free  return  of  the  blood  from 
the  head  through  the  jugular  veins,  they  produce  a  tendency  to  coma.  With  these 
sj'mptoms  there  are  often  also  purging,  and  an  excoriated  anus. 

The  acrid  matters  furnished  by  the  ulcerating  and  gangrenous  throat  irritate  the 
nasal  membrane  in  me  one  direction,  and  that  of  the  alimentary  canal  in  the  other. 
We  thus  account  for  the  running  from  the  nose,  the  soreness  of  the  aloe  nasi  and 
upper  lip,  and  the  smarting  diarrhosa :  and  the  swelling  of  the  parotids  and  neigh- 
bouring glands  is  evidently  caused  by  absorption  of  the  irritating  and  poisonous  mai- 
\ri  from  the  ulcerated  throat.     There  is  just  the  same  relation   and  dependency 


SCARLET    FEVER.  99^ 

between  these  different  local  alterations,  as  between  the  enlarged  mesenteric  glands, 
and  ulceration  of  the  follicles  of  Peyer  in  continued  fever;  between  a  bubo  in  the 
groin,  and  a  chancre  on  the  glans  penis.  It  is  the  condition  of  the  throat  that  gives 
rise,  in  these  cases,  to  the  most  formidable  symptoms.  The  system  is  reinoculated 
from  that  source.  Whenever  I  see  the  glands  much  enlarged  at  the  angle  of  the 
jaw,  and  beneath  the  jaw,  in  a  child  labouring  under  scarlet  fever,  I  augur  ill  of  the 
case.  Sometimes  the  mischief  extends  into  the  larynx,  and  so  destroys  the  patient. 
But  this  is  probably  a  very  rare  event.  There  is,  however,  still  another,  and  a  very 
common  consequence  of  the  throat  affection — I  mean  inflammation  of  the  Eustachian 
tube,  reaching  sometimes  the  tympanum  itself,  and  causing  permanent  deafness, 
either  by  closintr  up  the  tube,  or  by  the  destruction  of  the  membrana  tympani,  and 
of  the  little  bones  belonging  to  it.  In  one  case,  which  was  under  my  own  care,  I 
observed  that,  for  a  short  time  before  death,  every  time  the  child  swallowed,  a  part 
of  the  fluid  food  ran  out  immediately  at  one  of  its  ears.  I  had  no  opportunity  of 
examining  the  state  of  the  part  after  death,  but  the  disorganization  arising  from  the 
sloughing  ulceration  of  the  throat  must  have  been  frightful. 

Scarlet  fever  sometimes  befalls  parturient  women ;  and  then  it  almost  always 
proves  fatal.  I  have  seen  three  instances  only  of  recovery  from  this  perilous  com- 
plication. 

Scarlatina  simplex  is  scarcely,  I  repeat,  a  disease.  Sydenham  has  said  of  it  that 
it  is  "fatal  only  through  the  officiousness  of  the  doctor." 

Even  when  the  patient  has  escaped  from  the  complaint  itself,  he  is  often  exposed 
to  great  hazard  and  distress  from  its  consequences.  Children  who  have  suffered  a 
severe  attack  of  scarlet  fever  are  liable  to  fall  into  a  state  of  permanent  bad  health, 
and  to  become  a  prey  to  some  of  the  many  chronic  forms  of  scrofula  :  boils,  strumous 
ulcers,  diseases  of  the  scalp,  sores  behind  the  ears,  scrofulous  swellings  of  the  cervical 
glands  and  of  the  upper  hp,  chronic  inflammation  of  the  eyes  and  eyelids.  The  same 
afiiicting  results  are  very  common  after  small-pox  also,  and  measles. 

I  have  several  times,  when  the  rash  of  scarlet  fever  was  disappearing,  known  pain 
and  sweUing  of  the  larger  joints  to  supervene,  simulating  very  closely  the  local  phe- 
nomena of  subacute  rheumatism :  and  I  have  noticed  that  the  painful  joints  were 
eased  and  benefited  by  friction  ;  a  circumstance  which  may  help  to  distinguish  this 
articular  affection  from  true  rheumatism.  Another  distinctive  circumstance  seemed 
to  be  that,  although  all  these  patients  were  children,  the  heart  in  no  instance  became 
implicated,  in  connection  with  the  tumid  joints.  Upon  this  point,  however,  my  own 
experience  may  have  been  fallacious.  Dr.  Scott  Alison  has  recently  invited  atten- 
tion to  the  subject,  in  an  interesting  essay  "  On  Pericarditis,  a  complication  and 
sequela  of  Scarlatina."  Accepting  his  facts,  I  should  ascribe  the  articular  affection, 
and  the  cardiac  affection,  whether  they  occurred  together  or  separately,  to  one  and 
tlie  same  cause  ;  namely,  to  the  retention  in  the  blood  of  a  poisonous  excrement,  by 
the  default  of  the  principal  emunctories,  and  especially  of  the  kidney. 

But  certainly  the  most  common,  and  a  very  serious  sequel  of  scarlatina,  is  ana- 
sarca, sejous  infiltration  of  the  subcutaneous  areolar  tissue,  accompanied  often  with 
dropsy  of  the  larger  serous  cavities.  So  common  is  this  that  Cullen  has  even  intro- 
duced the  circumstance  as  a  part  of  his  definition  of  scarlet  fever.  He  found  the 
dropsy  a  very  manageable  complaint ;  but  it  really  is,  in  many — nay,  in  most  cases, 
if  we  look  to  its  probable  ultimate  consequences  —  a  most  formidable  one.  This 
affection  belongs  to  the  class  o{  febrile  dropsies.  It  appears  to  have  no  relation,  or, 
if  any,  an  inverse  relation,  to  the  violence  and  danger  of  the  preceding  exanthem. 
It  is  much  more  common  after  a  mild  than  after  a  severe  disease.  This,  in  all  pro- 
bability, is  owing  to  the  circumstance  that  less  care  and  caution  are  observed  in  the 
milder  cases  during  the  dangerous  period  of  desquamation  and  convalescence;  a 
•oeriod  more  dangerous,  in  that  variety  of  scarlatina,  than  any  other.  In  the  graver 
cases  the  convalescence  is  slower,  and  more  doubtful ;  and  accidental  or  carele.-s 
exposure  to  cold  is  more  guarded  against,  or  takes  place  later:  whereas,  in  the 
slighter  kinds  of  the  disorder,  the  patients  are  apt  to  go  out  while  the  new  cuticle  is 
still  forming.  If  you  carefully  trace  the  histories  of  dropsy  succeeding  to  scarlet 
fever,  you  will  almost  always  find  that  the  fever  had  been  trifling ;  and  that  the 


1000  SCARLET   FEVER. 

patient,  considering  himself  well  or  nearly  so,  had  heedlessly  encountered  a  cold  or 
damp  atmosphere  so  soon  as  he  fell  himself  strong  enough  to  leave  the  sick  chamber. 
Plenciz,  who  has  written  well  on  this  subject,  and  who  was  quite  aware  of  its  im 
portance,  remarks  that  those  patients  who  have  had  much  desquamation  of  the 
cuticle  are  the  most  liable  to  the  dropsy ;  that  it  is  more  frequent  in  winter  than  in 
summer ;  and  in  such  as  are  early  exposed  to  the  open  air  after  having  passed 
through  the  fever,  than  in  those  who  remain  longer  at  home.  When  the  desquama 
lion  is  over,  and  the  new  surface  has  become  in  some  degree  hardened,  the  peril  is 
past.  According  to  the  observations  of  Dr.  Wells,  the  dropsical  symptoms  com- 
monly show  themselves  on  the  twenty-second  or  twenty-third  day  after  the  commence- 
ment of  the  preceding  fev^er.  They  have  been  known  to  begin  as  early  as  the 
sixteenth,  and  as  late  as  the  twenty-fifth  day.  When  no  dropsy  took  place  before 
the  end  of  the  fourth  week,  Dr.  Wells  always  ventured  to  state  that  it  was  no  longer 
to  be  dreaded. 

This  anasarca  is  seldom  observed  except  in  children  and  young  persons.  The  age 
of  the  oldest  patient  that  Dr.  Wells  had  known  to  be  so  affected  was  seventeen.  Of 
ten  instances  of  the  disease  seen  by  Dr.  Blackall,  six  occurred  in  children  not  exceed- 
ing the  age  of  ten,  and  two  others  in  persons  who  were  respectively  ten  and  sixteen 
years  old. 

We  cannot  infer,  from  this,  that  the  susceptibility  of  this  dropsical  condition  lessens 
as  years  increase.  The  great  prevalence  of  this  variety  of  dropsy  in  early  life  has 
no  direct  relation  to  age  as  a  predisposing  cause.  The  fact  is  explained  by  the 
accidental  peculiarities  of  the  antecedent  disease.  The  contagion  of  scarlet  fever  is 
active  and  widely  diffused.  Few  children  escape  its  agency.  Few  are  capable 
of  taking  the  disorder  a  second  time.  It  follows  that  scarlet  fever  is  rare  in  adult 
life  :  and  as  dropsy  succeeds  that  disease  in  a  very  limited  number  of  instances  only, 
drops}'  arising  in  connection  with  scarlet  fever  must,  at  the  adult  age,  be  still  mor^ 
Mncommon. 

Yet  it  is  not  unknown.  One  of  Dr.  Blackall's  ten  patients  was  thirty,  another 
forty-two  years  old.     Both  of  these  were  women. 

In  this,  as  in  other  species  of  febrile  dropsy,  the  urine  is  ver\'-  constantly  troubled, 
bloody,  albuminous ;  and  it  is  an  interesting  fact,  that  the  chronic  form  of  renal 
dropsy,  manifesting  itself  at  some  distance  of  time,  has  been  distinctly  traced  back 
to  its  source  in  the  acute  anasarca  immediately  consequent  upon  scarlet  fever.  The 
sequence  has  occurred,  in  all  probability,  much  oftener  than  it  has  been  noticed. 
There  is  scarcely  room  for  doubting  that  the  series  of  organic  changes  in  the  kidney, 
described  by  Dr.  Bright,  do  frequently  date  their  origin  from  an  attack  of  febrile 
anasarca:  and  in  proportion  as  facts,  accurately  observed,  accumulate  on  this  sub- 
ject, the  chain  of  connection  becomes  more  clearly  visible  between  acute  febrile 
dropsy,  dropsy  succeeding  scarlet  fever,  and  chronic  renal  dropsy.  It  is  evident, 
indeed,  that  the  first  two  of  these  three  are,  in  their  characters  and  exciting  causes, 
identical,  the  only  difference  between  them  consisting  in  the  remarkable  predis- 
position towards  the  second,  impressed  upon  the  body  by  the  preceding  exanthem. 
Both  of  them  again  are,  in  many  instances,  initiative  of  the  third. 

It  is  natural  therefore  to  expect  that  in  the  variety  of  lebrile  dropsy  now  under 
consideration,  as  well  as  in  those  which  I  formerly  described,  ii\flammation,  and 
especially  inflammation  of  the  serous  membranes,  should  be  common,  and  evidenced 
by  its  unequivocal  effects.  And  it  is  so.  But  the  dropsy,  I  am  persuaded,  has  no 
essential  connection  with  common  inflammation  of  any  part,  unless  the  state  of  the 
kidney  be  of  that  kind.  I  have  examined  the  body  very  carefullj'  in  fatal  cases,  and 
found  the  serous  cavities  full  of  clear  liquid,  without  a  trace  of  redness  or  of  any  of 
the  unmistakeable  products,  or  events,  of  inflammatory  action. 

The  earliest  threatenings  of  this  formidable  complamt  demand  attention.  It  is 
iisualh'  preceded,  for  a  day  or  two  or  longer,  by  languor  and  peevishness  ;  frequently 
by  nau.'iea  and  vomiting,  and  a  costive  state  of  the  bowels.  The  pulse,  in  the  out- 
set, has  been  found  slow,  and  Beating  with  irregular  intervals ;  but  it  afterwards 
becomes  frequent.  The  urine,  at  first,  is  scant}'  as  well  as  altered  in  appearance. 
The  face  becomes  pale,  and  chuffy.     Sometimes,  as  the  disease  proceeds,  violen* 


SCARLET   FEVER.  1001 

headache,  dilatation  of  the  pupils,  convulsions,  or  palsy,  denote  effusion  within  the 
head.  Much  more  frequently  the  pleurae  are  the  seat  of  the  internal  dropsical  accu- 
mulation, and  dyspnoea  is  a  prominent  symptom.  Ascites,  to  any  considerable 
amount,  is  rare. 

The  contagion  of  scarlet  fever  is  active,  but  uncertain.  It  is  not  so  strong,  nor  so 
uniform  in  its  operation,  as  that  of  small-pox ;  but  it  seems  to  be  pecuharly  subtle 
and  tenacious.  Fomites  infected  with  the  variolous  poison  soon  lose  their  power  to 
excite  the  disease  if  they  are  freely  exposed  to  fresh  air.  But  the  contagion  of  scarlet 
fever  lurks  about  an  apartment,  or  chngs  to  furniture  and  clothes,  for  a  very  loner  time, 
even  after  some  care  has  been  taken  to  purify  them.  Of  this  I  have  known  several 
remarkable  examples.  You  will  be  asked  at  what  period  the  danger  of  impartino- 
the  disease  on  the  one  hand,  or  of  catching  it  on  the  other,  is  over;  and  I  would 
recommend  you  to  answer  that  you  do  not  know.  I  am  sure  I  do  not :  and  therefore 
I  always  decline  the  responsibility  of  giving  an  oracular  opinion  on  the  matter. 

I  may  arrange  what  I  have  to  say  of  the  treatment  of  scarlet  fever,  according  to 
the  three  varieties  of  it  already  mentioned,  the  scarlatina  simplex — anginosa — and 
maligna. 

The  first  of  these  requires  nothing  more  than  confinement  to  the  house ;  and  the 
observance  of  the  antiphlogistic  regimen  in  regard  to  diet ;  and  regulation  of  the 
bowels. 

With  respect  to  the  management  of  the  severer  forms  of  scarlet  fever,  great  differ- 
ences of  opinion  have  prevailed.  I  should  recommend  you  to  look  into  Dr. Williams's 
book  on  Morbid  Poisons,  for  some  interesting  and  satisfactory  information  on  this 
head.  Satisfactory  to  me  at  least  it  is,  because  the  result  of  it  goes  to  justify  that 
kind  of  practice  which  I  have  always  considered  to  be  the  safest  and  the  best  in  this 
disorder. 

Tn  the  scarlatina  anginosa,  the  treatment  I  employ  is  very  much  the  same  as  that 
which  I  consider  proper  for  many  cases  of  continued  fever.  If  the  heat  of  the  surface 
be  very  great  and  distressing,  I  should  certainly  recommend  the  cold  affusion,  but 
cold  or  tepid  sponging  will  be  very  refreshing  and  beneficial.  If  dehrium  should 
come  on,  I  would  shave  the  scalp,  and  apply  cold  to  it,  and  take  away  some  blood 
by  leeches  :  and  the  leeches  I  would  apply  to  the  throat  rather  than  to  the  temples; 
for  the  tonsils,  in  this  form  of  the  disorder,  are  more  swelled  and  inflamed,  and  pro- 
bably a  part  of  the  head  aff^ection  may  arise  from  disturbance  of  the  balance  of  the 
cerebral  circulation,  produced  by  the  tumefaction  around  the  great  veins  that  return 
the  blood  from  the  head.  By  leeching  the  throat  you  relieve  that  part,  and  at  the 
same  time  the  head  also.  U  the  fever  were  extreme  and  the  delirium  violent,  I 
would  take  blood  cautiously  from  the  arm,  while  the  patient  was  sitting  up,  and  care- 
fully watch  the  effect. 

When  none  of  these  untoward  head  symptoms  declare  themselves,  all  that  we 
have  to  do  is  to  keep  the  bowels  open  by  moderate  laxatives.  The  patient  may  take 
sahne  draughts,  which  are  grateful  and  cooling.  The  citrate  of  ammonia  thus  ad- 
ministered, is  what  I  frequently  prescribe  :  and  if  the  pulse  be  without  hardness,  and 
feeble,  I  order  an  excess  of  the  carbonate  of  ammonia,  so  that  four  or  five  grains  of  it 
in  each  dose  may  remain  unsaturated  by  the  lemon-juice. 

With  respect,  then,  to  this  form  of  the  complaint,  the  principles  of  treatment  are, 
not  to  interfere  unnecessarily;  to  take  blood  when  certain  symptoms  require  it,  but 
to  take  no  more  than  seems  likely  to  be  sufficient  for  the  purpose  in  view ;  to  bear  in 
mind  that  the  system  is  labouring  under  a  morbid  poison,  which  we  cannot  eliminate 
from  the  blood,  but  the  dangerous  effects  of  which  we  are  to  watch  and  obviate. 

In  that  worst  form  of  scarlet  fever,  the  scarlatina  maligna,  all  our  care  will  too  often 
be  in  vain.  There  appear  to  me  two  main  sources  of  danger.  The  one  arises  from 
the  primary  impression  of  the  contagious  poison  upon  the  body,  and  particularly  upon 
the  nervous  system,  which  is  overwhelmed  by  its  influence.  The  patients  sink  often 
at  a  very  early  period,  with  but  littla  affection  either  of  the  throat  or  of  the  skin.  If 
we  can  save  such  patients  at  all,  it  must  be  by  the  liberal  administration  of  wine  and 
bark,  to  sustain  the  flagging  powers  until  tlie  deadly  agency  of  the  poison  in  some 
measure  passes  by.  But  another  source  of  danger  arises  from  the  gantrrenous  ulrera 

4i2 


1002  SCARLET    FEVER. 

tion  which  is  apt  to  ensue  in  the  fauces,  when  the  patient  is  not  killed  by  the  first 
violence  of  the  contagion.  The  S3'stem  is  re-inoculated,  I  believe,  with  tlie  poisonous 
secretion  from  the  throat.  Now  under  these  circumstances  also,  quina,  or  wine — and 
upon  the  whole  I  should  give  the  preference  to  wine — are  to  be  diligently,  though 
watchfully  given.  And  something  may  be  done,  by  way  of  gargles,  to  correct  the 
state  of  the  throat,  and  to  prevent  the  distressing  and  perilous  consequences  which 
would  otherwise  be  likely  to  flow  from  it.  A  weak  solution  of  the  chloride  of  soda 
may  be  employed  for  this  purpose;  and  if  the  disease  occur  in  a  child  that  is  not 
able  to  gargle,  this  solution  may  be  injected  into  the  nostrils,  and  against  the  fauces, 
by  means  of  a  syringe  or  elastic  bottle.  The  effect  of  this  application  is  sometimes 
most  encouraging.  A  quantity  of  offensive  sloughy  matter  is  brought  away ;  the 
acid  discharge  is  rendered  harmless  ;  the  running  from  the  nose,  and  diarrhoea,  cease  ; 
and  the  disease  is  converted  into  a  form  which  approximates  to  the  scarlatina  angi- 
nosa.     This  is  a  great  improvement  upon  the  old  plan  of  ordering  capsicum  gargles. 

Of  late  I  have  been  in  the  habit  of  directing  a  solution  of  the  chlorate  of  potass  in 
water,  (a  drachm  to  a  pint,)  as  a  drink  for  patients  in  scarlet  fever,  and  in  the  typhoid 
forms  of  continued  fever.  This  practice  was  suggested  to  me  by  Dr.  Hunt,  who 
tells  me  he  has  long  emplo5'ed  it  with  advantage.  Under  the  use  of  a  pint,  or  pint 
and  a  half,  of  this  solution  daily,  I  have  remarked,  in  many  instances,  a  speedy  im- 
provement of  the  tongue,  which,  from  being  furred,  or  brown  and  dry,  has  become 
cleaner,  and  moist. 

From  several  distinct  and  highly  respectable  sources,  chlorine  itself  has  been 
strongly  pressed  upon  my  notice,  as  a  most  valuable  remedy  in  the  severest  forms 
of  scarlet  fever.  My  informants  have  stated,  that  whereas  they  formerly  dreaded 
to  be  summoned  to  cases  of  that  disease,  they  now,  having  had  experience  of  the 
virtues  of  chlorine,  felt  no  misgivings  in  undertaking  its  treatment.  Since  these 
representations  were  made  to  me,  I  have  not  had  opportunities  enough  of  trying 
this  drug  to  enable  me  to  speak  confidently  of  its  sanative  power ;  but  I  shall  cer- 
tainly employ  it  in  future.  I  presume  that  its  disinfecting  properties  may,  in  part, 
account  for  the  good  it  does.  It  probably  deprives  the  foul  secretions  of  their  noxious 
qualit3^ 

In  the  fourth  volume  of  the  Medical  Gazette,  INIessrs.  Taynton  and  Williams,  of 
Bromley,  write  in  high  praise  of  this  remedy.  I  will  give  you  the  formula  for  its 
preparation. 

Two  drachms  of  the  chlorate  of  potass  are  to  be  dissolved  in  two  ounces  of 
hydrochloric  acid,  previously  diluted  with  two  ounces  of  distilled  water.  The  solu- 
tion must  be  put  imm.ediately  into  a  stoppered  bottle,  and  kept  in  a  dark  place. 

Tv\'o  drachms  of 'this  solution,  mixed  with  a  pint  of  distilled  water,  constitute  the 
chlorine  mixture  ;  of  which  a  tablespoonful,  or  two,  according  to  the  age  of  the  pa- 
tient, may  be  given  for  a  dose,  frequently. 

We  must  not  omit,  in  this,  as  well  as  in  the  other  forms  of  the  complaint,  to 
pay  attention  to  the  state  of  the  bowels,  and  by  no  means  to  allow  them  to  remain 
costive. 

I  have  seldom  used  blisters  in  this  disease ;  but  an  experienced  phj'sician  has 
lately  told  me  that,  when  appli'^d  early  to  the  neck  and  throat,  they  seem  to  render 
the  affection  of  the  fauces  mild. 

When  the  patient  is  at  length  convalescent,  he  will  require  careful  watching  till 
that  period  has  gone  by  at  which  the  dropsical  symptoms  are  apt  to  appear.  It  is 
by  neglect  or  imprudence  that  these  symptoms  are  brought  on.  The  patient  should 
be  sedulously  protected  from  all  exposure  to  cold,  and  wet,  and  fatigue ;  indeed  he 
ought  not  to  be  permitted  to  go  out  of  the  house  until  the  process  of  desquamation 
is  fairly  over ;  and  I  would  not  willingly  let  a  patient  go  out  till  some  little  time  after 
ihis.  AVhen  dropsical  symptoms  do  occur,  if  they  be  very  slight,  they  may  be  re- 
moved in  general  by  purgatives,  and  by  digitalis.  The  hitartratc  of  potass  is  a  good 
remedv  too  in  such  cases,  and  the  use  of  the  warm  bath,  v.-hich  may  be  repeated 
every  night. 

But  if  there  be  anj-  indication  of  inflammatory  disease  within,  we  must  adoj/4 
•^nore  active  measures.    We  have  not,  now,  to  contend  with  the  depressing  influence 


SCARLET    FEVER.  1003 

of  the  6riginal  poison,  but  we  have  to  dread  the  consequences  of  acute  inflammation  ; 
or  of  the  sudden  effusion  of  fluid,  the  mere  presence  and  pressure  of  which  may 
fatally  oppress  vital  organs.  We  should  have  for  our  object  to  arrest  the  inflamma- 
tion—  or  to  promote  the  removal  of  the  effused  fluid  —  by  blood-letting,  and  by  the 
exhibition  of  purgative  medicines,  and  of  mercury.  The  worst  case  of  this  kind  that 
I  ever  witnessed  occurred  in  a  boy  of  fifteen,  the  son  of  a  tradesman  in  my  neigh- 
bourhood. He  had  had  scarlet  fever,  mildly,  and  had  got  well,  or  nearly  well,  of  it, 
as  he  believed ;  and  he  went,  one  evening,  into  his  father's  stable,  and  stayed  there 
some  time  in  the  cold,  during  the  period  of  desquamation.  A  day  or  two  afterwards 
he  began  to  have  headache,  and  in  a  few  hours  more  was  seized  with  convulsions 
of  one  side  of  the  body,  coma,  and  at  length  hemiplegia ;  and  his  face  and  extremi- 
ties became  at  the  same  time  anasarcous.  A  large  quantity  of  blood  vi'as  taken  from 
his  arm,  he  was  cupped  on  the  temples,  and  took  mercury,  till  in  a  short  space  of 
time  he  was  profusely  salivated.  Under  this  treatment  the  coma  and  dropsy  rapidly 
disappeared,  and  he  presently  recovered  the  use  of  his  palsied  limbs,  and  got  quite 
well.  I  make  no  doubt  that  some  effusion  took  place  within  the  cranium,  as  well 
as  into  the  subcutaneous  areolar  tissue.  The  plan  of  treatment  followed  in  this 
case,  modified  according  to  particular  circumstances,  is  that  which  I  should  again 
pursue,  and  therefore  what  I  should  recommend  you  to  pursue,  in  similar  emer- 
gencies. 

You  are  probably  aware  that  belladonna  is  believed  by  many  to  exert  a  preventive 
and  protecting  influence  upon  the  body  against  the  contagion  of  scarlet  fever.  Hah- 
nemann, the  author  of  the  Homoeopathic  hypothesis  (and  thereby  of  much  mischief 
to  mankind),  was  the  first  to  assert  this.  It  is  said  that  belladonna  administered  in 
small  doses  causes  sometimes  a  rash  resembhng  that  of  scarlatina.  It  certainly  is 
apt  to  produce  dryness  and  redness  of  the  fauces.  I  know  nothing  by  my  own  expe- 
rience of  the  alleged  conservative  power  of  this  vegetable ;  but,  in  the  small  quan- 
tities recommended,  there  can  be  no  harm  in  trying  h,  provided  that  its  employment 
does  not  lead  to  a  neglect  of  other  precautions.  Three  grains  of  the  extract  of  bel- 
ladonna are  dissolved  in  an  ounce  of  distilled  water;  and  three  drops  of  the  solution 
are  given  twice  daily  to  a  child  under  twelve  months  old,  and  one  drop  more  for 
every  year  above  that  age.  It  is  affirmed  that  if  this  remedy  does  not  prevent  the 
disease,  it  will  render  it  mild  ;  and  that  if  it  be  taken  four  or  five  days  before  exposure 
to  the  contagion,  the  resulting  scarlatina  never  proves  fatal. 

[The  question  in  relation  to  the  prophylactic  properties  of  the  belladonna  in  this  disease 
is  a  highly  interesting  one.  The  severe  and  fatal  character  of  scarlet  fever,  particularly  when 
it  occurs  as  an  epidemic,  renders  every  means  of  prevention  that  can  be  depended  upon 
with  any  degree  of  certainty,  of  vast  importance.  In  proof  of  the  power  of  the  belladonna 
to  guard  those  who  have  been  placed  under  its  influence  from  an  attack  of  scarlatina,  we 
have  certainly  some  very  strong  and  respectable  testimony.  In  a  paper  published  by 
Bayle,  in  1830,  it  is  stated  that  of  2027  individuals  to  whom  the  belladotma  was  adminis- 
tered, 1948  were  preserved  from  scarlet  fever,  and  79  were  attacked.  Dusterberg  reports, 
tliat  all  who  were  placed  under  the  influence  of  the  belladonna  for  the  space  of  two  weeks, 
were  preserved  from  the  scarlet  fever.  In  order  to  ascertain  the  real  value  of  the  article,  he 
purposely  omitted  to  administer  it  to  one  child  in  ea,ch  family,  and  this  one  alone,  according 
to  his  report,  was  seized  with  the  disease.  He  adds,  however,  that  occasionally  a  child 
who  had  only  been  taking  the  remedy  during  three  or  four  days,  was  attacked,  but  the  fever 
was  in  such  cases  always  mild,  and  often  only  manifested  its  presence  by  the  occurrence 
of  desquamation.  Zeuch,  physician  to  the  Miliary  Hospital  for  Children,  in  Tyrol,  after  84 
of  the  cliildren  were  attacked  with  scarlet  fever,  was  induced  to  try  the  prophylactic  powers 
of  belladonna  on  the  remaining  61  children:  with  a  single  exception,  all  of  these  were 
preserved  from  the  fever,  although  it  prevailed  all  around  them.  Schenk,  Berndt,  Kiihler, 
JVIeglin,  De  Lens,  and  many  other  respectable  practitioners,  speak  in  equally  high  terms  of 
the  preservative  properties  of  the  belladonna.  We  have  ourselves  given  the  belladonna  to 
a  number  of  children,  on  several  occasions  when  the  scarlet  fever  was  prevailing  epid°mi 
caily,  witli  a  view  of  testing  its  prophylactic  powers;  but  although  redness  and  dryness  oi" 
the  throat,  and  a  diffuse  scarlet  effervescence  were  produced  by  it,  yet  in  the  majority  of 
cases,  we  never  found  it  in  any  instance  to  exhibit  the  sliglitest  influence  in  shielding  those  who 
took  it  from  an  attack  of  the  disease,  or  in  mitigating  in  any  degree  its  severity.  In  one  case, 
the  efflorescence  produced  by  the  belladonna  was  kept  up  for  forty-eight  hours;  in  a  week 
afterwards  the  child  was  attacked  bv  the  fever  in  its  most  violent  form,  and  died  on  the  >biir».)i 


J  004  ERYSIPELAS. 

day.  Recently,  however,  Dr.  Stievenart,  of  Valenciennes,  has  published  the  results  of  a 
very  extensive  trial  of  the  belladonna,  as  a  prophylactic  during  the  prevalence  of  epidemic 
scarlatina:  Avhich  results,  if  they  are  correctly  stated,  and  all  sources  of  error  have  been 
carefully  guarded  against  in  tlie  performance  of  the  experiments  upon  vi^hich  they  are 
founded,  go  very  far  to  prove  that  the  belladonna  does  actually  possess  the  property  of 
shielding  the  constitution  from  an  attack  of  scarlet  fever.  An  epidemic  of  the  disease 
ravaged,  during  the  winter  of  1840-1,  several  villages  in  the  neighbourhood  of  Valen- 
ciennes, when  Dr.  Stievenart  was  induced  to  try  the  prophylactic  properties  of  belladonna. 
The  fatality  of  the  epidemic  was  such  that  30  had  already  died  out  of  96  attacked ;  conse- 
que,ntly  any  means  of  prevention  was  a  subject  of  vast  importance.  In  a  small  village, 
out  of  250  individuals,  200  took  the  belladonna,  and  were  all  preserved  from  the  attack  of 
scarlet  fever.  Of  the  fifty  others,  14  were  seized  with  the  fever,  and  four  of  them  died.  At 
the  village  of  Curgies,  Dr.  Stievenart  administered  the  belladonna  to  the  children  at  the 
public  school,  and  allowed  them  to  continue  at  their  lessons,  and  have  free  co<nraunicatioa 
with  the  other  children  of  the  village.  All  to  whom  the  belladonna  was  r^ministered 
escaped  the  scarlet  fever,  while  a  few  who  refused  to  take  it  were  seized  with  th«5  disease. 

The  belladonna  was  administered  in  two  forms — in  solution,  or  as  a  powder.  Two  grains 
of  the  recent  alcoholic  extract  of  belladonna  were  dissolved  in  an  ounce  of  any  aromatic 
infusion,  and  of  this  two  drops  were  given  to  a  child  of  one  year  old,  daily,  for  niie  or  ten 
days  :  an  additional  drop  being  given  for  every  additional  year  of  age.  The  largest  daily  dose 
was,  however,  limited  to  twelve  dro]TS.  When  the  belladonna  was  used  in  the  form  of 
poMaler,  half  a  grain  of  the  powdered  root  was  mixed  with  a  small  quantity  of  sugar,  and 
,  divided  into  ten  doses.  One  of  these  was  given — morning  and  evening — to  children  of 
from  one  to  two  years  old;  two  powders,  at  the  same  periods,  to  those  from  three  to  five; 
three  powders  to  those  from  six  to  nine ;  four  to  those  from  ten  to  fifteen,  and  five  to 
adults.  These  small  doses  never  produced  the  toxocological  effects  of  belladonna ;  in  fact, 
they  scarcely  exhibited  any  marked  action.  In  five  or  six  cases  Dr.  Stievenart  observed  a 
rash  similar  to  that  of  measles ;  and,  in  a  few  other  cases,  headache,  with  dilatation  of  the 
pupils,  dryness  of  the  fauces,  and  a  slight  soreness  of  the  throat,  but  which  had  no  resem- 
blance to  that  of  scarlatina  anginosa.  In  all  the  other  cases  no  sensible  or  apparent  effect 
resulted  from  the  administration  of  the  remedy.  Dr.  Stievenart,  generally,  continued  xhe 
use  of  the  belladonna  for  from  nine  to  ten  days ;  in  some  cases,  it  was  given  for  fifteen  days. 
He  thinks  this  period  sufficiently  long  to  put  the  system  under  the  influence  of  the  preserva- 
tive powers  of  the  remedy :  but  recommends  to  resume  its  use  if  the  epidemic  returns  or 
breaks  out  again  with  renewed  violence. — C] 


LECTURE  LXXXIX. 

The  Plague.    Erysipelas.    Erythema  Nodosum.    Urticaria.    Prurigo.    Scabies 

Of  that  group  of  contagious  exanthemata  of  which  I  undertook  to  give  you  some 
general  account,  two  only  remain  to  be  noticed,  viz.,  the  plague  and  erysipelas. 

Concerning  one  of  these,  the  plague — as  I  have  never  seen,  and  hope  never  to 
see  it ;  and  as,  with  Cullen,  I  "  think  it  unfit  for  a  person  who  has  never  seen  the 
disease  to  atietnpt  its  particular  history" — I  shall  not  presume  to  offer  you  any  obser- 
vations in  detail.  It  is  a  very  malignant  kind  of  contagious  fever;  prevailing,  at 
certain  times  and  places,  epidemically ;  attended  with  a  sort  of  eruption,  namely, 
with  buboes  and  carbuncles ;  and  not  furnishing,  apparently,  any  sure  or  permanent 
security  acrainst  its  future  recurrence.  In  Dr.  Forbes'  Select  Medical  Bibliography, 
you  will  find  a  long  list  of  works  on  the  plague,  I  would  second  Dr.  Culien's 
recommendation,  that  you  should  consult  those  authors  only  who  have  themselves 
had  personal  experience  of  the  disease.  Among  the  publications  that  fall  within 
this  rule  may  be  mentioned.  Dr.  Russell's  History  of  the  Plague  as  he  saw  it  in 
Aleppo ;  Sir  James  M'Grigor's  Medical  Sketches ;  Sir  Arthur  Brooke  Faulkner's 
Account  of  the  Plague  which  occurred  at  Maka  in  1813;  Desgenettes'  Histoire 
Medicale  de  I'Armee  d'Orient ;  and  Assalini's  description  of  the  malady  as  he  wit- 
nessed it  when  in  attendance  upon  the  French  army  in  Egypt, 


ERYSIPELAS.  1005 

I  proceed,  therefore,  to  erysipelas.  And  I  wish,  in  the  first  place,  to  fix  and  define 
fhat  specific  complaint  of  which  alone  I  propose  at  present  to  speak.  The  term  ery- 
sipelas has  been  employed  by  medical  men  in  a  very  loose  and  vague  manner.  Any 
diffused  redness  and  inflammation  of  the  skin  is  apt  to  be  set  down  as  erysipelas ; 
and  hence  we  have  disputes  as  to  the  distinction  between  erysipelas  and  erythema. 
But  it  would  tend,  in  my  humble  judgment,  to  the  formation  of  more  settled  opinions 
in  respect  to  erysipelas,  if  the  term  were  restricted  to  that  disease  in  which  the  inte- 
guments of  the yace  and  head  become  diffusely  inflamed.  The  phrase  erysipelatous 
inflammation  may  properly  enough  be  applied  to  other  cases,  similar  to  this,  in  so 
far  as  the  condition  of  the  shin  is  concerned ;  but  in  what  I  should  consider  true 
erysipelas,  in  the  medical  sense  of  the  word,  there  are  other  characters  belonging  to 
the  disorder,  quite  as  important  as,  and  more  distinctive  than,  the  cutaneous  affection. 
What  is  usually  spoken  of  as  erysipelas  of  the  face  and  head,  and  what  I  would 
call  simply  erysipelas,  falls  naturally  within  that  group  of  exanthematous  diseases 
which  includes  small-pox,  measles,  scarlet  fever,  the  plague,  and  continued  fever. 
It  is  an  idiopathic  inflammatory  disorder,  running  a  tolerably  regular  and  definite 
course;  attended  by  inflammation  of  the  integuments  of  the  body,  or,  in  other  words, 
by  an  eruption;  ohen  prevailing  epidemically,  and  capable  of  being  communicated. 
under  circumstances  favourable  to  its  propagation,  from  one  person  to  another.  Its 
power  to  protect  the  constitution  from  its  own  recurrence  is  less  certain  ;  but  in  truth, 
so  many  different  affections  have  been  lumped  together  under  a  common  name,  that 
the  proper  phenomena  of  true  erysipelas  have  not  been  made  sufficiently  an  object 
of  separate  study  to  enable  us  to  speak  with  any  confidence  on  this  point.  I  recol- 
lect, however,  a  certain  female  who  has  been  three  or  four  times  my  patient  in  the 
hospital  with  erysipelas :  and  one  of  the  night  nurses  there,  whom  I  treated  for  that 
complaint  some  time  ago,  is  now  lying  ill  of  the  same  disorder,  under  the  care  of  one 
of  my  colleagues. 

Erysipelas,  in  the  sense  now  explained,  called  in  Scotland  the  rose,  and  in  this 
country  St.  Anthony^s  fire,  resembles  other  disorders  of  the  same  group  in  these 
points  also,  that  the  fever  precedes  the  local  inflammation,  that  certain  premonitory 
symptoms  frequently  go  before  the  outbreak  of  the  disease,  and  that  sore  throat  is  an 
early,  and  almost  a  constant,  accompaniment  of  the  complaint.  The  patient  feels  ill — 
shivery,  feeble,  languid,  and  often  drowsy.  The  actual  attack  generally  sets  in  with 
distinct  rigors ;  and  the  pulse  is  often  very  frequent  from  the  first,  for  many  hours, 
perhaps,  before  the  redness  commences.  Very  commonly  there  is  also  manifest  dis- 
turbance of  the  alimentary  canal,  marked  by  nausea  and  vomiting,  and  not  unfre- 
quently  by  diarrhoea.  Then  some  part  of  the  face,  usually  one  side  of  the  nose,  or 
one  cheek,  or  the  rim  of  one  of  the  ears,  begins  to  feel  hot,  stiff",  and  tingling:  and  upon 
examining  it  you  find  it  to  be  of  a  deep  continuous  red  colour,  and  to  be  swelled  and 
hard.  The  redness  and  swelling  gradually,  and  sometimes  rapidly,  extend  them- 
selves :  they  are  defined  by  a  distinct  elevated  margin  ;  which  advances,  and  invades 
progressively  the  neighbouring  heakhy  surface,  until  the  whole  of  the  fa^e,  or  of  the 
scalp,  or  of  both,  is  occupied  with  the  inflammation.  The  lips  swell  enormously, 
the  cheeks  enlarge,  the  eyes  are  sealed  up  by  their  oedematous  and  prominent  Hds, 
and  all  traces  of  the  natural  countenance  are  effaced.  I  know  of  no  disease,  except 
perhaps  the  confluent  small-pox,  which  so  completely  and  speedily  deforms  and  dis- 
guises the  visage  of  the  patient.  A  stranger  seeing  a  young  female  in  the  height  of 
the  disorder,  and  revisiting  her  after  her  recovery,  is  astonished  at  the  change.  It 
seems  as  if,  by  some  magic  process,  such  as  we  read  of  in  our  nursery  tales,  a  hide- 
ous monster  has  been  metamorphosed  into  a  comely  damsel. 

The  inflammation  frequently  spreads  from  the  face  and  forehead,  or  ears,  to  tlie 
hairy  scalp ;  and  from  the  head  it  travels  backwards,  in  some  cases,  to  the  neck  and 
the  shoulders.  Sometimes — and  in  this  it  exactly  resembles  a  scald — the  inflamed 
surface  becomes  covered  with  irregular  bullae,  or  blisters  ;  but  often  there  is  no  vesi- 
cation. This  circumstance,  therefore,  which  has  been  mentioned  by  some  as  fui 
nishing  a  point  of  distinction  between  erythema  and  erysipelas,  fails  of  that  purpose. 

In  many  cases  the  inflammation  is  quite  superficial :  in  others  it  dips,  as  it  were, 
through  the  skin,  and  affects  the  subcutaneous  areolar  tissue ;  and  then,  and  there 


1006  ERYSIPELAS. 

suppuration,  and  even  sloughing  of  that  tissue,  are  apt  to  take  place.  We  find  this 
to  be  the  case  often  in  the  loose  tissue  of  the  eyelids ;  and  it  is  more  common  on  the 
scalp  perhaps  than  on  the  face. 

Afier  the  redness  has  lasted  three  or  four  days,  it  fades,  the  sv/ollen  surface  sub- 
sides, and  desquamation  ensues ;  and  as  the  inflammation  creeps,  perhaps,  gradually 
from  one  part  of  the  surface  to  another,  you  may  find  the  face  becoming  pale,  and 
covered  with  patches  of  dead  cuticle,  while  the  scalp,  or  the  upper  part  of  the  neck, 
is  becoming  red.  Sometimes  those  parts  of  the  inflamed  surface  on  Avhich  bhsters 
had  formed  are  covered  with  crusts,  rather  than  with  merel}''  dead  and  dry  cuticle. 
In  almost  all  these  cases  of  erysipelas  of  the  head  and  face  there  will  be  found  to  be 
redness  and  soreness  of  the  throat  also;  although  this  is  not  always  inquired  into, 
or  complained  of. 

There  is  considerable  variety  in  the  intensity  and  complication  of  the  symptoms. 
Sometimes  the  suff^erer  lies  patiently  still,  yet  apparently  conscious  and  rational,  till 
the  tumefaction  diminishes,  and  he  is  again  able  to  open  his  eyes.  Generally  there 
is  some  wandering  of  the  mind,  especially  at  night ;  and  in  bad  cases  there  is  much 
delirium,  and  at  length  complete  coma,  and  the  patient  dies  at  the  end  of  a  few  days. 
In  some  of  these  cases  the  inflammation  has  extended  to  the  encephalon  ;  in  others 
it  is  probable  that  the  functions  of  the  brain  are  disturbed  through  the  febrile  derange- 
ment of  the  circulation.  When  death  takes  place,  and  the  head  is  examined,  serous 
fluid  is  usually  discovered  beneath  the  arachnoid,  and  in  the  cerebral  ventricles ;  and 
the  veins  of  the  pia  mater  are  turgid.  I  have  stated  before  that  I  doubt  whether 
such  appearances  are  always  to  be  attributed  to  inflammation.  Sometimes  there  are 
no  morbid  appearances  at  all  within  the  skull. 

It  is  said  that  the  erysipelas  does,  now  and  then,  suddenly  desert  the  surface;  and 
that  inflammation  of  some  internal  part,  and  particularly  of  the  brain,  is  apt  to  follow 
such  rapid  subsidence  of  the  external  malady.  I  presume  that  this  metastasis  is 
rare.  I  do  not  recollect  to  have  seen  it.  But  the  extension  of  the  inflammation,  the 
supervention  of  delirium  and  coma,  while  the  external  inflammation  continues,  are 
of  common  occurrence. 

This,  then,  is  one  way  in  which  erysipelas  is  accustomed  to  prove  fatal ;  by  efTu- 
sion  within  the  head,  and  coma. 

And  there  is  another  mode  in  which  death  is  not  unfrequently  brought  about,  and 
which  has  not  been  so  much  attended  to ;  I  mean  by  the  affection  of  the  throat. 
The  patient  dies  sometimes  almost  suddenly;  unexpectedly;  you  cannot  account  for 
the  unlooked-for  dissolution.  But  if  the  throat  be  examined  you  may  (sometimes  at 
least)  there  discover  the  solution  of  the  mystery.  The  sub-mucous  tissue  of  the 
glottis  and  epiglottis  is  filled  with  serum,  the  chink  of  the  larynx  has  been  nearly  or 
completely  closed,  and  the  patient  has  died  of  apncea.  This  is  just  analogous  to 
what  takes  place  externally :  the  enormous  sAvelling  of  the  eyelids,  and  lips,  and 
face,  is  owing,  in  a  great  degree,  to  serous  fluid  poured  out  into  the  swh-cutaneous 
areolar  membrane. 

Another  Avay  in  which  erysipelas  may  kill,  is  by  gradual  asthenia.  Without  any 
stupor  or  much  wandering,  without  any  marked  affection  of  the  breath,  the  pulse 
becomes  weaker  and  weaker,  the  surface  cold,  and  the  heart  at  length  ceases  to  pul- 
sate.    This  mode  of  dying  is  less  common  in  this  disorder  than  the  other  two. 

The  causes  of  erysipelas  are  various,  and  often  obscure.  I  have  stated  that  it  is 
tjommunicable,  by  contagion,  from  person  to  person :  yet  this  contagious  property  is 
so  feebly  marked,  that  it  is  denied  by  many.  It  is  more  active  at  certain  times,  at 
certain  seasons,  at  certain  places,  than  at  others ;  which  is  the  same  thing  as  to  say 
that  there  are  predisposing  causes  of  the  disease;  that  there  are  influences  which 
augment  the  susceptibility  of  the  body  to  the  agency  of  the  poison. 

I  believe  that  on  the  continent  they  do  not  allow  erysipelas  to  be  contagious  at  all ; 
but  very  satisfactory  evidence  of  the  fact  has  been  collected  by  several  of  our  own 
practitioners.  In  the  second  volume  of  the  Tratisactions  of  a  Society  for  the  Im- 
provement of  Medical  and  Chirurgical  Knowledge,  Dr.  Wells  has  brought  together 
several  examples  in  which  the  complaint  appeared  to  be  unequivocally  propagated 
'iy  contagion.     "I  visited  (says  he),  on  the  8th  of  August,  1796,  in  Vine  street, 


ERYSIPELAS.  1007 

Clerkenwell,  an  elderly  man,  named  Skelton,  who  had  been  attacked  several  days 
before  with  erysipelas  of  the  face.  In  about  a  week  afterwards  he  died.  On  the 
19th  of  the  following  month,  I  saw  a  Mrs.  Dyke,  of  about  seventy  years  of  age,  the 
landlady  of  the  house  in  which  Skelton  had  been  a  lodger,  and  found  her  labouring 
under  an  erj^sipelas  of  her  face.  I  inquired  whether  any  person  in  her  house  had 
been  ill  of  the  same  disease  since  the  death  of  Skelton,  and  was  told  that  his  wife  had 
been  seized  with  it  a  few  days  after  his  decease,  and  had  died  in  about  a  week. 
During  my  attendance  upon  Mrs.  Dyke,  an  old  woman,  her  nurse,  was  attacked  with 
the  same  disorder,  and  was  sent  to  her  parish-workhouse,  where  she  died.  Mrs 
Dyke  has  since  informed  me  that  a  young  man,  the  nephew  of  Skelton,  was  taken 
with  the  disease  of  which  his  uncle  had  died,  shortly  after  visiting  him,  and  survived 
the  attack  only  a  kw  days.  That  she  herself  had  been  several  times  with  Skelton 
and  his  wife  during  their  sickness,  and  after  their  death  had  removed  some  furniture 
from  the  room  they  had  occupied  to  her  own  apartment."  Dr.  Wells  relates  other 
histories  of  the  same  kind,  all  occurring  when  there  was  no  particular  epidemic  of 
erysipelas  prevailing  to  account  for  them.  Professor  Arnott  has  given  some  other 
examples,  still  more  striking,  of  the  propagation  of  erysipelas  from  one  person  to 
another,  not  only  under  the  same  roof,  and  in  the  same  locality,  but  also  when  the 
parties  lived  at  a  distance  from  each  other,  and  the  intercourse  between  them  had 
been  casual  and  temporary.  These  cases  are  stated,  I  think,  in  the  fifty-seventh 
volume  of  the  London  Medical  and  Physical  Journal.  The  following  incident  has 
been  told  me  upon  good  authority.  A  man  living  somewhere  in  Westminster  fell  ill 
of  idiopathic  erysipelas.  In  that  state,  for  some  reason  or  other,  he  was  removed 
thence  ;  and  his  brother,  who  was  a  servant  in  or  near  Portland  Place,  received  him 
clandestinely  into  his  master's  house,  and  allowed  him  (for  two  nights,  I  believe)  to 
share  his  bed.  That  brother  was  soon  attacked  with  erysipelas;  and  in  the  course 
of  his  illness  was  visited  by  his  master.  The  master  also  was  attacked ;  and  it  is 
worthy  of  remark,  that  in  both  master  and  servant  the  disease  showed  itself  just 
seven  days  after  they  had  respectively  come  near  another  who  was  a&cted  with  it. 
Dr.  Elliotson  gives  an  account  of  having  suffered  the  disease  in  his  own  person.  It 
came  on  in  him  five  days  after  the  bseath  from  one  of  his  patients,  over  whom  he 
was  stooping  to  examine  the  skin,  and  who  had  erysipelas  badly,  and  died  of  it,  had 
come  upon  his  face.  "  I  turned  away  (he  says)  disgusted,  and  said,  I  hope  I  have  not 
caught  it ;  but  five  days  afterwards,  having  forgotten  the  circumstance,  I  was  seized 
with  it."  More  than  once  I  have  had  occasion  to  remark  that  successive  tenants 
of  the  same  bed  in  a  hospital  have  been  seized  with  erysipelas  after  admission. 

But  allowing,  as  1  think  we  cannot  but  allow,  that  contagion  is  one  of  the  exciting 
causes  of  erysipelas,  there  are  others  which  more  frequently  excite  it.  At  least  there 
are  many  instances  of  the  disorder  in  which  we  can  trace  no  exposure  to  contagion, 
and  in  which  we  can  perceive  some  other  probable  reason  for  its  occurrence.  Some- 
times, no  doubt,  it  comes  on  without  any  obvious  cause.  The  application  of  cold 
often  gives  rise  to  it.  Irregularity  of  diet  is  said  to  do  the  same.  Violent  mental 
emotions  are  also  accused  of  being  occasionally  its  cause :  it  is  said  to  have  been 
brought  on  both  by  anger,  which  is  an  exciting,  and  by  fear,  which  is  a  depressing, 
passion.  It  is  incidental  to  what  I  have  called  purulent  infection  of  the  blood.  Many 
cases,  not  to  be  distinguished  in  their  appearances  and  eflects  from  idiopathic  erysi- 
pelas, result  from  local  injury.  I  have  already  told  you  that  there  is  no  inconsistency 
or  absurdity  in  supposing  that  a  disorder  which  originates  in  some  common  cause, 
may  be  capable  of  spreading  in  the  way  of  contagion.  And  the  testimony  of  Mr. 
Lawrence  (who  is  not  prone  to  admit  of  contagion  on  light  grounds)  goes  to  the  effect 
that  such  is  the  case  with  the  disease  in  question.  He  mentions  an  instance  m  which 
erysipelas  of  the  head  and  face,  which  commenced  after  the  insertion  of  a  seton  in 
the  neck,  appeared  to  him  to  have  affected  two  individuals  by  contagion. 

I  say  that  erysipelas  further  resembles  the  disorders  of  the  group  in  which  I  have 
placed  it,  that  it  sometimes  prevails  epidemically :  and  on  those  occasions,  like  tho 
rest  of  the  group,  its  occurrence  is  promoted  by  all  circumstances  that  tend  to  debili- 
tate the  body  :  by  intemperance  ;  by  previous  disease  ;  by  low  spirits  and  anxiety  , 
hy  insufficient  nourishment ;  and  by  foul  air.     It  used  to  be  much  more  common 


1008  ERYSIPELAS. 

formerly  in  hospitals  than  it  is  at  present ;  when  less  attention  was  paid  to  cleanliness 
and  ventilation. 

Er3'sipelas  is  another  of  the  diseases  concerning  the  treatment  of  which  there  has 
been,  and  there  is,  a  most  embarrassing  difference  of  opinion.  Some,  prescribino- 
according  to  a  name,  tell  you  that  it  is  inflammation,  and  therefore  that  the  remedies 
of  inflammation,  and  especially  blood-letting,  are  to  be  vigorously  emploj^ed.  Others 
declare  that  the  safety  of  the  patient  hes  in  the  early  and  hberal  administration  of 
wine  and  bark.  You  will  not  think  me  a  trimmer,  I  hope,  or  one  who  is  content 
with  indecisive  practice,  when  I  state  that  neither  of  these  plans,  in  my  judgment,  is 
universally  either  proper  or  safe  ;  yet  that  each  of  them  is  the  best,  under  certain  cir- 
cumstances. 

I  think  the  more  you  see  of  this  disease  the  more  convinced  you  will  be  that  it  ia 
not  to  be  cut  short  by  any  particular  mode  of  treatment ;  that  it  ivill  run  a  certain 
course  ;  and  that  it  will  generally  terminate  sooner  or  later,  by  resolution,  whether 
remedies  be  employed  or  not.  It  does  not  follow  from  this  that  i^medies  are  of  no 
use  :  but  it  does  follow  that  we  are  to  exhibit  them,  not  with  the  view  of  curing  the 
disorder,  but  with  the  view  of  conducting  it  safely  to  its  termination. 

If  you  look  at  the  history  of  erysipelas,  and  of  the  notions  which  have  prevailed 
respecting  it,  you  will  find  that  the  opinions  in  favour  of  giving  support,  and  of  ab- 
staining, as  much  as  possible  from  the  abstraction  of  blood,  greatly  preponderate.  In 
the  outset  of  the  complaint,  if  the  pulse  be  hard  as  well  as  frequent,  and  there  be 
much  headache,  and  active  delirium,  you  must  take  blood  either  from  the  arm,  or 
from  the  neck  by  cupping,  or  by  leeches  from  behind  the  ears.  But  (I  speak  of  the 
disease  as  it  occurs  in  London)  the  time  for  this  kind  of  practice  soon  passes  by  :  and 
when  you  do  bleed  from  the  arm,  you  must  (in  this  town)  bleed  with  caution,  and  in 
the  upright  posture ;  that  the  desired  effect  may  be  produced  by  the  abstraction  of 
the  smallest  quantity  of  blood. 

In  all  cases  it  will  be  right  to  purge  the  patient  briskly  at  the  commencement. 
A  full  dose  of  neutral  salts,  or  of  rhubarb  atid  magnesia,  will  answer  better,  I  think, 
in  these  cases,  than  calomel  and  senna.  If  j-ou  see  the  patient  very  early,  and  if 
there  be  any  nausea  or  oppression  of  the  stomach,  it  will  be  proper  to  administer  an 
emetic. 

In  most  instances  you  will  soon  perceive  evidence  of  great  debility :  a  feeble  as 
well  as  di  frequent  TpVihe ',  tremors;  a  dry  and  brown  tongue  often.  And  these 
symptoms  increase,  if  you  then  persist  in  drawing  blood.  The  carbonate  of  am- 
monia does  great  good  sometimes  in  such  a  condition :  and  this  I  am  very  much  in 
the  habit  of  giving.  The  bad  cases  of  erysipelas  are  apt  to  baffle  us  all.  I  am  not 
aware  that  I  lose  more  of  them  than  my  neighbours.  Speaking  generally,  a  large 
majority  of  my  patients  get  well ;  but  I  do  not  bleed  one  patient  in  a  hundred,  from 
the  arm. 

I  am  bound,  however,  to  set  before  you  the  kind  of  evidence  which  exists  in  favour 
of  the  bark ;  or  rather  of  the  sulphate  of  quina,  which  is  what  I  mean  when  I  speak 
of  the  bark. 

Dr.  Fordyce,  Dr.  Wells,  Dr.  Heberden — all  men  of  great  sagacity  and  experience 
-recommend  the  treatment  by  bark.  Dr.  Jackson,  an  American  physician,  advn 
r^tes,  I  see,  the  same  plan.  He  says  that  after  a  purge,  and,  if  necessary,  an  emetic, 
the  sulphate  of  quina  should  be  given  in  as  large  doses  as  the  patient  will  bear;  that, 
from  twelve  to  twenty-five  grains  in  the  twenty-four  hours  will  generally  suffice  ;  and 
that  we  may  know  when  the  dose  is  sufficient  by  a  buzzing  which  comes  on  in  the 
ears.  Dr.  EUiotson  also — whom  I  here  quote  the  more  willingly  because  I  think  he 
is  rather  of  an  antiphlogistic  turn  than  otherAvise,  in  general — says,  that  he  has  never 
seen  quina  do  harm,  even  in  active  tonic  erysipelas  ;  and  that  in  doubtful  cases,  when 
you  hesitate  whether  to  bleed  and  put  the  antiphlogistic  plan  in  force,  or  to  stimulate 
and  support,  the  quina  is  always  a  safe  and  eligible  medicine.  Dr.  Williams,  of  St. 
Thomas's  Hospital,  thinks  better  still  of  wine,  which  he  gives  in  all  cases  from  the 
very  beginning. 

I  have  hitherto  limited  my  observations  to  erysipelas  of  the  face  and  head  as  it 
occurs  in  London :  and  I  have  done  so  because  I  really  believe  that  in  the  purer 


ERYSIPELAS.  1009 

air  of  the  country,  and  in  young,  strong,  vigorous  country  persons,  bleeding  may  be 
proper  and  requisite.  You  will  find  country  practitioners  pretty  well  agreed  on  this 
point. 

But  taking  the  disease  as  I  see  it  here,  I  should  say  that  many  cases  do  well  with 
but  little  care  or  interference  from  medicine ;  that  many  also,  but  a  fewer  number 
than  the  former,  prove  fatal  under  whatever  plan  of  treatment  may  be  adopted ;  and 
that  many  patients  are  to  be  saved,  by  judicious  management,  who  would  otherwise 
die. 

The  first  requisite  for  rescuing  these  perilous,  yet  recoverable  cases,  is  that  they 
should  be  perpetually  watched  and  tended.  The  indications  of  treatment  may  alter 
from  one  hour  to  another,  and  it  is  only  by  great  vigilance  on  the  part  of  the  medical 
attendant,  and  on  the  part  of  an  intelligent  and  obedient  nurse,  that  medicine  obtains 
its  full  chance  of  bringing  the  patient  through. 

After  clearing  out  the  alimentary  canal,  then,  I  would  not  be  active  in  either  way, 
unless  I  saw  some  plain  indication  for  activity.  If  the  pulse  became  weaker,  and  I 
did  not  feel  sure  about  the  propriety  of  stimulating,  I  would  give  five  or  six  grains 
of  the  carbonate  of  ammonia  every  four  hours,  and  beef-tea.  If  the  disease  went  on 
smoothly  under  that  treatment,  well  and  good.  If  the  powers  still  continued  to  sink, 
I  should  have  recourse  to  wine,  or  to  both  bark  and  wine  ;  but  of  the  two,  I  am  more 
friendly  to  wine ;  and  as  the  patients  like  it  better,  you  may  be  more  sure  of  their 
taking  it.  If,  on  the  other  hand,  there  were  much  headache,  and  the  pulse  were 
hard,  and  the  febrile  distress  great,  I  should  apply  a  few  leeches,  and  prescribe  the 
tartarized  antimony  in  a  saline  draught.  The  bowels  should  not  be  allowed  tq  be- 
come confined;  but  the  mild  aperients  are  better  than  the  drastic  in  these  cases. 

Various  external  medicaments  have  been  used  and  recommended  for  the  inflamed 
part.  Putting  leeches  upon  it ;  puncturing  it  with  needles,  or  lancets  ;  covering,  or 
surrounding  it  with  blister,  or  with  the  lunar  caustic  in  substance  or  in  strong  solu- 
tion ;  dusting  the  surface  over  with  magnesia,  or  flour ;  smearing  it  with  various 
unguents,  and  particularly  with  mercurial  ointment;  keeping  it  wet  with  some  cold 
lotion  ;  or  fomeniing  it  with  hot  flannels. 

Now  of  all  these  local  appliances,  that  which,  according  to  my  own  observation, 
is  the  most  useful,  and  which  affords  the  greatest  comfort  to  the  patient,  is  the  last 
that  I  mentioned ;  fomentation  by  flannels  wrung  out  of  a  hot  decoction  of  poppy- 
heads.  But  in  order  to  give  this,  also,  fair  play,  it  should  be  continual;  not  used 
for  half  an  hour,  and  then  intermitted ;  but  it  should  be  one  person's  business  to 
apply  the  fomentation  assiduously,  as  long  as  it  is  soothing  and  grateful  to  the  pa- 
tient. In  a  few  cases,  and  but  a  few,  the  warm  appHcations  have  been  disHked,  and 
cold  lotions  preferred ;  and  when  such  is  the  case,  there  is  no  risk  incurred  by  usinw 
them,  so  far  as  I  know ;  no  hazard,  I  mean,  such  as  you  may  read  of,  of  the  inflam- 
mation being  repelled  from  the  surface,  and  driven  in  upon  some  vital  organ.  The 
local  treatment  most  in  favour  with  our  apothecary  at  the  hospital  is  that  of  covering 
the  inflamed  face  and  head  with  flour,  by  means  of  a  dredging-box.  The  patients 
declare  that  the  flour  cools,  soothes,  and  comforts  them.  Now  this  is  a  more  conve 
nient,  and,  in  some  respects,  a  more  eligible,  application  than  that  of  hot  flannels 
It  is  less  hkely  to  fail  of  its  purpose  through  the  negligence  of  the  nurse. 

[Keeping  the  inflamed  surface  constantly  covered  with  perfectly  fresh  hof,"s  lard,  has 
a  very  soothing  effect,  and  tends  to  reduce  the  violence  of  the  inflammation.  We  have 
occasionally  employed  an  ointment  formed  of  acetate  of  lead  fifteen  grams,  rubbed  up  with 
one  ounce  of  hog's  lard,  and  have  been  pleased  with  its  effects. — C] 

So  much  for  erysipelas,  as  it  usually  comes  under  the  notice  and  the  manao-ement 
of  the  physician.  You  are  aware  that  an  affection  of  the  skin  very  similar  to  thai 
which  I  have  been  describing,  and  called  also  by  the  same  name  of  erysipelas,  is 
very  common  in  other  parts  of  the  body ;  on  the  extremities  especially,  and  occa- 
sionally on  the  trunk :  and  it  will  travel  sometimes  from  an  extremity  till  it  reaches 
the  head.  These  varieties  of  cutaneous  inflammation  are,  in  most  instances,  the 
indirect  consequences  of  some  local  injury ;  of  punctured  wounds ;  of  the  stings  of 
insects,  or  the  bites  of  venomous  reptiles :  of  mere  scratches  sometimes.  Or  th« 
cutaneous  inflammation  will  spread  from  old  sores ;  or  supervene  upon  dropsica! 
64  4  k 


1010  ERYSIPELAS. 

limbs.  It  is  curious  that  these  complaints  also  are  much  more  apt  to  occur,  and 
oven  to  multiply  by  a  sort  of  contagion,  or  in  virtue  of  some  epidemic  atmospheric 
influence — at  certain  times  and  places  than  at  others.  You  will  find  there  are  pe- 
riods when  the  surgeons  of  hospitals  dread  to  perform  any  operation,  lest  it  should 
be  followed  by  this  spreading  inflammation  of  the  skin.  There  are  many  points  of 
great  interest  connected  with  these  diversified  forms  of  what  is  called  erysipelas  ; 
they  are  more  liable  to  be  attended  with  gangrene  than  erysipelas  of  the  face  and 
scalp:  on  the  other  hand,  they  are  more  liable  also  to  be  complicated  with  inflam- 
mation of  the  subcutaneous  areolar  tissue,  and  with  suppuration ;  and  to  require 
incisions  to  relieve  the  great  tension  of  the  inflamed  parts,  and  to  facilitate  the  escape 
of  the  pus,  or  of  sloughy  dead  portions  of  areolar  tissue;  but  all  these  r^:atters  be- 
long rather  to  surgery,  and  have  been  discussed,  I  make  no  doubt,  by  the  Professor 
of  Surgery. 

[Erysipelas  is  of  frequent  occurrence  in  the  earlier  period  of  infancy,  and  is  among  the 
most  fatal  of  the  diseases  which  occur  at  that  period.  It  very  generally  terminates  in  death 
especially  when  it  occurs  during  the  first  month.  Its  danger  gradually  diminishes  as  the 
child  advances  in  age,  but  even  when  it  attacks  after  the  fourth  month,  the  greater  portion 
of  the  cases  terminate  fatally.  • 

The  invasion  of  the  disease  is  always  extremely  insidious.  The  child  appears  somewhat 
morose ;  his  sleep  is  slightly  diminished,  and  he  sucks  rather  less  than  before  ;  with  these 
trifling  symptoms,  there  is  associated  a  small  patch  of  redness  upon  the  pubes,  which  is 
painful  upon  pressure.  The  redness  gradually  spreads  over  the  abdomen  and  thighs,  and 
is,  occasionally,  disseminated.  When  the  redness  extends  to  the  hands  and  feet,  these  parts 
acquire  a  degree  of  redness  and  swelling  far  greater  than  that  of  any  other  part.  The  geni- 
tal organs,  in  some  cases,  sphacelate,  in  consequence  of  the  local  inflammation,  and  in  many 
acquire  an  emphysematous  appearance.  In  place  of  appearing  first  upon  the  pubes,  the 
erysipelas  has  been  known  to  extend  from  the  areola  of  the  vaccine  vesicle,  less  frequently 
from  any  accidental  laceration  of  the  skin  or  from  the  excoriations  so  common  in  the  cuta- 
neous folds  of  the  groin  and  other  parts. 

The  disease  at  first  ajjpears  perfectly  local — it  is  not  until  several  days  have  elapsed,  that 
general  uneasiness  and  fretfulness  present  themselves.  The  colour  of  the  skin,  and  the 
expression  of  the  countenance,  often  remain  for  some  days  without  exhibiting  any  striking 
change,  when,  suddenly,  an  ashy  cadaverous  paleness  is  observed ;  the  child  cries  inces- 
santly, there  is  constant  jactitation,  and  complete  loss  of  sleep.  These  symptoms  are  suc- 
ceeded by  deep  stupor  and  death.  The  pulse  is  at  first  frequent,  and  the  heat  of  the  skin 
sinks  only  during  the  fatal  stupor  which  precedes  death.  Convulsions,  diarrhoea,  and  vomit- 
ing are  seldom  observed.  When  the  progress  is  such  as  we  have  described,  peritonitis  has 
occurred — which  is,  according  to  M.  Trousseau,  a  frequent  disease  in  children,  and  one 
which  has  not  hitherto  been  accurately  described.  The  duration  of  infantile  erysipelas 
varies  considerably,  sometimes  being  extremely  short,  in  others,  on  the  contrary,  being  pro 
longed  to  the  end  of  the  week. 

In  post-mortem  examinations,  the  cutaneous  disease  is  occasionally  the  only  morbid  change 
detected ;  but  when  peritonitis  (a  frequent  complication)  has  occurred,  the  umbilical  vein 
is  often  found  inflamed,  and  filled  with  pus,  as  far  as  the  transverse  furrow  of  the  liver 
while  inflammatory  exudations  are  found  on  the  peritoneal  stirface  of  the  abdominal  viscera 

According  to  IM.  Trousseau,  infantile  erysipelas  is  principally  observed  when  puerpera. 
fever  prevails  in  the  wards  of  the  lying-in  hospitals  of  Paris.  The  infants  appear  to  inherit 
from  their  mother  a  purulent  diathesis,  and  seem  to  be  still,  within  certain  limits,  subject  tc 
the  same  maladies  as  the  mother,  whose  constitution  has  so  lately  been  theirs.  The  peri- 
tonitis of  the  infant  may  be,  therefore,  as  properly  termed  puerperal  as  that  of  the  mother, 
because  its  general  cause  is  to  be  sought  for  in  the  circumstances  which  have  accompanied 
the  last  stage  of  child-bearing,  and  parturition.  It  is  natural  that  the  skin  should  be  the  seat 
of  disease,  from  its  having  been  so  recently  called  upon  to  the  performance  cf  functions  as 
new  as  they  are  important. 

In  the  infants  predisposed  to  erysipelas,  the  umbilical  cicatrix  does  not  form  readily,  and 
the  ulceration  which  results  is  sometimes  the  occasional — the  local  cause — of  the  cutaneou.' 
disease. 

Dr.  F/'ebe  {Journal  fur  Kinderkrankheiten)  describes  a  form  of  erysipelas  which  commence! 
about  the  umbilicus,  within  a  few  weeks  after  birth,  and  is  frequently  accompanied  with 
ulceration  of  the  navel,  and  infiltration  of  lymph  or  pus  into  the  subcutaneous  cellular  tissue, 
and  deposus  of  a  similar  nature  in  the  partially  obliterated  umbilical  vessels.  It  is  attended 
with  great  and  rapidly  increasing  exhaustion,  and  occasionally  convulsive  symptoms  of  more 
or  less  severity.  It  is  most  generally  fatal ;  often  within  the  course  of  forty-eight  hours,  and 
M-ithout  having  extended  more  than  three  fingers'  breadth  around  the  navel. 

Dr.  Friebe  is  inclined  to  view  this  form  of  infantile  erysipelas  as  a  variety  of  partial  indu- 


ERYSIPELAS.  1011 

ration  of  the  cellular  substance,  in  consequence  of  the  cachectic  condition  of  the  infants  in 
whom  it  usually  occurs,  and  the  peculiar  character  of  the  inflammation  —  while  the  circum- 
stance of  the  umbilical  vessels  being,  in  fact,  converted  into  fibrous  cords,  previously  to  the 
commencement  of  the  disease,  leads  him  to  believe  that  it  cannot  arise  from  the  umbilical 
phlebitis. 

We  have  met  very  frequently  with  this  form  of  infantile  erysipelas  among  the  children  of 
the  poor,  and  our  observations  have  convinced  us  that,  in  the  majority  of  cases  at  least,  it  is 
dependent  upon  phlebitis  of  the  umbilical  vessels ;  the  evidences  of  inflammation  of  the 
latter  were  unquestionably  present  in  almost  every  instance  in  which  we  have  made  an 
examination. 

In  regard  to  the  treatment  of  infantile  erysipelas,  although  in  those  cases  in  which  the 
disease  occurs  soon  after  birth  there  is  but  little  chance  of  saving  the  life  of  the  child,  yet 
when  the  patient  is  a  few  months  old,  we  may  do  much  in  arresting  the  progress  of  the  dis- 
ease, and  conducting  it  to  a  favourable  termination. 

We  may  remark,  however,  that  erysipelas  is  always  to  be  considered  a  dangerous  disease 
during  infancy,  but  more  particularly  when  it  occurs  in  infants  of  a  weakly  and  unhealthy 
Habit  of  body. 

The  bowels  should  be  freely  opened  by  a  grain  or  two  of  calomel,  followed  in  a  few 
hours  by  a  teaspoonful  of  castor  oil,  or  a  simple  laxative  enema,  and  they  should  be  kept  in 
a  free  condition  subsequently,  by  the  exhibition,  every  three  hours,  of  divided  doses  of  calo- 
mel, combined  with  minute  doses  of  ipecacuanha  and  extract  of  hyosciamus  —  the  addition 
of  the  latter  is  calculated  to  prevent  or  allay  irritation,  without  interfering  with  the  aperient 
action  of  the  calomel.  When  the  skin  is  warm  or  dry,  the  liquor  acetatis  amoniae  alone,  or 
combined  with  antimonial  wine,  will  often  prove  beneficial,  as  will  also  the  occasional  use 
of  the  warm  or  tepid  bath. 

If  symptoms  of  cerebral  disease  should  occur,  a  leech  or  two  should  be  applied  to  the 
temples, — cold  applications  to  the  scalp, — the  bowels  should  be  freely  opened  by  calomel, 
followed  by  castor  oil,  or  purgative  enemata,  and  warm  sinapised  pediluvia  should  be 
resorted  to. 

In  a  few  cases  where  the  parts  occupied  by  the  disease  are  decidedly  red  and  swollen,  a 
few  leeches  applied  upon  the  sound  skin,  in  the  neighbourhood  of  the  inflammation,  will 
often  prove  beneficial.  Much  judgment,  however,  is  required,  to  discriminate  the  kind  of 
cases  which  are  likely  to  be  benefited  by  local  depletion.  As  a  general  rule,  a  very  mode- 
rate abstraction  of  blood  will  be  sufiicient. 

When  a  tendency  to  gangrene  is  obvious,  and  the  disease  assumes  a  low  typhoid  charac- 
ter, it  will  be  necessary  to  resort  at  once  to  the  use  of  the  carbonate  of  ammonia,  in  doses 
adapted  to  the  age  of  the  patient,  and  the  urgency  of  the  symptoms;  and  at  the  same  time, 
the  child  should  be  nourished  at  the  breast  of  a  healthy  nurse,  or  if  weaned,  its  diet  should 
consist  of  animal  jellies  dissolved  in  water,  beef  tea,  chicken  water,  or  sago.  It  is  all  im- 
portant in  these  cases  that  the  patient  be  removed  to  a  healthy  situation,  where  he  can  enjoy 
the  tonic  influence  of  a  pure,  free  atmosphere.  When  the  symptoms  of  prostration  are 
more  considerable,  we  may  combine  the  use  of  the  ammonia  with  the  sulphate  of  quinia 
and  extract  of  hyosciamus. 

Should  diarrhcea  ensue,  particularly  after  suppuration  has  taken  place,  it  should  be  imme 
diately  checked  by  the  cretaceous  mixture,  with  the  addition  of  tincture  of  kino  and  lauda- 
num. When  the  discharges  from  the  bowels  are  of  a  vitiated  character,  or  attended  with 
griping  or  colicy  pains,  a  few  drops  of  turpentine,  three  times  a  day,  will  be  found  a  very 
valuable  remedy.  The  turpentine  may  be  combined  with  the  tincture  of  kino  and 
laudanum. 

With  respect  to  the  local  treatment  —  washing  the  inflamed  parts  frequently  with  tepid 
water,  or  some  mucilaginous  fluid,  will,  in  many  cases,  be  productive  of  very  great  relief  to 
the  patient,  and  occasionally  will  produce  an  abatement  of  the  disease ;  in  the  intervals,  the 
parts  may  be  dusted  with  powdered  starch,  or  covered  with  carded  cotton. 

When  there  is  decided  redness,  swelling  and  tension  of  the  skin,  a  lotion,  composed  of  a 
solution  of  equal  parts  of  the  acetate  of  lead  and  subcarbonate  of  ammonia,  has  been  highly 
recommended.  Covering  the  parts  with  rags  wet  with  the  camphorated  tincture,  is  said  to 
prove  often  very  beneficial.  Others  recommend  a  wash  composed  of  a  solution  of  corrosive 
sublimate,  three  grains  to  the  ounce  of  water,  or  of  nitrate  of  silver  of  the  same  strength. 
It  is  said  that  the  progress  of  the  disease  has  been  promptly  arrested  by  applying  once  or 
twice  a  very  strong  solution  of  the  nitrate  of  silver,  by  means  of  a  pencil,  upon  the  sound 
skin,  for  about  an  inch  around  the  margin  of  the  inflammation.  One  of  the  best  applications 
in  cases  which  exhibit  an  early  tendency  to  gangrene,  is  the  chloride  of  lime  in  soiution.  in 
the  proportion  of  half  a  drachm  to  a  pint  of  water.  Velpeau  has  employed  with  advantage 
a  solution  of  half  an  ounce  of  the  sulphate  of  iron  to  eight  ounces  of  water. 

The  local  remedies  just  recited  are  to  be  employed  in  the  early  stages,  previous  to  the  rup- 
ture  of  the  vesications,  and  to  the  occurrence  of  suppuration  or  gangrene. 

Among  the  local  remedies  which  appear  to  be  the  most  generally  applicable  to  Infantilo 


1012  ERYTHEMA. 

erysipelas,  is  a  blister  sufBciently  large  to  extend  over  the  inflamed  skin,  and  for  a  short  dis- 
tance beyond  it;  after  vesication  has  been  produced,  the  serum  should  be  evacuated,  and  the 
vesicated  surface  dressed  with  fresh  lard.  When  the  erysipelas  occurs  upon  the  extremi- 
ties, a  blister  applied  around  the  limb,  beyond  the  inflamed  surface,  will  frequently  arrest 
the  progress  of  the  disease  in  that  direction.  When  we  have  resorted  to  blisters,  which  are 
only  proper  in  the  early  stages  of  the  disease,  we  have  applied  them  along  the  edges  of  the 
inflamed  portion,  partly  upon  it,  and  partly  upon  the  sound  skin,  removing  them  at  the  end 
of  three  hours,  and  immediately  covering  the  parts  with  a  soft  emollient  poultice,  with  the 
addition  of  lard.  The  most  important  result  which  we  have  derived  from  the  use  of  blis- 
ters is  to  prevent  the  spread  of  the  disease. 

The  mercurial  ointment  has  been  strongly  recommended  in  the  treatment  of  infantile  ery- 
sipelas. I*  is  to  be  spread  on  a  piece  of  soft  linen,  with  which  the  affected  parts  are  to  be 
covered. 

In  cases  attended  with  an  intolerable  sensation  of  burning,  we  have  often  derived  benefit 
from  the  local  application  of  a  watery  solution  of  opium. 

In  a  large  number  of  instances,  however,  no  benefit  whatever  will  be  derived  from  any 
local  application.  M.  Trousseau  states  that  he  has  tried  every  imaginable  one  —  ointments, 
lotions,  blisters,  even  the  actual  cautery  —  without  suspending  the  progress  of  the  disease. 
Three  cases  only,  occurring  within  the  month,  has  he  seen  recover  under  the  use  of  the 
etherial  solution  of  camphor,  and  baths  containing  corrosive  sublimate.  The  disease  is  cer- 
tainly a  very  unmanageable  one  when  it  occurs  in  very  young  infants ;  we  have  nevertheless 
seen  it  in  children  a  few  months  old  in  many  instances  promptly  arrested  by  the  remedies 
already  detailed. 

Whenever  the  cellular  membrane  is  involved  in  the  disease,  free  incisions  should  be  early 
made,  as  well  to  unload  the  vessels,  and  relieve  the  swelling  and  distension,  as  to  give  exit 
»o  the  purulent  fluid  and  dead  portions  of  cellular  structure.  The  pus,  if  allowed  to  remain, 
will  travel  beneath  the  skin,  and  between  the  muscles  and  tendons,  and  thus  increase  the 
danger  and  extent  of  the  disease.  After  the  incision,  the  part  should  be  covered  with  soft; 
emollient  poultices,  and  kept  as  much  as  possible  at  rest,  and  in  an  elevated  position. 

When  the  erysipelas  terminates  in  gangrene,  washes  of  a  solution  of  the  chloride  of  lime, 
of  the  chloride  of  soda,  of  a  few  drops  of  creasote  diff"used  in  water,  or  of  a  strong  decoc- 
tion of  black-oak  bark,  should  be  immediately  employed,  or  the  sphacelated  surface  may  be 
covered  with  the  charcoal  or  yeast  poultice.  A  wash  of  a  very  strong  solution  of  the  sul- 
phate of  copper  will  in  some  cases  arrest  the  progress  of  the  gangrene. 

When  convalescence  has  been  established,  some  light  mineral  tonic  or  the  mineral  acids, 
largely  diluted,  should  be  administered.  The  child  should  be  allowed  a  nourishing  diet; 
he  should  be  daily  immersed  in  a  warm  or  tepid  bath,  and  enjoy  a  dry,  fresh,  wholesome 
atmosphere. — C] 

Very  closely  connected  with  erysipelas,  and  continually  confounded  with  it,  is  ery- 
thema. It  also  consists  in  superficial  redness  of  some  portion  of  the  skin  ;  but  is  not 
attended  with  inflammation  of  the  areolar  texture  under  the  skin ;  nor  with  vesica- 
tion ;  nor,  in  general,  with  fever ;  nor  is  it  peculiar  to  the  face  and  head. 

There  are  numerous  varieties  of  erythema  described  by  writers  on  cutaneous  dis- 
orders, to  whom  I  must  refer  you  for  an  account  of  them.  Willan  and  Bateman ; 
Wilson;  Willis;  Rayer;  Ahbert ;  and  Biett,  as  his  practice  and  lessons  are  re- 
ported by  two  of  his  pupils. 

The  only  variety  on  which  I  am  disposed  to  say  a  word,  is  one  which  is  attended 
with  more  or  less  febrile  disturbance.     I  mean  what  is  called  erythema  nodosum. 

This  curious  affection  occurs  much  more  often  in  young  women  than  in  any  other 
persons  ;  sometimes  in  feeble  boys.  The  eruption  is  commonly  preceded  for  a  few 
days  by  indisposition,  and  some  slight  degree  of  fever.  Then  red  elevated  spots 
come  out,  on  the  fore  part  of  the  legs,  and  occasionally,  but  very  rarely,  on  the  arms. 
The  redness  appears  in  oval  patches,  of  which  the  long  diameter  is  parallel  to  the 
axis  of  the  hmb.  They  are  pretty  large  patches,  an  inch  and  half  long,  and  an 
inch  broad  perhaps,  and  they  evidently  project  and  form  bumps  upon  the  anterior 
surface  of  the  leg.  From  their  look,  you  would  suppose  abscesses  were  about  to 
form ;  but  after  lasting  a  few  da5^s,  the  red  colour  fades,  or  rather  changes  to  a  blue, 
and  the  protuberances  gradually  subside.  This  eruption  seems  sometimes  connected 
with  disturbance  of  the  menstrual  functions.  Rayer  has  seen  it  occur  in  connection 
with  acute  rheumatism.  So  have  I.  A  patient  of  mine  in  the  hospital  was  attacked 
with  acute  rheumatism  of  the  joints  immediately  upon  the  cessation  of  erythema 
nodosum.     In  another  this  order  was  reversed. 

Now  I  am  persuaded  that,  after  an  aperient,  rest,  the  horizontal  posture,  and 


URTICARIA.  1013 

qjiina,  constitute  the  proper  treatment  of  this  affection.  I  had  once  a  housemaid,  in 
whom  the  disorder  appeared,  and  was  attended  with  unusually  high  fever,  and  much 
indisposition.  I  treated  her,  therefore,  antiphlogistically ;  i.  e.,  I  kept  her  on  \o:v 
diet,  and  gave  purgatives  ;  bat  the  disease  went  on.  Fresh  knots  came  out  as  the 
old  ones  faded.  At  length,  T  do  not  remember  why,  I  prescribed  some  quina  for 
her ;  and  the  improvement  was  immediate,  and  very  striking.  She  relapsed,  how- 
ever, once  or  twice,  upon  leaving  off'  the  bark  ;  but  by  persisting  subsequently  in 
its  use  for  some  days  after  she  appeared  to  be  well,  a  permanent  cure  was  effected. 
Since  that  time — now  ten  or  twelve  years  ago — I  have  seen  a  good  many  exam- 
ples of  erythema  nodosum,  and  I  have  treated  them  all  alike ;  viz.,  first  with  an 
aperient,  and  then  with  the  sulphate  of  quina :  and  they  have  all  rapidly  got  well. 
Probably  they  would  have  recovered  nearly  as  soon  under  some  other  tonic  treat- 
ment ;  but  I  have  been  so  well  satisfied  with  this,  since  I  began  it,  that  I  have  felt 
no  temptation  to  try  any  other. 

There  is  a  rash  which  is  well  known,  and  very  tormenting,  and  therefore  not 
without  interest,  although  it  is  almost  always  without  danger;  I  mean  urticaria.  It 
is  arranged  by  CuUen  among  the  exanthemata ;  but  it  does  not  properly  belong  to 
the  group  to  which  I  would  restrict  that  name,  for  it  is  not  contagious,  and  it  may 
happen  to  the  same  person  a  hundred  times  over.  The  eruption  consists  of  what, 
from  analogy,  are  called  wheals ;  i.  e.,  of  httle  solid  eminences,  of  irregular  outline, 
but  generally  roundish  or  oblong,  and  either  white  or  red,  or  (which  is  most  common) 
both  red  and  white ;  the  whiteness  occupying  steadily  the  central  and  most  project- 
ing part  of  the  spot,  or  becoming  manifest  there  when  the  integuments  are  put  upon 
the  stretch.  The  rash  is  accompanied  with  intense  heat,  a  burning  and  tinghng  iu 
the  affected  spots,  and  great  itching  and  irritation. 

In  truth,  both  the  appearances  upon  the  skin,  and  the  sensations  that  attend  them, 
are  very  much  like  the  appearances  and  feelings  produced  by  the  stinging  of  nettles. 
Hence  its  trivial  name,  nettle-rash  ;  which  is,  indeed,  the  same  in  meaning  with  the 
scientific  appellation,  urtica  being  the  Latin  for  a  nettle.  Similar  appearances  follow 
almost  immediately  upon  a  smart  blow  with  a  cane,  or  with  the  lash  of  a  whip,  on 
the  skin.  Red  stripes  or  wheals  arise,  and  within  the  reddened  surface  one  or  more 
elevated  spots  of  a  white  colour  are  visible. 

There  are  two  varieties  of  urticaria :  one  in  which  the  complaint  runs  a  short 
course,  and  soon  subsides,  and  may  be  considered  acute ;  another  in  which  it  is 
chronic,  and  either  persistent  or  intermittent.  The  acute  form  is  attended  with  fever- 
ishness,  which  sometimes  begins  two  or  three  daj^s,  but  commonly  not  more  than  a 
few  hours,  before  the  eruption  ;  or  the  fever  and  the  rash  may  commence  together. 
In  most  cases,  perhaps  in  all,  the  disorder  is  intimately  linked  with  some  derange- 
ment, manifest  or  latent,  of  the  digestive  organs ;  and  it  may  often  be  traced  to  the 
use  of  particular  articles  of  food.  It  is  very  curious  that  the  contact  of  certain  sub- 
stances with  the  mucous  membrane  of  the  ahmentary  canal  should  affect  the  external 
tegument  precisely  in  the  same  manner  as  the  virus  of  the  nettle,  and  some  other 
irritants,  when  these  are  applied  to  the  skin  itself.  The  offending  articles  of  food  do 
not  produce  the  cutaneous  affection  in  all  persons,  nor  even  necessarily  in  the  same 
person  at  all  times.  But  there  are  some  edible  substances  which  are  much  morf. 
likely  than  others  to  be  followed  by  nettle-rash.  Certain  vegetable  matters  are  very 
apt  to  excite  the  disorder  in  some  persons :  oatmeal ;  almonds,  especially  the  bitter 
almonds  ;  any  bitter  kernels  ;  particular  species  of  strawberries  ;  raw  cucumbers  ; 
mushrooms.  Some  of  the  vegetable  substances  used  in  medicine  are  known  to  have 
frequently  the  same  effect;  capivi,  for  example;  the  cubebs  pepper;  valerian 
Urticaria  has  been  brought  on  by  drinking  porter,  or,  most  probably,  by  some  of  the 
drugs  with  which  our  porter  is  sophisticated.  These  effects  are  not  confined  to  vege- 
table substances.  Shell-fish  is  a  common  source  of  nettle-rash.  I  have  known  it  to 
be  occasioned  by  prawns  ;  crabs,  sometimes,  have  the  same  unpleasant  consequence; 
and,  still  more,  muscles.  An  hour  or  two  after  some  one  of  fhese  substances  has 
been  swallowed,  and  perhaps  much  sooner,  nausea  is  fek,  and  oppression  about  thfl 

4k2 


1014  URTICARIA. 

epig-astrium ;  the  patient  becomes  gidd}-,  his  face  and  head  sometimes  swell,  his  skin 
begins  here  and  there  to  burn  and  tingle,  and  presently  the  eruption,  as  I  have  already 
described  it,  breaks  forth.  It  is  attended  with  intolerable  itching  and  pricking  sensa- 
tions, especially  at  night,  when  the  patient  is  warm  in  bed,  or  when  the  affected  sur- 
face is  exposed  to  the  air.  Vomiting  and  diarrhoea  often  supervene,  and  prove  the 
natural  cure  of  the  attack. 

We  read  that  this  disorder  has  sometimes  proved  fatal;  but  this  must  be  under 
■very  unusual  circumstances  of  weakness  in  the  patient,  or  of  some  peculiar  virulence 
in  the  exciting  cause. 

The  chronic  form  of  the  complaint  is  apt  to  be  very  obstinate  and  teasing.  It 
comes  and  goes,  and  comes  again.  The  evening  is  one  of  its  favourite  periods.  In 
those  who  are  subject  to  it,  the  itching  and  the  wheals  are  readily  brought  on  by 
scratching  or  rubbing  the  surface.  This  is  the  urticaria  evanida  of  Willan.  Dr. 
Heberden  had  known  persons  afflicted  in  this  way  for  ten  years  together.  I  have 
observed  nettle-rash  to  occur  in  connection  with  sudden  and  violent  paroxysms  of 
dyspncea,  resernbhng  asthma  fits  ;  so  that  I  could  not  help  suspecting  that  the  mucous 
membrane  of  the  respiratory  passages  was  irritated  after  the  same  fashion  with  the 
external  skin. 

Even  the  chronic  variety  of  urticaria  is,  in  some  instances  at  least,  produced  by 
certain  ingesta :  and  the  peccant  substance  may  often  be  detected,  and  the  tiresome 
malady  be  cured,  by  following  the  simple  and  judicious  plan  recommended  by  Wil- 
lan ;  namely,  that  of  instructing  the  patient  to  abstain,  for  a  while,  from  all  his  cus- 
tomary articles  of  diet,  one  by  one,  in  their  turn.  This  experiment  does  not,  indeed, 
always  answer.  The  urticaria  will  sometimes  abide,  notwithstanding ;  so  that, 
although  it  probably  depends  in  all  cases  upon  some  disordered  condition  of  the  sto- 
mach or  bowels,  we  cannot  say  that  such  disorder  is  always  the  consequence  of 
something  that  has  been  swallowed. 

The  treatment  to  be  adopted  in  the  acute  or  febrile  nettle-rash,  when  it  depends 
upon  something  recendy  received  into  the  stomach,  is  that  which  common  sense 
would  suggest,  and  which  nature  often  plainl}'  indicates.  We  seek  to  expel  the 
offending  material  by  an  emetic,  and  by  purgatives ;  and,  this  being  done,  the  cure 
is  completed.  In  the  more  chronic  and  recurring  varieties,  we  endeavour,  in  the  first 
place,  by  making  the  experiment  recommended  by  Dr.  Willan,  to  detect,  that  we  may 
thenceforth  interdict,  any  article  of  diet  which  may  have  caused  the  disorder.  If 
we  fail  in  this  attempt,  our  object  must  be  to  correct  that  faulty  state  of  the  digestive 
organs,  or  to  neutrahze  that  inbred  poison,  upon  which  the  cutaneous  affection 
depends.  Laxatives  and  antacids  are  found  to  be  the  most  successful  means  of 
attaining  these  ends.  They  may  be  given  together,  or  separately.  Rhubarb  and 
magnesia  ;  the  carbonate  and  sulphate  of  magnesia  ;  castor  oil.  The  snake-root  has 
obtained  some  repute  as  a  remedy  for  urticaria.  You  may  prescribe,  therefore,  if 
you  please,  a  scruple  each  of  the  carbonates  of  magnesia  and  of  soda,  in  the  infusion 
of  serpentaria. 

External  applications  seem  to  be  of  but  little  avail  in  this  disease ;  and  those 
which  do  appear  to  be  of  service,  act  uncertainly,  and  produce  different  effects  in 
different  persons.  The  warm  bath  sometimes  gives  ease  in  the  severer  cases.  In 
the  more  chronic  form  of  the  disorder,  spirituous  washes,  vinegar,  sea-bathing,  are 
things  to  be  tried.  And  cases  are  related  in  which,  when  every  other  expedient 
has  "failed  to  give  permanent  relief,  removal  to  a  warmer  chmate  has  been  success- 
fuL  Dusting  the  itching  surface  with  flour  has,  in  my  experience,  afforded  much 
temporary  comfort.  Still  more  effectual,  perhaps,  is  a  lotion  (first  recommended  by 
Wilkinson,  in  a  little  work  on  skin  diseases),  composed  of  a  drachm  of  the  carbonate 
of  ammonia,  a  drachm  of  the  acetate  of  lead,  and  eight  ounces  of  rosewater. 

I  should  add,  that  Dr.  EUiotson  has  found  bleeding  verj'  efficacious  in  relieving 
patients  affeeted  with  acute  or  febrile  urticaria.  And  you  may  have  recourse  to  the 
lancet  if  the  patient  be  strong  and  plethoric,  and  his  pulse  warrant  it ;  and  if  he  be 
so  impatient  of  the  irritation  as  not  to  be  willing  to  wait  the  effect  of  other  treatment, 
which  would  probably  be  quite  as  effectual,  though  not  quite  so  rapid. 


PRURIGO.  1015 

Prurigo — Itching — is  a  cutaneous  affection,  bearing  some  analogy  to  urticaria,  at 
least  in  the  sensations  which  accompany  it.  And  a  most  terrible  and  melancholy 
affection  it  often  proves  to  be.  Sometimes  the  parts  of  the  skin  which  are  the  seat 
of  the  itching  do  not  present  any  perceptible  deviation  from  the  condition  of  health ; 
but  in  the  majority  of  instances  you  will  find,  upon  close  inspection,  that  they  are 
covered  vi'ith  papulre,  which  are  nearly  of  the  same  colour  with  the  skin  itself. 
Willan  therefore  places  prurigo  in  the  order  of  Papula3.  He  describes  several 
varieties  of  this  troublesome  complaint:  prurigo  mitis;  prurigo formicans ;  prurigo 
senilis.  The  torment  experienced  by  patients  suffering  under  the  severer  forms  of 
the  malady  is  scarcely  describable  ;  they  scratch  and  tear  themselves  incessantly  till 
the  blood  flows,  their  sleep  is  broken,  and  their  lives  are  rendered  perfectly  misera- 
ble. Sometimes  this  itching  is  diffused  irregularly  here  and  there  over  the  surface ; 
sometimes  it  affects  the  extremities  only ;  and  frequently  it  has  a  still  more  limited 
habitat,  occurring  round  the  anus,  when  it  is  called  prurigo  pofZicw;  or  on  the  scro- 
tum, prurigo  scroti;  or,  worst  form  of  all,  the  prurigo  pudendi  muliebris. 

All  these  forms  of  prurigo  are  apt  to  be  aggravated  by  heat,  and  by  exposure  to 
the  air;  they  are,  therefore,  especially  distressing  when  the  patient  undresses  and 
goes  to  bed.  The  scratching  tears  away  the  summits  of  the  papulae,  and  some 
watery  fluid  mixed  with  blood  escapes,  and  concretes  into  small,  thin,  black  scabs. 
In  the  prurigo  formicans,  the  itching  is  combined  with  other  painful  and  disagreeable 
sensations,  which  different  patients  describe  in  different  terms :  the  feeling  is  like 
the  creeping  of  ants,  or  the  stinging  of  insects,  or  as  if  hot  needles  were  thrust  into 
the  skin.  The  prurigo  senilis,  occurring,  as  that  name  implies,  in  old  persons,  is 
usually  very  obstinate,  and  often  effectually  destroys  all  comfort  for  the  rest  of  the 
patient's  life. 

In  such  cases  as  I  have  now  been  mentioning,  great  care  should  be  taken  tho 
roughly  to  cleanse  the  surface  of  the  body  :  and  the  diet  should  be  rigidly  plain.  All 
kinds  of  rich  sauces,  hot  condiments,  pickles,  and  indigestible  substances,  should  be 
peremptorily  forbidden.  Various  local  applications  have  been  praised ;  but  they  are, 
in  most  cases,  used  in  vain :  lime  water,  decoction  of  dulcamara,  lotions  composed 
of  prussic  acid  in  an  emulsion  of  bitter  almonds,  a  dilute  solution  of  creasote,  decoc- 
tion of  stavesacre,  and  of  digitals,  ointments  containing  mercury,  tar  ointment,  and  a 
hundred  ot|;iers.  In  one  instance  lately,  where  the  ingenuity  of  another  practitioner 
had  been  fruitlessly  exhausted,  I  was  fortunate  enough  to  effect  perfect  relief  by 
smearing  the  itching  surface  with  an  ointment  containing  a  small  quantity  of  aconi- 
tine.  Of  internal  remedies,  sarsapariUa,  alkalies,  arsenic,  the  iodide  of  potassium, 
dulcamara,  are  the  most  hopeful.  When  these  means  fail,  opium  is  our  best,  and 
indeed  our  only  resource. 

The  local  forms  of  prurigo  are  frequently  connected  with  local  disease,  and  are 
most  likely  to  be  relieved  by  measures  directed  against  the  primary  disorder.  Pru- 
rigo podicis  is  sometimes  dependent  on  the  presence  of  ascarides  in  the  rectum.  The 
same  troublesome  affection  is  not  an  uncommon  symptom  of  intern"\l  piles :  and  it 
sometimes  accompanies  stone  in  the  bladder. 

The  prurigo  pudendi  muliebris — itching  of  the  genitals  in  females — is  sometimes 
so  constant  and  tormenting,  and  the  impulse  to  scratch  the  itching  part  so  urgent,  as 
to  drive  the  unhappy  patient  from  society.  It  even  gives  rise,  in  some  severe  cases, 
to  nymphomania.  It  may  proceed  from  leucorrhcea:  it  is  frequently  a  sign  of  uterim. 
disease.  It  most  commonly  affects  women  in  whom  the  menstrual  discharge  has 
ceased  to  appear. 

[We  have  met  with  it  just  as  frequently  in  the  menstruating  female  as  in  thost  m  M'hom 
the  menses  had  ceased :  some  females  are  troubled  with  it  during  pregnancy  and  ai  uo  other 
period. — C] 

I  have  never  had  an  opportunity  of  trying  the  aconitine  in  such  cases.  The  local 
application  which  has  been  found  most  serviceable  is  the  yelloiu  ^fJas/■^,  which,  as  you 
probably  know,  is  a  solution  of  corrosive  sublimate  in  lime  water,  in  the  proportion 
of  a  drachm  to  a  pint. 

[A  saturated  solution  of  borax  will  give,  in  many  cases,  very  prompt  relief;  and  by  a  poi 
severance  in  its  use  a  permanent  cure  may  often  be  effected. — C] 


1016  SCABIES. 

You  will  sometimes  be  consulted — at  least  I  have  been,  on  more  than  one  occa- 
sion— about  itching  of  the  pubes  and  scrotum,  produced  by  the  presence  of  the  pe- 
diculi  that  are  vulgarly  called  crab-lice.  The  patients  are  sometimes  quite  unaware 
of  the  cause  of  the  itching-.  You  may  relieve  them  by  the  wash  I  have  just  men- 
tioned ;  or,  by  a  more  elegant  lotion,  made  by  dissolving  corrosive  sublimate  in  a 
little  spirit,  and  adding  rose  water.  A  single  washing  with  such  a  lotion  will  destroy 
the  whole  colony  :  and  the  vermin  become  much  more  visible  after  this  violent  death, 
turning  black,  and  relaxing  their  hold  upon  the  skin. 

Prurigo  is  a  convenient  generic  name  for  these  cutaneous  affections,  of  which  the 
prominent  feature  is  the  teasing  sensation  that  accompanies  them.  But,  besides  all 
these,  there  is  a  specific  disorder,  which,  from  the  intensity  of  that  sensation,  is  em- 
phatically termed  the  itch,  and  which  deserves  a  short  notice  ;  for  it  is  exceedingly 
common,  and  exceedingly  distressing,  and  (what  is  more  interesting  still)  it  is  easy 
of  cure.  It  is  one  of  the  very  few  complaints  for  which  we  possess  a  specific  or 
infallible  remedy. 

Scabies,  or  the  itch,  is,  as  every  body  knows,  contagious  ;  but  it  is  contagious  only 
in  that  particular  sense  which  implies  contact.  It  is  not  producible  by  any  effluvia 
which  the  atmosphere  can  convey :  it  requires,  for  its  propagation,  that  the  healthy 
person  should  touch  the  diseased  person,  or  some  substance  which  has  been  in  con- 
tact with  his  unhealthy  skin.  Certain  parts  of  the  skin  are  more  liable  to  it  than 
others.  It  is  most  common  at  the  roots  of  the  fingers  and  thumbs,  between  them  as 
it  were ;  on  the  wrists ;  between  the  toes ;  in  the  flexures  of  the  joints.  It  may 
spread  to  almost  every  part  of  the  trunk  or  of  the  extremities;  but  all  observers 
agree  in  stating  that  it  is  seldom  or  never  seen  upon  the  face  and  head ;  a  curious 
but  unaccountable  exemption. 

The  eruption  is  at  first  papular,  and  then  vesicular,  presenting  a  number  of  pointed 
watery  heads.  When  ihe  inflammation  is  aggravated  by  intemperate  habits,  or  by 
the  scratching  from  w^hich  the  patient  is  unable  to  refrain,  the  vesicles  are  liable  to 
be  converted  into  pustules :  and  this  has  needlessly  been  made  a  separate  species  of 
itch,  scabies  puntlenta,  pocky  itch :  you  see  large  pustules,  filled  with  a  yellow  viscid 
matter,  standing  on  an  inflamed  base.  If  you  are  not  aware  of  these  varieties  and 
changes,  you  may  make  unlucky  errors  of  diagnosis ;  affi'ont  your  patient  by  telling 
him  he  has  the  itch  when  he  has  it  not;  or  suffer  him  unconsciously  to  betray  and 
shame  himself  by  communicating  it  to  others,  when  he  has.  You  will  easily  under- 
stand how  it  has  come  to  be  considered  a  disgrace  to  have  the  itch :  for  it  is  fostered 
and  propagated  in  most  unfashionable  places,  amidst  poverty,  vulgarity,  and  filth. 
Yet  the  most  delicate  and  high-bred  lady  may  contract  the  distemper ;  and  when 
once  it  is  contracted,  it  will  go  on  indefinitely,  through  life,  unless  proper  means  are 
adopted  for  its  cure.     It  never  gets  well  if  left  to  itself. 

One  very  curious  point  in  this  discreditable  malady,  is  its  connection  with  a  pecu- 
liar insect,  called  accordingly  the  acurus  scabiei.  The  existence  of  this  ectozoon  had 
long  been  affirmed  and  denied  ;  but  the  vexed  question  has  at  length  been  set  at  rest 
by  the  public  demonstration  of  the  acarus,  by  a  M.  Renucci,  to  a  number  of  medical 
practitioners  in  Paris.  It  has  since  been  often  detected  and  exhibited  here.  Dr. 
Nevinsonhas  lately  assured  me  that  he  furnished  Shaw,  the  naturalist.  Dr.  Wollaston, 
and  others,  with  living  itch-mites,  for  examination,  forty  years  ago.  One  reason, 
probably,  why  it  has  often  been  searched  for  in  vain,  is,  that  the  acari  are  not  equally 
numerous  with  the  vesicles:  there  is  not  an  insect  for  every  vesicle.  Another  reason 
is,  that  persons  have  not  known  exactly  where  to  look  for  the  insect.  It  is  not  in  the 
pustides  or  vesicles ;  but  7iear  them  ;  at  the  extremity  of  a  short,  small,  superficial 
tunnel  or  furrow  which  runs  from  them.  A  third  reason  why  the  inject  had  so  long 
and  so  often  escaped  detection,  is  to  be  found  in  its  minuteness.  It  is  barely  visible 
Oy  the  naked  eye  ;  but  under  the  microscope  it  is  seen  to  be  a  most  formidable 
monster,  in  outline  like  a  tortoise,  and  having  eight  legs.  I  show  you  here  its  por- 
trait ;  not  a  fittle,  but  enormously  magnified.  I  hope  to  procure  for  you  the  privilege 
of  seeing  the  creature  itself.  The  first  that  I  can  catch  I  will  ask  Professor  Jones 
0  show  you  by  means  of  his  microscope. 


HERPES.  1017 

There  is  good  reason  for  believing  that  this  parasitic  animal  is,  not  merely  a 
casual  companion,  but  the  veritable  cause,  of  scabies.  Various  attempts  have  been 
made,  and  made  in  vain,  to  produce  the  disease  by  inoculation  of  the  fluid  from  the 
vesicles.  On  the  other  hand,  transportation  of  the  acarus  has  always  excited  the 
eruption. 

These  facts  explain  how  it  is  that  the  itch,  though  readily  communicable  by  direct 
contact,  or  by  fomites,  is  not  communicable  through  the  medium  of  the  air ;  that 
fomiles  long  retain  the  contagious  property ;  and  that  the  disease  is  curable  by  what- 
ever destroys  the  acari.  I  believe  that  the  complaint  called  the  mange,  in  dogs, 
camels,  and  sheep,  has  the  same,  or  a  similar  origin. 

Now  svlphur  is  as  sure  to  cure  the  itch  as  quinia  is  to  stop  an  ague.  I  presume 
that  it  kills  the  acarus ;  but  whatever  may  be  its  modus  operandi,  I  have  never 
known  it  fail  to  remove  true  scabies.  It  is  applied  externally  ;  and  the  only  objec- 
tions to  its  use  are  its  disagreeable  smell,  and  the  dirtiness  that  belongs  to  ointments : 
but  these  inconveniences  are  far  outweighed  by  its  certain  efficacy.  Although 
many  substitutes  for  this  substance  have  been  recommended,  I  pretermit  them  all, 
and  advise  you  to  employ  the  sulphur  ointment,  of  which  you  may  disguise  the 
smell  by  the  addition  of  a  little  bergamot,  and  the  colour  by  intermixing  a  small 
quantity  of  vermilion. 

The  ointment  should  be  carefully  rubbed  all  over  the  skin,  at  bed-time,  and  most 
especially  on  parts  visibly  affected  with  the  eruption.  The  patient  should  sleep 
enveloped  in  a  flannel  dress.  The  rubbing  should  be  repeated  night  and  morning, 
and  in  two  or  three  days  the  complaint  will  be  subdued.  Then,  thorough  ablution 
with  soap  and  warm  water,  and  the  destruction  of  the  contaminated  clothes  by  fire, 
will  complete  the  purifying  process. 


LECTURE  XC. 

Herpes;  Eczema;  Pompholix ;  Lepra;  Psoriasis ;  Im,petigo;  Boils ;  Carbuncle; 
Purpura;  Scurvy.     Conclusion  of  the  Course. 

If  you  look  at  the  lists  of  genera  and  species  appended  to  the  various  works  which 
treat  exclusively  of  cutaneous  diseases,  you  will  find  that  they  are  exceedingly 
numerous.  But  these  disorders  differ  widely  in  their  relative  importance ;  and  the 
principles  upon  which  their  remedial  management  proceeds  are  not  so  greatly  diversi- 
fied as  these  "  tables  of  contents"  might  lead  you  to  suppose.  I  have  spoken  pretty 
fully  of  the  most  serious  and  interesting  of  these  maladies — I  mean  of  the  febrile  ex- 
anthemata ;  but  I  have  no  time  left  for  pursuing  in  detail  the  host  of  chronic  affec- 
tions to  which  the  human  skin  is  subject.  Nor  do  I  much  regret  this.  To  become 
expert  in  the  diagnosis  of  these  blemishes,  and  in  curing  such  as  are  curable  by  our 
art,  you  must  see  them  with  your  own  eyes.  Verbal  descriptions  of  their  changeful 
characters  are  of  comparatively  little  service  or  interest.  They  are  among  the  things 
that  require  to  be  "oculis  subjecta  fidelibus."  Even  pictured  representations  convey 
but  an  inadequate  notion  of  the  morbid  appearances  they  are  designed  to  portray. 
The  lecturer  on  skin  diseases  should  have  actual  patients  before  him,  to  whose  bodies 
he  could  point. 

In  this,  the  final  lecture  of  the  course,  I  can  do  no  more  than  offer  you  some  very 
cursory  remarks  upon  some  of  the  genera  into  which  nosologists  have  distributed  this 
class  of  disorders ;  and  I  may  premise,  that  the  treatment  of  the  genus  mcludes,  for 
the  most  part,  that  of  the  species. 

Ve-nclcs  are,  as  you  know,  small  transparent  elevations  formed  by  a  drop  of 
aqueous  fluid  effused  beneath  the  cuticle.  Sometimes  they  are  thinly  scattered, 
over  the  surface;  sometimes  collected  into  clusters:  sometimes  situated  on  a  red 
patch  of  skin ;  sometimes  quite  free  from  redness.  The  whole  crop  comes  out  at 
once  in  some  cases ;  in  others  the  vesicles  appear  in  irregular  succession.     They 


1018  HERPES. 

terminate  also  in  various  \va3's  :  by  llje  reabsorption  of  the  jiquid,  and  slight  desqua- 
mation ;  by  the  giving  way  of  the  cuticle,  and  the  formation  of  little  scabs,  under 
which  new  cuticle  is  generated ;  and  sometimes,  though  rarely,  by  ulceration. 

Of  the  vesicular  class  of  cutaneous  disorders  I  have  already  described  the  three 
most  important;  namely,  cow-pox,  chicken-pox,  and  the  itch. 

Another  not  uninteresting  genus  of  this  class  is  herpes.  This  is  a  transient  non- 
contagious eruption,  consisting  of  red  patches  of  irregular  form  and  variable  size, 
upon  each  of  which  stands  a  crop  of  vesicles.  The  eruption  runs  a  definite  course  ; 
and  its  several  periods — its  beginning,  its  increase,  its  acme,  and  its  decline — are 
completed,  when  its  progress  is  not  interfered  with,  in  about  ten  days.  These  cha- 
racters, once  known,  are  easily  recognized  :  and  it  is  of  importance  that  )'ou  should 
recognize  them.  Not  that  the  disorder  itself  is  of  any  great  moment;  nor  that  it  is  at 
all  under  the  influence  of  remedies ;  but  because  it  may  be  confounded  with  some 
graver  malady.  For  example,  Herpes  pracputlalis  is  a  very  common  and  a  very 
trifling  species,  affecting  the  foreskin  ;  but  it  might  readily  be  mistaken  for  the  result 
of  the  poison  of  syphilis,  and  so  cause  much  alarm  and  distress  to  the  subject  of  it, 
and  entail  upon  him  perhaps  a  needless  course  of  mercury,  and  bring  unmerited 
suspicion  upon  the  person  with  whom,  whether  lawfully  or  unlawfully,  he  might 
have  been  connected.  .  It  has  nothing  whatever  to  do  with  sexual  intercourse  ;  and 
it  requires  no  treatment  beyond  cold  ablution,  and  the  interposition  of  a  piece  of  lint 
between  the  prepuce  and  the  glans  penis.  In  like  manner  another  species.  Herpes 
cirdnaius,  the  vesicular  ringworm,  is  liable,  when  it  appears  upon  the  hairy  scalp, 
to  be  mistaken  for  that  pest  of  schools  and  of  school-boys,  the  faiiis  confertus,  or 
porrigo  scutulata  of  Willan,  the  common  scald-head;  a  complaint  which  is  naturally 
shunned  as  filthy,  stubborn,  and  contagious.  Herpes  iris  is  a  mere  curiosity.  la 
this  species  each  group  of  vesicles  is  surrounded  by  four  concentric  erythematous 
rings,  of  different  shades  of  colour.  The  rings  form  and  fade  in  succession,  one  after 
another,  by  a  slight  extension  of  the  inflammation  each  time.  The  spots  constituting 
the  eruption  have  been  likened  to  small  parti-coloured  cockades.  But  the  most 
singular  species  of  all  is  the  Herpes  zoster,  in  which  the  separate  patches  lie  in  the 
direction  of  a  band  that  encircles  half  the  circumference  of  the  body.  Hence  its 
names,  zoster,  zona,  zona  ignea,  and  in  our  vernacular  tongue,  the  shingles ;  and 
even  this  Dr.  Johnson  derives  from  the  Latin,  cinguhan,  a  girdle. 

]Most  commonly  the  zone  is  confined  to  the  trunk  of  the  bod3%  has  a  somewhat 
oblique  direction  like  a  sword  belt,  and  occupies  exactly  one-half  of  the  circle,  lying 
between  the  linea  alba  and  the  spine  on  one  side  onl}'.  Sometimes,  however,  it  ex- 
tends from  the  trunks  to  the  limbs.  Thus  it  may  begin  in  the  loins,  pass  obliquely 
across  the  flank,  and  terminate  at  the  inner  part  of  the  thigh.  Or  it  may  commence 
from  the  upper  part  of  the  spine,  cross  the  shoulder,  and  end  on  the  arm  or  forearm. 
In  the  year  1833  I  saw  a  lady  affected  with  this  strange  eruption,  in  whom  the  clus- 
ters of  vesicles  began  near  the  spine  in  the  neck,  passed  over  the  scapula,  then  to 
the  shoulder  and  axilla,  whence  the  main  line  ran  along  the  outer  side  of  the  upper 
arm  till  it  reached  the  elbow,  where  it  turned  inwards,  followed  the  inner  side  of  the 
forearm,  went  across  the  palm  of  the  hand,  and  terminated  by  two  or  three  patches 
upon  the  palmar  and  inner  side  of  the  ring  finger.  Very  rarely  indeed  it  appears  on 
the  limbs  only.  Once  I  have  seen  it  limited  to  the  thigh  and  leg,  where  it  corre- 
sponded to  the  course  of  the  sciatic  nerve.  Once  I  have  known  it  spread  from  the 
neck,  behind,  up  to  the  hairy  scalp.  The  most  common  situation  of  the  demi-cinc- 
ture  is  across  the  base  of  the  thorax.  It  is  a  curious  feature  of  this  curious  disorder, 
that,  in  nineteen  cases  out  of  twenty,  according  to  Biett,  it  occupies  the  right  half  of 
the  body.  Of  this  singular  preference  of  the  right  side,  if  indeed  it  be  a  general  fact, 
I  can  give  you  no  explanation.  I  have  seen  some  fifteen  cases  of  the  complaint 
since  I  began  to  attend  to  that  circumstance,  and  in  ten  of  these  the  eruption  was  on 
the  right  side.  Raj-er,  in  the  first  edition  of  his  book,  said  that  eight  cases  in  ten 
v.-ould  be  found  to  be  on  that  side  ;  but  a  longer  experience  has  reduced  that  propor- 
tion. Of  fifty-three  examples  seen  by  himself,  thirty-seven  only  were  on  the  right, 
and  sixteen  on  the  left.  Reil  states  that  he  has  always  observed  it  on  the  left  half 
of  the  body;  and  Mehlis,  among  twenty-five  patients,  counted  sixteen  in  whom  the 


ECZEMA.  1019 

left  side  was  affected.  This  statistical  point  remains,  therefore,  to  be  settled,  if  it  be 
worth  settling,  by  a  larger  induction  of  particular  cases.  The  zone  seldom  trans- 
gresses the  median  line  at  either  extremity,  unless  perhaps  the  redness  of  the 
extreme  patches  may  extend  a  few  lines  further.  It  is  said,  however,  in  some  ex- 
ceedingly rare  instances,  to  complete  the  circuit  of  the  body.  There  is  a  vulgar  but 
erroneous  notion,  that  the  eruption  proves  fatal  when  it  thus  surrounds  the  whole  of 
the  trunk  ;  and  this  notion  is  as  old  as  the  time  of  Pliny,  who  says,  "  Zoster  appella- 
tur,  et  enecat  si  cinxerit." 

The  most  important,  because  the  most  distressful,  of  the  symptoms,  is  an  intense 
darting  pain,  described  by  the  patients  as  being  deep-seated,  very  acute,  and  shooting 
through  the  chest.  Fortunately,  however,  this  is  by  no  means  a  common  incident. 
I  have  met  with  it  in  two  or  three  cases  only.  Sometimes  the  pain  precedes  the 
eruption  ;  more  often  it  accompanies  it ;  and  it  is  apt  to  last,  in  spite  of  remedies,  for 
some  time  after  the  eruption  has  disappeared.  Mr.  North  tells  me  that,  in  a  female 
patient  of  his,  this  pain  continued  to  be  severe  and  intractable  for  eighteen  weeks. 
That  this  is  a  rare  complication  of  the  disorder  we  gather  from  the  experience  of 
M.  Biett,  who  never  once  witnessed  this  symptom  in  more  than  500  cases  of  shingles. 
The  severe  and  intermitting  character  of  the  pain,  and  the  peculiar  direction  of  the 
row  of  herpetic  patches,  lead  to  the  belief  that  the  whole  malady  may  arise  from  some 
fault  in  the  nervous  system.  Of  its  causes  we  have  no  certain  knowledge.  It  is 
said  to  attack  young  persons  more  especially,  and  those  who  have  fine  and  delicate 
skins,  and  the  male  more  frequently  than  the  female  sex.  But  I  suspect  that 
these  assertions  rest  on  a  very  loose  foundation.  Of  the  fifteen  cases  already  men- 
tioned, ten  occurred  in  females.  One  of  the  patients  was  a  child  two  years  and  seven 
months  old  ;  another  was  an  aged  man  of  about  seventy-five.  In  several  instances  I 
have  found,  upon  inquiry,  that  the  patients,  being  children,  were  in  the  nightly  habit 
of  wetting  their  beds.  Whether  this  has  been  anything  more  than  a  casual  coinci- 
dence, I  do  not  know ;  but  my  attention  was  first  directed  that  way,  some  years  ago, 
by  Mr.  Wheeler,  the  apothecary  at  St.  Bartholomew's  Hospital,  who  told  me  that  he 
had  often  noticed  the  same  circumstance.  According  to  Bateman,  the  disorder 
"seems  occasionally  to  arise  from  exposure  to  cold  after  violent  exercise.  Sometimes 
it  has  appeared  critical,  when  supervening  on  bowel  complaints.  Like  erysipelas,  it 
has  been  ascribed  by  some  authors  to  paroxysms  of  anger."  Schwartz  saw  three 
cases  which  followed  violent  fits  of  passion ;  and  Plenck  affirms  that  he  had  known 
it  occur  twice  after  furious  anger — and  a  copious  potation  of  beer. 

The  duration  of  the  eruption  is  from  ten  days  to  a  fortnight;  but  it  is  liable  to  be 
considerably  prolonged  by  troublesome  ulceration,  whenever  the  vesicles  and  crusts 
are  prematurely  chafed  off  by  friction  or  pressure. 

Very  little,  as  you  must  perceive,  can  be  done,  or  is  requisite  in  the  way  of  treat- 
ment. The  patient  is  to  be  cautioned  against  rubbing  off  the  heads  of  the  vesicles. 
Attention  should  of  course  be  paid  to  the  state  of  the  stomach  and  bowels ;  and  the 
diet  should  be  regulated.  Our  main  business  is  to  look  on,  and  to  endeavour  to  set 
right  whatever  may  be  manifestly  wrong. 

Should  the  eruption  be  attended  or  followed  by  the  intense  shooting  pain  which 
sometimes,  but  not  often,  harasses  the  patient,  it  will  be  right  to  apply  opiates,  by 
friction,  over  the  afftcted  region.  I  would  use  the  aconitine  ointment  in  such  a  case. 
Warm  baths  will  also  be  proper :  and  as  the  pain  is  probably  neuralgic,  the  carbonate 
of  iron  is  a  remedy  which  ought  to  be  tried. 

Eczema  is  another  genus  of  the  vesicular  class  of  diseases.  It  is  characterized, 
in  its  commencement,  by  an  eruption  of  very  minute  vesicles,  scarcely  prominent, 
closely  crowded  together,  and  requiring  a  microscope  sometimes  to  render  them 
distinctly  visible.  They  terminate  either  by  the  re-absorption  of  the  fluid  they 
contained,  or  by  the  formation  of  superficial  moist  excoriations.  Eczema  is  not 
contagious. 

There  are  several  species  or  varieties  of  this  form  of  cutaneous  disorder  also.  It 
is  sometimes  produced  by  great  heat,  and  particularly  by  the  heat  of  the  sun  ;  and 
this  is  named  eczema  solan;  heat-sjjot :  sometimes  by  the  contact  of  irritating  sub- 


1020  ECZEMA. 

Stances  with  the  skin,  as  in  what  is  vulgarly  called  the  grocer's  itch,  afll-cting  the 
hands  of  those  who  are  much  conversant  with  sugar.  Eczema  often  occurs  upon  the 
scalp,  and  constitutes,  I  believe,  the  most  frequent  form  of  what  is  commonly  named 
scald-head,  porrigo,  or  tinea  capitis.  But  the  most  severe  of  all  its  species  is  that 
which  has  received  the  name  o{  Hydrargyrum.,  Erythema  mercuriale,  and  Eczema 
riibrum  mercuriale.  This,  as  these  names  imply,  is  an  occasional  consequence  of 
mercury;  an  unusual  consequence,  no  doubt,  and  one  that  happens  only  in  a  few 
peculiar  constitutions  ;  but  you  ought  to  know  it,  in  case  it  should  follow  the  use  of 
mercury  prescribed  by  j'ourselves. 

The  eruption  begins  usually  in  the  groins  and  upon  the  thighs.  It  is  at  first  red, 
and  is  accompanied  by  much  heat  and  itching.  It  soon  extends,  in  the  severer  cases, 
over  the  whole  body ;  and  an  innumerable  multitude  of  very  minute  glittering  vesi- 
cles may  be  seen,  with  the  aid  of  a  magnifying  glass,  from  the  beginning.  Like  that 
of  erysipelas,  the  eruption  is  attended  with  a  good  deal  of  swelling.  The  intumes- 
cence of  the  face  is  such  as  to  close  up  the  eyes :  and  the  disorder  becomes  febrile, 
in  its  course  ;  for  there  is  seldom  much  fever  at  the  onset.  The  vesicles  increase  in 
size,  turn  milky,  burst,  and  pour  forth  an  acrid  exudation,  that  irritates  and  inflames 
the  skin  with  which  it  comes  in  contact,  and  thus  increases  the  local  complaint.  The 
distress  and  worry  occasioned  to  the  patient  by  the  fetid  smell  of  the  discharge,  by 
the  stiffening  which  it  causes  of  his  bodj'-linen,  and  by  the  heat  and  itching,  are,  I 
conceive,  the  main  causes  of  the  febrile  disturbance.  The  discharged  matter  is  apt 
to  become  thick  and  hard,  and  to  present  the  appearance  of  large  scabs :  and  in  this 
state  the  nature  of  the  disease  may  very  easily  be  understood,  it  being  impossible  to 
say,  when  it  is  seen  for  the  first  time  under  these  circumstances,  whether  it  was 
originally  vesicular  or  not. 

The  duration  of  this  harassing  distemper  is  variable.  It  may  be  over  in  a  fort- 
night, or  it  majj^  last  several  weeks.  It  terminates  by  the  cessation  of  the  discharge, 
and  then  the  cuticle  detaches  itself  in  large  flakes.  Sometimes  in  this  disease  also 
the  epidermis  falls  entire  from  the  hand,  like  a  glove. 

Without  being  dangerous  to  life,  this  disorder  is  apt  to  be  obstinate.  It  is  not 
much  within  the  control  of  remedies.  What  little  can  be  done  is  chiefly  palhative. 
The  mildest  local  applications  must  be  used :  tepid  water,  barley-water,  strained 
gruel.  The  warm  bath,  when  circumstances  permit.  Poultices  are  sometimes  of 
much  service,  in  preventing  the  hardening  of  the  matter  that  exudes,  and  so  obvi- 
ating one  source  of  irritation.  Flour,  or  powdered  charcoal,  may  be  sprinkled  over 
the  eruption  in  the  slighter  and  early  cases,  for  the  purpose  of  absorbing  the  dis- 
charge. Equal  parts  of  olive-oil  and  lime-water  make  a  soothing  liniment,  which 
may  be  applied  by  means  of  a  feather.  The  local  remedies  may  fairly  be  varied, 
for  sometimes  one,  and  sometimes  another,  is  found  to  give  rehef.  The  patient's 
linen  must  be  frequently  changed,  especially  whenever  it  becomes  stiffand  hard  with 
the  exudation. 

With  respect  to  the  general  treatment,  opiates  to  procure  rest,  and  to  allay  irrita- 
tion, are  probably  indispensable.  The  bowels  must  be  kept  moderately  open,  but 
no  severe  purging  should  be  employed,  for  the  patient  must  at  all  events  undergo  a 
long  and  weakening  process,  and  therefore  it  must  be  our  care  that  the  treatment  be 
as  little  weakening  as  possible.  In  protracted  cases,  where  there  is  much  exhaustion, 
wine  may  with  propriety  be  given  ;  and,  almost  always,  good  strong  broths.  As  the 
disorder  declines,  some  of  the  reputed  tonics  may  be  prescribed  ;  the  mineral  acids, 
quina,  sarsaparilla. 

I  need  not  say  that,  in  such  cases,  you  must  be  scrupulous  in  seeing  that  no  more 
mercury  is  administered  or  apphed. 

A  separate  class  of  cutaneous  diseases,  very  analogous,  however,  to  that  which  we 
nave  been  describing,  is  the  class  of  bullae,  or  blebs.  Anatomically  speaking,  there 
IS  but  little  difference  between  the  two :  bullse  are  large  vehicles.  When  the  erup- 
tion is  at  its  height,  it  is  composed  of  hemispherical  prominences  of  various  sizes, 
iVom  that  of  a  pea  to  that  of  a  hen's  egg,  and  having  the  shape  and  appearance  of 
ihe  bubbles  raised  in  a  pool  of  water  by  a  hard  shower  of  rain.     They  are  formed 


POMPHOLIX.  1021 

Dy  the  efTusion  of  a  serous,  or  a  sero-puriform  fluid,  between  the  true  skin  and  the 
cuticle.  You  can  oiily  be  sure  of  the  diagnosis  when  you  see  the  eruption  in  this 
stage  of  its  progress. 

The  best  example  of  this  class  is  that  which  is  called  by  some  writers  Pemphigus^ 
by  others  Pompholix. 

It  is  characterized  by  the  presence  of  bullse,  varying  in  their  magnitude,  commonly 
distinct,  but  numerous,  springing  up  in  successive  crops,  on  one  or  more  parts  of  the 
surface.  At  first  these  bullfe  are  nearly  transparent,  and  contain  a  thin  limpid  serum  ; 
but  they  become  gradually  opaque,  pearl-coloured,  and  ultimately  many  of  them 
acquire  a  reddish  tinge. 

Pemphigus  has  been  described  as  being  sometimes  acute,  sometimes  chronic. 
The  acute  form  is  attended  with  smart  fever,  the  bullse  rise  spontaneously  or  in 
quick  succession,  run  their  course,  and  disappear;  and  then  the  disease  is  over. 
This  is  a  very  rare  form.  In  general  the  bullse  continue  to  come  out ;  the  complaint 
is  spread  over  weeks,  or  months,  or  years ;  and  it  is  accompanied  by  httle  or  no 
febrile  reaction.  This,  on  the  other  hand,  is  a  common  form  of  disease.  It  is  the 
Pompliolix  diutinus  of  Willan  andBateman.  The  eruption  often  occupies  all  parts 
of  the  body  at  the  same  time,  or  in  succession ;  in  other  cases  it  is  confined  to  a 
limited  space.  I  have  most  frequently  seen  it  on  the  forearms  and  legs.  When  the 
bullee  are  very  numerous,  they  may  give  rise  to  some  febrile  symptoms,  but  not  else. 
The  complaint  may  be  indefinitely  prolonged  by  successive  crops. 

The  eruption  begins  in  small  red  points,  the  formation  of  which  is  attended  with 
a  slight  pricking  sensation.  Some  patients  have  likened  this  sensation  to  that  which 
accompanies  the  passage  of  the  electric  spark.  In  the  centre  of  each  of  these  spots, 
the  cuticle  becomes  hfted,  Avhile  the  circumference  of  the  spot  enlarges,  so  that  bullsB 
are  rapidly  formed,  often  in  the  space  of  a  few  hours  only,  as  big  as  a  hazelnut,  or  a 
walnut:  or  the  blebs  may  even  be  much  greater  than  that.  Either  in  consequence 
of  their  distension,  or  of  the  pressure  made  upon  them  by  the  movements  of  the 
patient,  some  of  these  bullse  burst,  and  a  straw-coloured  serum  exudes.  Then  the 
epidermis  collapses  into  folds  and  wrinkles ;  or  if  it  be  detached  at  a  part  of  the 
margin  of  the  bulla,  it  is  rolled  back,  so  as  to  expose  a  portion  of  the  red,  painful, 
and  smarting  surface  beneath  it.  Towards  the  third  or  fourth  day,  when  the  buUas 
lose  their  transparency,  and  the  liquid  they  contain  becomes  reddish,  those  bullse 
which  have  not  been  broken  sink  down  and  wither ;  the  cuticle  is  no  longer  stretched  ; 
but,  sodden  by  the  serous  fluid,  it  assumes  a  whitish  hue,  becomes  opaque,  and  forms 
at  length  small  brownish  flat  crusts,  of  no  great  thickness. 

In  the  meantime  fresh  bullse  appear  by  the  side  of  the  former  ones,  and  pursue 
the  same  course  ;  so  that  generally  you  may  see,  in  the  same  person,  tense  bullae  con- 
taining a  transparent  and  yellowish  serum ;  thin  crusts ;  and  irregular  patches  of 
various  size,  slightly  excoriated. 

This  is  the  ordinary  course  of  chronic  pemphigus :  and  I  say  it  may  thus  go  on 
for  months  or  years. 

The  disease  is  most  frequently  observed  in  persons  of  debilitated  habits.  It  is 
sometimes  apparently  the  result  of  intemperance  ;  or  of  the  use  of  bad  or  insufficient 
food.  In  Biett's  experience  it  has  often  been  coincident  with  the  fatty  liver.  When 
the  disorder  is  chronic  and  uncomplicated,  the  treatment  found  useful  is  such  as  we 
might  expect  benefit  from,  knowing  the  constitutions  in  which  the  disease  is  most 
apt  to  occur,  and  the  causes  which  seem  at  least  to  favour  its  occurrence,  if  they  do 
not  produce  it:  regulation  of  the  bowels;  good  nourishing  food;  tonic  medicines, 
bitters,  and  especially  quina  and  the  mineral  acids.  Biett  describes  this  kind  of 
treatment  to  have  been  very  successful  in  St.  Louis ;  and  that  not  only  in  old  and 
worn-out  subjects,  but  also  in  the  young,  especially  when  the  complaint  has  been 
chronic.     Bateman  recommends  the  same  general  plan. 

Local  applications  have  seldom  been  much  employed,  except  some  mild  ointment 
to  the  excoriated  parts.  Biett  advises  emollient  lotions,  or  even  opiate  washes  when 
much  irritation  exists ;  but  a  case  recorded  in  the  Medical  Gazette,  by  Dr.  Graves, 
of  Dublin,  affords  a  remarkable  instance  of  a  cure  by  local  applications  alone :  an*! 

4l 


1022  LEPRA. 

it  is  a  case  worth  recollecting,  although,  as  he  justly  remarks,  we  ought  not  to  gene- 
ralize from  a  single  instance. 

His  patient  was  a  boy,  fourteen  years  old,  of  slender  frame  and  delicate  consti- 
tution, yet  enjoying  uninterrupted  health,  except  the  cutaneous  disease,  which  had 
lasted  five  years.  During  that  time  the  succession  of  bullae  had  seldom  ceased.  The 
bullfe  were  very  numerous,  occupying  not  merely  the  face  and  extremities,  but  the 
trunk  also ;  and  they  were  in  various  stages  of  their  progress,  some  healing  after 
having  burst,  some  of  a  larger  size  and  unbroken,  others  small,  and  recent. 

Dr.  Graves  observes,  that  from  the  descriptions  of  Bateman,  and  of  Biett,  although 
both  authors  describe  it  correctly,  we  should  scarcely  form  a  notion  of  the  occasional 
severity  of  this  disorder.  He  had  seen  two  examples  of  it  in  young  men,  where  the 
irritation  and  suffering  produced  by  the  constant  exposure  of  large  portions  of  skin 
denuded  of  epidermis,  had  operated  most  unfavourably  on  the  general  health,  almost 
banishing  sleep,  and  reducing  the  patients  to  a  state  of  great  debility.  These  cases 
did  not  yield  to  the  method  of  treatment  recommended  by  authors  ;  and,  therefore, 
Dr.  Graves  determined,  whenever  another  opportunity  should  occur,  to  have  recourse 
to  a  new  plan. 

In  the  boy  in  question,  therefore,  he  had  all  the  bullae  opened  with  a  lancet,  and 
the  denuded  surface  of  the  corium  was  then  touched  with  a  stick  of  lunar  caustic. 
The  nitrate  of  silver  was  also  apphed  to  the  skin  around  each  buUas,  for  the  breadth 
of  a  line ;  and  the  recent  pimples,  which  indicated  the  formation  of  a  future  bulla, 
were  all  treated  in  the  same  way.  The  boy  was  then  washed,  and  supplied  with 
clean  linen. 

This  single  application  of  the  nitrate  of  silver  had  not  merely  the  effect  of  entirely 
destroying  the  morbid  action  in  the  portions  of  the  skin  which  were  at  the  time 
affected,  but  (what  was  very  remarkable)  no  fresh  bull;E  made  their  appearance  after- 
wards :  none  at  least  had  appeared  for  four  months,  when  he  wrote  his  account.  The 
only  part  where  a  repetition  of  the  process  was  required,  was  the  palm  of  the  hand, 
where  the  thickness  of  the  cuticle  rendered  it  more  difficult  to  expose  the  diseased 
surface  of  the  cutis  to  the  full  action  of  the  caustic. 

It  might  strike  you  from  this  cure  of  a  long  standing  disorder,  so  readily,  by  mere 
local  means,  that  the  disease  propagated  itself  from  one  part  of  the  surface  to  another, 
by  a  sort  of  re-inoculation.  But  it  has  been  fully  proved  that  the  disease  is  not  con- 
tagious. A  Mr.  Gaitskill  engrafted  himself,  with  impunity,  with  the  fluid ;  and 
analyzed  it,  and  found  it  apparently  Uke  the  thin  serum  of  hydrocephalus.  Dr. 
Graves,  therefore,  supposes  that  the  cure  was  owing  to  the  simultaneous  destruction 
of  all  the  parts  of  the  skin  that  were  in  a  state  of  morbid  action  :  a  morbid  action 
which  would  have  been  olherwnse  propagated  to  other  portions  of  the  surface,  by 
what  is  called  the  sympathy  of  continuity. 

The  class  of  scaly  eruptions — the  squamas — is  distinguished  by  the  occurrence  of 
red  spots  or  blotches,  upon  which  lamina  of  altered  cuticle  form,  and  are  thrown  off, 
and  constantly  renewed.  You  wnll  perceive  that,  anatomically,  this  class  of  cutaneous 
disorders  has  a  close  analogy  with  the  rashes  ;  and  yet  it  is  separated  from  them  by 
very  obvious  particulars.  In  the  exanthemata  of  Willan  and  Bateman,  the  redness 
is  followed  by  desquamation  ;  in  the  squamce  these  two  appearances  co-exist :  in  the 
exanthemata  the  sequence  of  redness  and  desquamation  takes  place,  in  general,  once 
only :  in  the  squamae  the  morbid  cuticle  continues  for  an  indefinite  time  to  scale  oft 
again  and  again,  in  successive  fragments,  from  the  abiding  red  patch  of  skin. 

Lepra,  psoriasis,  and  ptyriasis,  and  some  sj^phihtic  eruptions,  constitute  the  prin- 
cipal of  the  squamous  affections. 

Lepra  is  a  very  common  disorder  of  this  class ;  hence  its  name,  lepra  viJgaris. 
It  consists  in  red  scaly  patches,  of  various  dimensions,  but  always  affecting  a  circular 
or  e^'iptical  shape,  and  scattered  over  different  parts  of  the  body.  It  commoniy 
begins  on  the  limos,  most  usually  near  the  joints  ;  just  below  the  knees,  or  the 
elbows  ;  and  Dr.  William  Budd  has  pointed  out  the  curious  fact  that  these  patches, 
especially  when  they  are  few,  and  the  disease  is  recent,  are  distributed  symmetrically, 
each  spot  on  the  one  limb  answering  in  situation  to  a  similar  spot  on  the  fellow  Hmb. 


PSORIASIS.  1023 

This  shows  that  the  disease  is  a  blood  disease  ;  that  it  depends  upon  some  poison, 
introduced  from  without,  or,  more  probably,  bled  within  the  body.  By  degrees  the 
patches  both  enlarge  in  size,  and  multiply  in  number,  and  extend  along  the  extre 
mities  to  the  trunk.  The  eruption  is  seldom  seen  upon  the  hairy  scalp,  or  upon  the 
hands.  As  the  patches  enlarge  they  sometimes  become  confluent ;  but  even  then, 
the  outhne  of  the  confluent  scaly  space  is  defined  by  arcs  of  circles,  and  the  disorder 
is  sufficiently  distinguishable  from  psoriasis.  It  is  not  easy  to  set  these  things 
before  you  in  mere  verbal  description.  To  have  seen  lepra  once,  is  to  know  it  for 
ever. 

When  the  patches  begin  to  get  well,  the  restoration  of  the  altered  surface  to  its 
natural  condition  and  appearance  commences  in  the  centre — i.  e.,  in  the  spot  first 
affected  —  and  proceeds  outwardly  towards  the  circumference :  so  that  the  scaly 
redness  assumes  a  ring-like  arrangement.  This  ring  becomes  gradually  narrower  and 
narrower ;  at  length  its  continuity  is  here  and  there  broken  ;  and  at  last  it  vanishes 
entirely. 

The  eruption  does  not,  however,  run  any  definite  course.  Sometimes  it  goes 
rapidly  through  its  phases ;  in  other  cases  it  persists  for  a  very  long  period.  It  is 
not  at  all  contagious. 

Neither  is  lepra  attended,  in  general,  with  much  local  inconvenience,  nor  with 
much  constitutional  disturbance.  When  the  eruption  is  very  copious  and  extensive, 
and  especially  when  it  is  plentiful  or  almost  continuous  around  the  larger  joints,  it 
renders  the  movements  of  the  limbs  stiff  and  difficult;  and  even  sometimes  painful, 
from  the  cracking  of  the  inflamed  surface  as  it  is  stretched  in  the  bending  of  the 
joint. 

But  I  have  seldom  found  the  lepra  to  exist  unconnected  with  some  disorder  of  the 
digestive  organs.  Usually  the  connection  is  that  of  alternation,  and  not  of  co-existence. 
The  patient  is  dyspeptic  till  the  eruption  comes  out,  and  then  the  dyspepsia  is  re- 
lieved :  and  it  often  returns  as  the  leprous  patches  disappear.  The  eruption  is  the 
more  unsightly :  the  dyspepsia  is  the  more  troublesome.  This  alternation  would 
seem  to  mark  the  shifting  location  of  the  matereis  niorbi. 

When  the  patches  are  small,  and  chronic,  and  white,  that  variety  is  no  longer 
called  lepro  vulgaris,  but  lepro  alpho'ides ;  and  there  certainly  is  another  distinct 
variety,  of  a  more  blue,  or  livid,  or  copper  colour  than  the  ordinary ;  and  a  result  of 
the  poison  of  syphilis.  It  is  named  accordingly  syphilitic  lepra.  This  species  will 
get  well  under  the  influence  of  mercury ;  which,  so  far  as  my  observations  go,  does 
not  cure  the  others. 

Psoriasis  is  closely  allied  to  lepra.  When  it  occurs  in  distinct  patches  it  is  often 
difficult  to  say  to  which  genus  the  eruption  belongs.  In  general  the  patches  of 
psoriasis  are  not  so  broad  as  those  of  lepra ;  their  edges  are  less  raised,  and  their 
centres  less  depressed ;  the  scales  adhere  more  firmly ;  and  the  patches  are  less  uni- 
form and  less  circular. 

But  psoriasis  frequently  spreads  itself  over  large  portions  of  the  skin,  and  it  may 
come  to  occupy  nearly  the  whole  surface  of  the  body.  It  is  then  called  psoriasis 
diffusa.  It  often  renders  the  patient  hideous  to  look  at.  The  scaly  incrustation  is 
interspersed  with  chaps,  furrowing  the  skin  in  aU  directions,  and  following  parti- 
cularly its  natural  folds  and  angles.  These  cracks,  when  the  skin  is  put  upon  the 
stretch  by  the  movements  of  the  patient,  are  apt  to  bleed.  In  these  severer  cases 
(which  are  said  to  be  examples  of  psoriasis  inveterata),  the  laminse  of  altered  cuticle 
are  thick,  and  very  abundant.  They  fall  off  perpetually,  or  are  rubbed  off,  and  may 
be  shaken  from  the  patient's  clothes,  or  collected  in  handfuls  from  his  bed. 

Both  these  scaly  disorders,  lepra  and  psoriasis,  require  the  same  kind  of  treatmcni. 

I  believe  that  external  applications  are  of  but  little  use.  I  have  tried  a  good  many 
and  have  lost  all  confidence  in  them,  with  the  exception  of  the  warm  bath.  What 
ever  tends  to  improve  the  general  health,  will  hasten  the  departure  of  these  eruptions. 
I  believe  that  they  sometimes  depend  upon  the  presence,  or  the  generation,  of  an 
excess  of  acid  in  the  system ;  and  that  they  are  often  to  be  cured  by  alkaline  reme- 
dies I  am  sure.  I  have  seen  many  cases  of  psoriasis  rapidly  improve,  and  get  ulti- 
mately well,  under  full  doses  of  the  liquor  pot  ass  se  ;  from  half  a  drachm  to  a  drachm, 


1024  IMPETIGO — BOILS. 

three  or  four  times  daily,  in  a  glass  of  milk,  or  of  water,  or  of  beer.  Another  inter- 
nal remedy  from  which  1  have  seen  manifest  improvement  result,  is  arsenic ;  orjven 
with  the  cautions,  and  in  the  doses,  which  I  have  more  than  once  spoken  of.  These 
are  the  two  remedies  of  which  I  have  the  most  experience ;  but  neither  of  them  is 
intallible ;  and  you  will  have  to  try  many  things  in  succession,  for  patients  are  very 
desirous  of  getting  rid  of  the  disfiguring  eruption,  even  when  it  does  not  interfere 
with  their  health  or  comfort.  Now  the  Harrowgate  waters,  a  strong  decoction  of 
dulcamara,  pitch-pills  (and  if  pitch-pills,  I  should  suppose  a  fortiori  creasote), 
tincture  of  cantharides,  and  the  iodide  of  potassium,  are  remedies  of  some  renown  for 
tnese  scaly  diseases.  Of  the  syphilitic  lepra  I  repeat  that  mercury  will  prove  a  cure. 
In  all  cases  the  diet  must  be  regulated,  and  all  kinds  of  stimulating  food  abstained 
from.  Dr.  Bateman  knew  a  man  who  was  always  attacked  with  lepra  if  he  took 
spices  with  his  food,  or  drank  ardent  spirits  :  and  a  patient  of  my  own  got  rid  of  long 
standing  and  very  troublesome  psoriasis  of  the  scrotum,  upon  adopting,  for  other 
reasons,  a  very  abstemious  and  simple  mode  of  living. 

Among  the  pustular  diseases  of  the  skin  there  is  one  which  assumes  many  forms, 
and  is  termed  impetigo.  Whatever  may  be  the  minuter  peculiarities  of  this  erup- 
tion, its  general  characters  are  the  following.  It  consists  of  crops  of  pustules,  some- 
times scattered  irregularly,  sometimes  collected  into  groups.  The  pustules  burst,  or 
are  broken,  dry  up,  and  scab  over.  The  crusts  are  yellowish,  and  very  friable,  and 
resemble  in  appearance  little  masses  of  candied  honey ;  or  sometimes  they  look  like 
small  pieces  of  dirty  plaster.  From  beneath  these  crusts  a  considerable  discharge 
continues  to  take  place ;  the  crusts  become  thicker  and  larger,  and  around  the  mar- 
gins the  skin  is  red  and  raw,  as  it  is  also  beneath  them. 

We  have,  I  say,  various  forms  of  this  complaint ;  impetigo  Jigiirata,  impetigo 
sparsa,  &c.  It  often  borders  closely  on  eczema,  so  that  authors  describe  an  eczema 
impetiginodes,  or  an  impetigo  eczeniatodes.  These  varieties  are  delineated  by 
Rayer,  by  Willan,  and  Bateman,  and  by  others ;  and  knowing  their  character,  you 
can  examine  and  study  their  appearances  for  yourselves.  Impetigo  is  a  non-conta- 
gious disorder. 

Sometimes  this  complaint  occurs  in  an  acute  form,  and  is  attended  with  fever.  In 
such  cases  its  removal  will  be  accelerated  by  bleeding  the  patient ;  and  the  blood 
drawn  will  be  found  to  present  the  buffy  coat.  Whatever  local  apphcations'  are 
made  should  not  be  unctious.  It  is  seldom  that  impetigo  will  bear,  or  be  the  bettei 
for,  ointments.  Purgatives  and  alkalies  internally,  and  a  very  weak  spirit  or  alka 
line  lotions  externally,  with  a  scrupulous  diet,  constitute,  I  beheve,  its  best  treatment 
When  the  complaint  is  chronic,  and  the  discharge  copious,  the  oxide  of  zinc  ha» 
often  a  very  beneficial  effect.  It  may  be  dusted  over  the  affected  surface,  from  a 
thin  muslin  bag;  or  it  may  be  applied  in  the  shape  of  a  lotion  —  fifteen  grains  to  an 
ounce  of  rose-water.  You  will  find  this  a  most  useful  lotion  for  that  disfiguring  im- 
petiginous eruption  which  sometimes  covers  the  faces  of  children  like  a  mask,  and 
is  called  cnista  laclea.  The  phrase  crusta  lactea  is,  however,  very  loosely  employed 
by  medical  men. 

There  is  a  very  common,  and  a  very  teasing  pustular  disease  of  the  skin,  usually 
called  a  boil,  in  some  parts  of  England  a  push,  and  by  the  learned  furunculus. 

First,  there  is  a  slight  degree  and  extent  of  hardness  to  be  felt,  a  tender  knot,  just 
beneath  the  surface,  which  soon  begins  to  look  red,  and  a  small  swelling  arises,  which 
gradually  increases  up  to  a  certain  size,  that  of  a  large  pea,  or  of  a  hazelnut,  or  of  a 
walnut.  The  tumour  is  painful,  and  undergoes  a  process  of  slow  suppuration. 
Some  time  from  the  fourth  to  the  eighth  day  it  acquires  a  conical  or  pointed  form, 
and  its  apex  becomes  of  a  white  or  yellow  colour.  At  last  the  cuticle  gives  w-ay, 
and  the  patient  begins  to  congratulate  himself  that  the  little  abscess  is  ripe,  and  that 
his  troubles  are  nearly  over.  But  he  is  disappointed ;  an  insignificant  quantity  of 
pus  mixed  with  blood  escapes,  and  leaves  visible  a  mass  of  dead  areolar  tissue — a 
core  as  it  is  called — of  greater  diameter  than  the  opening,  which  is  commonly  small. 
\t  last,  two  or  three  days  perhaps  after  this,  the  slough  is  expelled,  in  company  \iitb 


1 


CARBUNCLE — PURPURA.  1025 

more  pus,  and  a  deep  cup-like  cavity  remains,  which  soon,  however,  fills  up,  and 
the  boil  is  really  over. 

These  litile  phlegmons  frequent  the  buttocks,  the  thighs,  the  arm-pits,  the  nape  of 
the  neck,  the  abdomen.  They  may  occur  almost  anywhere.  They  are  apt  to  come 
in  crops,  or  in  a  series :  and  any  kind  of  irritation  suffices  to  cause  them  when  a 
constitutional  tendency  to  their  formation  exists.  I  have  known  a  piece  of  soap- 
plaster  applied  to  the  skin  give  occasion  to  a  long  succession  of  boils.  Poultices, 
apphed  to  promote  the  suppuration  of  any  existing  furunculus.  are  believed  to  en- 
courage, by  their  warmth,  the  growth  of  others  around  it.  In  truth,  these  phlegmons 
belong  primarily  and  essentially  to  the  subcutaneous  areolar  tissue  rather  than  to  the 
skin.  Dr.  Prout  corroborates  the  statement  of  Cheselden  that  they  are  often  accom- 
panied by  a  saccharine  condition  of  the  urine.  You  know  probably  that,  in  Dr. 
Prout's  theory  of  assimilation,  the  areolar  tissue  represents  the  saccharine  aliment. 

The  individual  boils  are  intractable  ;  the  state  of  the  system  which  engenders  them 
may  perhaps  be  corrected.  Some  dab  them,  when  nascent,  with  a  solution  of  cor- 
rosive sublimate  in  spirit;  some  support  them  with  sticking  plaster ;  others  apply 
poukices ;  and  others  again  cut  the  hard  tumour  through  while  it  is  yet  crude.  Do 
what  you  will,  you  can  seldom  prevent  or  accelerate  their  dehberate  course ;  but  I 
believe  that  by  applying  leeches,  or  cold,  you  may  prolong,  though  you  cannot  ar- 
rest, that  course. 

Sarsaparilla,  and  the  liquor  potassae,  and  where  the  system  is  below  par,  the  sul- 
phate of  quina  and  a  generous  diet,  are  found  useful.  Sugar,  and  saccharine  food 
of  all  kinds,  should  be  scrupulously  avoided. 

Carbuncle,  alias  anthrax,  is  a  gigantic  boil ;  but  it  is  far  more  serious  than  the 
common  furuncle,  not  only  in  respect  to  its  magnitude,  and  to  the  amount  of  suffer- 
ing which  it  occasions,  but  also  on  account  of  the  constitutional  vice  that  it  betokens. 
A  carbuncle  is  a  large,  flat,  circumscribed,  very  hard,  and  very  painful  tumour,  of  a 
purplish  red  colour,  and  attended  with  a  sensation  of  burning  heat.  Its  ultimate 
diameter  may  be  three  or  four  inches,  or  more.  It  ends  in  the  formation  of  a  deep 
slough,  of  more  than  corresponding  dimensions,  and  the  destruction  of  the  skin  above 
it.  A  number  of  pinhole  openings  at  length  present  themselves  on  the  dark  red 
surface,  and  disclose  the  immense  core  beneath. 

This  serious  complaint  occurs  chiefly  in  advanced  life,  in  corpulent  males,  and  in 
persons  who  have  lived  fully.  It  is  frequently  attended  with  diabetes.  The  tumour 
is  more  often  situated  upon  the  nape  of  the  neck,  or  between  the  shoulders,  than 
elsewhere.  It  produces  high  constitutional  disturbance  and  irritation.  Surgeons 
are  in  the  habit  of  dividing  the  firm  mass  into  quarters,  by  deep  crucial  incisions. 
This  is  a  sharp  remedy,  but  it  purchases  speedy  ease  by  removing  that  tension  of 
the  inflamed  parts  whereupon  the  pain  chiefly  depends.  I  am  persuaded,  however, 
that  this  severe  operation  is  done  too  indiscriminately.  If  the  tension  be  not  mani- 
fest, and  there  is  not  much  complaint  of  pain,  you  had  better,  in  my  opinion,  leave 
these  tumours  to  the  care  of  nature,  and  address  your  remedies  to  the  system  at  large. 
Support  is  often  needed  ;  and  opiates  are  sometimes  indispensable ;  and  the  bowels 
must  be  kept  clear  by  purgatives. 

I  shall  not  attempt  to  discuss,  even  in  this  cursory  and  disjointed  manner,  any 
more  of  the  inflammatory  affections  of  the  skin,  whether  acute  or  chronic :  but  I 
wish,  before  I  conclude,  to  direct  your  attention  to  a  peculiar  morbid  condition,  of 
much  greater  interest  and  consequence  than  most  of  those  which  I  have  just  been 
describing.  I  mean  the  malady  which  is  best  known  by  the  appellation  o^ purpura, 
or  the  purples,  and  which  usually,  though  it  must  be  confessed  very  incorrectly, 
is  ranked  among  cutaneous  disorders.  It  is  strictly  a  hemorrhage.  Its  external 
phenomena  are  so  obvious,  and  so  well  known,  that  I  need  not  dwell  upon  them.  . 
Small  round  spots  appear  on  various  parts  of  the  surface,  generally  upon  the  legs 
first  and  most  plentifully,  of  a  dull  red,  or  of  a  deep  purple  colour.  They  are  accom- 
panied by  no  local  pain,  by  no  sensation  of  any  kind.  Pressure  upon  them  docs 
not  efface  the  colour,  nor  render  it  fainter,  as  it  does  that  of  inflammatory  spots  of  the 
skin.  There  is  scarcely  ever  any  prominence  of  the  purple  stigmata ;  but  they  are 
sometimes  intermixed  with  livid  blotches,  with  appearances  exactly  resemblinjj 
65      ,  4La 


1026  SCURVY. 

bruises ;  and  both  the  circular  spots  and  the  ill-defined  vibices  undergo,  before  they 
disappear,  the  same  changes  of  colour,  from  red  to  a  greenish  yellow,  which  a  bruise 
undergoes.  In  fact  the  anatomical  condition  of  a  bruise  is  exactly  the  same  with  the 
condition  of  the  diffused  livid  blotches  of  purpura.  In  each  case  the  colour  is  the 
result  of  ecchymosis.  With  all  this,  passive  hemorrhages  from  various  parts,  and 
particularly  from  the  mucous  membranes,  are  common. 

It  is  clear,  therefore,  that  this  complaint  cannot  be  regarded  as  a  cutaneous  com- 
plaint, even  in  the  loose  sense  in  which  that  epithet  is  sometimes  applied  to  affec- 
tions that  are  really  beneath  the  skin,  but  visible  through  it.  The  hemorrhage 
takes  the  form  of  red  or  purple  spots  when  the  quantity  of  blood  extravasated  in 
the  same  place  is  only  a  drop.  And  the  spots  are  not  peculiar  to  the  skin,  nor  to 
the  subcutaneous  tissues,  but  are  found,  occasionally,  upon  all  the  internal  surfaces 
also,  and  within  the  substance  of  the  several  viscera.  I  have  seen  these  purple 
spots  on  the  mucous  surface  of  the  mouth,  the  throat,  the  stomach,  and  the  intes- 
tines, on  the  pleurae  and  pericardium  in  the  chest,  on  the  peritoneal  investment  of  the 
abdominal  organs,  in  the  substance  of  the  muscles,  and  even  upon  the  membranes 
of  the  brain,  and  in  the  sheaths  of  the  larger  nerves ;  and  I  have  known  them  to 
be  accompanied  with  large  extravasations  of  blood  in  most  of  the  vital  organs  of 
the  body. 

The  superficial  markings  of  purpura,  the  red  and  purple  spots  and  livid  blotches, 
exactly  resemble  the  spots  and  bruise-like  stains  which  characterize  sea-scurvy ; 
and  I  confess  that  I  formerly  regarded  the  two  affections  as  being  identical,  or  as 
mere  varieties  of  the  same  disorder.  But  it  is  not  so.  For  a  very  full  and  inte- 
resting account  of  scurvy,  I  must  refer  you  to  an  essay,  by  Dr.  Budd,  in  the 
Librurij  of  Practical  Medicine.  He  has  there  collected  from  various  sources,  and 
exhibited  in  a  clear  light,  convincing  evidence  that  scurvy  is  caused — neithei;  by  con- 
tagion, nor  by  cold  weather,  nor  by  impurity  of  the  air,  nor  by  the  continued  use  of 
salt  provisions,  all  of  which  have  been  alleged  as  sources  of  the  disease,  but — by  the 
privation,  for  a  considerable  length  of  time,  of  fresh  succulent  vegetables.  Now 
purpura  often  makes  its  appearance  when  there  has  been  no  deficiency  of  such  food, 
and  no  remarkable  abstinence  from  it.  Scurvy  is  most  common  in  winter,  or  the 
beginning  of  spring;  purpura  in  the  fruit  seasons,  in  summer  and  autumn.  In 
scurvy  the  gums  are  uniformly  soft,  and  swelled,  and  spongy,  and  bleed  readily  ; 
this  is  no  necessary  feature  in  purpura.  Scurvy  is  marked  by  extreme  debility  and 
dejection  of  spirits  ;  it  is  always  rendered  worse  by  blood-letting  and  by  mercury  ; 
and  it  is  infallibly  and  rapidly  cured  by  the  administration  of  lemon-juice,  or  of 
other  fresh  fruits  and  vegetables.  Purpura,  on  the  other  hand,  often  requires  vene- 
section for  its  cure ;  is  not  constantly  nor  surely,  if  ever,  benefited  by  the  anti-scor- 
butic juices ;  is  not  alwa3^s  attended  by  sponginess  of  the  gums,  nor  by  feeblenesr 
of  the  mind  and  body ;  and  I  have  seen  it  clear  speedily  away  upon  the  superven- 
tion of  mercurial  salivation  and  hypercatharsis. 

Lemon-juice  is  really  a  specific  against  scurvy,  whether  it  be  employed  as  a  pre- 
ventive or  as  a  remedy.  It  supphes  something  to  the  blood  which  is  essential  to  its 
healthy  properties.  Its  virtues  were  known  in  this  country  full  two  hundred  years 
ago,  as  appears  by  the  work  entitled  The  Surgeon'' s  Mate,  or  Military  and  Domes- 
tic Medicine,  by  John  Woodall,  Master  in  Surger}' :  London,  1636.  But  the  merit 
of  making  the  fact  generally  known,  and  of  procuring  the  S3'stematic  introduction  of 
lemon-juice  into  nautical  diet,  by  an  order  from  the  Admiralty,  is  due  to  Dr.  Blair 
and  Sir  Gilbert  Blane,  in  their  capacity  of  Commissioners  of  the  Board  for  sick  and 
wounded  seamen,  in  1795.  "The  effect  (says  Sir  John  Herschel)  of  this  wise  mea- 
.-sure  may  be  estimated  from  the  following  facts.  In  17&0  the  number  of  cases  of 
scurvy  received  into  Haslar  Hospital  was  14.57  :  in  1806  one  only,  and  in  1807  one.''^ 
He  adds,  "  there  are  now  many  surgeons  in  the  navy  who  have  never  seen  the 
.lisease." 

Dr.  Budd,  however,  has  assured  me  that  the  Dreadnought  hospital-ship,  at  Green- 
■vich,  is  often  full  of  cases  of  scurvy;  most  of  the  patients  so  affected  having  just 
<\rrived  in  imrchant-sliips,  from  a  long  voyage.     This  surely  ought  not  to  be. 


SCURVY.  1027 

It  could  not  be  if  the  owners  of  those  vessels  knew  how  easily,  surely,  and  cheaply, 
this  truly  dreadful  scourge  may  be  averted. 

Scarcely  less — if  indeed  less  at  all — of  anti-scorbutic  virtue,  belongs,  fortunately, 
to  that  common  esculent  root,,  the  potato.  Jiaw  potatoes  have  long  been  in  good 
repute,  both  for  the  cure  and  for  the  prevention  of  scurvy :  but  raw  potatoes  are 
neither  palatable  nor  easy  of  digestion ;  and  it  is  a  great  discovery,  which  we  owe  to 
the  sagacity  of  Dr.  William  Baly,  that  this  vegetable  is  equally  effective  for  these 
purposes,  when  cooked.  During  some  months  of  continued  observation  of  the  pri- 
soners confined  in  the  Penitentiary  at  Milbank,  I  had  remarked,  without  being  able 
to  account  for  it,  that  among  the  small  number  of  soldiers,  committed  for  compara- 
tively short  periods,  for  offences  against  military  discipline,  scurvy  was  not  uncom- 
mon ;  whereas  I  noticed  it  in  one  instance  only  among  the  much  more  numerous 
class  of  convicts,  whose  term  of  imprisonment  was  considerably  longer.  Dr.  Baly 
was  afterwards  appointed  Physician  to  the  Penitentiary,  and  the  same  curious  fact 
soon  caught  his  attention :  and  he  has  traced  the  cause.  By  the  examination  and 
comparison  of  various  dietaries — those,  namely,  which  have  been  adopted  at  different 
periods  in  the  Penitentiary  itself,  those  which,  at  the  same  period,  were  prescribed 
respectively  for  the  military  offenders,  and  for  the  ordinary  convicts,  and  those  in  use 
in  sundry  other  gaols  in  which  scurvy  has  occurred  with  different  degrees  of  fre- 
quency— he  has  shown,  most  satisfactorily,  that  the  liability  to  the  malady  has  a  strict 
relation  to  the  amount  of  succulent  vegetables  consumed  by  the  prisoners,  and  espe 
cially  of  potatoes.  "  Wherever  this  disease  has  prevailed,  there  the  diet  of  the 
prisoners,  though  often  abundant  in  other  respects,  has  contained  no  potatoes,  or  only 
a  very  small  quantity.  In  several  prisons,  the  occurrence  of  scurvy  has  wholly 
ceased  on  the  addition  of  a  few  pounds  of  potatoes  being  made  to  the  weekly  dietary. 
There  are  many  prisons  in  which  the  diet,  from  its  unvaried  character,  and  the 
absence  of  animal  food,  as  well  as  green  vegetables,  is  apparently  most  inadequate 
to  the  maintenance  of  heakh ;  and  where,  nevertheless,  from  its  containing  abundance 
of  potatoes,  scurvy  is  not  produced."  * 

Now  potatoes  are  food  as  well  as  medicine,  and  they  are  a  cheap  kind  of  food, 
and  it  may  be  hoped  that  a  more  general  knowledge  of  their  anti-scorbutic  properties, 
even  when  cooked,  will  abolish  this  wretched  complaint,  whenever  a  good  supply 
of  them  is  obtainable.  Dr.  Baly  believes  that  from  three  to  six  pounds,  weekly,  for 
each  person,  would  suffice.     He  thus  accounts  for  their  salutary  influence. 

"A  glance  at  the  chemical  analysis  of  the  potato  at  once  explains  its  anti-scorbutic 
virtue.  The  various  fruits,  succulent  roots,  and  herbs,  which  have  the  property  of 
preventing  and  curing  scurvy,  all  contain,  dissolved  in  their  juices,  one  or  more 
organic  acids — such  as  the  citric,  tartaric,  and  malic  acids.  Sometimes  these  acids 
exist  in  the  free  state,  but  more  generally  they  are  combined  with  potash,  or  lime, 
or  with  both  these  bases.  Now  potatoes  have  been  submitted  to  most  elaborate 
chemical  examination  by  Einhoffand  Vauquelin;  and  by  both  these  chemists  they 
have  been  found  to  contain  a  vegetable  acid  in  considerable  quantity.  According  to 
Einhoff,  this  acid  is  the  tartaric  combined  with  potash  and  lime.  According  to 
Vauquelin  it  is  the  citric  partly  in  combination  with  those  bases,  and  partly  in  the 
free  state.  The  farinaceous  seeds,  as  wheat,  barley,  oats  and  rye,  which  are  destitute 
of  anti-scorbutic  property,  contain  no  organic  or  vegetable  acids." 

The  same  causes  which  give  rise  to  sea  scurvy  will  produce  precisely  the  same 
effect  on  land.  Of  this  I  must  give  you  one  illustration  from  my  own  case-book.  In 
August,  1830,1  admitted  into  the  Middlesex  Hospital  a  blacksmith,  thirty-five  years 
old,  covered  \vith  round  purple  spots  of  various  sizes,  and  with  irregular  blotches  of 
ecchymosis.  He  had  vomited  blood  on  the  preceding  day.  He  was  continually 
coughing  up  blood  at  the  time  of  his  admission,  and  his  wife  estimated  the  whole 
quantity  that  he  had  then  lost  to  be  more  than  half  a  pailful.  The  interior  of  his 
mouth  and  palate  was  pouring  forth  blood  from  a  number  of  livid  fungous  tumours 
formed  by  the  extravasation  of  blood  into  the  areolar  tissue  beneath  the  membrane, 
and  the  subsequent  rupture  of  that  membrane.  He  was  passing,  blood  by  the  bowels 
also  ;  and  his  urine  was  loaded  with  blood. 

Here  were  the  symptoms  of  scurvy  strongly  marked.     In  the  man's  history  \\f. 


1028  SCURVY. 

could  trace  its  peculiar  cause.  He  had  long  been  subsisting  on  very  poor  and 
insufficient  nutriment,  seldom  eating  any  meat,  but  living  almost  entirely  on  tea, 
coffee,  and  bread  and  butter.  He  had  been  too  ill  and  weak  to  work  regularly,  yet 
he  had  been  obliged  occasionally  to  over-exert  himself  to  obtain  a  scanty  supply 
of  food  for  himself,  his  wife,  and  a  large  family  of  children.  He  had  been  a 
settled  dram-drinker,  but  for  some  time  had  taken  much  less  of  that  stimulus ; 
merely  because  he  had  not  the  means  of  procuring  it.  His  pulse  was  frequent  and 
feeble. 

1  had  not  much  hope  that  this  patient  could  be  saved  by  any  treatment.  He  was 
immediately  put  upon  a  diet  of  roast  meat,  and  began  to  take  daily  half  a  pint  of 
fresh  lemon-juice  diluted  with  a  pint  and  a  half  of  water.  This  plan,  with  some  tonic 
medicine,  was  commenced  on  the  3d  of  August.  He  improved  at  once.  On  the 
8th  all  the  hemorrhage  had  ceased  ;  the  fungous  tumours  in  the  mouth  had  disap- 
peared, leaving  small  scars  in  the  places  they  had  occupied:  and  the  discoloration 
of  the  skin  was  almost  gone.  The  amendment  was  so  striking  and  rapid,  and  so 
immediately  consequent  upon  the  institution  of  the  treatment,  that  no  room  was  left 
for  mistaking  recovery  for  cure. 

It  is  chiefly  by  investigating  the  previous  history  of  the  patient,  and  by  noting  the 
degree  of  strength  that  he  possesses,  and  the  condition  of  his  pulse,  that  we  are 
guided  in  our  diagnosis  of  ambiguous  cases.  The  late  Dr.  Parry,  of  Bath,  was  one 
of  the  first  to  point  out  the  efficacy  of  abstinence,  venesection,  and  purgatives,  in 
some  instances,  at  least,  of  purpura.  I  may  refer  you  to  an  example  of  this  kind 
detailed  in  the  Medical  Gazette  for  the  5th  of  April,  182S.  It  occurred  in  one  of 
Dr.  Latham's  hospital  patients ;  and  several  of  the  symptoms  were  very  like  those 
I  have  just  been  relating.  In  particular  the  whole  tongue  was  livid,  one  half  of  it 
presenting  the  appearance  of  a  large,  black,  bleeding  fungus  ;  and  on  the  inner 
surface  of  each  cheek  were  several  black  fungoid  patches.  The  patient  was  void- 
ing also  unmixed  blood  from  the  bowels.  In  this  case  there  was  no  evidence  of  the 
operation  of  any  debilitating  cause,  and  the  pulse,  though  frequent,  was  hard. 
Bleeding  from  the  arm  always  gave  relief  to  his  uneasy  sensations :  he  was  purged 
also,  and  put  upon  low  diet.  Under  this  plan  he  steadily  improved,  and  in  four  or 
five  days  no  vestige  of  the  complaint  remained  except  the  fading  spots.  For  some 
time  afterwards,  however,  "  the  frequent  use  of  active  purgatives,  and  a  rigid  re- 
striction to  a  low  diet,  were  necessary  to  obviate  costiveness,  and  to  keep  down  the 
circulation,  which  had  a  tendency  to  become  over-active." 

You  are  not  to  suppose  that  all  cases  of  purpura  bear  this  sthenic  character,  or 
require  these  heroic  remedies.  Your  treatment  must  be  guided  by  the  previous 
circumstances  and  habits  of  the  patient,  by  the  state  of  his  pulse,  and  by  the  other 
symptoms  which  accompany  the  purple  spots.  And  when  you  are  in  doubt  what 
plan  to  pursue,  make  a  cautious  tentative  bleeding.  Take  away  a  couple  of  ounces 
at  a  time,  into  a  wineglass,  note  carefully  the  appearance  of  the  blood  itself,  and  the 
effect  of  the  blood-letting  upon  the  patient ;  and  then  go  on  more  boldly,  or  abstain 
thenceforth  altogether  from  the  lancet,  according  to  circumstances.  In  many  case? 
your  chief  reliance  will  be  placed  in  the  watchful  employment  of  purgatives.  Thesft 
have  been  highly  recommended  by  Dr.  Harty,  of  Dublin,  as  having  proved  eminently 
successful  in  his  practice.  The  late  Dr.  Whitlock  Nicholl,  and  others,  have  spoken 
in  terms  of  strong  praise  of  the  oil  of  turpentine,  administered  in  moderate  and  re- 
peated doses,  as  a  remedy  in  purpura. 

I  have  adverted  to  one  pecuhar  source  of  danger  in  purpura,  the  hazard  that  blood 
maybe  effused  in  some  vital  organ  Avhere  even  a  slight  amount  of  hemorrhage  suffices 
to  extinguish  life.  Dr.  Bateman  states  that  he  had  seen  three  instances  in  which 
persons  were  carried  off,  while  affected  with  purpura,  by  hemorrhage  into  the  lungs. 
During  the  course  of  one  week,  in  the  year  1825,  I  was  present  at  two  inspections 
in  the  dead  house  of  St.  Bartholomew's  Hospital,  illustrative  of  the  same  point  in 
respect  to  another  vital  organ,  and  involving  a  question  in  forensic  medicine.  The 
subjects  of  examination  were  both  of  them  women  of  middle  age,  who  had  been 
brought  into  the  hospital  covered  with  purple  spots  and  bruise-like  discolorations, 
and  suffering  hemorrhage  from  the  mucous  membranes.     Each  of  these  women  de- 


CONCLUSION.  1029 

clared  that  the  apparent  bruises  were  marks  of  beatings  received  from  her  husband 
One  of  them  became  suddenly  hemiplegic  a  httle  while  before  she  died.  Of  the 
manner  of  dissolution  in  the  other  case  I  am  not  sure.  In  both  instances  a  consider- 
able quantity  of  blood  was  spread  over  the  surface  of  the  brain,  between  its  mem- 
branes ;  and  in  one  of  them  blood  had  been  shed  also  into  the  cerebral  substance, 
which  it  had  extensively  lacerated. 

It  may  be  worth  mentioning  that  in  one  of  these  corpses  there  Avere  indications, 
either  of  unusually  rapid  putrefaction  after  death,  or  (what  I  think  more  probable) 
of  some  degree  of  decomposition  even  before  life  was  extinct.  This  woman  died 
in  the  evening,  and  the  body  was  examined  the  next  day,  twelve  or  fourteen  hours 
afterwards.  A  quantity  of  fetid  gas  escaped  from  the  cavity  of  the  abdomen  as 
soon  as  it  was  opened,  and  small  bubbles  of  air  were  seen  to  ooze  from  the  areolar 
tissue  of  various  parts  of  the  body.  Even  when  incisions  were  made  into  the  liver, 
air  frothed  up,  as  it  might  do,  under  ordinary  circumstances,  from  a  section  of  the 
lungs. 

I  have  no  time  left  for  discussing  the  pathology  of  these  complaints.  They  are 
eminently  blood-diseases.  In  scurvy  the  blood  is  starved  of  some  essential  ingre- 
dient, which  the  juice  of  lemons,  and  other  fresh  succulent  vegetables,  readily  sup- 
plies and  renews.  When  drawn  from  a  vein  the  blood  is  often  visibly  unnatural. 
A  very  small  quantity  was  taken  before  I  saw  him,  from  the  arm  of  the  blacksmith 
whose  case  I  just  now  mentioned.  After  standing  for  some  time,  it  continued  to  fill 
the  whole  area  of  the  vessel  in  which  it  had  been  received,  without  any  apparent 
contraction,  or  separation  of  serum.  On  its  flat  upper  surface  was  a  thick,  gray, 
semi-transparent  jelly,  and  beneath  this  there  was,  strictly  speaking,  no  coagulum, 
but  a  black  semi-fluid  substance  of  the  consistence  of  syrup.  Huxham  describes 
similar  appearances.  "  The  blood  of  such  persons  (says  he),  when  it  hath  been 
drawn  off",  always  appears  a  mere  gore,  as  it  were,  not  separating  into  crassamentum 
and  serum  as  usual,  but  remaining  in  a  uniform  half  coagulated  mass,  generally  of 
a  livid  or  darker  colour  than  usual,  though  sometimes  it  continues  long  very  florid  ; 
Out  it  alwaj'^s  putrefies  very  soon."  In  another  place,  when  describing  a  particular 
case,  he  says,  "  I  found  that  neither  of  the  portions  of  the  blood  that  had  been  drawn 
had  separated  into  serum  and  crassamentum  as  usual,  though  it  had  stood  many 
hours ;  but  continued,  as  it  were,  half  coagulated,  and  of  a  bluish  hvid  colour  on 
the  top.  It  was  most  easily  divided  on  the  slightest  touch,  and  seemed  a  purulent 
sanies  rather  than  blood,  with  a  kind  of  sooty  powder  at  bottom." 

Dr.  Budd,  however,  states  that  in  some  cases  of  scurvy  the  separation  of  blood  into 
serum  and  clot  is  as  perfect,  and  takes  place  as  readily,  as  in  healthy  blood. 

When  you  recognize  the  disease  as  genuine  scurvy,  and  trace  a  previous  absti- 
nence, whether  forced  or  voluntary,  from  fresh  vegetables,  the  treatment  is  plain ; 
you  must  supply  the  kind  of  nutriment  which  has  been  defective,  and  support 
your  patient's  strength  in  such  other  ways  as  the  circumstances  of  the  case  may 
dictate. 

And  now,  gentlemen,  I  must  needs  stop.  Here  ends  my  course.  And  if  this 
were  all  I  had  to  say,  I  should  say  it  with  something  like  glee,  and  you,  no  less  than 
myself,  would  rejoice  that  at  length  a  breathing-place  and  holiday  had  arrived.  But 
I  cannot  feel  so  when  I  add  that  this  is  the  last  lecture,  not  of  this  course  merely,  but 
the  last  of  any  kind,  that  I  am  ever  hkely  to  dehver  in  King's  College.  I  cannot 
say  this  without  concern  and  regret. 

I  am  quite  aware  that  my  lectures  have  been  in  many  respects  imperfect.  They 
have  been  very  unequal  to  my  own  wishes.  But  they  have  been  as  full,  and  as 
carefully  weighed,  as  my  broken  leisure,  and  irregular  opportunities,  and  slender 
ability,  would  permit.  I  can  only  hope  that  at  any  rate  I  have  not  misled  you.  If 
I  have  been  intelligible,  if  I  have  drawn  such  a  sketch  of  a  great  and  difficult  subject 
as  may  help  you  in  studying  it  for  yourselves,  I  have  achieved  my  task.  I  told  you, 
in  the  outset,  that  I  could  not  here  teach  you  the  practice  of  physic,  but  only  its 
principles.  It  would  be  idle  for  me  to  speculate  further  upon  the  success  of  my 
endeavours.    You  are  to  be  the  judges  of  that  matter.   Whatever  rules  and  precepts 


J  030  CONCLUSION. 

I  have  laid  down,  you  will  soon  test  by  your  own  experience,  and  adopt  or  reject 
them  accordingly.  The  well-known  maxims  of  Bacon  apply  with  especial  truth  to 
medical  instructors  and  their  pupils.  "  Etsi  non  displiceat  regula,  oportet  discentem 
credere  ;  h«iic  tamen  conjungendum  est,  oportet  jam  edodum  judicio  suo  idi ;  dis- 
cipuli  enim  debent  magistris  temporariam  solum  fidem,  judiciique  suspensionem, 
donee  penitus  imbiberint  artes :  non  autem  plenam  libertatis  ejurationem,  perpe- 
tuamque  ingenii  servitutem." 

Retiring  reluctantly  from  this  place,  in  obedience  to  the  force  of  circumstances, 
there  are  yet  many  things  to  comfort  and  console  me.  It  is  a  great  satisfaction  to 
reflect  that  I  have  never  had  any  serious  disagreement  with  yourselves ;  have  never 
received  any  but  the  most  respectful  and  kind  treatment  either  from  my  present  or 
from  any  preceding  class.  I  have  reason  to  thank  you  —  and  I  do  thank  you  —  for 
the  courtesy  and  attention  you  have  at  all  times  shown  me.  It  is  a  source  of  gratifi- 
cation also  that  I  carry  with  me  the  good  will,  as  I  believe,  of  my  excellent  colleagues  ; 
and  that  I  go  without  having  forfeited  any  of  that  confidence  which  the  Council  first 
reposed  in  me  as  their  servant,  when  they  offered  me,  without  solicitation,  the  chair 
I  now  resign. 

Had  I  been  a  few  years  younger,  unembarrassed  by  previous  official  engagements, 
and  somewhat  more  at  leisure  than  I  am,  I  should  have  been  glad  and  proud  to  have 
attached  myself  to  the  new  hospital,  and  to  have  laboured  still  in  the  cause  of  King's 
Collefre,  and  of  its  Medical  School.  But  it  is  otherwise  ordered :  and  I  will  men- 
tion, as  the  last  source  of  consolation  in  taking  leave  of  you,  my  conviction  that  to 
you  my  loss  (if,  without  presumption,  I  may  so  venture  to  speak  of  my  resignation,) 
"will  be  more  than  supplied  by  my  successor.  I  know  that  gentleman  well.  I  know 
indeed  the  world  knows,  his  talents.  He  was  highly  distinguished  in  the  Senate 
House  at  Cambridge.  He  has  since  devoted,  and  Avill  continue  to  devote,  the  powers 
of  a  very  strong  intellect,  in  the  investigation  of  disease.  Dr.  Budd  is  one  of  the  most 
strenuous  cultivators  of  our  science  that  I  am  acquainted  with  :  and  I  am  confident — 
without  any  affectation  of  modesty — that  he  will  soon  give  a  much  better  course  of 
lectures  than  you  have  heard  from  me.  That  you  may  prosper  in  his  instruction, 
and  afterwards ;  that  by  the  humane  exercise  of  our  noble  calling  you  may  do  good 
in  3'our  generation,  to  others,  and  so  to  yourselves ;  is  my  earnest  desire  and  prayer. 
I  hope  it  is  unnecessary  for  me  to  assure  you  that  I  shall  always  continue  to  take  a 
lively  interest  in  your  welfare  individually;  and  that  it  uill  give  me  sincere  pleasure 
if  I  shall  find  any  future  opportunity  of  rendering  you  any  service.  Gentlemen,  I 
do  not  like  this  sort  of  parting,  and  I  will  not  further  protract  the  pain  that  belongs 
U)  it ;  but  bid  you  finally,  and  most  cordially — Farewell. 


INDEX. 


Abdomen,  diseases  of  the,  727. 

dropsy  of  the,  741. 

mode  jf  examining,  728. 

paracentesis  of  the,  751. 

regions  of,  728. 

tumours  of  the,  749. 
Abdominal  dropsy,  740. 

palpitation,  729. 

percussion,  729,  742. 

respiration,  521. 

tumours,  749,  904. 
Abscess,  110. 

of  the  brain,  256. 
liver,  842. 
lungs,  561. 
Abscesses,  disseminated,  710. 
Acute  inflammation,  124. 
Adhesive  inflammation,  108. 
.iEgophony,  527. 
Ague,  435. 

cake,  856. 
Air,  impurity  of  a  cause  of  disease,  75,  and 

[note'\,  76. 
Air  passages,  foreign  bodies  in  the,  656. 
Albuminous  urine,  877. 

nephritis,  886. 
Alveolar  cancer,  138. 
Amaurosis,  213. 
Amygdalitis,  485. 
Ansemia,  42,  50. 

accidents  and  diseases  attended  by,  51. 

anatomical  characters,  50. 

death  by,  50. 

phenomena,  51. 
Anaesthesia,  facial,  336,  343. 

of  other  parts,  344. 
Anasarca,  169,  887,  999. 

cardiac,  174,  888. 

with  pulmonary  disease,  173,  890. 

renal,  174,  891. 

treatment,  178,  892. 
Aneurism, 'thoracic,  700. 

of  the  heart,  661—674. 
Angina  maligna,  995. 

parotidoea,  479. 

pectoris,  679. 
Anthrax,  1025. 
Anorexia,  776. 

Antimony  in  inflammation,  155. 
Antiphlogistic  regimen,  142. 
Anus,  artificial,  791. 
Aorta,  diseases  of  the,  662,  675,  700. 


Aphtha,  482. 

pathology  of  [no^e],  483. 
Apnoea,  anatomical  characters,  53. 

causes  of,  52. 

death  by,  51. 

diseases  in  which  it  occurs  as  a  mode  <rf 
death,  54. 

general  pathology  of,  53. 

phenomena,  52. 
Apoplexy,  298. 

diagnosis,  299,  327. 

phenomena,  304,  308. 

morbid  anatomy,  313. 

treatment,  328. 

pulmonary,  611. 
Arachnitis,  237. 

Arachnoid  membrane,  inflammation  of,  237. 
Areolar  tissue,  inflammation  of,  119. 

induration  of,  120. 

dropsy  of,  169. 
Arterial  tissue,  eflects  of  inflammation  on,  123, 
Arthritic  ophthalmia,  209. 
Artificial  anus,  791. 
Ascaris  lumbricoides,  826 — 837. 

vermicularis,  826—837. 
Asiatic  cholera,  805. 
Ascites,  740. 

causes,  744. 

diagnosis,  741. 

treatment,  748. 
Asphyxia,  death  from,  52. 
Asthenia,  anatomical  characters,  50. 

death  by,  51. 

diseases  in  which  it  occurs  as  a  mode  oi 
dying,  51. 

phenomena,  51. 
Asthma,  621. 

associated  organic  changes,  719. 

grinders,  647. 

hay,  545. 

spasmodic,  621,  623,  716. 

thymic,  512. 
Atmospherical  temperature  a  cause  of  disease, 

60. 
Atrophy,  30—31. 

of  the  brain,  260. 
Auscultation,  general  account  of,  52 1. 

Bastard  croup,  512. 
Bajle,  granulations  of,  626. 
Belladonna   as    a   preventive    of    scarlet   fever 
no/e],  1003. 

0031J 


1032 


INDEX. 


Bellows  sound  of  the  heart,  665. 
Belly,  dropsy  of  the,  740. 
Bihary  concretions,  850. 
Bilious  remittent  fever  [no/e],  964. 
Bleeding  from  lungs,  608,  638. 

stomach,  766. 
Blisters,  as  a  remedy  in  inflammsition,  159. 
Blood,  buffy  coat  of,  95—103. 

diseases  of,  39. 

spitting  of,  638. 

state  of  in  inflammation  [no/e],  104. 

urination  of,  899. 

vomiting  of,  766. 
Blood-letting,  as  a  remedy  in  inflammation,  143. 
Blood-vessels,  state  of  in  inflammation,  99. 
Bloody  urine,  899. 

flux,  816. 
Boils,  1024. 
Bowels,  inflammation  of,  784. 

mechanical  obstruction  of,  786,  787,  788. 

perforation  of,  734. 
3rain  and  nervous  system,  diseases  of  the,  220. 

abscess  of,  257. 

atrophy  of  the,  261. 

cancer  of  the,  258. 

dropsy  of  the,  278. 

effects  of  pressure  on  the,  225,  309. 

hemorrhage  in  the,  299,  300,  316. 

hypertrophy  of  the,  259  [note], 

induration  of  the,  258. 

inflammation  of  the,  123,  239. 

meningitis  of  the,  237. 

mortification  of  the,  124. 

softening  of  the,  255. 

suppuration  of  the,  256. 

tubercles  of  the,  258,  269,  and  [note], 

tumours  in  the,  258. 

tapping,  285. 
Branks,  480. 
Breathing,  abdominal,  521. 

bronchial,  527,  563. 

cavernous,  634. 

puerile,  526,  565. 

thoracic,  519. 

vesicular,  527,  530. 
Bright's  kidney,  878. 

anatomical  characters,  878. 

signs  of,  879. 

changes  in  the  urine,  879. 
in  the  blood,  881. 

course  of  the  disease,  882. 

secondary  affections,  882. 

causes,  883. 

nature,  884, 
Bronchi,  dilated,  551. 
Bronchial  respiration,  527,  563. 

polypi,  121,  549. 
Bronchitis,  acute,  529 — 537. 

morbid  anatomy,  639,  551. 

treatment,  535. 

chronic,  537 — 547. 

varieties  of,  548. 

prevention,  534. 
Bronchocele,  469, 
Bronchophony,  527.  565. 


Buffy  coat  of  blood,  95 — 102. 
Bullae,  925,  1021. 

Calculi,  renal,  858. 
Cancer,  135. 

alveolar,  138. 

colloid,  138. 

«atephaloid,  138. 

intimate  structure,  139,  and  137  [note]. 

origin,  139. 

propagation,  140. 

treatment,  141. 

varieties,  137,  and  [note'\. 

of  the  brain,  258. 
lungs,  656, 
stomach,  762. 
Canine  madness,  368. 
Capillaries,  state  of  in  inflammation,  99. 
Carbuncle,  1026. 
Carcinoma  of  the  stomach,  762. 
Cardiac  dropsy,  170,  174,  889. 
Cardialgia,  778. 
Carditis,  rheumatic,  683. 
Carnification  of  the  lungs,  583. 
Catalepsy,  424. 
Causes  of  disease,  57. 

cold,  65. 

exciting,  58. 

heat,  61. 

hereditary  predisposition,  77. 

impurity  of  the  air,  75. 

predisposing,  58. 

seasons,  73. 
Catarrh,  528. 

chronic,  547,  548. 

dry,  622. 

epidemic,  539, 

senile,  537. 

summer,  545. 
Catarrhal  ophthalmia,  181. 
Catarrhus  aestivus,  545. 
Cavernous  respiration,  633. 
Cellular  tissue,  dropsy  of,  169. 

induration  of,  120. 
Cerebral  diseases,  229. 

hemorrhage,  299,  301,  316. 
Cerebro-Spinal  Meningitis,  292  [no/e]. 
Chemosis,  185. 
Chicken-pox,  991. 
Child-bed  fever,  731. 
Child-crowing,  512. 
Cholera,  sporadic,  798. 

epidemic,  805. 

morbid  anatomy,  806. 
mode  of  propagation,  807. 
modes  of  attack,  809. 
treatment,  811. 

infantum,  811  [note'j^. 
Chorea,  399. 

Chronic  inflammation,  124. 
Chylous  urine,  897. 
Circulation,  disturbance  of  as  a  symptom  of  dis 

ease,  90. 
Cirrhose  liver,  120,  744 — 845. 
Coagulable  lymph,  107. 


INDEX. 


1033 


Cold,  a  cause  of  disease,  65. 

as  a  remedy  in  inflammation,  158. 

in  the  head,  530. 
chest,  529. 
Colic,  784 — 792. 

from  lead,  792. 

symptoms,  795  [no^e]. 
treatment,  796. 
Colloid  cancer,  138. 
Coma,  death  by,  52,  55,  300. 

phenomena,  55. 

diseases  in  which  it  occurs  as  a  mode  of 
dying,  56. 
Concretions,  biliary,  850. 

intestinal,  823. 

renal,  858. 
Congestion,  41. 

active,  45. 

local,  43. 

mechanical,  45. 

passive,  47. 
Conjunctiva,  inflammation  of,  181,185,191, 196. 
Consumption,  626. 

curability  of  [no^e],  644. 
Contagion,  928,  949. 
Continued  fever,  935. 
Convulsions,  Salaam,  414  [note"]. 
Cord,  spinal,  general  pathology  of,  288. 

inflammation  of,  290. 
Coryza,  530. 
Cough,  a  symptom  of  disease,  89,  520. 

hysterical,  418. 

nocturnal,  periodic,  516  [note"]. 
Coup  de  soleil,  64. 
Crepitation,  a  sign  of  disease,  631, 
Cretinism,  475. 
Croup,  502. 

bastard,  512. 

false,  515  [no/e], 

spasmodic,  512,  and  [noiej,  515. 

causes  of,  515. 

diagnosis,  512  [woie]. 

prognosis,  507. 

symptoms,  503. 

treatment,  507. 

tracheotomy  in,  510  [note]. 
Cutaneous  diseases,  924. 
Cutaneous  tissue,  inflammation  of,  121. 
Cynanche  laryngitis,  491. 

maligna,  994. 

parotidea,  479. 

tonsillaris,  485. 

trachealis,  502. 
t?ysticercus  cellulosus,  829. 

Dance  of  St.  V^tus,  405. 
Death,  sudden,  pathology  of,  48. 
by  anaemia,  50. 

apnoca,  52. 

asthenia,  50. 

coma,  55,  300. 

inanition,  51. 

syncope,  61. 
Debility,  a  symptom,  88. 
Delirium  of  drunkards,  245. 


4h 


Delirium  tremens,  245. 

treatment,  250,  254  [note]. 

in  continued  fever,  938. 
Devonshire  colic,  793. 
Diabetes,  868. 
Diagnostic  signs,  80,  83. 
Diarrhcea,  798. 

adiposa,  822. 

chronic,  800  [noiej. 

crapuiosa,  798. 
Diathesis,  lithic,  862. 

oxalic,  865. 

phosphatic,  862. 

scrofulous,  126,  134. 
Dietetic  rules  for  dyspeptics,  782. 
Digitalis,  as  a  remedy  in  inflammation,  156. 
Disease  defined,  18. 
Digestion,  physiology  of,  774. 
Dilatation  of  bronchi,  551. 

heart,  674. 

oesophagus,  725. 
Diuresis,  chronic,  876. 
Disease,  causes  of,  57. 

hereditary  tendency  to,  59,  77, 
Diseases  of  the  abdomen,  727. 

aorta,  652,  675,  700. 

blood,  39. 

brain  and  nervous  system,  220. 

Bright's,  878. 

cerebral,  229. 

cutaneous,  896. 

eye,  180. 

fluids,  39. 

gall  bladder,  855. 

heart,  660. 

intestines,  784. 

kidneys,  856. 

liver,  841. 

lungs,  528. 

(Esophagus,  722. 

pancreas,  856. 

skin,  924. 

spleen,  856. 

stomach,  753. 

thorax,  518. 

veins,  707. 
Displacement  of  parts,  38. 
Dizziness,  a  symptom,  85. 
Dracunculus,  831. 

Dropsy,  general  pathology  of,  168 — 170,  888. 
Dropsy,  varieties,  171. 

phenomena,  174. 

prognosis,  178. 

treatment,  178. 

of  the  areolar  tissue,  169,  887. 

of  the  belly,  741. 

of  the  brain,  277. 

cardiac,  174,  889, 

chest,  582. 

ovarian,  741—746,  749. 

renal,  173. 

after  scarlet  fever,  997. 
Drunkards,  delirium  of,  245. 
Dura  mater,  inflammation  of,  231. 
Dying,  modes  of,  48. 


1034 


INDEX. 


Dysenter}',  814.  • 

causes,  81i. 

phenomena,  815. 

morbid  anatomy,  817  [7?o/e]. 

treatment,  818  [no/e]. 

chronic,  821  [Ho^el. 
Dyspepsia,  757,  774. 
Dyspeptics,  dietetic  rules  for,  782. 
Dyspnoea,  a  symptom,  90,  519. 

general  pathology,  519. 

Ecstacy,  425. 
Eczema  solare,  1020. 

rubrum  mercuriale,  1020. 
Effusion  of  serum  from  inflammation,  106. 

coagulable  lymph,  107. 

pus,  109. 
Egyptian  ophthalmia,  184,  186. 
Exhalation,  hemorrhage  from,  160. 
Emaciation,  a  symptom,  91. 
Emphysema  of  the  lungs,  553,  618. 

interlobular,  618,  624. 

sub-p!eural,  624. 

vesicular,  618. 
Empyema,  110. 
Encephalitis,  239. 

phenomena,  240. 

morbid  anatomy,  241. 

treatment,  242. 
Encephalon,  inflammation  of,  240. 
Encephaloid  cancer,  138. 
Endocarditis,  rheumatic,  683. 
Endocardium,  morbid  states  of,  676. 
Engorgement  of  the  lungs,  559. 
Enteritis,  784. 

diagnosis,  785. 
Entozoa,  825. 

mode  of  production,  832, 
Epidemic  catarrh,  539. 

cholera,  805. 
Epilepsy,  379. 

phenomena,  380. 

varieties,  381. 

pathology,  386. 

morbid  anatomy,  387. 

treatment,  393. 

feigned,  391. 
Epistaxis,  468. 

Erysipelas,  phlegmonoides,  199. 
Erysipelas,  1004. 

in  young  infants,  1010  ^note]. 
Erythema,  121,  1014. 

nodosum,  1014. 
Events  of  inflammation,  100. 
Examination  of  abdomen,  728. 
Exanthemata,  925. 
Exciting  causes  of  disease,  58. 
Eye,  diseases  of  the,  180. 

r'ace-ache,  433. 

Facial  anaesthesia,  336,  342. 

neuralgia,  429. 

paralysis,  337. 
Falling  sicknesa,  379. 
False  membranes  of  the  pleura,  580. 


False  membranes  of  the  trachea,  516. 
Fatty  transformation  of  tissues,  36. 

liver,  632,  845, 
Fever,  inflammatory,  93,  115. 

continued,  934. 

hay,  545. 

hectic,  94,  116,  610. 

intermittent,  435. 

puerperal,  730. 

remittent,  964  [riotej. 

scarlet,  994. 

typhoid,  95,  934. 
Filaria  medinensis,  831. 
Flatulence,  777. 
Fluids,  diseases  of,  39. 
Fluxes,  796. 
Fungus  hsematodes,  141. 
Furunculus,  1025. 

Gall-bladder,  diseases  of,  855. 

Gall-stones,  850. 

Gangrena  Senilis,  114. 

Gangrene,  from  inflammation,  112 — 119. 

of  the  lungs,  562. 
Gastric  hemorrhage,  766. 
Gastritis,  acute,  753. 

phenomena,  754. 

morbid  anatomy,  755. 

treatment,  757. 

chronic,  757. 

acute,  of  infants,  760  [no/el. 
Gastrodynia,  779. 
Generation,  spontaneous,  833. 
Giddiness,  a  symptom,  85. 
Glottis,  oedema  of,  500. 
Goitre,  469. 

Gonorrhoea!  ophthalmia,  191. 
Gout,  922. 

Granulations  of  Bayle,  626. 
Gravel,  fit  of  the,  859. 

different  kinds  of,  860. 
Gravedo,  529. 

Gray  and  red  softening  of  the  lungs,  561. 
Grinder's  asthma,  647. 
Grippe,  539. 
Guinea  worm,  831. 
Gulta  serena,  213. 

Haematemesis,  706. 

hysterical,  419. 

vicarious,  767. 
Hsematuria,  899. 
Haemoptysis,  638. 

hysterical,  419. 
Hemorrhages,  general  pathology,  159. 

active  and  passive,  162. 

diagnosis,  166. 

habitual,  161. 

treatment,  166. 

vicarious,  162. 
Hemorrhage,  a  result  of  inflammation,  107 

of  the  brain,  298,  300,  316. 

cerebral,  298,  300,  316 

gastric,  766. 

nasal,  467. 


INDEX. 


1035 


Hemorrhage,  pulmonary,  608. 

spinal,  332. 

vesical,  899. 

vicarious,  161,  768. 
Hay-asthma,  545. 
Headache,  sick,  780. 
Health,  what  is,  18. 
Heart,  diseases  of,  660. 

aneurisms  of,  661,  674. 

bellows  sound  of,  666. 

dilatation  of  the,  674. 

dropsy  from,  172. 

hypertrophy  of,  660,  671. 

morbid  sounds  of,  666. 

natural  sounds  of,  663. 

palpitation  of,  668. 

rupture  of,  674. 

valvular  disease  of,  675. 
Heart-burn,  778. 
Heat  a  cause  of  disease,  61 — 63. 

a  symptom  of  inflammation,  96, 
Hectic  fever,  94,  117,638. 
Hemicrania,  434. 
Hemiplegia,  310,  333. 
Hepatic  abscess,  842. 
Hepatization  of  the  lungs,  33,  560. 
Hepatitis,  acute,  841. 

treatment,  843,  and  [note]  852. 

chronic,  845. 
Hereditary  disposition  to  disease,  59,  77. 
Herpes,  1017,  1018. 

cjrcinatus,  1018. 

iris,  1018, 

praeputialis,  1018. 

zoster,  1018. 
Hobnail  liver,  120,  745,  845. 
Hooping  cough,  552. 

pathology  of,  555  [note]. 
Hydatids,  829. 
Hydrargyrum,  1020. 
Hydrocephalus,  acute,  263. 

chronic,  278. 

spurious,  278. 
Hydrophobia,  360. 

phenomena,  361. 

causes,  366. 

morbid  anatomy,  374. 

in  the  dog,  372. 

pathology,  374. 

treatment,  374. 

prevention,  377. 
Hydrothorax,  582. 
Hypersemia,  41. 
Hypertrophy,  26 — 30. 

of  the  brain,  259. 

heart,  660,  671. 
thyreoid  gland,  469. 
Hypochondriasis,  781. 
Hysteria,  413. 

phenomena,  414. 

diagnosis,  414. 

pathology,  415. 

treatment  of,  421. 


Hysterical  affection  of  joints,  419 
cough,  417. 
hfematemesis,  418. 
laryngitis,  417. 
palsy,  417. 
peritonitis,  417. 

Icterus,  847. 

Ileus,  784. 

Impetigo,  1024. 

Impure  air,  a  cause  of  disease,  75 

Inanition  a  cause  of  death,  51. 

Indigestion,  757,  774. 

Induration,  32. 

of  the  areolar  tissue,  120. 

of  the  brain,  258. 

of  the  cellular  tissue,  120. 
Infants,  purulent  ophthalmia  of,  196. 
Infiltration  of  the  lungs,  purulent,  561     . 

tubercular,  629. 
Inflammation,  general  account  of,  92 

acute,  124. 

adhesive,  108. 

arachnoid,  237. 

areolar  tissue,  119. 

arteries,  122. 

bowels,  784. 

brain,  123,  241. 

chronic,  124. 

conjunctiva,  181,  195. 

cutaneous  tissues,  121. 

dura  mater,  231. 

encephalon,  240. 

events  of,  105. 

eye,  181. 

fibrous  tissue,  906. 

hectic  fever  from,  117. 

intestines,  784. 

iris,  202. 

kidneys,  856. 

larynx,  491. 

liver,  842. 

lungs,  559. 

mucous  membrane,  121. 

oesophagus,  726  [no/e]. 

of  the  several  tissues,  119. 

parotid,  479. 

pericardium,  683. 

peritoneum,  729. 

phenomena,  93. 

pia  mater,  237 

pleura,  579. 

pyrexia,  115. 

retina,  213. 

serous  tissue,  120. 

skin,  120. 

spinal  cord,  290—295. 

state  of  minute  blood-vessels  in,  100  '  note\ 

stomach,  753. 

synovial  membrane,  120. 

thorax,  518. 

tonsils,  485. 

trachea,  502. 


1036 


INDEX. 


[nflammation,  treatment,  142. 

typhoid  fever,  117. 

varieties  of,  124. 

veins,  122,  707. 
Inflammatory  fever,  94,  115. 
Influenza,  539. 

Inoculation  of  small-pox,  981. 
Intellect,  affections  of,  symptom  of  disease,  87. 
Intermittent  fever,  435. 

exciting  cause,  440. 

pathology,  448. 

phenomena,  435. 

prophylaxis,  465. 

species,  437. 

treatment,  456. 
Interlobular  emphysema,  620,  624. 
Intestinal  concretions,  823. 

worms,  825. 
Intestines,  diseases  of  the,  784. 

inflammation  of,  784. 

perforation  of,  734. 
Iritis,  202. 

syphilitic,  209. 
Ischuria  renalis,  866. 
Itch,  1016. 
Itching,  a  symptom,  84. 

Jaundice,  847. 

phenomena,  847. 

pathology,  848 — 852  [note]. 

prognosis,  852. 

treatment,  852  [rao/e],  854  text. 

Kidney,  diseases  of,  856. 
Bright's,  859. 
inflammation  of,  856. 
suppuration  of,  858. 

Laryngismus  stridulis,  512. 
Laryngitis,  491—500. 

hysterical,  417. 

spasmodic,  515  ^note]. 
Larynx,  acute  inflammation  of,  491. 

chronic  "  500. 

syphilitic  ulceration  of,  500. 

warty  growths  of,  501. 
Larjngeal  oedema,  499. 

phthisis,  614—632. 

ulceration,  500,  614,  632. 
Laryngeo-tracheitis,  502  [nofe]. 
Lead  colic,  792. 

palsy,  793. 
Lecturer  on  medicine,  duties  of  a,  24. 
Lepra,  1022. 
Jjife,  conditioris  of,  48. 
Lithic  diathesis,  852. 
Iiiver,  diseases  of,  841. 

abscess  of,  842. 

cirrhose,  120,  745,  845. 

fatty,  632,  845. 

hobnail,  120,  745,  845. 

inflammation  of,  842- 


Liver,  suppuration  of,  842. 
Lobular  pneumonia,  560. 
Locked  jaw,  352. 
Lumbricoid  worms,  826 — 838 
Lungs,  diseases  of  the,  528. 

abscess  of,  561. 

cancer  of,  656. 

carnification  of,  583. 

consumption  of,  626. 

emphysema  of,  553,  618 

engorgement  of,  559. 

gangrene  of,  561. 

hemorrhage  from,  504. 

hepatization  of,  32,  560. 

inflammation  of,  559. 

melanosis  of,  652. 

oedema  of,  625. 

purulent  infiltration  of,  561. 

red  and  gray,  softening  of,  5b 

sounds  of,  521. 

splenization  of,  559. 

tubercles  of,  675. 

tubercular,  infiltration,  629. 
Lymph,  coagulable,  107. 

MaculiB,  924. 

Malaria,  441.  • 

circumstances  which  influence,  450. 

condition,  necessary  to  produce,  443. 

eflTects  of,  on  human  body,  446. 

influence  of  soils  in  evolving,  447. 

ultimate  effects  of,  454. 
Malignant  cholera,  805. 
Measles,  993. 
Medicine,  principles  of,  22. 

duties  of  a  lecturer  on,  23. 
Melsena,  769. 
Melanosis,  true,  652. 

spurious,  654. 
Meningitis  of  the  brain,  237. 

cerebro-spinal,  292  [note], 

encephalica,  287  [/?o/e]. 

spine,  290. 

tubercular,  264. 
Mercury,  a  remedy  in  inflammation,  153. 
Metastasis,  105. 
Mercurial  eczema,  1020. 

tremor,  412. 
Miliary  tubercles,  626. 
Modes  of  dying,  48. 
Morbilli,  993. 
Mortification,  95,  112,  119. 

of  the  brain,  123. 
Mucous  membrane,  inflammation  of,  121. 

morbid  anatomy  of,  551. 
Mucous  rattle,  532. 
Mumps,  480. 
Murmur,  respiratory,  526,  530. 

bellows,  666. 
MuscsB  volitantes,  a  symptom,  86,  238. 
Muscular  tissue,  inflammation  of,  123. 

Nasal  hemorrhage,  467. 


INDEX. 


1037 


Nausea,  a" symptom,  85. 
Nephralgia,  856. 
Nephritis,  856. 

albuminous,  886. 
Nervous  system,  diseases  of,  220, 

physiology  of,  220. 

pathology  of,  224. 
Nervous  tissue,  inflammation  of,  123. 
Nettle  rash,  1013. 
Neuralgia,  426. 

facial,  429. 
Nutrition,  lesions  of,  38. 

Obliteration  of  veins,  712. 

Obstruction  of  bowels,  mechanical,  785, 786, 788. 

CEdema,  171. 

of  the  glottis,  500. 

lungs,  625, 

laryngeal,  499. 
(Esophagus,  diseases  of,  722. 

dilatation  of,  725. 

inflammation  of,  726  [no/e]. 

stricture  of,  722. 
Old  persons,  catarrh  of,  537. 
Opium,  a  remedy  in  inflammation,  157. 
Ophthalmia,  arthritic,  210. 

catarrhal,  181. 

Egyptian,  185,  186. 

gonorrhoeal,  190. 

purulent,  184. 

purulent  in  infantSj  196. 

pustular,  198. 

rheumatic,  210. 

strumous,  198. 
Orthopncea,  a  symptom,  88. 
Ovarian  dropsy,  741,  745,  749. 
Ovaries,  extirpation  of,  749. 
Oxalic  diathesis,  864. 

Pain,  a  symptom,  84,  95. 
Painter's  colic,  792. 
Palpation  of  the  abdomen,  729. 
Palpitation,  669. 
Palsy,  310,  332. 

facial,  337. 

from  lead,  793. 

hysterica],  417. 

local,  336. 

shaking,  410. 
Pancreas,  diseases  of  the,  856. 
Papula,  924. 
Paracentesis  thoracis,  597. 

abdominis,  751. 
Paralysis  agitans,  410. 

facial,  337. 

from  lead,  793. 

of  one  side,  310,  333. 

partial,  336. 
Paraplegia,  310,  333. 
Parotitis,  479. 
Pathology,  26. 

of  sudden  death,  49. 


Pectoriloquy,  527 — 635. 
Pemphigus,  1021. 
Percussion  of  thorax,  522. 
of  abdomen,  729,  742. 
Pericarditis,  683. 

Pericardium,  diseased  conditions  of,  537. 
Periodicity,  448. 
Peripneumonia  notha,  537. 
Peritonitis,  acute,  729. 
treatment,  736. 
chronic,  740. 
hysterical,  416. 
tubercular,  739. 
Pertussis,  552. 
Petechia,  649. 

Phlegmasia  dolens,  122,  171,  708. 
Phlebitis,  123,  707. 
Phosphatic  diathesis,  864. 
Phrenitis,  239. 
Phthisis,  626. 

auscultatory  signs,  633. 
its  connection  with  tubercles,  626. 
diagnosis,  641. 
general  symptoms,  635. 
granulations  of  Bayle,  643. 
intercurrent  pleurisy,  631. 
laryngeal,  500,  615,  632. 
statistics,  646. 
treatment,  648. 
varieties,  642. 
vomicae,  630. 
Physician,  duties  and  responsibilities  of  a,  25. 
Pia  mater,  inflammation  of,  237. 
Pictonum,  colica,  792. 
Pimples,  924. 
Plague,  1004. 
Plethora,  41,  43. 
Pleura,  inflammation  of,  580. 
morbid  anatomy,  580. 
false  membranes  of,  580. 
Pleurisy,  580. 

Pleuro-pneumonia,  559,  580. 
Pneumonia,  559. 

in  children,  574  [note]. 
lobular,  561,  84;j. 
morbid  anatomy,  562. 
prognosis,  570.  / 

treatment,  571, 
Pneumonia  notha,  537. 

typhoid,  602  [note]. 
Pneumo-thorax,  593. 
Podagra,  912. 

Polypi,  bronchial,  121,  548. 
Polysarcia,  28. 
Pompholix,  1021. 
Predisposing  causes  of  disease,  58. 
Predisposition,  hereditary,  77. 
Pressure  on  the  brain,  effects  of,  225,  309. 
Principles  of  medicine,  22. 
Prognostic  signs,  81,  83. 
Proximate  causes,  57. 
Prurigo,  1014. 
Psoriasis,  1013. 


4M3 


1038 


INDEX. 


Ptj'alisni,  spontaneous,  481. 

Puerile  respiration,  526,  565. 

Puerperal  iever,  731. 

Pulmonary  tissue,  inflammation  of,  559. 

Pulmonary  apoplexy,  612. 

consumption,  626. 

emphysema,  618. 

hemorrhage,  608. 

vesicles,  dilatation  of,  621. 
Pulse,  indications  of,  in  disease,  90. 
Purging:,  as  a  remedy  in  inflammation,  151. 
Purpura,  1026. 
Purulent  ophthalmia,  184. 

of  infants,  195. 

infiltration  of  the  lungs,  561. 
Pus,  109. 
Pustulae,  924. 
Pustular  ophthalmia,  193. 
Pyrexia,  with  inflammation,  94,  115. 
Pyrosis,  779. 

Quinsy,  485. 

RaUies  canina,  368,  372. 
Eamollissement  of  the  brain,  255. 
Red  and  gray  softening  of  the  lungs,  561. 
Redness,  a  symptom  of  inflammation,  98. 
Regimen,  antiphlogistic,  142. 
Regions  of  the  thorax,  524. 

abdomen,  728. 
Remittent  fever,  964  [no^e]. 
Renal  dropsy,  173. 

calculi,  859. 

Resolution,  an  event  of  inflammation,  94 106, 

Respiration,  abdominal,  531. 

bronchial,  527, 

cavernous,  634. 

natural  sounds  of,  531. 

puerile,  526. 

thoracic,  519,  730. 

vesicular,  530. 
Respiratory  murmur,  526,  531. 
Retinitis,  214. 
Revaccination,  989. 
Rheumatic  ophthalmia,  185 — 210. 

carditis,  683. 
Rheumatism,  acute,  906. 

varieties,  907. 

connection  with  disease  of  heart,  683. 

chronic,  911. 
Rhonchus,  531 — 563. 
Round  worms,  826. 
Rubeola,  993. 

St.  Vitus'  dance,  405. 
Salaam  convulsions,  414  [no/e]. 
Salivation,  spontaneous,  481. 
Scabies,  1016. 
Scarlet  fever,  996. 

species,  996. 

diagnosis,  997. 

symptoms,  997. 


Scarlet  fever,  sequela;  of,  999. 
treatment,  1000. 
prophylaxis,  1003. 
Sciatica,  434. 
Scirrhus,  138. 
Scrofula,  agency  of  impure  air  in  production  of, 

76  [no/el. 
Scrofulous  diathesis,  126 — 134.     ^ 
inflammation,  126. 
ophthalmia,  198. 
Scurvy,  1026. 

Seasons,  influence  of  the,  73. 
Senile  catarrh,  537. 
Sensations,  morbid,  as  symptoms,  86. 
Serous  tissues,  inflammation  of,  120. 
Serum,  efTusion  of,  106. 
Shaking  palsy,  410. 
Sibilus,  530. 
Sick  headache,  780. 
Signs  of  disease,  82. 
Scirrhus,  a  symptom,  85. 
Skin,  inflammation  of,  121. 
Sloughing,  95. 
Small-pox,  975. 

complications,  977. 
diagnosis,  976. 
species,  977. 
symptoms,  976. 
treatment,  988. 
Sneezing,  a  symptom,  89. 
Softening,  34. 

of  the  brain,  255. 
of  the  heart,  674 — 681. 
red  and  gray  of  the  lungs,  561. 
spine,  298. 

of  the  stomach,  756,  760  [no/e]. 
Solids,  alterations  of  the,  in  disease,  26 

change  of  situation  in  the,  38. 
Sore-throat,  inflammatory,  485. 

malignant,  995. 
Sounds  of  the  lungs,  521. 

heart,  663,  666. 
Spasm,  a  symptom,  88. 
Spasmodic  asthma,  621,  023,  716. 
cholera,  805. 
croup,  512  [?2o/e]. 
diseases,  345. 
laryngitis,  515  [note]. 
stricture  of  oesophagus,  724. 
Sphacelus,  113,  119. 
Specific  inflammation,  125. 
Spinal  cord,  pathology  of,  288. 
physiology  of  the,  288. 
inflammation  of,  290,  292. 
Spinal  hemorrhage,  332. 

meningitis,  291. 
Spleen,  diseases  of,  856. 
Splenization  of  the  lungs,  560. 
Spontaneous  generation,  834. 

salivation,  481. 
Spotted  fever,  940. 
Spitting  of  blood,  638. 
Spurious  croup,  512. 


INDEX. 


1039 


Spurious  hydrocephalus,  276. 
SquamjB,  924,  1022. 
Starvation,  death  by,  52. 
»  Stomach,  diseases  of  the,  753. 
cancer  of  the,  762. 
hemorrhage  from  the,  766. 
inflammation  of  the,  753. 
perforation  of  the,  735. 
softening  of  the,  756 — 760  [notej. 
ulceration  of  the,  735,  758. 
Strictures  of  the  oesophagus,  723. 
Strongulas  gigas,  832. 
Strumous  diathesis,  133. 

ophthalmia,  198. 
Sub-pleural  emphysema,  624. 
Succussion,  528. 
Sudamia,  649. 

Sudden  death,  pathology  of,  49. 
Suffocation,  death  by,  52. 
Summer  catarrh,  545. 
Summer  complaint  of  infants,  811  [note]. 
Suppression  of  urine,  866. 
Suppuration,  94^  109. 
of  the  brain,  256.  . 
diffuse  of  the  lungs,  561. 
of  the  kidney,  858. 
of  the  liver,  842. 
of  the  spine,  298. 
Swelling,  a  symptom  of  inflammation,  99. 
Symptoms,  general  account  of,  79. 
diagnostic,  80. 
prognostic,  81. 
pathognomonic,  83. 
Syncope,  death  by,  51. 

anginosa,  680. 
Synovial  membrane,  inflammation  of,  120. 
Syphilitic  ulceration  of  the  larynx,  500. 
iritis,  209. 

Tabes  mesenterica,  129 

Tffinia,  827. 

Tape  worm,  827 — 838. 

Tapping  the  brain,  284. 

Tegumentary  membranes,  inflammation  of,  121. 

Temperature,  vicissitudes  of,  a  cause  of  disease, 

69. 
Tetanus,  345. 
Thorax,  diseases  of,  517. 

auscultation  of,  521. 

inflammation  ofj  517. 

paracentesis  of,  597. 

percussion  of,  522. 

regions  of,  524. 
Thoracic  respiration,  521,  730. 

aneurisms,  700. 
Thrush,  482. 
Thymic  asthma,  512. 
Thyreoid  glands,  hypertrophy  of,  469 
'i'ic  douloureux,  429. 
Tinnitus  aurium,  a  symptom,  87. 
Tissues,  effects  of  inflammation  in  the,  119. 

atrophy  of,  30. 

hypertrophy  of,  26. 


Tissues,  induration  of,  32. 
softening  of,  33. 
transformation  of,  35. 
To  and  fro  sound  of  heart,  687. 
Tonsillitis,  485. 
Tonsils,  inflammation  of,  485. 
Tonsils,  enlarged,  491,  and  [note]. 
Tormina,  784. 

Trachea,  false  membranes  of,  506. 
foreign  bodies  in,  656. 
inflamed,  502. 
Tracheitis,  502. 
Tracheotomy  in  croup,  510,  and  \nott\ 

laryngitis,  494. 
Transformation  of  tissues,  35. 
Traumatic  tetanus,  347. 
Tremor,  a  symptom,  88. 

mercurial,  412. 
Trembles,  412. 
Trichina  spiralis,  830. 
Tricocephalus  dispar,  827. 
Trismus,  346. 
Tubercle,  126. 

forms  of,  129  \notb\. 
diffusion  of  in  children,  131  \tiote\. 
of  the  brain,  258—269,  and  [note] 
iungs,  626. 
peritoneum,  739. 
Tuberculffi,  925. 

Tubercular  infiltration  of  lungs,  629. 
meningitis,  264. 

morbid  anatomy,  268,  and  [no/e]. 
peritonitis,  739. 
phthisis,  626. 
Tumours  of  abdomen,  749,  904. 

in  brain,  258. 
Typhoid  fever,  95,  935. 
Twulioul  pneumonia,  602  \note\. 

I  Ulceration,  95,  111. 

/aryngeal,  501,  615,  632. 
of  the  stomach,  735,  757. 
syphilitic,  of  the  larynx,  501. 
tubercular     "         «  631. 

Urine,  albuminous,  877. 
bloody,  898. 
chylous,  897. 
diabetic,  868. 

morbid  conditions  of,  862 — 868,  877, 
retention  of,  hysterical,  420. 
saccharine,  868. 
suppression  of,  866. 
Urticaria,  1013. 

varieties,  1013. 
treatment,  1014. 

Vaccination,  982. 

Valves  of  the  heart,  diseases  of,  675, 

Varicella,  991. 

Variola,  975. 

Veins,  diseases  of,  707. 

inflammation  of,  122,  707. 

obliteration  of,  712. 


1040 


INDEX. 


Venesection,  143. 

Venous  tissue,  under  inflammation,  122. 

Vertigo,  a  symptom,  85. 

Vesiculae,  925,  1017. 

Vesicles  of  the  lungs,  dilated,  621. 

Vesicular  emphysema,  619. 

respiration,  527,  531,  564. 
Vicarious  hemorrhage,  162,  767. 
Vicissitudes  of  temperament  a  cause  of  disease,  68. 
Viscera,  inflammation  of  the,  120. 
Vomicae,  628 — 630. 
Vomiting,  776. 
Vomiting  of  blood,  766. 

hjsterical,  418. 


Warmth,  external,  a  remedy  in  inflammation, 

158. 
Warty  growth  of  larynx,  501. 
Wasting,  a  symptom,  91. 
Water  brash,  779. 

stroke,  266. 
Worms,  825. 

varieties,  825. 

round,  826. 

flat,  827. 

mode  of  production,  833. 

symptoms  of,  837. 

treatment,  838. 
Zona  ignea,  1018. 


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acconiplished.  The  chapters  follow  each  other  in  the  order  in  which  dissections  are  usually  con- 
ducted in  this  country,  and  as  each  region  is  taken  up,  every  detail  regarding  it  is  fully  descril:>ed 
and  illusiraled,  so  that  the  student  is  not  iuJerrupted  ia  his  labors,  by  the  necessity  of  referring  froui 
oae  portion  q(  tiie  volume  to  another. 


ANALYTJCAL    COMPENDtUM 

OF  MEDICAL  SCIENCE,  containiag  Anatomy,  Physiology,  Surgery,  Midwifery, 

Chemistry,  Materia  Medica,  Tlierapeutics,  and  Practice  of  Medicine.  By  John  Neill,  M.  D., 
&ud  F.  G.  S.MiTH,  M.  D.  New  and  enlarged  edition,  one  thick  volume  royal  12mo.  o[  over 
1000  pag^s,  with  374  illustrations.    I^^  See  Neill,  p.  24. 

ABEL   (F.    AJ,    F.  C.  S.    AND    C.    L.    BLOXAM. 
HANDBOOK  OF  CHEMISTRY,  Theoretical,  Practical,  and  Technical ;  with  a 

Recommendatory  Preface  by  Dr.  Hofmann.  In  o«e  large  octavo  volume,  extra  cloth,  of  662 
pages,  v/ith  illustrations.     $3  25. 

It  must  be  understood  that  this  is  a  work  fitted  for 
tiie  earnest  studeat,  who  resolves  to  pursue  for  lum- 
eell'  a  steady  searcli  into  the  clieniieal  mysteries  of 
creation.  For  such  a  student  tlie  '  Handbook'  will 
prove  an  excellent  guide,  since  he  will  find  ia  it, 
cot  merely  the  approved  modes  of  analytical  investi- 
gration,  b«t  laost  descriptions  of  the  apparatus  ne- 


eesBary,  with  such  manipulatory  details  as  rendered 
Faraday's  '  Cliemical  Manipulations'  so  valuable  at 
tlie  time  of  its  publication.  Beyond  this,  the  im- 
portauce  of  the  work  is  increased  by  tlie  introduc- 
tiim  of  much  of  the  technical  chemistry  of  the  manu- 
factory.— Df.  Hofnianx,'' s  Fveface. 


ASHWELL   (SAMUEL),   M.  D., 

Obstetric  Physiciaa  acd  Lecturer  to  Guv's  Hospital,  London. 

A  PRACTICAL  TKEATISE  ON  THE  DISEASES  PECULIAR  TO  WOMEN. 

illustrated  by  Cases  derived  from  Hospital  and  Private  Practice.  Tliird  American,  from  the  Third 
and  revised  London  edtlioJi.  I«  one  octavo  v^olume,  extra  cloth,  of  52S  pages.  (Lately  Piib- 
U-sked.)     $3  00. 


The  most  useful  practical  work  oa  the  subject  in 
Che  English  language.  —  Boston  Med.  and  Surg. 
Journal. 

The  most  able,  and  certainly]  the  most  etatidard 
and  practical,  work  on  female  diseases  that  we  have 
yet  seea. — Medico-C hirurgical  Review. 

The  young  practitioner  will  find  it  invaluable, 
while  tiioee  who  have  had  most  experience  will  yet 


find  Boraething  to  learn,  and  much  to  commend,  in  a 
l)ook  which  shows  so  much  patient  observaticm, 
practical  skill,  and  sound  sense. — British  and  Fo- 
reign Med.  Review. 

We  commend  it  to  our  readers  as  the  best  practi- 
cal treatise  on  the  subject  which  has  yet  appeared. 
— London  Lancet. 


ARNOTT   (NEILL),  M.  D. 

ELEMENTS    OF    PHYSICS;    or  Natural  Philosophy,  General  and  Medical. 

Written  lor  universal  use,  in  plain  or  non-technical  language.  A  new  edition,  by  Isaac  Hays, 
M.  D.  Complete  in  otje  octavo  volume,  leather,  ol'  484  pages,  with  about  two  hundred  illustra- 
tions.    ^2  6U. 

BENNETT   (HENRY),  M.  D. 
A  PRACTICAL   TREATISE    ON  INFLAMMATION  OF  THE  UTERUS, 

ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Disease.  Fourth 
American,  from  the  third  and  revised  London  edition.  To  which  is  added  {July,  1856),  a  K  kview 
OF  THE  PiiESENT  State  OF  Uterine  Pathology.  In  cuie  neat  octavo  volume,  extra  cloth,  of 
r)00  pages,  with  wood-cuts.    $2  00. 

The  addition  of  the  "Review"  presents  the  most  recent  aspects  of  the  questions  discussed  in 
tids  well-known  work,  bringing  it  down  to  the  latest  moment. 

This  edition  has  beea  carefully  revised  and  altered,  |  When,  a  (e\v  years  back,  the  first  edition  of  the 
and  various  additions  have  been  made,  which  render  present  work  was  published,  the  subject  was  one  al- 
it  more  complete,  and,  if  possible,  more  worthy  of  most  entirely  unknown  to  the  obstetrical  celebrities 
the  high  appreciaticxi  in  wliicli  it  is  held  by  the  i  of  the  day  ;  and  even  now  we  have  reason  to  know 
medical  profession  throughout  the  world.  A  copy  that  the  bulk  of  the  profession  are  not  fully  alive  to 
should  be  in  the  possession  of  every  phyatciaa. —    the  importance  and  frequency  of  the  dfsease  of  which 


it  takes  cognizance.  The  present  edition  is  so  much 
enlarged,  altered,  and  improved,  that  it  can  scarcely 
be  considered  tlie  same  work.— iJr.  lianlcing's  Ab- 
stract. 


Charleston  Med.  Journal  and  Review 

We  are  firmly  of  opinion  that  in  proportion  as  a. 
knowledge  of  uterine  diseases  becomes  more  appre- 
ciated, this  work  will  be  proportionably  established 
as  a  text-book  in  tke  profession. — The  Lancet.  | 

Also,  just  ready,  by  the  same  author,  and  for  sale  separate, 

A  REVIEW  OF  THE  PRESENT  STATE  OF  UTERINE  PATHOLOGY. 

1  small  vol.  Svo.     50  cents,  in  flexible  cloth. 

In  this  little  work,  which  can  be  had  either  in  connection  with  the   "Practical  Treatise,"  or 
separate,  the  author  presents  his  latest  views  with  regard  to  the  various  doctrines  which  have  re- 
cently been  brought  forward  on  this  interesting  question,  under  the  following  heads  : — 
Chap.    .Preliminary.     II.  Sketch  of  Uterine  Pathology.     III.  Objections.     IV.  The  Leucorrhoea 

Theory  — the  Syphilis  Theory  —  the  Ovarian  Theory.    V.    The  Displacement  Theory.    VI. 

Summary. 


BLANCHARD   &    LEA'S   MEDICAL 


BROWN    (ISAAC    BAKER), 

Surgeon-Accoucheur  to  St.  Mary's  Hospital,  &c. 

ON  SOME  DISEASES  OF  WOMEN  ADMITTING  OF  SURGICAL  TREAT- 

MENT.     With  handsome  illustrations.     One  vol.  8vo.,  extra  cloth.     {Now  Ready.)     $L  60. 

Mr.  Brown  has  earneil  for  himself  a  high  reputa-    anil  merit  the  careful  attention   of  every   surgeon- 
tion  in  the  operative  treatment  of  sundry  diseases  1  accoucheur. — Association  Journal. 
and  injuries  to  which  females  are  peculiarly  subject,  i      ,,^    ,  i      -^  ,■       •  „         i-       ^u-    v     u 

, '.    '".1""^  ^  ,„„,.i,  ,u.'i  if  ,c  or,  irr,,„„.t.,v,t        Wb  lavB  HO  hesitatioH  in  recommending  this  book 

^^' e  can  trulv  say  ot  his  worK  that  it  is  an  important  I  .     .^i  <•  i     ii     •■  /•     n  i  i 

addition  to  obstetrical  literature.  The  operative  :  '"  ^'f  c^^^'^f"'  ""/"tion  of  a  1  surgeons  who  make 
suggestions  and  contrivanoes  which  Mr.  Brown  d.-  ,  fe.rtile  complaints  a  part  of  heirstudyandpract.ee. 
scnbes,  exhibit  much  practical  sagacity  and  ^i,ni,    -Dublin  Quarterly  .Journal. 


BENNETT   (J.    HUGHES),    M.D.,    F.  R.  S.  E., 

Professor  of  Clinical  Medicine  in  the  University  of  Edinburgh,  <fcc. 

THE  PATHOLOGY  AND   TREATMENT  OF  PULMONARY  TUBERCU- 

LOSIS,  and  on  tiie  Local  Medication  of  Pharyngeal  and  Larj'ng-eal  Diseases  frequently  mistaken 
for  or  associated  with,  Phthisis.  In  one  handsome  octavo  volume,  extra  cloth,  with  beautiful 
wood-cuts.     pp.  130.     {Latelij  Issued.)     $1  25. 


SUDD  (GEORGE),  M.  D.,  F.  R.  S., 

Professor  of  Medicine  in  King's  College,  London. 

ON   DISEASES   OP   THE   LIVER.     Second  American,  from  the  second  and 

enlarged  London  edition.     In  one  very  handsome  octavo  volume,  extra  cloth,  with  four  beauti- 
fully colored  plates,  and  numerous  wood-cuts.     pp.  40S.     $3  00. 
For   many  years,  Dr.  Budd's  work  must  be  the  I  the  subject  has  been  taken  up  by  so  able  and  experi- 

aulhority  of  the  i;reat  mass  ol  British  practitioners    enced  a  physician — British  and  Foreign  Medico- 

on  the  hepatic  diseases  ;  and  it  is  satisfactory  that  I  Chirurgical  Review. 

BY  THE  SAME  AUTHOR.      [NoiV  HeadlJ.) 

ON  THE   ORGANIC   DISEASES   AND  FUNCTIONAL  DISORDERS  OP 

THE  STOJMACH.     In  one  neat  octavo  volume,  extra  cloth.     $150.     A  new  work,  1856. 

While  special  treatises  havebeen  multiplying  upon  almost  all  the  different  classes  of  diseases,  there 
has  long-  been  fijlt  the  want  of  an  authoritative  work  on  the  disorders  of  the  stomach,  which  con- 
stitute, perhaps,  a  larger  proportion  of  the  daily  practice  of  the  physician  than  any  other  class  of 
maladies.  To  supply  this  want  has  been  the  object  of  the  author,  and  his  reputation  is  an  ample 
g-uarantee  of  the  value  of  his  labors. 

From  the  high  position  occupied  by  Dr.  Budd  as  |  style,  the  .subjects are  well  arranged,  and  the  practi- 
a  teacher,  a  writer,  and  a  practitioner,  it  is  uliuost  I  cal  precepts,  both  of  diagnosis  and  treatment,  denote 
needless  to  state  tliat  the  present  book  may  be  con-  I  llie  character  of  a  thouglitful  and  experienced  phy- 
sulted  with  great  advantage.  It  is  written  in  an  easy  I  sician. — London  Med.  times  and  Gazette,  Dec.  1S55. 


BIRD  (GOLDING),  A.  M.,  M.  D.,  Sic. 
URINARY     DEPOSITS:     THEIR     DIAGNOSIS,    PATHOLOGY,    AND 

THERAPEUTICAL  INDICATIONS.     A  new  and  enlarged  American,  from  the  last  improved 
London  edition.   With  over  sixty  illustrations.    In  one  royalT2mo.  vol,  extra  cloth,  pp.372.  §130. 

It  can  scarcely  be  necessary  for  us  to  say  anything  i  extension  and  satisfactory  employment  of  our  thera- 
of  the  merits  of  this  well-known  Treatise,  which  so  peutic  resources.  In  the  preparation  of  this  new 
admirably  brings  into  practical  application  the  re-  edition  of  his  work,  it  is  obvious  that  Dr.  Golding 
suits  of  ttiose  microscopical  and  chemical  researches  Bird  lias  spared  no  pains  to  render  it  a  faithful  repre- 
regarding  the  physiology  and  pathology  of  the  uri-  sentation  of  the  present  state  of  scientific  knowledge 
na7y  secretion,  which  have  contributed  so  much  to  \  on  the  suhiect  it  emhrnces.— The  British  and  Foreign 
the  increase  of  our  diagnostic  powers,  and  to  the  I  Medico-C hirurgical  Review. 

BY    THE   SAME   At'THOR. 

ELEMENTS  OF  NATURAL  PHILOSOPHY;  being  an  Experimental  Intro- 
duction to  the  Physical  Sciences.  Illustrated  with  nearly  four  hundred  wood-cuts.  From  the 
third  London  edition.     In  one  neat  volume,  royal  12mo,  extra  cloth,     pp.402.     §125. 


BILLING'S  PRINCIPLES  OF  MEDICINE.— 
Second  American,  from  tlie  Fifth  and  Improved 
I.ondon  edition.  In  one  handsome  octavo  volume, 
extra  cloth.   250  pages.     Sfl  25. 

BLAIflSTON'S  PRACTICAL  OBSERVATIONS 
ON  CERTAIN  DISEASES  OF  THE  CHEST, 
and  .  n  tlie  Princiiiles  of  Auscultation.  In  one  vol., 
cloth,  8vo     pp.384.     ®1  "25. 

BTRROWS  ON  DISORDERS  OF  TIIE  CERE- 
URAli  CIRCULATION,  and  on  the  Connection 
between  the  Affections  lU'  the  Brain  and  Diseases 
of  tlie  Heart.  In  one  8vo.  vol.,  extra  clolh,  with 
c-..l.irtd  pbites.    pp. -210.     SI  25. 

BEM.E  ON  THE  LAWS  OF  HEALTH  IN  RE- 
LATION TO  ?<II\D  AND  BODY.  A  Series  of 
Lettfrs  from  an  old  Practitioner  to  a  Patient.  In 
•lie  volume,  royal  12mo.,  extra  cloth,  pp.  296. 
80  cents. 


BUSHNAN'S  PHYSIOLOGY  OF  ANIMAL  AND 
VEGETABLE  LIFE;  a  Popular  Treatise  on  the 
Functions  and  Phenomena  of  Organic  Life.  In 
one  handsome  royal  ]2mo.  volume,  extra  cloth, 
with  over  100  illustrations,     pp.231.     80  cents. 

BUCKLER  ON  TIIE  ETIOLOGY.  PATHOLOGY, 
AND  TREATMENT  OF  FIBRO-BRONCHI- 
TIS   AND    RHEUMATIC    PNEUMONIA.      In 

one  Svo.  volume,  extra  clolh.     pp.150.     §125. 

BLOOD  AND  URINE  (MANUALS  ON).  BY 
JOHN  WILLIAM  GRIFFITH.  G.  OWEN 
REESE,  AND    ALFRED    MARKWICK.      One 

thick    volume,    royal    12ino.,    extra    cloth,    with 
plates,    pp.  460.     $1  25. 

BRODIE'S  CLINICAL  LECTURES  ON  SUR- 
GERY.    1  vol.  8vo.,  cloth.    350  pp.     $125. 


AND   SCIENTIFIC    PUBLICATIONS. 


BARLOW   (GEORGE  H.),    M .  D. 

Physician  to  Gay's  Hospital,  London,  &c. 

A  MANUAL  OF  THE  PRACTICE  OF  iMEDICINE.     With  Additions  by  D, 

F.  CoNDiE,  M.  D.,  author  of'' A  Praclieal  Treatise  on  Diseases  of  Children,"  &c.  In  one  hand- 
some oclavo  voliuue,  leather,  of  over  bOO  pages.  (A  new  work.,  just  ready,  1856.)  $2  75. 
The  position  of  the  author  as  physician  to  Guy's  Hospital  and  other  large  public  institutions,  is 
a  sufficient  guarantee  of  the  extent  and  value  of  the  experience  which  is  here  systematically  re- 
corded and  condensed.  His  aim  throughout  has  been  to  produce  a  practical  work,  on  which  the 
student  can  rely  as  a  guide,  and  to  which  the  practitioner  can  refer  with  confidence.  The  additions 
by  the  editor  comprise  chapters  on  Cerebro-spinal  PJeningitis,  Cholera  Infantum,  and  Yellow  Fever, 
besides  numerous  notes  wherever  the  diseases  or  practice  of  this  country  seemed  to  render  them 
necessary  or  desirable. 


We  most  empliatically  commend  it  to  the  attention 
of  the  profession,  as  deserving  rheir  confidence — a 
depository  of  practical  knowledpie,  from  which  they 
may  draw  with  great  benefit. — Cincinnati  Med.  Ub- 
teri-er,  Mar.  1656. 

The  student  has  long  been  in  want  of  a  gocd  ele- 
mentary work  on  tlie  Practice  of  Medicine.  In  Dr. 
Bailow's  Manual  that  want  is  supplied;  and  we 
have  no  question  that  it  will  at  once  be  installed 
as  tlie  favorite  text-book  in  ail  Medical  Schools. — 
Medical  Times  and  Gazette. 

We  recommend  Dr.  Barlow'sManual  in  the  warm- 
est manner  as  a  most  valuable  vade-mccutn.  We 
have  had  frequent  occasion  to  consult  it,  and  have 
found  it  clear,  concise,  practical,  and  sound.  It  is 
eminently  a  practical  work,  containing  all  that  is 
essential,  and  avoiding  useless  theoretical  discus- 
sion. The  work  supplies  what  has  been  for  some 
time  wantiig,  a  manual  of  practice  based  upon  mo- 
dern discoveries  in  pathology  and  rational  views  of 
treatment  of  disease.  It  is  especially  intended  for 
the  use  of  students  and  junior  practitioners,  but  it 


will  be  found  hardly  less  useful  to  the  experienced 
physician.  The  American  editor  has  added  to  tlie 
work  three  ehajiters — <m  Cholera  Infantum,  Yellow 
Fever,  and  Cerebro-spinal  Meningitis.  These  addi- 
tions, the  two  first  of  which  are  indispensable  to  a 
work  on  practice  destined  for  the  profession  in  this 
country,  are  executed  with  great  judgment  and  fi- 
delity, by  Dr.  Condie,  who  has  also  succeeded  hap- 
pily in  imitating  the  conciseness  and  clearness  of 
style  which  are  such  agreeable  characteristics  of 
the  original  book. — Boston  Med.  and  Surg.  Journal, 
Feb.  1&3G. 

We  have  looked  through  this  volume  with  very 
great  satisfaction  ;  it  is  written  in  an  easy  and  plea- 
sant style,  and  the  short  though  lacid  expositions  of 
disease,  clearness  of  description,  and  soundness  of 
precept  will  make  it  a  welcome  visitor  in  the  library 
of  every  practitioner.  It  combines  the  simplicity  of 
old  CuLLEN,  Willi  the  elegance  of  Watson,  and  al- 
though not  so  copious  as  other  works  we  might  men- 
tion, it  will,  nevertheless,  become  a  standard  autho- 
rity.— American  Lancet,  Mar.  1856. 


BARTLETT  (ELISHA),  M.  D. 
THE   HISTORY,  DIAGNOSIS,   AND  TREATMENT   OF  THE   FEVERS 

OF  THE  UNITED  STATES.     A  new  and  revised  edition.     By  Alonzo  Clahic,  M.  D.,  Prof. 

of  Physiology  and  Pathology  in  the  N.  Y.  Coll   of  Physicians  and  Surgeons,  &c.     In  one  octavo 

volume,  of  six  hundred  pages,  extra  cloth.     {Nearly  Ready.) 

The  masterly  and  elegant  treatise  by  Dr.  Bartlett 
is  invaluable  to  the  American  student  and  practi- 
tioner.— Dr.  Holmes's  Report  to  the  JSat.  Med.  Asso- 


etation. 

We  regard  it,  from  the  examination  we  have  made 
of  it,  the  best  work  ou  fevers  extant  in  our  language. 


and  as  such  cordially  recommend  it  to  the  medical 
public. — St.Lo-uis  Medical  and  Surgical  Journal. 

Take  it  altogether,  it  is  the  most  complete  history 
of  our  fevers  which  has  yet  been  published,  and 
every  practitioner  should  avail  himself  of  its  con- 
tents.—  Tke  Western  Lancet. 


BOWMAN  (JOHN   E.),  M.D. 
PRACTICAL   HANDBOOK   OF   MEDICAL    CHEMISTRY.     Second  Ame- 

rican,  from  the  third  and  revised  Engli.^h  Edition.     In  one  neat  volume,  royal  12mo.,  extra  cloth, 

with  numerous  illustrations,     pp.  2S8.    [Now  Ready,  1856.)     $1  25. 

Presenting,  in  a  condensed  and  convenient  form,  at  a  very  low  price,  the  applications  of  Chemistry 
to  the  practical  purposes  of  Clinical  Medicine,  this  work  supplies  a  want  which  has  long  been 
felt  by  the  physician.  The  numerous  editions  which  have  been  called  for  both  in  England  and  this 
country,  suliiciently  attest  the  success  with  which  the  author  has  carried  out  his  plan. 

BY  THE  SAME  AUTHOR. 

INTRODUCTION    TO    PRACTICAL    CHEMISTRY,    INCLUDING    ANA- 

LYSIS.    With  numerous  illustrations.    In  one  neat  vol.,  royal  12mo.,  extra  cloth,    pp.350.    $125. 


CURLING    (T.    B.),    F.  R.S., 
Surgeon  to  the  Londim  Hospital,  President  of  the  Hunterian  Society,  &c. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS,  SPERMA- 
TIC CORD,  AND  SCROTUM.  Second  American,  from  the  second  and  enlarged  English  edj- 
tion.  In  one  handsome  octavo  volume,  extra  cloth,  with  numerous  illustrations,  pp.  420.  (Now 
Ready,  1856.)     $2  00. 

In  the  revised  English  edition,  of  which  this  is  a  reprint,  the  author,  for  want  of  space,  omitted 
the  Anatomical  Introduction.  By  a  more  condensed  style  of  printing,  room  has  been  found  in  the 
present  volume  to  retain  this  important  portion  without  rendering  the  work  inconveniently  lur"-e. 
Some  of  the  notef;  of  the  former  American  editor  have  also  been  incorporated,  and  a  number  of  new 
illustrations  introduced.  With  these  improvements,  and  the  thorough  revision  which  it  has  enjoyed 
at  the  hands  of  the  author,  it  will  be  found  fully  worthy  to  retain  the  authoritative  position  which 
it  has  acquired  with  regard  to  this  class  of  atiections. 


We  now  take  farewell,  for  the  present,  o{  this  ex- 
cellent treatise,  placing  it  on  our  book  shelves  by 
the  side  of  Cooper  on  Fractures  and  Dislocations, 
and  other  similar  standard  and  valuable  works  — 
^550.  Med.  Jojtrnnl,  Jan.  1856. 

We  shall  not  devote  any  further  space  to  the  work 
under  netice,  as  it  is  so  well  known  to  the  profession 


already.  We  can  only  say  that  it  should  be  in  the 
library  of  every  practical  surgeon.  The  present  edi- 
tion is  much  improved,  contains  numerous  wood- 
cuts, and  several  accounts  of  cases  illustrating  the 
various  diseases  of  the  testicles.— ilfed.  Tinus  and 
Gazette,  Feb.  1S56. 


BLANCHARD  &  LEA'S   MEDICAL 


CARPENTER  (WILLIAM    B.),   M.  D.,  F.  R.  S.,  &.C., 

Examiner  in  Piiysiology  and  Comparutive  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  applications  to 

Psychology,  Palholog^',  Therajieutics,  Hygiene,  and  Forensic  Meilicine.  A  new  American,  from 
the'  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations.  Edited,  with  addi- 
tions, by  Francis  Gurney  SiMiTH,  M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  Pennsyl- 
vania Medical  College,  Arc.  In  one  very  large  and  beautiful  octavo  volume,  of  about  nine  hundred 
large  puges,  handsomely  printed  and  strongly  bound  in  leather,  with  raised  bands.  {Just  Issued, 
1856.)    §4  Z^. 

In  the  preparation  of  this  new  edition,  the  author  has  spared  no  labor  to  render  it,  as  heretofore, 
a  complete  and  lucid  exposition  of  the  most  advanced  condition  of  its  important  subject.  The 
amouiit  of  the  additions  required  to  efl'ect  this  object  thoroiiglily,  joined  to  the  former  laige  size  of 
the  volume,  presenting  objections  arising  from  Ilie  unwieldy  bulk  of  the  work,  he  has  omitted  all 
those  portions  not  bearing  directly  upon  Hujhan  Physioi^ogy,  designing  to  incorporate  them  in 
his  forthcoming  Treatise  on  General  Physiology.  As  a  full  and  accurate  text-book  on  the  Phy- 
siology of  Man,  the  work  in  its  present  condition  therefore  presents  even  greater  claims  upon 
the  student  and  physician  than  those  which  have  beretoiore  won  for  it  the  very  wide  and  distin- 
guished favor  which  it  has  so  long  enjoyed.  The  additions  of  Prof.  Smith  will  be  found  to  supply 
whatever  may  have  been  wanting  to  the  American  student,  while  the  introduction  of  many  new 
illustrations,  and  the  most  careful  mechanical  execution,  render  the  volume  one  of  the  most  at- 
tractive as  yet  issued. 

For  upwards  of  thirteen  years  Dr.  Carpenter's]  To  eulogize  tliis  great  work  would  be  superflaous. 
■work  has  been  considered  by  tlie  i)rofession  gene-  We  should  observe,  liowever,  that  in  tliis  edition 
rally,  both  in  this  country  and  England,  as  the  most  tlie  authtir  has  remodelled  a  large  portit)n  of  the 
valuable  compendium  on  tlie  sul)ject  of  physiology  i  former,  and  the  editor  has  added  much  matter  of  in- 
in  our  language.  7'his  distinction  it  owes  to  the  high  i  terest,  especially  in  the  form  of  illustrations.  We 
attainments  and  unwearied  industry  of  its  aecom-  j  may  confidently  recommend  it  as  the  most  complete 


plishod  author.  The  present  edition  (which,  like  the 
last  American  one,  was  prepared  by  the  author  him- 
selt"),  is  the  result  of  such  extensive  revisii  n,  that  it 
may  almost  be  considered  a  new  work.  We  need 
hardly  say,  in  concluding  this  brief  notice,  that  while 
the  work  is  indispensable  to  every  stuilent  of  medi- 
cine in  this  country,  it  will  amply  repay  the  practi- 
tioner for  its  perusal  by  the  interest  and  value  of  its 
contents. — Boston  Med.  and  Surg.  Journal. 

This  is  a  standard  work — the  text-book  used  by  all 
medical  students  who  read  the  English  language. 
It  has  passed  through  several  editions  in  order  to 
keep  pace  with  the  rapidly  growing  science  of  Phy- 
siology. Nothing  need  be  said  in  its  praise,  for  its 
merits  arfe  universally  known;  we  have  nothing  to 
fay  of  its  defects,  for  they  only  appear  where  the 
science  of  which  it  treats  is  incomplete. —  Western 
Lancet. 

The  most  complete  exposition  of  physiology  which 
any  language  can  at  present  give. — Brit,  and  For. 
Mtd.-Chirurg.  KevietB. 

The  greatest,  the  most  reliable,  and  the  best  book 
on  the  subject  which  we  know  of  in  the  English 
language. — Stethoscojte. 


work  on  Human  Physiology  in  our  language. — 
Houthern  Med.  and  Surg.  Journal,  December,  1855. 

The  most  complete  w^ork  on  the  science  in  out 
language. — Am.  Med.  Journal. 

The  most  complete  work  now  extant  in  our  la»- 
gviage. — N.  O.  Med.  Register. 

The  best  text-book  in  the  )at\guage  on  this  ea- 
tensive  subject. — LoTidon  Med.  Times. 

A  complete  cyclopcedia  of  this  branch  of  science. 
—N.  Y.  Med.  Times. 

The  profession  of  this  country,  and  perhaps  also 
of  Europe,  have  anxiously  and  for  some  time  awaited 
the  announcement  of  this  new  edition  of  Carpenter's 
Human  Physiology.  His  former  editions  have  for 
many  years  been  almost  the  only  text-book  on  Phy- 
sioU)gy  in  all  our  medical  schools,  and  its  circula- 
tion among  the  profession  has  been  unsurpassed  by 
any  work  in  any  department  of  medical  science. 

It  is  quite  unnecessary  for  us  to  speak  of  thi» 
work  as  its  merits  would  justify.  The  mere  an- 
nouncement of  its  appearance  will  afTord  the  highest 
pleasure  to  every  student  of  Physiology,  while  its 
perusal  will  be  of  infinite  service  in  advancing 
physiological  science. — Ohio  Med.  and  Surg.  Jonm. 


BY  THE  SAME  AUTHOR.     {Lately  Issued.) 

PRINCIPLES  OF  COMPARATIVE   PHYSIOLOGY.     New  Araeriean,  from 

the  Fourth  and  Revised  London  edition.  In  one  large  and  handsome  octavo  volume,  with  over 
three  hundred  beaulilul  illustrations,  pp.  752.  Extra  cloth,  $4  80  ;  leather,  raised  bands,  $5  25. 
The  delay  which  has  existed  in  the  appearance  of  this  work  has  been  caused  by  the  very  thorough 
revision  and  remodelling  which  it  has  undergone  at  the  hands  of  the  author,  and  the  large  number 
of  new  illustrations  which  have  been  prepared  for  it.  It  will,  therefore,  be  found  almost  a  new 
work,  nnd  fully  up  to  the  day  in  every  department  of  the  subject,  rendering  it  a  reliable  text-book 
for  all  students  engaged  in  this  branch  of  science.  Every  effort  has  been  made  to  render  its  typo- 
graphical finish  and  mechanical  execution  worthy  of  its  exalted  reputation,  and  creditable  to  the 
nsechanical  arts  of  this  country. 


This  book  should  not  only  be  read  bat  thoroughly 
studied  by  every  member  of  the  profession.  None 
are  too  wise  or  old,  to  be  benefited  thereby.  But 
especially  to  the  younger  class  would  we  cordially 
commend  it  as  best  fitted  of  any  work  in  the  English 
language  to  qualify  them  for  the  reception  and  com- 
prehension of  those  truths  which  are  daily  being  de- 
veloped in  physiology. — Medical  Counsellor. 

Without  pretending  to  it,  it  is  an  encycloppdia  of 
the  subject,  accurate  and  complete  in  all  respects — 
a  truthful  reflection  of  the  advanced  state  at  which 
the  science  has  now  arrived. — Dublin  Quarterly 
Jottrnnl  of  Medical  Science. 

A  truly  magnificent  v/ork — in  itself  a  perfect  phy- 
siological study. — Ranking'' s  Abstract. 

This  work  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken ;    t  is  one 


no  man,  we  believe,  could  have  brought  to  so  suc- 
cessful an  issue  as  Dr.  Carpenter.  It  required  for 
its  production  a  physiologist  at  once  deeply  read  in 
the  labors  of  others,  capable  of  taking  a  general, 
critical,  and  unprejudiced  view  of  tht)8e  labors,  and 
of  combining  the  varied,  heterogeneous  materials  al 
his  disposal,  so  as  to  form  an  harmonious  whole. 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  its  unity,  of  the  admirable  manner  in  which 
material  has  l>een  brought,  from  the  most  various 
sources,  to  conduce  to  its  completeness,  of  the  lucid- 
ity of  the  reasoning  it  contains,  or  of  the  clearness 
of  language  in  which  the  whole  is  clothed.  Not  the 
profession  only,  but  the  scientific  world  at  large, 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  this 
great  work.  It  must,  indeed,  add  largely  evem  to 
his  high  reputation. — Medital  Times. 


AND    SCIENTIFIC   PUBLICATIONS. 


CARPENTER  (WILLIAM   B.),   M .  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 
{Now  Ready,  June,  1S56.) 

THE  MICROSCOPE  AND  ITS  REVELATIONS.      With  an  Appendix  con- 

taining  the  Applications  of  the  Microscope  to  Clinical  Medicine,  fcc.     By  F.  G.  Smith,  M.  D 
Illustrated  by  four  hundred  and  thirty-lour  beautiful  engravings  on  wood.     In  one  large  and  ver- 
handsome  octavo  volume,  of  724  pages,  extra  cloth,  $4  00  ;  leather,  $4  50. 
Dr.  Carpenter's  position  as  a  microscopist  and  physiologist,  and  his  great  experience  as  a  teacher, 
emuiently  qualify  him  to  produce  what  has  long  been  wanted — a  good  text-book  on  the  practical 
use  of  the  microscope.     In  the  present  volume  his  object  has  been,  as  stated  in  his  Preface,  "  to 
combine,  within  a  moderate  compass,  that  information  with  regard  to  the  use  of  his  '  tools,'  which 
is  most  essential  to  the  working  microscopist,  with  such  an  account  of  the  objects  best  fitted  for 
his  study,  as  might  qualify  him  to  comprehend  what  he  observes,  and  might  thus  prepare  him  to 
benefit  science,  whilst  expanding  and  refreshing  his  ownmind  "     That  he  has  succeeded  in  accom- 
plishing this,  no  one  acquainted  with  his  previous  labors  can  doubt. 

The  great  importance  of  the  microscope  as  a  means  of  diagnosis,  and  the  number  of  microsco- 
pists  who  are  also  phy.-^icians,  have  induced  the  American  publishers,  with  the  author's  approval,  to 
add  an  Appendix,  carefully  prepared  by  Professor  Smith,  on  the  applications  of  the  instrument  to 
clinical  medicine,  together  with  an  account  of  American  Microscopes,  their  modifications  and 
accessories.  This  portion  of  the  work  is  illustrated  wilh  nearly  one  hundred  wood-cuts,  and,  it  is 
hoped,  will  adapt  the  volume  more  particularly  to  the  use  of  the  American  student. 

Every  care  has  been  taken  in  the  mechanical  execution  of  the  work,  which  is  confidently  pre- 
sented as  in  no  respect  inferior  to  the  choicest  productions  of  the  London  press. 

The  mode  in  which  the  author  has  executed  his  ikitentions  may  be  gathered  from  the  following 
condensed  synopsis  of  the 

CONTENTS. 
Introduction — History  of  the  Microscope.      Chap.  I.   Optical   Principles  of  the  Microscope. 
Chap.  II.    Construclion  of  the  Microscope.      Chap.  III.    Accessory  Apparatus.     Chap.  IV. 
Management  of  the  Microscope      Chap.  V.  Preparation,  Moimting,  and  Collection  of  Objects. 
Chap.  VI.  Microscopic  Forms  of  Vegetable  Life — Protophytes.     Chap.  VII.  Higher  Cryptoga- 
mia.     Chap.  VIII.  Piianerogamic  Plants.     Chap.  IX.  Microscopic  Forms  of  Animal  Life — Pro- 
tozoa— Animalcules.     Chap.  X.  Foraminifera,  Polycystina,  and  Sponges.     Chap.  XI.  Zoophytes. 
Chap.  XII.    Echinodermala.     Chap.  XIII.    Polyzoa   and  Compound   Tunicata.     Chap.  XIV. 
Molluscous  Animals  Generally.     Chap.  XV.  Annulosa.     Chap.  XVI.  Crustacea.     Chap.  XVII. 
Insects  and  Arachnida.     Chap.  XVIII.  Vertebrated  Animals.     Chap.  XIX.  Applications  of  the 
Microscope  to  Geology.     Chap.  XX.  Inorganic  or  Mineral  Kingdom — Polarization.     Appendix. 
Microscope  as  a  means  of  Diagnosis — Injections — Microscopes  of  American  Manufacture. 
Those  who  are  acquainted  with  Dr.  Carpenter's 
previous  writings  on  Animal  and  Vegetable  Physio- 
logy, will  fully  understand  how  vast  a  store  of  know- 
ledge he  is  able  to  bring  to  bear  ujion  so  comprehen 


and  even  those  who  have  no  previous  acquaintance 
with  the  construction  or  uses  of  this  instrument, 
will  find  abundance  of  information  conveyed  in  clear 
and  simple  language. — Med.  Times  and  Gazette. 
May,  lb56. 


sive  a  subject  as  the  revelations  of  the  microscope  ; 

BY   THE   SAME   AUTHOR. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 

LOGICAL  ANATOMY".     Second  American,  from  a  new  and  revised  London  edition.     With 
one  hundred  and  ninety  illustrations.    In  one  very  handsome  octavo  volume,  leather,    pp.  566 

$3  00. 

In  publishing  the  first  edition  of  this  work,  its  title  was  altered  from  that  of  the  London  volume, 
by  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  and  with  the  author's  sanction 
tne  title  of  "Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise. 

To  say  that  it  is  the  best  manual  of  Physiology  i  Those  who  have  occasion  for  an  elementary  trea- 
now  before  the  public,  would  not  do  sufficient  justice  tise  on  Physiology,  cannot  do  better  than  to  possess 
to  the  author. — Buffalo  Medical  Journal.  themselvesof  the  manual  of  Dr.  Carpenter. Medical 

In  his  former  works  it  would   seem  that  he  had     Examiner. 
exhausted  the  suliject  of  Physiology.  In  the  present.        The   best  and  most  complete  expose  of   modern 
hegivestheessence,a8itwere,  of  the  whole. — N.  Y.\  Physiology,   in  one  volume,  extant  in  the  English 
Journal  of  Medicine.  |  language. — St.  Louis  Medical  Journal. 

BY  THE  SAME  AUTHOR.     {Preparing.) 

PRINCIPLES  OF   GENERAL   PHYSIOLOGY,    INCLUDING   ORGANIC 

CHEMISTRY  AND   HISTOLOGY.     Wilh   a  General  Sketch  of  the  Vegetable  and  Animal 

Kingdom.     In  one  large  and  very  handsome  octavo  volume,  with  several  hundred  illustrations. 

The  subject  of  general  physiology  having  been  omitted  in  the  last  editions  of  the  author's  "  Comr 

parative  Physiology"  and  "  Human  Physiology,"  he  has  undertaken  to  prepare  a  volume  which 

shall  present  it  more  thoroughly  and  fully  than  has  yet  been  attempted,  aiid  which  may  be  regarded 

as  an  introduction  to  his  other  works. 

BY   THE   SAME    AUTHOR. 

A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DISEASE.     New  edition,  with  a  Preface  by  D.  F.  Condie,  M.  D.,  and  explanations  of 
scientific  words.     In  one  neat  I2mo.  volume,  extra  cloth,    pp.  178.     [Just  Issued.)     50  cents. 


CHELIUS   (J.  M.),    M.  D., 

Professor  of  Surgery  in  the  University  of  Heidelberg,  &c. 

A  SYSTEM  OF  SURGERY.     Translated  from  the  German,  and  accompanied 

with  additional  Notes  and  References,  by  John  F.  South.     Complete  in  three  very  large  octavo 
volumes,  of  nearly  2200  pages,  strongly  bound,  with  raised  bands  and  double  titles.     $10  00. 


BLANCHARD  &  LEA'S  MEDICAL 


CONDIE  (D.  F.),  M.  D.,  &.c. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHiIdREN.    Fourth 

edition,  revised  and  augmented.    In  one  large  volume,  8vo.,  leather,  of  nearly  750  pages.  $3  00. 
From  the  Author's  Preface. 

The  demand  for  another  edition  has  afflirded  the  author  an  opportunity  of  again  subjecting  the 
entire  treatise  to  a  careful  revision,  and  of  incorporating  in  it  every  important  observation  recorded 
since  the  appearance  of  the  last  edition,  in  reference  to  the  pathology  and  therapeutics  of  the  several 
diseases  oi  which  it  treats. 

In  the  preparation  of  the  present  edition,  as  in  those  which  have  preceded,  while  the  author  has 
aj^proprialed  to  his  use  every  important  fact  that  he  has  found  recorded  in  the  works  of  others, 
having  a  direct  bearing  upon  either  of  the  subjects  of  which  he  treats,  and  the  numerous  valuable 
observations — pathological  as  well  as  practical — dispersed  throughout  the  pages  of  the  medical 
journals  of  Europe  and  America,  he  has,  nevertheless,  relied  chiefly  upon  his  own  observations  and 
experience,  acquired  during  a  long  and  somewhat  extensive  practice,  and  under  circumstances  pe- 
culiarly well  adapted  for  the  clinical  stud}'  of  the  diseases  of  early  life. 

Every  species  ol  hypothetical  reasoning  has,  as  much  as  possible,  l>een  avoided.  The  author  lias 
endeavored  throughout  the  work  to  conline  himself  to  a  simple  statement  of  well-ascertained  patho- 
logical facts,  and  plain  therapeutical  directions — his  chief  desire  being  to  render  it  what  its  title 
imports  it  to  be,  a  practical  treatise  on  the  diseases  of  children. 

Dr.  Condie's  scliolarship,  acumen,  industry,  and  :      We  feel  assured  from  actual  experience  that  no 
practical  sense  are  manifested  in  this,  as  in  all  his  !  physician's  library  can  be  complete  without  a  copy- 
numerous  contributions  to  science. — Dr.  Holmes''s  \  of  this  work. — N.  Y.  Journal  of  Medicine. 
Report  to  the  American  Medical  Association.  I       .         ..   ,  ,  ...  ,  ,.  ,       , 

.  T-v      ^     J-   ^  A  veritable  paediatric  encyclopaedia,  and  an  honor 

Taken  as  a  whole,  in  our  judgment.  Dr.  Condie  s    j^  American  medical  literature.— OAio  Medical  and 


Treatise  is  the  one  from  the  perusal  of  which  the 
practitioner  in  this  country  will  rise  with  the  great- 
est satisfaction. — Western  Journal  of  Medicine  and 
Surgery. 

One  of  the  best  works  upon  the  Diseases  of  Chil- 
dren in  the  English  language. — Western  Lancet. 

Perhaps  the  most  full  and  complete  work  no^v  be- 


Surgical  Journal. 

We  feel  persuaded  that  the  American  medical  pro- 
fession wiU  soon  regard  it  not  only  as  a  very  good, 
but  as  the  veky  best  "  Practical  Treatise  on  the 
Diseases  of  Children." — American  Medical  Journal. 

We  pronounced  the  first  edition  to  be  the  best 
fore  the  profession  of  tlie  United  States;  indeed,  we  j  work  on  the  diseases  of  children  in  the  English 
may  say  in  the  English  language.  It  is  vastly  supe- i  language,  and,  notwithstanding  all  that  has  been 
rior  to  most  of  its  predecessors. — Transylvania  Med.  I  published,  we  still  regard  it  iu  that  light. — Medical 
Journal.  I  Examiner. 


CHRISTISON   (ROBERT),  M.  D.,  V.  P.  R.  S.  E.,  &c. 

A  DISPENSATORY;  or,  Commentary  on  the  Pharmacopoeias  of  Great  Britain 

and  the  United  States;  comprising  the  Natural  History,  Description,  Chemistry,  Pharmacy,  Ac- 
tions, Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica.     Second  edition,  revised  and  im- 
proved, with  a  Supplement  containing  the  most  important  New  Remedies.     With  copious  Addi- 
tions, and  two  hundred  and  thirteen  large  wood-engravings.     By  R.  Eglesfeld  Griffith,  M.  D. 
In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  of  over  1000  pages.  $3  50. 
It  is  not  needful  that  wt  should  compare  it  with     this  branch  of  knowledge  which  the  student  has  a 
the  other  pharmucopceias  extant,  which  enjoy  and     right  to  expect  in  such  a  work,  we  confess  the  omis- 
inerit  the  confidence  of  the  profession  :  it  is  enough     sion  has  escaped  our  scrutiny.  We  cordially  recoin- 
to  say  that  it  appears  to  us  as  perfect  as  a  Dispensa-     mend  this  work  to  such  of  our  readers  as  are  in  need 
tory,  in  the  present  state  of  pharmaceutical  science,     of  a  Dispensatory.     They  cannot  make  choice  of  a 
could  be  made.     If  it  omits  any  details  pertaining  to  ,  better. —  Western  Journ.  of  Medicine  and  Surgery. 


COOPER  (BRANSBY   B.),  F.  R.  S. 
LECTURES  ON  THE   PRINCIPLES   AND    PRACTICE   OF   SURGERY. 

In  one  very  large  octavo  volume,  extra  cloth,  of  750  pages.    S3  00. 


COOPER  ON  DISLOCATIONS  AND  FRAC- 
TURKS  OF  THE  JOINTS  —Edited  by  Bkansby 
D.  Cooper,  F.  R.  S.,  &c.  With  additional  Ob- 
servations by  Prof.  J.  C.  Warren.  A  new  Ame- 
rican edition.  In  one  handsome  octavo  volume, 
extra  cloth,  of  about  500  iiages,  with  numerous 
illustrations  on  wood.     $3  '25. 

COOPER  ON  THE  ANATOMY  AND  TREAT- 
MENT OF  ABDOMINAL  HERNIA.  One  large 
volume,  imperial  Svo.,  extra  cloth,  with  over  130 
lithographic  figures.     $2  50. 

COOPER  ON  THE  ANATOMY  AND  DISEASES 
OF  THE  BREAST,  with  twenty-five  Miscellane- 
ous and  Surgical  Papers.  One  large  volume,  im- 
perial 8vo.,  extra  cloth,  with  252  figures,  on  36 
plates.     S2  50. 

COOPER  ON  THE  STRUCTURE  AND  DIS- 


EASES OF  THE  TESTIS,  AND  ON  THE 
THYMUS  GLAND.  One  vol.  imperial  Svo.,  ex- 
tra cloth,  with  177  figures  on  29  plates.     $.2  00. 

COPLAND  ON  THE  CAUSES,  NATURE,  AND 
TREATxMENT  OF  PALSY  AND  APOPLEXY. 
In  one  volume,  royal  12mo.,  extra  cloth,  pp.  32G. 
60  cents. 

CLYMER  ON  FEVERS:  THEIR  DIAGNOSIS, 
PATHOLOGY,  AND  TREATMENT  In  one 
octavo  volume,  leather,  of  GOO  pages.     $1  50. 

COLOiVIBAT  DE  L'lSERE  ON  THE  DISEASES 
OF  FE.MALES,  and  on  the  special  Hygiene  of 
their  Sex.  Translated,  with  many  Notes  and  Ad- 
ditions, by  C.  D.  Meigs,  M.  D.  Second  edition, 
revised  and  improved  In  one  large  volume,  oc- 
tavo, leatlier,  with  numerous  wood-cuts.  pp.  720. 
S3  50. 


CARSON   (JOSEPH),  M.  D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania. 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA  MEDICA 

AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.     Second  and  revised  edi- 
tion.    In  one  very  neat  octavo  volume,  extra  cloth,  of  208  pages.     (Now  Ready.)    $1  50. 


AND    SCIENTIFIC    PUBLICATIONS. 


CHURCHILL  (FLEETWOOD),  M.  D.,  M.  R.  r.  A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.  A  new  American, 

from  the  last  and  improved  English  edition.  Edited,  witli  Notes  and  Additions,  by  D.  Francis 
CoNDiE,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Children,"  &c.  With  139 
illustrations.     In  one  very  handsome  octavo  volume,  leather,    pp.510.     $3  00. 

No  work  holds  a  higher  position,  or  is  more  de- 
servinn;'  of  being  placed  in  the  hands  of  the  tyro, 
the  advanced  student,  or  the  practitioner. — Medical 
Exaviiner . 


To  bestow  praise  on  a  book  that  has  received  such 
marked  approbation  would  be  superfluous.  We  need 
only  say,  therefore,  that  if  the  first  edition  was 
thought  worthy  of  a  favorable  reception  by  the 
medical  public,  w^e  can  confidently  aflirm  that  this 
will  be  found  nuieh  more  so.  The  lecturer,  the 
practitioner,  and  the  student,  may  all  have  recourse 
to  its  pages,  and  derive  from  their  perusal  much  in- 
terest and  instruction  in  everything  relating  to  theo- 
retical  and  practical  midwifery. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  work  of  very  great  merit,  and  such  as  we  can 
confidently  recommend  to  the  study  of  every  obste- 
tric practitioner. — London  Medical  Gazette. 

This  is  certainly  the  most  perfect  system  extant. 
It  is  the  best  adapted  for  the  purposes  of  a  text- 
book, and  that  which  he  whose  necessities  confine 
him  to  one  book,  should  select  in  preference  to  all 
others. — Southern  Medical  and  Surgical  Journal. 

The  most  popular  work  on  midwifery  ever  issued 
from  the  American  press. — Charleston  Med.  Journal. 

Were  we  reduced  to  the  necessity  of  having  but 

one   work   on  midwifery,  and  permitted    to  choose, 

•ve  would  unhesitatingly  take  Churchill. —  Western 

Med.  and  Surg.  Journal. 

It   is   impossible   to  conceive  a  more  useful   and 

■"gant    manual   than    Dr.  Chnrehill's   Practice   of 

Iidwifery. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
the  subject  which  exists. — N.  Y.  Annalist. 


Previous  editions,  under  the  editorial  supervision 
of  Prof  R.  M.  Huston,  have  been  received  with 
marked  favor,  and  they  deserved  it ;  but  this,  re- 
printed from  a  very  late  Dublin  edition,  carefully 
revised  and  brought  up  by  the  author  to  the  present; 
time,  does  present  an  unusually  accurate  and  able 
exposition  of  ever)'  important  particular  embraced 
in  the  department  of  midwifery.  *  *  The  clearness, 
directness,  and  precision  of  its  teachings,  together 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  in 
the  foremost  rank  of  works  in  this  department  of  re- 
medial science. — N.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  the 
very  best  text-book  and  epitome  of  obstetric  science 
which  we  at  present  possess  in  the  English  lan- 
guage.— Montlily  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  greatamount  of  statistical  research 
which  it  contains,  have  served  to  place  it  in  the  first 
rank  of  works  in  tliis  departmentof  medical  science. 
—  N.  Y.  Journal  of  Medicine. 

Few  treatises  will  be  found  better  adapted  as  a 
text-book  for  the  student,  or  as  a  manual  for  the 
frequent  consultation  of  the  young  practitioner. — 
American  Medical  Journal. 


BY  THE  SAME  AUTHOR.      (Now  Readi/,  1856.) 

ON  THE  DISEASES  OF  INFANTS   AND   CHILDREN.     Second  American 

Edition,  revised  and  enlarged  by  the  author.    Edited,  with  Notes,  by  W.  V.  Keating,  M.  D.    In 

one  large  and  handsome  volume,  extra  cloth,  of  over  700  pages.     $3  00,  or  in  leather,  $3  2-5. 

In  preparing  this  work  a  second  time  for  the  American  profession,  the  author  has  spared  no 
labor  in  giving  it  a  very  thorough  revision,  introducing  several  new  chapters,  and  rewriting  others, 
while  every  portion  of  the  volume  has  been  subjected  to  a  severe  scrutiny.  The  efforts  of  the 
American  editor  have  been  directed  to  supplying  such  information  relative  to  matters  peculiar 
to  this  country  as  might  have  escaped  the  attention  of  the  author,  and  the  whole  may,  there- 
fore, be  safely  pronounced  one  of  the  most  complete  works  on  the  subject  accessible  to  the  Ame- 
rican Profession.  By  an  alteration  in  the  size  of  the  page,  these  very  extensive  additions  have 
been  accommodated  without  unduly  increasing  the  size  of  the  work. 

A  few  notices  of  the  Ibrmer  edition  are  subjoined  : — 

We  regard  this  volume  as  possessing  more  claims 
to  completeness  than  any  other  of  the  kind  with 
which  we  are  acquainted.  Most  cordially  and  ear- 
nestly, therefore,  do  we  commend  it  to  our  profession- 
al brethren,  and  we  feel  assured  that  the  stamp  of 
their  approbation  will  indue  time  be  impressed  upon 
it.  After  an  attentive  perusal  of  its  contents,  we 
hesitate  not  to  say,  that  it  is  one  of  the  most  com- 
prehensive ever  written  upon  the  diseases  of  chil- 
dren, and  that,  for  coi)iousnessof  reference,  extent  of 
research,  and  perspicuity  of  detail,  it  is  scarcely  to 
be  equalled,  and  not  to  be  excelled,  in  any  lan- 
guage.— Dublin  Quarterly  Journal. 


After  this  meagre,  and  we  know,  very  imperfect 
notice  of  Dr.  Churchill's  work,  we  shall  conclude 
by  saying,  that  it  is  one  that  cannot  fail  from  its  co- 
piousness, extensive  research, and  general  accuracy, 
to  exalt  still  higher  the  reputation  of  the  author  in 
this  country.  The  American  reader  will  be  particu- 
larly pleased  to  find  that  Dr.  Churchill  has  done  full 
justice  tliroughout  his  w^ork  to  the  various  American 
authors  on  tliis  subject.  The  names  of  Dewees, 
Eberle,  Condie,  and  Stewart,  occur  on  nearly  every 
page,  and  these  authors  are  constantly  referred  to  by 
the  author  in  terms  of  the  highest  praise,  and  with 
the  most  liberal  courtesy. — The  Medical  Examiner. 


The  present  volume  will  sustain  the  reputation 
acquired  by  the  author  from  his  previous  works. 
The  reader  will  find  in  it  full  and  judicious  direc- 
tions for  the  management  of  infants  at  birth,  and  a 
compendious,  but  cle^r  account  of  the  diseases  to 
which  children  are  liable,  and  the  most  successful 
mode  of  treating  them.  VVe  must  not  close  this  no- 
tice without  calling  attention  to  the  author's  style, 
which  is  perspicuous  and  polished  to  a  degree,  we 
regret  to  say,  not  generally  characteristic  of  medical 
works.  We  recommend  the  work  of  Dr.  Churchill 
most  cordially,  both  to  students  and  practitioners, 
as  a  valuable  and  reliable  guide  in  the  treatment  of 
the  diseases  of  children. — Am.  Journ.  of  the  Med. 
Sciences. 

We  know  of  no  work  on  this  department  of  Prac 
tical  Medicine  which  presents  so  candid  and  unpre- 
judiced a  statement  or  posting  up  of  our  actual 
knowledge  as  this. — N.  Y.  Journal  of  Medicine. 

Its  claims  to  merit  both  as  a  scientific  and  practi- 
cal work,  are  of  the  highest  order.  Whilst  we 
would  not  elevate  it  above  every  other  treatise  on 
the  same  subject,  we  certainly  believe  that  very  few 
are  equal  to  it,  and  none  superior. — Southern  Med. 
and  Surgical  Journal. 


BY  THE   SAME   AUTHOR. 


ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES  PE- 
CULIAR TO  WOMEN.  Selected  from  the  writings  of  British  Authors  previous  to  the  close  of 
the  Eighteenth  Century.    In  one  neat  octavo  volume,  extra  cloth,  of  about  450  pages.     $2  50. 


10 


BLANGHAKD    &    LEA'S    MEDICAL 


CHURCHILL  (FLEETWOOD),    M.  D.,  M.  R.  I ,  A,,    &.c. 
OX  THE  DISEASES  OF  WOMEN;  including  those  of  Pregnancy  and  Child- 

bed.  A  new  American  edition,  revised  by  the  Author.  With  Notes  and  Additions,  by  D  Fran- 
cis CoNDiE,  M.  D.,  author  of  "A  Practical  Treatise  on  the  Diseases  of  Children."  Li  one  large 
and  handsome  octavo  volunme,  with  wood-cuts,  leather,  pp.  684.     S3  00. 


■\Venow  reg;retfully  take  leave  of  Dr.  ChurcliiirB 
book.  Had  our  typographical  limits  permitted,  we 
should  gladly  have  borrowed  more  from  its  riolily 
st<irpd  pages.  In  conclusion,  we  heartily  recom- 
mend it  to  the  profession,  and  would  at  the  same 
time  express  our  firm  conviction  that  it  will  not  only 
add  to  the  reputation  of  its  author,  but  will  prove  a 
work  of  great  and  extensive  utility  to  obstetric 
practitioners. — Dublin  Medical  Press. 

Former  editions  of  this  work  have  been  noticed  in 
previous  numbers  of  the  Journal.  The  sentiments  of 
high  conmiendation  expressed  in  those  notices,  have 
only  to  be  repeated  in  this;  not  from  the  fact  that 
the  profession  at  large  are  not  aware  of  the  high 
merits  which  this  work  really  possesses,  but  from  a 
desire  to  see  the  principles  and  dt>ctrines  therein 
contained  more  generally  recognized,  and  mijre  uni- 
versally earned  out  in  practice. — N.  Y.  Journal  of 
Medicine. 

We  know  of  no  author  who  deserves  that  appro- 
bation, on  "  the  diseases  of  females,"  to  the  same 
extent  that  Dr.  Churchill  does.  His,  indeed,  is  the 
only  thorough  treatise  we  knnw  of  on  the  subject; 
and  it  may  be  commended  to  practitioners  and  stu- 
dents as  a  masterpiece  in  its  particular  department. 
The  former  editions  of  this  work  have  been  com- 
mended strongly  in  this  journal,  and  they  have  \von 
their  way  to  an  extended,  and  a  well-deserved  popu- 


larity. This  fifth  edition,  before  us,  is  well  calcu- 
lated to  maintain  Dr.  Churchill's  high  reputation. 
It  was  revised  and  enlarged  by  the  author,  for  his 
American  publishers,  and  it  seems  to  us  that  there  ig 
scarcely  any  species  of  desirable  information  on  ite 
subjects  that  may  not  be  found  in  this  work. — Tin 
Western  Journal  of  Medicine  and  Surgery. 

We  are  gratified  to  announce  a  new  and  revised 
edition  of  Dr.  Churchill's  valuable  work  on  the  dis- 
eases of  females  We  have  ever  regarded  it  as  one 
of  the  very  best  works  on  the  subjects  embraced 
within  its  scope,  in  the  English  language;  and  the 
present  edition,  enlarged  and  revisetl  by  the  author, 
renders  it  still  more  entitled  to  the  confidence  of  the 
profession.  The  valuable  notes  of  Prof.  Huston 
have  been  retained,  and  contribute,  in  no  small  de- 
gree, to  enhance  the  value  of  the  work.  It  is  a 
source  of  congratulation  that  the  publishers  have 
permitied  the  author  to  be,  in  this  instance,  his 
own  editor,  thus  securing  all  the  revision  which 
an  author  alone  is  capable  of  making. — The  Western 
Lancet. 

Asa  comprehensive  manual  for  students,  or  a 
work  of  reference  for  practitioners,  vee  only  speak 
with  common  justice  when  we  say  that  it  surpasses 
any  other  that  has  ever  issued  on  the  same  sub- 
ject from  the  British  press. — The  Dublin  Quarterlp 
Journal. 


DICKSON   (S.    H.>,    M.  D., 

Professor  of  Institutes  and  Practice  of  Medicine  in  the  Medical  College  of  South  Carolina. 

ELEMENTS  OF  MEDICINE;    a  Compendious  View  of  Pathology  and  Thera- 

pentics,  or  the  History  »nd  Treatment  of  Diseases.     In  one  large  and  handsome  octavo  volume, 

of  7-50  pages,  leather      (No^v  Ready.)     $-3  75. 

As  an  American  text-book  on  the  Practice  of  Medicine  for  the  student,  and  as  a  condensed  work 
of  reference  for  the  practitioner,  this  volume  will  have  strong  claims  on  the  attention  of  the  prolession. 
Few  physicians  have  had  wider  opportunities  than  the  author  for  obsen'ation  and  experience,  and 
few  perhaps  have  used  them  belter.  As  the  result  of  a  life  of  study  and  practice,  therefore,  the 
present  volume  will  doubtless  be  received  with  the  welcome  it  deserves. 

This  book  is  eminently  what  it  professes  to  be;  a  I  clear  and  accurate  descriptions,  purity,  and  simpli- 
distmguishcd  merit  in  these  days.  Designed  for  city  of  style,  and  soundness  of  precept,  the  reader 
"  Teachers  and  Students  of  Medicine,"  anil  admira-  will  find  much  to  admire  and  adopt,  and  lot  a  little 
bly  suited  totheir  wants,  \\'e  think  it  will  be  received,  \  that  calls  for  deep  reflection.  We  cordially  recom- 
on  its  own  merits,  with  a  hearty  welcome. — Boston  mend  this  volume  to  our  readers,  vrhether  old  prac- 
Med.  and  Surg.  Journal.  titioners  or  students,  for  we  take  it  that  the  physician 

Indited  by  one  of  the  most  accomplished  writers    should  always  be  a  student.— ^wericaw  Lancet. 
of  our  country,  as  well  as  by  one  who  has  long  held  |      Prof.  Dickson's  work  supplies,  to  a  great  extent, 
a  high  position  among  teachers  and  practitioners  of!  a  desideratum  long  felt  in  American  medicine. — iV. 
medicine,  this  ^vork  is   entitled   to   patronage   and     O.  Med.  and  Surg.  Journal. 


careful  study.  The  learned  author  has  endeavored 
to  condense  in  this  volume  most  of  the  practical 
matter  contained  in  his  former  productions,  so  as  to 
adapt  it  to  the  use  of  those  who  have  not  time  to 
devote  to  more  extensive  works. — Southern  Med.  and 
Surg.  Journal. 

We  can  strongly  recommend  Dr.  Dickson's  work 
to  our  readers  as  one  of  interest  and  practical  utility. 


Estimating  this  work  according  to  the  purpose  for 
which  it  is  designed,  we  must  think  highly  of  its 
merits,  and  we  have  no  hesitation  in  predicting  for 
ita  favorable  reception  by  both  studentsand  teachers. 

Not  professing  to  be  a  complete  and  comprehensive 
treatise,  it  will  not  be  found  full  in  detail,  nor  filled 
with  discussions  of  theories  and  opinions,  but  em- 
bracing all  that  is  essential  in  theory  and  practice, 


■well  deserving  of  a  place  in  their  libraries  as  a  book  I  it  is  admirably  adapted  to  the\vants  of  the  American 


of  referenc*  ;  and  we  especially  commt-nd  the  first 
part  as  presenting  an  admirable  outline  of  the  princi- 
ples of  medicine. — Dublin  Quarterly  Journal,  Ftb. 
1S50 

This  volume,  while  as  its  title  denotes  it  is  a 
compendious  view,  is  also  a  comprehensive  system 
of  practice,  perspicuously  and  pleasantly  written, 
and  admirably  suited  to  engage  the  interest,  and  in- 
struct the  reader. — Peninsular  Journal  of  Medicine, 
Jan.  1850. 

This  volume  is  designed  as  a  text-book  for  teachers 
and  students;  but  its  merits  extend  far  beyond  its 
modest  dedication  ;  It  is  a  complete  treatise  upon  me- 
dicine, and  one  that  will  stand  the  test  of  years.  The 
arrangement  is  simple,  a  feature  oflentimes  obscured 
in  otherwise  excellent  works.  This  Treatise  is  a 
valuableaddition  to  our  medical  literature,  and  in  the  |  Lancet. 


student.  Avoiding  all  that  is  uncertain,  it  presents 
more  clearly  to  the  mind  of  the  reader  that  which  is 
established  and  verified  by  experience.  The  varied 
and  extensive  reading  of  the  author  is  conspicuously 
apparent,  and  all  the  recent  improvements  and  dis- 
coveries in  therapeutics  and  pathology  are  chroni- 
cled in  its  pages. —  Charleston  Med.  Jcyumal. 

In  the  first  part  of  the  work  the  subject  of  gene- 
ral pathology  is  presented  in  outline,  giving  a  btau- 
tiful  picture  of  its  distinsruishing  features,  and 
throughout  the  succeeding  cliapters  we  find  that  he 
has  kept  scrupulously  within  the  bounds  of  sound 
reasoning  and  legitimate  deduction.  Upon  the 
whole,  we  do  not  hesitate  to  pronounce  it  a  superior 
work  in  its  class,  and  that  Dr.  Dickson  merits  a 
place  in  the  first  rank  of  American  writers. — Western 


DAY'S  PRACTICAI-  TREATISE  ON  THE  DO- 
.^lESTIC  MANAGEMENT  AND  MORE  IM- 
PORTANT DISEASES  OF  ADVANCED  LIFE. 
One  volume,  octavo,  cloth,  226  pages.    SI  00. 


DE  JONGH  ON  COD-LIVER  OIL,  comparatively 
considered,  with  its  Chemical  and  Therapeutic 
Properties.  In  one  12mo.  vol.,  ex.  cloth.  75  cents. 


AND    SCIENTIFIC    PUBLICATIONS. 


11 


DRUITT   (ROBERT),   M.R.  C.S.,   &.c. 
THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY.     A  new 

American,  from  the  improved  London  edition.  Edited  by  F.  W.  Sargent,  M.  D.,  author  of 
"Minor  Surg-ery,"  &rc.  Illustrated  with  one  hundred  and  ninety-three  wood-engravings.  In 
one  very  handsomely  printed  octavo  volume,  leather,  of  576  large  pages.     $3  00. 


Dr.  Druitt's  researches  into  the  literature  of  his 
subject  have  been  not  only  extensive,  but  well  di- 
rected ;  tlie  most  discordant  authors  are  fairly  and 
impartially  quoted,  and,  while  due  credit  is  given 
to  each,  their  respective  merits  are  weighed  with 
an  unprejudiced  hand.  The  grain  of  wheat  is  pre- 
served, and  the  chaff  is  unmercifully  stripped  off. 
The  arrangement  is  simple  and  philosophical,  and 
the  style,  though  clear  and  interesting,  ie  so  precise, 
that  the  book  contains  more  inform.ition  condensed 
into  a  few  words  than  any  other  surgical  \vork  with 
which  we  are  acquainted. — London  Medical  Tinus 
and  Gazette. 

No  work,  in  our  opinion,  equals  it  in  presenting 
BO  much  valuable  surgical  matter  in  so  small  a 
compass. — St.  Louis  Med.  and  Surgical  Journal. 

Druitt's  Surgery  is  too  well  known  to  the  Ameri- 
can medical  profession  to  require  its  announcement 
anywhere.  Prohnbly  no  work  of  the  kind  has  ever 
been  more  cordially  received  and  extensively  circu- 
lated than  this.  The  fact  that  it  comprehends  in  a 
comparatively  small  compass,  all  the  essential  ele- 
ments of  theoretical  and  practical  Surgery — that  it 
ie  found  to  contain  reliable  and  authentic  informa- 
tion on  the  nature  and  treatment  of  nearly  all  surgi- 
cal afTeetions — is  a  sufficient  reason  for  the  liberal 
patronage  it  has  obtained.  The  editor.  Dr.  F.  W. 
Sargent,  has  contributed  much  to  enhance  the  value 
of  the  work,  by  such  American  improvements  as  are 
calculated  more  perfectly  to  adapt  it  to  our  own 
views  and  practice  in  this  country.  It  abounds 
everywhere  with  spirited  and  life-like  illustrrtions, 
which  to  the  young  surgecm,  especially,  are  of  no 
minor  consideration.  Every  medical  man  frequently 
needs  just  such  a  work  as  this,  for  immediate  refer- 
ence in  moments  of  sudden  emergency,  when  he  has 
not  time  to  consult  more  elaborate  treatises. — The 
Ohio  Medical  and  Surgical  Journal. 

The  author  has  evidently  ransacked  every  stand- 
ard treatise  of  ancient  and  modern  times,  and  all  that 


is  really  practically  useful  at  the  bedside  will  be 
found  in  a  form  at  once  clear,  distinct,  and  interest- 
ing.— Edinburgh  Monthly  Medical  Journal. 

Druitt's  work,  condensed,  systematic,  lucid,  and 
practical  as  it  is,  beyond  most  works  on  Surgery 
accessible  to  the  American  student,  has  had  much 
currency  in  this  country,  and  under  its  present  au- 
spices promises  to  rise  to  yet  higher  favor. — Tht 
Western  Journal  of  Medicine  and  Surgery. 

The  most  accurate  and  ample  resume  of  the  pre- 
sent state  of  Surgery  that  we  are  acquainted  with. — 
Dublin  Medical  Journal. 

A  better  book  on  the  principles  and  practice  of 
Surgery  as  now  understood  in  England  and  America, 
has  not  been  given  to  the  profession. — Boston  Medi- 
cal and  Surgical  Journal. 

An  unsurpassable  compendium,  not  only  of  Sur- 
gical, but  of  Medical  Practice. — London  Medical 
Gazette. 

This  ^vork  merits  our  warmest  commendations, 
and  we  strongly  recommend  it  to  young  surgeons  as 
an  admirable  digest  of  the  principles  and  practice  of 
modern  Surgery. — Medical  Gazette. 

It  maybe  said  with  truth  that  the  work  of  Mr. 
Druitt  affords  a  complete,  though  brief  and  con- 
densed view,  of  the  entire  field  of  modern  surgery. 
We  know  of  no  work  on  tlie  same  subject  having  the 
appearance  of  a  manual,  which  includes  so  many 
topics  of  interest  to  the  surgeon  ;  and  the  terse  man- 
ner in  w^hicli  each  has  been  treated  evinces  a  most 
enviable  quality  of  mind  on  the  part  of  the  author, 
who  seems  to  have  an  innate  power  of  searching 
out  and  grasping  the  leading  facts  and  features  of 
the  most  elaborate  productions  of  the  pen.  It  is  a 
useful  handbook  for  the  practitioner,  and  we  should 
deem  a  teacher  of  surgery  unpardonable  wlio  did  not 
recommend  it  to  his  pupils.  In  our  own  opinion,  it 
is  admirably  adapted  to  the  wants  of  the  student. — 
Provincial  Medical  and  Surgical  Journal. 


DUNGLISON,    FORBES,    TWEEDIE,    AND    CONOLLY. 

THE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE:  comprising  Treatises  on 

the  Nature  and  Treatment  of  Disea.<es,  Materia  Medica,  and  Therapeutics,  Diseases  of  Women 
and  Children,  Medical  Jurisprudence,  Arc.  ifec.  In  four  large  super-royal  octavo  volumes,  of 
3254  double-columned  pages,  strongly  and  handsomely  bound,  with  raised  bands.  $12  00. 
*jjf*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed  by 
sixty-eight  distinguished  physicians,  rendering  it  a  complete  library  of  reference  for  the  country 
practitioner. 

The  most  complete  work  on  Practical  Medicine  I  titioner.  This  estimate  of  it  has  not  been  formed 
extant;  or,  at  least,  in*  our  language.— £«^'aio  from  a  hasty  examination,  but  after  an  intimate  ac- 
quaintance derived  from  frequent  consultation  of  it 
during  the  past  nine  or  ten  years.  The  editors  are 
practitioners  of  established  reputation,  and  the  list 
of  contributors  embraces  many  of  the  most  eminent 
professors  and  teachers  of  London,  Edinburgh,  Dub- 
lin, and  Glasgow.  It  is,  indeed,  the  great  merit  of 
this  work  that  the  principal  articles  have  been  fur- 
nished by  practitioners  who  have  not  only  ilevoted 
especial  attention  to  the  diseases  about  \vhieh   they 


Medical  and  Surgical  Journal. 

For  reference,  it  is  above  all  price  to  every  prac- 
titioner.—  Western  Lancet. 

One  of  the  most  valuable  medical  publications  of 
the  day — as  a  work  of  reference  it  is  invaluable. — 
Western  Journal  of  Medicine  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher,  a 
work  for  ready  and  frequent  reference,  (me  in  which 


modern  English  medicine  is  exhibited  in  the  most    have  written,  but  have  also  enjoyed  opportunities 


advantageous  light. — Medical  Examiner. 

We  rejoice  that  this  work  is  to  be  placed  within 
the  reach  of  the  profession  in  this  country,  it  being 
unquestionably  one  of  very  great  value  to  the  prac- 


for  an  extensive  practical  acquaintance  with  them, 
and  whose  reputaticm  carries  the  assurance  of  their 
competency  justly  to  appreciate  the  opinions  of 
others,  while  it  stamps  their  own  doctrines  with 
high  and  just  authority. — American  Medical  Journ. 


DEWEES'S  COMPREHENSIVE-  SYSTEM  OF 
MIDWIFERY.  Illustrated  by  occasional  cases 
and  many  engravings.  Twelfth  edition,  with  the 
author's  last  improvements  and  corrections  In 
one  octavo  volume,  extra  cloth,  of  600  pages.  S3'i(). 

DEWEES'S  TREATISE  ON  THE  PHYSICAL 
AND  MEDICAL  TREATAIENT  OF  CHILD- 
REN. Tenth  edition.  In  one  volume,  octavo, 
extra  cloth,  518  pages.     $2  80. 

DEWEES'S  TREATISE  ON  THE  DISEASES 
OF  FEMALES.  Tenth  edition.  In  one  volume, 
octavo,  extra  cloth,  532  pages,  with  plates.  8-3  00. 


DANA  ON  ZOOPHYTES  AND  CORALS.    In  one 

volume,  imperial  quarto,  extra  cloth,  with  wood- 
cuts. SI5  00.  Also,  AN  ATLAS,  in  one  volume, 
imperial  fidio,  with  sixty-one  magnificent  colored 
plates.     Bound  in  half  morocco.     S:30  00. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER. 
In  one  very  l;irgeand  handsome  octavo  volume,  ex- 
tra cloth,  of  700  pages,  with  .300  wood-cuts.  $-1  00. 

FRICK  ON  RENAL  AFFECTIONS;  their  Diag- 
nosis and  Pathology.  With  illustrations.  One 
volume,  royal  12iuo.,  extra  cloth.    75  cents. 


12 


BLANGHARD   &    LEA'S    MEDICAL 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

MEDICAL   LEXICON;   a  Dictionary  of  IMcclical  Science,  containing  a  concise 

Explanation  of  the  various  Subjects  and  Terms  ot  Physiology,  Paiholosry,  Hyo-iene,  Therapeutics, 
Pharniacolog-y,  Obstetrics,  Medical  Jurisprudence,  Arc.  With  the  French  and  other  Synonymes; 
Notices  ofClimate  and  of  celebrated  Mineral  Waters;  Formulae  for  various  Ollicinal,  Empirical, 
and  Dietetic  Preparations,  etc.  Thirieenth  edition,  revi>ed.  is  now  ready.  In  one  very  thick 
octavo  volume,  of  over  nine  hundred  large  double-columned  pages,  strongly  bound  in  leather, 
■with  raised  bands.     $4  00. 

Every  successive  edition  of  this  work  bears  the  marks  of  the  industry  of  the  author,  and  of  his 
determination  to  keep  it  fully  on  a  level  with  the  most  advanced  state  of  medical  science.  Thus 
nearly  fifteen  thoisand  words  have  been  added  to  it  within  the  last  tew  years.  As  a  complete 
Medical  Dictionary,  therefore,  embra6ing  over  FIFTY  THOUSAND  DEFINITIONS,  in  all  the 
branches  of  the  science,  it  is  presented  as  meriting  a  continuance  of  the  great  favor  and  popularity 
which  have  carried  it,  within  no  very  long  space  of  time,  to  a  thirteenth  edition. 

Every  precaution  has  been  taken  in  the  preparation  of  the  present  volume,  to  render  its  mecha- 
nical execution  and  typographical  accuracy  worthy  of  its  extended  reiintation  and  universal  use. 
The  very  extensive  additions  have  been  accommodated,  without  materially  increasing  the  bulk  ol 
the  volume  by  the  employment  of  a  small  but  exceedingly  clear  type,  cast  for  this  purpose.  The 
press  has  been  watched  with  great  care,  and  every  effort  used  to  insiue  the  verbal  accuracy  so  ne- 
cessary to  a  work  of  this  nature.  The  whole  is  printed  on  fine  while  paper ;  and,  while  thus  exhi- 
biting in  every  respect  so  great  an  improvement  over  former  issues,  it  is  presented  at  the  original 
exceedingly  low  price. 

AVe  welcome  it  cordi.THj';  it  is  an  a(lniiral)le  work,  !  readers  to  its  peculiar  merits;  and  wre  need  do 
and  indispensable  to  all  literary  niediial  men.  The  i  little  more  tlian  state,  in  reference  to  the  present 
labor  which  has  been  bestowed  upon  it  is  something  reissue,  that,  notwithstandinsj  the  large  additions 
prodigious.  The  work,  however,  has  now  been  I  previously  made  to  it,  no  fewer  than  four  thou- 
done,  and  we  are.  happy  in  the  thought  that  no  hu-  j  sand  terms,  not  to  be  found  in  the  preceding  edi- 
man  beins  will  have  again  to  undertake  the  same  !  tion,   are    contained    in    the  volume    before    us. — 


gigantic  task.  Revised  and  corrected  from  time  to 
time,  Dr.  Dunglison's  '■  Medical  Lexicon"  will  last 
for  ctnturies.—BTitish  and  Foreign  Med.-Chirurg. 
Revieio. 

The  fact  that  this  excellent  and  learned  work  has 
passed  through  eight  editions,  and  that  a  nintli  is 
rendered  necessarj'  by  the  demands  of  the  publi*, 
affords  a  sufficient  evidence  of  tlie  general  apprecia- 
tion of  Dr.  Dunglison's  labors  bythe  medical  pro- 
fession in  England  and  America.  It  is  a  book  which 
will  be  of  great. service  to  the  student,  in  teaching 
him  tlie  meaning  of  all  the  technical  terms  used  in 
medicine,  and  will  be  of  no  less  use  to  the  practi- 
tioner who  desires  to  keep  himself  on  a  level  with 
the  advance  of  medical  science. — London  Medical 
Times  and  Gazette. 

In  taking  leave  of  our  author,  we  feel  eompelled  |  perly  appreciated  by  his  own  countrymen  ;  and  we 
to  confess  that  his  work  bears  evidence  of  almost    can  only  confirm  their  judgment,  by  recommending 


Whilst  it  is  a  wonderful  monument  of  its  author's 
erudition  and  industry,  it  is  also  a  work  of  great 
practical  utility,  as  we  can  testify  from  our  own 
experience;  for  we  keep  it  constantly  within  oui 
reach,  and  make  very  frequent  reference  to  it, 
nearly  always  finding  in  it  the  information  we  seek. 
— British,  and  Foreign  Med.-Chirurg.  Revieio. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent 
of  references.  The  terms  generally  include  short 
physioliigjcal  and  pathological  descriptions,  so  that, 
as  the  author  justly  observes,  the  reader  does  not 
possess  in  this  work  a  mere  dictionary,  but  a  book, 
which,  while  it  instructs  him  in  medieal  etymo- 
logy, furnishes  him  with  a  large  amount  of  usefnl 
information.     The  author's  labors  have  been  pro- 


incredible  labor  having  been  bestowed  upon  its  com 
position. — Edinburgh  Journal  of  Med.  Science. 

A  miracle  of  labor  and  industry  in  one  who  has 
written  able  and  voluminous  works  on  nearly  every 
branch  of  medical  science.  There  couKI  be  no  more 
useful  book  to  the  student  or  practitioner,  in  the 
present  advancing  age,  than  one  in  which  would  be 
found,  in  addition  to  the  ordinary  meaning  and  deri- 
vation of  medical  terms — so  many  of  which  are  of 
modern  introduction — concise  descriptions  of  their 


this  most  usel'ul  volume  to  the  notice  of  our  cisat- 
lantic readers.  Nomedical  library  will  be  complete 
without  it. — London  Med.  Gazette. 


It  is  certainly  more  complete  and  comprehensive 
than  any  with'  which  we  are  acquiiinted  in  the 
English  language.  Few,  in  fact,  could  be  found 
belter  qualified  than  Dr.  Dunglison  for  the  produc- 
tion of  such  a  work.  Learned,  industrious,  per- 
severing, and  accurate,  he  brings  to  the  task  all 
,  ,  ,  .  1    11  .^1  •         1  ,1  the   peculiar    talents   necessary   for    its  successfuJ 

explanation  and  einployment;  andall  this  and  much     performance;    while,   at  the  same  time,   his  fami- 
more  IS  contained  in  the  volume   bef.ire  us      It  is  j  Uj^^ity  with  the  writings  of  the  ancient  and  modern 


therefore  almostas  indispensable  to  the  other  learned 
professions  as  to  our  own.  In  fact,  to  all  who  may 
have  occasion  to  ascertain  the  meaning  of  any  word 
belonging  to  the  many  branches  of  medicine.  From 
a  careful  examination  of  the  present  edition,  we  can 
vouch  for  its  accuracy,  and  for  its  bein^  brought 
quite  up  to  the  date  of  publication  ;  the  autlior  states 
in  his  preface  that  hehasadded  to  it  about  four  thou- 
sand terms,  which  are  not  to  be  found  in  the  prece- 
ding <>ne.  —  Dublin  Quarterly  Journal  of  Medical 
Sciences. 

On  the  appearance  of  the  last  edition  of   this 
valuable  work,   we   directed   the  attention  of  our 


"  masters  of  our  art,"  renders  him  skilful  to  note 
the  exact  usage  of  the  several  terms  of  science, 
and  the  various  modificaticms  which  medical  term- 
inology has  undergone  with  the  change  of  theo- 
ries or  the  progress  of  improvement.  —  American 
Journal  of  the  Medical  Sciences. 

One  of  the  most  complete  and  copious  known  to 
the  cultivators  of  medieal  science. — Boston  Med. 
Journal. 

The  most  comprehensive  and  best  English  Dic- 
tionary of  medical  terms  extant. — Buj/alo  Medical 
Journal . 


BY   THE   SAME   AUTHOR. 


THE  PRACTICE  OF  I^IEDICINE.     A  Treatise  on  Special  Pathology  and  The- 

rapeutics.     Third  Edition.     In  two  large  octavo  volumes,  leather,  of  1,500  pages.     S6  25. 

ferings  of  the  race.— Boston  Medical  and  Surgical 
Journal. 


Upon  every  topic  embraced  in  the  work  the  latest 
information  will  be  found  carefully  posted  up. — 
Medical  Examiner. 

The  student  of  medicine  will  find,  in  these  two 
elegant  volumes,  a  mine  of  facts,  a  gathering  of 
precepts  and  advice  from  the  world  of  experience, 
that   will  nerve  him  with   courage,   and  faithfully 


It  is  certainly  the  most  complete  treatiseof  which 
we  have  any  knowledge. —  Western  Journal  of  Medi- 
cine and  Surgery. 

One  of  the  most  elaborate  treatises  of  the  kind 


direct  him  in  his  efforts  to  relieve  the  physical  suf-  '  we  have. — Southern.  Med.  and  Surg.  JoumcU. 


AND    SCIENTIFIC    PUBLICATIONS. 


13 


DUNGLISON    (ROBLEY),    M.  D., 

Professor  of  Institutes  of  Medicine  in  tlie  JeiTerson  iMeilical  College,  Philadelphia. 

HUMAN    PHYSIOLOGY.      Eiglith   edition.      Thoroughly  revised   and  exten- 

sively  modified  and  enhuged,  with  five  hundred  and  thirly-tvvo  illustrations.     In  two  larjre  and 

handsomely  printed  octavo  volumes,  leather,  of  about  ISOO  pag-es.     (Just  Ready,  185G.)     $7  00. 

In  revi-ing  this  work  for  its  eighth  appearance,  the  author  has  spared  no  labor  to  render  il  worthy 
u  continuance  of  the  very  great  favor  which  has  been  extended  to  it  by  the  profession.  The  whole 
contents  have  been  rearranged,  and  to  a  great  extent  remodelled  ;  the"  investigations  which  of  late 
years  have  been  so  numerous  and  so  important,  have  been  carefully  examined  and  incoip  )rated, 
and  the  work  in  every  respect  has  been  brought  up  to  a  level  with  the  present  slate  of  the  subject. 
The  object  of  the  aullior  has  been  to  render  it  a  concise  but  comprehensive  treatise,  containing  the 
\Vhole  body  of  phy>iological  science,  to  which  the  student  and  man  of  >cience  can  at  all  times  refer 
with  the  certainly  of  finding  whatever  they  are  in  search  of,  fully  presented  in  all  its  aspects;  and 
on  no  former  edition  has  the  author  bestowed  more  labor  to  secure  this  re>ult. 

A  similar  improvement  will  be  found  in  the  typographical  execution  of  tlie  volumes,  which,  in 
this  respect,  are  superior  to  their  predecessors.  A  large  number  of  additional  wood-cuts  have  been 
introduced,  and  the  series  of  illustrations  has  been  greatly  modified  by  the  substitution  of  many 
new  ones  for  such  as  were  not  deemed  satisfactory.  By  an  enlargement  of  the  page,  these  very 
considerai)le  additions  have  been  accommodated  without  increasing  the  size  of  the  volumes  to  an 
extent  to  render  them  unwieldy. 


It  has  long  since  taken  rank  as  one  of  the  medi- 
cal classics  of  our  language.  To  say  that  it  is  by 
far  the  best  text-book  of  physiology  ever  pul)lisheJ 
in  this  country,  is  but  echoing  the  general  testi- 
mony of  the  profession. — N.  Y.  Journal  of  Medicine. 

There  is  no  single  book  we  would  recommend  to 
the  student  or  physician,  with  greater  confidence 
than  the  present,  because  in  it  will  be  found  a  mir- 
ror of  almost  every  standard  pliysiologieal  work  of 
the  day.  We  most  cordially  recommend  the  work 
to  every  member  of  the  profession,  and  no  student 


should  be  without  it  It  is  the  completest  work  on 
Physiology  in  the  English  language,  and  is  highly 
creditable  to  the  author  and  publishers. — Canadian 
Medical  Journal. 

The  most  complete  and  satisfactory  system  of 
Physiology  in  the  English  language. — Amer.  Med. 
Journal. 

The  best  work  of  the  kind  in  the  English  lan- 
guage.— Sillinian's  Journal. 

The  most  full  and  complete  system  of  Physiology 
in  our  language. — Western  Lancet. 


BY   THE   SAME   AUTHOR. 

GENERAL    THERAPEUTICS    AND    MATERIA  MEDICA;    adapted  for  a 

Medical  Text-book.     Fit'lh  edition,  much  improved.     With  one  hundred  and  eighty-seven  illus- 
trations.    In  two  large  and  handsomely  printed  octavo  vols.,  leather,  of  about  1100  pages.  $6  00. 

Asa  text-book  for  students,  for  whom  it  is  par- 
ticularly designed,  we  know  of  none  superior  to 
it. — St.  Louii  Medical  and  Surgical  Journal. 


In  this  work  of  Dr.  Dunglison,we  recognize  the 
same  untiring  industry  in  the  collection  and  em- 
bodying of  facts  on  the  several  subjects  of  which  he 
treats,  that  has  heretofore  distinguished  him,  and 
we  cheerfully  point  to  these  volumes,  as  two  of  the 
most  interesting  that  we  know  of.  In  noticing  tlie 
additions  to  this,  the  fourth  edition,  there  is  very 
little  in  the  periodical  or  annual  literature  of  the 
profession,  published  in  the  interval  which  has 
elapsed  since  the  issue  of  the  first,  that  lias  escaped 
the  careful  search  of  the  author.  Asa  book  for 
reference,  it  is  invaluable Charleston  Med.  Jour- 
nal and  Review. 

It  may  be  said  to  be  the  work  now  upon  the  sub- 
jects upon  which  it  treats. —  Western  Lancet. 


It  purports  to  be  a  new  edition,  but  it  is  rather 
a  new  book,  so  greatly  has  it  hern  improved,  both 
in  the  amount  and  quality  of  the  matter  which  it 
contains. — N.  O.  Medical  and  Surgical  Journal. 

We  bespeak  for  this  editi(m,  from  the  profession. 
an  increase  of  patronage  over  any  of  its  former 
ones,  on  account  of  its  increased  merit.  —  N.  Y. 
Journal  of  Medicine. 

We  consider  this  work  unequalled. — Boston  Med. 
and  Surg.  Journal. 


BY  THE  SAME  AUTHOR,     {A  new  'Edition.) 

NEW  REMEDIES,  WITH  FORMULAE  FOR  THEIR  PREPARATION  AND 

ADMIXISTKATJON.     Seventh  edition,  with  extensive  Additions.     In  one  very  large  octavo 

volume,  leather,  of  770  pages,     {Just  Ready,  May,  185G.)    §;.3  75. 

Another  edition  of  the  "  New  Remedies"  having  been  called  for,  the  author  has  endeavored  to 
add  everything  of  moment  ihat  has  appeared  since  the  publication  of  the  la>t  edition. 

The  chief  remedial  lueai.s  which  have  obtained  a  place,  for  the  first  time,  in  this  volume,  either 
owing  to  their  having  been  recently  introduced  into  pharmacology,  or  to  their  having  received  novel 
applications — and  which,  con^equently,  belong  to  the  category  of  "New  ILemedies" — are  the  fol- 
lowing : — 

^  Apiol,  Caffein,  Carbazotic  acid.  Cauterization  and  cathet'-rism  of  the  larynx  and  trachea,  Cedron, 
Cerium,  Chloride  of  bromine.  Chloride  of  iron.  Chloride  of  sodium,  Cinchonicine,  Cod-liver  olein. 
Congelation,  Eau  de  Pagiiari,  Galvanic  cautery,  Hydriodic  ether.  Hyposulphite  of  soda  and  silver, 
Inunction,  Iodide  of  sodium.  Nickel,  Permanganate  of  potassa,  Phosphate  of  lime,  Pumpkin,  Quinidia, 
Rennet,  Saccharine  carbonate  of  iron  and  manganese.  Santonin,  Tellurium,  and  Trauinaticnie. 

The  articles  treated  of  in  the  former  edilions  will  be  found  to  have  undergone  considerable  ex- 
pansion in  this,  in  order  that  the  author  might  be  enabled  to  introduce,  as  far  as  practicable,  the 
results  of  the  subsequent  experience  of  others,  as  well  as  of  his  own  observalion  and  relleclion; 
and  to  make  the  w^ork  still  more  deserving  of  the  extended  cireulatimi  with  which  the  preceding 
editions  have  been  favored  by  the  profession.  By  an  enlargement  of  the  page,  the  numerous  addi- 
tions have  been  incorporated  without  greatly  increasing  the  bulk  of  the  volume. — Preface. 

One  of  the  most  useful  of  the  aiillior's  works. — 
Southern  Medical  and  Surgical  Journal. 

This   elaborate    and    useful    volume    should    be 
found  in  every  medical  library,  for  as  a  book  of  re 


ference,  for  physii'ians,  it  is  unsurpassed  by  any 
other  work  in  existence,  and  the  double  index  for 
diseases  and  for  remedies,  will  be  found  greatly  to 
enhance  its  value. — ISew  York  Med.  Gazette. 


The  great  learning  of  the  author,  and  his  remark- 
able industry  in  pushing  his  researches  into  every 
source  whence  information  is  derivable,  h;is  enabled 
him  to  throw  together  an  extensive  mass  of  facts 
and  statements,  accompanied  by  full  reference  to 
authorities;  which  last  feature  renders  the  work 
practically  valuable  to  investigators  who  desire  to 
examine  the  original  papers. — The  American  Journal 
of  Pharmacy. 


14 


BLANCHARD    &;   LEA'S    MEDICAL 


ERICHSEN    (JOHN), 

Professor  of  Surgery-  in  University  Co3)ege,  London,  &e. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Surgical 

Injuries,  Diseasks,  and  Operations.  Edited  by  John  H.  Bkinton,  M.  D.  Illustrated  with 
three  luindred  and  eleven  engravings  on  wood.  In  one  large  and  handsome  octavo  Tolume,  oi 
over  nine  hundred  closely  printed  pages,  leather,  raised  band.s.     §4  25. 

It  is,  in  our  humb)e  joHgment.  decideilly  llie  best  1  rarely  eneounter  cases  requiring  surgieal  raanage- 
book  of  the  kind  in  the  English  (ariguage.    Strange     meat. — Stethoscope. 

that  just  such  liooks  are  notoflener  pro<laced  by  puh-        Embracing,  as  will  he  pereeiv^-d.  the  whole  sursi- 
(ic  leachp_rs_or_surgery  in  this  _eouiiiry  a»id^  Great  |  gal  domain,  and  each  division  of  itself  almost  coW>- 


Brilain.  Indeed,  it  is  a  malterof  great  astonishnnent. 
hut  no  less  true  than  astonishing,  that  oi  the  many 
■works  on  surgerj-  repnblished  in  ihis  cnontry  wijhin 
the  last  fifteen  or  twenty    years  as  te.xtbooks   for 


medical  students,  this  is  the  oi.ly  one  ihat  even  ap-  i  best  single  volume  now  exiam  on  the  sul.je 
proximaiesto  ihe  fiilnlinenl  of  the  peeunar  wants  of  |  „.,,),  „reai  pleasure  we  add  ii   to  our  text  b- 


young  men  just  entering  upon  the  siiidy  of  this  ti  ranch 
of  the  profession. —  WtsiemJour  .of  Med.  ani  Surgery. 

Its  value  is  greatly  enhanced  by  a  very  copious 
well-arransed  index.  We  regard  this  as  one  of  the 
most  valuable  contributions  to  modern  surgery.  To 
one  entering  his  tioviiiate  of  practice,  we  regard  ii 
ibemosi  serviceable  guide  which  he  can  consult.  He 
will  find  a  iulnessof  detail  leadinghim  through  every 
step  of  the  operation,  and  not  deserting  him  until  the 
final  issue  of  the  case  is  decided.  For  the  same  rea- 
.?on  we  recommend  it  to  those  whose  routine  of  prac- 
tice lies  ill  such  parts  of  ilie  eouiitry  that  they  must 


plete  and  perfect,  each  chapter  full  and  explicit,  each 
suhiect  faithfully  exhibited,  we  can  on)y  express  our 
esiimaie  of  it  in  the  aggregate.  "We  consider  it  an 
excellent  contribution  to  surgery,  as  probably  the 

'?et,  and 
books. — 


pie 
NaskviUe  Journal  (^Medicine  and  Sur^ir^ 

Prof.  Eriehsen's  worV,  for  its  size,  has  not  l>eea 
surpassed;  his  nine  hundred  and  eight  pages,  pro- 
fusely illustraied.  are  rich  in  physiological,  patholo- 
gical, and  operative  suggestions,  do'-trines,  details, 
and  processes;  and  wi}/  prove  a  reliable  resource 
for  information,  both  to  physician  and  suraeon,  in  the 
hour  of  peril —iV.  0.  Med.  and  Surg  Journal. 

M'e  are  acQuainted  with  no  other  work  whereia 
so  much  good  sense,  sound  principle,  and  prnctieai 
inferences,  stamp  every  page. — American  Lancet. 


ELLIS  (BENJAMIN),  M.D, 
THE   MEDICAL  FORMULARY :   beicg  a  Collection  of  PrescriptioDs,  (5emed 

from  Ihe  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America  and  Europe. 
Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  To  which  is  added 
an  Appendix,  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Ether  and  Chloroform.  Ti>8 
whole  accompanied  with  a  few  brief  Pharmaceittic  and  Medical  Observations.  Tenth  edition, 
revised  and  much  extended  by  Robert  P.  Thomas,  M.  D.,  Professor  of  Materia  Medica  in  the 
Philadelphia  College  of  Pharmacy.  h\  one  neat  octavo  volume,  extra  eloth,  of  29o  pages.  (Lately 
Issued.)     $1  75. 


After  an  examination  of  the  new  matter  and  the 
alterations,  we  believe  the  reputation  of  the  work 
built  up  by  the  author,  and  the  late  distinguished 
editor,  will  continue  to  flourish  under  the  auspices 
of  the  present  editor,  who  has  the  industry  and  accu- 
racy, and,  we  would  say,  conscientiousness  requi- 
site for  the  lesponsjble  task. — Am.  Jour,  of  P harm. 


It  wi)l  prove  partie»>ar)y  useful  to  students  and 
yot»ng  prsictitioners,  as  the  most  important  prescrip- 
tions employetl  in  mo<iern  practice,  which  lie  scat- 
tered through  our  medical  literature,  are  here  col- 
lected and  "conveniently  arranged  for  refereaee. — 
Charleston  Med.  Jo-Hmal  axd  Kevieie. 


FOWNES  (GEORGE),   PH.  D.,  &c. 
ELE:MENTARY    CHE:^IISTRY;    Theoretical  and  Practical.     With  mimerom 

iHnstrations.     A  new  American,  from  the  last  and  revised  London  edition.     Edited,  with  Addi- 
tions, by  Robert  Bridges,  M.  D.     In  one  large  royal  12mo.  volume,  of  over  550  pages,  whh  ISl 
wood-cuts.    {Late/y  Issued.)     In  leather,  SI  00;  extra  cloth,  $1  3-5. 
"We  know  of  no  better  text- lK)o)t,  especinDy  in  the  )      The   v/ork  of  l>r.   Powiies  has  losg  been  before 


difhcult  department  of  organic  chemistry,  upon 
which  it  is  particularly  full  and  satisfactory.  We 
would  recommend  it  to  preceptors  as  a  capital 
"  office  book"  for  their  students  who  are  beginners 
in  Chemistry.     It  is  copiously  illustrated  with  ex- 


the  pubhe,  and  its  merits  have  been  fufly  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.  AVe  do  not,  of  course,  piaee  it  in  a  rank 
superior  to  tlie  works  of  Brande,  Graham,  Turner, 
Gregory,   or  Gmetin,  but  v/e  say  that,   as  a  work 


cellent  wood-cuts,  and  alt<igether  admirably  "got     for  students,  it  is  preferaWe  to  any  of  them. — Lom- 
ap." — N.  .1.  Medical  Rtporter.  \  don  Journal  of  Medicine. 

A  8t:;nd.ird  manual,  which  h.is  long  enjoyed  the  A  work  well  adapted  to  the  wants  of  the  etndent. 
reputation  of  embodying  much  knowledge  in  a  small  It  is  an  excelient  exposition  of  the  chief  doetrines 
8pace.  The  author  hasachieved  the  difficult  task  of  and  facts  of  modern  chenijstry.  Thesizeof  the  work, 
condensation  with  masterly  tact.  His  hook  is  con-  (  and  still  more  the  condensed  yet  perspicnons  style 
cise  without  being  dry,  and  brief  without  being  too  i  in  which  it  is  written,  abs(dve  it  from  the  charges 
dogmatical  or  general. —  Yirginia  Med.  a^d  Surgical  \  very  properly  urged  against  most  manuals  termed 
JoMTttal.  \  popular. — Edinburgh  Journal  of  Medical  Seienes. 


FERGUSSON   (WILLIAM),  F.  R.  S., 

Professor  of  Surgery  in  King's   Coilege,  London,  Ac. 

A  SYSTEM  OF  PRACTICAL  SURGERY.     Fourth  American,  from  the  third 

and  enlarged  London  edilit>n.     In  one  large  and  beautifully  printed  octavo  volume,  of  about  700 

pages,  with  393  handsome  illustrations,  leather.     S3  00. 

The  most  iinportant  subjects  in  connection  with  [  practitioner,  and  was  more  carefully  arranged  to 
practical  surge/y  which  have  been  more  recentlv  that  single  purpose  than  this. — if.  Y.  Med.  Journal. 
brought  under  the  notice  of,  and  discussed  by,  the  T|,g  .^jdition  of  many  new  pages  makes  this  work 
surgeons  of  Great  Hntnin,  are  fully  and  dispassion-  „„re  than  ever  indispensable  ro  the  student  and  prac- 
ately  considered  by  Mr.  Ferg.isson,  and  that  which  !  tMonet.—Rartking's  Abstract. 
was  before  ^vantmg  has  now  been  suppiieo,  so  that  i  ,  ,  . 

we  can  now  look  upon  it  as  a  work  on  practical  sur-  Among  the  numerous  works  upon  surgery  pub- 
eerv  instead  of  one  on  oiierative  surgery  alone,  lished  of  late  years,  we  know  of  none  we  value 
Medical  Times  and  Gazette.  "»">■«  highly  than  the  one  before  us.     It  is  perhaps 

the  very  best  we  have  for  a  text-book  and  for  ordj- 

No  work  was  ever  written  which  more  nearly    nary  reference,  being  concise  and  eminent'.y  practi- 
compreheuded  the  necessities  of   the  student  and  1  cai. — Southern  Med.  and  SMrg.  Jo^moi. 


AND   SCIENTIFIC    PUBLICATIONS, 


15 


FLINT  (AUSTIN),  M.  D., 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  Uaiversity  of  Louisville,  &c. 
(All  Important  ]\'cto  IVor/c.) 

PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OF  DISEASES  AFFECT- 
ING THE  RESPIRATORY  ORGANS.  In  oae  large  and  handsome  octavo  volume,  extra 
cloth,  636  pages.     (Now  Ready.)     $3  00. 

The  author  has  aimed  in  the  present  work  to  supply  a  vacanoy  in  medical  literature,  viz:  "a 
work  limited  to  diseat^es  affecting-  the  respiratory  organs,  treating  iiiextenso  and  almost  exeltisively 
of  the  principles  and  practice  of  physical  exploration,  as  applied  to  the  diagnosis  of  those  aflections." 
The  intricacy  and  importance  of  the  subject  demand  a  fuller  and  oiore  detailed  exoosition  than  has 
been  accorded  to  it  in  any  volume  as  yet  accessible  to  the  American  profession  ;  while  the  high  re- 
putation which  the  author  has  acqiiirHJ  by  his  researches  in  kindred  topics  sulFiciently  manifests  his 
ability  to  render  the  present  work  a  text-book  of  great  practical  utility  for  the  student,  and  a  source 
to  which  the  praetitioner  can  at  all  times  refer  with  certainty. 
A  very  condensed  summary  of  the  contents  is  subjoined. 

CONTENTS. 


INTRODUCTION. 

Section  I.  Preliminary  points  pertaining  to  the  Ana- 
tomy and  Physioldonf  of  the  Respiratory  Appara- 
tus. Section  II.  Topographical  Divisioas  of  the 
Chest. 


PART  I. 

Physicai,  Exploration  of  the  Chest. 

Chap.  I.  Definitions— Different  Methods  of  Explora- 
tions— General  Remarks.  Chap.  IT.  Percussion. 
Chap.  III.  AiiseultJition.  Chap.  IV.  Inspection. 
Chap.  V.  Mensuration.  Chap.  VI.  Palpation. 
Chap.  VII.  Succussion.  Chap.  VIIl.  Recapitu- 
latory Enumeration  of  the  Physical  Si^ns  fur- 
nished by  the  several  methods  of  Exploratioa. 
Chap.   IX.  Correlation  of  Physical  Signs. 


PART  11. 

Diagnosis  of  Diseases  .\ffecting  the  Respiua- 
TORV  Organs. 

Chap.  I.  Bronchitis,  Pulmonary  or  Bronchial  Ca- 
tarrh. Chap.  II.  Dilatation  and  Contraction  of 
the  Bronchial  Tubes — Pertussis — Asthma.  Chap. 
III.  Pneumonitis — Imperfect  E.xpansii)n  (Atelec- 
tasis) and  Collapse.  Chap.  IV.  Emphysema. 
Chap.  V.  Pulmonary  Tuberculosis  Bronchial 
Phthisis.  Chap.  VI.  Pulmonary  Q3dema— Gan- 
grene of  the  Lungs — Pulmonary  Apople.'cj' — Can- 
cer of  the  liUnss — Cancer  in  the  Mediastinum. 
Chap.  VII.  Acute  Pleuritis — Clironic  Pleuritis — 
Empyema — Hydrothorax  — Pneumothorax — Pneu- 
mo-Uydrothorax--Pleuralgia-- Diaphragm  a  tic  Her- 
nia. Chap.  VIll.  Diseases  affecting  tiie  Trachea 
and  Laryn.x  —  Poreiirn  Bodies  in  the  Air-passages. 
Appendix.  On  the  Pitch  of  the  Whispering  Souffle 
over  Puluioaary  Excavations. 


GRAHAM   (THOMAS),   F.R.S., 

Professor  of  Chemistry  in  University  College,  London,  &c. 

THE  ELEMENTS  OF  CHEMISTRY.     Including  the  application  of  the  Science 

to  the  Arts.  With  numerous  illustrations.  With  Notes  and  Additions,  by  Robert  Bridges, 
M.  D.,  &c.  &c.     Second  American,  from  the  second  and  enlarged  London  edition. 

PART  I.  (Lately  Issued)  large  8vo.,  430  pages,  185  ilJustratioas.     $1  50. 

PART  II.  (Preparing)  to  match. 

GRIFFITH  (ROBERT  E.),   M.  D.,  &c. 
A  UNIVERSAL  FORMULARY,  containing  the  methods  of  Preparing  and  Ad- 

m'  iiefering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceu- 
j!  t«.  Second  Edition,  thoroughly  revised,  with  numerous  additions",  by  Robert  P.  Thomas, 
J*.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  larg-e  and 
handsome  octavo  volume,  extra  cloth,  of  over  600  pages,  double  columns,  (jicst  Issued.)  $3  00; 
DC  bound  in  sheep,  $3  25. 

It  was  a  work  requiring  much  perseverance,  and  j  tioner  can  possihly  have  in  his  possession. — Mtdical 
when  piiblishe<l  was  iook-ed  upon  as  by  far  the  in^si    Chronicle. 


work  of  its  kind  that  ha<t  issued  from  the  American 
press.  Prof  Thoraai  has  certainly  "improved."  a? 
well  as  added  oihis  Formulary,  and  has  rendered  it 
additionally  deserving  of  the  confidence  of  pharraa- 
aeutiste  and  physicians. — Am.  Joumal  of  Pharmacy. 

We  are  happy  to  announ<-e  a  new  and  improved 
edition  of  this,  one  of  the  most  valualtle  and  useful 
works  that  have  emanated  from  an  Amf'rican  pen. 
It  would  do  credit  to  any  country,  and  will  be  found 
of  daily  usefulness  to  practitioners  of  medicine;  it  is 
better  adapted  to  their  purposes  than  the  dispensato 
ries. — Soul/iern  Med.  and  Surg.  Journal. 

A  new  edition  of  this  well-known  work,  edited  by 
R.  P.  Thomas,  M  D.,  affords  occasion  for  renewinsj 
our  commendation  of  so  useful  a  handbook,  which 
ought  to  be  universally  studied  by  medical  men  of 
every  class,  ami  made  use  of  by  way  of  reference  by 
office  pupils,  as  a  standard  authority.  It  has  Iveen 
much  enlariied,  and  now  condenses  a  vast  amount 


The  amountof  useful,  every-day  matter,  for  a  prac- 
ticing physician,  is  really  immense. — Boston.  Med. 
nnd  Surg.  Journal. 

This  is  a  work  of  six  hundred  and  fifty  one  pa^es, 
embracinf^  all  on  the  subject  of  preparin<?  and  admi- 
nistering medicines  lh,-\tcan  be  desired  l)y  ihe  physi- 
cian and  pharmaceutist  —  Western  Lancet. 

In  short,  it  is  a  full  and  complete  work  of  the  kind 
and  should  bo  m  ilie  hands  of  every  physician  and 
apothecary.     O.  Mtd.  and  Surg.  Jnicmal 

We  predict  a  preat  sale  for  this  work,  and  we  espe- 
ciallv  recommend  it  to  all  nudical  teachers. — Rieh- 
tnoHd  Stethoscope. 

Thiseditifmof  Dr  Griffith's  work  has  been  jrreatly 
imiiroved  l)y  the  revision  and  ample  additions  of  Dr. 
Thomas,  and  is  now,  we  believf,  one  of  Ihe  most 
complete  works  of  its  kind  in  any  lanafiias^.  The 
adilitions  amount  to   about   seventy   pnjes,  and    no 


of  needful  and  necessary  knowledjre  in  small  com-  1  effort  ha<;  heen  spared  to  include  in  ihpui  all  the  re- 


pass.   The  more  of  such  books  the  better  for  the  pro- 
lession  and  the  public  —N.  Y.  Med.  Gazette. 

It  is  one  of  the  most  useful  books  a  country  practi- 


rent  improvements  which  have  been  i>ublifhi-d  in 
medical  journals,  and  systematic  treatises.  A  work 
of  this  kinrl  appears  to  us  indispensable  to  the  physi- 
cian, and  ih^reis  none  we  can  more  cordially  recom- 
'  mend.— JV.  Y.  Journal  of  Medicine. 


BY   THE   SAME    AUTHOR. 


MEDICAL  BOTANY;  or,  a  Description  of  all  the  more  important  Plants  used 

iu  Medicine,  and  of  their  Properties,  Uses,  and  Modes  of  Administration.     In  one  lar^e  octavo 
voiume,  extra  cloth,  of  704  pages,  handsomely  printed,  with  nearly  350  illustrationsoa  wood.  $3  00. 


16 


BLANCHARD   &    LEA'S    MEDICAL. 


GROSS  (SAMUEL  D.),   M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Piiiladelphia,  fcc. 

A   PRACTICAL    TREATISE   ON   THE    DISEASES,    INJURIES,  AND 

IMALFOKMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND,  AND 
THE  URETHRA.  Second  Edition,  revised  and  mnch  enlarged,  with  one  hundred  and  eigrhty- 
foiir  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine  hundred  pages. 
{Just  Issued.)     In  leather,  raised  bands,  $5  25;  extra  cloth,  $4  75. 

The  author  has  availed  himselfof  the  opportunity  afforded  by  a  call  for  a  new  edition  of  this 
work,  to  thoroughly  revise  and  render  it  in  every  respect  worthy,  so  far  as  in  his  power,  of  the  very 
flattering  reception  whicM  has  been  accorded  to  it  by  the  profession.  The  new  matter  thus  added 
amounts  to  almost  one-third  of  the  original  work,  while  the  number  of  illustrations  has  been  nearly 
doubled.  These  additions  pervade  every  portion  of  the  work,  which  thus  has  rather  the  aspect  of 
a  new  treatise  than  a  new  edition.  In  its  present  improved  form,  therefore,  it  may  confidently  be 
presented  as  a  complete  and  reliable  storehouse  of  information  on  this  important  class  of  diseases, 
and  as  in  every  way  fitted  to  maintain  the  position  which  it  has  acquired  in  Europe  and  in  this 
country,  as  the  standard  of  authority  on  the  subjects  treated  of. 
A  volume  replete  with  truths  and  principles  of  the  |  provements,  it  ^vill  probably  remain  one  of  the  most 


utmost  value  in  the  investigation  of  these  diseases. — 
American  Medical  Journal. 

On  the  appearance  of  the  first  edition  of  this  work, 
the  leading  English  medical  review  predicted  that  it 
would  have  a  "  permanent  place  in  the  literature  of 
surgery  ^vorthy  to  rank  witii  the  best  works  of  the 
present  a?e."  This  prediction  has  been  amply  ful- 
filled. Dr.  Gross's  treatise  has  been  found  to  sup- 
ply completely  the  want  which  has  been  felt  ever 
since  the  elevation  of  surgery  to  the  rank  of  a  science, 
of  a  good  practical  treatise  on  the  diseases  of  the 
bladder  and  its  accessory  organs.  Philosiphical  in 
its  design,  methodical  in  its  arrangement,  ample  and 
.sound  in  its  practical  details,  it  may  in  truth  be  said 
to  leave  scr.rcely  any'hing  to  be  desired  on  so  im- 
portant a  subject,  and  with  the  additions  and  modi- 
ficatiuns  resulting  from  future  discoveries  and  im- 


valuable  works  on  this  subject  so  long  as  the  science 
of  medicine  shall  exist. —  Boston  Med.  and  Surg. 
Journal. 

Dr.  Gross  has  brought  all  his  learning,  experi- 
ence, tact,  and  judgment  to  the  task,  and  has  pro- 
duced a  work  worthy  of  his  high  reputation.  AVe 
feel  perfectly  safe  in  recommending  it  to  our  read- 
ers as  a  monograph  unequalled  in  interest  and 
practical  value  by  any  other  on  the  subject  in  our 
language. — Western  Journal  of  Med.  and  Sicrg. 

"Whoever  ^vill  peruse  the  vast  amount  of  valuable 
practical  information  it  contains,  and  wliich  we 
have  been  unable  even  to  notice,  will,  we  think, 
agree  with  us,  that  there  is  no  work  in  the  English 
language  \vhich  can  make  any  just  pretensions  to 
be  its  equal. — N.  Y.  Journal  of  Medicine. 


BY  THE  SAME  AUTHOR.     {Just  Issued). 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIR-PAS- 

SAGES.     In  one  handsome  octavo  volume,  extra  cloth,  with  illustrations,     pp.  468.     S"2  75. 

A  very  elaborate  work.  It  is  a  complete  summary  conclude  by  recommending  it  to  our  readers,  fully 
of  the  whole  subject,  and  will  be  a  useful  book  of  persuaded  that  its  perusal  wjll  afford  them  much 
reference. — British  and  Foreign  Medico-Chirurg.  practi'-al  information  well  convej-ed,  evidently  de- 
Revietv.  rived  from  considerable  experience  and  deduced  from 

A  highly  valuable  book  of  reference  on  a  most  im-  \  ^^  ample  collection  of  facts.  — Dutim  Quarterly 
portant  subject  in    the  practice  of  medicine.     We  i  Journal,  May,  1855. 

BY  THE  SAME  AUTHOR.     (Preparijig.) 

A  SYSTEM  OF  SURGERY;  Diagnostic,  Pathological,  Therapeutic,  and  Opera- 

live.     With  very  numerous  engravings  on  wood. 

BY   THE   SAME   AUTHOR. 

ELEMENTS  OF  PATHOLOGICAL  ANATOMY;  illustrated  by  colored  En- 
graving's, and  two  hundred  and  fifty  wood-cuts.  Second  edition,  thoroughly  revised  and  greatly 
enlarged.  Jn  one  very  large  and  handsome  imperial  octavo  volume,  leather,  raised  bands,  pp. 
82-2.    65  75. 


GLUGE  (GOTTLIEB),   M .  D., 

Professor  of  Physiology  and  Pathological  Anatomy  in  the  University  of  Brussels,  &c. 

AN  ATLAS   OF   PATHOLOGICAL   HISTOLOGY.     Translated,  with  Notes 

and  Additions,  by  Joseph  Leidy,  M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylva- 
nia. In  one  volume,  very  large  imperial  quarto,  extra  cloth,  with  320  figures,  plain  and  colored, 
on  twelve  copperplates.     $5  00. 


GARDNER'S  .MEDICAL  CHEMISTRY,  for  the 
nse  of  Students  and  the  Profession.  In  (me  royal 
Vimo.  vol.,  ex.  cloth,  pp.  306,  with  illustrations. 
SI  00. 

HARRISON'S  ESS.AY  TOWARDS  A  CORRECT 
THEORY  OF  THE  NERVOUS  SVSTE.M.  la 
one  octavo  volume,  leather,  292  pages.     SI  50. 


HUGHES'  CLINICAL  INTRODUCTION  TO 
THE  PRACTICE  OF  AUSCULTATION  AxND 
OTHER  .AIODESOF  PHYSICAL  DIAGNOSIS, 
IN  DISE.ASES  OF  THE  LUNGS  AND  HEART. 
Sec<md  American,  from  the  second  London  edition. 
1  vol.  loyal  12mo.,  ex.  cloth,  pp.  304.     SI  00. 


HAMILTON   (FRANK    H.),    M.   D., 

Professor  of  Surgerv,  in  Buffalo  xMedical  College.  <fcc. 

A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS. 


In  one  handsome 


octavo  volume,  with  numerous  illustrations.     (Prepari/ig.) 

The  numerous  improvements  which  this  important  branch  of  surgery  has  received  from  the  skill 
and  ingenuity  of  American  surgeons,  renders  particularly  appropriate  and  valuable  a  complete  and 
systematic  original  vi'ork  on  the  subject.  The  es-ays  which  Professor  Hamilton  has  published  on 
kindred  topics  are  already  widely  and  favorably  known,  and  give  earnest  that  his  forthcoming  work 
will  prove  indispensable,  both  as  a  text-book  for  llie  student,  aud  as  a  guide  for  the  practitioner. 


AND    SCIENTIFIC    PUBLICATIONS. 


17 


HOBLYN  (RICHARD  D.),  M.  D. 
A  DICTIONARY  OF  THE  TERMS   USED  IN  MEDICINE  AND  THE 

COLLATERAL  SCIENCES.  By  Richard  D.  Hoblyn,  A.  M  ,  &c  A  new  American  from 
the  last  London  edition.  Revised,  with  numerous  Additions,  by  Isaac  Hays,  M.  D.,  editor  of 
the  "  Americsn  Journal  of  the  Medical  Sciences."  In  one  iarsre  royal  12mo.  volume,  leather, 
of  over  500  double  columned  pages.     (Noio  Ready,  1856.)     SI  50. 

The  preat  care  bestowed  on  the  revision  of  this  vi^ork,  and  the  extensive  additions  made  to  it  by  the 
editor,  have  caused  the  delay  in  its  appearance.  While  careAillv  excluding-  obsolete  words,  it  has 
been  his  aim  to  render  it  a  complete  manual  of  definitions,  in  which  the  student  of  medicine  or  of 
its  allied  sciences  might  feel  assured  of  being  able  to  find  concise  explanations  of  all  terms  occur- 
ring in  his  course  of  reading.  The  amount  of  the  additions  thus  made,  may  be  estimated  from  the 
fact  that  the  present  edition  contains  fully  one-third  more  matter  than  the  last,  the  number  of  pages 
having  been  increased  by  over  one  hundred,  notwithstanding  an  enlargement  of  the  size  of  the  page, 
while  at  the  same  time  it  has  been  kept  at  the  former  exceedingly  low  price. 

If  the  frequency  with  which  we  have  rel'erred  to  |  nor  desire  to  procure  a  larger  work.  —  American 
this  volume  since  its  reception  from  the  pul)" 


two  or  three  weeks  ago,  be  any  criterinn  for  the 
future,  the  bin  iing  will  soon  have  to  be  renewed,  even 
with  careful  hHutlling.  We  find  that  Dr.  Hays  has 
done  the  profession  great  service  by  his  careful  and 
industrious  labors.  The  Dictionary  has  thus  liecoine 
eminently  suited  to  our  medical  bretliren  in  this 
country.  The  additions  by  Dr.  Hays  are  in  brackets, 
and  we  believe  there  is  not  a  single  page  but  bears 
tliese  insignia;  in  every  instance  which  we  have  thus 
far  noticed,  the  additinns  are  really  needed  and  ex- 
ceedingly valuable.  We  heartily  commend  the  work 
to  all  who  wish  to  I)p  au  cnurnnt  in  medicul  termi- 
nology.— Boston  Med.  and  Surg.  Journal. 

To  both  practitioner  and  student,  we  recommend 
tills  dictionary  as  being  convenient  in  size,  accurate 
in  definition,  and  sufficiently  full  and  complete  for 
ordinary  consultation. — Charleston  Med.  Journ.  and 
Review. 

Admirably  calculated  to  meet  the  \vant3  of  the 
practitioner  or  student,  who  has  neither  the  means 


Lancet. 

Hoblyn  has  always  been  a  favorite  dictionary,  and 
in  its  present  enlarged  and  improved  form  will  give 
greater  satisl'action  thiinever.  The  American  editor, 
Dr.  Hays,  has  made  many  very  valuable  additions. 
— N.J.  Mid.  Reporter. 

To  supply  the  want  of  the  medical  reader  arising 
from  this  cause,  we  know  of  no  dictionary  better 
arranged  and  adapted  than  the  one  bearing  the  above 
title.  It  is  not  encumbered  with  the  obsolete  terms 
of  a  bygone  age,  but  it  contains  all  that  are  now  in 
use  ;  embracing  every  department  of  medical  science 
down  to  the  very  latest  date.  The  volume  is  of  a 
convenient  size  to  be  used  by  the  medical  student, 
and  yet  large  enough  to  make  a  respectable  appear- 
ance in  the  library  of  a  physician. — Western  Lancet. 

Hoblyn's  Dictionary  has  long  been  a  favorite  with 
us.  It  is  the  best  book  of  definitions  we  have,  and 
ought  always  to  be  upon  the  student's  table. — 
Southern  Med.  and  Surg.  Journal. 


HUNTER  (JOHN). 
TREATISE  ON  THE  VENEREAL  DISEASE. 

Dr.  Ph.  Ricord,  Surgeon  to  th«  Venereal  Hospital  of  Paris. 
F.  J.  Btr.MSTEAD,  M.  D.     In  on«  octavo  volume,  with  plates. 
Also,  HUNTER'S  COMPLETE  WORKS,  with  Memoir,  Notes,  &c.  &c. 
volimies,  leather,  with  plates.    510  00. 


With  copious  Additions,  by 

Edited,  with  additional  Notes,  by 
$3  25.     gy  See  Ricord. 

In  four  neat  octavo 


HORNER  (WILLIAM  E.),  M.  D., 
Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

SPECIAL    ANATOMY    AND    HISTOLOGY.     Eighth  edition.     Extensively 

revised  and  modified.      In  two  large  octavo  volumes,  extra  cloth,  of  more  than  one  thousand 
pages,  handsomely  printed,  with  over  three  hundred  illustrations.     $6  00. 

This  edition  enjoyed  a  thorough  and  laborious  revision  on  the  part  of  the  author  shortly  before 
his  death,  with  the  view  of  bringing  it  fully  up  to  the  existing  state  of  knowledge  on  the  subject  of 
general  and  special  anatomy.  To  adapt  it  more  perfectly  to  the  wants  of  the  student,  he  introduced 
a  large  number  of  additional  wood-engravings,  illustrative  of  the  objects  described,  while  the  pub- 
lishers have  endeavored  to  render  the  mechanical  execution  of  the  work  worthy  of  its  extended 
reputation. 


JONES  (T.   WHARTON),   F.  R.  S., 

Professor  of  Ophthalmic  Medicine  and  Surgery  in  University  College,  London,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OP   OPHTHALMIC    MEDICINE 

AND  SURGERV.  With  one  hundred  and  ten  illustrations.  Second  American  from  the  second 
and  revised  London  edition,  with  additions  b/  Edward  Hartshorne,  M.D.,  Surgeon  to  Wills' 
Hospital,  cVc.  In  one  large,  handsome  royal  r2mo.  volume,  extra  cloth,  of  500  pages.  {Now 
Ready.)     $1  ,50. 

The  thorough  revisions  which  this  work  has  undergone  at  the  hands  of  both  author  and  editor 
have  brought  it  thoroughly  up  to  the  present  state  of  the  subject,  and  have  rendered  it  complete, 
without  detracting  from  its  character  as  a  manual,  or  deviating  from  its  original  object  of  affording 
a  digest  of  the  present  condition  of  ophthalmic  science  for  study  and  reference  by  those  whose 
leisure  does  not  admit  of  their  perusing  the  larger  works  of  Mackenzie  or  Lawrence.  By  an  en- 
largement of  the  size  of  the  page,  the  numerous  additions  to  this  edition  have  been  accommodated 
without  increasing  the  bulk  of  the  volume,  and  at  the  very  low  price  at  which  it  is  offered,  a  con- 
tinuance of  the  favor  which  it  has  hitherto  received  is  confidently  expected. 


We  are  confident  that  the  reader  will  find,  on 
perusal,  tlint  the  p.\ecution  of  the  work  amply  fulfils 
the  promise  of  the  preface,  and  sustains,  in  every 
point,  the  already  h  gh  reputation  of  the  author  as 
an  ophthalmic  surgeon  as  well  as  a  physiolocist 
and  pathologist.  The  book  is  evidently  the  result 
of  much  laljor  and  research,  .ind  has  been  written 
with  the  greatest  care  and  attention;  it  possesses 
that  best  quality  which  a  general  work,  like  a  sys- 
tem or  manual  can  show,  viz  :  the  quality  of  having 
all  the  materials  whencesoever  derived,  so  thorough- 


ly wrought  up,  and  digested  m  the  author's  mind, 
as  to  come  forth  with  the  freshness  and  jmpressive- 
ness  of  an  original  production.  \Ve  entertain  little 
doubt  that  this  book  will  be<'ome  \vliat  its  author 
hoped  it  might  become,  a  m:inu:il  for  daily  reference 
and  consult:! tion  by  the  student  and  the  general  prac- 
titioner. The  work  IS  m.nrkcd  by  that  correctness, 
clearness,  and  precision  of  style  which  distinguish 
all  the  productions  of  the  learned  author. — British 
and  For.  Med.  Review. 


IS 


JBLANCHAKD    &   LEA'S    MEDICAL 


JONES  (C.   HANDFIELD),  F.  R.  S.,  &.   EDWARO   H.   SIEVEKING,   M.D., 

Assistant  Physicinns  and  Lecturers  in  St.  Mary's  Hospital,  London. 

A  MANUAL  OF  PATHOLOGICAL   ANATOMY.     First  American  Edition, 

Revised.  Willi  three  himdred  and  ninety-seven  handsome  wood  engravings.  In  one  large  and 
beautiful  octavo  volume  of  nearly  750  pages,  leather.  (Lately  Issued.)  $3  73. 
Asa  concise  te.ict-book,  containing,  in  a  condensed  authors  have  not  attempted  to  intrude  new  views  on 
form,  a  complete  outline  of  what  is  known  in  the  their  professional  brethren,  but  simply  to  lay  before 
domain  of  Pathological  Anatomy,  it  is  perhaps  the  them,  what  has  long  been  wanted,  an  outline  of  the 
best  work  in  the  English  languaare.  Its  great  merit  present  condition  of  pathological  anatomy.  In  this 
consists  in  its  completeness  and  brevity,  and  in  this  they  have  been  completely  successful.  The^vorkis 
respect  it  supplies  a  great  desideratum  in  our  lite-  one  of  the  best  compilations  which  we  have  ever 
rature.  Heretofore  the  student  of  pathology  was  perused.  The  opinions  and  discoveries  of  all  the 
obliged  to  glean  from  a  great  number  of  monographs,  leading  pathologists  and  physiologists  are  engrossed, 
and  the  field  was  so  e.xtensive  that  hut  few  cuftivated  so  that  by  reading  any  subject  treated  in  the  book 
it  with  any  degree  of  success.  The  authors  of  the  you  have  a  synopsis  of  the  views  of  the  most  ap- 
present  work  have  sought  to  corrret  this  defect  by  proved  authors. — Charleston  Medical  Journal  and 
placing  before  the  reader  a  summary  of  ascertained     Review. 

facts,  together  with  the  opinions  of  the  most  eminent         ^g  j,ave  no   hesitation  in   recommending   it  as 

worthy  of  careful  and  thorough  study  by  every  mem- 
ber of  the  profession,  old  or  young. — N.  W.  Med. 
and  Surg.  Journal. 

From  the  casual  examination  we  have  given  we 
are  inclined  to  regard  it  as  a  text-book,  plain,  ra- 
tional, and  intelligible,  such  a  book  as  the  practical 
man  needs  for  daily  reference.  For  this  reason  it 
will  be  likely  to  be  largely  useful,  as  it  suits  itself 
to  those  busy  men  who  have  little  time  for  minute 
investigation,  and  prefer  a  summary  to  an  elaborate 


pathok)gists  both  of  the  Old  and  New  World.  As  a 
simple  work  of  reference,  therefore,  it  is  of  great 
value  to  the  student  of  pathological  anatomy,  and 
should  be  in  every  physician's  library. — Western 
Lancet. 

We  urge  upon  our  readers  and  the  profession  a^ene- 
rally  the  importance  of  informing  themselves  in  re- 
gard to  modern  views  of  pathology,  and  recommend 
to  them  to  procure  the  work  before  us  as  the  best 
means  of  obtaining  this  information. — Stethoscope. 


In  offering  the  above  titled  work  to  the  public,  the  I  Uea.tise.— Buffalo  Medical  Journal 


KIRKES  (WILLIAM   SENHOUSE),    M.  D., 

Demonstrator  of  Morbid  Anatomy  at  St.  Bartholomew's  Hospital,  &c.;  and 

JAMES   PAGET,   F.  R.  S., 

Lecturer  on  General  Anatomy  and  Physiology  in  St.  Bartholomew's  Hospital. 

A    MANUAL    OF    PHYSIOLOGY.     Second  American,  from  the  second  and 

improved  London  edition.    With  one  hundred  and  sixty-five  illustrations.     In  one  large  and 

handsome  royal  12mo.  volume,  leather,     pp.  550.     $2  00. 

In  the  present  edition,  the  Manual  of  Physiology 
has  been  brought  up  to  the  actual  condition  of  the 
science,  and  fully  sustains  the  reputation  which  it 


has  already  so  deservedly  attained.  We  consider 
the  work  of  MM.  Kirkes  and  Paget  to  constitute  one 
of  the  very  best  handbooks  of  Physiology  we  possess 
— presenting  just  such  an  outline  of  the  science,  com- 
prising an  accf>unt  of  its  leading  facts  and  generally 
admitted  principles,  as  the  student  requires  during 
his  attendance  upon  a  course  of  lectures,  or  for  re- 
ference whilst  preparing  for  examination. —  Am. 
Medical  Journal. 

We  need  only  say,  that,  without  entering  into  dis- 
cussions of  unsettled  questions,  it  contains  all  the 
recent  improvements  in  this  department  of  medical 
science.     For  the  student  beginning  this  study,  and 


the  practitioner  who  hag  but  leisure  to  refresh  his 
memory,  this  book  is  invaluable,  as  it  contains  all 
that  it  is  important  to  know,  without  special  details, 
which  are  read  with  interest  only  by  those  who 
would  make  a  specialty,  or  desire  to  possess  a  criti- 
cal knowledge  of  the  subject. — Charleston  Medical 
Journal. 

One  of  the  best  treatises  that  can  be  put  into  the 
hands  of  the  student. — London  Medical  Gazette. 

Particularly  adapted  to  those  who  desire  to  pos- 
sess a  concise  digest  of  the  facts  of  Human  Physi- 
ology.— British  and  Foreign  Med.-Chirurg.  Review. 

We  conscientiously  recommend  it  as  an  admira- 
ble "  Handbook  of  Physiology." — London  Journal 
of  Medicine. 


KNAPP'S  TECHNOLOGY;  or.  Chemistry  applied 
to  tiie  Arts  and  to  Manufactures.  Edited,  with 
numerous  Notes  and  Additiims,  by  Dr.  Edmund 
RoxALDs  and  Dr.  Thomas  Richardson.  First 
American  edition,  w^ith  Notes  and  Additions,  by 
Prof.  Walter  R.  Jonxsox.  In  two  handsome 
octavo  volumes,  extra  cloth,  printed  and  illus- 
trated in  the  highest  style  of  art,  with  about  500 
wood- engravings.     SO  00. 

LALLEMAND  ON  THE  CAUSES,  SYMPTOMS, 
AND  TREATMENT  OF  SPERMATORRHCEA. 
Translated  and  edited  by  Hexry  J.  McDougal. 
In  one  volume,  octavo,  extra  cloth,  320  pages. 
Second  American  edition.     $X  75. 

LUDLOW'S    MANUAL    OF    EXAMINATIONS 


upon  Anatomy  and  Physiology,  Surgery,  Practice 
of  Medicine,  Chemistry,  Obstetrics,  Materia  Me- 
dica.  Pharmacy,  and  Therapeutics.  Designed  for 
Studentsof  Medicine  throughout  the  Unittd  States. 
A  new  edition,  revised  and  improved.  In  one  la'ge 
royal  12mo.  volume,  with  several  hundred  illus- 
trations. (Preparing.) 
LEE'S  CLINICAL  MIDWIFERY.  In  one  royal 
l'2mo.  volume,  extra  cloth,  of  23S  pages.  75  cents. 

LISTONS  LECTURES  ON  THE  OPERATIONS 

OF  SURGERY.  Edited,  with  numerous  Addi- 
tions and  Alterations,  by  T.  D.  Mutter,  M.D. 
In  one  large  and  hnndsome  octavo  volume,  leather, 
of  566  pages,  with  '2J6  wood-cuts.    $3  00. 


HANDBOOKS 


LARDNER  (DIONYSIUS),  D.  C.  L.,  &c. 

OF    NATURAL    PHILOSOPHY    AND    ASTRONOMY. 


Revised,  with  ntiinerous  Additions,  by  the  American  editor.  First  Course,  containing  Mecha- 
nics, Hydrostatics,  Hydraulics,  Pneumatics,  Sound,  and  Optics.  In  one  large  royal  12mo. 
volume,  of  750  pages,  with  424  wood-cuts.  SI  75.  Second  Course,  containing  Heat,  Electricity, 
Magnetism,  and  Galvanism,  one  volume,  large  royal  r2mo.,  of  450  pages,  with  2.50  illustrations. 

51  25.  Third  Course  (7iow  ready),  containing  Meteorology  and  Astronomy,  in  one  lar£re  volume, 
royal  12mo.  of  nearlj'  eight  hundred  pages,  with  thirty-seven  plates  and  two  hundred  wood-cuts. 

52  00.  The  whole  complete  in  three  volumes,  of  about  two  thousand  large  pages,  with  over  one 
thousand  figures  on  steel  and  wood.  $5  00.  Any  volume  sold  separate,  strongly  bound  in  leather. 
The  various  sciences  treated  in  this  work  will  be  found  brought  thoroughly  up  to  the  latest  period. 


AND    SCIENTIFIC    PUBLICATIONS. 


19 


LEHMANN    (C.    G.) 
PHYSIOLOGICAL    CHEMISTRY.      Translated  from  the   second   edition   by 

George  E.  Day,  M.  D.,  F.  R.  S.,  &:c.,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of  Chemistry 
in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations  selected  from 
Funlce's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Complete  in  two  large 
and  handsome  octavo  volumes,  extra  cloth,  containing  1200  pages,  with  nearly  two  hmidred  illus- 
trations.    (Noio  Ready.)     $6  00. 

This  great  work,  universallv  acknowledged  as  the  most  complete  and  authoritative  exposition  of 
the  principles  and  details  of  Zoochemistry,  in  its  passage  through  the  press,  has  received  from 
Professor  Rogers  such  care  as  was  necessary  to  present  it  in  a  correct  and  reliable  form.  To  such 
a  work  additions  were  deemed  superfluous,  but  several  years  having  elapsed  between  the  appear- 
ance in  Germany  of  the  first  and  last  volume,  the  latter  contained  a  supplement,  embodying  nume- 
rous corrections  and  additions  resulting  from  the  advance  of  the  science.  These  have  all  been  incor- 
porated in  the  text  in  their  appropriate  places,  while  the  subjects  have  been  still  furtner  elucidated  by 
the  insertion  of  illustrations  from  the  Atlas  of  Dr.  Otto  Fun  ke.  With  the  view  of  supplying  the  student 
with  the  means  of  convenient  comparison,  a  large  number  of  wood-cuts,  from  works  on  kindred 
subjects,  have  also  been  added  in  the  form  of  an  Appendix  of  Plates.  The  work  is,  therefore,  pre- 
sented as  in  every  way  worthy  the  attention  of  all  who  desire  to  be  familiar  with  the  modern  facts 
and  doctrines  of  Physiological  Science. 


Already  well  known  and  appreciated  by  the  scien- 
tific world,  Professor  Lehmanii's  great  work  re- 
quires no  laudatory  sentences,  as,  under  a  ne\vgarb, 
it  is  now  presented  to  us.  The  little  space  at  ouf 
command  would  ill  suffice  to  set  furlh  even  a  small 
portjim  of  its  excellences.  To  all  whose  studies  or 
professional  duties  render  tlie  revelations  of  Physio- 
logical Chemistry  at  once  interesting  and  essential, 
tliese  volumes  will  be  indispensable.  Highly  com- 
plimented by  European  reviewers,  sought  fur  with 
avidity  by  sclinlars  of  every  nation,  and  admirably 
wrii  ten  throughout,  it  is  sure  to  win  a  welcome  and 
to  be  thoroughly  studied. — Boston  Med.  and  Surg. 
Journal,  Dec.  1855. 


The  most  important  contribution  as  yet  made  to 
Physiological  Chemistry. — Am.  Journal  Med.  Sct- 
ences,  Jan.  1S.56. 

The  present  volumes  belong  to  the  small  class  of 
medical  literature  which  comprises  elaborate  works 
of  the  highest  orderof  merit. — Montreal  Med.  Chron- 
icle, Jan.  1S5G. 

The  ^v()rk  of  Lehmann  stands  unrivalled  as  the 
most  comprehensive  boolc  of  reference  and  informa- 
tion extant  on  every  branch  of  the  subject  on  which 
it  treats. — Edinburgh  Monthly  Journal  of  Medical 
Science. 

All  teachers  must  possess  it,  and  every  intelligent 
physici;in  ouarht  todo  likewise. — Southern  Med.  and 
Surg.  Journal,  Dec.  1^55. 

BY  THE  SAME  AUTHOR.     {No7o  Ready,  1856.) 

MANUAL  OF  CHEMICAL   PHYSIOLOGY.      Translated  from  the  German, 

with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory  Essay  on  Vital 
Force,  by  Samuel  Jackson,  M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  University  of 
Pennsylvania.  With  illustrations  on  wood.  In  one  very  handsome  octavo  volume,  extra  cloth, 
of  336  pages.     $2  25. 

The  original  of  this  work,  though  but  lately  issued  by  its  distinguished  author,  has  already 
assumed  the  highest  position,  as  presenting  in  their  latest  development  the  modern  doctrines  and 
discoveries  in  the  chemistry  of  life.  The  numerous  additions  by  the  translator,  and  the  Introduc- 
tion by  Professor  Jacicson  will  render  its  physiological  aspect  more  complete  than  designed  by  the 
author,  and  will  adapt  it  for  use  as  a  text-book  of  physiology,  presenting  more  thorouglil)^  than  has 
yet  been  attempted,  the  modifications  arising  from  the  vast  impulse  which  organic  chemistry  has 
received  within  a  few  years  past. 

From  Prof.  Jacksoii's  Introductory  Essay. 
In  adopting  the  handbook  of  Dr  Lehmann  as  a  manual  of  Organic  Chemistry  for  the  use  of  the 
students  of  the  University,  and  in  recommending  his  original  work  of  Physiological  Chemistry 
for  their  more  mature  studies,  the  high  value  of  his  researches,  and  the  great  weigtit  of  his  autho- 
rity in  that  important  department  of  medical  science  are  fully  recognized. 


The  present  volume  will  be  a  very  convenient  one 
for  students,  as  offering  a  brief  epitome  of  the  more 
elaborate  work,  and  as  containing,  in  a  very  con- 


densed  form,   the   positive   facts   of   Physiological 
Chemistry. — Ain.  Journal  Med.  Sciences,  April,  1856. 


LAWRENCE  (W.),   F.  R.  S.,  &.C. 
A  TREATISE    ON   DISEASES    OP    THE    EYE.     A    new  edition,   edited, 

with  numerous  additions,  and  2^3  illustrations,  by  Isaac  Hays,  M.  D.,  Surgeon  to  Will's  Hospi- 
tal, &c.  In  one  very  large  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leather 
with  raised  bands.     $5  00. 

This  work  is  so  universally  recognized  as  the  standard  authority  on  the  subject,  that  the  pub- 
lishers in  presenting  this  new  edition  have  only  to  remark  that  in  its  preparation  the  editor  has 
carefully  revised  every  portion,  introducing  additions  and  illustrations  wherever  the  advance  of 
science  has  rendered  them  necessary  or  desirable,  constituting  it  a  complete  and  thorough 
exponent  of  the  most  advanced  state  of  the  subject. 

This  admirable  treatise— the  safest  guide  and  most  \  octavo  pages— has  enabled  both  author  and  editor  to 
comprehensive  work  of  reference,  wliich  is  within  do  justice  to  all  the  details  of  this  subject,  and  eon- 
the  reach  of  the  profession. — Stethoscope.  j  dense  iathis  single  volume  the  present  state  of  our 

!  knowledge  of  the  whole  science  in  this  department, 

This  standard  text-book  on  the  department  of  whereby  its  practical  value  cannot  be  excelled.  We 
which  it  treats,  has  not  been  superseded,  by  any  or  ■  heartily  commend  it,  especially  as  a  book  of  refer- 
all  of  the  numerous  publications  on  the  subject  i  ence,  indispensable  in  every  medical  library.  The 
heretofore  issued.  Nor  with  the  multiplied  improve-  ;  additions  of  the  American  editor  very  greatly  en- 
ments  of  Dr.  Hays,  the  American  editor,  is  it  at  all  j  hance  the  value  of  the  work,  exhibiting  the  learning 
likely  that  this  great  work  will  cease  to  merit  the  and  experience  of  Dr.  Hays,  in  the  light  in  which  he 
confidence  and  preference  of  students  or  practition-  j  ought  to  be  held,  as  a  standard  authority  on  all  sub- 
erg.     Its  ample  extent — nearly  one  thousand  large  |  jects  appertaining  to  this  specialty .—  iV.  y'.  illerf.  Gaz. 


20 


BLANCHARD    &    LEA'S    MEDICAL 


LA   ROCHE   (R.),    M.  D.,  &.c. 
YELLOW  FP^VER,  considered  in  its  Historical,  Pathological,  Etiological,  and 

Therapeutical  Relations.     Including  a  Sketch  of  the  Disease  as  it  has'occurred  in  Philadelphia 
from  Itiyyto  1854,  with  an  examination  of  the  connecIic)ri>  between  it  and  the  fevers  known  undtr 
tlie  same  name  in  other  parts  of  temperate  as  well  as  in  tropical  regions      In   two  large  and 
handsome  octavo  volumes  of  nearly  1500  pages,  extra  (;loth.     (IVoiv  Ready.)     $7  00. 
The  publishers  are  happy  in  being  able  at  length  to  present  to  the  prolession   this  great  work, 
which  they  are  assured  will  be  regarded  as  an  honor  to  the  medical  literature  of  the  coiuitry.     As 
tlie  result  of  many  years  of  personal  observation  and  study,  as  embodying  an  iniellisent  rcs'/ime  of 
all  that  has  been  written  regarding  the  disease,  and  as  exhausting  tlie  subject   in  all    its  various 
aspects,  these  volumes  must  at  once  take  the  position  of  the  standard  authority  and  work  of  refer- 
ence on  the  many  important  questions  brought  into  consideration. 


From  Profesfor  S.  H.  Dickson,  Charlestcn,  S.  C, 
September  18,  1855. 

A  monument  of  intellisrent  and  well  applied  re- 
search, iiUnost  without  example.  It  is,  indeed,  in 
itself,  a  large  iilirary,  and  is  de.stined  to  constitute 
tjie  special  resm-t  as  a  book  of  reference,  in  the 
subject  of  which  it  treats,  to  all  future  time. 

We  have  not  time  at  present,  en<:aged  as  we  are, 
by  day  and  by  nisht,  in  the  work  of  coml)ating  this 
very  disease,  now  prevailm?  in  oui  citv,  to  do  more 
than  give  this  cursory  notice  of  what'we  consider 
as  undoubtedly  the  most  able  and  erudite  medical 
publicali(m  our  country  has  yet  produced  But  in 
view  of  the  startlin.-  fact,  that  this,  the  most  malig- 
nant and  unmanageable  disease  of  modern  times, 
has  for  several  years  been  prevailing  in  our  country 
to  a  greater  extent  than  ever  before;  tliat  it  is  no 
longer  confined  to  either  large  or  small  cities,  but 
penetrates  country  villages,  plantations,  and  farm- 
houses; that  it  is  treated  with  scarcely  better  suc- 
cess now  than  thirty  or  forty  years  ago;  that  there 
is  vast  mischief  done  by  ignorant  pretenders  to  know- 
ledge in  regard  to  the  disease,  and  in  view  of  the  pro- 
bability that  a  majority  of  southern  physicians  will 
be  called  upon  to  treat  the  disease,  we  trust  that  this 
able  and  comprehensive  treafise  will  We  very  gene- 
rally read  in   the  south.— Memphis  Med,  Recorder. 

This  is  decidedly  the  great  Americ.in  medical  work 
of  theday — a  full,  complete,  and  systematic  treatise, 
unequalled  by  any  other  upon  the  all-important  sub- 


erection  of  this  towering  monument  to  liis  own  fame, 
and  to  the  glory  of  the  medical  literature  of  liis  own 
country.  It  is  destined  to  remain  the  great  autho- 
rity upon  the  subject  of  Yellow  Fever  The  student 
and  physician  will  find  in  these  volumes  a  r^sumi 
,of  the  sum  total  of  the  knowledge  of  the  world  upon 
'the  awful  scourge  which  tliey  so  elaborately  discuss. 
The  style  is  so  soft  and  so  pure  as  to  refresh  and  in- 
vigorate the  mind  while  absorbing  the  Miouglits  of 
the  gil"ted  author,  while  the  publishers  have  suc- 
ceeded in  bringing  theextern.-ils  into  a  most  felicitous 
harmony  with  the  inspiration  that  dwells  within. 
Take  it  all  in  all,  it  is  a  bonk  we  nave  often  dreamed 
of,  but  dreamed  not  that  it  would  ever  meet  our 
waking  eye  as  a  tangible  reality. — Aashville  Journal 
of  Medicine. 

We  deem  it  fortunate  that  the  splendid  work  of 
Dr.  La  Roche  should  have  been  issued  from  the  press 
at  this  particular  time.  The  ^vant  of  a  reliable  di- 
gest of  all  that  is  known  in  relation  t .  this  frightful 
malady  has  long  been  felt — a  want  very  satisfactorily 
met  in  the  work  before  us.  We  def-m  it  but  faint 
praise  to  say  that  Dr.  La  Rtche  has  succeeded  in 
presenting  the  profession  with  an  able  and  complete 
monograph,  one  which  will  find  its  way  into  every 
well  ordered  library. —  Va.  Stethoscope. 

Although  we  have  no  doubt  that  controversial 
treatises  on  the  mode  of  origin  and  propagation  of  the 
fever  in  question  ■will,  as  heretofore,  occasionally 
appear,  yet  it  must  be  some  time  befr>re  another  sys- 


jeetof  \  ellow  Fever.  The  laborious,  indefatigable,  i  tematic  work  can  arise  in  the  face  of  so  admirable 
and  learned  author  has  devoted  to  it  many  years  of  and  carefully  executed  a  one  as  the  present.  It  is  a 
arduous  research  and  careful  study,  and  the  result]  mine  of  information,  quite  an  encyclopa?dia  of  refer 


is  such  as  will  reflect  the  highest' honor  upon  the 
author  and  our  country.— Sou/Aern  Med.  and  Surg. 
Journal. 

The  genius  and  scholarship  of  thisgreat  physician 
could  not  have   been  belter  employed  than  in  the 


ences,  and  r£'.<w??jt' of  knowledge  relative  to  what  has 
been  recorded  upon  the  subject.— Lo)u/o»  Lancet. 

A  miracle  of  industry  and  research,  constituting 
a  complete  library  of  reference  on  the  disease  of 
which  it  treats. —  Dublin  Quarterly  Journal. 


BY  THE  SAME  AUTHOR. 

PNEU3I0XIA ;  its  Supposed  Connection,  Pathological  and  Etiological,  with  Au- 
tumnal Fever>,  including  an  Inquiry  into  the  Existence  an(rMorbid  Agency  of  Malaria.  la  one 
handsome  octavo  volume,  extra  cloth,  of  500  pages.    $.3  00. 

A  more  simple,  clear,  and  forcible  exposition  of  I  This  work  should  be  carefully  studied  by  Southern 
the  groundless  nature  and  dangerous  tendency  of  |  physicians,  embodying  as  it  does  the  reflections  of 
certain  patliological  and  etiological  heresies,  has  |  an  original  thinker  and  close  observer  on  a  subject 
seldom  been  presented  to  our  notice.— A'.  Y.  Journal  peculiarly  their  uwn.— Virginia  Med.  and  Surgical 
of  Medicine  and  Collateral  Science.  I  Journal. 


MULLER  (PROFESSOR  J.),   M.  D. 
PRINCIPLES  OF  PHYSICS   AND   METEOROLOGY.     Edited,  with  Addi- 

lions,  by  R.  Eklesfeld  Griffith,  M.  D.     In  one  large  and  handsome  octavo  volume,  extra 
cloth,  with  550  wood-cuts,  and  two  colored  plates,    pp.  636.     $3  50. 

The  Physics  of  MQUer  is  a  work  superb,  complete,  I  tion  to  the  scientific  records  of  this  country  may  be 
unique  :  thegreatest  want  known  to  English  Science  |  duly  estimated  by  the  fact  that  the  cost  of  I'lie  ori^i- 
eould  not  have  been  better  supplied.  The  work  is  I  nal  drawings  and  engravings  alone  has  exceeded  the 
ol  surpassing  interest.     The  value  of  this  contribu-  |  sum  of  £'2,000.— Lancet. 


MAYNE'S    DISPEXSATORY     AND     THERA-  ! 
PEUTICAL    RE.ME.MHRaNCKR.     Comprising  ' 
the  entire  lists  of  .Materia  Medica.  with  every  I 
Practical  Formula  contained  in  the  three  "feritish 
Pharmacopoeias.    With  relative  Tables  subjoined,  ! 
illustrating,  by  upwards  of  six  hundred  and  sixty 
examples,  the  Extemporaneous  Forms  and  Com- 
binations   suitable    for   the  diiTerent    Medicines. 
Edited,  with  the  addition  of  the  Formula  of  the 
United  States  Pharmacopoeia,  by  R.  Eglesfeld  ' 
Griffith,  AI.  D.  In  one  12mo  volume,  extra  cloth, 
of  300  large  pages.    75  cents. 


MATTEUCCrS  LECTURES  ON  THE  PHYSI- 
CAL PHEXOVIENA  OF  LIVING  BEINGS. 
Edited  by  J.  Pereira,  M.  D.  In  one  neat  royal 
I'imo.  volume,  extra  cloth,  with  cuts,  .3dS  pages. 
$1  00. 

MALGAIGNE'S  OPERATIVE  SURGERY,  based 
on  Normal  and  Pathological  Anatomy.  Trans- 
lated from  the  French  by  Frederick  Brittan, 
A.  B.,  M.  D.  Withnumerousillustrationstmwood. 
In  one  handsome  octavo  Volume,  extra  cloth,  of 
nearly  six  hundred  pages.     $2  25. 


4 


AND    SCIENTIFIC    PUBLICATIONS. 


21 


MEIGS  (CHARLES   D.),  M.  D., 

Professor  of  Obstetrics,  &c.  in  tlie  Jefferson  Medical  College,  Philadelphia. 

OBSTETRICS:  THE  SCIENCE  AND   THE   ART.     Second  edition,  revised 

and  improved.     With  one  hundred  and  thirty-one  illustrations.     In  one  beautifully  printed  octavo 
volume,  leather,  of  seven  hundred  and  liity-two  large  pages.     $3  75. 

The  rapid  demand  for  a  second  etiition  of  thi.s  work  is  a  sufficient  evidence  that  it  has  supplied 
a  desideratum  of  the  profession,  notwithstanding  the  numerous  treatises  on  the  same  subject  which 
have  appeared  within  the  last  few  years.  Adopting  a  system  of  his  own,  the  author  has  combined 
the  leading  principles  of  his  interesting  and  dilficult  subject,  with  a  thorough  exposition  of  its  rules 
o/' practice,  presenting  the  results  of  long  and  extensive  experience  and  of  familiar  acquaintance 
with  all  the  modern  writers  on  this  department  of  medicine.  As  an  American  Treatise  on  Mid- 
wifery, which  has  at  once  assumed  the  position  of  a  classic,  it  possesses  peculiar  claims  to  the  at- 
tention and  study  of  the  practitioner  and  student,  while  the  numerous  alterations  and  revisions 
which  it  has  undergone  in  the  present  edition  are  shown  by  the  great  enlargement  ol  the  work, 
which  is  not  only  increased  as  to  the  size  of  the  page,  but  also  in  the  number. 

BY  THE  SAME  AUTHOR.     (^Lately  Issued.) 

WOMAN :  HER  DISEASES  AND  THEIR   REMEDIES.     A  Series  of  Lee- 

tures  to  his  Class.     Third  and  Improved  edition.     In  oue  large  and  beautifully  printed  octavo 
volume,  leather.         pp.  672.     $3  GO. 

The  gratifying  appreciation  of  liis  labors,  as  evinced  by  the  exhaustion  of  two  large  impressions 
of  this  work  within  a  few  years,  has  not  been  lost  upon  the  author,  who  has  endeavored  in  every 
way  to  render  it  worthy  of  the  favor  with  which  it  has  been  received.  The  opportunity  thus 
aflbrded  for  a  second  revision  has  been  improved,  and  the  work  is  now  presented  as  in  every  way 
superior  to  its  predecessors,  additions  and  alterations  having  been  made  whenever  the  advance  of 
science  has  rendered  them  desirable.  The  typographical  execution  of  the  work  will  also  be  found 
to  have  undergone  a  similar  improvement,  and  the  work  is  now  confidently  presented  as  in  every 
way  worthy  the  position  it  has  acquired  as  the  standard  American  text-book  on  the  Diseases  of 
Females. 


It  contains  a  vast  amount  of  practical  knowledge, 
by  one  who  has  accurately  ol)served  and  retained 
the  experience  of  many  years,  and  who  tells  tiie  re- 
sult in  a  free,  familiar,  and  pleasant  manner. — Dub- 
lin Quarterly  Journal. 

There  is  an  off-liand  fervor,  aglow,  and  a  warm- 
heartedness infecting  the  effort  of  Dr.  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  re.iuler  through  from  beginning  to  end.  Be- 
sides, the  book  teems  with  solid  instruction,  and 
it  shows  the  very  highest  evidence  of  ability,  viz., 
the  clearness  with  which  the  information  is  pre- 
sented. VVe  know  of  no  lietter  test  of  one's  under- 
standing a  sulijcct  than  the  evidence  of  the  power 
of  lucidly  explaining  it.  The  most  elementary,  as 
well  as  tlie  obscurcKt  subjects,  under  the  jiencil  of 
Prof.  Meigs,  are  isolated  and  made  to  stand  out  in 

BY  THE  SAME  AUTHOR.     (Lately  Puhlished.) 

ON    THE    NATURE,    SIGNS,    AND    TREATxMENT    OF    CHILDBED 

FEVER.     In   a  Series  of  Letr?rs  addressed  to  the  Students  of  his  Cliis.     In  one  handsome 
octavo  volume,  extra  cloth,  ol  365  pages.     $2  50. 


such  bold  relief,  as  to  produce  distinct  impressions 
upim  the  mind  and  memory  of  the  reader.  —  Th« 
Charleston  Med.  Journal. 

Professor  Meigs  has  enlarged  and  amended  this 
great  work,  for  such  it  unquesti(mably  is,  having 
passed  the  ordeal  of  criticism  at  home  and  abroad, 
but  been  improved  thereby  ;  for  in  tliis  new  edition 
tlie  author  has  introduced  real  improvements,  and 
increased  the  value  and  utility  of  the  book  im- 
measuralily.  It  presents  so  many  novel,  bright, 
and  sparkling  thoughts;  such  an  exuberance  of  new 
ideas  on  almost  every  page,  that  we  confess  our- 
selves to  have  become  enamored  witli  tlie  book 
and  its  author ;  and  cannot  withhold  our  congratu- 
lations from  our  Philadelphia  confreres,  that  such  a 
teacher  is  in  their  service. — N.  Y.  Med.  Gazette. 


The  instruct ive  and  interestin";  author  of  this 
work,  whose  previous  labors  in  the  department  of 
medicine  which  he  so  sedulously  cultivates,  have 
placed  his  countrymen  under  deep  and  aliiding  obli- 
gations, ;ig:iin  challenges  their  admiration  in  the 
fresh  and  vigorous,  attractive  and  racy  pages  before 
us.  It  is  a  delectable  book.  *  *  *  Tliis  treatise 
upon  child-lied  fevers  will  have  an  extensive  sale, 
being  destined,  as  it  deserves,  to  find  a  place  in  the 
library  of  every  practitioner  who  scorns  to  lag  in  the 
rear  of  his  hret^iren. — Nashville  Journal  of  Medi- 
cine and  Surgery. 


This  book  will  add  more  to  his  fame  than  either 
of  those  which  bear  his  name.  Indeed  we  doubt 
whether  any  material  improvement  will  be  made  on 
the  teachings  of  this  volume  for  a  century  to  come, 
since  it  is  so  eminently  practical,  and  based  on  pro- 
found knowledge  of  the  science  and  consummate 
skill  in  the  ar«  of  healing,  and  ratified  by  an  ample 
and  extensive  experience,  such  as  few  men  have  the 
industry  or  good  fortune  to  acquire. — N.  Y.  Med. 
Gazette. 


BY   THE   SAME   AUTHOR  ;    WITH" COLORED  PLATES.      (Lately  Puhlished.) 

A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK 

OF  THE  UTEllUS.     With  numerous  plates,  drawn  and  colored  from  nature  in  the  highest 
style  of  art.     In  one  handsome  octavo  volume,  extra  cloth.     f4  50. 

The  object  of  the  author  in  this  work  has  been  to  present  in  a  small  compass  the  practical  results 
of  his  long  experience  in  this  important  and  distressing  class  of  diseases.  The  great  changes  intro- 
duced iiiio  practice,  and  the  accessions  to  our  knowledge  on  the  subject,  within  the  last  few  years, 
resulting  from  the  use  of  the  metroscope,  brings  within  the  ordinary  practice  of  every  physician 
numerous  cases  which  were  formerly  regarded  as  incurable,  and  renders  of  great  value  a  work  like 
the  pre.*ent  combining  practical  directions  for  diagnosis  and  treatment  with  an  ample  series  of  illus- 
trations, copied  accurately  from  colored  drawings  made  by  the  author,  after  nature. 

BY   THE   SAME   AUTHOR. 

OBSERVATIONS   ON    CERTAIN    OF    THE    DISEASES    OF    YOUNG 

CHILDREN.    In  one  handsome  octavo  volume,  extra  cloth,  of  214  pages.    $175 


22 


BLANCHARD    &    LEA'S    MEDICAL 


MACLISE   (JOSEPH),    SURGEON, 
SURGICAL  ANx\TOMY.     Forming  one  volume,   very  large  imperial  quarto. 

With  s^ixty-eig-ht  large  and  splendid  Plates,  drawn  in  the  hest  style  and  beamifully  colored.    Con- 
taining one  hundred  and  ninety  Figures,  many  of  them  the  size  of  life.     Together  with  copious 
and  explanatory  letter-press.     Strongly  and  handsomely  bound  in  extra  cloth,  being  one  of  the 
cheapest  and  best  executed  Surgical  works  as  yet  issued  in  this  country.    $11  00. 
*^*  The  size  of  this  work  prevents  its  transmission  through  the  post-otlice  as  a  whole,  but  those 

who  desire  to  have  copies  forwarded  by  mail,  can  receive  them   in  five  parts,  done  up  m  stout 

wrappers.    Price  $9  00. 


One  of  the  greatest  artistic  triumplis  of  the  age 
in  Surgical  Anatomy. — British  American  Medical 
Journal. 

Too  much  cannot  be  said  in  its  praise;  indeed, 
we  have  not  language  to  do  it  justice. — Ohio  Medi- 
cal and  Surgical  Journal. 

The  most  admirable  surgical  atlas  we  have  seen. 
To  the  practitioner  deprived  of  demonstrative  dis- 
sections upon  the  human  subject,  it  is  an  invaluable 
companion. — N.  J.  Medical  Reporter. 

The  most  accurately  engraved  and  beautifully 
colored  plates  we  have  ever  seen  in  an  American 
book — one  of  the  best  and  cheapest  surgical  works 
ever  published. — Buffalo  Medical  Journal. 

It  is  very  rare  that  so  elegantly  printed,  so  well 
illustrated,  and  so  useful  a  work,  is  offered  at  so 
moderate  a  price. — Charleston  Medical  Journal. 

Its  plates  can  boast  a  superiority  which  places 
them  almost  beyond  the  reach  of  competition. — Medi- 
cal Examiner. 

Every  practitioner,  we  think,  should  have  a  -work 
of  this  kind  within  reach. — Southern  Medical  and 
Surgical  Journal. 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  given. — Boston 
Medical  and  Surgical  Journal. 

As  a  surgical  anatomist,  Mr.  Maclise  has  proba- 
bly no  superior. — British  and  Foreign  Medico-Chi- 
rurgical  Review. 

Of  great  value  to  the  student  engaged  in  dissect- 
ing, and  to  the  surgeon  at  a  distance  from  the  means 


of  keeping  up  his  anatomical  knowledge. — Medical 
Times. 

The  mechanical  execution  cannot  be  excelled. — 
Transylvania  Medical  Journal. 

A  work  which  has  no  parallel  in  point  of  accu- 
racy and  cheapness  in  the  English  language. — N.  Y. 
Journal  of  Medicine. 

To  all  engaged  in  the  study  or  practice  of  their 
profession,  such  a  work  is  almost  indispensable. — 
Dublin  Quarterly  Medical  Journal. 

No  practitioner  whose  means  will  admit  should 
fail  to  possess  it. — Banking's  Abstract. 

Country  practitioners  will  find  these  plates  of  im- 
mense value. — N.  Y.  Medical  Gazette. 

We  are  extremely  gratified  to  announce  to  the 
profession  the  completion  of  this  truly  magnificent 
work,  which,  as  a  whole,  certainly  stands  unri- 
valled, both  for  accuracy  of  drawinaf,  heauty  of 
coloring,  and  all  the  requisite  explanations  of  the 
subject  in  hand. — The  New  Orleans  Medical  and 
Surgical  Journal. 

This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy that  has  come  under  our  observation.  We 
know  of  no  other  work  that  would  justify  a  stu- 
dent, in  any  degree,  for  neglect  of  actual  dissec- 
tion. Ju  those  sudden  emergencies  that  so  often 
arise,  and  which  require  the  instantaneous  command 
of  minute  anatomical  knowledge,  a  work  of  this  kind 
keeps  the  dettiils  of  the  dissecting-room  perpetually 
fresh  in  the  memory. — The  Western  Journal  of  Medi- 
cine and  Surgery. 

The  very  low  price  at  which  this  work  is  furnished,  and  the  beauty  of  its  execution, 
requii-e  an  extended  sale  to  compensate  the  publishers  for  the  heavy  expenses  incurred. 


MOHR  (FRANCIS)    PH.  D.,  AND  REDWOOD  (TH  EOPH  I  LUS). 
PRACTICAL    PHARMACY.     Comprising  the  Arrangements,  Apparatus,  and 

Manipulations  of  the  Pharmaceutical  Shop  and  Laboratory.  Edited,  with  extensive  Additions, 
by  Prof.  William  Procter,  ot  the  Philadelphia  College  of  Pharmacy.  In  one  handsomely 
printed  octavo  volume,  extra  cloth,  of  570  pages,  with  over  500  engravings  on  wood.     $2  75. 


MACKENZIE   (W.),    M.D., 

Surgeon  Oculist  in  Scotland  in  ordinary  to  Her  Majesty,  &c.  &c. 

A  PRACTICAL   TREATISE  ON   DISEASES    AND  INJURIES  OF   THE 

EYE.  To  which  is  prefixed  an  Anatomical  Introduction  explanatory  of  a  Horizontal  Section  ol 
the  Human  Eyeball,  by  Thomas  Wharton  Jones,  F.  R.  S.  From  the  Fourth  Revised  and  En- 
larged London  Edition.  With  Notes  and  Additions  by  Addinell  Hewson,  M.  D.,  Surgeon  to 
Wills  Hospital,  &:c.  ice.  Inone  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  with 
plates  and  numerous  wood-cuts.     (_I\'ow  Ready.)     $5  25. 

The  treatise  of  Dr.  Mackenzie  indisputably  holds  i  accordance  with  the  advances  in  the  science  which 
the  first  place,  and  forms,  in  respect  of  learning  and    have  been  made  of  late  years.     Nothing  worthy  of 

repetition  upon  any  branch  of  the  subject  appears  to 
have  escaped  the  author's  notice.  We  consider  it 
the  duty  of  every  one  who  has  the  love  of  his  profes- 
sion and  the  welfare  of  his  patient  at  heart,  to  make 
himself  familiar  with  this  the  most  complete  work 
in  the  En2;lish  language  upon  the  diseases  of  the  eye. 
— Med.  Times  and  Gazette. 

The  fourth  edition  of  this  standard  work  will  no 
doubt  be  as  fully  appreciated  as  the  three  former  edi- 


researcli,  an  FIncyclopoEdia  unequalled  in  extent  by 
any  other  work  of  the  kind,  either  English  or  foreign. 
— Dixon  on  Diseases  of  the  Eye. 

Few  modern  books  on  any  department  of  medicine 
or  surgery  have  met  with  such  extended  circulation, 
or  have  procured  for  their  authors  a  like  amount  of 
European  celebrity.  The  immense  research  which 
it  displayed,  the  thorough  acquaintance  with  the 
subject,  practically  as  well  as  theoretically,  and  the 


able  manner  in  which  the  author's  stores  of  learning  '>""s.  It  is  unnecessary  to  say  aword  in  its  praise, 
and  experience  were  rendered  available  for  general;  f'""  tlie  verdict  has  already  been  passed  upon  it  by 
use,  at  once  procured  for  the  first  edition,  as  well  on  '  "'^  most  competent  judges,  and  "  Mackenzie  on  the 


the  continent  as  in  this  country,  that  high  positicm 
as  a  standard  work  which  each  successive  edition 
has  more  firmly  established,  in  spite  of  the  attrac- 
tions of  several  rivals  of  no  mean  ability.  This,  the 
fourth  edition,  has  been  in  a  great  measure  re-writ- 
ten;  new  matter,  to  tlie  extent  of  one  hundred  and 
fifty  pages,  has  been  added,  and  in  several  instances 
formerly  expressed  opinions  have  been  modified  in 


the  most  competent  judges,  and  ' 
Eye"  has  justly  obtained  a  reputation  which  it  is 
no  figure  of  speech  to  call  world-wide. — British  and 
Foreign  Medico-Chirurgical  Review. 

This  new  edition  of  Dr.  Mackenzie's  celebrated 
treatise  on  diseases  of  the  eye,  is  truly  a  miracle  of 
industry  and  learning.  We  need  scarcely  say  that 
he  has  entirely  exhausted  the  subject  of  his  specialty. 
— Dublin  Quarterly  Journal. 


AND    SCIENTIFIC    PUBLICATIONS. 


23 


MILLER  (JAMES),   F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Edinburgh,  &c. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and  revised 

Edinburgh  edition.    In  one  large  and  very  beautiful  volume,  leather,  of  700   pages,  with  two 

hundred  and  forty  exquisite  illustrations  on  wood.     (Noiv  Ready,  1856.)        $3  75. 

The  extended  reputation  enjoyed  by  this  work  will  be  fully  maintained  by  the  present  edition. 
Thoroughljf  revised  by  the  author,  it  will  be  found  a  clear  aiad  compendious  exposition  of  surgical 
science  in  its  most  advanced  condition. 

In  connection  with  the  recently  issued  third  edition  of  the  author's  "  Practice  of  Surgery,"  it 
forms  a  very  complete  system  of  Surgery  in  all  its  branches. 

The  work  of  Mr.  Miller  is  ton  well  and  too  favor- 
ably known  anions:  us,  as  one  of  our  best  text-books, 
to  render  any  further  notice  of  it  necessary  than  the 
announcement  of  a  new  edition,  the  fovrth  in  our 


country,  a  proof  of  its  extensive  circulation  amon: 
us.  As  a  concise  and  reliable  exposition  of  the  sci- 
ence of  modern  surgery,  it  stands  deservedly  high — 
we  know  not  its  superior. — Boston  Med.  and  Surg. 
Journal,  May,  1856. 

The  works  of  Professor  Miller  are  so  well  known 
to  the  profession,  that  it  is  unnecessary  for  us  say 
anything  in  relation  to  their  general  merits.  The 
present  edition  of  his  "Principles,"  however,  de- 
serves a  s)iecial  notice,  from  the  number,  variety, 
and  faithfulness  of  its  illustrations.  The  \vood-cuts 
are  beautifully  executed,  and  many  of  them  are  new 
and  exceedingly  iristructive,  particularly  those  illus- 
trating mortifieation,  <liseased  and  fractured  bones, 
and  the  varieties  of  aneurism. — WesternLancet, May, 
1856. 

This  edition  is  far  superior,  both  in  the  abundance 
and  quality  of  its  material,  to  any  of  the  preceding. 
We  hope  it  will  be  extensively  read,  and  the  sound 
principles  which  are  herein  taught  treasured  up  for 
future  application.      The  work    takes    rank  with 

BY  THE  SAME  AUTHOR.     (Lately  Published.) 

THE  PRACTICE  OF  SURGERY.  Third  American  from  the  second  Edin- 
burgh edition.  Edited,  with  Additions,  by  F.  W.  Sargent,  M.  D  ,  one  of  the  Surgeons  to  Will's 
Hospital,  &c.  Illustrated  by  three  hundred  and  nineteen  engravings  on  wood.  In  one  large 
octavo  volume,  leather,  of  over  700  pages.     $3  75. 

No  encomium  of  ours  could  add  to  the  popularity  I  his  works,  both  on  the  principles  and  practice  of 
of  Miller's  Surgery.  Its  reputation  in  this  country  I  surgery  have  been  assigned  the  highest  rank.  If  we 
is  unsurpassed  by  that  of  any  other  work,  and,  when    were  limited  to  but  one  work  on  sursery.  that  one 


Watson's  Practice  of  Physic;  it  certainly  does  not 
fall  behind  that  great  work  in  soundness  of  princi- 
ple or  depth  of  reas<ining  and  research.  No  physi- 
cian who  values  his  reputation,  or  seeks  the  interests 
of  his  clients,  can  acquit  himself  before  his  God  and 
the  world  without  making  himself  familiar  with  the 
sound  and  philos<iphical  views  developed  in  the  fore- 
going book. — New  Orleans  Med.  and  Surg.  Journal. 

Without  doubt  the  ablest  exposition  of  the  prin- 
ciples of  that  branch  of  the  he;iling  art  in  any  lan- 
guage. This  opinion,  deliberately  formed  after  a 
careful  study  of  the  first  edition,  we  have  had  no 
cause  to  change  on  examining  the  second.  This 
edition  has  undergone  thorough  revision  by  the  au- 
thor; many  expressions  have  been  modified,  and  a 
mass  of  new  matter  introduced.  The  hook  is  got  up 
in  the  finest  style,  and  is  an  evidence  of  the  progress 
of  typography  in  our  country. — Charleston  Medical 
Journal  and  Revieio. 

We  recommend  it  to  both  student  and  practitioner, 
feeling  assured  that  as  it  now  comes  to  us,  it  pre- 
sents the  most  satisfactory  exposition  of  the  modern 
doctrines  of  the  principles  of  surgery  to  be  found  in 
any  volume  in  any  language. — N.  Y.  Journal  of 
Medicine. 


taken  in  connection  with  the  author's  Princijiles  of 
Surgery,  constitutes  a  whole,  without  reference  to 
which  no  conscientious  surgeon  would  be  willing 
to  practice  his  art.  The  additions,  by  Dr.  Sargent, 
have  materially  enhanced  the  value  of  the  work. — 
Southern  Medical  and  Surgical  Journal. 

It  is  seldom  that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
"  Principles"  and  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merited  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  well-informed  man,  who  knows 
exactly  what  he  is  talking  about  and  exactly  how  to 
talk  it. — Kentucky  Medical  Recorder. 

By  the  almost  unanimous  voice  of  the  profession, 


should  be  Aliller's,  as  we  regard  it  as  superior  to  all 
others. — St.  Louis  Med.  and  Surg.  Journal. 

The  author,  distinguished  alike  as  a  practitioner 
and  writer,  has  in  tliisand  his  "  Principles,"  pre- 
sented to  the  profession  <ine  of  the  most  complete  and 
reliable  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, concise,  and  lucid.  Few  have  the  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  the  attention;  indeed, 
he  appears  to  make  the  very  process  of  condensation 
a  means  of  eliminating  attractions.  Whether  as  a 
text-book  for  students  or  a  book  of  reference  for 
practitioners,  it  cannot  be  too  strongly  recommend- 
ed.— Southern  Journal  of  Med.  and  Phys.  Sciences. 


NEILL   (JOHN),    M.  D., 

Professor  of  Surgery  in  the  Pennsylvania  Medical  College,  &c. 

OUTLINES  OF  THE  ARTERIES.     With  short  Descriptions.     Designed   for 

the  Use  of  Medical  Students.     With  handsome  colored  plates.     Second  and  improved  edition. 
In  one  octavo  volume,  extra  cloth.     $1  25. 

OUTLINES  OF  THE  NERVES.     With  short  Descriptions.     Designed  for  the 

Use  of  Medical  StuderUs.    With  handsome  plates.    Second  and  improved  edition.    In  one  octavo 
volume,  extra  cloth,     f  1  25. 

OUTLINES   OF  THE  VEINS   AND  LYMPHATICS.     With  short  Descrip- 

tions.     Designed  for  the  Use  of  Medical  Students.  With  handsome  colored  plates.  In  one  octavo 
volume,  extra  cloth.     $1  25. 
ALSO — The  three  works  done  up  in  one  handsome  volume,  half  bound,  with  numerous  plates,  pre- 
senting a  complete  view  of  the  Circulatory,  Nervous,  and  Lymphatic  Systems.     $3  25. 

and  the  reading  of  larger  works. — N.  Y.  Journal  of 
Medicine. 


This  book  should  be  in  the  hand  of  every  medical 
student.  It  is  cheap,  portable,  and  precisely  the 
thing  needed  in  studying  an  important,  though  diffi- 
cult part  of  Anatomy.  —  Boston  Med.  and  Surg. 
Journal. 

We  recommend  every  student  of  medicine  to  pur- 
chase a  copy  of  this  work,  as  a  labor-saving  ma- 
chine, admirably  adapted  to  refresh  the  memory, 
with  knowledge  gained  by  lectures,  dissections, 


This  work  is  from  the  pen  of  a  Philadelphia  ana- 
tomist, whose  familiar  knowledge  of  the  subject  has 
been  aided  by  the  press,  the  result  of  which  is  a  vo- 
lume of  great  beauty  and  excellence.  Its  fine  exe- 
cution commends  it  to  the  student  of  Anatcuny.  It 
requires  no  other  recommendations. — Western  Joum. 
of  Medicine  and  Surgery. 


S4 


BLANCHARD    &    LEA'S   MEDICAL 


NEILL  (JOHN),   M.  D., 

Surgeon  to  the  Pennsylvania  Hospital,  &c.;  and 

FRANCIS  GURNEY   SMITH,   M.D., 

Professor  of  Institutes  of  Medicine  in  the  Pennsylvania  INIedical  College. 

AN  ANALYTICAL   COMPENDIUM    OF   THE    VARIOUS   BRANCHES 

OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.     A  new  edition,  revised 

and  improved.     In  one  very  large  and  handsomely  printed  roj-al   l"2mo.  volume,  of  about  one 

thousand  pages,  with  three  hundred  and  seventy-four  illustrations  on  wood.     Strongly  bound  in 

leather,  with  raised  bands.     {Now  Ready,  1856.)     $3  00. 

The  very  flattering  reception  which  has  been  accorded  to  this  work,  and  the  high  estimate  placed 
upon  it  by  the  profession,  as  evinced  by  the  constant  and  increasing  demand  which  has  rapidly  ex- 
hausted two  large  editions,  have  stimulated  the  authors  to  render  the  volume  in  its  present  revision 
more  worthy  of  the  success  which  has  attended  it.  It  has  accordingly  been  thoroughly  examined, 
and  such  errors  as  had  on  former  occasions  escaped  observation  have  been  corrected,  and  whatever 
additions  were  necessary  to  maintain  it  on  a  level  with  the  advance  of  science  have  been  introduced. 
The  extended  series  of  illustrations  has  been  still  further  increased  and  much  improved,  while,  by 
a  slight  enlargement  of  the  page,  these  various  additions  have  been  incorporated  without  increasing 
the  buUc  of  the  volume. 

The  work  is,  therefore,  again  presentedaseminently  worthy  of  the  favor  with  which  it  has  hitherto 
been  received.  As  a  book  for  daily  reference  by  the  student  requiring  a  guide  to  his  more  elaborate 
text-books,  as  a  manual  for  preceptors  desiring  to  stimulate  their  students  by  frequent  and  accurate 
examination,  or  as  a  soiu'ce  from  which  the  practitioners  of  older  date  may  easily  and  cheaply  acquire 
a  knowledge  of  the  changes  and  improvement  in  professional  science,  its  reputation  is  permanently 
established. 

In  the  rapid  course  of  lectures,  where  work  for  ;  what  it  \vas  when  they  left  it  olT. — The.  Stethoscope 
the  students  is  heavy,  and   review  necessary  for  an  |      ^ve  recommend  it  to  our  readers  as  the  best  work 

f^^^™"?.!!!'":  ^.•.''r"!'.l!".U^  "'ri,i'"iL\"i"".I  !;„   "'  '  "^  t'>e  l^-inJ  with  which  we  are  acquainted.— Med. 
,^„„t  „  ,.«,.,  „..„  ««„  ,=  «„<.    ,„  ,„..>  >,„  .,,      J^xatniner,  April,  1850. 


it  is  almost  a  sine  qua  non.  The  one  before  us 
in  most  of  the  divisions,  tlie  most  unexceptionable 
of  all  books  of  the  kind  that  we  know  of.  The 
newest  and  soundest  doctrines  and  the  latest  im- 
provements and  discoveries  are  explicitly,  tbouo^h 
concisely,  laid  before  the  student.  Of  course  it  is 
useless  for  us  to  recommend  it  to  all  last  course 
students,  but  there  is  a  class  to  whom  we  very 
sincerely  commend  this  cheap  book  as  worth  its 
weight  in  silver  —  that  class  is  the  graduates  in 
medicine  of  more  than  ten  years'  standing,  who 
have  not  studied  medicine  since.  They  will  perhaps 
find  out  from  it  that  the  science  is  not  exactly  now 


j      Having  made  free  use  of  this  volume  in  our  ex- 
aminatidns  of  pupils,   we   can  speak  from   experi- 
ence in  recommending  it  as  an  admirable  compend 
i  for  students,  and  as  especially  useful  to  preceptors 
'  who  examine  their  pupils.     It  will  save  the  teacher 
j  much  labor  by  enabling  him  readily  to  recall  all  of 
the   points    upon  which   his    pupils   should   be  ex- 
amined.    A  work  of  tills  sort  should  be  in  the  hands 
of  every  one  who  takes  pupils  into  his  office  witli  a 
view  of  examining  them;  and  this  is  unquestionably 
the  best  of  its  class. — Transylvania  Med.  Journal. 


NELIGAN  (J.    MOpRE),  M.  D.,  M.  R.  I. A.,  &.c. 

(A  sjjiendid  icork.     Notv  Ready.) 

ATLAS  OF  CUTANEOUS  DISEASES.     In  one  beautiful  quarto  volume,  extra 

cloth,  with  splendid  colored  plates,  presenting  nearly  one  hundred  elaborate  representations  of 

disease.     $4  50. 

This  beautiful  volume  is  intended  as  a  complete  and  accurate  representation  of  all  the  varieties 
of  Diseases  of  the  Skin.  While  it  can  be  consulted  in  conjunction  with  any  work  on  Practice,  it  has 
especial  reference  to  the  author's  "  Treatise  on  Diseases  of  the  Skin,"  so  favorably  received  by  the 
profession  some  years  since.  The  publishers  feel  justified  in  saying  that  no  more  beautifully  exe- 
cuted plates  have  ever  been  presented  to  the  profession  of  this  country. 

The  diagnosis  of  eruptive  disease,  however,  under  ;  placed  within  its  reach  and  at  a  moderate  cost  a  most 
all  circumstances,  is  very  difficult.  Nevertheless  I  accurate  and  well  delineated  series  of  plates  illus- 
Dr.  Neligan  has  certainly,  "as  far  as  possible,"  j  trating  tlie  eruptive  disorders.  These  plates  are  all 
given  a  faithful  and  accurate  representation  of  this  drawn  from  the  life,  and  in  many  of  them  the  daguer- 
class  of  diseases,  and  there  can  be  no  doubt  that    reotype  has  been  employed  ^vith  great  success.   Such 


these  plates  will  be  of  great  use  to  the  student  and 
practitiimer  in  drawing  a  diagnosis  as  to  the  class, 
order,  and  species  to  which  the  particular  case  may 
belong.  While  looking  over  the  "  Atlas"  we  have 
been  induced  to  examine  also  the  "  Practical  Trea- 
tise." This  was  published  in  1852,  and  we  are  in- 
clined to  consider  it  a  very  superior  work,  combin- 
ing accurate  verbal  description,  with  sound  views 
of  the  pathcdogy  and  treatment  of  eruptive  diseases. 
— Glasgow  Medical  Journal. 

The  profession  owes  its  thanks  to  the  publishers  of 
Neligan's  Atlas  of  Cutaneous  Diseases,  for  they  have 

BY  THE  SAME  AUTHOR. 

A   PRACTICAL  TREATISE   ON   DISEASES   OP   THE    SKIN. 

neat  royal  12mo.  volume,  extra  cloth,  of  334  pages.     $1  00. 


works  as  these  are  especially  useful  to  country  prac- 
titioners, who  have  not  an  opportunity  of  seeing  the 
rarer  forms  of  cutaneous  disease,  and  hence  need  the 
aid  of  illustrations  to  give  them  the  requisite  infor- 
mation on  the  subject.  With  tliese  plates  at  hand, 
the  inexperienced  practitioner  is  enabled  to  discri- 
minate with  much  accuracy,  and  he  is  thus,  com- 
paratively speaking,  put  on  an  equal  footing  with 
those  who  have  had  the  opportunity  of  visiting  the 
large  hospitals  of  Europe  and  America. —  Va.  Med. 
Journal,  June,  1856. 


In  one 


We  must  say  he  bears  off  the  palm  for  clearness, 
conciseness,  and  rigid  plainness  of  expression.  This 
style  enables  him  to  compress  much  in  a  single  sen- 
tence, without  in  any  degree  injuring  the  sense,  but, 
on  the  contrary,  making  it  more  comprehensive  and 
impressive.  By  far  the  largest  proportion  of  the 
volume  is  devoted  to  therapeutic  considerations. 
Not  merely  are  I'ull  details  of  treatment  and  formulae 
given  at  the  close  of  each  section,  but  an   entire 


chapter  is  devoted  to  "  those  general  points  in  thera- 
peutics which  are  specially  applicable  to  this  class 
of  affections."  The  present  work  forms  a  favorable 
contrast  to  the  voluminous  and  disputed  details  of 
many  of  its  predecessors,  and  will,  ^ve  feel  assured, 
be  admirably  conducive  to  facilitating  the  study  of 
the  student,  and  improving  the  practice  of  the  prac- 
titioner.— Dublin  Quarterly  Journ.  of  Med.  Science. 


S!^  The  two  volumes  will  be  sent  by  mail  on  receipt  of  Five  Dollars. 


OWEN  ON  THE  DIFFERENT  FORMS  OF 
THE  SKELETON,  AND  OF  THE  TEETH. 


One  vol.  royal  12mo.,  extra  cloth,  with  numerous 
illustrations.     (Just  Issued.)     $1  25. 


AND   SCIENTIFIC    PUBLICATIONS. 


25 


{Now  Comjdete.) 

PEREIRA  (JONATHAN),  M .  D.,  F.  R.  S.,  AND  L.  S. 

THE    ELEMENTS    OF    MxVTERIA    MEDIGA    AND    THEllAPEUTICS. 

Third  American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medicinal  Substanceis  in  use  in  the  civilized  world,  and  forming  an  Encyclopaedia  of  Materia 
Medica.  Edited,  with  Additions,  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  of  2100  pages, 
on  small  type,  with  about  500  illustrations  on  stone  and  wood,  strongly  bound  in  leather,  with 
raised  bands.     $9  00. 

Gentltjmen  who  have  the  first  volume  are  recommended  to  complete  their  copies  without  delay. 
The  first  volume  will  no  longer  be  sold  separate.     Price  of  Vol.  11.  $5  00. 


Wlien  we  rememlier  that  Philology,  Natural  His- 
tory, Botany,  Chemistry,  Physics,  and  the  Micro- 
scope, are  all  brought  forward  to  elucidate  the  sub- 
ject, one  cannot  fail  to  see  that  the  reader  has  here 
a  work  wortliy  of  the  name  of  an  eneyclopsedia  of 
Materia  JFcdica.  Our  ow^n  opinion  of  its  merits  is 
that  of  its  editors,  and  also  that  of  the  whole  profes- 
sion, both  of  this  and  foreign  countries— namely, 
"  tliat  in  copiousness  of  details,  in  extent,  variety, 
and  accuracy  of  information,  and  in  lucid  explana- 
tion of  difficult  and  recondite  subjects,  it  surpasses 
all  other  works  on  Materia  Medica  hitherto  pub- 
lished." VVe  cannot  close  this  notice  without  allud- 
ing to  the  special  additions  of  tlie  American  editor, 
which  pertain  to  the  prominent  vegetable  produc- 
tions of  this  country,  and  to  the  directions  of  the 
United  States  Pliarmacopoeia,  in  connection  with  all 
the  articles  contained  in  the  volume  which  are  re- 
ferred toby  it.  The  illustrations  have  been  increased, 
and  this  edition  by  Dr.  Carson  cannot  well  be  re- 
garded in  any  other  light  than  that  of  a  treasure 
which  should  be  found  in  the  library  of  every  physi- 
cian.— Neiv  York  Journal  of  Medical  and  Collateral 
Science. 


The  third  edition  of  his  "Elements  of  Materia 
Medica,  although  completed  under  the  supervision  of 
others,  is  by  far  the  most  elaborate  treatise  in  the 
English  language,  and  will,  while  medical  literature 
is  cherished,  continue  a  monument  alike  honorable 
to  his  genius,  as  to  his  learning  and  industry. — 
American  Journal  of  Phartnucy. 

The  work,  in  its  present  shape,  forms  the  most 
comprehensive  and  C(nnplete  treatise  on  materia 
medica  extant  in  the  English  language.  —  Dr. 
Pereira  has  been  at  great  pains  to  introduce  into 
his  work,  not  only  all  the  information  on  the 
natural,  chemical,  and  commercial  history  of  njedi- 
cines,  'vvhich  might  be  serviceable  to  the  physician 
and  surgeon,  but  whatever  might  enable  his  read- 
ers to  understand  thoroughly  the  mode  of  prepar- 
ing and  manufacturing  various  articles  employed 
either  for  preparing  medicines,  or  for  certain  pur- 
poses in  the  arts  connected  with  materia  medica 
and  the  practice  of  medicine.  The  accounts  of  the 
physiological  and  therapeutic  effects  of  remedies  are 
given  with  great  clearness  and  accuracy,  and  in  a 
manner  calculated  to  interest  as  well  as  instruct  the 
reader. —  Edinburgh  Medical  and  Surgical  Journal. 


PEASELEE   (E.  R.),   M .  D., 
Professor  of  Anatomy  and  Physiology  in  Dartmouth  College,  &c. 

HUMAN  HISTOLOGY,  in  its  application,g  to  Physiology  and  G-eneral  Pathology; 

designed  as  a  Text-Book  for  Medical  Students.     With  numerous  illustrations.     In  one  handsome 

royal  r2nio.  volume.     (Prepariiig.) 

The  sul>jeet  of  this  work  is  one,  the  growing  importance  of  which,  as  the  basis  of  Anatomy  and 
Physiology,  demands  for  it  a  separate  volume.  The  book  will  thereibre  supply  an  acknowledged 
deficiency  in  medical  text-books,  while  the  naine  of  the  author,  and  his  experience  as  a  teacher  lor 
the  last  thirteen  years,  is  a  guarantee  that  it  will  be  thoroughly  adapted  to  the  use  of  the  student. 


PIRRIE  (WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE    PPJNCIPLES  AND  PRACTICE   OP   SURGERY.     Edited  by  John 

Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the  Pennsylvania 
Hospital,  ifcc.  In  one  very  handsome  octavo  volume,  leather,  oi'7S0  pages,  with  316  illustrations. 
$3  75. 


We  know  of  no  other  surgical  work  of  a  reason- 
able size,  wherein  there  is  so  much  theory  and  prac- 
tice, or  where  subjects  are  more  soundly  or  clearly 
taught. — The  Stethoscope. 

There  is  scarcely  a  disease  of  the  bones  or  soft 
parts,  fracture,  or  dislocation,  that  is  not  illustrated 
by  accurate  wood-engravings.  Then,  again,  every 
instrument  employed  by  the  surgeon  is  thus  repre- 
sented. These  engravings  are  not  only  correct,  but 
really  beautiful,  showing  the  ast<inishing  degree  of 
perfection  to  which  the  art  of  wood-engraving  has 


arrived.  Prof.  Pirrie,  in  the  work  before  us,  has 
elaborately  discussed  the  principles  of  surgery,  and 
a  safe  and  effectual  practice  predicated  upon  them. 
Perhaps  no  work  upon  this  subject  heretofore  issued 
is  so  full  upon  the  science  of  the  art  of  surgery. — 
Nashville  Journal  of  Medicine  and  Surgery. 

One  of  the  best  treatises  on  surgery  in  the  English 
language. — Canada  Med.  Journal. 

Our  impression  is,  that,  as  a  manual  for  students, 
Pirrie's  is  the  best  work  extant. —  Western  Med.  and 
Surg.  Journal. 


PANCOAST   (J.),  M.  D., 

Professor  of  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia,  &e. 

OPERATIVE  SURGERY;  or,  A  Description  and  Demonstration  of  the  various 

Processes  of  the  Art;  including  all  the  New  Operations,  and  exhibiting  the  State  of  Surgical 
Science  in  its  present  advanced  condition.     Complete  in  one  royal  4to.  volume,  extra  clolh,  of 
380  pages  of  letter-press  description  and  eighty  large  4to.  plates,  comprising  486  illustrations. 
Second  edition,  improved.     $10  00. 
This  excellent  work  is  constructed  on  the  model 

of  the  French  Surgical  Works  by  Velpeau  and  Mal- 

t^aigne;  and,  so  far  as  the  English  language  is  con- 


cerned, we  are  proud  as  an  American  to  say  that, 

OF  ITS  KIND  IT  HAS  NO  SUPKRIOK.— iV.  Y.  Joumal  of 

Medicine. 


PARKER   (LANGSTON), 

Surgeon  to  the  Queen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OF  SYPHILITIC  DISEASES,  BOTH  PRI- 
MARY AND  SECONDARY;  comprisingtheTreatment  of  Constitutional  and  Confirmed  Syphi- 
lis, by  a  safe  and  successful  method.  With  numerous  Cases,  Formulee,  and  Clinical  Observa- 
tions. From  the  Third  and  entirely  rewritten  London  edition.  la  one  neat  octavo  volume, 
extra  cloth,  of  316  pages.     {Just  Issued.)     $175. 


26 


BLANCHARD    &    LEA'S    MEDICAL 


PARRISH    (EDWARD), 

Lecturer  on  Practical  Pharmacy  and  Materia  Medica  in  the  Pennsylvania  Academy  of  Medicine,  &c. 

AN  INTRODUCTION  TO  PRACTICAL  PHARMACY.  Designed  as  a  Text- 
Book  for  the  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  For- 
mulae and  Prescriptions.  In  one  handsome  octavo  volume,  extra  cloth,  of  550  pages,  with  243 
Illustrations.    {Now  Ready,  1856.)    $2  75. 

This  work,  while  necessary  to  the  educated  pharmaceutist,  will  also  be  found  of  the  greatest 
importance  to  those  practitioners  who,  residing  at  a  distance  from  apothecaries,  are  called  upon  to 
dispen^e  as  vi'ell  as  to  prescribe.  The  author  has  not  only  given  a  thorough  outline  of  the  principles 
of  pharmacy  and  its  general  processes,  but  has  also  presented  their  special  applications  in  the  details 
of  preparing  all  the  dillerent  classes  of  medicines,  illustrated  with  numerous  engravings  of  apparatus 
and  implements,  which,  in  all  cases,  are  of  the  simplest  description.  Under  the  diflerent  heads 
are  contained  many  tables  and  syllabi  of  classes  of  medicines,  presenting  the  remedies  of  the 
United  States  Pharmacopoeia,  together  with  many  new  ones,  so  arranged  as  to  render  their  relations 
of  easy  comprehension,  and  embodying  all  the  more  important  formulae  of  the  Pharmacopoeia,  as 
well  as  many  others  Irom  the  practice  of  distinguished  physicians,  not  hitherto  in  print.  Especial 
notice  has  been  taken  of  the  numerous  important  remedies  recently  obtained  from  our  indigenous 
flora,  and  their  composition  and  preparation  pointed  out. 

The  long  experience  of  the  author  as  a  teacher  of  pharmacy  has  rendered  him  familiar  with  the 
wants  of  students,  and  entirely  competent  to  supply  them.  He  has  acct)rdingly  descended  to  those 
minutiae  which  so  often  interpose  difficulties  in  the  way  of  the  young  practitioner,  who  has  hitherto 
had  no  practical  guide  to  point  out  the  modes  of  overcoming  them. 

A  careful  examination  of  this  work  enables  us  to,  Medica ;  it  familiarizes  him  with  the  compounding 


speak  of  it  in  the  highest  terms,  as  being  the  best 
treatise  on  practical  pharmacy  with  which  we  are 
acquainted,  and  an  invaluable  vade-mecum,  not  only 
to  the  apothecary  and  to  those  practitioners  who  are 
accustomed  to  prepare  their  own  medicines,  but  to 
every  nietiical  man  and  medical  student.  Througli- 
out  the  work  are  interspersed  valuable  tables,  useful 
formula;,  and  practical  hints,  and  the  whole  is  illus- 
trated by  a  large  number  of  excellent  wood-engrav- 
ings.— Boston  Med.  and  Surg.  Journal. 

This  is  altogether  one  of  the  most  useful  books  we 
have  seen.  It  is  just  what  we  have  long  felt  to  be 
needed  by  apothecaries,  students,  and  practitioners 
of  medicine,  most  of  Avhom  in  this  country  have  to 
put  up  their  own  prescriptions.  It  bears,  upon  every 
page,  the  impress  of  practical  knowledge,  conveyed 
in  a  plain  common  sense  manner,  and  adapted  to  the 
comprehension  of  all  who  may  read  it.  No  detail 
has  been  omitted,  however  trivial  it  may  seem,  al- 
though really  important  to  the  dispenser  of  medicine. 
— Southern  Med.  and  Surg.  Journal. 

To  both  the  country  practitioner  and  the  city  apo- 
thecary this  work  of  Mr.  Parrish  is  a  godsend.  A 
careful  study  of  its  contents  will  give  the  young 
graduate  a  familiarity  ^vith  the  value  and  mode  of 
administering  his  prescriptions,  which  will  be  of  as 
much  use  to  his  patient  as  to  himself. —  Fa.  Med. 
Journal. 

Mr.  Parrish  has  rendered  a  very  acceptable  service 
to  the  practitioner  and  student,  by  furnishing  thi 


[  drugs,  and  supplies  those  minutiae  which  but  few 
practitioners  can  impart.  The  junior  practitioner 
■will,  also,  find  this  volume  replete  with  instruction. 
— Charleston  Med.  Journal  and  Review,  Mar.  1656. 

There  is  no  useful  information  in  the  details  of  the 
apothecary's  or  country  physician's  office  conducted 
according  to  science  that  is  omitted.  The  young 
physician  will  find  it  an  encyclopedia  of  indispensa- 
ble medical  knowledge,  from  the  purchase  of  a  spa- 
tula to  the  compounding  of  the  most  learned  pre- 
scriptions. The  work  is  by  theablest  pharmaceutist 
in  the  United  States,  and  must  meet  with  an  im- 
mense sale. — Nashville  Journal  of  Medicine,  April. 
1856. 

We  are  glad  to  receive  this  excellent  w^ork.  It 
\vill  supply  a  want  long  felt  by  the  profession,  and 
especially  by  the  student  of  Pharmacy.  A  large 
majority  of  physicians  are  obliged  to  compound 
their  own  medicines,  and  to  them  a  work  of  this 
kind  is  indispensable. — JV.  O.  Medical  and  Surgical 
Journal. 

We  cannot  say  but  that  this  volume  is  one  of  the 
most  welcome  and  appropriate  which  has  for  a  long 
time  been  issued  from  the  press.  It  is  a  work  which 
we  doubt  not  will  at  once  secure  an  extensive  cir- 
culation, as  it  is  designed  not  only  for  the  druggist 
and  pharmaceutist,  but  also  for  tlie  great  body  of 
practitioners  tliroughout  the  country,  who  not  only 
have  to  prescribe  medicines,  but  in  the  majority  of 
instances  have  to  rely  upon  their  own  resources- 


book,  which  contains  the  leading  facts  and  principles    whatever  these  may  be— not  only  to  compound,  but 


of  the  science  of  Pharmacy,  conveniently  arranged 
for  study,  and  with  special  reference  to  those  features 
of  the  subject  which  possess  an  especial  practical  in- 
terest to  the  physician.  It  furnishes  the  student,  at 
the  commencement  of  his  studies,  vi^ith  that  infor- 
mation which  is  of  the  greatest  importance  in  ini- 


tiating him  intothedomainof  Chemistry  and  Materia  '  Lancet,  March  24,  1856. 


also  to  manufacture  the  remedies  they  are  called 
upon  to  administer.  The  author  has  not  mistaken 
tlie  idea  in  writing  this  volume,  as  it  is  alike  useful 
and  invaluable  to  those  engaged  in  the  active  pur- 
suits of  the  profession,  and  to  those  preparing  to  en- 
ter upon  the  field  of  professional  labors. — American 


RICORD  ( 
A  TREATISE  ON  THE  VENEREAL 

With  copious  Additions,  by  Ph.  Ricord,  M.  D. 
M.  D.  In  one  handsome  octavo  volume,  extra 
Every  one  will  recognize  the  attractiveness  and 
value  which  this  work  derives  from  thus  presenting 
the  opinions  of  these  two  masters  side  by  side.  But, 
it  must  be  admitted,  what  has  made  the  fortune  of 
the  book,  is  the  fact  that  it  contains  the  '-most  com- 
plete embodiment  of  the  veritable  doctrines  of  the 
Hopital  du  Midi,"  which  has  ever  been  made  public. 
The  doctrinal  ideas  of  M.  Ricord.  ideas  which,  if  not 
universally  adopted,  are  iiicoiiiesiably  dominant,  have 
heretofore  only  been  interpreted  by  more  or  less  skilful 


P.),   M.  D., 

DISE  ASE.     By  John  Hunter,  F.  R.  S. 

.     Edited,  with  Notes,  bv  Freeman  J.  Bumstead, 
cloth,  of  520  pages,  with  plates.     $3  25. 

I  secretaries,  sometimes  accredited  and  sometimes  not. 

I  In  the  notes  to  Hunter,  the  master  substitutes  him- 
self forhis  interpreters,  and  gives  hisoriginal  thoughts 
to  the  world  in  a  lucid  and  perfectly  iiilelligible  man- 
ner. In  conclusion  we  can  say  that  this  is  iucon- 
lestably  the  best  treatise  on  syphilis  with  which  we 
are  acquainted,  and,  as  we  do  not  often  employ  the 
phrase,  we  may  be  excused  for  expressing  the  hope 
lliat  it  may  find  a  place  in  the  library  of  every  phy- 
sician.—  Virginia  Med.  and  Surg.  Journal. 


BY   THE  SAME   AUTHOR. 


ILLUSTRATIONS  OF  SYPHILITIC  DISEASE. 
Translated  by  Thomas  F.  Bettox,  M.  D.  With 
fifty  large  quarto  colored  plates.  In  one  large 
quarto  volume,  extra  cloth.     S15  00. 


LETTERS  ON  SYPHILIS,  addressed  to  the  Chiet 
Editor  of  the  Union  Medicale.  Translated  by  W. 
P.  Lattimore,  M.D.  In  one  neat  octavo  vol- 
ume, of  270  pages,  extra  cloth.    S2  00. 


AND    SCIENTIFIC    PUBLICATIONS. 


27 


RAMSBOTHAM  (FRANCIS   H.),   M.D. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND 

SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly 
revised  liy  the  Author.  With  Additions  by  W.  V.  Keating,  M.  D.  In  one  large  and  handsome 
imperial  octavo  volume,  of  6-50  pages,  strongly  bound  in  leather,  with  raised  bands;  with  sixty- 
four  beamifiil  Plates,  and  numerous  Wood-cuts  in  the  text,  containing  in  all  nearly  two  hundred 
large  and  beautiful  figures.    (Lately  Issued,  18-56.)  §-5  00. 

In  calling  the  attention  of  the  profession  to  the  new  edition  of  this  standard  work,  the  publishers 
would  remark  that  no  eflbrts  have  been  spared  to  secure  for  it  a  continuance  and  extension  of  the 
remarkable  favor  with  which  it  has  been  received.  The  last  London  issue,  which  was  considera- 
bly enlarged,  has  received  a  further  revision  from  the  author,  especially  for  tliis  country.  Its  pas- 
sage through  the  press  here  has  been  supervised  by  Dr.  Keating,  who  has  made  numerous  addi- 
tions with  a  view  of  presenting  more  fully  whatever  was  necessary  to  adapt  it  thoroughly  to 
American  modes  of  practice.  In  its  mechanical  execution,  n  like  superioritj-  over  former  editions 
will  be  found. 

From  Prof.  Hodge,  of  the  University  of  Pa. 
To   the  American  public,  it  is  most  valuable,  from  its  intrinsic  undoubted  excellence,  and  as  being 
the  best  authorized  exponent  of  British  Midwifery.    Its  circulation  will,  1  trust,  be  extensive  throughout 
our  country. 

The  publishers  have  shown  their  appreciation  of :  cine  and  Surgery  to  our  library,  and  confidently 
the  merits  of  this  \vork  and  secured  its  success  by  recommend  it  to  our  readers,  with  the  assurance 
the  truly  elegant  style  in  which  they  have  brought  that  it  will  not  disappoint  their  most  sanguine  ex- 
it out,  excelling  themselves  in  its  production,  espe-  |  pectations. —  Western  Lancet. 

cinlly  in  its  plates.  It  is  dedicated  to  Prof.  Meigs,  |  jj  jg  unnecessary  to  say  anything  in  regard  to  the 
and  has  tlie  emphatic  endorsement  of  Prof.  Hodge,  i  utility  of  this  work.  It  is  already  appreciated  in  our 
as  the  best  exponent  of  British  Midwit^ery.  \\  e  •  country  for  the  value  of  the  matter  the  clearness  of 
know  of  no  text-book  which  deserves  in  all  respects  I  jtg  style,  and  the  fulness  of  its  ilhistrath.ns.  To  the 
to  be  m..re  highly  recommended  to  students,  and  we  physician's  library  it  is  indispensable,  while  to  the 
could  wish  to  see  It  in  the  handsof  every  practitioner,  i  student  as  a  text-book,  from  which  to  extract  the 


for  they  will  find  it  invaluable  for  reference. — Med 
Gazette. 

But  once  in  a  long  time  some  brilliant  genius  rears 
his  head  above  the  horizon  of  science,  and  illumi- 
nates and  purifies  every  department  that  he  investi- 
gates ;  and  his  works  become  types,  by  wliich  innu- 
merable JmiL.itors   model  tlieir   feeble   productions 


material  for  laying  the  foundation  of  an  education  on 
obstetrical  science,  it  has  no  superior. —  Ohio  Med. 
and  Surg.  Journal. 

■\Ve  will  only  add  that  the  student  will  learn  from 
it  all  he  need  to  know,  and  the  practitioner  will  find 
it,  as  a  book  of  reference,  surpassed  by  none  other. — 


ucli  a  genius  we  find  in  the  younger  Ramsbotham,  1  Stethoscope 
and  such  a  type  we  find  in  the  work  now  before  us.  !  The  character  and  merits  of  Dr.  Ramsbotham's 
The  binding,  paper,  type,  the  engravings  anil  wood-  i  work  are  so  well  known  and  thoroughly  established, 
cuts  are  all  so  excellent  as  to  make  this  book  one  of ,  tliat  comment  is  unnecessary  and  praise  superfluous, 
the  finest  specimens  of  the  art  of  printing  that  have  I  The  illustrations,  which  are  numerous  and  accurate, 
given  such   a  world-wide  reputation   to  its   enter- !  are  executed  in  the  highest  style  of  art.     We  cannot 

prising  and  liberal  publishers.     We  welcome  Rams-  I  too  highly  recommend  the  work  to  our  readers. St. 

botham's  Principles  and  Practice  of  Obstetric  Medi-  I  Louis  Med.  and  Surg.  Journal. 


ROKITANSKY   (CARL),    M.D., 

Curator  of  the  Imperial  Pathological  Museum,  and  Prolessor  at  the  University  of  Vienna,  &c 

A    MANUAL    OF  PATHOLOGICAL    ANAT03IY.     Four   volumes,   octavo, 

bound  in  two,  extra  cloth,  of  about  1200  pages.     (Now  Ready.)     $-5  50 
Vol.  I. — Manual  of  General  Pathological  Anatomy.     Translated  by  W.  E.  Swaine. 
Vol.  II. — Pathological  Anatomy  of  the  Abdominal  Viscera.     Translated  by  Edward  Sieveking, 
M.D.  ' 

Vol.  III. — Pathological  Anatomy  of  the  Bones,  Cartilages,  Muscles,  and  Skin,  Cellular  and  Fibrous 

Tissue,  Serous  and  Mucous  Membrane,  and  Nervous  System.     Translated  by  C.  H.  Moore. 
Vol.  IV. — Pathological  Anatomy  of  the  Organs  of  Respiration  and  Circulation.     Translated  bv  G 

E.  Day. 
To  render  this  large  and  important  work  more  easy  of  reference,  and  at  the  same  time  less  cum- 
brous and  costly,  the  four  volumes  have  been  arranged  in  two,  retaining,  however,  the  separate 
paging,  &rc. 

The  publishers  feel  much  pleasure  in  presenting  to  the  profession  of  the  United  States  the  great 
work  of  Prof  Rokitansky,  which  is  universally  referred  to  as  the  standard  of  authority  by  the  pa- 
thologists of  all  nations.  Under  the  auspices  of  the  Sydenham  Society  of  London,  the  combined 
lal>or  of  four  translators  has  at  length  overcome  the  almost  insuperable  ditliculties  which  have  so 
long  prevented  the  appearance  of  the  work  in  an  English  dress,  while  the  additions  made  from 
various  papers  and  essays  of  the  author  present  his  views  on  all  the  topics  embraced,  in  their  latest 
published  form.  To  a  work  so  widely  known,  eulogy  is  unnecessary,  and  the  publishers  would 
merely  state  that  it  is  said  to  contain  the  results  of  not  less  than  thirty  thousand  i)ost-mortem 
examioations  made  by  the  author,  diligently  compared,  generalized,  and  wrought  into  one  com- 
plete and  harmonious  system. 

The  profession  is  too  well  acquainted  with  the  re- 
pu^tion  of  Rokitansky's  work  to  need  our  assur- 
ance that  this  is  one  of  the  most  profound,  thorough, 
and  valiKilde  books  ever*issued  from  the  medical 
press.  It  is  sui  generis,  and  has  no  standard  of  c(un- 
jiarison.  It  is  only  necessary  to  announce  that  it  is 
issued  in  a  form  as  cheap  as  is  compatible  with  its 
size  and  preservation,  and  its  sale  follows  as  a 
matter  of  course.  No  library  can  be  called  com- 
plete without  it. — Buffalo  Med.  Journal. 

An  attempt  to  give  our  readers  any  adequate  idea 
of  the  vast  amount  of  instruction  accumulated  in 
these  volumes,  would  be  feeble  and  hopeless.  The 
effort  of  the  distinguished  author  to  concentrate 
in  a  small  space  his  great  fund  of  knowledge,  has 


so  charged  his  text  with  valuable  truths,  that  any 
attempt  of  a  reviewer  to  epitomize  is  at  once  para- 
lyzed, and  must  end  in  a  failure. — Weitfn  Lancet. 

As  this  is  the  highest  source  of  knowledge  upon 
the  important  subject  of  which  it  treats, ^no  real 
student  can  alford  to  be  without  it.  The  American 
liublishers  have  entitled  themselves  to  tlie  thanks  of 
the  profession  of  their  country,  for  tliis  timeous  and 
beautiful  edition. — Nashville  Journal  of  Medicine. 

As  a  book  of  reference,  therefore,  this  work  must 
prove  of  inestimable  value,  and  we  cannot  too  highly 
recommend  it  to  the  profession.— CAar/eiion  Med. 
Journal  and  Review,  Jan.  1856. 

This  book  is  a  necessity  to  every  practitioner. — 
Am.  Med.  Monthly. 


30 


BLANCHARD   &   LEA'S   MEDICAL 


TAYLOR  (ALFRED  S.),  M.  D.,  F.  R.  S., 

Lecturer  on  Medical  Jurisprutlence  and  Chemistry  in  Guy's  Hospital. 

MEDICAID  JURISPRUDENCE.     Fourth  American,  from  the  fifth  improved  and 

enlarged  English  Edition.     Willi  Notes  and  References  to  American  Decisions,  by  Edward 

Hartshorne,  M.  D.     In  one  large  octavo  volume,  leather,  of  over  seven  hundred  pages.     (Just 

Ready,  June,  1S56.)     $3  00. 

Thi-;  standard  work  has  lately  received  a  very  thorough  revision  at  the  hands  of  the  author,  who 
has  introduced  whatever  was  necessary  to  render  it  complete  and  satisfactory  in  carrying  out  the 
objects  in  view.  Tne  editor  has  likewise  used  every  exertion  to  make  it  equally  thorough  with 
regard  to  all  matters  relating  to  the  practice  of  this  country.  In  doing  this,  he  has  carefully  ex- 
amined all  that  has  appeared  on  the  subject  since  the  publication  of  the  last  edition,  and  has  incorpo- 
rated all  the  new  information  thus  presented.  The  work  has  thus  been  considerably  increased  ui 
size,  notwithstanding  which,  it  has  been  kept  at  its  former  very  moderate  price,  and  in  every  resp)ect 
it  w'\.\\  be  found  worthy  of  a  continuance  of  the  remarkable  favor  which  has  carried  it  through  so 
many  editions  on  both  sides  of  the  Atlantic.     A  few  notices  of  the  former  editions  are  appended. 


We  know  of  no  work  on  Medical  Jurisprudence 
which  contains  in  tiic  same  space  anything  like  the 
same  amount  of  valuable  matter. — lY.  Y.  Journal  of 
Medicine. 

No  work  upon  the  subject  can  be  put  into  the 
hands  of  students  either  of  law  or  medicine  which 
will  engage  them  more  closely  or  profitably  ;  and 
none  could  be  offered  to  the  busy  jiractitioner  of 
either  calling,  for  the  purpose  of  casual  or  hasty 
reference,  that  would  be  more  likely  to  afford  the  aid 
desired.  We  therefore  recommend  it  as  the  best  and 
safest  manual  for  daily  a.se.-^American  Journal  oj 
Medical  Sciences. 

So  well  is  this  work  known  to  the  members  both 
of  the  medical  and  legal  professions,  and  so  highly 
is  it  appreciated  by  them,  that  it  cannot  be  necessary 
for  us  to  say  a  word  in  its  commendation  j  its  having 
already  reached  a  fourth  edition  being  the  best  pos- 
s'ble  testimony  in  its  favor.  -The  autlior  has  ob- 
viously subjected  the  entire  work  to  a  very  careful 
revision. — Brit,  and  Foreign  Med.  Chirurg.  Review. 

This  work  of  Dr.  Taylor's  is  generally  acknow- 
ledged to  lie  one  of  the  ablest  extant  on  the  subject 
of  medical  jurisprudence.     It  is  certainly  one  of  the 


most  attractive  books  that, we  have  met  with;  sup- 
plying so  much  both  to  interest  and  instruct,  that 
we  do  not  hesitate  to  affirm  that  after  having  once 
commenced  its  perusal,  few  could  be  prevailed  upoa 
to  desist  before  completing  it.  In  the  last  London 
edition,  all  the  newly  observed  and  accurately  re- 
corded facts  have  been  inserted,  including  much  that 
is  recent  of  Chemical,  Microscopical,  and  Patholo- 
gical research,  besides  papers  on  numerous  subjects 
never  before  published .-CAorZe«2o«  Medical  Journal 
and  Review. 

It  is  not  excess  of  praise  to  say  that  the  volume 
before  us  is  the  very  best  treatise  extant  on  Medical 
Jurisprudence.  In  saying  this,  we  do  not  wish  to 
be  understood  as  detracting  from  the  merits  of  the 
excellent  works  of  Beck,  Ryan,  Traill,  Guy,  and 
others;  but  in  interest  and  value  we  think  it  must 
be  conceded  that  Taylor  is  superior  to  anything  that 
has  preceded  it.  Tlie  author  is  already  well  known 
to  the  profession  by  his  valuable  treatise  on  Poisons  ; 
and  the  present  volume  will  add  materially  to  his 
high  reputation  for  accurate  and  extensive  know- 
ledge and  discriminating  judgment. — N.  W.  Medical 
and  Surgical  Journal. 


BY   THE    SAME   AUTHOR. 

ON  POISONS,  IN  RELATION  TO   MEDICAL  JURISPRUDENCE  AND 

MEDICINE.    Edited,  with  Notes  and  Additions,  by  R.  E.  Griffith,  M.  D.    In  one  large  octavo 
volume,  leather,  of  6S8  pages.     $3  00 


TODD  (R.  B.),   M.  D.,  AND  BOWMAN  (WILLIAM),   F.  R.  S. 
PHYSIOLOGICAL    ANATOMY   AND    PHYSIOLOGY  OF  MAN.     With 

numerous  handsome  wood-cuts.    Parts  I,  II,  and  III,  in  one  octavo  volume,  552  pages.     $2  50. 
Part  IV  will  complete  the  work. 

The  first  portion  of  Part  IV,  with  numerous  original  illustrations,  was  published  in  the  Medical 
News  and  Library  for  1853,  and  the  completion  will  be  issued  immediately  on  its  appearance  in 
London.  Those  who  have  subscribed  since  the  appearance  of  the  preceding  portion  of  the  work 
can  have  the  three  parts  by  mail,  on  remittance  of  $2  50  to  the  publishers. 

WATSON    (THOMAS),    M.  D.,    Sec. 
LECTURES    ON    THE    PRINCIPLES    AND    PRACTICE    OF   PPIYSIC. 


Third  American  edition,  revised,  with  Addit 
"Treatise  on  the  Diseases  of  Children,"  tzc. 
large  pages,  strongly  bound  with  raised  bands. 

To  say  that  it  is  the  very  best  work  on  tlie  sub- 
ject now  extant,  is  but  to  echo  the  sentiment  of  the 
medical  press  throughout  the  country.  —  iV.  O. 
Medical  Journal. 

Of  the  text-books  recently  republished  Watson  is 
very  justly  the  principal  favorite. — Holmes^s  Rep. 
to  Nat.  Med.  Assoc. 

By  universal  consent  the  work  ranks  among  the 
very  best  text-books  in  our  language. — Illinois  and 
Indiana  M^d.  Journal. 

Resrarded  on  all  hands  as  one  of  the  very  best,  if 
not  the  very  best,  systematic  treatise  on  practical 
medicine  extant. — St.  Louis  Med.  Journal. 


ions,  by  D.  Francis  Condie,  M.D.,  author  of  a 
In  one  octavo  volume,  of  nearly  eleven  hundred 

§3  25. 

Confessedly  one  of  the  very  best  works  on  the 
principles  and  practice  of  physic  in  the  Knglish  or 
any  other  language. — Med.  Examiner. 

Asa  text-book  it  has  no  equal;  as  a  compendium 
of  pathology  and  practice  no  superior. — New  York 
Annalist. 

We  know  of  no  work  better  calculated  for  being 
placed  in  the  hands  of  the  student,  and  for  a  text- 
book;  on  every  important  point  the  author  seems 
to  have  posted  up  his  knowledge  to  the  day. — 
Amer.  Med.  Journal. 

One  of  the  most  practically  useful  books  that 
ever  was  presented  to  the  student.  —  N.  Y.  Med. 
Journal. 


V/HAT   TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER   DEATH,    IN    MEDICAL   CASES. 

Published  under  the  authority  of  the  London  Society  for  Medical  Observation.  A  new  American, 
from  the  second  and  revised  London  edition.  In  one  very  handsome  volume,  royal  12mo.,  extra 
cloth.     {Just  Issued.)     $1  00. 


To  the  observer  who  prefers  accuracy  to  blunders 
and  precision  to  carelessness,  this  little  book  is  in- 
valuable.— N.  H.  Journal  of  Medicine . 


One  of  the  finest  aids  tea  young  practitioner  we 
have  ever  seen. — Peninsular  Journal  of  Medicint. 


It  offers  to  the  student  all  the  assistance  that  can 
be  expected  from  such  a  work. — Medical  Examiner. 

The  most  complete  and  convenient  manual  for  the 
student  we  possess. — American  Journal  of  Medical 
Science. 

In  every  respect,  this  work  as  an  anatomical 
o;uide  for  the  student  and  practitioner,  merits  our 
warmest  and  most  decided  praise. — London  Medical 
Gazette. 


AND    SCIENTIFIC    PUBLICATIONS.  31 

WILSON    (ERASMUS),   M.D.,    F.  R.  S., 

Lecturer  on  Anatomy,  London. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.     Fourth  Ameri- 

can,  from  the  last  English  edition.     Edited  by  Paul  B.  Goddard,  A.  JM.,  M.  D.     Wilh  two  hun- 
dred and  filly  illustrations.     Beautifully  printed,  in  one  large  octavo  volume,  leather,  of  nearly 
six  hundred  pages.     $3  00. 
In  many,  if  not  all  the  Colleges  of  the  Union,  it 

has  become  a  standard  text-book.     This,  of  itself, 

is  sufficiently  expressive  of  its  value.     A  work  very 

desirable   to   the   student;    one,  the    possession   of 

which   will   greatly   facilitate   his   progress  in  the 

Btudy  of  Practical  Anatomy. — New  York  Journal  of 

Medicine. 

Its  author  ranks  with  the  highest  on  Anatomy. — 
Southern  Medical  and  Surgical  Journal. 

BY  THE  SAME  AUTHOR.     (Now  Ready.) 

THE    DISSECTOR'S  MANUAL;  or.  Practical  and  Surgical  Anatomy.     Third 

American,   from  the  last  revised  and  enlarged  Englii-h  edition.     Modified  and  rearranged,  by 
"William  Hunt,  M.  D.,  Demonstrator  of  Anatomy  in  the   University  of  Pcnn>ylvania.     In  one 
large  and  handsome  royal  12mo.  volume,  leather,  of  5S2  pages,  with  154  illustrations.     $2  00. 
The  modifications  and  additions  which  this  work  has  received  in  passing  recently  through  the 
author's  hands,  is  sufficiently  indicated  by  the  fact  that  it  is  enlarged  by  more  than  one  hundred 
pages,  notwithstanding  that  it  is  printed  m  smaller  type,  and  with  a  greatly  enlarged  page.     So  com- 
plete has  the  author  rendered  it,  that  the  editor  has  found  but  little  to  do,  except  in  rearranging 
it  to  suit  the  mode  of  dissection  practised  in  this  country,  and  in  introducing  a  large  number  of 
additional  illustrations.     Of  these,  many  new  ones  have  been  engraved  expressly  tor  the  work, 
and  the  series  throughout  will  be  found  greatly  enhanced  in  value.     The  typographical  execulicsu 
of  the  volume  has  undergone  a  like  improvement,  and  in  everyrespect  the  work  is  presented  as  merit- 
ing an  increase  of  the  favor  which  it  has  hitherto  enjoyed  as  a  sound  practical  guide  to  the  study  oi 
anatomy. 

It  remains  only  to  add,  that  after  a  careful  exami-  I  ing  very  superior  claims,  well  calculated  to  facilitate 
nation,  we  have  no  hesitation  in  recommending  this")  their  studies,  and  render  their  labor  less  irksome,  by 
work  to  the  notice  of  those  for  whom  it  has  been  I  constantly  keeping  before  them  definite  objects  of 
expressly  written — the  students — as  a  guide  possess-  |  interest. — The  Lancet. 

BY   THE  SAME   AUTHOR. 

ON   DISEASES    OF   THE    SKIN.     Third  American,  from  the  third  London 

edition.     In  one  neat  octavo  volume,  of  about  five  hundred  pages,  extra  cloth.     $1  75. 

The  "  Diseases  of  the  Skin,"  by  Mr.  Erasmus  I  in  that  department  of  medical  literature. — Medico- 
Wilson,  may  now  be  regarded  as  the  standard  work  |  Chirurgical  Review. 

BY   THE   SAME   AUTHOR. 

ON    CONSTITUTIONAL    AND    HEREDITARY    SYPHILIS,   AND    ON 

SYPHILITIC  ERUPTIONS.     In  one  small  octavo  volume,  extra  cloth,  beautifully  printed,  with 
four  exquisite  colored  plates,  presenting  more  than  thirty  varieties  of  syphilitic  eruptions,  f  2  25. 

BY    THE   SAME   AUTHOR.      {Just  IssUed.) 

HEALTHY  SKIN;  A  Popular  Treatise  on  the  Skin  and  Hair,  their  Preserva- 
tion and  Management.  Second  American,  from  the  fourth  London  edition.  One  neat  volume, 
royal  12mo.,  extra  cloth,  of  about  300  pages,  with  numerous  illustrations.  $1  00  ;  paper  cover, 
75  cents. 


WHITEHEAD  (JAMES),    F.  R.  C.  S.,    &c. 

THE  CAUSES  AND  TREATMENT  OP  ABORTION   AND   STERILITY; 

being  the  Result  of  an  Extended  Practical  Inquiry  into  the  Physiological  and  Morbid  Conditions 
J    of  the  Uterus.    Second  American  Edition.    In  one  volume,  octavo,  extra  cloth,  pp.  36S.    $175. 

WALSHE   (W.    H.),    M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 

DISEASES    OF    THE    HEART,    LUNGS,    AND    APPENDAGES;    their 

Symptoms  and  Treatment.    In  one  handsome  volume,  extra  cloth,  large  royal  12mo.,  512  pages. 

ft  50. 

We  consider  this  as  the  .ablest  work  in  the  En-  I  the  author  being  the  first  stethoscopist  of  the  day  — 
glish  language,  on  the  subject  of  which  it  treats;  |  Charleston  Medical  Journal. 

WILDE   (W.    R.), 

Surgeon  to  St.  Mark's  Ophthalmic  and  Aural  Hospital,  Dublin. 

AURAL  SURGERY,  AND  THE  NATURE  AND  TREATMENT  OF  DIS- 
EASES OF  THE  EAR.  In  one  handsome  octavo  volume,  extra  cloth,  of  476  pages,  with 
illustrations.     $2  80. 

This  work  certainly  contains  more  information  on  laws,  and  amenable  to  the  same  general  methods  of 
the  subject  to  which  it  is  devoted  than  any  other  treatment  as  other  morbid  proces.ses.  The  work  is 
with  which  we  are  acquainted.  We  feel  grateful  to  not  written  to  supply  the  cravings  of  popular  patroii- 
the  author  for  his  manful  effort  to  rescue  this  depart-  age,  but  it  is  wholly  addres.sed  to  the  profession,  and 
ment  of  surgery  from  the  hands  of  the  empirics  who  bears  on  every  page  the  impress  of  the  reflections 
nearly  monopolize  it.  We  think  he  has  successfully  of  a  sagacious  and  practical  surgeon.— Ta.  Surg,  and 
shown  lliat  aural  diseases  are  not  beyond  the  re-  Med.  Journal. 
sources  of  art;  that  they  are  governed  by  the  same 


32  BLANCHARD    &    LEA'S    SCI  E  N  TIF  IC  PUBLICAT  1  ONS. 


WEST   (CHARLES),    M.  D., 

Accoucheur  to  and  Lecturer  on  Midwifery  at  St.  Bartholomew's  Hospital,  Physician  to  the  Hospital  for 

Sick  Children,  ice. 

LECTURES    ON   THE    DISEASES    OF  INFANCY  AND   CHILDHOOD. 

Second  American,  from  the  Second  and  Enlarged   London   edition.      In  one  volume,  octavo, 
extra  cloth,  ol  nearly  five  hundred  pages.    (Just  Issued.)     $2  00. 


We  take  leave  of  Dr.  West  with  great  respect  for 
his  attainments,  a  due  appreciation  of  his  acute 
powers  of  observation,  and  a  deep  sense  of  obliga- 
tion for  this  valuable  contribution  to  our  profes- 
sional literature.  His  book  is  undoubtedly  in  many 
respects  the  best  we  possess  on  diseases  of  children. 
Dublin  Quarterly  Journal  of  Medical  Science. 

Dr.  West  has  placed  the  profession  under  deep  ob- 


ligation by  this  able,  thorough,  and  finished  work 
upon  a  subject  which  almost  daily  taxes  to  the  ut- 
most the  skill  of  the  general  practitioner.  He  has 
with  singular  felicity  threaded  his  way  through  all 
tlie  tortuous  labyrinths  of  the  difhcult  subjecthe  has 
undertaken  to  elucidate,  and  has  in  many  of  the 
darkest  corners  left  a  light,  which  will  never  be 
extinguished. — Nashville  Medical  Journal. 


BY  THE  SAME  AUTHOR.     {Nearly  Ready.) 
Puhli-^hing  i7i  the  '■'Medical  News  and  Library^''''  for  1S56. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     In  two  parts. 

Part  I.  8vo.  of  about  300  pages,  comprising  the  Diseases  of  the  Uterus. 

Part  I[.   {Pre/paring).,  will  contain  Diseases  of  the  Ovaries,  and  of  ail  the  parts  connected 

Willi  the  Uterus  ;  of  the  Bladder,  Vagi.na,  a.nd  External  Organs. 
The  object  of  the  author  in  this  work  is  to  present  a  complete  but  succinct  treatise  on  Female 
Di»etl^^es,  embodying  the  results  of  his  experience  during  the  last  ten  years  at  St.  Bartholomew's 
and  the  Midwilery  Hospitals,  as  well  as  m  private  practice.  The  characteristics  which  have  se- 
cured to  his  former  works  so  favorable  a  reception,  cannot  fail  to  render  the  present  volume  a 
-standard  authority  on  its  important  subject.  To  show  the  general  scope  of  the  work,  an  outline  ol 
the  Contents  of  Part  I.  is  subjoined. 

Lectures  J,  II. — Introductory — Symptoms — Examination  of  Symptoms — Modes  of  Examina- 
tions. Lectures  ///.,  IV  ,  V — Disorders  of  Menstruation,  Amenorrhoea,  Menorrhagia,  Dys- 
menorrhosa.  Lectures  VI.,  VII.,  VIII. — Inflammation  of  the  Uterus,  Hypertrophy,  Acute 
Inflammation,  Chronic  Inflammation,  Ulceration  of  the  Os  Uteri,  Cervical  Leucorrhoea.  Lectures 
IX  ,  X.,  XL,  XII ,  XIII. — Misplacement  of  the  Uterus,  Prolapsus,  Anleversion,  Retrover- 
sion, Inversion.  Lectures  XIV.,  XV.,  XVI. ,  XVII. — Uterine  Tu.mors  and  Outgrowths, 
Mucous,  Fibro-cellular,  and  Glandular  Polypi,  Mucous  Cysts,  Fibrinous  Polypi,  Fibrous  Tumors, 
Fibrous  Polypi,  Fatty  Tumors,  Tubercular  Diseases.  Lectures  XVII1.,'XIX.,  XX. — Cancer 
OF  the  Uterus. 
Part  IL  will  receive  an  equally  extended  treatment,  rendering  the  whole  an  admirable  text-book 
for  the  student,  and  a  reliable  work  for  reference  by  the  practitioner. 

BY  the  same  author.     {Just  Issued) 

AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OF  ULCER- 
ATION OF  THE  OS  UTERI.    In  one  neat  octavo  volume,  extra  cloth.    $1  00. 


WILLIAMS  (C.   J.   B.),    M.  D.,    F.  R.  S., 

Professor  of  Clinical  Medicine  in  University  College,  London,  &c. 

PRINCIPLES   OF  MEDICINE;   comprising  General  Pathology  and  Therapeu- 

tics,  and  a  brief  general  view  of  Etiology,  Nosology,  Semeiology,  Diagnosis,  Prognosis,  and 
Hygienics.  Edited,  with  Additions,  by  Meredith  Clymer,  M. D.  Fourth  American,  from  the 
last  and  enlarged  Loudon  edition.     In  one  octavo  volume,  leather,  of  476  pages.     $2  50. 

The  best  exposition  in  our  language,  or,  we  be-  I  Few  books  have  proved  more  useful,  or  met  with 
lieve,  in  any  language,  of  rational  medicine,  in  its  |  a  more  ready  sale  than  this,  and  no  practitioner 
present  improved  and  rapidly  improving  state. —  I  should  regard  his  library  as  complete  without  it. 
British  and  Foreign  Medico-C hirurg .  Revieio.  \  — Ohio  Med.  and  Surg.  Journal. 


YOUATT   (WILLIAM),   V.  S. 

THE    HORSE.      A  new  edition,  with  numerous  illustrations;   together  with  a 

general  history  of  the  Horse;  a  Dissertation  on  the  American  Trotting  Horse  ;  how  Trained  and 

Jockeyed;  an  Account  of  his  Remarkable  Performances;  and  an  Essay  on  the  Ass  and  the  Mule. 

By  J.  S.  Skinner,  formerly  Assistant  Postmaster-General,  and  Editor  of  the  Turf  Register. 

One  large  octavo  volume,  extra  cloth.     $1  50. 

The  attention  of  all  who  keep  horses  is  requested  to  this  handsome  and  complete  edition  of  a 
work  which  is  recognized  as  the  standard  authority  on  all  matters  connected  with  veterinary  medi- 
cine. The  very  low  price  at  which  it  is  now  ottered,  free  by  mail,  places  it  within  the  reach  ol 
every  one. 

BY   the   same   author. 

THE   DOG.     Edited  by  E.  J.  Lewis,   M.  D.     With   numerous   and  beautiful 
illustrations.    In  one  very  handsome  volume,  crown  Svc,  crimson  cloth,  gilt.    $1  25. 

ILLUSTRATED  MEDICAL  CATALOGUE. 

BLANCHARD  &  LEA  have  lately  issued  a  Catalogue  of  their  Medical,  Surgical,  and  Sci- 
entific Publications,  containing  descriptions  of  the  works,  with  Notices  of  the  Press,  and 
specimens  of  the  Illustrations,  making  a  very  handsome  pamphlet  of  sixty-foiu*  large  octavo 
pages.  Copies  will  be  sent  by  mail,  and  the  postage  paid,  on  application  to  the  Publishers, 
by  inclosing  six  cents  in  postage  stamps. 


UNIVERSITY  OF  CALIFORNIA  AT  LOS  ANGELES 

THE  UNIVERSITY  LIBRARY 
This  book  is  DUE  on  the  last  date  stamped  below 


I  9  r969j   ^^^^^^ 


'87 


AUG  1 5  RECD 
AUG  1  2  RBffl 

BIOMED  M  2  74 

JANISREC'O 
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FEB  8    RECO 

BlOMEOBIOME&iid^^d 

AUG  0  3  RECO 

SEP    ^^^^^ 

RECD 

Form  L-9-15))i-7.'35 


SEP  0  8  1987 


UNIVEKi 


.1  CALIFORNIA 


LOS  ANGELES 
LIBRARY 


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